Transcript

Luisa’s intro [00:00:00]

Luisa Rodriguez: Welcome to 80k After Hours. I’m Luisa Rodriguez — an imposter posing as a podcast host.

In this episode, I speak with therapist Hannah Boettcher.

Our goal was to get really concrete about the types of mental health issues people interested in effective altruism face, and the tools Hannah uses to address them in her therapy practice. Hannah practises a lot of acceptance and commitment therapy, which focuses on accepting difficult thoughts and feelings rather than challenging them, and commits to acting in line with one’s values even when those internal experiences push you to act otherwise.

To really explore how Hannah helps her clients, we wanted to use loads of specific, real-world examples. But to protect her clients’ confidentiality, we primarily focused on issues I’ve struggled with myself as a result of my engagement with EA — which made for an unusually personal conversation that’s less like an interview and more like a therapy session. This format ended up being so unlike our 80,000 Hours Podcast episodes — and the conversation was so narrowly focused on mental health struggles in effective altruism in particular — that we decided it was a better fit for After Hours.

In this interview turned therapy session, Hannah and I discuss:

• The effectiveness of therapy, and tips for finding a therapist
• Moral demandingness
• Internal family systems-style therapy
• Motivation and burnout
• Exposure therapy
• Grappling with world problems and x-risk
• Perfectionism and imposter syndrome
• And the risk of over-intellectualising

Okay, here’s our conversation.

The interview begins [00:01:44]

Luisa Rodriguez: Hi, everyone, I’m here with Hannah. Hannah is a clinical psychologist who primarily works with people trying to do good with their careers. She did her undergraduate studies at Brown before getting her PhD at Boston University, where her doctoral research focused on transdiagnostic interventions for emotional disorders — which are treatments that can be used to help people struggling with tendencies that underlie a range of mental health symptoms.

Thanks for coming on the podcast, Hannah.

Hannah Boettcher: Thanks for having me.

Luisa Rodriguez: So we often interview people working directly on pressing global problems — things like global pandemics, AI safety, global health. But this interview we’re going to do a bit differently. So we’re not going to talk directly about global pressing problems; instead we’re going to talk about the mental health struggles that people trying to work on those pressing problems sometimes experience.

Before we go any further, though, as we were prepping for this episode, you flagged that it can be tricky to talk about mental health issues while practising as a clinical psychologist, because of course you don’t want to violate anyone’s privacy. So I basically wanted to be really explicit with our listeners about the workaround that we’ve planned: we’re going to make it very explicit from the beginning that we won’t talk about specific people you’ve worked with, and we’ll instead just use hypothetical people with concerns that are common in the people you work with, or common in people that you know are trying to do good with their careers. And if I have any relevant life experiences, we’ll sometimes use that as an example. Does that all sound right, Hannah?

Hannah Boettcher: Yeah, that sounds good. The thing I’d add here too is that I am going to give a tonne of advice, and my hope is that it will be useful to listeners. And at the same time, I recognise that everyone is working with their own experience. So my hope is that listeners will feel empowered to take what’s useful and leave the rest — and certainly listen to your experience and consult with your providers, if you have them, for personalised advice.

Luisa Rodriguez: Yeah, great addition.

The effectiveness of therapy [00:03:48]

Luisa Rodriguez: What do we know about the effectiveness of therapy?

Hannah Boettcher: So broadly speaking, we have known for a long time, and it’s not controversial, that psychotherapy is efficacious and effective — so under control settings and less controlled settings. And in meta-analytic evidence, the effect size of psychotherapy is approximately 0.8 in comparison to no treatment — and that’s conventionally considered a large effect size. Another way to say this would be that in comparison to not getting therapy, getting therapy explains 14%ish of the outcomes in randomised controlled trials.

Luisa Rodriguez: And how does it compare to other interventions that might help people with their mental health?

Hannah Boettcher: I actually don’t have factoids on hand here, but I can say 14% might not sound great, depending on what your priors are, but this is actually really good for healthcare: it’s on par with or better than effects of medications, both psychiatric and medically, and it’s superior to plenty of medical interventions that are considered effective.

Luisa Rodriguez: Worthwhile. OK, yeah, that is helpful. I don’t think I had a very strong reaction to 14% either way. What do we know about how effective different types of therapy are? Are those compared in studies?

Hannah Boettcher: Yes, these are definitely compared head to head. And something that’s really interesting here is that specific treatment ingredients or therapeutic “modalities” are actually not strong predictors of better outcomes in psychotherapy.

Luisa Rodriguez: Right, this is a thing I’ve actually heard before, and it basically totally blew my mind. I don’t know where I got it, but I just really strongly had the impression that CBT, for example, was like a much more evidence-backed therapeutic approach than some others. So is it that any kind of therapy is just equally good, or is it that there are other things that explain variation in how helpful people find therapy?

Hannah Boettcher: Well, you’re definitely not alone in having that impression. Academic psychology and practicing clinicians don’t do a great job of communicating this idea that different modalities don’t predict better outcomes. And CBT is an example where there happens to be a tremendous literature on CBT being efficacious, but that’s not the same thing as saying that it’s better than all other modalities.

So what’s going on here is that there are other factors that contribute more to outcome, basically, and they don’t seem tethered to exactly what modality is being done.

Luisa Rodriguez: Yeah. That’s wild. Can you say what those other factors are?

Hannah Boettcher: Yeah. Most of it is related to the therapeutic relationship. There’s the therapeutic alliance, which is like a sense of being collaborative and on the same team with your therapist. Empathy is huge here, a big predictor of outcome is the client perceiving their therapist as empathetic. Similarly, a sense of genuineness, trustworthiness, and engagement. And expectancy is really important too.

Luisa Rodriguez: What’s “expectancy” there?

Hannah Boettcher: So the client going in and thinking, “This has a chance of helping me,” and having a coherent story about how that might be the case.

Luisa Rodriguez: Right, OK. So it kind of sounds like: Do you like your therapist? Do you get on and trust them? Do they seem genuine and authentic to you? Do you feel like they care about you? And then do you think it could help you? Like, do you think it’s going to work?

Hannah Boettcher: And all of this cashes out in greater engagement and input and retention, where the client is sort of actively participating in their therapy.

Luisa Rodriguez: OK, that makes sense. So why is it then that therapists tend to focus on particular modalities? Like you with ACT, and others with psychodynamic or whatever?

Hannah Boettcher: So I’m totally guilty of acting like ACT is the best, or ACT and CBT are the best or something, despite knowing that modality is not magical. But that is because it’s actually useful for my “common factors” — these things like building therapeutic relationships and engaging clients: it’s actually useful if I’m able to convey what I genuinely believe about these modalities being a useful framework. So I can actually credibly claim that ACT is helpful, because I use it on myself. And that is better for getting client a clear sense of what it’s like to be in therapy with me, so they can actually know, and also it can increase expectancy if I’m able to convey a coherent and compelling story that’s basically a theory of change.

Luisa Rodriguez: That you just really believe in, where you can just authentically be like, “This is how this works. I really believe it works.”

Hannah Boettcher: Yeah, exactly. It’s almost like it’s useful for the common factors to act as if you believe that the modality is doing a lot of the work.

Luisa Rodriguez: Right, yeah, that’s a funny little twist. Just making sure I understand: it sounds like different therapists might find that different approaches resonate more with them, and maybe have helped them more, as individual people. And so you’ll lean into those because you believe in them, and because they suit you and match with your thinking style.

Hannah Boettcher: And it’s a description of what you’re offering. It’s what the client can expect to get.

Luisa Rodriguez: And so for that reason, different therapists will have different approaches, and that probably does feed into how well the therapy works. But it’s not directly because, at least as far as we know, a certain approach is much more effective than others, basically.

Hannah Boettcher: Yeah. And if this sounds surprising to listeners, we should flag a couple of reasons that it’s not quite as wild as it might seem. For one, the common factors research is only comparing “bona fide treatments”: interventions that are designed to be therapeutic and have a theory of change. It’s not like literally any old thing is an equivalent bet or something like that.

Luisa Rodriguez: OK. Taking a really extreme example, you could imagine a therapeutic technique where, like, if someone expresses a fear, you throw water at them to surprise them into being averse to expressing that fear or something. If you had a ridiculous treatment, that might not hold up, just because we’re calling it therapy.

Hannah Boettcher: Totally. That probably would not meet the definition of “bona fide treatment.” Although, amusingly enough, there have been cases where clinicians tried to design a neutral placebo condition that was absent therapeutic ingredients, and it actually was effective.

Luisa Rodriguez: No way!

Hannah Boettcher: Yes. And it became considered evidence-based.

Luisa Rodriguez: Do you know an example?

Hannah Boettcher: Yeah, so an example here is present-centred therapy, which was developed originally as a placebo for PTSD treatment. And forgive me if I’ve gotten these details a bit wrong, but it was something like: when the client talks about their trauma, just direct their attention back to the present — so we’re not doing exposure-based processing. And also, when they express trauma-related cognitions, don’t try to restructure them or do anything differently. So we’re not doing cognitive work and we’re not doing exposure — we’re just being with the client and bringing their attention back to the present.

And these were real therapists, though, so they presumably were offering some of the common factors of empathy and a sense of collaboration. And the client ideally felt seen, and they trusted the therapist. And yeah, it delivered good outcomes. So now PCT is evidence-based for PTSD.

Luisa Rodriguez: That is super interesting. I’d never heard that. Was there anything else that kind of makes this fact make more sense to you?

Hannah Boettcher: Yeah. So even on the common factors view, progress still happens via the client making changes. It’s not like we’re claiming that it doesn’t matter what happens as a result of therapy or something like that.

And it may even be the case that for a given client, there is a particular kind of change that needs to happen. So if somebody has a really clear-cut experience where avoidance is maintaining their anxiety, it’s probably true that they need to do something that looks topographically like exposure therapy. But they need not only see an exposure therapist, right? Some people might decide to confront their fears as a matter of self-compassion, or because they have restructured irrational automatic thoughts and decided that they’re not credible, or because they’ve done a values-based approach that didn’t deliberately teach exposure, but they realise that they wish to move in that direction. But in each of these worlds, the client goes and enters the situation and change is achieved. It’s just not all down to how that happens.

Luisa Rodriguez: Right. So to some extent some of the modalities are different frameworks, with some pretty common underlying suggested changes?

Hannah Boettcher: Yes.

Luisa Rodriguez: Cool. Yeah, I agree, that does make it make more sense.

Luisa Rodriguez: Hey listeners, Luisa here. If you’ve heard episode #149 of the 80,000 Hours podcast with Tim LeBon, you might remember Tim saying CBT is considered the therapeutic approach with the strongest evidence base. There’s no paradox here: it’s true that CBT has the most research evidence behind it, good theoretical models, and loads of great treatment programs are CBT-based. But to Hannah’s point, specific therapeutic ingredients don’t seem like the key factor that predicts treatment outcomes.)

Intrinsic vs instrumental framings of therapy [00:14:21]

Luisa Rodriguez: For someone interested in trying therapy themselves, what can they expect? What do you see as the goal?

Hannah Boettcher: Well, I think about the goal as increasing psychological flexibility: this sitting with internal experience and nonetheless choosing your response to the world based on your values. But more generally, I’d say the goal of therapy is building skills and insight in the service of personally meaningful change — and the client gets to decide what that is.

