Showing posts with label Books and Reading. Show all posts
Showing posts with label Books and Reading. Show all posts

Friday, August 4, 2023

"The Power of Us" by Jay Van Bavel & Dominic Packer: a recommendation, review, and applications in psychiatry

 Jay Van Bavel and Dominic Packer are social psychologists whose recent book, The Power of Us, is a nice review of basic social psychology with a unique emphasis on the impact of identity and group affiliation on human behaviour and cognitive biases.  

This book would be an excellent accompaniment to The Righteous Mind, by Jonathan Haidt, and Blueprint, by Nicholas Christakis.   Haidt looks at individual differences in values as a factor affecting group behaviour.  For example, people who value loyalty and "purity" (as opposed to "compassion" or "fairness") as cardinal values may be more likely to have strong group adherence, and may be more accepting of hierarchical or paternalistic systems; such traits could lead in particular to involvement with conservative groups.   Haidt argues (and I strongly agree) that such values and traits have a strong hereditary basis (though are also partly influenced by environment & cultural milieu) and have evolved in humans due to selective advantages for those who have a strong inclination towards group affiliation.  But of course, too much loyalty can be a bad thing, if it causes people to adhere loyally to groups which are engaging in harmful behaviour--we see this problem in the news every day.    Christakis looks at group dynamics in an interesting mathematical way, with successful or unsuccessful group behaviour influenced by the structure of connectedness, which in turn is influenced by leadership styles, external factors,  and individual personality traits.  

The subject of group affiliation, identity, with associated biases, polarization, and conflict, is an incredibly important subject in the world today.  Group-based divisions arguably are a primary cause of political problems and war across the world, and lead to delays and inefficiencies in solving world problems such as poverty, environmental degradation, and war.  On the positive side, strong group allegiance has led to most of humanity's great achievements through history.  Most great accomplishments in the sciences, the arts, in politics, and in the law, involve large-scale collaboration.   

Group affiliation is a powerful source of identity for all of us.  If we have a strong attachment to a group, we are likely to favour ingroup members.   This is normal and ubiquitous,  but it can lead in an extreme case to hating or persecuting outgroup members.   To prevent this, it can be helpful to have a culture of interacting respectfully or collaboratively, or recreationally, with outgroup members (Jonathan Haidt made this point years ago, in The Righteous Mind).  It could be especially effective if any such recreational activity could blend members from different groups.  The authors cite some very successful examples of these ideas, such as having a soccer league in Iraq where each team was required to have players assigned equally from different conflicted religious groups.  The resulting games allowed each player, and each team, to like, respect, and enjoy outgroup members, since they became teammates,  leading to reduced conflict in their communities afterwards.  A famous example from classic social psychology research is the "Robbers Cave" experiment from the 1950s, in which antagonistic groups of teenage boys later worked together in friendship and harmony if they had to collaborate together to solve a problem external to them both.  

The chapter on "fostering dissent" is especially insightful.  The authors make the point that voicing a dissenting opinion within a group is socially costly.  Even if the dissent is about an important logical or moral issue, the risk of dissenting can be to make other group members angry, and therefore threaten one's position as a group member.  You risk being seen as disloyal or disrespectful.  They argue that you have to really care about your group to be willing to voice dissent.  I see this could often be true, but sometimes particular individuals are more oppositional or defiant, due to character traits, leading to frequent dissent even if they don't particularly care about their group status.  Another problem with dissent is that other group members may have quietly agreed with the dissenter's position, but it could be costly for them to endorse the dissent, since it could make them look bad or immoral for not having brought it up first.  So a default position in groups would be to maintain the status quo, and for dissent to be risky, even if the group is engaging in harmful behaviours or beliefs.   Unfortunately, this can cause harmful behaviour to be perpetuated in some groups, and for dissenters to be punished or ostracized.  Recent examples of this include U.S. politician Liz Cheney, who has spoken out against the deeply immoral behaviour in the leadership of her political party.  Unfortunately, she was defeated in the subsequent election.  While she should be seen as someone defending the honour, integrity, and values of her group, therefore protecting the group's long-term interests, she instead has been seen by her own ingroup members as disloyal, and punished for it.  I hope her own story is not over, and that her principled behaviour may prevail in the end.  

