Dr. Daniel Knoepflmacher (Host): Hello, and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind.

As we record this episode, we're about six weeks away from the 2024 Presidential Election. When describing the race for president, journalists use words like historic, unprecedented, and high stakes. With two assassination attempts, 24-hour news outlets broadcasting every new outrage, and competing apocalyptic visions of what will happen if the other side wins, it's no wonder Americans feel stressed and divided.

While people on opposite sides of the political spectrum rarely see eye to eye these days, most would agree that the emotional temperature is high and uncertainty about our collective future is even higher. All of this has an impact on mental health in our country. A 2020 study from the Journal of Economics and Human Biology used data from a national household survey that showed anxiety, depression, medication, prescriptions, and mental health care visits all increased in the months leading up to the last presidential election. This is only one example of research that provides data for something we already know because we feel it whenever we turn on the TV or talk about the news with our friends and loved ones.

So, on this special election year episode of the podcast, we'll examine the psychological and social impact of contemporary American politics and share some basic strategies for weathering the stormy news cycles in the weeks and months ahead. Fortunately, I have the perfect person to discuss all of this with me today, Dr. Richard Friedman. Who could be better suited to discuss mental health and national politics than an esteemed professor of Psychiatry here at Weill Cornell, who also happens to be an established writer for the Atlantic and other major magazines and newspapers?

Richard, you were the first guest to come on this podcast, and I'm really grateful to have this opportunity to have you back again. So, thank you so much for joining me today.

Dr. Richard Friedman: Daniel, it's my pleasure to be with you, as always.

Dr. Daniel Knoepflmacher: Well, I want to begin. I want to start by asking you about the whole premise of our discussion of electoral politics and mental health. I hope you think this premise is valid because otherwise we're going to have a very short episode. So, Richard, do you think contemporary American politics is negatively impacting mental health in our country?

Dr. Richard Friedman: I don't think there's a doubt about it. And this is always said about this kind of observation, that these are anecdotal observations. But there's no question that the emotional temperature of the country in anticipating the outcome of this election is so high. We're so riven with such political polarization in the country that instead of disagreeing with one another, we demonize one another. And depending upon which political group you're in, you see the other as an enemy not just as a fellow citizen or a fellow human being, but somebody who's actually bad, who has views and beliefs that are different from your own. So yes, I would say that in this environment, there's no question that the polarization is having a negative impact on overall well-being, emotional, psychiatric well-being.

Dr. Daniel Knoepflmacher: Well, I ask you this question because, while I believe that the increased attention that's being paid to mental health in this country, it's definitely an overall positive development for our society, I think it's led to destigmatization of mental illness. I think it gets more people seeking care that they need. That said, there have been concerns raised about how these trends in popular culture can lead to the pathologizing of normal human suffering. And elections are part of a cycle every four years. So tying this back to the election, where do you draw the line between people who are understandably upset about their side losing versus those who are struggling with clinically significant mental health problems?

Dr. Richard Friedman: So, I would say, when you make a distinction between everyday distress, which we all feel, unless you're not conscious. Looking at what's happening in the world and in the country, everybody feels some level of upset and distress versus distress that gets in the way of your ability to function to be effective in all the spheres of your life, your relationships, your work. That level of distress crosses the line from everyday distress, let's say, into clinical domain, whether you're talking about anxiety, you're talking about depression. And I think that the level of everyday distress is higher.

If you just look at what's going on on social media, whether it's YouTube or it's X, or it's TikTok, it's ablaze with misinformation, disinformation, passionate views that are highly emotionally charged. And if you look at cable news, it's the same thing. So everywhere you go, you find highly emotionally stimulating material related to politics, and there's no getting away from it.

Dr. Daniel Knoepflmacher: Well, I love how when you were saying that, I heard a siren in the background here in New York City. So, it was like entering the tension of New York City into your response. Following up on what you said, there is definitely going to be disappointment among a big portion of our electorate, no matter what the results are in November. But, really, I think an important part of elections is the uncertainty of them, because none of us know who will win. And uncertainty can lead to anxiety. So since 2016, looking and preparing for this episode, I saw that there's been several quantitative and qualitative studies that have linked increased stress and anxiety to the last few general elections. So, what do you think are the factors that have made these last three elections, and I'm including this one in 2024, what has made them more anxiety-provoking?

