Sunday, June 9, 2019

Review: "The Righteous Mind" by Jonathan Haidt

I recommend this book.

In The Righteous Mind, Jonathan Haidt shows that different people have different foundations which underlie their moral judgments or beliefs.

 On the "left," the foundations of fairness and charity are more prominent.  On the "right," the foundations of loyalty and "purity" are more prominent. 

These styles or foundations may be propagated in culture or family upbringing,  but also are partly influenced by heredity (genes).  In the middle part of the book, Haidt argues that each of these moral foundations can convey improved survival or natural selective advantage to whole groups.   For example, a group which values loyalty very strongly as a moral foundation is more like to be cohesive, and therefore more resilient to various stresses, including warfare or internal discord.

Haidt concludes his book with a strong message that we should empathize with people or groups which have different moral foundations, rather than simply fight with them or view them as enemies.  He espouses the goal of befriending opponents, including those who have different political or religious beliefs or moral foundations.  Such friendship would then reduce extremes of polarization and conflict, and allow groups to move forward more peacefully.

I respect his thesis very much, of cultivating understanding and empathy for people or groups which have different moral, religious, or political beliefs than one's own.  In a psychotherapy environment, such empathy is required in order for progress to occur, even when the therapist may object strongly to aspects of the patient's behaviour.

But I have some criticisms of Haidt's thesis:

Haidt seems to disparage the importance of reason or rationality.  In a type of "straw man" argument, he suggests that "reason" without other moral foundations such as loyalty, is insufficient or even pathological.   He uses a metaphor of a person or a mind being like an elephant, a powerful creature guided by instincts and passions, with the "rider" of the elephant being our "reason" or logical faculties.  The "rider" is described as a recent evolutionary development, intended to serve the elephant, rather than rule over it.

He anticipates in the book that some people will disagree with him on this.  I certainly do.  I do not disagree that the development of sophisticated reason or rationality is a recent development in evolutionary history, that it indeed did develop in service to the "elephant,"  and that there are strong selective advantages for "non-rational" qualities, which remain prevalent in nature.  But the evolutionary presence of traits is not evidence of their high moral value.

Modern rationality is the foundation of the justice system.  Imagine a court system, a scientific lab, a factory producing safety equipment, or a spacecraft agency such as NASA, which would not hold reason as the highest foundation in its decision-making, but instead would consider "loyalty" or "purity" as most important.  Such foundations would, and often have, led to disaster.

I realize that some applications of reason may in retrospect prove not so "reasonable" after all.  Reason is always fallible, and can be the foundation of huge mistakes--not just technical failures due to mistaken ideas that were apparently well-supported at the time (e.g. the belief in medical remedies such as bloodletting), but also moral catastrophes.   But the process of reason requires it to be flexible, to monitor itself for mistakes, to be willing to make corrections when new information arises.  This differs from "loyalty" which is by definition resistant to change despite the arrival of new information. 

"Loyalty" could be considered a component of "reason" which requires a waiting period before acting on new ideas.  It could be like electing a senator for a 6 year term, with other representatives elected for 2 year terms.  The senators would be more resistant to rapid or erratic whims of a capricious populace, while the representatives would be poised to act more quickly; the two chambers would ideally lead to an effective equilibrium, sensitive to change, but not impulsively so.

I am not saying that "loyalty" or "purity" are unimportant, but they cannot be viewed as morally equivalent to reason, on some kind of equal footing, such that differences between people can be understood simply as cultural variation.

I was bothered in Haidt's book by his passing disparaging reference to "new atheists" such as Richard Dawkins, more or less dismissing the value of their ideas without acknowledging their wisdom or contribution.  There are major problems with these thinkers which warrant fair criticism, but they do deserve respect and attention.  This is ironically contrary to Haidt's best conclusion, which is to have some empathy and respect for viewpoints different from one's own.

I am more allied to scholars such as Steven Pinker or Paul Bloom, who are "rationalists" in their approach to psychology and morality.    But I have to admit that Jonathan Haidt is an important thinker as well, and deserves respect and attention.