An approach to solving the dissent problem is to have a leadership structure or ethos in groups which encourages respectful disagreement, without fear of punishment or other consequences.  Also it is vitally important, as a persuasive factor, to frame dissent or challenge with the group's long-term well-being in mind--to remind others of the group's core values, of the group's long-term interests, with a dissenting view intended to be a service to the group rather than merely a criticism.  

On a larger scale, I think it is always helpful to expand the circle of our groups.  Instead of focusing on local or national or religious or political allegiances, why not focus on a shared humanity.  Some of the guiding insights of many of the world's religions, such as Christianity, were to expand a circle of love, respect, and inclusion to outgroup members, and not to shrink into insular, bitter enclaves judgmental of others outside of their own ranks.  

Psychiatric issues always exist in a social context.  Patients will always have group allegiances or identities.  These could involve religion, politics, gender, race, family, occupation, etc.  It is important to understand these group allegiances, empathize with them, and communicate therapeutic ideas with the group allegiances in mind.   Encouragement or advice for change carries a high risk of failing if it is expressed in such a way as to challenge a person's individual or group-based values.  A survey of group affiliation and identity factors should be an essential part of a psychiatric history, and an ongoing theme in a therapeutic dialogue.  



Friday, May 26, 2023

Foolproof, by Sander van der Linden: a recommendation, review, and analogy with psychotherapy

I strongly recommend a new book by Cambridge psychologist Sander van der Linden, entitled Foolproof: why misinformation infects our minds and how to build immunity.

I have followed van der Linden's research for several years, alongside other experts who are studying the psychology of persuasion, misinformation, and propaganda.    This area has been an interest of mine for many years, after discovering psychologists such as Cialdini and Kahneman.  

This is a subject that everyone needs to learn about!  Persuasive techniques (for good and for bad) have always been with us through history; the power and influence of these techniques will only continue to escalate, thanks to the internet era, and now the era of artificial intelligence (AI).  

I have discussed these issues in other posts, such as:


and 


and 

Garth Kroeker: "GroupThink" (October 6, 2016) 

Van der Linden reviews the history and scope of misinformation.  Among the many current examples are conspiracy theorists impacting public opinion and policy, political influencers attempting to sway elections, propagandists from other countries defending violent or oppressive policies or sowing discord among their opponents, and of course the anti-vaccine community.  

There are a couple of acronyms he introduces: the word CONSPIRE can help us to recognize some of the common features of conspiracy theories:  

C = contradictory.  Most conspiracy theories feature contradictions.  For example, there could be a belief that some awful event is a hoax, but then also a belief that the awful event is real but was caused by evil conspirators.  

O = over-riding suspicion.    A sense of general distrust that goes beyond the topic of the conspiracy theory, particularly a distrust of official or mainstream explanations.  

N = nefarious plot.  A belief that there is a shadowy group of evildoers, such as government officials, corporations, or (at worst) a particular racial or ethnic group, who behind the scenes have caused some bad thing, perhaps with a motive to advance themselves.  

S = "something's wrong."  The belief that regardless of any acknowledged or corrected fact about an event, there's something going on that isn't right.  

P = persecuted individual.  The belief that someone is being deliberately harmed (most commonly, the believers in the conspiracy theory).  

I = immune to evidence.  Presentations of evidence often have little or no effect to change the opinion of people having conspiracy theory beliefs, in fact evidence could even "backfire" and cause the conspiracy theorist to become even more entrenched, or to believe that you or your sources of evidence are all biased or part of the conspiracy.   Such immunity to evidence is common among people who have limited expertise or knowledge about science, but could also be present in some highly educated people.  A conspiracy theorist who does have more scholarly expertise may understandably deploy statistical or psychological terminology to defend their beliefs; for example, by accusing other scholars of having psychological biases (such as confirmation bias).

Re = reinterpreting randomness.  This is creating a false causal story about random, unrelated events.   Humans in general are prone to doing this.   

It's interesting as a psychiatrist to reflect on the "CONSPIRE" factors above.  They are very often present in frank psychotic states, or in milder variants such as paranoid personality.  The tendency to have paranoid thoughts exists as a trait on a continuum in the population.  This trait has various environmental causes, but also has a high heritability.   It is a typical psychotic symptom to believe that there is a special, often ominous explanation behind pseudorandom events.    