Dr. Richard Friedman: I think two main elements. One is an emotional one, and the other is a political one that causes terrible emotional distress. On the emotional side, I think what's happened is the hyperpartisan nature of politics, it's so accentuated in the country where people who are outside your political tribe are not just viewed as people with whom you have different points of view about policy, but are morally cast into a bad category. You're the enemy. The word enemy is used a lot as opposed to my fellow Republican, if I'm a Democrat, or my fellow Democrat, if I'm a Republican. No, it's the enemy. So, that is a term which is used by political leaders and their tribe, and you hear it over and over and over again. So, that raises the level of anxiety that people hear, because the language signals to people that this is a battle, like an apocalyptic battle and that the consequence of losing is an existential threat. Not just you lose some, you win some, but that this is an all-out battle for the existence of the country. Mistakes like that, it's easy to see that people would be extremely on edge because if they lose, some terrible thing may happen.

Dr. Daniel Knoepflmacher: Well, definitely this heightened sense of danger, I'm just trying to contextualize that because we have to acknowledge that fear is a really effective tool for motivating people to do things and especially voting in this case. And I think of that famous Daisy ad that the Johnson campaign used against Goldwater with this little girl plucking petals and then ending in this huge mushroom cloud. So, thinking that that was happening in the '60s, I imagine there's been other major apocalyptic seeming stressors at other points. Do you think that the apocalyptic language that campaigns are using today is making people even more anxious than whatever somebody in 1964 was thinking with the specter of nuclear annihilation?

Dr. Richard Friedman: Possibly, but I also think it's the behavior, the real life behavior, leaving nothing to the imagination, which has people legitimately concerned, because if you have politicians who will literally say publicly that they may or may not accept the results of an election you cast doubt about the very nature of the structure of government. And so if you're talking about uncertainty, if you tell people in a democracy that It's not clear whether elections can be legitimate, you essentially undermine the trust that people have in the very process that they have to participate in. So, that adds to the sense of insecurity. And that's a real thing. That's not an imagined thing. So, to distinguish between always with our patients when they have anxieties, we say, "Well, that anxiety is exaggerated," and that's a hyperbolic belief. In this case, you're actually listening to real statements of political leaders, and so some anxiety is warranted and is realistic.

Dr. Daniel Knoepflmacher: That's a really great point, which I hadn't thought of, that the uncertainty comes even when Your side wins, because if the other side doesn't accept it, and many people storm the Capitol, who knows what certainty there is, even from a normal, peaceful transfer of power.

Dr. Richard Friedman: Yes, and you know, you pointed this out, Daniel, before that we've evolved to read uncertainty as not just an uncomfortable situation, but potentially a dangerous one, because if you don't know what's around the corner, it gives you great adaptive survival advantage to assume it might be bad. So, you prepare yourself when something is uncertain for something that might be unpleasant, whether you know, it's an election or you're waiting for a biopsy result or any number of things. But if you also are told by political leaders that no matter what happens, they may not accept the outcome, how can you not be anxious?

Dr. Daniel Knoepflmacher: Well, you talked about this threshold between distress about the election versus psychiatric illness that could be diagnosed and perhaps addressed with treatment. And someone's distress might fall below or above that threshold. I'm wondering, what groups would you say are more at risk for anxiety or depression during this election season?

Dr. Richard Friedman: I would say you're dealing with a stressor that we all are feeling, but if you happen to have a known history of, depression, or an anxiety disorder, like generalized anxiety, or you have social anxiety disorder, you have panic attacks, or obsessive compulsive disorder, you're much more likely to be set off by a social stress, like an election, and a highly polarized environment, and I think we're seeing this. I certainly see this in patients who I work with, very, very frightened and upset and for all the reasons that we were talking about, but even more so because at baseline, they experience the world as an anxiety-provoking place, even when it may not be. Imagine how they feel when it is.