Any author of a book has a tendency to have some inflexibility in their position afterwards, due to several psychological biases.  If you have publicly asserted a position, and have become famous for it, you are more likely to maintain it in order to appear consistent, even if there are good arguments against it.  There can be some degree of ego involved as well--people don't like to admit that they are wrong.  I wish there was a little bit more humility when scholars or experts assert positions on these issues. 

I am not an author (except for this modest blog), but I know that I have an ego as well, and I would have a tendency to defend positions that I have asserted, even when they may need to be changed or adapted.  I need to watch this tendency in myself, as we all do in ourselves.

In some cases, it may not be possible to have a friendly, empathic dialogue in a setting of conflict, oppression, or injustice.  Haidt does not explore this type of scenario adequately.  Friendship and empathy are neglected in the management of conflict and polarization, but it is important to acknowledge as well that some of the necessary forces of positive change and justice can be rather more difficult and conflict-ridden.

The Psychology of Meetings

What does psychology teach us about the components of an effective or positive meeting?

Daniel Kahneman described psychological dynamics in meetings, such that those who contribute first or most vocally tend to bias the discussion excessively. 

Quieter members of a group may have important contributions, but they are never heard.   

A majority view can tend to prevail.   Dissenting positions are often suppressed by peer pressure.

People can be afraid to express themselves, due to fear of consequences. 

Many speakers or presenters in meetings are lecturing about information that is already well-known to most or all of the members, therefore this type of lecture is arguably a very inefficient use of everyone's time. 

Suppression of dissent or counterargument is the most powerful and morally troubling bias in persuasion and group dynamics. 

Overt bias in group dynamics and suppression of dissent can occur in overt ways, such as with an authoritarian meeting style.  But there can be subtler mechanisms, such as when a presenter is charming, articulate, humourous, rhetorically skilled, and equipped with attractive visuals.  Good food probably helps as well.  We all enjoy such presentations, but it is important not to let our enjoyment cause us to shut down our critical thinking.  Otherwise, a presentation can be more like a marketing campaign, a revival meeting, or a political rally. 

One tactic to reduce this effect can be to ask members to offer their opinions or questions, anonymously if necessary, before the meeting begins, so that opinions are not suppressed by the social dynamics in the group itself.  It can be helpful if the leader of a group is the last person to speak, rather than the first. 

A related bias in many presentations is the "focusing illusion."  Here, a single idea, plan, or thesis is presented, perhaps with good rhetorical style, nice visuals, and strong supportive evidence.  This leads to a strong persuasive effect.  But if there is only one single idea, plan, or thesis, without presentation and fair discussion of alternatives, the audience will be unduly persuaded towards the single plan they hear about.   In some extreme cases, what may seem like a reasoned, balanced,  presentation may instead be more similar to a sales pitch or a political rally.  To prevent the focusing illusion, it is important to allow time in presentations for debate, counterargument, and alternative ideas.   Audience members should be strongly encouraged to think for themselves, to question, and to debate. Many audience members might be reluctant to do this, even if it is allowed, because they may feel it is rude or disrespectful to the presenter.

Another big problem in meetings has to do with the efficient use of time.  Sometimes an hour is spent on a subject which could have taken just a few minutes of focused attention.   In other areas of our lives, such as when we are listening to music, or watching a TV program, or reading a newspaper, we would rapidly divert our attention to something else if the activity was not useful or enjoyable.  But in most meetings you are stuck there, with no capacity to change the activity.

I find that the "cost" of meetings is often not acknowledged.  By cost, I do not mean the direct financial cost, which could often be zero (though not always, if there is rented space, catered food, or  lost income).    I mean the cost in terms of the other activities that could have been done instead.  For example, if the meeting is attended by 24 psychotherapists, the total cost of a one hour meeting is 24 "person-hours" of psychotherapy time.  The value of "24 person-hours" of psychotherapist time is equal to the treatment of 4 depressed patients with a course of CBT for 6 sessions each.   We should acknowledge the costs, and keep these 4 untreated depressed patients in mind as we sit through the meeting.