Of course, sometimes there are explanations for events which differ from the mainstream understanding.  Through history there have always been maverick scientists,  who demonstrated something new and important, despite the objections or condemnation of their peers.  One example that has always bothered me was Alfred Wegener, who in 1912 was the first to propose the theory of continental drift; he was ridiculed and dismissed by his peers, who couldn't believe that entire continents could move across the face of the earth; Wegener tragically died before his theory was proved correct.   We have to be open to consider alternative theories.  However, maverick scientists, unlike conspiracy theorists, have clear evidence to support their claims; their reasoning does not contain contradictions; they are not immune to evidence, do not reinterpret randomness, and do not have ominous, over-riding suspicious beliefs about persecution.  

Van der Linden's next acronym is "DEPICT", to help remember features of manipulative communication:
  
D - discrediting.  The manipulative communicator will portray experts who disagree with them (such as scientific leaders, or even entire communities such as leading scientific journals), as biased, poorly qualified, incompetent, or having some nefarious agenda.  It is frustrating to have a scientific debate with someone who is engaging in such discrediting, since any sound evidence you raise with them will be dismissed as invalid.  

E - emotional.  Using strong emotional language to induce fear, anger, or disgust as a persuasive tool.  

P - polarization.  Framing issues, and people who have positions on these issues, in a "black or white" fashion, rather than as shades of grey.  This leads to a false sense of dichotomy, and encourages the formation of teams of opponents holding increasingly extreme positions, and increasing disrespect for those who disagree. 

I - impersonation.  Using fake experts to bolster a claim.   A variant of this is using an actual expert, but whose expertise has nothing to do with the issue at hand.  

C - conspiracy theories.  Encouraging conspiracy theory beliefs. 

T - trolling.  Attacking, insulting, or threatening opponents, usually in an online environment, such as on social media.  Such harassment has at times been so intense that scientists or policy experts (including in public health) have been afraid to speak out, fearing for their safety.  

Van der Linden's work focuses on how we can best deal with misinformation.  He concludes with an analogy:  misinformation must be dealt with by "immunizing" ourselves against it.  

In order to build immunity against an infectious disease, it is necessary to be exposed to a weakened version of the pathogen, in order to train the immune system, such that future doses of pathogens would be dealt with quickly.  

Infectious diseases are much easier to manage, with much less risk of harm or spread, by building immunity, rather than by only relying on treatment after infection.   

Similarly, it is much harder to "treat" misinformation after the fact.  Tactics to "treat" misinformation would be debate, education, and careful review of evidence.  But many people who have fallen into a misinformation "rabbit hole" are difficult to reach or persuade using reasoned debate.  Such debate may even cause the misinformed person to become even more angry or stubbornly adherent to their ideas.    

It is better to prevent people from falling into the rabbit hole in the first place--not by eliminating rabbit holes (which is impossible) but by teaching people how to identify and manage rabbit holes if they encounter them.  

The idea of "vaccination" is presented as an analogy throughout the book.  But beliefs and persuasion are not exactly like the body's immune system.  It's a very good analogy, but not perfect.  Much of the phenomenon van der Linden is talking about is explainable through learning theory:   we learn much better if we actually practice "hands on" with things, rather than just passively absorbing theory.  If you want to learn mathematics, you actually have to work through a lot of problems, not just read about how to do them.  If you want to learn how to ride a bike or drive a car, you have to practice cycling and driving, not just read about those things in a book!  As part of the practice, it is best to face challenging situations, and learn through experience how to overcome them.  

Similarly, to deal with emergencies, it is imperative to do behavioural practice many times as a preparation.  We have to do fire drills to prepare for a potential fire.  Pilots need to practice many times in a simulator how to manage engine failure.  If you only read about something, or learn about something, without practicing, you can't possibly become proficient, especially under pressure.  

To deal with misinformation, we have to practice, hands-on, dealing with misinformation, at first with "easy" examples, then more and more difficult ones.  