Dr. Daniel Knoepflmacher: I've seen it in my practice as well. And one other or two other categories that come to mind, and I'd like to hear your thoughts on this, is I've seen it where there have been people who have undergone some sort of trauma that let's say they were refugees from another society where there was political upheaval and they're here and something about this rhetoric and election is particularly distressing for them.

Another, which makes sense, and I've actually seen some research about this with, I think, the 2016 election and members of the LGBTQ+ community, that there was heightened anxiety among groups that are marginalized by the rhetoric of a campaign. And certainly, we're seeing that right now with Springfield, Ohio, where there's a specific targeting of a population. And there's no doubt that people are going to feel additional stress and anxiety as a result of that. So, I'm curious to hear your thoughts on that.

Dr. Richard Friedman: I'm glad that you brought that up because I think that target populations that are marginalized and disfavored at any one moment by political figures, whether they're immigrants in the case of Haitian immigrants in this cycle, or whether we're talking about other groups that are discriminated against people of color, LGBTQ, populations at various times, you know, the focus and the vitriol and political dialogue will turn to them. And so, they've been sensitized already by prior treatment. And as you said, if you have a history of trauma, you're much more likely to be sensitive to environments like a political election that's hyperpolarized and find it very anxiety-provoking.

Dr. Daniel Knoepflmacher: Well, you've talked about the divisiveness and certainly, in my lifetime, I don't remember a period that has felt this polarized to me, but beyond how that might cause an individual anxiety based on the election, based on pre-existing psychiatric conditions. I'm wondering specifically how the divisiveness impacts people's mental health interpersonally.

Dr. Richard Friedman: I think that, generally, if people are aware that there's a lot of disagreement and passionate disagreement in the environment around them, the atmosphere itself is emotionally unsettling. It's like, you know, when you were growing up and your parents were arguing. If you have the general feeling of safety in your relationships with people, you can tolerate that. But what happened if you grew up in a household in which there was a lot of expressed emotion and not safety, either material safety or emotional safety? Being in an environment where people are shouting and saying bad things about one another can be extremely upsetting, especially if you come from an environment where you don't necessarily have to have been traumatized but are sensitized to discord.

Dr. Daniel Knoepflmacher: And also, in your workplace, I hear this about friendships where there is such a divide in political opinion and, frankly, view of reality in our collective society, that impacts people as well.

Dr. Richard Friedman: Yes. And this gets to what's right around the corner, I guess, in our discussion. What should we be thinking about or doing to help ourselves deal with this very fraught situation and maybe try to close the divide a little bit? when you were confronted with such vitriol and division publicly, such that it spills over into our everyday lives with strangers.

Dr. Daniel Knoepflmacher: Well, we will get to that very soon. But before we do, I want to ask you about another stressful aspect of our election season. And last election ended after the election with the storming of the Capitol on January 6th. This year, we've had two assassination attempts. Really, violence has increased in both the '20 and '24 electoral cycles, which of course is yet another anxiety-provoking element in contemporary American politics. How do you think political violence relates to the fear, the apocalyptic rhetoric and divisiveness that we've been discussing today.

Dr. Richard Friedman: So, there's a lot of research about this, and there's no question that violent rhetoric on the part of politicians has a kindling effect on behavior so that if you demonize your opponents where you make them seem less equal or less human, what you essentially do is you deprive them of the ability to take refuge in empathy, so that people will see them as less than equal and less than human, and it can even provide your followers with a moral rationale for harming them, because they are seen as dangerous. They're taking things away from you. They may change your life in ways that are undesirable. They may take your jobs away. They're a threat. So, it provides a context and a pretext for setting the stage for violent behavior towards groups that are targeted with speech, with inflammatory political speech.

Dr. Daniel Knoepflmacher: And I guess you couple that with the freedom to use guns and the availability of them, and it makes for risky situation in our culture.