Luisa Rodriguez: OK, so the goal is to basically not totally get rid of their symptoms — or that might not be the terminal goal, though it might be nice if they went down — but a key goal from your perspective is to give people the option, the freedom to choose to behave differently by using these skills.

I know you see a lot of people trying to have as big an impact with their career as they can, and I imagine many of them come to you wanting therapy because they think maybe it’s holding them back from having a bigger impact. And so they’re coming to you to be like, “Help me get rid of these mental health issues so that I can do more good.” To what extent does that feel like a helpful or healthy motivation? As opposed to something like, “I’d like to come to therapy so that I can be more well, because my mental wellbeing is valuable”? I personally have just struggled with this.

Hannah Boettcher: Totally. So the first would be an instrumental framing and the latter would be an intrinsic framing. I do have thoughts here. I think that clients get to decide their reasons for getting therapy, and ultimately that is their purview. With that said, in my observation, taking an intrinsic approach to valuing mental health tends to work better — both as a matter of subjective wellbeing, and, poignantly enough, as a matter of achieving one’s ends — than taking a strictly instrumentalised approach to mental health.

And that’s because an instrumental approach carries some risks. One of the risks is: this sense of being chronically just barely OK, if you’re always allocating mental wellness units to impact or something like that. It’s also an incomplete definition of mental health in my view, which is like it’s only functioning and no subjective experience — and that just doesn’t feel like a full description of what it is to be “well.”

So I think that if people endorse purely instrumental reasons for working on mental health, they may nonetheless benefit from behaving as if they intrinsically value their mental health — because this sort of implicates some work that’s maybe not directly implicated by the instrumental view, but is actually useful. So things like self-compassion and rest and fun and levity, which are maybe a little bit harder to directly justify, but nonetheless create a flourishing being that both feels better and is more effective.

Luisa Rodriguez: Yeah, that makes sense. So even if you only want to improve your mental health so that you can do more good, your experience is that thinking about it as if you just want to improve your mental wellbeing broadly might yield better outcomes across the board. I’m trying to think if people will have objections to that. Do you think there are ever tradeoffs there?

Hannah Boettcher: Oh, absolutely, certainly. And I think that there’s a lot of work worth doing in finding a balanced amount of pure intrinsic wellbeing that serves your need for wellness and also can be levered to have higher impact. And if someone came to me and was like, “I reject this view and I want to take a purely instrumental approach,” I would say, “OK, I think that is risky, but let’s give it a try.” And if that works, amazing, and there’s no more to say about it — and then it’d be a question of workability.

Luisa Rodriguez: Yeah, that makes a lot of sense to me.

Tips for finding a therapist [00:18:45]

Luisa Rodriguez: So for anyone hearing this and thinking, “There are a bunch of skills I want to learn here; they might make my life better, and they might make me better able to try to address some of these pressing problems,” what should someone look for in a therapist?

Hannah Boettcher: Great question. Remembering that the common factors in therapy drive a lot of the outcomes, you definitely want to find someone with whom you feel like there’s a personal fit and where the approach is cogent and compelling to you.

So this is a matter of feeling it out in many cases. You want to feel for empathy, genuineness, and an ability to describe mental health in ways that you find compelling. Even though we’ve said that modality doesn’t matter on average, it may matter for you. So if you know something about how you model your mental health, you may want to find a therapist who models it similarly. So if you have a meditation practice, maybe a third wave or mindfulness-based therapy will be good for you; if you’re looking to make super concrete behavioural changes, maybe a behaviour therapist; and so forth.

An interesting thing here is that the therapist’s years of experience and training background doesn’t matter as much as people think, so don’t worry as much about that.

Luisa Rodriguez: Wow, that’s surprising.

Hannah Boettcher: I know. It’s rough for those of us who went to grad school. But if it matters to you — if you know, as a client, “I want my therapist to have an academic background” — then look for that. But again, this is all down to your own expectancy and engagement. And something for listeners to know is that most therapists offer free consultations, where you can just feel out your chemistry and hear about their approach. It’s typically like a 15- or 30-minute call, and you can do multiple of these: therapist shopping is commendable if it’s an option available to you.

Luisa Rodriguez: Do therapists sometimes expect for the potential client to be like, “That wasn’t that helpful,” or like, “The fit wasn’t there, and I actually think I might try to find someone else”? Because that, to me, would be super anxiety-inducing.

Hannah Boettcher: As the client? To give that feedback?

Luisa Rodriguez: Yeah, exactly. To be like, “Thanks for the consultation; I want to keep shopping around.” Is that common enough that therapists can handle it?

Hannah Boettcher: We can definitely handle it, for sure. And we also want it. Because we don’t want to be forcing someone to do therapy that they don’t find resonant — that’s painful and ineffective. I think most clients will typically say something that’s like, “I decided it’s not the right time to start therapy” or something.

But however you can, don’t start therapy with someone that you don’t feel is a good fit. Or if you find later that you’re not a good fit with your therapist, give them feedback. See if you two can find your way to a better dynamic. And if not, you can switch therapists. This is preferable on the therapist’s view, for sure.

Luisa Rodriguez: Right, OK. So the therapist will want that and support you, and they will not feel super offended?

Hannah Boettcher: 100% yes.

Luisa Rodriguez: Cool. I feel like that’s advice I needed early on. I got really lucky and really resonated with the first therapist I tried. But for people who don’t have that experience, it’s allowed and encouraged to keep shopping around. Is there any other advice you have on trying to get the most from therapy?

Hannah Boettcher: Yes. In addition to finding an approach that is a good fit for you, you definitely want to set goals and track progress in some way, so that you have a sense of where you’re going and whether you’re getting there. You can do this formally with outcome monitoring, so your therapist may give you questionnaires to fill out routinely. Or you can also do it informally, where you just name goals, qualitatively, and then ask, “How are we doing on these things?”

And if you’re ever sitting in therapy and you’re like, “I’m not sure what we’re trying to accomplish here,” you definitely want to bring that up — because there’s no reason that should ever be the case, that you feel confused about what’s the point of what you’re doing.

And then, more pragmatically, things that I find helpful would be setting an agenda at the top of every session. And taking notes, but sparingly: so just to remember important themes or certainly action items, but not so much that it takes you out of the discussion with your therapist. And assigning homework or between-session commitments, where you can try out whatever is being discussed — because 99% of your life is outside of therapy, and we do know that skills need to be practiced in the relevant context in order to root.

Luisa Rodriguez: I remember being super surprised when I started getting homework for therapy. “I thought I was just going to talk to you and you were going to solve my problems as we chatted.” But I’ve personally found that I love therapy homework. I know that’s probably not the case for everyone, but I was pleasantly surprised to realise that it was often really interesting exercises. And I got to learn about myself, and look forward to my therapy homework, which I didn’t expect. But good to know that it’s also helping me.

Hannah Boettcher: Yeah. And I think that’s the other thing I would say: give your therapist feedback. You may be your therapist’s main source of helpful feedback loops, and to the extent that you have useful constructive criticism or positive feedback for them, they would appreciate it — probably more than you realise — to hear that.

Luisa Rodriguez: What kinds of feedback loops do therapists even get?

Hannah Boettcher: Well, we get client feedback and we can get outcome tracking. But outcome monitoring does not feel actually super tight, because there are a tonne of contextual factors, obviously, in a client’s life, so it’s sort of hard to tell a really tight story about how effective I am as a therapist, just by looking at a bunch of graphs.

Luisa Rodriguez: Sorry, that’s graphs of, like, you get people to report on their symptoms and track them over time?

Hannah Boettcher: Yeah. Sorry, to be clear here, when I say “outcome monitoring,” I mean yes, exactly: that the client fills out surveys or questionnaires that are either symptom measures or like measures of cognitive flexibility — like “How much am I buying into my thoughts?” or something like that. And then you could look at those graphs over time.

Luisa Rodriguez: But also that’s hard, because maybe you lost your job in the middle of that and so you actually got more depressed. It’s really hard to tell the story of the therapist’s value add there.

Hannah Boettcher: And therapists aren’t immune to motivated reasoning, where we tell stories about how I did the best I could and it was good — and client feedback is the one thing that can kick us out of that, if you can directly let us know what’s been helpful and unhelpful.

Luisa Rodriguez: Right, yeah. Wow. I hadn’t thought about that before. I guess it’s just like the client and the therapist in the sessions, and really, that’s probably most of what you’ll get.

Hannah Boettcher: Well, some therapists have supervisors, even if they’re independently licenced, but I think it’s more common for that not to be the case. Almost everyone I know, myself included, does a lot of peer consultation and peer supervision. So that’s another source of feedback looping. But it requires the therapist to know what they are struggling with and need input on.

Luisa Rodriguez: OK, so you might go to your peers and be like, “I’ve got this person with really bad imposter syndrome. She runs this podcast and she’s a mess, and I don’t know how to help her…”

Hannah Boettcher: Would I ever say they’re a mess? Never. I would say, “Wow, this person is mightily suffering and quite stuck.”

Luisa Rodriguez: That does seem more helpful. But if you knew that you really struggled to help people with imposter syndrome, you have peers and you can be like, “Give me some advice. What should I do with that?”

Hannah Boettcher: Yeah, I have multiple. I have an ACT one and an EA one and a regular one. It’s actually wonderful to have a lot of contact with peers, especially when you’re in private practice.

Luisa Rodriguez: I didn’t realise that was a thing. Super cool.

Taking a transdiagnostic approach [00:27:12]

Luisa Rodriguez: So a thing in particular that you are excited about in your therapy practice is this idea of taking a transdiagnostic approach to therapy. Can you explain what that means?

Hannah Boettcher: Totally. So formally, the mental health system operates on a categorical medical model for classification and treatment, so diagnosis and treatment.

Luisa Rodriguez: So “categorical” being like, you’re either in a category or you’re not. So you’re either depressed or you’re not. Or you’re… I don’t know, what are the other ones?

Hannah Boettcher: Yeah, we have this huge book called the DSM, the Diagnostic and Statistical Manual, that’s like literally just hundreds of lists of symptoms. And it’s like, “OK, they say they’re anxious. Well, do they have difficult-to-control worry about more than one domain? Has it lasted for six months? Do they have at least three of these other…? OK, they have generalised anxiety disorder.”

And there are tonnes of advantages of a categorical approach: it’s good for communication between therapists and clients, and among clinicians; and some clients find it useful, like, “Hey, there’s a name for what this is, and other people have it too.” It is necessary for insurance reimbursement in most cases — so even if your difficulties don’t fall into a clear category, your therapist still has to assign something.

And with all that said, it is not a description of the territory: it’s not the case that mental health actually comes in really clean, separable categories. The actual truth is that people have lots of symptoms that can cut across different categories. Maybe they have a presentation that doesn’t fit cleanly into a category, and oftentimes meet criteria for more than one thing at once. And it’s a little misleading to say someone who is, let’s say, temperamentally super anxious and avoidant has like six different anxiety disorders, if it’s actually the case that they’re under the influence of a general process.

That’s where the transdiagnostic approach comes in, which is looking for and then intervening on the shared underlying processes that put a person at risk for and then maintain a variety of different mental health problems.

Luisa Rodriguez: To make that more concrete, what’s an example of one of those underlying processes?

