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July 7, 2020

BehindTheMedspeak: "Sometimes, the Why Really Isn't Crucial" — Sally Satel, M.D.

Dr. Satel is a psychiatrist who writes occasional pieces for the New York Times, among others.

Her Times essay summarized quite nicely why many times the best course is not to reason why but, rather, to do or die.

It follows.

Sometimes, the Why Really Isn’t Crucial

"Why do I use drugs?" I am asked every few weeks by a patient in our methadone clinic.

I take the query as a good sign; curiosity about oneself is usually healthy. But the premise behind the question — that a person can reliably identify the psychic roots of an addiction, or any other act of self-sabotage — is highly overrated.

Research psychologists have known for decades that it is very difficult to determine causation in mental life and thus, of behavior. For one thing, we can never perform an experiment. Take my patient Karen, 50, who spent most of the 1990s smoking crack. She is certain that the decade-long binge would never have happened had her mother not died when she was 12. We will never know if she is right because we cannot rewind Karen's life, play it again, and see what would have happened if her mother had lived.

Reconstructing the story of one's life is a complicated business for other reasons. What scientists call hindsight bias kicks in when we try to figure out the causal chain of events leading to the current situation. We may well come up with a tidy story but, inevitably, it will contain large swaths of revisionist history. It's not that we bias ourselves deliberately; it happens because the mind tends to make events in the past appear comprehensible and orderly. We forget the uncertainties that might have beset us as we struggled in real time.

Narratives are shaped also by a natural tendency to focus on information that confirms theories we already hold. These theories — for example, that molested children are likely to grow up to have sexual compulsions of their own — may be imbibed from the media, self-help books, or therapists.

If our own accounts of our actions are often so slanted and embellished, is composing them simply a misbegotten quest? Surely not. To a therapist, the attempt signals that patients are aware that they have a problem worthy of attention. And the narratives themselves can help them make sense out of confusion. This, in turn, can diminish anxiety and exaggerated guilt. Such relief might be sufficient in and of itself for some, or, depending on the goals of therapy, it could embolden a patient to make further healthy adjustments.

But the grail-like search for insight can also backfire when it becomes a way for patients to avoid the hard work of change. This was my experience with Joe, a 24-year-old heroin addict. At every session, Joe would talk about his childhood relationship with his father, seeking new clues for how it damaged him and drove him to heroin.

When I tried to change the topic to on-the-job stresses, which he linked to heroin craving, he said he’d rather "do psychotherapy." Joe was forestalling the need to make practical changes. The many-layered drama with his dad doubled as an excuse for using heroin, absolving him of the responsibility to quit. When I proposed that possibility to him, he said, "Maybe you’re right." But nothing really changed. He died of an accidental overdose a few months later.

Finally, insight has no guaranteed relationship to change. A colleague of mine treated a 45-year-old woman, Joan, who came for therapy because she hated her chunky body. Joan firmly believed that once she discovered The Reason for her overeating she would stop.

After a few months, Joan told my colleague that her father had developed cancer the year she went off to college.

"You know, I never made the connection until now," she announced triumphantly, "but I started overeating when he began to waste away. It's like I was trying to nourish him through myself."

A poignant metaphor, yes, but months later she hasn't lost a pound.

It is time to retire the myth that insight is a prerequisite for change. For the patients in our clinic, change without hard-won insight is the rule. And who has time to wait? Not Natalie. This past month she and I worked on getting an abusive, shiftless boyfriend out of her apartment; finding tutoring for her son; and building a new social network to replace the drug users that she used to hang out with.

At this stage in her treatment, awareness of what she needs to do will get Natalie further than insight. Less chaos in her life means less anxiety and that means less risk of relapse.

Down the road she may ask, "Why did I use drugs?" But in the meantime, what's important for Natalie and her son is that she is determined to stop.

Frederic C. Bartlett, a British psychologist, coined the term "effort at meaning" to describe the human impulse to make sense of feelings and circumstances. Self-explorers be warned: it is an effort often fraught with distortion and even hazard, when it prevents one from making the changes that need to be made in the present.

Don't think that the search for reasons is limited to behavior: in the O.R. sudden disasters and happenings oftimes lend themselves — especially among those with little experience — to exhaustive searches for logical causation.

I am reminded of an epigram attributed to Suzuki Roshi: "In the mind of the beginner there are many possibilities. In the mind of the expert, there are few."

Many times it's best not to even bother trying to find a reason.

Forrest Gump had it right: "Compost happens."

July 7, 2020 at 02:01 PM | Permalink


Good point, hadn’t thought about that angle. If you are in a basin with water rushing in, the how and why of the water is second fiddle to getting the hell out.

Posted by: xoxoxoBruce | Jul 7, 2020 4:55:17 PM

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