Dr. Richard Friedman: Yes, it's a conflagration. We have more guns than we have people.

Dr. Daniel Knoepflmacher: Well, we've described many ways in which this election is distressing. I want to turn to what you brought up just a moment ago, which is what can we do about it? How can people help themselves and help others during these stressful times? So, I want to go through some of the specific areas we covered. And you talked about first that population that has preexisting anxiety disorders or history of depression or maybe stress reactions due to prior trauma. Can you talk about what can be done for people who have these diagnoses?

Dr. Richard Friedman: Sure. And I think that what I'm about to say holds for everybody, not just those with prior psychiatric problems, and that is titrating and limiting exposure to upsetting information, which means we have a certain amount of control over how much we take in. So, for example, friends of mine will spend an evening watching cable news and find that by the end of the evening, not surprisingly, they're highly upset and anxious.

Now, you could argue, did they really learn anything useful in the way of information? No, because one look at the newspaper or cable news in the morning and once at night is plenty to know what actually happened that day. The rest is commentary. And so if you hear something over and over and over again, the repetition is quite upsetting. So, that's gratuitous. And I always say, "Turn off the TV. Don't doom scroll. Stop looking at social media. Are you really finding new information?" The answer is no. Everybody will say it. And I've asked this question many times to patients, to friends. They say the same thing, "No, I'm not. But I can't resist looking at the polls five times a day." They're not done five times a day. So, it's essentially exposing yourself over and over and over again in a sense traumatizing yourself, with a small "t", to information that provides no new data. So, that's one thing. Limit exposure in a way that's useful. Now, if you're overstimulated, decrease the stimulation. You're not going to lose out.

Dr. Daniel Knoepflmacher: I am definitely guilty of getting sucked into that repetition, whether it's looking at the polls or the news, which is incredibly repetitive in each day. I want to turn to another group that we talked about earlier, and that's groups who are being targeted based on their identity by campaigns with dehumanizing or discriminatory rhetoric.

Dr. Richard Friedman: Yeah. Here I think the critical thing that would be really helpful is a sense of community. So that you take comfort and refuge in your social network, whatever that is. That would be the LGBTQ community. You spend time in the consolation of others. And social contact is critically important, not just with everyday distress, but, you know, general mental health. So, I think, finding people who understand you and care about you and spending time with them is critically important.

Dr. Daniel Knoepflmacher: I think that we're touching on a core theme here, which is community, social connection. And that's some of what's been eroded in all of this, both by demonization of certain groups, but also by the polarization. And I'm curious, thinking about that specifically for people, who have friends, colleagues, family on the opposite end of the ideological spectrum, this political divide becomes very personal. So, what advice do you have for people who are trying to navigate those potential conflicts?

Dr. Richard Friedman: So, I would say you can go one of two ways, and then I'll reveal my hand and say which one I would prefer. One is that you avoid discussing things if it's so hard to talk about it. You know, let's say you have family members who are on the opposite political spectrum than you, and it was a nice holiday dinner, and the last thing you want to do is discuss politics. That's one way you could avoid it. And if it's too hot a topic and there's no way to bridge the divide, maybe sometimes that's the best thing.

Or you could try another tact, which is what I would prefer, and I try it myself. And that is a kind of exercise in thinking, how do you talk to people who you know you disagree with, who you know are from the opposite tribe? How do you talk to people who believe very differently than you do? Well, it's a kind of exercise in empathy and I just want to stress at the outset it doesn't mean you have to agree with them. It doesn't mean you even have to like them. But it does mean that you have to first withhold your judgment and try to learn about how they think, meaning you have to be curious about them and understand, and ask them, "So, tell me all about how you came to this view about your life," and try to understand them. And it goes a long way, actually, in making people feel understood and heard. They may not agree with you either, but they're actually anticipating that you're going to tell them something like, "Oh, you must be a terrible person if you're voting for X, Y, or Z." Instead, you say, "So, explain to me what it is you like about this candidate. And what are they doing that will make your life better?" Just curiously, and you withhold judgment. It's in the back of your mind. You're aware that you're making judgment, that you disagree, you don't like this candidate, but your task here is like an anthropologist. Learn about them. How did they get there? How did they think about this? And don't give any judgment whatsoever.

