Synergies #2: Judgmental Thinking

Is ‘Judgmentalness’ A Symptom?

A reality of our society is that most people don’t “complete” psychodynamic psychotherapy to see resolutions of their childhood conflicts. Most often this is for cost reasons, or as people feel better they often fade from the psychological treatment; too often falling back on longer-term medications or relapses when perhaps psychological resolution would have been realistic.

As medications have improved over the years so have psychotherapies. Scienctific research on psychotherapy is being used to determine which elements of individual and group therapies that are effective and efficient, and CBT/DBT (and other techniques) have risen to the top. In these models the therapist takes a more active role, mostly teaching patients to focus on the here and now, and how to change thoughts, feelings and behaviors.

For treatment to be effective and enduring, the patient must also take an active role in brining the work of therapy sessions into their everyday life:

• Doing homework assignments

• Creating new healthy self-care routines

• Learning how to stick with new routines

As the clinician, we should be educating our patients on the process of change and getting their “buy-in” and understanding that change takes work. We should start with goal setting, and agree on goals, such as improving motivation, self-esteem, understanding and managing emotions, and elimination of anxiety symptoms.

One example of how this can all come together is around the concept of “Judgmentalness.” What type of judging am I referring to?  There’s a black or white, “all or nothing” judging that we carry from childhood– about whether we’re normal or not, “adequate” or “inadequate,” “a success” or “a failure.” In a Cognitive Therapy model this distorted thinking is at the heart of most anxiety and depression.

“Judgmental thinking” is very closed, defensive, blaming and cynical.  Self-esteem must be earned, and worth is conditional.  People feel they must put on a false front, and that they would ultimately be rejected if their flaws became known.  “Nonjudgmental thinking” is hopefully more like how we view others– that there is no such thing as a worthless human being– compassionate, open-minded, but skeptical.  Not blaming or judging but yet holding people accountable for their actions.

As Psychiatrists we’ve all observed the difference between a mind which is in a state of non-judgement and acceptance of self, versus a mind that is self-critical, rejecting, and fearful of rejection and abandonment by others for not being normal.  I’m convinced there’s a switch in the brain.

While psychotherapeutic methodologies which focus on the past work on “why” people believe what they do, and helping them earn the feeling of “I’m ok,” newer methodologies, and SSRI’s get us there much faster.

We can identify this “Pathological Judgmentalness” early on in treatment– educate the patient about the suffering it causes, that it’s not really the way they see other people, and how it comes from childhood thinking.  They will agree, and we will agree that that won’t change anything.  But by working on it together this thinking can change.

As I honed in more on the concept of “Judgmentalness” through my work in DBT and Mindfulness, I also started to observe the effects of psychotropic medication on this “symptom.”  We know that the SSRI’s frequently reduce anxiety over a few weeks- this includes worrying, obsessing and ruminating.  These symptoms are closely linked to the “Judgmental state.”

Consider the following case example. R. S. is a 35 year old male who has had anxiety symptoms most of his life.  His anxiety was mostly about his inadequacies, and fears they would be exposed. He was soon to be a new dad, and wanted to overcome his anxiety issues, be more focused and productive at work, and a better father and husband.

He was interested in trying both medication and psychotherapy.  Escitalopram  was very effective in just a few weeks for his anxiety symptoms. He came for a few psychotherapy sessions, as he felt better we were also reinforcing the differences in how he thought and felt before the medication versus with. There was a world of difference.  Judgmental world, non-judgmental world.  When he slipped off his medication after several weeks his mind went right back to judgmental world.

But he’d had a taste.  He knew there was another way to think.  He also saw how easy it is to slip back.  Through devoted CBT, Mindfulness practice and DBT skills work he is a very happy dad, so far still on a (smaller) dose of Escitalopram.  He’s got the concept that we grow up with these beliefs from childhood, and they become part of us.  We have to make changes in our values and self-care routines to help prevent these beliefs overtaking us.  By learning new psychological skills (such as Mindfulness practice, relaxation exercises, cognitive techniques, and emotion regulation skills) we can learn to settle and refocus our mind.

My inner psychodynamic therapist asks “but if we got to the core emotions and impulses (i.e. toward his father) and he released them cathartically would that reduce the necessity of having to actively practice the self-help skills? Would the core beliefs be less likely to haunt him in the future?  On the other hand mindfulness teaches the individual how accept events and emotions from the past without blaming and that is very liberating. Mindfulness helps the practitioner to “absorb” the trauma and emotions from the past and learn how to live in the present.  Judgmentalness (blame/shame/guilt) is a huge component of the suffering. Non-judgmentalness is a cornerstone of Mindfulness and the practice actively re-trains the brain.

#judging #medication #doctors #mindfulness #therapists