Magical Thinking, Redux

magic

Photo: Bohman

One of my patients suffers from chronic constipation due to irritable bowel syndrome. During the twenty years since she was first diagnosed, her symptom pattern has remained remarkably consistent: she has perhaps 1-2 bowel movements per week, occasionally accompanied by some mild cramping. Even she admits the symptoms are more a bother than a worry. And yet, every time I prescribe a new medicine for one of her other ailments, within a day or two she calls me up complaining that it’s causing her to become constipated. When I ask if she means that while on the new medicine she has fewer bowel movements or more abdominal pain, her answer is always no.

And yet she adamantly refuses to continue with the new medication, insisting it’s the cause of a symptom complex she’s had for two decades. And no matter how cogently I argue that the new medicine can’t be to blame (and I’m always careful to pick medicines not known to cause or exacerbate constipation), she refuses to continue with it.

Though certainly she could be right about one or even two pills exacerbating her constipation, the likelihood that all sixteen pills I’ve given her have caused the same exact symptom in the context of the symptom already existing is just too far-fetched. A much more likely explanation is that she’s indulging in magical thinking.

Magical thinking is defined as believing that one event happens as a result of another without a plausible link of causation. For example: “I got up on the left side of the bed today; therefore it will rain.” The problem with this definition, however, is that exactly what constitutes “a plausible link of causation” can be difficult to pin down. If we were to take this phrase to its logical extreme, we’d have to consider a belief in anything that hasn’t been scientifically proven to represent magical thinking. On the other hand, rejecting the use of any and all criteria with which to judge cause and effect leaves us vulnerable to believing that anything can cause anything—or even worse, that an effect can occur without a cause at all.

Perhaps, then, a more nuanced definition of magical thinking would be believing in things more strongly than either evidence or experience justifies. Though I can’t prove the sun will rise in the East tomorrow, because it has every day since I’ve been alive, such a belief couldn’t then be said to represent magical thinking. But because every person who’s ever jumped off a building or a bridge has gone down and not up, believing that flapping my arms hard enough would enable me to float into the sky certainly would.

Problems with this definition remain, however. For one thing, simply in order to live we have to believe things without proof. If we refused to believe what our doctors, plumbers, electricians, barbers, or nannies told us without first being shown incontrovertible evidence, our lives would come to a grinding halt. For another thing, some questions we burn to answer aren’t necessarily provable or disprovable. An estimated 90% of the American people believe in God, yet no evidence for God’s existence has ever been demonstrated scientifically—and further, some would argue, doesn’t need to be. Which would mean that technically 90% of the American population is guilty of magical thinking (a statement, I imagine, that puts me at risk for becoming unpopular with 90% of you).

On the other hand, maybe not. As much as we yearn to know truths about the world around us (and inside us), we can only ever see objective reality through the lens of subjective experience. We may all agree objective evidence abounds for the existence of gravity, but that’s only because we all have the same subjective experience of having our feet pulled back to Earth every time we take a step.

Which opens up the possibility that we could conclude something is true for which there is only subjective evidence or experience (meaning, not objectively demonstrable to anyone else) and not be guilty of magical thinking. If eating highly processed carbohydrates (“white death” my wife calls it) reproducibly makes me feel sleepy or irritable, concluding the former caused the latter would be entirely rational, yet impossible for me to prove to anyone else.

I think we can say, however, there exists a world of difference between a thought process that leads you to conclude it will rain today because you awoke on the left side of your bed and a thought process that leads you to conclude life is eternal because you’ve had a vivid memory of a past life (which, by the way, I’m not arguing would necessarily convince me; I don’t actually know what would convince me). You could certainly question the validity of such a memory—or even the sanity of such a person—but, unlike with the first example, not the thought process that created the belief.

We can’t escape the intrinsic subjectivity with which we experience and interpret objective events. The best we can do is rigorously question the criteria we use to decide something is true. I suppose, then, what I’m ultimately arguing for is a constant, well-balanced degree of healthy skepticism about everything.

WHY WE SHOULD AVOID MAGICAL THINKING

Clear and sophisticated thinkers remain consistently wary of the influences that put them at risk for magical thinking, always cognizant that why they believe what they do is influenced by so many things besides their reasoning minds:

  1. What their parents taught them from an early age.
  2. What they want to believe is true.
  3. What their experience suggests should be true.