Applying these ideas to psychotherapy: CBT (cognitive-behavioural therapy) is very important and useful, but at worst it can be too passive.  Many people engaging in CBT do a lot of passive learning, they do written exercises in a workbook, but do not really practice deliberate exposure to uncomfortable stimuli.  The "vaccine" analogy could be useful to incorporate into CBT for treating depression or anxiety.   This is something that I have advocated for many years, mainly an emphasis on the "B" part of CBT.  To deal with panic attacks, it is most helpful to actually practice having panic attacks, in safe, controlled conditions!   To deal with depressive thoughts, it could be a useful exercise to invent simulated depressive thoughts, at first mild ones, then more challenging ones, to understand the mechanism by which they are created, and to practice facing them without being negatively affected.   This exposure therapy is like van der Linden's "vaccine."  But most therapists don't emphasize this enough, they only try to teach people to relax or cope with symptoms after they have occurred.  One of the purposes of talking about past emotional trauma is to recreate the painful events in the mind, but in a limited, controlled, "virtual" form, within the safe context of a therapy office.  In this way talking therapy has a vaccine-like effect.  

Linden's book is a must-read, not only for those interested in propaganda or misinformation, but also for anyone wanting a better understanding of the mind itself, with ideas that touch upon managing almost any life adversity, including mental illnesses.  

References: 


Linden, S. V. D. (2023). Foolproof: Why Misinformation Infects Our Minds and How to Build Immunity. WW Norton.


Thursday, August 18, 2022

How Minds Change by David McRaney: a book review and discussion

David McRaney, in his new book called "How Minds Change" (2022), reviews our understanding of why people can form tenacious beliefs which are resistant to change, leading to political polarization, conspiracy theorists, hate groups, cults, anti-vax groups, climate change denialism, etc.  

I have discussed a lot of this material in some of my previous posts.   A big focus in McRaney's book is on what strategies are most effective to help with these problems.  He shows that simply presenting facts to a person with entrenched beliefs is usually ineffective, and could even cause the person to become even more entrenched in their beliefs.  Instead, there are several techniques discussed which have much better success.  These techniques are to some degree common-sensical, and are foundations of what might be found in any compassionate interaction, or any psychotherapy scenario.  

He discusses several such strategies, including deep canvasing, the elaboration likelihood model (ELM), street epistemology, and motivational interviewing.  All of these are similar--I'll summarize the core features here: 

1) establish rapport.  Empathize.  The communicator must seem trustworthy, credible, respectful, and reliable.   Obtain consent to talk about the issues at hand.  

2) Ask how strongly the person feels about a particular issue;  repeat back and clarify; identify a confidence level, such as from 0 to 10; ask how they chose that number; ask how they've judged the quality of their reasons for their choice;  summarize; make sure you've done a good job summarizing correctly.  

3) If there are core values influencing the person's opinion, such as about the importance of family, community, safety for children, freedom, loyalty, etc. be sure to empathize, acknowledge, and affirm these.  If there are core values in common, be sure to emphasize the commonality.  

3) If their confidence level was not at an extreme (0 or 10), ask why not?  

4) Ask if there was a time in their life before they felt this way about the issue, and if so what led to the change?  

5) share a story about someone affected by the issue.

6) Share a personal story about why and how you reached your own position, but do not argue.  

7) ask for their rating again, then wrap up and wish the person well, possibly with an invitation to talk again.  

Notably, these techniques do not involve arguing about facts, such as about scientific data.  A person holding strong entrenched beliefs may consider contrary facts or data to be false, biased, or irrelevant.  They may feel like they are betraying their ingroup or their sacred values if they were to change their position.   Yet elsewhere in the book there is an emphasis on facts as well, it is just that there would need to be a tipping point of information frequency within the person's ingroup, beyond which the group opinion starts to change suddenly.  Below that level, facts are easily dismissed, ignored, or even used to ironically consolidate their previous beliefs, while labeling the fact-provider as a misguided or even evil outsider.  

In some of McRaney's examples, he shows, as I have discussed before, that strong ingroups can be the main factors causing resistance to rational changes in belief, even if the ingroup's beliefs are causing great harm to themselves and are contrary to their core values (the anti-vax movement is an example).  He points out that sometimes people need to leave these ingroups for other reasons, before they become amenable to changing their beliefs.  Exiting the ingroup sometimes needs to happen first.  But this can be unlikely to happen.  To facilitate ingroup members being able to leave, there would need to be a kind, respectful, compassionate approach.  If we only show anger and hostility to these ingroups, the members are more likely to rally together, as if protecting themselves from an enemy attack.  

