Cognitive Balance and Positive Associations

There are many patients who are continuously faced with the possibility of death. These patients have to come to grips with their own finiteness. Then they are able to live a very different quality of life, knowing that death can occur anytime, but hoping that there will still be many more weeks and months ahead. These patients should not be avoided; How does a professional person respond to a nonprofessional person when told that You are cold and indifferent to death? The implications of such inefficiencies in intra-household negotiations are important. In her insightful survey of the relationship between economic development and women's empowerment, Esther Duflo of MIT concludes: This means that we cannot rely on the family to correct imbalances in society. Households are affected by the very same gender norms, leading not only to inequities but to everyone being worse off. If women do not contribute their knowledge in meetings and do not have access to the resources they need, we all are worse off for it. In an ambitious project, Ashraf and McGinn are studying whether teaching girls how to negotiate might be able to address some of this. Specifically, they examine the impact of teaching Zambian girls how to negotiate with their parents, guardians, and other adults about their future. The stakes are high. The girls they are teaching frequently must negotiate for the right to remain in school, marry later, or say no to sugar daddies offering to pay for school tuition and supplies in return for sex. Their randomized controlled trial is still ongoing. It aims to measure the impact of negotiation training on education and health outcomes in the lives of about 3,000 girls in eighth grade in Lusaka public schools. Deceptions and manipulation require you to understand the cognitive process of your victim. Machiavellians know the reaction to expect when they tell you a particular thing, and what to expect if they say another thing. That ability to cognitively empathize with you is what they use to their advantage when they lie, deceive, and exploit your kindness, weaknesses, and vulnerability. Even more interesting, research has shown that some High Machs can emotionally empathize with others; Specifically, researchers discovered that some Machiavellians subset can bypass empathy.

That is, they have the full human capacity to understand the thoughts and feelings that may arise as a result of being deceived, manipulated, or lied to, but they go ahead with their malicious intent. This apparent lack of moral conscience has been considered an evolutionary advantage by many psychology researchers. This implies that Machiavellians have the advantage of pursuing their goals unabashedly without being held back by moral considerations. If a Machiavellian sets their eyes on something, they get it no matter what. However, there is a rising question in the scientific community about the possibility of Machiavellians forming long-lasting, mutually-satisfying relationships with other people if they can't even resonate with others emotionally, or care for their thoughts and feelings. I would look into the mirror and question whether there is not some truth in the statement. If I do not feel cold and indifferent toward this person's death and the grief of the family, I would regard it as part of the anger that this family is now going through in relation to the recent loss. When a family is in a stage of anger, especially after a sudden, unexpected loss, they often displace their anger onto nondeserving members of the health team. If it is unjustified, simply accept it as an expression of their turmoil. What dangers, if any, are there in becoming too involved emotionally with feelings of terminal patients? If you have a good team approach where other members of your staff watch over you and with whom you can share your own feelings, there is very little danger in becoming too involved. If you are working full time and in solo practice with many dying patients, there is a risk that you will get too involved, and thus too drained emotionally and physically. No one should work exclusively with dying patients. It is not possible to do this on a full-time basis. Does one develop through experience an intuition that says, Yes, now he is talking about his death? While early results are promising, they also show that these young women are up against a host of formal and informal constraints and quite aptly respond to them. However skilled you might be, overcoming biased environments on your own--in the workplace and at home, in Zambia or the United States--is hard and risky. In the spring of 2014, the failed attempt of an academic at negotiating a tenure-track job offer made the news in the United States. After she had made a few demands, the college withdrew the offer. A New Yorker article commenting on the case was aptly entitled Lean Out: The Dangers for Women Who Negotiate.