Another cost of a meeting is of psychological well-being of the attendees.  Many professional activities are psychologically neutral.  Others could be beneficial, because they lead to better group cohesion or social connection.  But others still could be demoralizing, depleting, or frustrating, if they have a negative dynamic.  They could add to the stress of the day, since other work  would have to be done later.  If the meeting is psychologically depleting then it would be harder to keep up with other work.

But of course, some meetings are effective, enjoyable, educational, and socially beneficial for individuals and groups.  They could help people and groups work more enjoyably and efficiently, could help solve problems in the work environment, and could help with creative planning for the future.  We need to find ways to have more of these!

While I am not normally a fan of using questionnaires extensively with  my patients, I have a simple suggestion for meeting management, based on some of the recent trends in psychotherapy research:  obtain and measure feedback data from attendees.  The absence of feedback can often give the impression that everyone feels ok with the process, and therefore there is no need to change.  Such data would need to be qualified, since the data gathering process itself involves a bias.  Reviewers of any service may be more likely to rate it more favourably, otherwise they might not have used the service in the first place.  For example, if you gather outcome data from customers at a fast food restaurant, you may get very positive reviews.  Such data should not be used as evidence that we should have more fast food restaurants in a community!  But with this proviso in mind, here is a suggested questionnaire for meeting attendees, to be submitted anonymously after each session, or after each segment of a meeting.    Each question could be rated on a scale with 0="not at all" and 5="very much":

1) I learned valuable new information in this meeting, which is likely to improve my work practices.
2) The presenter took too much time. *
3) Everyone's point of view was welcomed and respected.
4) Disagreement, counterarguments, and dissent were encouraged.
5) I got a fair chance to express my point of view.
6) The time spent at the meeting was worth the time, compared to my other tasks and duties which I missed due to attending the meeting. 
7) The meeting was a good chance to connect with my coworkers.
8) The presenter was articulate, engaging, and organized.
9) I enjoyed this meeting.
10) I was bored during this meeting. *
11) The process of this meeting was fair and respectful.
12) The meeting made use of time efficiently.
13) I would like more such meetings in the future.
14) There were instances of disrespectful or objectionable content in the meeting. *
15) The presenter, and fellow attendees, could be heard clearly.
16) The presenter and/or visuals could be seen clearly by all.
17) The presentation contained a lot of unnecessary jargon or needless complex terminology.*
18) The meeting began and ended on time, and stuck to the schedule as announced in advance.
19) The cost of the meeting (in terms of money and time) was acknowledged.
20) Personal information was requested of me which felt uncomfortable to share in a work setting.*

The starred items should be reverse-scored.  That is, for starred items, if you initially rate something as a "5" then it should be scored as "0."  The score could be summed, with a maximum score of 100 (a "perfect meeting" !)  and a minimum of 0 (the "worst possible").

I estimate an average score for most meetings in a relatively healthy organization would be about 60-70. 

Aside from only looking at the group average scores, it may be very important to look at the range of scores from all individuals, to ensure that outlier data is not just "dissolved" into the group average. 

Monday, October 22, 2018

"The Worried Well"

Sometimes, the phrase "the worried well" is used to describe people with problems which are felt to be minor or which would resolve easily on their own.

In one recent lecture, the expert was extremely articulate, intelligent, and inspiring, discussing the importance of educating people about mental illness, as part of a public health campaign.  But then, while using terminology such as "the worried well,"  he finished his sentence in dramatic hushed tones, saying that people who requested, or demanded, more care for what he felt were minor problems were demonstrating "...narcissistic entitlement."  To be a member of the "worried well," I guess the view is that seeking external help would be wasteful, unnecessary, and inefficient for the health care system.  This speaker was very persuasive, for many reasons.  He obviously had a kind heart, a very altruistic disposition, a commanding intelligence, and excellent rhetorical skills. 

I agree that people with extreme, incapacitating symptoms and having extreme, harsh living conditions (such as experiencing severe psychosis while living in severe poverty) require very urgent help.  The health care system must attend to this type of situation with a very high priority.  Mind you, a big part of the health care would be addressing the poverty and other environmental dangers with similar urgency as treating any psychiatric or medical symptoms. 