Dr. Daniel Knoepflmacher: I've been thinking a lot about this because I think empathy is the answer and it's a professional requirement, I believe, in the work that we do. Yet it takes lots of practice and I train residents and there's a lot of challenging situations where people who are training to become psychiatrists need to think about what the other person is thinking, a theory of their mind, what we call mentalization and why certain behaviors or lashing out or other things. What's underlying that? And I've seen something written about certain empathy exercises that are similar to what you're describing. And one thing that they talk about is this idea of reflecting back what someone has said, which is something used in psychotherapy often. But letting somebody say their point of view and then reflecting it back to them to show that you understand what they're saying and where that's coming from. Is that part of this kind of exercise that you're describing?

Dr. Richard Friedman: Yes, it's critical because it allows them to see that you have heard them and that you're considering what they say. And it gives them the sense of courtesy and the feeling that you actually were trying hard to understand their situation. And they actually appreciate that. And you don't have to say I don't agree with you or I agree with you. You just have to allow them to feel understood. And they could say, "Oh, I can see what you like about this person." And you can follow up with other questions, and other hypotheticals. And so, I know you like this, but what about that? And what actually are you hoping that this candidate will do for you? And sometimes, depending upon how far things go, you can say, "I'm curious. Is there anything that you might learn about this candidate that might alter the way you think or feel about them in any of these areas or any of these topics that's down the road somewhere?" But yes, if you reflect back to them, "I hear you," "I understand," "I see, now I understand why this person is appealing to you."

Dr. Daniel Knoepflmacher: Using a curiosity in your approach. And I wanted to ask you, if you can, to talk a little bit about the neuroscience underlying this, because we tend to be tribal as animals, as human beings, and the path to that us-them thinking seems like it comes pretty easy quickly when our fear is activated. And I was looking at some MRI research about empathy. And man, empathy is a lot more complicated in terms of the interconnectivity in the brain that you have to activate in order to be empathic with another human being. So, could you speak a little bit about that?

Dr. Richard Friedman: So, there is lot of evidence that very early on in development, kids recognize members of their own group. And so, you would think, well, the capacity for tribal identification is hardwired, and it is. But what's really interesting is even though that that is true, it's socially constructed. So to give an example, if you grew up in New York City, you're a Yankees fan or a Mets fan. And that's true, we are tribal, and your friends who are in Boston are rooting for the Red Sox. However, when you move to Boston, and you're there long enough, guess what? You probably become a Red Sox fan. So, the tribal identifications are hardwired. The capacity for thinking about in group and out group.

What's really interesting is we're plastic as to the content, which tribe you happen to be on. It's like color war. One year, you're blue team. One year, you're the yellow team. But it's the team you find yourself on at this moment in time. And what's very hopeful about this is though the capacity for being a member of a group is hardwired. Membership itself is variable and subject to all kinds of social influence, so you can change this. And one of the ways to do it is to have personal contact with people who are outside your group, so it prevents you from seeing them as an exemplar, but you see them more as an individual instead of being like a gay person, "This is Sam, my friend, who happens to be gay." And so, one way to overcome, discrimination is to have personal contact with members of a group that are disfavored. Everybody knows this.

Dr. Daniel Knoepflmacher: And that makes sense, that cognitively you're taking on a much bigger load if you see somebody as a whole human being than a single identity factor.

Dr. Richard Friedman: Yes. I hear these stories over and over again, you know, where people who live in small towns, where received wisdom is they're not likely to be tolerant of members of an out group. And yet when people are friends and have close relationships with members of groups that are disfavored, they're quite protective and caring.

Dr. Daniel Knoepflmacher: Well, we'll have to think about a national empathy effort. But to stick to smaller things, thinking about individuals in Psychiatry, we talk about defenses, and we categorize these. And what these are, are ways that psychologically we're able to handle negative affect, negative stress that we have psychologically based on certain things. And I'm curious if you could speak about some defenses that people might be employing to get through a stressful election season.