McRaney alludes to many of the practioners of techniques such as deep canvasing having many video examples of the technique, to help others learn and offer constructive feedback about the technique.  I think this would be something to check out online, to see examples of people working in this area lead a successful conversation leading to positive change.  Otherwise, like so many other techniques in health care or in life, we are stuck with just reading about an idea, rather than practicing and learning "hands on" with the guidance and feedback of others.  

The one critique I have of McRaney's book is that he leaves out discussion of many research leaders in the psychology of conspiracy theorists, cults, and persuasion.  Cialdini's work from decades ago is never mentioned.  Psychologists such as Sander Van Der Linden are not mentioned.  There are some other techniques suggested by these other researchers, including a "fake news inoculation" technique, in which you can learn and practice ways to protect yourself from misleading information.  See the website https://www.getbadnews.com/books/english/

Also, the book does not discuss individual variations in people as a factor affecting tenacity of belief, propensity to conspiracy beliefs, resistance to fact-based arguments, etc.  In my previous post (https://garthkroeker.blogspot.com/2021/09/conspiracy-theories-vaccine-hesitancy.html?m=1) I discuss factors such as past trauma and personality disorders as factors which could cause an individual to hold more rigid harmful or false beliefs.  There would need to be some varability in the approach to conversing with someone about these issues, given these individual variations.  It may be valuable to focus persuasive efforts on those most ambivalent or amenable to change within a strong ingroup.


 

Wednesday, May 25, 2022

"The Biology of Desire: Why Addiction is Not a Disease" by Marc Lewis

Marc Lewis explores the neurobiology of addiction in this short book, with proposed approaches to better understanding and helping people who are struggling with addictions.  

He comes across very clearly as a compassionate person, with a good understanding and personal experience in this area.  Probably someone who would be good to have as a therapist or support in the context of addictive problems.   

The book presents several case stories, which is always a compelling style in describing health care issues.  They could be a source of inspiration that could help people in their own journeys through addiction.  But of course testimonial accounts have only limited value in a scientific study, since they can introduce very strong biases in the reader, if not accompanied by references to large controlled studies.    

He has good reasons for disparaging what he calls "medicalization" of addiction, and emphasizing his opinion that addiction should not be considered a "disease."    Many of these reasons involve emphasis on what most of us would consider "bad medicine," i.e. institutional or even punitive treatment, simple remedies such as drug treatments given without addressing social or psychological issues, etc.    He particularly disparages psychiatrists, as though he thinks all psychiatrists enjoy the narrow or excessive brandishing of labels and dispensing of medications without attending to deep understanding, therapeutic compassion, and a biopsychosocial focus, with patients.  

So I found this part of his message to be tiresome.  Excessive narrow "medicalization" of almost any issue is not good medicine.  Almost any health condition, such as type II diabetes, heart disease, hypertension, and certainly conditions such as anxiety or depression, have spectrums of severity or chronicity; there are very important psychosocial factors, often present for years before the onset of the condition, that influence symptoms, severity, and progression.   There are feedback loops involving behaviour which cause spiralling exacerbations or rapidly accumulating harms in all of these conditions.  And treatments for diabetes or heart disease need to involve understanding and help with lifestyle, social, and economic factors affecting these conditions, with long-term goals in mind.    But it is not necessary to avoid calling diabetes a "disease."  Rather, the approach should be, in my opinion, to recognize that any disease state occurs on a continuum.  In many cases, there is no clear-cut line between disease or non-disease.   The word "disease" does not necessarily imply permanence, or need for invasive, narrow,  or institutional treatments.  For example, we could agree that viral pharyngitis is a disease, but is not one which normally requires medical intervention.  Just as in addiction, many conditions uncontroversially considered "diseases" or at least pathological states, such as pneumonia, COVID, migraine, sciatica secondary to disc prolapse, psychotic episodes, or brain injury, can often  recover on their own without any treatment at all; but for some sufferers of these conditions, the symptoms become relentlessly chronic or more difficult to deal with.    Just because something has the possibility of improving on its own, or through lifestyle improvements, after days, months, or years, does not mean that it shouldn't be considered a disease.  Furthermore, the improvements in many conditions can sometimes be associated with improved perspective or lifestyle, but sometimes the improvements are just random.  Many patients I've seen have engaged in all the healthy perspective-taking and good lifestyle habits you can imagine, but are still afflicted by the same tormenting symptoms.  Other patients somehow recover from severe problems without changing their lifestyles much at all.  