But people who might be described as the "worried well" are not necessarily exhibiting "narcissistic entitlement" to ask for help.    Even if there are narcissistic issues, work with an experienced therapist could be difficult and long-term, but of great potential benefit to the person and to the person's community.  In some cases, a person with mild or short-term symptoms may not desire or need very much help, but even a little bit of professional attention can make a big difference.   Sometimes the help might prevent a failed relationship, a failed term in university, a slide into more severe mental illness, or a disastrous life choice.

In some cases of extreme severity,  a long-term complex care regime is often needed (such as a community team involving physicians, social workers, occupational therapists, etc.).

But in other cases of extreme severity, sometimes brief, focused help is adequate, and is all that the person desires or needs.

In cases of "mild" severity (such as a person with relationship stresses and generalized anxiety), sometimes minimal help is really needed...the issues may settle down on their own.  Other times, just a few visits with a professional may be sufficient to help the person pass through the situation more comfortably.

But in other so-called "mild" cases, people may benefit greatly from having more ongoing help, such as a course of psychotherapy.  Symptoms, as measured on symptom scales, may not lead to alarm bells ringing, and may not even change very much, but timely or ongoing therapy may make a difference between the person succeeding, flourishing, or failing in their schooling, career development, or relationship life.  The most common symptom scales do not tend to measure these things directly.

Nowadays, it is hard to discuss such matters philosophically, without dealing with a question such as "but where is the evidence?"  or "Are your ideas evidence-based?"  The best evidence base for any health care claim would have to involve a prospective, randomized controlled study with very clear outcome criteria.   It is expensive and difficult to assemble such studies.   Much of what I am talking about above is not based on some specific "diagnosis" (though nowadays it is quite easy to form a list of DSM-V diagnoses) but on a person's subjective wish to have help.  Treatment studies, due to technical difficulties and expense, tend to be brief, single diagnosis-based, and based on fairly simple quantitative measurements (such as symptom scale data).   For this reason, a strict requirement for evidence-based treatments in mental health care will tend to favour brief techniques which have very clear evidence of reducing acute symptoms quickly as measured by questionnaires.  This favouring is not because the evidence is invalid (in fact, the evidence from these studies is informative and excellent), but because most studies will necessarily be short-term in this way.  Longer-term studies with more qualitative measures are much more difficult to do, and therefore there is much less published data.

But in many situations, the benefit from mental health treatments is longer-term, and may be more qualitative than a symptom questionnaire could pick up.

I do not at all mean to disparage the focus on effective, cost-efficient, brief treatment of mental health problems.  I also think it is valuable to challenge wasteful or unnecessary expensive practices, especially those which lack any good evidence at all.

But mental health care sometimes requires a steady, longer-term commitment to really take care of people, to make the effort to know people very well for a long period of time, to understand a person deeply, not just in terms of symptom scores.  A therapist or psychiatrist need not be simply a "provider" or technician to relieve symptoms.  Sometimes this is all a person wants, and that would be fine.   But if this the only thing the profession focuses on, then we risk having a health care system which becomes more impersonal, disconnected, and mechanical.  For psychiatrists, a very short-term focus will naturally favour simple prescriptive approaches such as medication trials (I am not "anti-medication" but I strongly discourage the practice of prescribing medications without knowing people well, and without addressing other holistic strategies for health care).   A more disconnected or impersonal health care system is harmful for patients, and is harmful for the community of therapists and other professionals.

Let's not use phrases such as "the worried well."  Let's not diagnose people who are asking for help, with "narcissistic entitlement."    While it is important to prioritize urgent needs, let's spend the time trying to understand and care for all people, without judgment.

Sunday, September 30, 2018

Medical Education

Medicine is a very strenuous professional program, but potentially full of incredible intellectual stimulation and personal challenge.

Having gone through medical school myself, and having gotten to know numerous medical students over the years, I have a few ideas about the medical education system:

The academic portion of medicine consists of an enormous amount of material crammed into a short period of time.  It requires students to prioritize study time with great care, to get the "big picture" of things.  Students with a very strong memory would have a huge advantage.  As a result, few students really get to savour the academic learning, to really think deeply about these important subjects.    For most, it is a stressful but superficial rush through vast areas of subject matter.  Students who are good with test-taking gamesmanship would have an advantage here.

