The Biology of Ethics
• David Mays, MD, PhD
• dvmays@wisc.edu
Outline
• Do we live by a “system” of values? If so,
where did these values come from?
• Fairness, empathy, logic, reciprocity, moral
emotions, and genes
• Do the genders differ in moral capacity?
– Do the genders differ at all?
• What does social science research tell us
about making ethical decisions?
Probably Not
• Many of our moral principles predate religion.
• Many atheists are quite moral.
• Most religions rely on simple deontological
rules. (Every morally relevant act is right or
wrong, regardless of the consequences vs.
utilitarianism)
• These rules do not explain the patterns of
moral judgments that people make in test
cases.
Preliminary Observations:
• We know that women tend to be more altruistic
than men, older people more altruistic than
younger, students less than nonstudents, people
with higher IQ’s tend to be more altruistic. But
there is no relationship between any standard
personality traits and altruism.
• Poor people tend to be more generous with
panhandlers than rich people.
• Consumer capitalism makes people feel like they
don’t have enough to give away.
The Train Problem #1
• An out-of-control train is racing toward five
hikers, who are unaware that it is coming.
Adam is standing by a switch and can send the
train down a side track, where one hiker is
hiking.
• Is it morally permissible for Adam to switch
the train?
The Train Problem #2
• An out-of-control train is racing toward five
hikers, who are unaware that it is coming.
Hitting a large object will cause the train to
stop automatically. Beth is standing on a
bridge over the track, beside a large man.
• Is it morally permissible to push the man onto
the track, stopping the train?
Moral Dilemmas: Other Examples
• You are a surgeon in an ER. Five people arrive
in critical condition, needing - 2 needing
kidneys, one a heart, one a liver, one a lung. A
healthy young person is waiting to give blood.
Should you take the organs from him?
• You are driving a car in the fog. Suddenly there
are 5 people standing in your lane. There is
one person standing in the other lane. Should
you swerve and hit the one person?
Moral Dilemmas: Final Case
• The Federal Government can either spend
$2,000,000 a year on continued life support
for a patient in a vegetative state, or spend
$2,000,000 on famine relief, saving the lives of
50,000 people.
• The child in the pond example: We are more
willing to help a single individual than many.
• Diffusion of responsibility and futility thinking.
Moral Dilemmas - Research
• There is no evidence that straightforward
deontological, utilitarian, or other rules account
for the differences we see in the train problems.
• People are confident in their judgments but are
largely clueless and incoherent in trying to
explain why they decide the way they do.
• There is strong emotional input accompanying
the decision. This emotional contribution is
probably shaped by an individual’s culture, and
may serve to reinforce action.
Human Capacities for Moral Behavior
•
•
•
•
•
Fairness
Reciprocity
Intuition for Social Contracts
Empathy
Moral Emotions
Can Other Animals Be Altruistic?
• Are primates capable of altruism? In one experiment, if
a rhesus monkey pulled a chain in his cage, he got food
(their only food!), but also delivered an electric shock
to a second monkey. One monkey stopped pulling the
chain for 5 days, one for 12.
• The closer a monkey was related to the other, the
longer it would go without food.
• One researcher saw a monkey pick up an injured
starling, climb the highest tree in the enclosure,
carefully unfold the bird’s wings, and loft it toward the
fence to get it airborne.
The Dictator Game
• Player 1 is given $10.
• Player 1 offers some amount of money to
Player 2.
The Dictator Game - Results
• Many players offer nothing, but some offer $5.
• People who play repeated games with
identified people develop a reputation and
generally give around $5.
The Ultimatum Game
• Player 1 is given $10.
• Player 1 then offers some amount to Player 2.
• If Player 2 rejects the offer, nobody gets
anything.
The Ultimatum Game - Results
• Players punish unfair offers even at personal
cost.
• Responders universally reject offers at $2 or
less.
Brain Studies of Fairness
• When reciprocity fails, or the offer is unfair,
imaging studies reveal significant activation of
the anterior insula, which plays a role in
negative emotions such as pain, distress,
anger, and disgust.
• When players engage in punishment, the
caudate nucleus is activated, a key center for
pleasurable experiences.
Fairness
• Notions of fairness permeate almost all aspects
of life. It is universal among all cultures. Human
beings have the innate capacity to monitor
fairness:
–
–
–
–
Some ability to keep tabs
To place values on different things
To judge when an inequity has occurred
To distinguish accidental from intentional giving and
reneging
– To determine if an unfair act is worthy of retribution
How is the Notion of Reciprocity Possible?
• Innate sense of fairness
• Strong sensitivity to and memory for
“cheating”
• Intuitions about trustworthy people
• Commitment to revenge
• Moral emotions:
– Warmth toward kindness, giving
– Guilt
Observations on Biological Reciprocity
• Animals don’t reciprocate, or when it
happens, every case involves a single
commodity, in a single context, over a very
short time period.
• Animals don’t punish.
• Unlike animals, humans can wait for days or
weeks for a larger reward versus a smaller
immediate reward.
Logic and Social Specialization
• Most people find the first problem is harder
than the second.
• Social contracts tap a specialization that is
present in all human beings. Our minds have
evolved a unique specialization to understand
social contracts and to detect violations.
• This kind of thought operates unconsciously
and automatically. The ability to detect
cheaters is found even in young children.
Empathy
• A newborn baby, barely able to see, can
imitate the facial expressions of adults within
1 hour of birth.
• Empathy is a kind of contagious emotional
expression. As adults we speak and gesture in
the same way as the person speaking to us.
Mirror Neurons
• Neurons in the pre-motor cortex show the same
level of activity when an individual reaches for an
object as when he watches someone else do the
same.
• This also occurs when subjects imagine an action.
• Recent research indicates that this system
activates when we see others experiencing a
disgusting event, or pain. It may underlie the
experience of empathy.
The Moral Emotions
• Pleasant emotions:
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–
–
–
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Awe
Gratitude
Love
Compassion
Acceptance
• Uncomfortable emotions:
–
–
–
–
Guilt
Shame
Regret
Remorse
Moral Emotions
• Moral emotions make it very difficult for us to
separate out logic from our feelings in
discussing moral dilemmas with other people.