Hannah Boettcher: Yeah, so having an aversive reaction to emotions: this is a factor that can vary across people, and the more you relate to emotions as sort of scary and unacceptable and dangerous and intolerable, the greater your risk for developing an emotional disorder. Likewise with avoidant coping: if you’re extremely prone to managing emotions with some kind of avoidance or suppression or control behaviour. Cognitive fusion could be another one: so do you habitually treat your thoughts as facts and immediately buy into them and obey them and whatnot?

And these can be treated with transdiagnostic skills. So like emotion acceptance is, of course, not only applicable to one diagnosis or another.

Luisa Rodriguez: Right, OK. I like that, partly because I currently am subclinical for depression and anxiety for the first time in many years, but I just really still want to go to therapy and keep developing skills to be less avoidant and get better at tolerating distress when I do feel it. And that’s one of maybe many reasons that people might find it helpful to treat processes rather than [individual conditions].

Hannah Boettcher: Exactly. Yeah, the line between mental wellbeing and mental ill-being kind of dissolves on this view, because we can just say what is going on, and by golly, it’s a version of something we all have to some degree. If it’s causing problems, let’s work on it.

Luisa Rodriguez: Cool. Well, that does seem really valuable. Is it increasingly common for therapists to think about it this way?

Hannah Boettcher: Yes. I actually think it’s quite common now. It used to be radical 15 or 20 years ago, but it’s how most therapists practice, at least implicitly, even if they don’t explicitly say that.

Luisa Rodriguez: Right, cool. Yeah, that just seems good. It’s a shame that insurance companies aren’t catching up yet.

Hannah Boettcher: I know.

Moral demandingness [00:31:29]

Luisa Rodriguez: Many of our listeners are pretty sympathetic to moral theories that say we ought to be trying to do basically as much good as we can with the resources we have — so our money and our time. And those views, taken to their logical extreme, end up being quite morally demanding. If you could be doing more good by donating more money, it’s hard to know when you can give yourself permission to stop, and where that line is.
And to be clear, moral demandingness isn’t itself a mental health issue, but it’s this descriptive thing that happens with certain moral philosophies that — in my experience, and I think in other people’s experiences — can take a toll on mental health, if you basically always worried that you could be doing more, maybe you should be doing more, and that there’s kind of no end to it.

I guess in my case, maybe making it a bit more concrete, I struggle a fair bit with guilt and shame about definitely not donating more, and then also not working more — where one of my biggest resources is my time, and I feel guilty that I don’t work harder.

A very acute decision that has been a source of anxiety for me for years is the decision of whether to have children. I just really, really want to have kids. I have forever, and I still feel really strongly about it. I actually probably feel more and more strongly about it. I just turned 29, and I’m just so, so excited about the idea. On the other hand, kids are really expensive, and they take loads of time. I probably will work less, and it just seems totally plausible that I’ll do maybe significantly less good if I choose to have kids.

Another twist is that I feel like there’s mixed evidence about the impact on your life of having kids. So I’m like, do I just want to have kids because of this weird biological thing? But actually it’s just going to be really hard and stressful and not make my life better? And then I’ll have all this guilt about not having a bigger impact for no reason.

So anyways, that’s pretty long winded. But I guess I wonder if this is a thing, maybe not this specific thing, but if this is a thing that comes up when you’re working with people on their mental health?

Hannah Boettcher: Yeah, absolutely. And it has this sort of shape where it sounds like a values question, but the natural prompt of, “OK, so what do you care about most? Just drive in that direction” doesn’t get us to a satisfactory place in cases where there are competing values, or potentially competing values, that all feel super important and meaningful.

I think there’s a couple of tools, though, that can help here as an alternative to just repeatedly demanding from ourselves that we choose the thing that matters most, or that we figure out what that thing is and then do it. There’s a few other approaches we can take.

Hannah Boettcher: You’re pointing at something that in ACT is called “workability,” which is the sort of pragmatic criterion for choosing actions. It’s basically saying, “Well, does it work?” — meaning: “If I use this strategy, will it get me the consequences I’m seeking without too many costs? Is it sustainable as an overall policy?”

It’s kind of like a reality check, and it’s meant as a counterweight to this exact dogmatism that we’re trying to not fall into. In a values-based framework — whether that’s like “doing the most good” morality stuff or ACT as an intervention — we don’t want to sort of have a blindered dogmatism in the way that we follow our values. Instead, we want to be able to be loose and hold things lightly and be heavily contextualised.

To sidestep out of a kind of rigid, dogmatic approach to values, instead of asking, “What ought I to do here?” as a matter of values, you can ask just on a pragmatic level, “What kind of consequences do I anticipate getting if I choose each of these things?” If you worked more, what do you think would happen? And just describe those worlds. Similarly, “If I just decided not to have kids and just called it a day, how would that turn out for me?” Do you have any insights on that?

Luisa Rodriguez: Yeah, it’s weird. It hit me pretty hard. I feel a pretty immediate sense of grief and loss, and some preliminary resentment — resentment that I think is toward the value of trying to do the most good. And I have some sense of liking that value less now, because it’s imposing too many costs on me, and I’m just like, “You’re too much. You’re too demanding.”

Hannah Boettcher: Yeah. Nice. So this is a place where it sounds like choosing, in an absolute sense, to put all of your energy behind one value runs the risk of leaving you feeling kind of alienated.

Luisa Rodriguez: “Alienated” is exactly the word, yeah. Alienated from the value. Spot on.

Hannah Boettcher: We can even step back from dogmatism about therapy skills. So even if we generally recognise that avoiding emotions can be problematic, or generally recognise that certain behaviours don’t work, there’s a level at which we can say, “Is some amount of emotion avoidance compatible with a rich and full life?” Definitely.

Multiplicity [00:37:39]

Hannah Boettcher: Actually, this makes me think of something else that’s maybe worth mentioning here, which is the idea of embracing multiplicity.

Luisa Rodriguez: OK, yeah. What does that mean?

Hannah Boettcher: So I’m not a therapist who specialises in multiplicity, and some therapists do. I don’t speak from formal expertise. But as a CBT therapist, I find that embracing multiplicity oftentimes is an assist to some CBT and ACT skills.

The idea here is that we can acknowledge that we do, in fact, care about more than one thing. And it does seem like we’re sort of, in trying to steward ourselves, steward quite a lot of different parts of ourselves. And instead of demanding that that not be true, by trying to impose a unitary moral theory, we could instead say, “Well, it looks like it is true. It does seem to be that I care about more than one thing.” And then directly engage with those aspects of yourself — usually in the form of a dialogue between parts or something of that nature. It can be a way of feeling less alienated and more integrated, even when you care about more than one thing.

Luisa Rodriguez: Yes. Right. This feels like it’s relating to this thing that I felt was amazingly depicted in Inside Out, the film.

Hannah Boettcher: Yes.

Luisa Rodriguez: Which was my first introduction to the theory that we’ve got parts of us that have different wants and different goals — and it doesn’t really work to just ignore some of them, which I think is what I wanted to be the case for a long time. I wanted it to be the case that I could just ignore the part of me that wanted kids and kind of advocate for the part of me that wanted to just do the most good that I possibly could. It doesn’t seem like my brain is just going to let me ignore one part of myself indefinitely — especially one that feels as strongly as this kids one does — and have that never come up and be angry and start demanding I listen to it.

Hannah Boettcher: Yeah. Right. In recognising that, and recognising that it’s not workable to tell a part of you to be quiet forever, you can even train in sort of the opposite of that: this motion of deliberately calling on parts of yourself to speak up. Just informally, we could say: “Luisa, what does the part of you that wants kids have to say about all of this?” Do you want to try a bit of perspective taking here?

Luisa Rodriguez: Let’s do it.

Hannah Boettcher: Nice. Actually, let’s start with the other part. Let’s hear from the part that’s like, “We shouldn’t want kids. Maybe we do, but we ought to not have them nonetheless, because that’ll reduce impact.” What does that part tend to think when you’re pondering this question?

Luisa Rodriguez: That part is like, “The stakes here are huge. You’re one person and you want one person’s worth of happiness through having kids, but I want to help make thousands or millions of people happier than they might be otherwise by working on these pressing problems with everything we’ve got. And I get it, you’re sad that you might not have kids, but yeah, that’s just not a strong enough reason. The overall calculus is just not in your favour here and we can’t justify it.”

Hannah Boettcher: Yeah. Do you notice any other reactions showing up as you articulate that voice?

Luisa Rodriguez: Yeah. It’s like the part of me that wants things, that wants happiness for myself is, like, really sad if we never get to do anything for ourselves. Definitely there’s a fear part that hears the way this impact-minded part is thinking about things, and it’s like, “That line of thinking never ends. Like, what’s your plan here? There will always be millions of people who could benefit from you doing another few hours of work.” I mean, that version is probably a bit strong, but…

Hannah Boettcher: But it’s saying, “Hold up, that’s not workable.”

Luisa Rodriguez: Yeah, that’s exactly what it’s doing.

Hannah Boettcher: Nice. One move to make here is to ask something like: Do you have any values that bear on how you would like to mediate among your parts? Like maybe meta values around self-stewardship? When you do meet a conflict like this, what’s the attitudinal stance you wish to take? Any thoughts there?

Luisa Rodriguez: It’s funny. There’s definitely a part of me that wants to be able to subjugate some of my parts entirely, that’s really demonised them. I don’t know. You could call it the selfish part. I could probably think of a more charitable name for it; I don’t know exactly what it’d be. It’s probably most akin to Joy in Inside Out, who wants me to be happy. Definitely part of me wants to be like, “Let’s get rid of her. She’s not helping us live out the values that we care most about.”

I don’t know. Can I get in touch with another part that’s more interested in having the parts be more collaborative? I think maybe there’s another part that’s interested in being realistic, and maybe really internalises this workability concept, and is basically like, “We’ve learned that we can’t totally banish that selfish joyful part. So we’re going to need to figure out how to work all together to make realistic decisions, given these competing needs.”

Hannah Boettcher: I imagine that “working all together” means you have to basically be able to credibly claim to Joy that you hear and respect her, and are actually going to take care of her.

Luisa Rodriguez: Right. And I don’t know that I currently can. Currently, I think I’m like, “I tolerate you, Joy, and I will give you just enough to appease you. Begrudgingly.”

Hannah Boettcher: Yeah. If you could get in touch with how you hope your relationship to this part might end up or evolve, any sense of that, even if the moral demandingness part protests here, how would you like to be talking to Joy if you evolved on this score?

Luisa Rodriguez: Yeah, probably with a lot of gratitude and appreciation. Just like, “Thank you so much for trying to help me live a joyful and meaningful life on this individual level. I do love feeling happy, and you are all about that. That’s really nice.”

Hannah Boettcher: Yeah. Nice. So clearly we’ve conclusively decided whether or not you’ll have kids, so I hope that was helpful.

Luisa Rodriguez: Yeah, thanks — that’s totally resolved! …What would it look like to conclusively resolve? I think some part of me knows that I’m going to, and would love to find more peace with that. Maybe it is actually engaging more with the moral demandingness part, being like, “I still really care about what you care about. We are still going to do our best, or do a lot, to do a lot of good. And also, you need to be a bit more realistic, because we apparently can’t live a joyless life.”

Hannah Boettcher: Yeah. Nice. I think that this really articulates the spirit of choosing under conditions of uncertainty or doubt or inner conflict: that we actually don’t aim for a complete absence of doubt or resistance or wishing it could be otherwise, but what we do aim for is willingness to nonetheless make a choice under these conditions. It sounds like it might be available for you to get to that level of willingness, even if no single one of your parts is 100% satisfied.