In order for everyone to be able to lean in, we need to make it safer. And we can--by changing the constraints people face. Behavioral design focuses on changing these constraints. Clearly, this is a tall order in a complex environment such as the one the Zambian eighth-grade girls face. But we have had significant successes in the past. Machiavellians have a reduced theory of mind--the ability to understand why people think in individually unique ways. Although similar, theory of mind is different from cognitive empathy because it covers a broader range from goals to aspirations, desires, and information in a person's head. Whereas cognitive empathy is just about the changes in thinking and feeling from moment to moment. To manipulate others, Machiavellians need to have a significant understanding of the drive behind their victims' actions and behaviors. However, research shows that Machiavellianism negatively links with the theory of mind and social-cooperative skills. This suggests that even though they appear to be, Machiavellians may not be as great at understanding and manipulating others as they think. Thus, while Machiavellianism comprises a set of beliefs and values about deceiving others to get what you want, there is no guarantee for Machiavellians that their deception and manipulation will be successful. Psychologists believe that behavior is driven by two individual neurological systems that are separate from each other: the behavioral activation system and the behavioral inhibition system. This is based on Grey's reinforcement sensitivity theory. The behavioral activation system is linked with tendencies such as social behavior, extraversion, and action-taking. Do you sometimes misfire? Does the patient sometimes announce his own death prematurely, or is his intuition always accurate? I do not know if this is intuition that says, Yes, now he is talking about his death. I think if you can hear and listen to patients, you'll know when they are talking about their own impending death and will respond to it. Naturally, all of us misfire once in a while.

The patient occasionally is concerned about his own premature death when, in fact, he has a fairly good prognosis. It is important to make the differential diagnosis between a pathological fear of death, where the concern of one's death arises with every little symptom, and a message from the patient who is terminally ill and who senses that his days are counted. Rather than intuition, I would say that experience and the art of listening will help you to misfire less often. Should one try to get the patient and the patient's family on the same level, that is to say, at the same stage of dying? For example, anger, denial, acceptance? For example, women's willingness to invest in their education has been shown to be a response to changing constraints. When the Pill became available, more women started to pursue professional degrees and work more often outside the home. The introduction of infant formula had a similar effect on married women of child-bearing age. And better household technologies, from dishwashers to microwaves, have helped all women participate more. These technological innovations were neither low-hanging fruit nor behavioral interventions. But they move beyond self-help approaches, as Anne-Marie Slaughter refers to women's attempts at moving toward gender equality themselves in her illuminating article Unfinished Business, and illustrate the power of changing people's opportunity sets. Given an opportunity, many and perhaps most people will take it. Sometimes a nudge rather than a shove is all it takes. For example, while conditional cash transfer programs, typically paid out to households that commit to sending their children to school, have been successful in increasing children's school attendance, they are expensive and complicated to administer. Recent evidence from Morocco shows that similar and even bigger effects can be achieved with a much smaller investment. In comparison, the behavioral inhibition system is connected with tendencies such as withdrawn behavior, introversion, and thinking instead of taking action. This means that the behavioral activation system is about approach, while the behavioral inhibition system is about avoidance. According to the latest research on the dark triad, psychopathy and narcissism are linked to greater activity levels in the behavioral activation system. In comparison, Machiavellianism is linked with higher levels of activity in the behavioral inhibition system. Therefore, narcissists and psychopaths are more likely to take action and socialize with others, so they engage in approach behaviors more.

Machiavellians, on the other hand, are more likely to avoid socializing with others. They depend on their thoughts and intuition more, so they engage in avoidant and withdrawn behavior. This correlates with the description of Machiavellians as cold, calculating manipulators who are always looking for ways to plot and exploit others, rather than proactively violating their humanity as psychopaths would. Machiavellianism is linked with alexithymia, which is the inability to recognize, label, and understand one's emotions properly. Alexithymic people tend to be cold, aloof, and detached from their emotional experiences. That is a utopic dream and I don't think this works. This is, again, projecting our own needs rather than accepting people wherever they are and being available when and if they are ready to move on to the next stage. How do you handle the Lazareth syndrome? I would rejoice with him. DENIAL AS A FIRST LINE OF DEFENSE How would you work with a patient who shows clinical evidence of cancer, but who refuses further diagnostic studies such as bronchoscopy or an exploratory operation for apparent cancer of the lung, or X rays to determine if the cancer is operable and/or likely to benefit from radiation treatment? A patient has the right to refuse treatment. I think you should level with him, you should tell him what you suspect, and you should give him the option, but it is up to him to reject it or to accept your offer. Why is it that many doctors still refuse to tell patients that they have terminal illnesses? Is this trend changing? What the researchers referred to as a labeled cash transfer was given to fathers not on the condition that their children attend school, but merely as part of an education support program. The sum was modest and could not be considered a meaningful incentive on its own. However, by explicitly tying the gift to the goal of education, the government was able to send a signal about the importance of education, make this salient to parents, and influence behavior. Redesigning the context in which women and men negotiate works in the same way. The labeled cash transfer equivalents to helping women negotiate more effectively are transparency, relational accounts, and negotiating on behalf of someone else.