Hypertension is a disease, with multifactorial causes, which often requires medication but always requires attention to lifestyle factors.   Simple, overly reductionistic medical treatments can sometimes help with certain disease states (such as repairing a broken limb) but in many or most disease states, medical treatments are only one branch of helping.  The other branches require attention to lifestyle factors, community or social supports, and possibly an existential focus, to help people regain an awareness and passion for long-term goals.  But this multi-pronged focus is what I consider to be normal medical care.  

Lewis argues that because the neurobiology of addiction features entirely "normal" activations of normal brain pathways, akin to learning or falling in love, addiction therefore should not be considered a disease.  But many conditions in medicine feature activation of normal physiologic functions as a component of their pathology.  For example, inflammatory states resulting from infection (this is a major pathology in COVID) are activations of the body's defenses to fight off pathogens, but the inflammation itself ends up causing severe tissue destruction.  The processes are all "normal" but the circumstances of the disease state (germ + host) cause the reaction to be disastrous.  A clear understanding of disease states, mechanisms, and medical interventions to interrupt this cycle, are indicated to save lives and prevent widespread tissue destruction.  

Addictive states can lead to similar destruction of bodies, minds, relationships, and careers.  Just because the mechanisms involve activations of normal neural pathways does not mean we should avoid diagnostic language.    Problems associated with pathologizing labels, such as stigma (from others or from self) do not mean we have to avoid such labels entirely, but it may mean that the labels should be used with care and humility, rather than in a pejorative manner.  

There is interesting neuroscience describing addictive processes, but sometimes discussion of this can devolve into making overly strong literal claims (e.g. about neuroplasticity), often based on compelling testimonial accounts, without as much robust statistical evidence to back these up.  This is a pitfall I've seen with other authors touching on this, such as Doidge.  The use of the neuroscientific language then becomes a tool of persuasion, which sounds impressive to most people.  But it is much more important in this area to back up claims, especially those based on case studies or testimonial accounts, with careful reference to large controlled studies.   

Lewis has good ideas and a passion for his subject, but his focus on addiction not being a "disease" is needless--it is to some degree a semantic squabble, which subtracts needlessly from the impact of his book.  


Monday, May 23, 2022

The Elephant in the Brain & The Folly of Fools

 Two more books to recommend:  


The Folly of Fools (2011) by Robert Trivers and The Elephant in the Brain (2018) by Kevin Simler & Robin Hanson are both about the human tendency to engage in deception: not only the deliberate deception of others but the deception of self.  

Trivers approaches this issue from the point of view of genetics (he was the first to characterize the evolutionary biology of reciprocal altruism).  The capacity to deceive can be beneficial to survival, as we see in many species of animals, and in many human examples.   But such deception can only work up to a certain point, an equilibrium point in terms of frequency, otherwise the strategy fails.  If deception was too frequent, the evolved strategies to counter deception would render the deceptive strategy ineffective.  Similarly, cheating can be an evolved strategy, but if cheating occurs too frequently in a population, it would no longer be effective due to widespread awareness and countermeasures in the population.    

Trivers goes on to argue that self-deception is a type of advanced deceptive strategy.  The capacity to effectively deceive others is enhanced if we can deceive ourselves.  If you REALLY believe you can win a fight (despite poor objective evidence), you are more likely to convince your opponent that you can win, and therefore are more likely to actually win, even if you utterly lack fighting skills. 

Unfortunately, self-deception leads to many serious problems in society.  Trivers goes through many examples, showing that horrible accidents, wars, biased research, and religious phenomena, are often driven by self-deceptive factors which end up causing disastrous results.  

His chapter called "religion and self-deception" is particularly recommended.  

While I consider this book important and highly recommended, I did find it often to be quite informal in reasoning, punctuated by forays into humour, but this could be a bit problematic when he is wandering into areas (for example about politics, wars, and religion) that many people could be quite sensitive or easily offended about.  There are bound to be sections in this book which could cause people some offense.  


The Elephant in the Brain is quite a remarkable review of ideas from social psychology and behavioural economics.  There is influence from Kahneman, Trivers (The Folly of Fools is referenced), Haidt, and many other leaders in the research of this area over the past decades.  I think it's astounding that these two authors, who are not specialists in these areas, produced such a comprehensive and compelling summary of this research.  