Luisa Rodriguez: Totally. Yes, that makes sense. I actually have totally had moral demandingness issues where I felt like I just couldn’t decide. And yeah, it does seem that realistically maybe the best you can do is get to a place where you can take action.

Veganism and capacity [00:46:50]

Luisa Rodriguez: Are there other examples of this that you’ve seen people struggle with?

Hannah Boettcher: Yeah, totally. One would be veganism or variations on plant-based diets. A lot of our listeners in the high-impact space feel super strongly about reducing the suffering of farmed animals. So the directional “ought” is, well, just don’t eat any animal products at all. And that trades off against things like convenience. And here I don’t mean that in a fluffy sense; I mean time and attention, as well as health for some people, or energy and physical wellbeing.

I think that this is a place where workability is essential. Because of how we get our food, it’s unworkable to always know exactly the origin of every constituent ingredient in a plant-based food or something like that. So at some point, if you don’t want to just stand in the grocery store googling where the sugar came from, you have to round off to “good enough.” And that can feel, I think, pretty ethically painful for people who take seriously this suffering — and nonetheless, it seems to be the only choice.

Luisa Rodriguez: Right, yeah. Right. What do you recommend for those people? Especially when there is no choice? It’s just accepting, I guess, that you will cause suffering?

Hannah Boettcher: Yeah. I mean, ouch. Even as you just said that, I had like a “No, I don’t want that” sort of reaction. That can’t be the best place to land.

I think we have to acknowledge that we are under conditions where in fact there is not a fully satisfactory choice available: we’re in a universe where tradeoffs exist, we have finite resources, we have multiple things we care about, and we have incomplete information. So we have to make guesses and take risks — and that hurts. So I think self-compassion and acceptance come in here, like, “Damn, I so am wishing this were not the case, and by golly, it looks like it still is.” And then I think that it’s a matter of recognising that we aren’t going to score 100% on any unitary definition of “rightness.” And then recognise that, “Well, I could just look at that and stall out forever, or I could make some moves.” And probably making moves is preferable to stalling out.

Luisa Rodriguez: Yeah, that totally sounds right. Are there any other common examples?

Hannah Boettcher: I think there’s kind of a shape of a thing here. This is a belief, actually, that I struggle with, that’s like: “If there is capacity left on the table, there has been a moral error.”

Luisa Rodriguez: Oh, man.

Hannah Boettcher: Yeah. That hits, right? I mean, it’s really quite a defensible position. The logic is like, “I do, in fact, wish to use resources for a purpose. Look, some unused ones: we should allocate them.”

Luisa Rodriguez: Yes. Concretely, I very much have this if it’s the end of a workday, and I have any more energy and I’m not totally spent, I could obviously do a bit more work. Or just money: like, if I have any savings, that feels wrong. And then what do we do?

Hannah Boettcher: Well, I think we have to get clear on two things that are true here alongside the very appealing philosophy proof.

One is that following that rule positions you to be in a constant state of just barely OK, right? Like, every time you get a unit of mental health from the wellness factory and you’re like, “Immediately distribute to impact!” then you’re basically almost empty, or like a little bit in the red all of the time. And that’s just very risky and costly. It’s obviously painful, but it’s also going to put you at risk for burnout and for needing to take longer breaks to basically recover and care for yourself.

It’s also, in my view, needlessly painful as a matter of subjective wellbeing, to be in a constant insufficiency state. Every time you have a sense of ease, if you’re rehearsing, “There’s been a moral error,” this is just a terrible way to live as a matter of your own internal experience.

Luisa Rodriguez: Totally, yeah.

Hannah Boettcher: This is a hard one though. It feels so compelling. And the thing I remind myself of is that that feeling of compellingness is simply an incomplete description of what’s true. It does feel really compelling to use 100% of my capacity, and I do really feel that urge to allocate capacity whenever it shows up. But if and when I ever do this — which I do occasionally try versions of it — I end up feeling the effects, and it is not preferable. It’s almost like I have to tell myself, “You’re not well calibrated on this. You think that you want zero slack and ease, but you want an amount.”

Luisa Rodriguez: Yeah, yeah. Greater than zero. Are you up for saying more about both cases where you found yourself trying to use 100% and then also how you know when you’re striking the wrong balance?

Hannah Boettcher: Yes. Nice. Cases where I try to use 100% could be like setting my schedule. I’m in solo practice, so I decide what hours I work, and how many clients I see, and how well I manage my time in session, and whether I give myself breaks between sessions. My clients will know I am not perfect at this, surprisingly.

Luisa Rodriguez: How dare you?

Hannah Boettcher: I know. So a question could be like: there seem to be a lot of effective altruists and people in the high-impact space who are very interested in a therapist who’s aligned with their values. I’m one of the few therapists who is. And this is the shape that it takes in other careers too, where you’re like, “No, really, I have this niche thing. I can contribute. I really ought to be doing it.”

But what I recognise is that at times when I’ve packed my schedule as full as the numbers allow, I end up being, I think, a less thoughtful therapist. I think there is a risk of resenting the work, which I very much do not want to do. I actually genuinely love therapy and being a therapist.

Luisa Rodriguez: Aw, that’s lovely.

Hannah Boettcher: Yeah, honestly, it’s the best. And it might be not the best if I was in a constant state of like, “Oh my goodness, I’m asking more of my brain that it really can’t give.”

Luisa Rodriguez: Totally.

Hannah Boettcher: So yeah, what’s the cost here? The cost is that I look at my calendar, and part of my mind is like, “You could do more. It kind of looks like you want to just have fun and chill.” And I kind of have to unhook from that thought, and just be like, “I see you. I see what you’re pointing at. You’re naming something that matters. And by the way, workability is also here.” So it’s an ongoing balance.

Luisa Rodriguez: Right, yeah. It’s a wonderful example. It’s also just very helpful to me, because I’m like, obviously you shouldn’t get as close to the line of too many clients, or whatever it is, such that you’re constantly… I think the image I have is kind of drowning, splashing around, keeping yourself just above water — that’s obviously not sustainable.

Hannah Boettcher: So obvious, right?

Luisa Rodriguez: It’s really obvious when you say it. It’s just in my case, that I need to be 100%.

Knowing your own ‘check engine’ lights [00:55:08]

Hannah Boettcher: So on your other question too, about how do you know? This is kind of a skill. I think about it as a matter of you have to know your own check engine lights, right? Like when is the system signalling that we’re going to be on empty soon?

Emotional lability is one: emotional ups and downs and fluctuations tend to be more frequent and a bigger amplitude when they’re depleted — at least in my case, and I think in a lot of people’s cases. So look for the cases where if you see a sweet commercial, you start crying, and then you’re just like, “Oh, yikes.”

And then I think a sense of physical rundownness, like getting more tired than usual or feeling kind of achy and unwell can sometimes be worsened by depletion.

Then also anhedonia.

Luisa Rodriguez: Can you define anhedonia?

Hannah Boettcher: Anhedonia is when you aren’t getting as much pleasure or interest or reward out of something that you otherwise expect would be bringing you reward. It’s a symptom of depression, but it can also just happen to any of us at any time. One of the conditions when it’s likely to show up is if you are burning out, or in an otherwise sort of painful, aversive relationship with something in your life.

So if I were to start not enjoying therapy, that would be a very bad sign. Well, it would be bad for my clients, and it would be an indicator that I might need a new relationship with therapy.

Luisa Rodriguez: Yeah, that’s just really helpful. I think it’s really easy for me to be dismissive of parts of me that are like, “This is too much.” My response is basically, “You just want to watch more TV,” or, “You’re just lazy; you don’t want to work that hard. That’s not a good reason to work less.” But having really concrete things to look out for.

Hannah Boettcher: I once read a blog post on laziness, and the take was that laziness doesn’t exist. The thing that we label as “laziness” actually reflects the system trying to meet a particular need. The claim is like, nobody actually has a value, and maybe this is wrong, but of just, in an absolute sense, of “get less of everything” or something. I do think there’s a real value in asking, “What is this thing that I’m calling laziness trying to compel me to do? And is this a need that I might want to take seriously?”

Luisa Rodriguez: Is it a need for rest? Is it a need for this thing called socialising that we kind of dismiss as frivolous, but actually we’ve spent hundreds of thousands of years being programmed to want? Yeah, laziness does not exist. Interesting. I do just kind of buy it, at least in my case. I want to do things. I want to do good. I want to do my job. I want to want to do my job. I want to also sometimes have leisure or hobbies that I like.

Hannah Boettcher: Or maybe you may, in fact, not always want that, but you may need it, right? Because you happen to be this embodied organism that requires rest.

Luisa Rodriguez: Yeah, that makes sense. I feel like it’s probably the case that there are a bunch of examples in other contexts where systems need slack: like businesses that have budgets where they have to build in 10% budget wiggle room so that they don’t overspend or something. I wonder if having those models or those examples closer to hand would help me be like, “This is like an established pattern in the world, where no one thinks that businesses can run at 100% capacity and never have issues. They all choose to do this thing called slack. And maybe we should just trust — including for-profits who want to maximise profit — that they are doing what’s best for the company or for the aim.”

Hannah Boettcher: Nice. Yeah, I think that is so true. It has a sort of similar function to looking at the example of a friend’s life or somebody else’s job to make it more vivid. It highlights that you can reconcile a unitary aim or a highly demanding moral theory with constraints. Moral theories don’t seem to look at constraints that much, and then all the application is where everything gets painful and complicated. But this example is exactly how they can fit together: you can price in constraints and do a constrained, yet better-than-nothing, attempt.

Luisa Rodriguez: Yes, right. Cool. Well, that I find helpful. I don’t know if others will, but maybe.

Do you have any thoughts on healthy — or maybe the better term is “workable” — ways to think about moral demandingness? For people who do put a lot of weight on these moral views but then struggle, like you said, with the application?

Hannah Boettcher: Yeah. I think it is recognising what a demanding moral theory can and can’t offer you, as a matter of how you have more than one job, in some sense — as the steward of your system or the agent that’s directing your body and whatnot. The moral theory is like a directional pointer toward one way that you might want to navigate. And as we’ve just gotten done saying: you’re embodied, you’re contextualised, you’re constrained. I think that the mistake we don’t want to make is thinking that once we have a good moral theory, there’s nothing else to see here and it’s just a matter of rigidly barreling in that direction. It’s recognising the kind of system that you are, and the kind of territory you’re in, and letting that be a starting set of assumptions — rather than spending a lot of time imagining or wishing that you were in a different world, or a different kind of being.

Luisa Rodriguez: Yeah, that sounds wise. It does feel like I had the experience of learning about a moral theory that resonated so much. I was like, “This: this feels like how I want to live my life.” But it was super tidy and clean and simple, and said very little about real life. It was just a very mathematical “doing lots of good is good.” That’s the core of it for me, I guess. Then there’s this frustrating thing that reality just makes it way more complicated. I guess people have to grapple with that and maybe grieve that a bit.