• Moral emotions are probably culturally
specific in their associations with certain
behaviors and reinforce behavior.
Problems With Morality
• The family: us vs. them
• Moral Disengagement
Moral Intuition: The Family
• Genetic relatives are more likely to:
–
–
–
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Live together
Work in each other’s gardens
Protect each other
Adopt each other’s orphaned children
• Genetic relatives are less likely to:
– Attack and kill each other
• Those outside the “family circle” are less likely to
be incorporated in the culture’s “moral thinking”
- i.e. morality does not apply.
Moral Disengagement
• People make unethical decisions when the selfregulatory processes that are normally in place are
deactivated.
• Eight mechanisms are typically used:
– 1) Moral justification (hiring young children for work
overseas is better than what might happen if they
couldn’t work)
– 2) Euphemistic labeling (collateral damage)
Mechanisms of Disengagement
• 3) Advantageous comparison (I just took a little money.
Some people stole a lot.)
• 4) Displacement of responsibility (My boss told me to do
it.)
• 5) Diffusion of responsibility (Everybody does it.)
• 6) Distorting consequences (The insurance company
won’t miss the money.)
Mechanisms of Disengagement
• 7) Dehumanization (us vs. them)
• 8) Attribution of blame (It’s OK to torture terrorists
because they brought it upon themselves.)
How Likely Are We to Disengage?
• Empathy inhibits moral disengagement.
• Cynicism makes disengagement easier.
• Those who believe strongly in fate are more likely to
disengage.
• Those who think of themselves as moral people are less
likely to disengage.
Gender
• Are there real differences in the way men and
women think about the world?
• Probably. It’s just that we don’t know what
they are.
Gender Differences
• The Brain
– Men have bigger brains, even adjusted for body
size, than women.
– Average IQ scores are equal but more males score
at the very top and very bottom.
– Men have more myelinated fibers (more inhibitory
neurons) with enhanced localized processing.
Thinking is more lateralized, focused(?)
– At rest, the brain is more attuned to the outside
world.
Gender Differences
• The Brain
– Women have more densely packed, unmyelinated
neurons than men, more interconnections are
used when problem solving, bilateral thinking.
– The superior temporal cortex (important language
center) is 29% larger.
– Blood flow is 15% higher.
– At rest, brain is more attuned to the internal
world.
Gender Differences
• The Brain
– Inhibitory areas for aggression and impulsivity are
larger in women (orbital frontal cortex.)
– In solving a 3-dimensional maze, men use the left
hippocampus (memory and spatial mapping)
while women use the prefrontal cortex (landmarks
and geometric cues.) Men are better are mentally
rotating maps, but women are better at
remembering positions and landmarks.
Math Differences: A Cultural Caveat
• Women do better on 3-dimensional rotation tests
when they are told they are naturally good at it.
• Boys younger than 13 scored 700 on the math
part of the SAT’s more often than girls at a ratio
of 13:1 in 1983. In 2005, the ratio fell to 2.8:1.
This is not “hard-wired.”
• At the International Mathematical Olympiad, top
rated teams from Bulgaria, Russia, and Germany
have 15-20 girls. The US typically has ~3.
Gender Differences
• Performance
– Verbal abilities mature earlier in girls,
mechanical/spatial thinking in boys.
– Boys don’t see or hear as well as girls. In kindergarten
girls are more articulate, have better handwriting, and
answer questions faster.
– Girls outperform boys throughout the entire
educational process. (133 girls graduate from college
for every 100 men.)
– Women are better at reading faces and body
language.
Gender Differences
• Performance
– Men are more likely to compete, especially
violently, and risk their lives for status.
– Men are better throwers, but women are more
dextrous.
– Men are better at word problems, but women are
better at calculation.
Gender Differences
• Performance
– Women are more sensitive to sound and smell
– Women have more intimate social relationships,
are more concerned about them, and feel more
empathy toward friends. They smile and laugh
more. (But they are a tough audience for
comedians.) In social situations, women utter
twice as many words as men do.
– Women are more attentive to infants’ everyday
cries and are more solicitous to children.
Gender Differences
• Pathology
– In child mental health services, the patients are
predominantly male, suffering from autism,
hyperactivity, learning disabilities, conduct disorders,
and depressive and anxiety syndromes, especially
phobias, including school phobia.
– Parents have more difficulties with their sons.
Teachers more difficulties with boys in their classes.
Boys have more problems with stuttering, dyslexia,
stress headaches, stomachaches, asthma, tics, and
spasms.
Gender Differences
• Pathology
– This all changes at puberty. After adolescence,
virtually all the major psychiatric disorders (except
substance abuse, schizophrenia, and impulse
control disorders) become substantially more
common in females.
– Depression and anxiety are twice as common in
adult women than men.
Gender Differences
• Pathology
– Friendship networks are larger in women, which
acts as a buffer and a stress.
– Marriage shields men against psychiatric illness,
but puts women’s mental health at risk.
– Women, in general, act as caretakers of spouses,
children, and aging parents, and may “pay the
price of caring.”
Gender Differences
• Response to stress
– When humans are stressed, oxytocin is released in
the brain causing increased bonding to others,
nurturing of children, and increased calming.
Testosterone reduces this effect, estrogen
increases it.
– Men often withdraw to cope with stress - watch
TV, work on a project.
– Women often process stress by wanting to talk
about it. (Men often don’t understand that.)
Gender Differences
• Response to stress
– Men typically interrupt and give solutions when a
woman is talking about stress, and say “You
shouldn’t be upset.” (This is a mistake.)
– Women tend to offer advice to a man when he is
not upset and may be quite happy with what he is
doing. This can cause a man to “tune out.”
Gender Differences: Cultural vs. Biological
• Men and women do not differ in moral
reasoning, level of intelligence, or basic
emotional traits. They share virtually all the
same genes.
• Men are not from Mars and Women are not
from Venus.
• Men and women are from Africa.
Summary: The Moral Faculty
• Human beings are born with the parts of a
universal moral “grammar” that constrains the
range of possible moral behavior.