Improving the criteria we use to judge the truth of things is difficult. But because what we believe ultimately determines how happy we’re capable of feeling, we must constantly try. After all, the risks of indulging in magical thinking are quite serious:

  1. Not making the necessary effort to achieve our goals. If we believe, for example, in the Power of Attraction as popularized by the book, The Secret, then we’re at risk for believing all we have to do is put out a clear enough visualization of what we want and wait for it to come to us. Unfortunately, we may find ourselves waiting a long time. How often do you find yourself hoping for something to happen when you should be doing something to make it happen?
  2. Making bad choices. Five of the 16 medications my patient has now refused to take are blood pressure medications. As a result, her blood pressure has remained uncontrolled for several years, placing her at significantly higher risk for strokes and heart attacks.
HOW CAN WE STOP THINKING MAGICALLY?

Magical thinking remains a subtle obstacle to making good decisions. But the more we observe ourselves, the more we can reduce our tendency to indulge in it:

  1. Consciously identify your desires and biases. Write them down. Try to identify their cause. Work to free yourself from them to the best of your ability.
  2. Demand proof when proof seems demonstrable. Try to remain intellectually “agnostic” toward what hasn’t been proven or isn’t provable, even if you find yourself emotionally inclined to believe it. Try to regard your belief as just that—an inclination—so that you’re not tempted to act with more confidence in your belief than is justified.
  3. Beware the tendency to let others think for you. This is as insidious as it is widespread. A journalist presents a position about a topic of the day and has his or her opinion accepted as fact. One friend makes a statement about another and everyone accepts it as true without bothering to investigate themselves. Though I don’t agree with many of the principles espoused by Ayn Rand in her book, The Fountainhead, the point she makes about how so many of us subjugate our judgment to others is worth taking to heart (a great read, by the way, which I highly recommend).

We all tend to cling not only to the things we believe but the reasoning that leads us to believe them. Despite all my efforts, I’ve not yet been able to break through my patient’s magical thinking about the cause of her constipation. So I continue to do what I’ve done: work to turn her thought process, bit by bit, more toward rational, scientific reasoning, hoping that she’ll figure out herself the thought error she keeps committing. But it’s slow going.

NEXT WEEK: An Alternative To Willpower For Losing Weight: Distraction, Avoidance, And Acceptance

13 comments to Magical Thinking, Redux

  • Paul Myron RPh

    I wonder if something else may be going on here such as being afraid of a cure. Is this woman getting a lot of attention for her condition? Is she not taking on challenges because of her condition? Is the condition an excuse?

  • Jude

    Great post. The subject matter can be very frustrating when dealing with not only patients, but anyone who has a mind set on just about anything. Religion, politics, gambling, relationships…the list could go on and on. It’s very difficult to change a person’s mind sometimes when they want to believe in something, even if the belief is to their disadvantage. What drives me nuts is when they want to be validated.

  • Alex,

    I’m curious to know if and how you would address diet issues if you had reason to believe they contributed to her condition.

    I’m a strong “believer” that diet has much to do with many ailments we in the West suffer from, and that by making changes in what consume, we can ameliorate or eliminate many symptoms that are today treated by prescription drugs.

    So two questions for you: do you agree that diet plays a significant role in the health or disease of some of your patients, and if so, is there any mechanism for you to advise on such dietary changes?

    I realize this requires a lot from the patient, but chief among those is a true desire to treat the root cause and not just the symptoms.

    I’d welcome your thoughts and insights on this approach.

    Steven: Though I think many of the statements made about the far-reaching influence of diet on disease currently have little evidence to support them, I also think some of that evidence is forthcoming. As you’ll see in next week’s post, for example, I think there’s emerging evidence that the epidemic of obesity in North America is due largely to an over consumption of carbohydrates. I have also improved the irritable bowel syndrome of many of my patients (with the diarrhea variety) by having them restrict carbohydrates. Celiac sprue (due to a true gluten allergy) is far more common than most people realize. And we’re just beginning to understand how the biomass of bacterial that live in our intestines do affect disease (and how it’s almost certainly affected by antibiotics, and how it many be affected by diet).

    Alex

  • chris

    To me, this post follows logically from last week’s post on mindfulness—especially last week’s points #1, #2, #3 and #7. #8 and #9.

