Wednesday, March 31, 2010

New Research Highlights the Impact of Rejection on Thinking and The Body

In an earlier post, I wrote about research that demonstrates a link between social rejection and physical pain. Well, a new study in a high quality journal (Journal of Personality and Social Psychology) has extended our understanding of the impact of rejection on the body. I've always liked the studies published in this journal because they are often clever and and well-executed.

The researchers tested a particular theoretical model of rejection. They ran an experiment where undergraduate students were placed into one of two groups: (1) "ambiguous rejection" and (2) "no rejection".

Without getting into too many details, the people in the "ambiguous rejection" group were put in a scenario where another person behaved in a way that may have been an act of rejection. Conversely, the people in the other group were put in a similar scenario -- where another person does not want to interact with them -- but it was obvious that it was not a rejection.

What the researchers found was very interesting. They found that people with low self-esteem who were rejected experienced the following sequence of events:

(1) they tended to blame themselves for the rejection (although there was little reason to do so),

(2) they rated themselves as being less likeable

(3) these first two events caused an increase in cortisol (I'll explain the significance of this below), and

(4) this increase in cortisol was followed by defensive behaviour. Specifically, the people who were rejected and had low-self-esteem were more critical of the person who rejected them.

Many of the things that these researchers demonstrated with an experiment, clinical psychologists like myself see all the time. It looks something like this:

A client comes to session feeling stressed and sad. They feel this way because of something that happened during the week. For example, a friend called and canceled plans because something important came up. They believe that the person rejected them because they are unlikeable, which then reinforces how they already think about themselves -- as being unlikeable to others. The client may eventually try and protect their sense of self by attacking the person in some way (ex: saying they are inconsiderate), or by distancing themselves from the relationship.

It is easy to see in this example that the person is feeling sad and stressed for almost no good reason. There was no obvious rejection. Their friend said that something else came up, and so they had to cancel plans. People do this all the time. Research shows that people with high self-esteem do not interpret this as being a rejection experience. Unfortunately, for those with LSE, their interpretation leads them down a dark path.

This research really adds to our understanding of this rejection process. The researchers were able to show that this rejection sequence leads to increases in cortisol. Prior research had already shown that rejection leads to increases in cortisol -- what makes this study unique is that a negative interpretation of rejection appeared to cause the increase in cortisol.

Psychologists know that negatively biased thinking can cause stress and negative emotions (I'll blog about this in more detail later), and now they know that negative thinking can negatively affect the body.

What is cortisol and how does it negatively affect the body?

Well, cortisol is what's know as a "stress hormone." It is commonly secreted by the body when physical safety is threatened. It was originally designed (through evolution) to prepare the body for an attack. It increases arousal and prepares us to handle an impending challenge. For example, if a stranger on the street started to push you around and threaten you, your body would secrete cortisol and other stress hormones.

However, cortisol does not only get released with threats to physical well-being. It also gets released when there are threats to our "social well-being." In other words, when we are rejected by others or even if our social status is threatened in some way (ex: a failure experience), then cortisol and other stress hormones are released in the body.

When cortisol is released repeatedly over time, it can have damaging effects on the body. Research has found associations between heightened levels of cortisol and lowered immune system functioning, cardiovascular disease, ulcers, complications involving diabetes (ex: high blood sugar), etc.

Again, this highlights the interplay between physical health and mental health. When someone has diabetes or high blood pressure, and they have problems with stress and negative thinking, the combination can be very negative to physical health. I've worked with a number of such patients, and when their coping ability improves, you can see the results in medical tests (ex: blood sugar levels drop).

To sum up, people who have negatively biased beliefs about themselves (ex: "I'm unlikeable") and other negatively biased thinking, they can easily get caught in a cycle of negative thinking - negative emotions - stress -- negative thinking, which can take its toll on the body.

Dr. Roger Covin
Montreal Psychologist

Thursday, March 25, 2010

Psychology, Obesity and Managing Your Emotions

I used to work at a health clinic in Calgary, Alberta where I got to work with a number of patients suffering from various physical health problems (ex: diabetes; obesity; hypertension). Now, you might be wondering – why would a psychologist be working with these people? Well, psychologists can play an important role for many health problems – in fact, we have a whole field in psychology devoted to this (behavioural medicine/ healthy psychology).

In an effort to show how psychology plays a role in various health problems, I’m going to follow-up my last post (on chronic pain), by discussing a new health problem:


Specifically, I’m going to talk about how a specific psychological factor (experiential avoidance – a mouthful, I know!!) can impact how much food people eat.