• Human capacities that allow us to care about
morality include:
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–
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Fairness
Reciprocity
Intuition about social contracts
Empathy
Moral emotions
Summary: The Moral Faculty
• Each principle generates an automatic and rapid
opinion about whether an act is morally
permissible or forbidden.
• These principles are inaccessible to conscious
awareness.
• Acquiring the moral system is fast and effortless,
requiring little or no instruction.
• Cultures “wire” these universal capacities in
specific ways, associating different behaviors with
our moral emotions. They become our cultural
values: e.g. autonomy, spiritual purity, etc.
Summary: The Moral Faculty
• It is the unconscious nature of the ethical
decision making process, combined with the
power of the emotional content, that makes
moral conflicts so intractable.
Morality
• What works - making the most people happy
in a pragmatic way?
– The Golden Rule: Do unto others as you want
them to do unto you.
– The Silver Rule: Don’t hurt others if you don’t
want to be hurt.
– The Bronze Rule: An eye for an eye.
– The Iron Rule: Might makes right.
– The Tin Rule: Kiss up to those above you. Kick
those below you.
The Prisoner’s Dilemma
• If you will confess that you both committed
the crime, and your cohort denies it, we will
let you go free and punish him with 5 years.
(sucker’s payoff)
• If you both deny the crime, we have enough
evidence to send you both to prison for 2
years. (mutual cooperation)
• If you both confess, you’ll both get 4 years.
(mutual treachery)
The Prisoner’s Dilemma: Winning
Strategies
• Tend to be generous, i.e. not trying to get
more than your opponent
• Tend to be hopeful, i.e. cooperating on the
first move or in the absence of information
• Tend to be forgiving, i.e. attempt to reestablish cooperation after an (accidental)
defection
• Don’t be a tyrant or a patsy
Research on Helping Others Become
More Ethical
• People who are emotionally secure show more
empathy to others. They are more likely to to
offer to do an unpleasant task for a stranger if
they had been made to feel more confident.
• Buddhist monks who practice compassion
meditation develop more compassion in day to
day situations, as measured by brain scans.
• One person who refused to shock the participant
in the classic experiment said he was raised in a
home that taught him to question authority and
in the army he was taught to refuse illegal orders.
Spirituality, Religion, and
Worldview in Mental Health
Care
Vignette #1
• A therapist began treating a homosexual man
for depression. The initial focus of treatment
was on the client’s depression, but after the
depression lifted, the issue of homosexuality
became more prominent. Only after
considerable therapeutic investment on the
client’s part did the therapist indicate that he
regarded homosexuality as sinful.
Vignette # 2
• A devoutly religious therapist pressed a
severely depressed nonreligious client to
engage with her in prayer. The client had not
anticipated a religious component to the
therapy and was not accustomed to religious
practice. She was quite troubled to find
herself drawn in, and her symptoms were
aggravated.
Vignette #3
• A therapist provided interpretations to a
devoutly religious man. In doing this, however,
she denigrated his long-standing religious
commitments as foolishly neurotic. Because of
the intensity of the therapeutic relationship,
the interpretations caused great distress and
appeared related to a subsequent suicide
attempt.
Religion in America
(Pew Forum on Religion and Public Life, Feb 2008)
Change in Denominations
(City University of New York Poll, 2001)
Pew Forum on Religion and Public Life
• 28% have left the religion they were raised in.
• The largest growth is in the unaffiliated group.
They are more likely 18-29 rather than older.
• However, more than 50% of people who say
they were unaffiliated as children have joined
an established religious group.
• (33% of white Evangelical Christians expect
the world to end in the next 50 years.)
Pew Forum on Religion and Public Life
• Black Americans are most likely to report a
religious affiliation.
• Hindus and Mormons are most likely to only
marry within their faith. (More Mormons work
in the FBI and CIA than any other religious
group.)
• Men are significantly more likely to say they
are unaffiliated than women (20% vs 13%)
Pew Forum on Religion and Public Life
• Depending on what “unaffiliated” is taken to
mean, the number of non-religious (secularist,
agnostic, atheist) outnumbers all other
religious groups except Christian.
• A more carefully worded survey done in
Europe and the USA by Financial Times/Harris
showed about 25% of Americans are “nonbelievers.”
Religion in America
(Pew Forum on Religion and Public Life, Feb 2008)
The New Mega-Churches
• People with new families are often drawn to
churches because they are worried about the
future of their children in this society.
• Tend to be places for social connection with
people of same values, rather than institutions
engaged in social critique. They are usually not
political.
• Services are not liturgical, more generic and quite
engaging.
• Large size is self-legitimizing.
Religion in America
• In one study of the 15 largest industrialized countries,
religious membership is higher in the US than in any
other country except Northern Ireland. There are
300,000 religious congregations in the US. (This
probably is the result of the separation of church and
state.)
• Americans are more likely to turn to religious
institutions when they have serious problems than to
the government or health and human services
organizations. 77% of those who seek medical care feel
that their religious beliefs are directly related to their
health concerns. Only 16% of health professionals ask
about spiritual issues.
Spiritual Beliefs and Your Doctor
• 85% of patients trust their doctor more if the
doctor addresses their spiritual concerns.
• 95% want their family practice doctor to a
consider their spiritual beliefs in the case of
serious illness, 86% when they are admitted to
a hospital
Prayer and Health Beliefs
(CBS poll, 1999)
• 30% of Americans believe a moral life prevents
illness
• 80% of Americans believe prayer can help people
recover from disease (2005 ABC and USA Today
poll)
• 50% of patients would like their physicians to join
them in prayer. (Yankelovich 1996)
• 63% believe a doctor should join a patient in
prayer if requested
• 34% believe prayer should be a standard part of
medicine
Prayer
• Physicians with strong religious beliefs
frequently pray alone for their patients. (Olive
1995)
• 33% of depressed or anxious individuals pray
about their health concerns and feel it helps.
(Astin 2000)
• In 2004, an Office of Prayer Research was
established at a meeting of the Parliament of
World’s Religions.
Prayer Research
• The health benefits of prayer, intercessory prayer, and
directed intention (Reiki, healing touch, etc) have been
investigated by many studies funded by the National
Institutes of Health. The findings are highly
inconsistent and basic issues of study methodology
continue to be debated in the research community.