    It seems to me that clear, undisputed causation is hard to come by. But there ARE associations, and I think we may mistake association for causation.

    I also feel that for me, personally, the older I get, the more I see “patterns.” After many experiences, the patterns seem to add up—to associations and once in a while, to causation.

    Sometimes magical thinking is the best we can do, don’t you think, Alex? We just don’t REALLY know . . .

    Chris: I think we really all need to become more comfortable with uncertainty…

    Alex

  • rdp

    I am so on your page with this post, Alex. But I have to ask you—as I have to ask myself in similar situations—which of the two of you is engaging in magical thinking when you prescribe these pills? If your patient has established a long history of refusing blood pressure (or other) medication, how does your continuing to prescribe differ from imagining you can fly if you jump off a ledge? Doesn’t it amount to your doing the same thing over and over in denial of the reality of what will happen?

    It isn’t so easy always to identify which are the rational beliefs and which are the “magical” ones. I am guilty of expecting people to operate in a logical fashion whenever possible. I continue to expect that (because it seems so obvious to me that is a better way to proceed), even in the face of abundant evidence most people will not (or will bracket their illogical opinions/actions from their general opinion of themselves as rational beings). Because I see my bias as “rational,” I persist in the face of evidence. Isn’t that magical thinking?

    Medications offer a near-perfect context for examining competing biases. In fact, medicine in general does. In my lifetime alone, medical wisdom has advocated many contradictory treatments. The patient who refused treatments in the past probably would have been labeled non-compliant. After those treatments have been discredited, however, the patient looks pretty smart. Looks to me as though you may need another sort of “key” to address this patient’s medical issues.

    rdp: No doubt my simply making the same arguments to my patient without better understanding the true cause of her objections, her thinking process, will continue to be futile. While it is perhaps a foolish strategy, I would disagree that the hope that someone will finally listen to and be convinced by reason and evidence represents magical thinking—just a poor understanding of how people make decisions!

    Alex

  • rdp

    Not the hope, perhaps, but the EXPECTATION people will listen to what we consider reason (after so much contrary evidence) is what I am suggesting may represent a kind of magical thinking.

    But on the other side of this issue, I do think some of us are reluctant to take medications for valid reasons. 1) Because we doubt pharmaceutical companies choose to pursue the most efficacious treatment rather than the one that offers them the greatest potential for profit (and we know patient well-being is not their primary concern). 2) Because we know drugs are developed on the basis of average responses, and knowing that, on average, patients show response to X tells us nothing about what our response will be, thereby exposing us to whatever risks the medication carries, with no sure payoff. 3) Because, sadly, we have had experience with doctors who treat us the same way pharmaceutical companies do—although not usually for profit, as representatives of some hypothetical “average” patient, with little regard for what might actually be some important clue to completing the puzzle of our individual good health. With this experience under our belts, we are reluctant to expose ourselves to ANY complication of our initial complaint.

    I also suspect (without any hard evidence) that we tend to use a chronic condition as the “voice” of our unwellness. People with back pain get more back pain, people with skin issues get worse, and people with IBS feel like their symptoms are exacerbated. Sometimes, in my experience, one is too close to feeling overwhelmed by having to deal with just the one issue to be able to risk adding another potential issue. The only way around this obstacle is to feel some better control over the initial condition, I think.

    rdp: Points well taken.

    Alex

  • Alex,

    How fortunate this patient has been to have you give it your all for so long. Have you considered discharging this person as your patient in order to help her move on to find another doctor who may be able to break through her magical thinking and help her resolve her medical conditions so she is not continuing to live at risk with her diseases?

    Is there ever a timeframe or a circumstance when you think it is appropriate or beneficial for a doctor to discuss with their patient the option of discharging that person from one’s care, in order to jolt them out of magical thinking or even non-compliance?

    Giselle M. Massi
    http://www.gisellemassi.com

    Giselle: I don’t think some other doctor out there has the “magic” answer to break through my patient’s magical thinking, so no, I haven’t thought to discharge her from my practice. My strategy has always been to stick with her and try different approaches. I don’t mind patients declining to comply with my advice. I mind it if it happens as a result of poor reasoning. But if I only kept perfectly compliant patients in my clinic, I’d have no patients at all.