Research shows that over-eating (including binge-eating) is more likely to occur when stress and/ or negative emotions are present.

However, people do not necessarily overeat every time they feel stressed, sad or upset. Another important factor is emotion regulation. Emotion regulation refers to a person’s ability to manage their negative emotions, and not allow these emotions to lead to regrettable behaviour.

Some people have poor regulation strategies. If someone often eats unhealthy food when feeling stressed or upset, this would be considered a poor strategy. The pattern of turning to food (or drugs or alcohol or sex,…) to feel better is not really new in Western society. However, what has changed is the ease with which we can get access to these things (but I’m digressing a bit here).

There does appear to be a certain segment of the population that are more likely to use eating for emotion-regulation (i.e., emotional eating). An important question then becomes, why have they “chosen” food instead of drugs? There are several potential answers to this question, which I will address later.

Perhaps an even more important question is, what kind of emotion regulation strategies are these ‘emotional eaters’ using? Well, to answer this question we must examine a particular style of emotion regulation – called experiential avoidance. However, for simplicity sake, let’s just call it EA.

EA can be a bit of a complex concept to explain. It will help to explain what it means by describing it as a process. So, here goes.

When people use EA, they…

(1) really do not like negative thoughts, feelings, stress, uncomfortable body sensations (e.g., anxiety symptoms), etc. You might be thinking “Hey, no one likes those things!” True, but you can not like something yet still tolerate it. People who have problems with EA have A LOT of trouble tolerating these things.

(2) they decide (often unconsciously) that they are simply unwilling to experience these problems, and

(3) they do something (often quickly) to control or escape these unwanted experiences.

For example, if a person does something unethical, they can (a) ponder their actions and process their guilt, or (2) avoid thinking of the mistake and suppress their emotion. In this example, the former strategy can be thought of as an ‘acceptance’ or ‘willingness’ to experience negative thoughts and emotions. The second strategy is ‘avoidance.’

Certain kinds of EA strategies are healthy and normal under certain contexts. For instance, trying to suppress boredom and disinterest while in a conversation with a friend or colleague is normal, and expected by social standards. However, when you chronically try to avoid or suppress psychological experiences, it can sometimes lead to psychological problems in the long run.

There are several ways in which avoidance/ suppression can cause problems:

(1) there can be what psychologists call a “rebound effect.” This occurs when we try to suppress something, but our attempts to suppress it only end up making it stronger. A classic example of this is the pink bear experiment (Spend the next minute trying not to let the image of a giant pink bear enter your mind – it’s near impossible).

In fact, researchers have shown that trying to suppress negative thoughts only increases their frequency over time (primarily under stress),

(2) EA can make people feel inauthentic and disconnected from their true self. I have worked with many people who constantly try to be very, very positive people (always trying to shut out negative things in their life). These people were not experiencing a full and genuine life (everyone feels sad, angry, anxious, etc. at least some of the time), and they experienced psychological problems as a result.

(3) many negative psychological experiences are actually somewhat useful. Worry (in moderation) helps people anticipate and prepare for potential problems in the future. Self-criticism can be considered a useful self-monitoring process that allows someone the opportunity to identify mistakes and make necessary corrections.

Of course, the question now becomes, how does EA lead to binge-eating? Well, research shows that individuals with a tendency to engage in binge-eating also tend to overuse EA strategies.

Why are binge-eating and EA associated?

Well, eating can be considered to be an avoidance strategy. Eating can help someone distract from unwanted experiences, and can directly calm any physical discomfort the person is feeling. Unfortunately, this strategy works really well. And so, people are more likely to repeatedly use it.

A similar problem is seen in other problems like depression and anxiety. People with depression or anxiety sometimes use alcohol or drugs to blunt the intensity of their emotional experience (i.e., the depressed person feels less sad and the anxious person less anxious, at least for the short term). However, these EA strategies can impair recovery because the processing of emotion is an important component of treatment (this latter point is beyond the point of this post).

The take home message here is that EA is great in the short-term – but very problematic in the long-term.

So, returning to a question posed earlier in this post, why to some people choose food, while other people choose alcohol/ drugs?

There are several possible answers to this question.

First, people can learn to cope with problems by modeling their parents. Some people overeat while stressed because they learned this coping strategy from their parents. For example, mothers will sometimes bake cookies or other sweets to give to their children when they are upset. This strategy can get reinforced (i.e., it works by reducing distress in the short term), and is used repeatedly across time, and into adulthood.