I’d actually love to talk more about self-compassion. I have to admit that I, for a long time, have just really bounced off the idea of self-compassion and off of compassion-focused therapy. It came up a number of times, and I kept being like, “No, I don’t want to do that.” My reaction to the idea of being more compassionate toward myself was like, that sounds like lowering my standards or letting myself off the hook or like some kind of over-the-top self-care that I don’t identify with. A little bit of like, “That sounds weak. I want to be strong.”

Hannah Boettcher: Yeah. That sounds like things I’ve heard inside my head and from clients before.

Luisa Rodriguez: OK, so it’s not just me. To some extent, I’ve made some progress on this. I don’t have those associations quite as strongly. But for listeners who do still have some of that, can you help us have a different framing?

Hannah Boettcher: Absolutely. The thing we’re aiming for is not “anything goes” or “my standards don’t matter.” The thing we’re aiming for is: No matter where I’ve set the standard, how can I show up for treating myself well and kindly and effectively along the way?

And let’s also be clear that self-compassion is actually useful. First of all, it’s justified. We’ve said this already: we are the sorts of creatures that suffer, and we suffer for reasons out of our control that we didn’t choose. In my view, that justifies compassion. But even separately from that, self-compassion works better than self-loathing and self-berating. When you’re in a constant state of self-criticism, this is kicking up additional suffering that you then have to metabolise. Whereas when you can relate as a matter of self-compassion, this actually enhances performance more than self-criticism does, and it makes for a better subjective experience.

Luisa Rodriguez: A better experience. Yeah, OK. That sounds totally right. Then I guess we’ve got to go all-in on self-compassion. Something more like: You are doing something super important, super brave, super valuable. Thank you for doing it.

Hannah Boettcher: Yes, yes. And you are materially creating a world where a lot of people are pushing toward impact, and that is worth being part of.

Luisa Rodriguez: That’s wonderful. Yeah. And it comes with pain probably for most people involved, probably for everyone involved, and that is hard, but thank you for doing hard things. Well, I guess it’ll be helpful for people to practice that kind of self-talk themselves. But on behalf of 80,000 Hours, for anyone struggling with this: Thank you. It can be really painful. Thank you for trying.

Perfectionism and imposter syndrome [01:05:32]

Luisa Rodriguez: OK, turning to another topic: Another common issue among people trying to do as much good as they can in their careers is perfectionism — in work or in academics. Have you found this to be common in your practice?

Hannah Boettcher: Yes.

Luisa Rodriguez: Is that like a “Yes, definitely”?

Hannah Boettcher: That’s a yes, definitely. I think it makes a lot of sense, in light of what we were just saying, of how natural it is to be drawn to compelling reasons around wanting to seek excellence and wanting to do good. This is an example of how an amount of this is adaptive and another amount is maladaptive. The thing we call “perfectionism” is when you lose track of the threshold at which it becomes no longer helpful, or you’re over-applying the helpful thing in places where it’s not a good fit.

Luisa Rodriguez: That makes sense. I’ve had the experience, and I think maybe others have the experience, of really, really believing that your perfectionism is helping you — and that to let go of it would be really bad. Do you mind saying more about how to know when perfectionist tendencies go from helpful to unhelpful?

Hannah Boettcher: I think one indicator would be if it’s causing you pain subjectively — like if you find yourself in a constant state of judging your work, or rehearsing basically some not-enoughness narrative, and that’s hurting you.

The other big reason would be if it’s costing you in ways that are greater than the benefit of the marginal perfecting. The sorts of costs I’m thinking of are around time and opportunity costs, and also particularly losing clarity on what does and doesn’t need to be perfected. An analogy here is frugality: if you find yourself overspending on a lot of things, and you’re like, “I need to make a change,” then the corrective is not “buy nothing going forward”; it’s about conserving your resources so that you can use money to purchase more value, and not use it when it doesn’t purchase more value.

I think perfectionism or optimising or things in this neighbourhood are the same, where we want to retain the option of judiciously applying the marginal rigour and precision and all the rest — when it is actually going to buy us more value. We have to discern when that is and isn’t the case, because otherwise we’ll run out of resources.

Luisa Rodriguez: Yes, that makes sense. The key thing here is to not stop trying to sometimes do things to really high standards, but be deliberate — “discerning” is the word you used, and I think that’s right — in figuring out which things to apply those high standards to. This is something I’ve struggled loads with. I do struggle less with it now, but definitely still struggle with it. How much improvement can people hope to get in this area if they were to work on it, either with a therapist or something else?

Hannah Boettcher: I don’t have a quantified sense here, but I think the answer is “noticeable.” It seems reasonable; I definitely have clients who would endorse, “I used to be super perfectionistic, and now I’m less so.” And that’s via essentially recognising the thing we just said: that it’s not workable to be uncritically perfectionistic in everything. The move is to become more discerning. To be clear, that can hurt: it actually has this cost of discomfort and feeling like you have to stop short of excellent in some cases. I think the recognition is that that discomfort is actually worth sitting with for the purpose of having a more workable approach.

I also think there are some cultural norms that are common in high-impact spaces that can amplify imposter syndrome a bit. So the sorts of questions that people are well-practiced asking about their projects — like: Where are the top problems? Which of these is neglected? How could we be doing better? If we’re doing things that aren’t a value add, we need to stop doing them — these sorts of questions that are useful for impact can easily start being applied to the self, where they pull for a deficit frame.

Then there’s also this sort of cultural norm or virtue around self-critique and humility. So if you’re complimented for your work, somebody in a high-impact space is probably going to be ready with an internal “Yeah, but…” Right? Because that’s a move that’s really well-practiced in these spaces.

Luisa Rodriguez: Totally. Just to dig in a bit more on a few of those things, some people are trying to do a lot of good, and some people are trying to do the most good they can — and in either case, maybe much more than is typical, we end up asking things like: Is what we’re doing good enough? Could we be doing more good? Do we have the right beliefs, or could we have the righter beliefs? Is this project that I’m working on going fine? How can I guess all the ways it could go wrong, so that it could go better?

And I guess it’s such an optimisation framing that ending up anywhere below optimal — which we don’t even know what optimal is, oftentimes, so it’s often pretty easy to tell a story where we are below optimal — then we’re setting ourselves up to feel inadequate, I guess.

Hannah Boettcher: Exactly.

Luisa Rodriguez: I think I both stand by the goal of trying to find ways to do better and to do more good. But how do you do that in a way that doesn’t also end up making you feel kind of chronically inadequate? Because you could always have done the project better or you could always be kind of reflecting more on your beliefs to make sure that you’ve got the right ideas about what the most pressing problems are or something.

Hannah Boettcher: I have a few thoughts on this. I think we are aiming for a place where we can decouple the scorecard from our worthiness. So it’s of course the case that in trying to optimise the good, we will always be falling short, right? The question is how much, and in what ways are we not there yet? And if we then extrapolate that to how much and in what ways am I not enough, that’s where we run into trouble. And I think that we miss the fundamental difference between performance and worthiness, and that we want to keep that difference vivid.

Exposure therapy [01:13:01]

Luisa Rodriguez: So what specifically does the work that helps people go from that extreme perfectionism to a bit more discerning?

Hannah Boettcher: There’s a couple of things that can help here. One is exposure therapy.

Luisa Rodriguez: Love exposure therapy. Do you mind describing it?

Hannah Boettcher: Exposure therapy is this classic, wonderful gift from traditional CBT that was originally developed for the treatment of phobic and fear-based conditions, like panic disorder, social anxiety, OCD, and so forth. The idea is that some of these anxiety and fear conditions are maintained by avoidance of the thing. So if you have a fear of flying, you definitely won’t overcome it by never flying.

On an exposure model, the idea is that if you deliberately and repeatedly get in touch with the fearful thing, you can learn that it’s survivable or tolerable. You can learn that your anxiety in that moment is itself survival and tolerable. And with time, this creates new learning: new non-fear or safety learning that inhibits the old fear associations.

Luisa Rodriguez: Right, OK. You basically have new experiences that are a bit better than you thought they might be, maybe much better than you thought they might be. And then your brain slowly learns to be like, “Actually, this thing doesn’t literally kill us. It might be scary still, but it’s better than we thought. We can probably do more of it.”

Hannah Boettcher: Yeah. I mean, this is “face your fears” just formalised, right? If you had a spider phobia, it’d be like: look at pictures of spiders, then look at a spider in a cage, then touch it, then let it crawl on you. And the cool thing about exposure is that it actually can work for other types of internal discomfort that aren’t a straightforward phobia — and that’s why it’s relevant to perfectionism.

Luisa Rodriguez: Yeah. How does it work?

Hannah Boettcher: Well, remember how I said in acceptance and commitment therapy, what we’re going for is an ability to coexist with internal experience and then act flexibly under those conditions? The way that the exposure model intersects with that is that if you can spend time in contact with a situation that creates internal discomfort, and practice feeling that discomfort — whatever that might be; whether that’s doubt, or a pull for perfectionism, or whatever — and then acting flexibly — in other words, not letting that discomfort pull you into basically avoidance moves — then you can learn essentially emotional self-efficacy. Just like the spider phobia person learned that spiders are tolerable, the perfectionist can learn that enoughness is tolerable.

Luisa Rodriguez: Right, right. Can you give an example?

Hannah Boettcher: Totally, yeah.

Luisa Rodriguez: Also, we can use me because I’ve still got loads of perfectionism going on.

Hannah Boettcher: Yeah. Why don’t you give an example of a time where you find yourself overusing perfectionism that’s not working for you?

Luisa Rodriguez: Yes, so many things. For me, perfectionism has always related to my imposter syndrome, where the idea is, “I’m a fraud and I don’t want anyone to find out. The best way for me to keep that hidden is by only letting people see my absolute best work. Maybe I’ll downplay how much time I spent on something so they don’t know that I literally thought about everything I could before sharing it with them.”

So there are a bunch of recent examples, but one was recently I needed to share a doc with a colleague. He was like, “Can you brainstorm some things for me?” — so probably meant for me to spend like 20 minutes. And instead I tried to think of every thought I could ever have about that topic, over like, five hours. And then I tried to edit all of the wording so it sounded really clever, and basically criticised everything about it as much as I could, then addressed those criticisms to basically make it as close to flawless as I could.

Hannah Boettcher: Yeah. It sounds like those mini behaviours that were part of the package here — the critiquing and the responding to critiques and whatnot — were serving this function of essentially reducing your anxiety about getting exposed.

Luisa Rodriguez: Yes, exactly.

Hannah Boettcher: Yeah, yeah. Nice example, because this actually hits on something that’s kind of crucial for making exposure go well, which is that the whole point is to engage with the tough thing without doing subtle avoidance moves.

Luisa Rodriguez: Oh, interesting.

Hannah Boettcher: Yeah. So with the spider example, if you go through the spider exhibit at the zoo, and you’re like, “Oh, I’m near the spider!” and you’re all crunched up and like looking through slits in your eyes, and you’re like, “I looked at it and it’s OK, as long as I know I can always run away,” then you’re essentially just entrenching this fearful relationship with it.

So if you are talking to yourself through the lens of like, “Yeah, I can brainstorm and send that back to him, as long as I spend four hours on it and identify literally everything and then fix it and make it perfect, and then I’m OK,” then that essentially doesn’t get you the cash value of the exposure — because you’ve just learned that you are OK conditional on a bunch of stuff that’s unworkable. We want to learn something more like “unconditional OK-ness” — not like truly, literally no conditions, but closer to that direction of, “I’m just going to be OK no matter what happens.”