Here are some ideas for change:

How about have a course system in medicine which allows people to gradually complete the academic section at their own pace?    This could allow people to take their time, master the material, and to enjoy it.

Some subjects in medicine, such as anatomy, are crammed into the first year, but then rarely touched upon after that, unless the student ends up doing a surgery residency, etc.  What about having some very basic subjects such as anatomy be reviewed regularly and immersively, with practical applications, so that students would deepen their knowledge and practical skill over time?

Practical skills in medicine, including interviewing, physical examination, and basic procedures, could be gradually introduced much earlier.  It is not necessary to understand biochemical pathways or histology, etc.,  to practice most clinical skills.   Many such practical skills improve, and become "second-nature," with years of practice, so why not start sooner?  This would make the work more interesting and relevant for the students, and ultimately would be very good for patients, because they would be dealing with medical students with better practical skills.

Review: "The Case against Education"

Bryan Caplan, an economist from George Mason University, has written a book called The Case Against Education: Why the Education System is a Waste of Time and Money.

It's quite a title, and quite a thesis, which touches a few nerves for those of us who have spent much of our lives studying and working in the education system.

Summary of the book

Here's my summary of his most important points as I saw them:

1) Degree programs at a university lead to less skill acquisition than what most people think...instead, grades and degrees and attendance at famous schools have mostly a "signaling value."  That is, a person with a diploma, a degree, or high grades is thought of more highly, and is therefore more likely to be given a better job or higher esteem in society, even though their actual skills may be no different from a person lacking such credentials.  If they did have more skills, it may not have been due to the degree, but rather they had more skills in the first place, and that's why they did the degree.  Having a degree could also be an indirect signal of being compliant and obedient, which might be considered attractive by some employers.

2) The social machinery of education therefore causes people to use enormous amounts of time and money for obtaining academic credentials that have mostly "signaling value" but have little use to them or to society otherwise.  Employers assess people based on these educational credentials;  this inflates their value.  Therefore, people who would be otherwise capable employees even without any such credentials must spend years of time, and tens of thousands of dollars, delaying their lives and careers in order to attend classes.

3) It is true that people who are more skilled or apt for some kind of career in the first place, are more likely to obtain these credentials.  But Caplan's point is that these same people would or could have been very similarly capable even if they had not spent years of time and money in the academic system. 

3) He recommends at the very least that education not be publicly funded.

Caplan does have some good data to support his positions, which he shows in his book.

Areas where I agree:

Here are some areas where I do agree with him:

1) I find it tragic to see students who are bored with their education.  Sometimes people have to sit through and struggle through years of classes, competing for grades, trying to complete their degrees, all the while not enjoying the process, not excelling, and not valuing the subject matter.  When the course or the degree is over, the experience is relief.  Sometimes the subject matter of the degree is never looked at again.  The entire experience is aversive or sometimes even traumatic, a repetitive blow to self-esteem with little redeeming value except for the certificate at the end.  People do this because it is considered a social norm and a family expectation to obtain a degree or to go to university. And people do this because employers require more and more academic credentials just to be considered for a job.

2) I agree that trades and technical training programs should be valued more highly.  Such training opportunities could start earlier in life, such as in high school. 

Areas where I disagree:

But here are areas in which I disagree with Caplan:

Caplan points out that people show evidence of having forgotten much of what they learned in university, not long after they finish.  But such tests of memory do not prove an absence of permanent learning.  Almost certainly, in most cases, people would re-learn the material much faster if exposed to it again.   For example, if you took a calculus or Spanish course 5 years ago, but had not used these subjects since then, you would probably score poorly on a test today.  But you would probably be able to re-learn the calculus or Spanish much more quickly than someone who had never taken the course at all.  Knowledge can sometimes go into a sort of "zip file" in the brain, which can't be used immediately, but can be re-awakened if needed. 