Second, there is some evidence to suggest that the biological response to food involves more pleasure and reinforcement for obese individuals, relative to the general population. Similar to theories of drug addiction (ex: the link between the dopamine system and cocaine), research shows that eating also involves a similar process, where food activates pleasure centres in the brain. Research shows that this pleasure response can be greater in obese people.

Finally, individuals might learn on their own that eating provides an escape from negative emotions. They can learn this later in life (e.g., adolescence; adulthood) through the media, peers, and even by chance (i.e., they stumble onto the fact that eating relieves negative affect).

I guess one of the main points I want to make with this post is that psychology is not discussed often enough when people (ex: government agencies; other health professionals) try and brainstorm ideas for treatment and prevention. I remember a former supervisor of mine discussing an obesity conference that was held in Canada a number of years ago. The organizers had people from almost every profession there to discuss ways of lowering obesity rates. They even had city planners there to discuss how to design urban areas to lower the incidence of fast-food eating. Yet, there were no psychologists! The people there had no clue why they would even need to invite a psychologist.

I’m hoping readers get to learn a bit more about the role that psychology can play – in mental and physical health issues.

Dr. Roger Covin
Montreal Psychologist

Wednesday, March 24, 2010

The Psychology of Chronic Pain

I'm going to switch gears a bit with this post, and discuss a new topic that I feel is important and interesting. I want to talk about how psychological factors can influence chronic pain. I would estimate that the majority of people would not see much of a connection. Most people assume that pain is simply due to some kind of injury to the body. And by extension, chronic pain is due to some injury that has not yet healed. This is partly true.

Usually, when someone with chronic pain is told that there are "psychological factors" affecting their pain, alarm bells go off. The immediate reaction tends to be:

- "You think I'm making this up?"
- "You think this is all in my head?"
- "You think I'm crazy?"

Unfortunately, these kinds of thoughts make chronic pain sufferers less likely to see a psychologist for help. It is not uncommon for a physiotherapist or a GP to recommend that their patients see a psychologist -- only to have their patient feel insulted!

It is for this reason that I wanted to provide a brief introduction to the role that psychology plays in chronic pain. I hope that those with chronic pain get to understand a little more about psychology and pain.

Let me start by answering the common questions written above:

Are you "crazy?" - No.
Is the pain "fake?" - Absolutely not.
Is the pain "all in your head?" - Absolutely yes! But pain is always in the head.

You see, pain is basically a combination of things. First, there is often some damage or injury to the body (ex: broken arm; dislocated disc; micro-tear in the shoulder). There are receptors in the body that detect these injuries and send the information to the brain through the spinal cord.

This "pain information" then gets processed in the brain. Technically speaking -- the pain is actually in your brain and not in the body -- but of course you "feel" it at the site of injury.

It is the interaction between pain information from the body and the way the brain processes this information that determines how severe the pain will be.

Given that the brain plays an important role in the pain experience, and everyone's brain is different, it is not surprising to learn that two people can have identical injuries, and yet have completely different pain experiences. This is where psychology comes into play.

There is a lot of research showing that negative emotions (ex: depression; anxiety; anger) and feelings of stress tend to be associated with more intense pain. In other words, if you are feeling very sad and stressed, your pain is probably going to be worse than if you were relaxed and happy.

Why? What's going on here?

Based on research findings, what seems to be happening is this -- negative emotions and stress influence the amount of pain information received from the spinal cord. Pain researchers believe there are "gates" in the spinal cord that can be opened and closed depending on various factors. One of the factors that determines how much information reaches the brain is emotion. When you are depressed, more pain information is allowed through the "gate" and the person experiences more pain.

The really unfortunate thing is that increases in pain create negative emotions and stress -- so people with chronic pain end up in a vicious cycle. It's not surprising that up to 50% of people with chronic pain end up suffering from problems with depression.

Emotions and stress are not the only psychological factors that affect pain levels. Here are some other interesting facts that show a pain-psychology connection:

1) Suppressing feelings of anger can worsen pain

2) A number of research studies show that the way you think about your pain can seriously affect pain severity

3) Personality factors can affect pain in indirect ways

4) People who are more sensitive to rejection have lower pain thresholds

I hope this blog helps people understand a little more about how pain works. Especially chronic pain sufferers.

If your physician, physiotherapist, massage therapist or any other professional you are working with recommends you see a psychologist - please don't be insulted! They are simply trying to improve your care. In fact, The International Association for the Study of Pain recommends that mental health professionals be included in the treatment of pain. It's a treatment option that deserves some consideration.

Dr. Roger Covin
Montreal Psychologist

Tuesday, March 23, 2010

How Does the Need to be Liked Affect your Self-Concept and Self-Esteem?