Dr. Richard Friedman: So, they range, of course, from the defenses that we all use from avoidance to sheer denial, "No, I don't like that scenario and so it's not possible." You just simply flatly say, "No, it's just not going to happen" to a complete capitulation to fear and anxiety, which is a loss in some way of adaptive strategy, to what would be one of the two best, I think, strategies. One is sublimation where, you know, you take your anxiety and you take your distress and you use it in a way that helps you move forward. Like for example, you could decide, "You know what? I'm very upset about this situation. I'm getting politically involved and I'm going to volunteer and I'm going to throw myself into this, and do all the work I can for the side that I identify with." Great demonstration of sublimation, right? You take this affect, this anxiety and distress, and you transform it into action or another one is humor. You make fun of yourself in the situation. Humor is a wonderful high order defense that allows us to have a sense of context, even dark humor. Why do you think people love to listen to all these comedy shows? Because it makes this all bearable.

Dr. Daniel Knoepflmacher: I think humor has been a bigger part of this election cycle. And it's definitely an effective, what we call mature defense against stress and despair. And I think being funny is, as you said, is a way to create distance from some really uncomfortable truths, and put them in a box that's more tolerable.

But I want to ask you a little more about this because I'm wondering about a scenario, could argue that maybe we're in this scenario, but I won't go out on a limb to say that, a scenario where a politician's impact on our country could be grave. Can then the humor defense maybe be problematic? And what I mean by that is because fear can be highly motivating and, as you said, can lead to sublimation or other ways to go into action, is there a risk that turning real threats into laugh lines might make people less likely to mobilize for necessary change when it's needed?

Dr. Richard Friedman: I think the critical element to that question is if it stops them from action, if it helps them feel effective and not overwhelmed with affect, so they're more likely to act, then it's a great thing. But if instead they take refuge in their humor and they substitute that for effective action, it would be catastrophic. Laughing all the way to the apocalypse would not be a good thing. On the other hand, If you are so anxious and so distressed that you are basically lying in a puddle of inaction, we don't want that either. So, you want this balance. And humor, I think, can help achieve it.

Dr. Daniel Knoepflmacher: That's such a good point. This is not an all or nothing thing you can sublimate, and when you get tired and worn out, still feel better by laughing. So, it's a yes-and. These are not mutually exclusive. Well, I'm going to wrap things up and ask you one last question. What do you advise to help people who are supporting a candidate who then ends up losing this election?

Dr. Richard Friedman: What I would say is you may feel that the world is ending. You may have a sense of doom. You may have all these terrible feelings, and they may be warranted in some instances, especially the election that we're looking at. And I would say the most important thing in a moment like that is recognizing that things often, feel worse than they turn out to be. And never despair, and give in to doom, and seek the consolation of loved ones. And I will just end with something my grandmother told me, which is that anxiety and sadness that is shared is cut in half. And joy, which is shared, is doubled.

Dr. Daniel Knoepflmacher: Well said. And that gets back to this theme of social connection as so protective for all of us. Glad to be socially connected to you, Richard, and just was thrilled to have you here today, coming back as our first repeat guest. And I just love always hearing your thoughts on the big issues facing Psychiatry and our country. And in this case, thinking about how this election is impacting the mental health in our country. So, thank you, as always, for talking to me and then doing it this time on a recording.

Dr. Richard Friedman: Daniel, it's such a pleasure talking with you. Thank you.

Dr. Daniel Knoepflmacher: And thank you to all who listened to this episode of On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms. That includes Spotify, Apple Podcasts, YouTube, and iHeartRadio. If you like what you heard today, please give us a rating and subscribe because if you do, you'll be able to stay up-to-date with all of our latest episodes. Please tell all of your friends about us. And of course, don't forget to vote on November 5th. We'll be back again next month with another episode. So until then, wishing you all health in body and mind.

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