The thesis of this book is that humans have a powerful motive to signal membership in groups.  The tendency to form ingroups is a powerful human trait, evolved over millions of years.  Group membership allows us to trust and collaborate with our group members, for safety, defence, maintaining a food supply, dealing with illness, finding a mate, and raising children.  But unfortunately, this tendency to form ingroups can become such a powerful motivation, often without our awareness, that it overwhelms reason, fosters needless and often terrible conflict with outgroup members, and can become very destructive or at least inefficient.    And the phenomenon tends to perpetuate itself, since members of ingroups (be it political or religious or cultural) tend to socialize, mate, and have children with fellow ingroup members.  

They refer to Bryan Caplan's argument about education, showing that a great deal of education leads to only an indirect signal of skill or competence.  Most people do not use subject matter they learned in university very often if at all in the work they do afterwards.  Instead, the degree and grades serve mainly as a competitive signal to employers about capacity to achieve work, conform stably to demands, etc.  I have reviewed Caplan's book elsewhere (I do have some disagreements about this).  

The authors show that political and religious membership have powerful ingroup effects.  The tendency to form strong beliefs about elements of religious doctrine can be understood as a badge of group membership; if one can engage in successful self-deception about these doctrinal elements, it is all the more effective as a group membership badge.    The beliefs become shibboleths which can allow some feeling of trust with co-believers, and a sense of distrust or frank dislike of outsiders.  Such belief systems can develop independently of rational moral reasoning.  While all religious systems contain positive insights about morality (e.g. "love your neighbour as yourself", "blessed are the meek", "blessed are the peacemakers," "judge not lest ye be judged", "do unto others as you would have them do unto you," etc.), the moral prominence of these beautiful insights is often lost in a cloud of doctrine that becomes more about maintaining an emblem of group involvement, an "us" vs. "them" mentality.  This mentality is a manifestation of an evolved trait pushing all humans towards group involvement, formation of local communities in which we can feel trust and belonging, but with the unfortunate consequence of having outgroups which we would not trust, and which we would treat with less positivity, warmth, and generosity.  

The same phenomena occur in political beliefs.  While there could be core rational beliefs about positions on a political spectrum, with regard to preferred economic strategy, international affairs, management of public works, etc., a great deal of political involvement involves doctrinaire beliefs that are badges of group membership, and which have nothing to do with any understanding of policy.  Most people don't even know what the policy positions are, exactly, of the candidates they vote for.   Many others support their ingroup's politicians even though the associated policies would be harmful to themselves economically or socially.    We have tragically seen this happen during the pandemic.  Extreme beliefs about vaccines, masks, etc. became emblems of political group membership; many people made decisions about these issues not because of rational evidence (which strongly supported vaccine and mask use, for the protection of everyone's health, including the anti-vaxxers' own health and well-being), but because of the beliefs of fellow ingroup members in political or religious factions.  Masks and vaccines have almost nothing whatsoever to do with religion or politics -- they are simply common-sensical public health measures -- but once these issues became badges of group involvement, the issue spiralled into disaster, to the detriment of everyone.  This is an extreme example of the phenomenon shown in the famous children's study, where kids randomly given shirts of a different colour end up forming hostile ingroups, opposed to each other.  In the case of the pandemic, a great deal of anti-vax belief was simply driven by factors akin to having a different shirt colour, just to show difference from an opposing outgroup.  

In both books, reference is made to psychiatric theory as an example of self-deception.  Psychoanalytic theory is basically a set of ideas akin to religious doctrine, with a strong ingroup community of "believers" who couch discussion of psychiatric issues through the lens of a theoretical system which is mostly fictional.  As with religions, there are core beliefs in psychoanalysis which reflect deep insight and wisdom.   For example, the idea of psychological defenses came from psychoanalysis, and is ironically an insight into the tendency for humans to engage in self-deception, with the implication that we should try to become aware of our defences, and to be able to set them aside.   Similar insights warning about self-deception can be found in religious texts.  But most of psychoanalytic theory is arbitrary, based on bizarre inferences made from case reports, coloured by the already biased opinions of the therapists.   But as with religious practices, much of the therapeutic value in psychoanalysis has nothing to do with the literal belief system, it has to do with the practice itself.   Visiting a trusted minister or priest, who would most likely be kind, gentle, understanding, supportive, and wise, could be a wonderfully healthy practice, as could a meditative practice of daily prayer, or visiting a congregation of loving friends.   These healthy and possibly healing effects would occur regardless of the belief system held by the group.  Similarly, the practice of psychoanalysis (or psychodynamic therapy more generally) requires frequent visits with a wise, compassionate, gentle, kind therapist who probably has some useful feedback about life problems, and there would be a healing effect of simply having a stable therapeutic relationship over a long period of time, irrespective of the fictional theoretical belief system held, such as strict Freudianism.  

