Since I was a teenager I have been reframing things. My mother was an anxious woman who worried about many things. In order to not upset her I realized that things had to be packaged positively. I became adept at repackaging many things that could be interpreted negatively into thing that were positive. I was able to observe the effect on my mother. Was this a form of deception or self-preservation or therapy? After becoming a psychiatrist I learned that a whole brand of psychotherapy was based upon this same notion of reframing. It is called cognitive therapy. It is one of the few types of psychotherapy that has been clinically proven to help people overcome a variety of mental symptoms including anxiety, depression and interpersonal problem. What began as a game soon became a form of self-preservation and now a form of treatment.
Several studies have been done that demonstrated that depressed individuals were more accurate in interpreting a video vignette that was showing a negative interaction between two people. Most depressed patients would conclude that this was proof that their negative perceptions were correct. This would reinforce their belief that they need to continue to hold fast to their negative views of the world. In another study of 2800 cardiac patients, those who score highest on a pessimism scale were thirty percent more likely to die in the next 15 years. So would you rather be more accurate or alive?
I clearly favor the optimistic perspective. What value comes from this more accurate interpretation? It leads to or perpetuates a negative mood state. It fosters paranoia and discontent. My view is more aligned with a statement I observed on a tee shirt on a website for the TV show House. It read, “Reality is highly over-rated.” I am not proposing that we totally disregard the facts that may lead to our demise. This is not a simple dichotomy as presented in the move, The Matrix, where we have a choice of pills. Taking one pill shows us reality and the opportunity to change it. Taking a different pill puts us into a state of total denial and enslavement.
More recent studies have pointed to better health among individuals with positive attitudes. In one large study carried out over 16 years, those who had a more optimistic scores as measured on a rating scale were 30% less likely to die. Deaths were mostly from cardiac reasons. One explanation was that the optimists took better care of themselves. Alternatively, being pessimistic resulted in more stress or the perception of greater stress. Perception may become reality.
I am proposing that reality can be viewed in multiple ways. It is as if two people are looking at a rectangular box. The one looking head on at one end sees a two dimensional square. The other looking at a slight angle sees a three dimensional box. In the two dimensional object there is nowhere to go or turn. It is flat without space. In the three dimensional world there is room to grow and expand. We are not as trapped and have more options. In this case our negative views become forms of enslavement or denials of alternative perceptions of reality that opens new opportunities.
I once learned an off color joke about a monkey, an elephant and three scientists on a deserted island. The scientists trained the monkey to put in and remove a plus from the elephant’s rear end. After the monkey was proficient in this task the plug was left in the elephant for four weeks. Upon this time the scientists released the monkey to remove the plug from the elephant whilst the scientists observed from a comfortable distance. Upon completion of the experiment the scientists compared their observations. The first scientist reported, “I saw tons and tons of excrement coming from the elephant.” The second scientist agreed, “It was amazing. I’ve never seen so much animal dung in my life.” The third scientist had a different take, “I saw a poor desperate monkey trying to put the plug back in.” There are always at least two viewpoints to every situation. Clearly one is affected by whether you are on the dumping or receiving end of a lot of excrement.
My first book, Psychiatry in Techno Colors: a psychiatrist’s memoir of lessons learnedabout diagnosis and treatment of anxiety and depression focused more on psychopharmacologic interventions. I realize that medications are not the only therapeutic intervention that I do. I have often joked that medications work better when I give them. This is more a reflection of some of the simple interventions that I do while prescribing medications. I believe most of these interventions fall into the category of encouraging cognitive reframes or different ways of viewing situations.
When discussing reframes or positive thinking, I think of the extremes as presented in Voltaire’s Candide or its modern satirical 1968 movie take off, Candy that had more sexual bent. In both cases the main character could only see the good in everything while harm and exploitation was done to them. Candide would remark after each atrocity that it was all for the best in the best of all possible worlds. Candy likewise saw only the good in others' exploitation of her. I don’t see these as models of appropriate reframing but of cautionary tales of taking positive thinking to absurd limits. Outright denial of reality is doomed to fail as an intervention but it is possible to see alternative perspectives that give us more control over our environment.
One model for depression is the learned helplessness model. This is when the individual after multiple failures gives up trying. There are two experimental models of this in animals. One is the swimming rat in the beaker paradigm. In this experiment a rat is placed in a large beaker of water. The walls are too high it to climb out of and it swims furiously to keep afloat. Just as it begins to sink from exhaustion the experimenter rescues the animal. After being placed in the same beaker for several experiments the animal gives up trying sooner and sooner. Some have suggested that the animal has just learned to not bother since it will be rescued anyway, but the next experiment implies otherwise. The second learned helplessness model consists of a large cage divided into two sections with an electric metal floor throughout but a lever switch on one side. A rat is placed in each compartment and the electric current is turned on. After jumping around helplessly the one rat discovers the lever switch that turns off the current. After several shocks it has learned to turn off the current fairly quickly. Both rats have received that same shocks but they behave very differently. The rat in the side with the switch behaves normally. While the rat without the switch appears anxious, shaky, doesn’t sleep well and eats poorly. This rat improves with antidepressant medication.
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