Problems include inadequate blinding, dropped data,
reliability of outcome measures, and lack of
independent replication.
• One of the best controlled studies failed to show that
prayer or other forms of distant healing intention had
any effect on patients diagnosed with glioblastoma
(Lake J, Spiegel D 2008).
Prayer/Nonlocal Intervention
• Questions that remain to be answered:
– Are certain forms of prayer or other forms of distant
healing intention more effective than any others?
– What is the role of empathy in healing?
– Does the distance of the intercessor or duration of the
intercession influence the outcome?
– What is the influence of researchers’ or patients’
attitudes on outcome?
– Do the prayer and the patient need to know each
other?
– Does the patient need to know he/she is being prayed
for?
Anomalous Experiences
• An experience that deviates from the usually
accepted explanations of reality
– Mystical
– Near-death
– Alien abduction
– Telepathy, clairvoyance, precognition
Belief in the Supernatural: Gallup
2005
Mystical Experiences
•
•
•
•
30-40%, increased during the last 30 years
Typically last 1-3 hours
Ineffable
Sense a unity of all things, timelessness,
spacelessness, loss of self
• Visions, voices, telepathy, contact with the dead,
new sense of purpose
• Often correlated with better psychological
functioning, promotes healing and change
Near-Death Experiences
• A clearly identifiable phenomenon that occurs in 5-30%
patients who are clinically dead and then resuscitated.
• Patients report a continuity of subjective experience,
including leaving the body, observing hospital events,
passing through a dark tunnel, experiencing a bright
light, meeting spiritual beings.
• Long-lasting effects include stronger empathy, more
involvement with family, greater sense of purpose, less
fear of death, more appreciation of life
Spirituality Effects Health - Positive
• Church attendees with sickle cell disease had
lower scores on pain measures (J of Nerv Ment
Dis, 2005)
• Personal devotion and conservative religious
beliefs were inversely related to substance abuse
and dependence (J Am Acad Child Adol Psych,
2000)
• Most associations of religious commitment and
mental health published in the professional
literature are positive (Am J Psych, 1992)
Spirituality Effects Health - Positive
• Religiously involved youth are less likely to be
antisocial (J Soc Issues, 1995)
• Adolescents’ religious commitment delays the
age of first sexual intercourse, but also makes
contraception less likely (J Marr Fam 1987)
• Religiousness is inversely related to anxiety (Prof
Psychol Res Pract, 1983)
• Religious injunctions may encourage people to
live a physically healthy lifestyle.
Spirituality Effects Health - Negative
• Countless people have died because their
religious beliefs have led them to refuse
medical care (Christ Sci, Jehovah’s Wit)
Spirituality Effects Emotional
Resilience
• Elderly African Americans with religious
involvement show higher levels of personal
growth, self-acceptance, positive relations with
others (J Couns Psych 2005).
• Religiosity predicts shorter time to remission of
depression (Handbook of Religion and Mental
Health, 1998)
• Personal devotion buffers the effects of life
events on individuals prone to depression (Am J
Psych, 1997)
Spirituality Effects Emotional
Resilience
• Being religious is associated with less
depression, better self-esteem and better selfcare among family caregivers of persons with
serious mental illness (Psych Serv 2006).
• Religious coping in schizophrenia (Am J Psych
2006)
Schizophrenia and Religion
• 100 clients
• 61% Christian, 9% other traditional religions, 12%
from minority religions (Christian Science,
Scientology, etc), 18% no religion
• 56% did not practice with other people, 14%
occasionally, 30% regularly
• Religion was important to 85%, 45% said it was
the most important thing in their lives. 78% said
it was essential in coping with day-to-day life.
Positive Coping - 71%
• “I always have the Bible with me. When I feel I
am in danger, I read it and I feel I am protected.”
• “For some time everyday, I feel other people can
control me from a distance. The Buddhist monk
told me it was only my imagination, and he
teaches me how to meditate. In this way, I
distance myself from this idea of control. I tell
myself this is just a symptom of my illness.”
• “If you tell yourself that you have an eternal life
ahead of you, you know that the voices will end.”
Positive Coping - 71%
• “I am anxious about meeting people, so
beforehand I pray that everything will be OK.
Then I am confident in the situation.”
• “When I feel despair, prayer helps me find peace,
strength, and comfort.”
• “My life did not turn out like I wanted. I dreamed
of being a movie star. I do not have a wife. I am
unable to work. I have been hospitalized against
my will. After all this, I consider myself happy.
God gives me all I need.”
Negative Coping - 14%
• “I suffer from being so isolated. I went to
church in order to meet people. But when I
read the Bible it disturbs me. I begin to think I
have behaved wickedly and then believe I am
the devil.”
• “I went to church to be healed. I believed
Jesus would help me, but this is a lie. More
problems came, like a curse, God is a cruel
God. I want to die because I suffer too much.”
Spirituality Effects Happiness
• Three character traits effect our sense of wellbeing:
– Self-directedness (responsible, purposeful,
resourceful)
– Cooperativeness (tolerant, helpful,
compassionate)
– Self-transcendence (intuitive, judicious, spiritual)
– (Psych Annals 2006)
Spirituality May Exacerbate Stress
• Persons with lesbian, gay, and bisexual
orientation experience detrimental effects
from most organized religion (J Couns Psych,
2005)
• Often religious guilt, especially of a
ruminative, obsessive quality, but also of the
general variety, complicates depression or
other personal adjustment to stress.
Spirituality May Be the Focus of
Psychiatric Illness
• Clients with psychotic disorders frequently
incorporate religious delusions and themes.
Spirituality is Fundamentally Related
to Suffering/Meaning
• The task of putting suffering into perspective
requires that the therapist and client grapple
with larger questions, e.g. a person who has
always believed and trusted God to take care
of him/her may feel betrayed or even
punished if he/she experiences grave
misfortune. (J Psychother Pract Res, 2001)
Some Boundary Questions
• How much should clinicians support the use of
religious practices that appear to be
therapeutic? Should they pray in a session?
• Is it ever appropriate for the therapist to share
his/her beliefs in the clinical relationship?
• Should a therapist ever treat a member of
his/her religious congregation?