And this is actually why we need another skill when we’re doing exposure, which is experiential acceptance. The mind is super threat-sensitive and great at threat management, and is always wanting to do these moves of like, get away from the scary thing, don’t feel discomfort — which itself is this proxy for threat — feel better, avoid, escape, and so forth. Experiential acceptance is like the antidote to that, as applied to internal experience: it’s about deliberately relating to your internal experience with an attitude of openness and curiosity, and willingness for whatever’s there to arise.

Luisa Rodriguez: That sounds really hard.

Hannah Boettcher: I know! It is very hard, and it’s exactly what’s needed to be able to engage with an exposure and not do these little mini avoidances, right? Because you essentially have to build this self-efficacy to feel the feeling of, “I really want to keep working on this doc, and this is super uncomfortable, and nonetheless I’m clicking ‘share.'”

Luisa Rodriguez: I have to share, right? Yeah. Cool. Can we make that even more concrete? I guess the idea here is with the doc, by spending way too much time on it and by preemptively guessing at what someone’s criticisms might be, I’m training my brain that if my colleague likes the doc, it’s plausibly only because I spent too much time on it.

Hannah Boettcher: Bingo.

Luisa Rodriguez: And I predicted the criticisms and addressed them in advance.

Hannah Boettcher: “And by the way, I totally would not have been able to handle the feeling of doing merely ‘good enough,’ so I definitely didn’t handle it.” Right? And you’ve learned nothing about your ability to sit with that.

Luisa Rodriguez: Totally. Totally. It’s like, “It would still be terrifying to do the actual brainstorm, and I’m probably still not competent enough without trying to be perfect to just share my thoughts with my colleague.”

So I literally have done things like, “OK, I’m not going to spend four hours and I’m not going to guess at all their criticisms.” But I share the doc with a bunch of caveats about how off-the-cuff this is — like, “If I spent 20 more minutes, I’d probably think of a bunch more things” — as a way to protect myself from having a person just see the actual work that they asked for, and maybe have that not be enough. And then I have this condition where it’s OK to just brainstorm, but it’s only OK if I caveat — which isn’t the full exposure.

Hannah Boettcher: That is preferable to the four-hour thing, for sure. Many of us do little mini avoidances of emotional discomfort all the time, and we’re not here to exterminate all of that, but you’re correct to functionally recognise that that has the effect of essentially training a slightly less useful lesson than the full version of, “I literally just brainstormed and sent it.”

Luisa Rodriguez: Right. Yeah, I guess maybe something like I don’t spend four hours, but I still spend two, that is still kind of protective and it’s costing me several hours. It’s an improvement, but keeps that conditionality in your head. And so then you have to just do the doc sharing? And then how do you do this experiential acceptance thing?

Hannah Boettcher: So yeah, behaviourally, you do basically the version of: “If Luisa were unencumbered by perfectionism and imposter syndrome, yet nonetheless did sincerely care about doing a good job, and was well calibrated on how much effort is reasonable to spend on various things, how much time would she take?” And then you would do the doc in that time and send it, behaviourally.

Internally, you’d be having to sit with a lot of uncomfortable thoughts and feelings, such as the one you just voiced. You can train the attitude of experiential acceptance meditatively — where you are in a formal seated session, looking in at emotional discomfort and greeting it and welcoming it with curiosity and openness.

You can also coach yourself in this attitude a little bit more informally. I do this for myself. Let’s say that I’m responding to an email that feels aversive. I might say, “OK, I’m noticing an urge to reread this thing again. Yes, I hear that. My mind is saying this thing about this could be really stressful depending on how they respond.” And that’s defusion*, by the way: I’m calling out “Here’s a thought,” and then there’s this attitude of like, “I can be with this” — so welcoming the feelings, like, “There’s room enough for this.” If it were meditative, it would be like, “Breathe into this, let this feeling be next to me.”

• Cognitive defusion refers to one way of relating to thoughts: it’s a mindful, stepped-back stance where you recognize that a thought is merely a habit of mind, that may or may not be true and wise, and may or may not be a good guide for your attention and energy. Then, you choose what to do in the presence of the thought, without trying to change it. This is different from traditional CBT, where the emphasis is on disputing thoughts whose content is irrational.

Hannah Boettcher: You can also ask, is there anything useful to extract from this feeling? Certainly we’re not here to just say there’s no information here, but the overall spirit is to coexist with what’s here, and don’t resist it — don’t try to get it to go away as a condition for sending the doc. It’s this duality of like, “I can have this discomfort in my backpack as I walk towards the thing.”

Luisa Rodriguez: Yeah. I’m just trying to really put myself in this moment, where I’ve done a quick brainstorm. I’m sharing it with my colleague. I just hate that they’re going to see my 20 minute brainstorm. Yeah. It makes me feel sick. It makes me feel anxious.

Hannah Boettcher: Oh, nice. Go to the embodied piece. This is actually part of experiential acceptance: contact with the raw felt experience. If you were to imagine this in your physical body, what are you imagining? What shape does it have? What properties does it have?

Luisa Rodriguez: I mean, I definitely feel sick. I want to flinch. I have a very strong impulse to distract myself — so maybe I press enter on the send button or whatever, but I might then not be able to do work for a bit because I’m so distressed about it. I might have to go do something more consuming to get distracted from the bad feeling. That’s really common for me.

Hannah Boettcher: Yeah. Super good catch there. Because if you hit send and then immediately go to Twitter or something, essentially you’ve lost some of the value of the acceptance practice, and potentially taught yourself an unhelpful lesson, which is, “I can do things as long as I get away from it immediately afterwards.” And that’s not necessarily workable.

Plus, it undersells you on a self-efficacy basis: we ultimately are trying to build trust with ourselves about being able to be in proximity to hard feelings and nonetheless choose what our next move is. I suppose if what you really wanted to do was go to Twitter after this — if that was values-aligned — then that would be no problem. But my guess is that you have other uses of your time that would arguably be more values-aligned.

Luisa Rodriguez: Yeah. I mean, probably I’d let myself off the hook if it was five minutes, but in practice, these things tend to be more like an hour. It’s like I lose an hour to an hour and a half just anxiously avoiding the anxious thing I had to do. Sometimes it’s like the rest of a workday, and that’s really unhelpful, and super costly. How do you get better at tolerating the distress of it without running away?

Hannah Boettcher: It really is a lot of practice with this experiential acceptance attitude. It’s like saying, “Oh, hello again” to this feeling. “Back already? All right, welcome.” So noticing this tightness, this super strong urge to tab over to the news: “All right. Wow, this is physically painful. OK. I can be with this.” There’s oftentimes an affirmation component, like, “I can be with this” or “This is welcome” or “There’s room enough for this all.” And it’s a lot of that motion. As well as the behavioural pieces, too. You’ll presumably get some information after you share that brainstorm that could be useful.

Luisa Rodriguez: Right, yeah. And it might either be like, “This doc was great, thanks so much,” and then that’s a helpful retraining for my brain: that that kind of thing can go really well. Or it might not be that good. And then what do you…?

Hannah Boettcher: And then that’s a new opportunity, that yeah, you can look directly at that discomfort and welcome that in and say, “Well, by golly, one of the risks of being efficient is that we sometimes get this negative feedback, and can I be with that?”

We should be super clear here. We’re not advocating just suffering in principle or something; this is all in the service of making freer choices that are more guided by your values. So I do not encourage you to do exposure just for the sake of exposure.

Luisa Rodriguez: You don’t think it’s intrinsically valuable?

Hannah Boettcher: Maybe I could agree with an argument like that, but the one I’m making here is do it on the path to freedom, going in the directions you want to go.

Luisa Rodriguez: And so what happens over time if you practice this more? I’ve had the experience of getting positive feedback on things that I spent less time on, and that’s felt very reassuring. I have never really mastered this skill of not distracting myself from the pain of having to share something that might be embarrassing to me. What are you working toward?

Hannah Boettcher: So in many cases, you’ll notice some decrease in your distress. And actually, that used to be considered the metric of progress in exposure therapy: distress habituation. Literally, people would rate their subjective units of distress and we would graph it, and it would go down with repeated trials.

But with both new research and the more ACT-y framing of like, we’re not exactly trying to get rid of all painful feelings, that’s usually not thought of as the main target of exposure these days. I think about the point of exposure — and in fact do descriptively see this when people do these techniques — as increasing willingness: a willingness to be in contact with something uncomfortable, and nonetheless exercise free choice. So in this case, it would be a willingness to feel this doubt about what’s going to happen, and nonetheless choose where you’re going to put your eyeballs — and it doesn’t have to be something distracting.

Luisa Rodriguez: Yeah. OK, so more and more instances where I just share the doc with my colleague — and I know that it’s probably going to feel bad, but I know that I can do it anyways. And I also know that I can then get back to work afterward, even if it doesn’t feel very good.

Hannah Boettcher: When you distract yourself from emotional pain, your distress goes down when you engage in something distracting. So you’re sort of reinforcing an escape move, and you miss out on some other information that you would otherwise get, which is that uncomfortable emotions don’t stay high forever. And you want to be able to watch the natural lifecycle of emotion and recognise that it actually does remit naturally. You would, in all likelihood, start learning that.

It’s also really common to have a sense of empowerment here, right? Like, “Heck, yes, I did this thing!” The orientation is not that you’re being victimised by your feelings; it’s that you are building a capacity to be with a much wider range of internal experiences, which is just really cool.

Luisa Rodriguez: Yeah, I like that framing. That does feel very motivating to me. Cool. That’s really, really helpful. Hopefully other people find it helpful as well.

The risk of over-intellectualising [01:32:39]

Luisa Rodriguez: Yeah, I want to move right on to common issues. Are there any other mental health issues that we haven’t talked about yet that you think might be especially common among people trying to do lots of good with their careers?

Hannah Boettcher: Yeah, one that is potentially common because it kind of hides in plain sight is the risk of over-intellectualising. I think that’s particularly likely to come up if you’re someone who has a lot of intellectual strengths, and that does seem true of this community of people trying to do a lot of good in their careers. I think that once again, we’ve got something that’s useful in some contexts, or to some degree, and becomes less useful when it’s over-applied.

I guess a cost of over-intellectualising could be that it misses out on other types of information that’s nonetheless relevant to a choice. So like the example of you deciding whether to have kids: if you just consult the moral proof, you get one answer — but when we actually look at workability, it’s not the case that all the relevant information is intellectual. Some of it is emotional, right?

Luisa Rodriguez: Right, right. Yeah. Are there any other examples of this and what the costs can be?

Hannah Boettcher: Yeah, another might be spending more time than is actually useful trying to build a super-coherent intellectual model of something, when you could actually figure out a wise response without having a complete model.

So let’s say calculating the expected value of a marginal hour of sleep versus a marginal hour of work or something like that. That’s a little bit of a caricatured example, but you can imagine if someone’s very used to using their mind to do these super-quantified models, and that that’s actually powerful and necessary in other parts of their life, applying that to mental health might feel natural. In fact, it’s actually useful to be able to inhibit some of that if there’s a wise choice that’s available that doesn’t depend on that.

I guess another thing is that intellectualising might have an emotional avoidant function, depending on how it shows up. Let’s say that you’re dealing with some kind of anxiety or something like that, maybe like performance anxiety at work. You could have a reflection or discussion in therapy that’s all about, like, “What’s the logic of status concerns, and where does that come from in humans?” — and basically engage with it on a philosophical or intellectual level. And if that means that you’re not doing the work of just sitting with what it feels like to be socially anxious, you may be doing yourself a disservice to stay at this intellectual level.

