Good Reasons for Bad Feelings

by Randolph M. Nesse

  A numerical score like that of the Apgar can be useful for research, but I discourage summing resource scores in a general setting because it can be misleading and hurtful. It is bad enough that people rate the appearance of others on a scale of 1 to 10; using numbers to compare people’s life resources is worse. However, recognizing the complex realities of individual motivational structures is essential for understanding the origins of symptoms. To get the needed information in a way that is gentle but efficient, here are some questions that I use, always adapted, of course, to the individual.

  QUESTIONS FOR INQUIRING ABOUT THE SITUATION IN EACH LIFE DOMAIN

  Social: Are there friends and groups that you spend time with? Do they appreciate you? Any big problems?

  Occupation: How are things going in your job (or other major social role, such as parenting or volunteer work)? Is it satisfying? Is it secure?

  Children and family: Do you have children? How are they doing? For adults who don’t have children, I ask: Is that fine for you? Are there family members you keep in close touch with? How are they doing?

  Income: How are things going financially? Is debt a problem?

  Abilities and appearance: Do you have any major health problems or concerns about your appearance or abilities?

  Love and sex: How are things going in your main relationship?

  In addition to recording the person’s access to each resource and the size of problems in each area, I also use one or two emotion words to summarize the overall situation for each area. It is fascinating and revealing to note that we have words so well suited to the diversity of situations that arise in pursuing goals.

  EMOTIONAL STATES FOR THE SITUATIONS IN EACH DOMAIN

  Excited by new opportunities

  Satisfied and secure in this area for the most part

  Hopeful that future success will relieve current dissatisfactions

  Dissatisfied by the inability to accomplish goals in this area

  Worried about threatened losses

  Sad after losses

  Confused about what to do in this area

  Frustrated by obstacles that block progress toward goals

  Demoralized by slow or no progress toward important goals

  Waiting for a better time to pursue goals in this area

  Accepting of the inability to reach goals in this area

  Trapped in the pursuit of an unreachable goal

  Disengaged emotionally after failing to reach goals in this area

  Uninterested because goals in this area are not relevant now

  As we discussed cases in clinic meetings, we sometimes used the ROSS to try to better understand people’s life situations. It changed our views of many patients. Some with severe mental illness nonetheless had friends, jobs, relatives, income, abilities, and a stable partner. One woman with severe obsessive-compulsive disorder spent hours washing her hands each day. Her husband was frustrated with the time she wasted and the limits her symptoms imposed on their social life, but he was supportive in general. Despite her symptoms, she worked, took care of her children, and kept up with her friends. Such patients usually get better.

  Others were in much worse situations. One desperately depressed young woman had severe multiple sclerosis. She was living alone in a small apartment on meager disability payments, unable to get around because she could not operate her wheelchair. She had no occupation, friends, relatives, groups, or places to go. Antidepressants don’t help much for people in such straits.

  The ROSS is not a substitute for validated instruments that measure symptoms or life events, and it does not elicit the same kind of rich information as a long clinical interview. It does, however, bring idiographic information into a nomothetic framework. The ROSS can be used to search for the causes of aversive emotions, the same way general physicians use a review of systems to search for possible causes of pain.

  Methods like the ROSS that combine idiographic and nomothetic approaches18,19 should predict treatment response and rates of relapse better than purely idiographic or purely nomothetic measures. Categories of motivational situations gleaned from the ROSS may help demonstrate the effectiveness of antidepressant drugs and could strengthen neuroscience studies. For instance, brain scans of people whose depression results from a recent loss may well be different from those whose depression results from pursuing an unreachable goal and may be different yet from those of people whose depression has been lifelong for no obvious reason. The benefits of an antidepressant may differ markedly for people whose depression results from pursuing an unreachable career goal as opposed to those who are bereaved or suffering from an infection. The cost to bring yet another modestly effective antidepressant to market is about $2 billion.20 It would cost only about 1 percent of that amount to develop the ROSS to the point where it could be used to assess drug effectiveness and neuroscience findings for people in different life situations.

  People in social traps with no way out are at high risk of suicide; using the ROSS to identify them could be lifesaving. A San Francisco social worker, Helen Herrick, organized a summer experience to encourage undergraduate students to consider mental health professions. I was one of the lucky participants. We all lived on the grounds of mental hospitals and were assigned to “observe as much as you can.” The experience was transformative. It succeeded in convincing me to become a psychiatrist but forever prevented me from taking only a psychiatrist’s point of view. Learning about Herrick’s research with the families of Golden Gate Bridge suicide victims was also a huge influence. She initially took the nomothetic approach of trying to find the factors all victims had in common. But after hundreds of interviews she concluded that no generalization would ever be adequate. Some people jumped while drunk or showing off, others to inflict guilt. Some sought revenge, some to join a lost loved one, some because of anxiety, depression, or psychosis, others because of dementia or terminal cancer. She concluded that individuals need to be understood as individuals. She convinced me.