Definitions
• Spirituality is concerned with one’s connection
to a larger context of meaning - that there is
more to life than the material
• Religion is the form that spirituality takes
within given traditions.
• Worldview is an intellectual response to life’s
most basic questions. It is one’s philosophy of
life.
Assumptions
• Everyone has a worldview and feels strongly
about its truth.
• What people believe makes a difference in
how they think, feel, and behave.
• Religion and spirituality can have positive and
negative effects.
Assumptions
• The worldview of the patient and clinician
contribute to the success or failure of the
treatment.
– Understanding the patient requires the clinician to
know the patient’s worldview.
– The worldview of the clinician influences his or
her clinical impressions and judgment.
History
• The roles of healers and priests have
overlapped as far back as we have records.
Gradually, mental illness was seen as a
medical problem rather than the result of
spiritual forces. Today, the biological model of
mental disorders dominates, and spiritual
concerns are regarded as useful information
about a patient’s culture and attitudes. For
some practitioners, their religious belief
motivates their practice.
Freud
• Freud’s worldview was strongly materialistic
and dogmatically atheistic, which fueled his
intense lifelong attack against spirituality. He
believed religion was childishness and hoped
people would soon outgrow it. (“God is
nothing other than an exalted father.”)
• “Religious people lack qualities essential to
mental health.” (A. Ellis, 1983)
“If I had my life to live over again,
I would devote myself to
psychical research rather than
psychoanalysis.”
Sigmund Freud, 1941
Neglecting the Spiritual
• Many psychiatrists have nearly ruled out
inquiry into religion in a near-phobic manner
that resembles the avoidance of sexual history
by physicians in the early 20th Century.
• This is complicated by the fact that the current
political climate has highly politicized matters
of faith and emphasized a conflict between
religion and science.
Spirituality and Psychiatry
• A recent survey shows that religious
physicians may be more prone to refer
distressed patients to clergy or other pastoral
counselors rather than to psychiatrists.
The Clergy and Mental Illness
• The clergy serve ~40% of Americans with
mental health problems. In fact, some studies
show that they are more likely to be sought
out for guidance on mental health issues.
• Women, people who have been widowed, and
the elderly are more likely to seek out clergy.
The Clergy and Mental Illness
• People seek care from clergy as often as they
seek help from mental health professionals for
depression, bipolar disorder, schizophrenia,
and obsessive compulsive disorder.
• 50-80% of clergy report their counseling
training in seminary as inadequate, yet less
than 10% referred those counseled to a
mental health professional.
The Clergy and Mental Illness
• In a recent study, almost half of 98 surveyed
clergy members failed to recognize serious
mental illness in 2 vignettes, and said they
would not refer them to more professional
help.
Changing Times?
• A 2007 survey of 2,000 psychiatrists indicates
that psychiatrists are more likely than other
physicians to address religion/spirituality in the
clinical setting and do so comfortably.
• 75% of psychiatrists describe spiritual influences
as positive (slightly higher for other physicians.)
• Psychiatrists (82%) are more likely to say that
religion can also have a negative influence than
other physicians (44%.)
• Only 6% of psychiatrists pray with patients (vs.
20% of other physicians.
Doing the Assessment
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Deal with personal discomfort
Listen
Be prepared to answer questions
Be aware of countertransference
Screening: FICA
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F - Is religious faith important to you?
I - Has faith influenced your life?
C - Are you part of a religious community?
A - Are there spiritual needs that should be
addressed?
Developmental History
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First religious experience?
Religious training?
Similarity to parents’ beliefs?
Any traumatic religious beliefs?
Conversion experience?
Desires for spiritual development?
Community
• Participation in church, synagogue, etc?
• Have you changed churches and why?
• What support have you received?
God
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Belief in the existence of God?
What is God like?
How has your belief influenced you?
How do you experience God?
Belief
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Single most important religious belief?
Beliefs that you doubt the most?
Beliefs you doubt the least?
Your understanding of suffering in the world?
What is a life with purpose?
Rituals and Practice
• Prayer?
• Other private religious practices?
• Attendance of worship services?
Spiritual Experience
• Any spiritual experiences?
• Impact on direction of life?
• Have you told others about these
experiences?
• Importance in daily life?
Fetzer Assessment Tools:
www.fetzer.org
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Daily spiritual experiences
Meaning
Values
Beliefs
Forgiveness
Private religious practices
Religious/spiritual coping/history
Commitment
Organizational religiousness
Spirituality in Clients
• Spiritual beliefs and feelings are usually private
and held to be sacred. A trusting relationship and
good treatment alliance are crucial.
• Treaters need to be aware of their own beliefs
and at the same time increase their awareness
and empathy for other spiritual traditions. The
clinician’s primary goal is to promote the client’s
self-determination and not be a missionary for
any particular value system.
Spirituality in the Clinical Setting
• The first step is communicating a genuine
interest in and compassion for the client.
Working With Anomalous Experiences
• Provide support without judgment
• Focus on how the client interprets the
experience, not whether or not it happened
• Normalize, if possible
• If it interferes with functioning, grounding,
expressive work, consultation with spiritual
professionals may be useful.
Psychosis or Religion?
• Patients with religious delusions demonstrate
intense belief that occupies their entire
thinking. They tend to endorse details that
exceed traditional expressions of this belief.
• Functioning and behavior typically
deteriorate. Other symptoms of psychiatric
illness can be seen.
Psychosis or Religion?
• Religious delusions
– Persecutory: usually involving the devil
– Grandiosity: usually involving God
– Belittlement: usually involving unforgivable sins
• When on unfamiliar ground, get consultation
with appropriate religious authorities.
Potential Transference Problems
• Practitioners need to remember they are
moving into emotionally volatile ground.
Some clients have experienced harsh or
punitive forms of religion, or abuse at the
hands of authority figures.
• Many practitioners are concerned that
addressing religion may appear to support
delusional thinking. (Spiritual Competency
Resource Center, www.internetguides.com)
Potential Transference Problems
• Clients may respond to therapist like a
religious figure in their life
• Clients may be ashamed in the presence of a
therapist of their own faith
• Clients may be suspicious of therapists who do
not share their traditional values
Countertransference
• Some of us have a difficult time bringing up
the issue at all
• Under the influence of religious
countertransference, a clinician can begin
acting rigidly and thoughtlessly toward a
client, as if the client only consisted of his
religious beliefs. It obstructs therapeutic
relationships, obscures treatment options,
and demeans the humanity of the clinician.