So that’s the sort of thing that I would encourage listeners to just watch for in their own experience. I definitely catch myself in therapy staying on an intellectual level — because it’s comfortable, too, for me — and we all have to sort of just be mindful of that risk.

Luisa Rodriguez: What kinds of things might you try with someone who does this move of over-intellectualising things?

Hannah Boettcher: Well, I think it would mostly be recognising it together, and having a functional understanding of what are the costs and benefits of starting at that level. And then when it’s happening, catch it in flight, and be like, “This is that thing again. Do we want to consent ourselves to continue an intellectual discussion, or do we actually want to opt out and hit this at an experiential level?”

Maybe one more thing to say here is that a common mistake that I make, and see other people making, is acting as if having an intellectual understanding of a mental health issue is approximately most of the work, when it’s actually approximately none.

Luisa Rodriguez: That sounds familiar.

Hannah Boettcher: And I say this with affection, because therapists are more guilty than anyone of this very thing, because we have great intellectual understanding. But the mistake happens when you go, “I know what needs to happen,” and then there’s like an unsaid end of the sentence, that’s like “…so, end of story.” All of the value practically is in the experiential skills practice — actually training in the relevant attitudes and the relevant behaviours — and that just cannot be done except in a lived way. But this is just so common, and I think it’s something to deliberately watch out for.

Luisa Rodriguez: Yeah. I mean, I definitely regularly will be like, “I recognise the perfectionism here” or “I recognise that’s my imposter syndrome.” And then I’m like, “Man, I’m so good at mental health — I recognised it!” Sometimes I notice that I’m just describing and not changing the thing or experimenting with a different reaction; often I am just like, “I’m done. I noticed that I had a perfectionist tendency come up, and I’m wise now.”

Hannah Boettcher: Well, certainly give yourself well-deserved kudos. This is better than not noticing, and there’s yet more value on the table.

Luisa Rodriguez: Yes. That makes a bunch of sense.

Grappling with world problems and x-risk [01:38:06]

Luisa Rodriguez: A lot of our listeners report struggling with a mental health issue that’s not so much about their anxiety and self-perceptions, but more about their anxiety about the pressing problems that do really seem to exist in the world, and how wearing they are, how tragic they are. So things like really grappling with the fact that millions of people die every year from preventable diseases, and also things like there might be pandemics or advances in technology that really are catastrophic.

And it’s one thing to understand those things on an intellectual level, but a whole other thing to understand them on an emotional level. I think a lot of people on my team at 80,000 Hours right now are really struggling with fear about how quickly AI might come, and what the consequences of that might be. I guess to start, is that something that you’ve observed?

Hannah Boettcher: Yeah. A lot of my clients take existential risks extremely seriously and would agree that there’s an appreciable chance that we’ll face an existential catastrophe in our lifetimes. In my observation, this isn’t often the central reason bringing someone to therapy, at least not yet or not with me. I think there is a pretty natural tendency to compartmentalise here, which may actually be adaptive in some cases.

Luisa Rodriguez: Right. Interesting. So maybe it’s another one of those cases where the truth-seeking might lead you to think that these problems are extremely scary, but the more workable or realistic approach to holding them in your day-to-day life is not trying to keep that reality about these risks super salient?

Hannah Boettcher: I think it’s about positioning that reality in a way that it pushes in the directions you’re trying to go and doesn’t keep you stuck. There is a way in which contemplating existential dread or suffering or mortality can actually be psychologically helpful: it can be clarifying of values; it can be energising for taking action. I’m someone who thinks about death more than anybody I know in my personal life, and I still think I don’t think about it enough.

Luisa Rodriguez: Really? Oh, interesting. Can you say more about that?

Hannah Boettcher: Yeah. Well, in the sense that I think there’s a real sense of urgency that is available if you really try to get in contact with the facts about the conditions we’re in. And that urgency can be really animating and can motivate you to do things that matter, and to not do things that don’t matter. That said, we all have to understand our own contexts, and whether we are relating to existential dread to the degree that’s personally meaningful and useful, or too much or too little.

Luisa Rodriguez: Right. I guess if you go back to the fight, flight, and freeze responses, you might be so afraid of these existential risks that you want to fight really hard against them, and that could be motivating. Or you might be so afraid of them that you freeze, and you can’t work on them, or that you want to run away from thinking about these problems. Is part of the process figuring out what your responses are like and where you want to lean into?

Hannah Boettcher: Exactly. You can understand the feeling of dread as a pointer to something that matters, right? Whenever you’re hurting, ask what’s under threat. And here, what’s under threat is quite a lot.

So one way I think you can work helpfully with existential dread is to ask: How do I export this sense of urgency into actions that are available to me? So if you’re horrified at the suffering of nonhuman animals, or really aghast at the risk of AI, this could motivate you to do work in those areas or to encourage other people to take them seriously.

And then the wise discernment comes in around, at what point have we crossed into the area of no longer helpful? There are levels of existential dread that are just painful and not helpful, right? It’s actually not better for you to be in a chronic state of physiological arousal. And it’s also not better for you to merely be ruminating. So in those cases, I think there’s a role for a compatible, but different, skill: mindful compartmentalising. It’s kind of like the healthy version of thought suppression.

Luisa Rodriguez: Interesting. Right, OK. How does that work?

Hannah Boettcher: So this is helpful for any case in which your mind really wants to worry about something that is not action-relevant in all the moments it’s presenting. And that applies to a lot of things, including x-risk. So the move is not to never think about it, but to commit to looking at the thing in a way that is constructive and deliberate and protective. It’s as if you’re corralling all of the pointless rumination that’s just polluting your airwaves, and concentrating it into a dedicated block.

So you literally schedule time to sit down and look at the thing, and during that time, you can constructively problem solve. So you can actually work on the problem, or schedule actions that you can take in the future, or something like that. And if there’s nothing that can be done, you can just sit in compassion or seek social support during that time.

Luisa Rodriguez: Right. So are you literally booking calendar time?

Hannah Boettcher: Yeah. Literally, you call it “worry time.” You could put it on your calendar.

Luisa Rodriguez: OK, and the thing that you’re doing in that worry time is either something like, “I’m worried about this risk and there’s something I can do to help. So here’s my plan.” Maybe it all fits in this hour; maybe it doesn’t. Maybe it’s a project I can do at work, or maybe it’s applying for jobs to try to work on that problem. Maybe there’s not anything you can do about it, and then it’s time boxing the amount of time that you spend really feeling grief or whatever it is.

Hannah Boettcher: Exactly.

Luisa Rodriguez: Cool. That’s new to me.

Hannah Boettcher: Yeah. And then when it’s outside of your worry time, how do you relate to these thoughts, right?

Luisa Rodriguez: Right. Because they’ll still come up, surely.

Hannah Boettcher: Oh, absolutely. Yes. Thank you, Mind. Because the mind thinks maybe you forgot.

Luisa Rodriguez: “Did you forget that millions of people die all the time? Because it’s a really big deal.”

Hannah Boettcher: Yeah. No lie, even you just saying that, my mind just went, “Oh shit, you really need to put a calendar event so you remember later.” This is just really how this works.

So we can use defusion and some redirecting to the present in these cases. So if you’re out trying to have fun, and you recognise that suddenly the mind is talking about existential risk, this is a time where you could go, “Actually, I’m at this concert. So thanks, Mind. I recognise you want to make sure I don’t forget, and believe me, I haven’t forgotten. We will think about AI tomorrow during worry time. For now, I’m going to enjoy this song.”

Luisa Rodriguez: Right. Yeah. Nice. There’s nothing I can do about AI during the song. There’s just nothing I could do right now.

Evolutionary psychology [01:46:27]

Luisa Rodriguez: I wanted to talk a bit about how you think about mental health and wellbeing more broadly. Are there any theories that you think explain why humans struggle with mental health and wellbeing as much as we do?

Hannah Boettcher: Yes. There are many theories, and the ones I find most useful start with an acknowledgment that pain and difficulty is built in at the base layer. So the headline might be: The mind was not designed for wellbeing. In fact, the mind was designed for fitness, or the things that supported fitness, for most of human history — here I mean things like physical survival especially, but also things like social cohesion and dominating the environment.

And I’m not an evolutionary psychologist, so forgive me if my framing is a bit coarse here, but I do find it useful and resonant with how I think about clinical issues. A big example here is how the mind handles threat detection and threat management, which we are amazing at. So if you think about what made for a fit early human, it’s: always scanning the horizon so you see the next predator or enemy; always ready to run or hide or fight; a “better safe than sorry” policy — so if something’s ambiguous, the guy who uses caution survives more than the one who doesn’t. And certainly sensitivity to social threats — so rejection or status concerns. These are the sort of threat-sensitive minds we’re still walking around with.

Luisa Rodriguez: Yeah. I guess our brains spent a lot more time with a lot more threats — and had more incentives to play it safe — than it has in the world we live in now, where there aren’t that many things that really, really threaten us. There are probably really very few things that threaten our survival.

Hannah Boettcher: At least on a moment-to-moment basis.

Luisa Rodriguez: Right. And then probably also somewhat fewer things that threaten our reproductive fitness.

I’m always kind of surprised that social threats are as hot to my brain as they are. Maybe I just don’t know that much about historical societies. Is it the case that there was a risk of abandonment or being ostracised so much that we still now are just constantly… I mean, maybe it’s not everyone, but at least for me, someone with social anxiety, I feel surprised that that threat system is so sensitive to the social stuff.

Hannah Boettcher: I actually don’t know, as a matter of magnitude of risk historically. But I think something to flag here is we’re talking about processes that are automatic and rapid, and not mediated by an intellectual appraisal of threat. So you may logically understand that it’s OK for your physical integrity if people reject you, but that’s not how the machine works, right? So I think we’re oftentimes going to see this sort of gap between an intellectual level of understanding and a felt sense of threat.

Luisa Rodriguez: Yeah. Interesting. I like that you used a positive framing when opening this idea: the idea that we’re “amazing” at detecting threats. I tend to be like, “What is wrong with you, threat system? You’re overreacting.” And probably even that is not super helpful to it.

Hannah Boettcher: Yeah. Let’s talk more on this front, because I think that having a sort of adversarial relationship with a mind that’s not serving us can make us hurt more. And there really is a way to have some sort of humorous affection for this mind of ours, and recognise that it’s really trying so hard to serve us.

So speaking of things that are different on the logical-versus-felt level, you’ve probably noticed that one of the things your system does when you feel under social threat is mobilise your fight, flight, or freeze system. So your autonomic nervous system is coming online, being like, “Oh my god. We might have to do something.” And you’re essentially getting physically ready to face a threat as if it’s a predator on the savanna — so ready to run away, maybe freeze and stay out of view, or check out your next move, or maybe kill it.

This system reflects the basic orientation to threat that we now use all the time, which is “get away from the thing.” You can think of it kind of like an overactive smoke alarm. Your threat detection mind goes off for fire, it goes off for smoke, it goes off for things that maybe smell a little bit like smoke or kind of feel like they remind you of smoke.

Luisa Rodriguez: Yes. That definitely feels super true in my experience. And the oversensitive smoke alarm is a metaphor that I’ve used in my therapy before, and I found super helpful.