  Data from the ROSS can be diagrammed to illustrate the flows of effort and resources in a person’s life. For instance, the upper left box in the diagram below illustrates an ordinary complicated life, in which every kind of resource is contributing to every other kind of resource in a complex matrix. The upper right shows a workaholic who puts all energy and time into working and getting money. The lower left shows someone whose effort goes almost exclusively into taking care of children, with investment in occupation and finances only as a means to that end. Finally, the party animal spends most of life’s effort trying to create status and relationships, mostly sexual relationships. These are all very different lives, with different events having very different influences on emotions.

  Some Patterns of Resource Allocation

  Know Thy Patient—So What?

  Back to the other half of the equation: What about the person? For about half of the patients I saw in clinic, their current life situations did not seem very relevant to their symptoms. Social anxiety, for many patients, was a lifelong problem that was not much influenced by events. Some people with depression have always had symptoms; others were fine until a specific trauma set everything off. Researchers and clinicians are fully aware that most problems arise when a potentially vulnerable person encounters a stressful situation. This is called a stress diathesis model, diathesis being a fancy word for “vulnerability.”21,22

  Sensitive types have emotional reactions that others would not. People who care enormously about their work have symptoms when there’s a problem in that area, not so much when there’s a problem in their marriages. The well-known psychologist and positive psychology researcher Edward Diener did a study to confirm this. He showed that changes in areas that are especially important to an individual have more influence on subjective
well-being.23

  Instead of attributing symptoms to stress or an event or characteristics of a person, an evolutionary view suggests an approach like that used in the rest of medicine. Joint pain, for example, can have many causes. It can result from repeated motions at work, abnormal posture at a desk, or some special exercise regimen. Other joint pain is caused by infection, rheumatoid arthritis, or lupus erythematosus. Doctors routinely investigate not just how “stress” on a joint and inflammation might arouse symptoms but the specific kinds of situations and mechanisms that cause pain in a specific joint in a specific individual.

  Some life situations cause certain kinds of symptoms so reliably that they might well qualify as diagnostic categories. Parents of children with cancer. People whose spouses are having affairs. Single people with married sexual partners. People whose spouses are alcoholic, violent, or both. People experiencing sexual harassment. People accused of sexual harassment. Single parents with insufficient money or social support. People struggling with a chronic debilitating illness. Employees whose bosses demean them. When we talk with friends, and when clinicians talk about cases at team meetings, they rely on such categories. Conducting a ROSS offers an opportunity to measure such situations and analyze how they affect symptoms and treatment responses.

  But these analyses are still far too simple. People have dramatically different personalities. They create the situations they find themselves in. The situations they find themselves in further create the person. Very often those situations are self-stabilizing. People who are resentful and angry provoke anger in those around them, confirming their view of the world. People who see good in everyone often find it, sometimes because they have created it. But trying to shift an individual’s worldview is like trying to replace the girders in a high-rise building. No amount of logic or argument helps much. What works is experiencing a kind of relationship that is different from all previous ones. Sometimes that happens with love, sometimes in relationships at school or work. It can happen in good intensive psychotherapy, especially when patients begin to recognize how they create the situations that torment them. People can change in fundamental ways. Helping them do that is difficult but satisfying work.

  CHAPTER 9

  GUILT AND GRIEF: THE PRICE OF GOODNESS AND LOVE

  Nature, when she formed man for society, endowed him with an original desire to please, and an original aversion to offend his brethren.

  —Adam Smith, The Theory of Moral Sentiments, 17591

  Our capacities for morality and loving, trusting relationships are human traits as distinctive as language and extraordinary intelligence. We view warm, secure relationships as normal and natural, so explanatory efforts go mostly toward relationship problems. Clinicians attribute them to relationship dynamics and characteristics of individuals, including mental disorders that often wreck marriages and families. The focus, as in the rest of medicine, is on why things go wrong for some people.

  By now you will anticipate the more fundamental questions an evolutionary view encourages: Why are humans social at all? Why do we feel it is so important to be a part of a group? Why do we care so much about what people think about us? How does the capacity to feel guilt give advantages? Why do we experience grief? Answers to these questions require turning the usual question on its head: How can the tendency to help others possibly provide a selective advantage? The mystery is not why some people have relationship problems; the mystery is how love and goodness are possible for organisms shaped to maximize Darwinian fitness.

  For most of the twentieth century, biologists assumed that cooperative tendencies evolved because they were good for groups. Groups with more altruistic individuals grow faster than other groups, so it seemed obvious that this would select for cooperative tendencies. This naive view met its demise in 1966, when George Williams pointed out that especially altruistic individuals would have fewer offspring than others, so alleles for altruism would be selected out. Debate about the idea was mostly within biology until the 1976 publication of The Selfish Gene by Richard Dawkins2 ignited an intellectual firestorm that still smolders.3,4,5

  Many voiced outrage, accusing Dawkins of saying that altruism was not possible. Others were gleeful, finally seeing support for their cynical view of life. Reactions to the controversy provided examples of every possible psychodynamic defense.6 The final paragraphs of Dawkins’s book suggested that knowledge about selfish genes should allow us to better control ourselves and transcend our impulses, but that was overwhelmed by his metaphor of robots obeying the dictates of selfish genes.