Potential Countertransference
Problems
• A zealous therapist may feel compelled to
convert the client to his/her beliefs.
• A therapists from the same tradition as their
client may be tempted to act as a spiritual
mentor.
• A therapist might recoil from a client with
spiritual views that the therapist finds
repugnant.
Negative Countertransference
• Antidotes:
– Work toward experiencing the client as a complex
human being
– Consciously utilize expressions of respect
– Show interest and listen attentively
• What life experiences made this an important belief?
• What was your life like at the time?
• With whom do you share this belief?
Potential Countertransference
Problems
• Therapists have been shown to pathologize
beliefs that they do not understand (karma,
primary importance of the soul, angels, what
happens after death is more important than
what happens during life, etc.)
• Therapists may underestimate pathology in
clients who do share their beliefs.
Boundary Basics
• When boundary crossings become harmful, they
are considered boundary violations.
• The specific effect of a boundary crossing needs
to be examined in the clinical context.
• In general, self-disclosures should be kept to a
minimum because of the power differential in the
therapy relationship. Clients may agree with the
therapist’s personal spiritual approach because
they fear their care will be compromised if they
disagree.
Boundaries: The Conundrum
• Clients deserve to know how the therapist will
respond when he/she hears about the abortion,
homosexuality, religious beliefs, moral failures,
etc. that are part of the client’s history and
possibly part of the chief complaint. This is an
issue of informed consent.
• Many clients want to know more than the
therapist feels comfortable sharing, for personal
and therapeutic reasons.
Probably OK
(Assuming a good assessment has ruled out significant religious
pathology)
• How much support?
– Research indicates that spirituality generally
enhances resilience and aids in the recovery from
illness.
• Pray in a session
– As above. However, A distinction must be made
between the client praying in the session and the
therapist joining in the prayer. Praying together
inserts a degree of mutuality into the situation
that must be more cautionary.
Caution
• How much self-disclosure?
– There are no clear answers. The classic approach
is the safest: when a client desires more
information about the therapist, the follow-up
should be an inquiry about the significance of that
information for the client and the therapy. “How
will this help you get better?”
Problematic
• Treating someone in your congregation?
• Introducing new spiritual beliefs that is not
part of the client’s tradition.
• Having spiritual blind spots
• Zealotry
Stress, Burnout, and Happiness
The Chronobiology of Getting Sick
– 12 - Gout
– 1 AM - Gallbladder
– 2 AM - GERD, peptic ulcer
– 3 AM - Congestive heart failure, pulmonary edema
– 4 AM - Cluster and migraine headaches
– 5 AM - Asthma attacks
• 6 AM - Death, all causes
• 7 AM - Allergic rhinitis, colds, flu, rheumatoid
arthritis, depression
• 8 AM to Noon - Angina, MI, sudden cardiac
death, TIA, stroke
• 1 PM - Stomach ulcer perforation
• 4 PM - Tension headache
• 5 PM - Intestinal ulcer perforation,
osteoarthritis
• 7 PM - Cholesterol rises
• 8 PM - Backache
• 9 PM - Restless legs syndrome
• 10 PM - Menopausal hot flashes
Stress
• 50-75% of routine medical practice is devoted to
complaints related to stress.
• Problems at work are more strongly associated with
health complaints than any other life stressor. 29% of
workers report that they feel “quite a bit or
extremely stressed at work.” (Yale Univ. Survey, 1997)
• Healthcare expenditures are 50% greater for workers
who report high levels of stress (J of Occ Env Med,
1998)
Stress Response: LC/NE Pathway
• LC/NE: The locus coeruleus (LC) secretes
norepinephrine (NE - related to adrenaline) in
the cortex, thalamus, limbic system,
hypothalamus, spinal cord. NE acts as a
neuromodulator. It also activates the
autonomic nervous system for fight or flight.
Heart rate, respiration, and blood pressure
increase.
Stress Response: HPA Axis
• Hypothalamic: When stress is perceived,
corticotropin-releasing hormone (CRH) and
vasopressin are secreted by neurons in the
hypothalamus. CRH causes the pituitary to
secrete ACTH. ACTH stimulates the adrenal
gland to release cortisol which increases
glucose levels and suppresses the
inflammatory/immune response. This is the
hypothalamus-pituitary adrenal axis (HPA.)
Cortisol
• The levels of glucocorticoids in the blood
typically follow a daily rhythm - high early in
the morning, low later in the day. They
increase glucose in the blood, control its
metabolism, and regulate the sleep wake
cycle.
• High levels of cortisol have many deleterious
effects on the body (Cushing’s disease).
Stress: Memory Effects
• Short term stress can enhance memory. But
chronic stress can impair attentional states
and learning later on. Ultimately, even
amnesia can be result.
• High levels of glucocorticoids lead to impaired
memory and neuronal cell death.
Hypothalamus
Locus Ceruleus
NE
CRF
Cortisol
(dissolves
brain)
Pituitary
Adrenal
ACTH
Common Physical Symptoms of Stress
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Headache
Back, shoulder, neck pain
Sleep problems
Difficulty concentrating
GI problems
Palpitations
Skin problems
Tics
Low energy
Common Emotional Symptoms of Stress
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Job dissatisfaction
Burnout
Irritability
Anxiety
Depression
Isolation, withdrawal
The Dimensions of Burnout
• Exhaustion: individual stress component feeling overextended, depleted of one’s
emotional and physical resources
• Cynicism: interpersonal component -negative
or callous, excessively detached response to
job
• Reduced efficacy/accomplishment: feelings of
incompetence and lack of achievement and
productivity
Burnout Effects
• Burnout is associated with various forms of
job withdrawal: absenteeism, turnover
• For people who stay on at work, burnout leads
to lower productivity and effectiveness, poor
job satisfaction, reduced commitment.
• Burnout has a negative impact on coworkers,
creating more interpersonal conflict and
disruption. It is contagious.