I just find it very confusing and surprising that it is best for my fitness to have as much fear and fight-or-flight instinct as I do. It feels like they kind of come out constantly, and they’re overwhelming, and they stop me from doing a bunch of things I care about. And maybe, again, we’ll get into being more grateful to that part of me at some point. But it just kind of surprises me that that’s all, I don’t know, optimal. Or not even just optimal, but that it even was selected for as much as it was.

But I guess it’s just really hard to really, really deeply understand and believe the extent to which our brains were moulded in an incredibly different environment, especially the part of the brain that’s doing the fight/flight response, which I guess is a very deep and old part. So maybe that’s part of what’s going on.

Hannah Boettcher: And recognising that, as a matter of fitness, wellness was just not that relevant.

Luisa Rodriguez: Right. Not selected for.

Hannah Boettcher: Exactly. Miserable creatures can do a lot on a fitness level. I think this is just deeply unintuitive, because we very naturally don’t want to be miserable. So in some sense, the confusion here is just a rearticulation of the original recognition, which is that there’s a difference between wellness and fitness.

Luisa Rodriguez: Right, yes. That actually does make it a bunch clearer, because all of these things — the fight, the flight — will be crude mechanisms and not perfect. The downsides of having them aren’t that big. Maybe beings are sadder and more scared, but that’s not going to kill them or prevent them from reproducing, except maybe in some extreme cases. So maybe some of the most extreme effects of these kinds of responses have been cut off, but not the moderate ones, where we’re just kind of low-level anxious all the time.

Hannah Boettcher: Yep. That sounds right.

Luisa Rodriguez: Cool. OK. Well, I guess that’s a bit sad to me. The fact that, as a default, our brains aren’t totally aligned with us and our desire to be well. But understanding that seems important. I don’t know. Do you have another framing for that that’s less sad?

Hannah Boettcher: Well, my framing does start with sadness and sort of bemusement, like, “Seriously, this was the setup?” But I think the place this can get to is compassion. We act as if we should be perfectly calibrated to our environments, and that not being so is some kind of failing. But when we recognise, like, man, the conditions we’re in, these are wild. And we’re running this machinery that kind of hurts all the time. Golly, we really deserve some kindness here.

Coping with unhelpful emotions [01:54:37]

Luisa Rodriguez: A related question I’ve wondered about. For a long time, I used to think of my emotions as much more grounded in “real or true things in the world” than I do now – kind of like physics. A bad thing happens, and then you feel sad as a result. How do you think about emotions — what they are, what they mean, and what they tell us?

Hannah Boettcher: The function of an emotion is to orient attention to the thing, to the stimulus, and then to organise and mobilise the appropriate response. So in the case of a positive emotion: let’s say you’re with somebody, and you feel a feeling of love. Maybe this motivates a response that’s like, “take care of this person; keep them around.”

And then in the case of an aversive emotion, like fear or disgust, the function is to get you to do those threat-management techniques that the mind is great at — so avoid it, escape it, control it, suppress it. Spit out the poison-tasting food, or run away from the thing that might be dangerous, or don’t go any nearer to the edge of the cliff. And it’s this felt sense of unpleasantness that animates that machinery. But one effect of that is that internal discomfort becomes like a proxy for threat, and resolving internal discomfort becomes like a proxy target. So we end up in this regime where we’re trying in effect not to feel bad, and as we’ll talk about, this can kind of get us in trouble.

The claim here is not that your emotions are outdated from evolution, and you should just not update at all when you have an emotion or something. It’s more like an emotion is a pointer: it’s wise to investigate, but remember that what you find there may not be the thing that it suggests. So we can have appreciation for our emotions as that sort of directional pointer, and then wisely check out: Is this pointing to something I need to react to? — and make that decision as a matter of choice, rather than the smoke alarm goes off and you run from the building.

Luisa Rodriguez: Yeah. That makes a bunch of sense. I guess if they’re like pointers, that means that we have to find a way to use them usefully — or wisely, as you put it — but not take everything they point at at face value. So how do we figure out how to engage with them? How do we figure out when they’re pointing at something real, when they’re pointing at something unhelpful?

Hannah Boettcher: That’s a huge question with many answers. So some of this is a matter of trying things and learning by experience. Some of it’s a matter of understanding your own history and your own emotional calibration — so is my system really hair-triggered by this one particular thing? And a lot of this is even remembering that we have the option to choose how we respond. Some of the therapy skills are around keeping a sort of thoughtful, healthy scepticism type of distance from emotions. So we can ask questions like, “If I buy into this feeling, and do exactly what it’s suggesting, where is that going to take me? And is that a place I want to go?”

I do think there’s a role for trusting and appreciating our emotions, remembering that of course they are functioning for this purpose of taking care of us. And something pretty important here is that the threat-management techniques that work really well on predators on the savanna don’t actually work so well on internal experience. So we said that a felt sense of threat becomes like a proxy for threat — but when you try really hard to run the script “don’t feel bad inside,” that actually doesn’t work that well. And that’s for a couple of reasons.

For one, we don’t have direct control over internal experience, or all aspects of it. You can’t give directions to your nervous system. You can’t choose your next thought. You can’t suppress thoughts directly, at least not forever. And attempts to sort of brute force control over your nervous system can often backfire. So if you’re afraid of panic attacks, and you say “stay calm, no matter what,” or if you try to suppress a specific thought, the thought “don’t think of X” becomes a cue for X. So it’s not that workable to avoid internal experience the way you would avoid a threat.

And then if you do get into habits of avoiding feeling badly emotionally, these can actually teach you, in some sense, the wrong lessons. So let’s say you’re socially anxious, and somebody invites you to a party. And your smoke alarm goes off, and is like, “This is a potentially socially threatening situation. You should get ready to run.”

Luisa Rodriguez: “People aren’t going to like you.”

Hannah Boettcher: Yeah, people aren’t going to like you. This could be a threat. And if you then decline the invitation, you will be handsomely rewarded by a sense of relief immediately, and that is reinforcing that sense of “Phew, the anxiety went away.” But then if you learn this as a habitual coping strategy, you’re internalising this lesson that’s like, “I can’t be anxious at parties.” And meanwhile, you’ve haven’t acquired any skills for partygoing or tolerance for being at parties and being anxious.

Luisa Rodriguez: Right. And probably get further entrenched in the belief that you would suck at a party.

Hannah Boettcher: Yes. Because you get no disconfirmatory evidence.

Luisa Rodriguez: Are there other examples of ways our brain has kind of evolved to be or to at least seems unhelpful with regards to our mental health and wellbeing?

Hannah Boettcher: You’ll notice a pattern that the unhelpful stuff is a helpful process that’s overapplied or excessive. A couple more tendencies of the mind that fit that description: the mind is constantly telling stories; constantly modelling the world; constantly judging, categorising: “This thing’s good; this thing’s bad. There’s a potential obstacle. How would I get around it?” This is useful as a matter of navigation. It also can condition some emotional responses, because the mind’s perception of what’s going on can itself be wrapped into this threat-detection or threat-management machine.

And we are creatures that learn by association — which is great and useful and efficient — and that’s a reason that internal representations of threat, or things that have been associated with threat in the past, can take on sort of a conditioned aversiveness because of that association. So this applies to things like smells and places and words, and it applies to imagining. Let’s say you imagine you’re going to fail, or you tell yourself “I’m worthless”: this feels like an encounter with failure or worthlessness. And language and the mind’s tendencies to model everything all the time just supercharges all of that, so we’re walking around sort of swimming in painful associations.

And then zoom out and recognise the landscape that we’re in too. So here’s a feature of the world that makes everything more difficult: you’ve noticed, on the map of life, the stuff of flourishing tends to be located right with the stuff of pain. So loving relationships require vulnerability; trying to achieve something that matters requires being in proximity to disappointment and risk and uncertainty. And this connection between values and pain is pretty fixed; there aren’t really paths we can find that reliably get us the good stuff and minimise risk of the painful stuff. Plus, there’s chaos and tragedy everywhere, and we can’t control it.

So this means that even the wisest and luckiest among us are going to be bumping into pain everywhere we go, especially if we’re trying to navigate towards something that matters. So we’re walking around with these threat-sensitive, judgemental minds. We’re running a program that’s like, “Try not to hurt.” It’s a pretty absurd state of affairs. And it leads to this bottom line, which is that psychological suffering isn’t an aberration; on the default settings, it’s the default outcome.

Luisa Rodriguez: Right. Yeah. And again, I’m needing to remind myself that it’s important to respond to that with compassion, rather than what I initially feel, which is frustration, anger, disappointment. I guess probably just all of those things are allowed.

And then, again, as we mentioned earlier, this does all get trickier in a context where we’re talking about spending your careers on trying to address really, really important global problems. So to the extent that the thing you’re saying is true — when we get close to things we value, we’re more likely to hit up on pain — we might expect this effort we’re all trying to collaborate on to be hard. And that seems to be true.

Eternal recurrence [02:04:32]

Luisa Rodriguez: So, to wrap up, a final question: Do you have a favourite thought experiment?

Hannah Boettcher: I do have one, actually, that is a good fit for this conversation because it’s kind of like a values clarification tool: Nietzsche’s formulation of eternal recurrence. Philosophers forgive me; this is how I remember it. It’s basically like: If a demon came to you and was like, “Your life is going to repeat in the exact same way that you live it over and over again forever,” would that be a good or a bad thing? Maybe the idea is that you should seek to live in such a way that that would be a good thing.

But the way that I use it on myself is to ask, “How does this action score on eternal recurrence? Would I still endorse doing this if I had to relive it forever?” And it’s not a perfect thought experiment — there’s maybe some important, painful things that you wouldn’t wish to relive but nonetheless are justified or something — but man, it totally makes it more vivid. And it’s helpful for me kicking out of doing mindless things that aren’t really serving me — because just in the starkness of infinity, it’s so much easier to see that.

Luisa Rodriguez: Yes, you’re absolutely right. Is the original thought experiment used in the context of people trying to figure out how to live their lives?

Hannah Boettcher: I have no idea. I’m sorry.

Luisa Rodriguez: No worries. Totally fine. Just curious. It’s a thought experiment I’ve never heard of.

Hannah Boettcher: I actually don’t even think it’s a thought experiment, by the way. It wasn’t designed as such. But yeah, go ask the many people you know who have professional philosophy degrees.

Luisa Rodriguez: “What’s going on here? Why do people think about this?” Cool. Well, that is all the time we have. Thank you so much for coming on the show, Hannah. It’s been such a pleasure.

Hannah Boettcher: Oh yeah. Thank you so much for having me. This has been a lot of fun.

Luisa’s outro [02:06:43]

Luisa Rodriguez: If you’re interested in more practical mental health advice, you could check out episode #100 on the original feed, where my colleague Keiran interviews my other colleague Howie on having a successful career with depression, anxiety, and imposter syndrome, and episode (#149) where Rob interviews Tim LeBon on how altruistic perfectionism is self-defeating.

Alright. Audio mastering and technical editing by Dominic Armstrong and Ben Cordell.

Editing for this episode by a combination of Katy Moore, Keiran Harris, and myself.

Full transcripts and an extensive collection of links to learn more are available on our site and put together by Katy Moore.

Keiran Harris produces the show. Thanks for listening.