  The idea that our brains were shaped to get us to behave in the interests of our genes is deeply disturbing. On first grasping it, I lay awake for nights wondering if my moral impulses were just manipulations at the behest of my genes. The core idea seemed necessarily true, but it was at odds with the guilt, social sensitivity, and genuine goodness I thought I saw in patients, friends, and myself. Were my attempts to do good, in the clinic and elsewhere, just subtle ways my genes were getting me to advance their interests? Even guilt and moral passions appeared to be selfish, from a gene’s point of view. It seemed as if Dawkins had found the evolutionary explanation for original sin.

  This not an arcane academic issue. What people believe changes how they behave. At the peak of debates about selfish genes, I sat by a fireplace one evening with evolution-minded colleagues planning a project. Each said in turn without apology, “I will help, but only if it is to my personal advantage.” The belief that we are selected for selfishness is a social corrosive. Its spread would make life more lonely and brutal than it already is. I fear that the idea may be spreading and that it may already have changed social reality.

  Economists have taken this seriously; Matt Ridley and Robert Frank soon weighed in about the implications.7,8 Frank found that taking an economics class decreased the willingness of students to contribute to public radio and to donate blood.9

  In the clinic it is obvious that what patients believe about human nature influences their lives and problems. To get a quick take on personality, I use a one-question test: “Could you tell me how you view human nature?” The answer most encouraging for therapeutic success is “Most people can be good or bad; a lot depends on the situation.” But the more common answers display the strong human tendency to judge most everything, including our whole species, as generally good or generally bad. Patients who say something like “Most people are pretty good; they try to do what is right,” tend to be neurotic and to do well in treatment relationships. But those who say “Most people are out for themselves, but what else can you expect?” tend to have problems with close relationships.

  Such beliefs are self-sustaining. People capable of trust pair up with similar others and are likely to have relationships that confirm their positive expectations. They shy away from cynical types. So, people who think that others are self-interested tend to have untrusting and often untrustworthy associates who confirm their views. I recall a dinner conversation about altruism at which the cynical distinguished visiting speaker said, “So, have any of you ever really experienced any altruistic behavior in your entire lives?” No one knew what to say.

  People defend their worldviews. Those who believe people are basically bad discount the possibility of altruism and trusting relationships. In therapy, they may go to considerable effort to confirm their beliefs. “You are just doing it for the money” is a routine test. Midnight phone calls demanding a house call to prevent suicide take the challenge to another level.

  Richard Alexander, the University of Michigan biologist who wrote one of the first books about the evolution of human morality,10 reported trying to convince his mentor that he was altruistic by describing going out of his way to avoid stepping on a line of ants. His mentor responded, “It might have been, until you bragged about it.”

  Viewing social life as a product of self-interest is anathema for others. I have asked many religious peop
le why they oppose teaching evolutionary biology. Their most common concern is that it will undermine motivations for moral behavior. There is little evidence for this. Nonreligious people are about as likely as religious people to get a divorce, go to prison, or otherwise violate social rules.11,12,13 However, many people have told me that their ability to control their selfish impulses depends on their belief in God. If that works for them, why would anyone want to interfere?

  George Williams was more disturbed by his own idea than most anyone else was. After spending years considering the implications, he came to the darkest possible conclusion: “Natural selection . . . can honestly be described as a process for maximizing short-sighted selfishness. . . . I account for morality as an accidental capability produced, in its boundless stupidity, by a biological process that is normally opposed to the expression of such a capability.”14 The irony is that George was an immensely moral man. He could have made a fuss to claim credit for the idea of kin selection based on a 1957 paper he wrote with his wife, Doris,15 but he didn’t. He was always generous in his work with me. But he saw no alternative to the logic that selection shapes behavior to maximize individual fitness.16

  Despite weeks of discussion, George never convinced me of his view. Perhaps my cultural background makes me unable to accept an unpleasant truth. As the grandson of missionaries, with plenty of early exposure to churches, I have always assumed that most people have inherent strong moral capacities. Choosing a helping profession exposed me to many others who were motivated to do good. Working with patients who have anxiety disorders further shaped or distorted my view of human nature. Most such patients are inhibited, guilty, socially sensitive people who try hard to do what is right. Subsequent experiences have given me a more worldly view. I didn’t know it was possible for someone to look you in the eye and make a commitment with no intention of keeping it. But like other people, I defend my core schemas, so I am more aware of moral behaviors and wishes to please others than examples of deception and selfishness. Others have had very different and less fortunate life experiences.