Leadership
• The mood of a leader is more powerful than
the mood of members of the group. In several
studies that have measured leaders and
workers moods before and after a task, the
leaders mood has proven to be very
contagious.
• Interestingly, “negative” contagion seems to
be stronger than “positive” contagion.
Symptoms of Burnout
• Physical Symptoms: fatigue, cognitive
impairment, sleep disruption, GI problems,
headache, inflammatory changes
• Emotional Symptoms: alienation, cynicism,
powerlessness
• Behavioral Symptoms: impatience, negativism,
frustration, irritability
Job/Situational Causes
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Overload: exhaustion
Role Conflict: competing demands
Role Ambiguity: lack of training
Severity of Client’s Problems
Lack of Support from Supervisors (more so
than coworkers)
Job/Situational Causes
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Lack of Feedback
Lack of Control
Lack of Autonomy
Lack of Reciprocal Loyalty
Lack of Perceived Fairness
Job/Situational Causes
• The psychological contract:When we first
begin working for an organization, we have
certain expectations about what that
employment will entail - the job we will be
doing, workload, resources, career
advancement, job security, etc. Larger social
and economic forces can bring about
significant changes in these things.
Personal Causes
• Personal causative factors are not as strong as
situational factors
• Younger, unmarried
• Gender neutral (although males tend to rate
higher in cynicism)
The Mismatch Paradigm of
Burnout
• Burnout arises from mismatches between the person
and the job in six domains. The greater the
mismatch, the greater the chance of burnout. The
better the match, the greater the likelihood of job
engagement.
• Mismatches arise when the initial psychological
contract was not clear, or the job changes.
• The six areas are: workload, control, reward,
community, fairness, and values.
1) Workload
– Energy can be exhausted to the point that the
person can no longer recover.
– Mismatch can also result from the wrong kind of
work in terms of skills or inclination.
– Work is especially draining when it requires
people to display emotions inconsistent with their
feelings.
2) Control
– Mismatches occur most often when workers feel
they do not have control over resources needed to
do their job most effectively.
– Workers may also feel overwhelmed by their
responsibility and feel that their responsibility
exceeds their authority.
3) Reward
– Financial rewards
– Social rewards are even more important to most
people. Feeling lack of appreciation and having
one’s hard work ignored devalues the work and
the worker.
– Lack of intrinsic reward (pride in work) is also
critical for burnout.
4) Community
– People can lose a sense of positive connection
with others at work. People thrive when they
share praise, comfort, happiness, and humor with
those they like and respect. They have a shared
sense of values.
– Jobs may isolate workers from one another, but
what is most destructive is chronic, unresolved
conflict.
5) Fairness
– Fairness communicates respect and confirms
people’s self-worth.
– Inequity of pay, workload, when there is cheating
or when promotions and evaluations are
mishandled, or when grievances are not handled
appropriately all increase cynicism and emotional
exhaustion.
– This dimension is the most predictive of future
burnout when it appears.
6) Values
– Employees may feel that their job requires them
to act unethically (lie).
– They may feel that their personal values are at
odds with their workplace, or that their workplace
has contradictory goals (maintain a high case load,
be culturally sensitive.)
Job Mismatch
• Individuals may place different importance on
these six factors. If you really support the
values of the organization, you may be able to
tolerate problems with reward, for example.
• Investigating job mismatch is a very fruitful
way to help supervisors and employees
concretely discuss burnout and encourage
engagement.
Individual Interventions
• People can learn new coping skills, but it has
not been shown that they can apply it at work
• At best, there may be a reduction in
exhaustion, but generally there is no change in
cynicism or self-efficacy.
• The most effective change requires integration
of workplace and individual needs.
“Count no man happy till he dies,
free of pain at last.”
Oedipus, The King
Sophocles
Happiness
• Does happiness come upon us suddenly, in
the most banal circumstances? Or is it
something we can control and plan for by hard
work and careful planning? Or both?
• What do we know?
The Frontal Lobe
• Our frontal lobes evolved quite quickly over
the last 3,00,000 years. Homo sapiens totally
exterminated all competitors.
• The frontal lobe allows us to simulate the
future.
Simulating the Future
• We spend 12% of our time each day
anticipating and planning the future. How
good at it are we?
• For dome things we are pretty good, but as far
as predicting our future happiness, the
simulator does not work well.
Example
• Would you rather win the lottery or become
disabled in this coming year?
The Data
• Researchers at UC studied both lottery
winners and individuals who sustained a
physical injury. Immediate levels of happiness
were higher (lottery winners), or lower
(physically injured), but after eight weeks or
less, people returned to the level of happiness
they had before the event.
The Effect of Disability on Happiness
• Able-bodied Univ. Ill students:
– Happy - 50% of the time
– Unhappy- 22% of the time
– Neutral - 29% of the time
• Univ Ill students with disabilities:
– Happy - 50% of the time
– Unhappy - 22% of the time
– Neutral - 29% of the time
The Psychological Immune System
• 90% of people believe they will regret things that
they do more than things they won’t do. But they are
wrong. People of every age and walk of life regret
not having done things more than regret things they
did (top three: not going to college, not grasping
business opportunities, and not spending enough
time with family and friends.) This is because the
psychological immune system has a harder time
manufacturing positive and credible views of inaction
rather than action.
What Would Make You Happy?
• Most people believe that having more money and
having children would make them happy.
• As far as children are concerned, most parents would
say that some of their best moments of happiness
involved their children, but on a day-to-day level,
people aren’t particularly happy when they’re
interacting with their children. Women looking after
their children are significantly less happy than when
they’re watching TV. (Children are hard work!)
Marital Satisfaction: 4 Studies
It isn’t necessary to be rich and
famous to be happy. It’s only
necessary to be rich.”
• Alan Alda
Can Money Buy Happiness?
• The historical research says money can buy
happiness and it already has.
• Throughout history, most people have been
racked by illness, the desperate hunger of
their children, continual drudgery, and the
threat of violent animals.
• However, data suggests that once you have
enough, more money does not make much
difference.
Money and Happiness
• People who make $50,000/yr are a lot happier
than those who make $10,000. But people
who make $5 million/year aren’t that much
happier than those who make $100,000/yr.
