Fable

Some symptoms of OCD might be describable as pathological doubt, for instance, that one’s hands are clean or that the doors are locked. A review of OCD treatments states, “pathological doubt is one of the central manifestations of this illness. The person goes to the door, shuts it, locks it, feels that it is locked, knows that it is locked, turns around, and walks away. All of a sudden, he or she feels that it is absolutely necessary to go back and check. It appears clinically that the memory of the action of locking the door is insufficient.” In this respect, patience with OCD might be seen as the mirror image of confabulating patients who are unable to doubt. The person with OCD seems to be trying to raise her epistemic standards, her standards of certainty, to absurdly high levels.

- William Hirstein
- Brain Fiction: Self-Deception and the Riddle of Confabulation (Philosophical Psychopathology)¹ pp 97-8

I have chosen not to use the word “epistemological” or its derivatives in my writing, but I frequently describe trauma as violations of core beliefs.²

In other words, a central features of trauma is its epistemological wound. To heal the wound is to create new “justified beliefs,” ones which withstand doubt. These types of beliefs are implicit - somatic markers, dispositions, scripts, biases, schemas - rather than explicit, cognitive conceits. The emergence of new “justified beliefs” will change the contents of thought and the responses to distress, perhaps significantly.

How do we create new learning which we accept rather than doubt? Our body generates such learning from exposure to new experience. In the case of recovering from trauma, our body must a) experience repetitive exposure to the associated distress with b) alternative as-if behaviors. This search process identifies then practices responses which will improve outcome.

Additionally, the reasons for the distress per se, are not significant, rather the nature of the distress is. Central to trauma is three categorical epistemological wounds:

• I am unable, a wound to our sense of agency. We doubt our ability to achieve and control.

• I am unworthy, a wound to our sense of attachment. We doubt our ability to have consistent access to attachment figures.

• I am ignorant, a wound to our beliefs. We doubt our understanding of ourself and the world around us.

Simply put, distress exacerbates the sensations of helplessness, worthlessness and cluelessness. Recovery enhances the sensations of competence, worthiness, and understanding.³

Repetitive thinking [RT], such as rumination, is universal. It is biologically fit and provides the opportunity to learn different responses to the distress of these categorical wounds. It is a necessary part of the healing and growth process. It is normal, however awful it might feel. And like all significant mental processes, it can become pathological. In this sense, RT is regulatory, and much more symptomatic of distress than the cause of distress.

One significant quality of posttraumatic growth [PTG] is the development of new “justified beliefs.” If RT is part of this development, then it should align with the markers of PTG. For this post, I am going to focus on the relationship of persistent sadness and RT.

In a recent study,⁴ Dolbier, Jaggars and Steinhardt discuss the relationship of depressive symptoms to PTG.

Depressive symptoms negatively related to growth, yet became a positive predictor after controlling for hopeful coping, self-leadership and self-esteem. Mediation tests suggested that depressive symptoms exert an indirect negative influence through the mediators of self-leadership and self-esteem; that is, those who have high depressive symptoms may also have lower levels of these personal characteristics, which in turn lead to less growth. Simultaneously, however, depressive symptoms have a direct positive relationship with growth;[ital. mine] that is, when self-leadership and self-esteem are controlled, depressive symptoms may serve as a ‘wake up call’ to the individual. These results suggest that growth occurs when individuals have a sufficient foundation of self-leadership and self-esteem present, yet sufficient distress to merit an examination of current beliefs and feelings in the context of past trauma and adaptations. As such, depressive feelings serve as a catalyst to disrupt and then help reshape basic beliefs about oneself and the world.

Watkins supports the point that RT is associated with recovery from depression:⁵

RT prospectively predicts reduced levels of depression, whether in (a) currently depressed patients receiving pharmacotherapy, (b) a community sample, and [sic] (c) 1st year law students...

Compared with abstract, evaluative rumination, experiential rumination reduced negative global self-judgments such as “I am worthless”, improved social problem solving, and increased specificity of autobiographical memory recall. These cognitive processes are implicated in the onset and maintenance of depression. These findings suggest that RT focused on the direct experience of moods and feelings reduces patterns of cognitive processing implicated in increased vulnerability for depression relative to RT focused on the causes, meanings, and consequences of moods and feelings. It is important to note that both variants of rumination involved focus on negative content: Both repetitively focused attention on the feelings and symptoms of patients with current depression.

Susan Nolan-Hoeksema, similarly:⁶

In light of the effectiveness of distraction and behavioral activation interventions for rumination and depression, it seems paradoxical that interventions designed to focus attention on distressing emotions and thoughts, such as experiential or mindfulness therapies, also have positive effects on depression in some studies...

If rumination serves to build a case for hopelessness, mindfulness techniques may reduce ruminations by challenging the validity of this case. Mindfulness strategies teach individuals that their thoughts are not necessarily true and do not control their actions and that they should instead to view their thoughts as outside of or distant from themselves. Thus, these techniques may challenge the validity of the case the ruminations have built for hopelessness and may train individuals not to mechanically accept the felt sense of hopelessness that comes with depression. Mindfulness or experiential interventions are thought to reduce worry and anxiety by reducing avoidance of painful images and negative emotions and by aiding in the processing of these images and emotions. These interventions may have similar effects on rumination, to the extent that it serves similar emotional avoidance functions.

Doblier et al. focus on the value of depressive symptoms. Watkins and Nolan-Hoeksema note the value of RT under the condition of depressive systems. Together they are constructive responses to trauma and the associated distress (with the caveat that these processes can become both maladaptive and pathological).

The persistence of sadness and the associated RT are processes of exposure and of “justified belief” creation. Recovery from distress and PTG would appear to be the transformation of repeated sadness caused by an epistemological wound into new assumptions, biases, schemas etc. designed to replace the loss of understanding. Such recovery would improve the experience of ability, worthiness, and understanding. It is likely that the constructive adaptation to the distress, rather than improved quality of thought, accounts for the recovery.

Musings on Posttraumatic Growth:

Growth Needs Sadness
Posttraumatic Growth From Awe
Growth Needs Sadness

A related essay:

Peanut Butter: Able, Worthy and Wise