Caplan himself shows that while there is a very high amount of signaling vs. skill acquisition in university education, it is not 100% signaling...that is, some true valuable learning has taken place, on average (in some subjects, such as engineering, more than others).  In many areas of life, we have such inefficiency, but that does not negate the importance or value of the activity.  For example, an exercise regime may only lead to a statistically small improvement in health variables, but such a small effect is still positive and desirable.

I find Caplan's comments about certain areas of study, such as within the arts, inappropriate and offensive.   All subjects, all human wisdom, has value...this is part of being human. We should cultivate respect for all forms of knowledge...however I do agree that we need not "force" people to study these things just for the sake of acquiring some signaling item such as a diploma.

Conclusion and personal reflections:

In conclusion, I have always felt that a broad education is valuable for individual lives and for society.

But I believe that educational pursuits should have a stronger focus on joy and meaning, with efforts made to reduce the predominance of signaling effects. 

I agree that we should reduce social or economic penalties for people who do not have formal educational credentials, as long as they can show and develop skill or expertise in other ways.

While I agree that we should value trade schools or other technical programs, I think broad education is important for technical students as well, to allow people to be well-informed and to have a greater esthetic appreciation for the arts, fine arts, and other subjects.  Of course, going to school is not necessary for esthetic appreciation, but school at its best can introduce people to beautiful areas of life that would not be discovered otherwise. 

I would like to see less polarization between arts and sciences programs...I would love to see more overlap.

I think it would be healthy for the activities of students in different faculties, including in the arts, to have immediate relevance and interaction with the community.  It would be interesting, for example, to have more outreach programs.  And maybe the encouragement for students to have their undergraduate essays published, so that all those hours of work writing would not just lead to a product that would be read one time by a professor or grad student, and then never looked at again.

People who are truly bored and struggling through material should at least have broader choices for their educational development, to favour subjects that truly interest them, so that people's youth need not be wasted in a drudgery of unsatisfying and demoralizing work.

My own experience of education through my life has been very positive and meaningful.  There are many esoteric subjects I studied long ago that I may not make much use of, but I consider them to be part of acquiring wisdom, and broad knowledge of the world. In my daily work, a broad education allows me to have better connection with students from many different faculties.

Most of us need some kind of formal structure to motivate us, and maybe some sort of prize at the end, such as a diploma.  Free access to education through the internet is a great thing, but this modality does not have such motivational factors.  I love learning but I am much more likely to get something out of a learning process if there is a more formal structure to it.

In the arts, Caplan seems to suggest that many subjects are wasteful.  Perhaps an example would be the study of Shakespeare.  But I can't help but note the local theatre company which produces Shakespeare plays all summer...all of the performances are packed, with people of all ages!   I think if we were to reduce exposure to literature in schools and universities, we would see a decline in these types of cultural activities, which would be a loss for us all.

But I do think that Shakespeare, if taught in school, should be made engaging, dynamic, and fun,  just like a good theatre production.

I strongly disagree with Caplan's opinion that we should reduce public funding for education.  Reduced funding would penalize those with lower income.  He suggests some kind of meritocratic system as well, which I favour too, but it seems to me that access to a high-quality, enjoyable public education should be a basic privilege granted to all citizens.   I do agree that there could be more educational options though, aside from the conventional, orthodox degree system which has prevailed during this century.

Relevance to mental health:

I bring up this issue in a mental health blog because one of the common environmental factors contributing to unhappiness, anxiety, and depression in young people is frustration with education.  Classes may be boring, excessively difficult, lacking in obvious meaning or purpose, or lacking in application to future life goals.  Classes are also expensive, causing students to be in a compromised financial state for years, relying upon loans or family support, or upon strenuous after-hours jobs.  Grades, if low, can cause demoralization.  Even if grades are high, they can drive a perfectionistic or obsessional quest at the cost of other healthy or enjoyable life activities (ironically, including learning).    Once a degree program is over, many students still have a hard time finding employment, even after a graduate degree.  Sometimes the jobs that are available have only an oblique relationship to the subject matter studied during the degree.

So I think it is good to examine the process of education itself, and to question some of the foundations, as part of helping young people to have good mental health.