• The data says that if you are poor, a little
money can buy a lot of happiness. But if you
are rich, a lot of money can only buy you a
little more happiness.
Does Money Buy Happiness?
• People with lots of money are not happier
than those with enough. Wealth is like health:
its absence breeds misery, but having it is not
guarantee of happiness.
• If people don’t worry about money, they
worry about something else.
• “I find all this money a considerable burden.” J
Paul Getty
Where Do We Go Wrong?
• When we put ourselves into the future, we
can’t escape how we feel in the present. But
we won’t feel the same in the future.
Where Do We Go Wrong?
• We overestimate the intensity and the
duration of our emotional reactions to
future events - the good and the bad
“impact” of the event. This is called
“Impact Bias.”
• Soon after a major event, we return to
normal so we can be motivated again. This
is called “Adaptation.” Our brains are not
trying to make us happy. They are trying to
regulate us. “Wanting” is structural. No
amount of “getting” can fill it up.
Impact Bias
• The data tell us, with a few exceptions, that if
it happened over three months ago, it has no
significance to us in terms of happiness.
• The problem is that we seem unable to learn
this. Our unimaginably successful consumer
driven culture is based on this phenomenon.
Anonymous
YOU CAN HAVE ANYTHING YOU
WANT. YOU JUST CAN’T HAVE
EVERYTHING YOU WANT.
Where Do We Go Wrong?
• We each have a happiness generator in our brains – a
kind of psychological immune system that allows us
to feel good enough to cope with bad situations.
• One month after getting fired, for example, we are
likely to say it was the best thing that ever happened
to us.
The Psychological Immune System
• We remain fairly ignorant of the workings of
this system (rationalization works better if you
don’t know what you’re doing.) So we don’t
anticipate it.
• It seems to work better in really bad situations
where we are stuck without options. Ironically,
we always try to avoid these situations like the
plague.
Where Do We Go Wrong
• We underestimate our comparing mind. We are
always looking at those around us and comparing our
circumstances to theirs. What makes people happy is
not wealth, for instance, but relative wealth. Most of
us would feel happier making $50,000/yr in a job
where the average salary is $40,000, than making
$60,000/yr in a job where the average is $70,000.
“I wish I came in first more
often.”
Michael Jordan
Newsweek 2/17/1992
“I have also learned why people work so
hard to succeed: It is because they envy the
things their neighbors have. But it is useless.
It is like chasing the wind…It is better to have
only a little, with peace of mind, than be busy
all the time with both hands trying to catch
the wind.”
Ecclesiastes 4:4
Predictors of Happiness
• Strong Influence on Happiness
– High self-esteem
– Optimistic and outgoing
– Close friendships/good marriage
– Work and leisure that engages skills (usually less
expensive - gardening, social contact, etc)
– Meaningful religious faith
– “Satisficers” (those who aim for good enough)
Predictors of Unhappiness
• Strong Influences on Unhappiness
– Hunger
– Disease
– Poverty
– Oppression
– Dangerous environment
– “Maximizers” (those who want the best)
Other Findings
• More sex correlates with more happiness.
• How well you sleep the night before has a
stronger correlation with how you enjoy the
day than your income.
• Setting realistic goals and accomplishing them
is associated with happiness.
• Sticking with your old favorites leads to
happiness more than seeking variety for its
own sake.
Can We Be Happy?
• Freud says, no.
• Madison Avenue says, yes.
• Science says, maybe.
Three Faces of Happiness
• Pleasure
• The good mood (set at birth, right vs. left
brain)
• Overall quality of life, satisfaction and
contentment (more about ethics and values)
Some Suggestions for Finding
Happiness (evidence-based, of course)
• Find ways to think less about yourself and
more about others.
• Spend time with friends.
• Be physically active.
• Be actively engaged in your activities.
• Cultivate a spiritual life.
Some Suggestions for Finding
Happiness
• Work on being a “Satisficer” rather than a
“Maximizer.”
– Restrict your options (two stores, e.g.)
– Realize when a choice has met your core
requirements
– Consciously limit the time spent on wondering
about other options that you have missed.
Some Suggestions for Finding
Happiness
• Research shows that humans are hard-wired
to scan for the bad. Aversive events get stored
more quickly in memory, and are more rapidly
recalled.
• Positive events are stored through the
standard memory systems and need to be
held in conscious awareness for 10-20 seconds
for them to be coded and held onto.
Some Suggestions for Finding
Happiness
• In other words, the mind is like Velcro for bad
experiences, and Teflon for good experiences.
(Mother Nature cares about grandchildren,
not happiness.)
• Help positive events become positive
experiences by paying extra attention to them.
Hold them in consciousness longer. Savor
them so they sink in.
Some Suggestions for Finding
Happiness
• Live longer. The 70’s are the best time of life.
(The 20’s and 30’s are among the least happy
decades for adults.) The shift begins around
age 50. They are faster to react to a smiling
face than to a sad or distressed face, the
amygdala calms faster during stressful
emotions, the prefrontal cortex more actively
quiets negative emotions.
Living Longer
• As we age, most of us change our goals to
focus more on achieving emotional wellbeing.
• “Socioemotional selectivity theory”: older
people, and people with shortened life spans,
put more emphasis on relationships and focus
on the positive. Younger people put their
emotions on hold until they reach their longterm goals.
Some Suggestions for Finding
Happiness
• Adaptation does mean that frequent small
events have a bigger impact than occasional
large events. This means spending fifteen
minutes every evening of your life with a
relaxed drink and a sympathetic friend will
make you happier than winning the lottery.
• “All happiness depends on a leisurely
breakfast.” John Gunther
Some Suggestions for Finding
Happiness
• Stop looking. Total happiness is not attainable.
By pursuing happiness, we cause it to recede
farther away from us. Seeking is the antithesis
of happiness. True happiness, or perhaps,
freedom from unhappiness, comes when we
are focused on living a life of generosity and
integrity.
“So it is that, instead of living we
hope to live. Forever preparing for
happiness, it is inevitable we
should not know it.”
Blaise Pascal
“Don’t worry. Be happy.”
• Bobby McFerrin