As I discussed in my last post, the need to be liked has a large biological basis, and can really affect all aspects of our lives. In this post, I am going to briefly talk about how this need affects our self-concept and self-esteem.

Generally speaking, the self-concept can be defined as your overall understanding of who you are as a person. I’m going to hold off on defining self-esteem for now – it is actually going to be a definition that is probably different than the ones you have heard before.

So, we all need to be liked to some degree. Therefore, it is important that we have some idea of how likeable we are to others. Figuring this out can be a very difficult process for many people. Not only that, but this process can lead some people to become depressed.

So, how do we know if we are likeable? Well, in order to answer this question, we need information about ourselves. We often get this information from other people. Specifically, we get feedback from other people to help know more about who we are – and whether we have likeable qualities (e.g., intelligence; attractiveness; sense of humour).

Think about it. I can only know that I am funny if people laugh at my jokes. Knowing if you are smart is greatly influenced by external feedback (ex: tests; other people’s comments). Similarly, people can estimate how attractive they are based on the responses they get from other people (ex: flirting; comments, etc.).

So, generally speaking, we need other people to help us understand ourselves. Easy right? This process of coming to understand yourself by looking for feedback from others can be a really tricky process. There are many complicating factors – here are a few:

(1) other people have their own motivations, and so they can hide their feedback from you (ex: you might find someone very attractive or really smart, and yet not reveal any of these beliefs because you want to avoid embarrassment). Unfortunately for the other person, they never get this really nice feedback.

(2) people can have biased perceptions of other’s behaviour. For example, if you noticed a stranger across a room smiling at you while they talked to their friend, you might assume they like you and are saying positive things. However, you might also interpret that smile as meaning they are mocking you! People who are shy usually make the latter interpretation.

(3) we all have different standards for accepting information. Does a grade of 70% on an exam mean you are smart, average or dumb? If someone rated your attractiveness as 7/ 10, does this mean you are attractive? People hold different standards, and unfortunately for some people, their standards are so high that they ignore feedback that is actually positive.

As a practicing psychologist, there is one phenomenon that I’ve noticed over the years that really affects people’s self-esteem and mood. You could call it an “irrational rejection phobia.” It is an extreme fear of being an unlikeable person, despite the fact that there is plenty of evidence that you are a likeable person. It occurs when a person constantly strives or desires to be above average on a particular trait. For example, I have worked with a number of young women who rate themselves as being a 7/10 in terms of physical attractiveness. If you consider that the average of this scale is 5/ 10, these women are telling me that they consider themselves to be above-average in terms of physical attractiveness. Yet, they are not at all satisfied with this fact – in fact, they are depressed by it! They actually want to be a 9/ 10 or 10/ 10.

Whenever I ask these same women how likeable they are, I usually discover that (a) their likeability rating closely matches their physical attractiveness rating, and (b) they want their likeability rating to be higher, despite being above average. Their thinking and behaviour resembles that of a person with a phobia. People with a fear of spiders want to be as far away from spiders as possible. Unless the spider is deadly (over 99% of the world’s spiders are not deadly), this is considered an irrational fear. When people strive to be as far away as possible from the “unlikeable” side of the 10-point scale (ex: 0-4), it too is an irrational fear.

There’s nothing wrong with wanting to avoid rejection, but there certainly reaches a point when it becomes abnormal.

Much research shows that when we are far away from reaching an important ideal or standard, we can feel depressed. For example, if it is really important for you to be thin and you are overweight, you are likely to be feel sad and perhaps depressed. As such, whenever people feel they have to be much better than they are currently (ex: much more attractive; much smarter; a lot funnier), they run the risk of feeling disappointed and sad.

As you can see, figuring out whether you are a likeable person can be a tough process. Yet, it is a very important component of mental health.

So, are you a likeable person? And how does the answer to this question affect your self-esteem? Well, the answer to this question is self-esteem. The traditional definition of self-esteem has typically been “it is the degree to which we like ourselves.” However, some psychologists are now advocating for a new and more accurate definition – Self-esteem reflects the degree to which people believe they are likeable to others.

Or put another way, self-esteem is a person’s estimation of how probable it is that other people will like them and want to be their friend.

This blog post demonstrates how sometimes normal psychological processes have the potential to become dysfunctional. In this case, it is normal to try and evaluate who you are as a person, and how likeable you are. It is also normal to try and avoid rejection and be liked by other people. However, each of these normal processes have the potential to go seriously wrong – and can even lead to mental health problems.

Dr. Roger Covin
Montreal Psychologist