    Alex

  • Michael

    Not to point out the obvious, but isn’t this pretty strong evidence for mental illness in your patient? Have you followed up with counselors or anyone in that area? Why are you prescribing medications to a patient who is incapable of grasping causality and therefore nearly certain to be in noncompliance? That’s certain failure.

    This feels a lot like Morgellon’s to me—where the mental illness is far more severe than the purported physical illness could ever be.

    Michael: She is, in fact, mentally ill and being treated. But that’s certainly no reason to abandon the hope that she might accept a treatment for another problem that might actually help her.

    Alex

  • Michael

    Hoping that someone will be eventually convinced isn’t magical thinking. Using the precise same techniques to attempt to convince someone after repeated failures . . . it’s not magical thinking, precisely. But it feels a lot like a hammer/nail issue.

  • Rob

    Dr. Lickerman, I’m happy I found your site and your book. For several years I’ve been very committed to taking a more skeptical approach to life, but I’ve also found much personal meaning and usefulness in the subjective spiritual experiences of mindfulness and meditation. Many sources, such as books, podcasts, and websites, would unfortunately mix the kind of mindful philosophies that I found comforting and inspirational with magical thinking that would turn me off. Your approach has been exactly what I have sought for many years. I love the way you incorporate not just your scientific wisdom as a medical doctor, but also a focus on building mental toughness and an ability to persevere as important parts of improving one’s mental health.

    Specifically to your point about how magical thinking can prevent us from taking the effort that is necessary to achieve our desired outcomes, boy can I confirm that piece of wisdom. One of the main reasons I’ve been so committed to improving my own skeptical thinking over the last several years has been that I kind of messed up my life in a lot of ways as a young adult as a direct result of my magical thinking. I was never a religious person, but I had some unchecked ways of thinking that were vaguely spiritual in a “mind so open that your brains might fall out” kind of way. In addition to kind of falling for some popular media personalities who got me thinking that they might actually able to talk to dead people (which is only a side note to the point I’m making now), I also had dreams about what my life would be like that I just felt destined to achieve if I only kept my mind on that path and “never gave up.” But because I believed myself to be destined to achieve my dreams, I ended up only half-assedly working toward those dreams as the years ticked by. Eventually reality forced me to face it. And that’s what brought me to both mindfulness and skepticism. They actually go perfectly together, and you are one the very few well-spoken voices I’ve found who promote that idea. I find much pleasure and meaning in your writing. So thanks.

    Rob: You sound like someone who’s learned important lessons from his own mistakes. That’s wisdom nothing can take away from you. Glad you like my site and my book.

    Alex

  • Helen

    Hi Alex,

    I agree with the writer above who mentioned diet as a cure. Like your patient I suffered from chronic constipation most of my life but since becoming a vegan I am now relieved of that problem. It’s really amazing.

  • @Helen:

    Going vegan was also in my mind when I wrote my earlier comment to Alex. My wife and I have both gone vegan—pushed beyond vegetarianism, with the hope to address my wife’s Rheumatoid Arthritis (RA).

    I was interested to know if Alex thought this (or any major dietary change) was something he could “prescribe” to his patients, and I too believe it would really improve the overall health of the patient. Did he see anyway to motivate his patients to make such a change.

    In our case, you couldn’t get us to change from a plant-based diet at this point even if we concluded it had no specific benefit for my wife’s RA. We just love the taste of the food, and how it makes us feel overall. So much lighter, with so much more energy.

    At one time we thought it was just too hard to do, and that it would be too much of a sacrifice. Now we look back and realize we were just conditioned by 50 years of poor dietary habits (Standard American Diet), and making the change was no harder (or easier) than changing any other bad habit.

    I’m glad you are seeing direct benefits as well.

  • Helen

    @Steven Crisp:

    Thanks for your support as this is new to me. I have been a vegetarian for about 4 years now but just started veganism a few months. I really feel the change in my digestion, which I have always had problems with even in childhood. I am now 60 and feel better than ever.

    In the beginning I thought it would be difficult to change, especially giving up cheese but I found that I am becoming more interested in different kinds of foods and taking pleasure in cooking. And there are so many alternatives today. Plus I feel great.

    I really think that doctors should advise their patients that one way to take responsibility for their health is by paying more attention to their diet.

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