While we can empathize and even endorse the benefits of ingroup membership phenomena, I believe it behooves us to strive for improved rationality, to guide our knowledge and decisions so as to benefit ourselves, our neighbours, and the world in the most effective way.  Societies across the world have improved in this way over the centuries, as Steven Pinker has shown us (see Enlightenment Now), but we have a lot of work to do to continue progress in building a just, peaceful, prosperous society.  

In both books, we are wisely cautioned to look to ourselves for our own self-deceptions.  It is another human tendency to see self-deception or folly in others, while not noticing our own.  In my case, I recognize this will be a work in progress.   I surely have beliefs or practices that are products of my ingroup or other biases; I hope that I will be able to keep working on better awareness of these issues over time, in service to my patients and to myself.   



Monday, April 25, 2022

Review: Shrinking Violets: The Secret Life of Shyness, by Joe Moran

 Joe Moran's book is a nice exploration of various historical figures (such as authors, poets, and musicians) who had what he calls "shyness."  Moran alludes to his own shyness as well.  

A thematic goal of the book is to understand shyness as a part of the tapestry and variety of human life, as opposed to a pathology that requires treatment, or that is even treatable at all.  

Moran is a good writer--he's an English professor, and it is always a delight to read a book in this type of genre written by someone with a mastery of the language.  

This book is interesting as a historical or biographical journey, but I found it quite limited as a serious study of shyness from a psychiatric point of view.  First of all, "shyness" is a very limited term to describe the many varieties of anxiety, introversion, personality styles, and autistic traits likely present in some of his case studies.  

Near the end of the book, Moran encourages a position of gentle acceptance of shyness, but this acceptance seems to disparage the potential value of attempting to help people manage or change their social anxiety or avoidance using therapeutic techniques.  One chapter is even called "The War Against Shyness," which is a pretty strong condemnation of the therapeutic culture.    

There are many shy people, who have what might be considered social anxiety or autistic traits, who might find therapy helpful, to improve social skills, to find ways of facing fears more comfortably, or even to reduce anxiety a notch (including with the help of medication).   We should always have modest or limited expectations of therapy; also we need to take care to affirm an accepting rather than a pathologizing stance, particularly when social behaviour and experience always exists on a spectrum.  Yet the best of modern therapy is affirming and accepting; it just helps people to suffer a little bit less, to help people have a little bit more freedom in their lives to do things they might find meaningful, enjoyable, or essential for survival or prosperity.  

Sunday, April 3, 2022

Review: Blueprint by Nicholas Christakis

 I am happy to have discovered Christakis and his work, in an area I would call “evolutionary sociology” or “mathematical sociology.”  

Blueprint: The Evolutionary Origins of a Good Society is an excellent companion to books by Steven Pinker, Jonathan Haidt, and Richard Dawkins, and even behavioural economists such as Kahneman, looking at issues concerning the genetic components of individual and group behaviour, and the intersection or interplay between “genetic” and “environmental.”     Christakis shares Pinker’s general optimism about human progress, though through a social and anthropological lens rather than a strictly individual, rationality-based one.  Haidt and Christakis both look at dynamics of group differences, Haidt as a psychologist, Christakis as a sociologist.  And Christakis looks at gene-environment interaction on a group level, a continuation or elaboration of Dawkins idea of an “extended phenotype.”  

Near the beginning of the book, there are very interesting case studies presented about small groups that isolated themselves from the rest of society, either through choice (e.g. the Shakers), or through disaster (shipwrecks), then having to develop some means of survival, stability, or happiness.  Some organizational styles were successful, especially when there was some form of effective but not overly rigid leadership, combined with respect for individual differences, and a culture encouraging playful interactions.   Some styles led to failure (a very low survival rate), such as if warring factions developed, “Lord of the Flies” style, or if the community was either too anarchistic, too insular, or too tyrannical.  

Christakis introduces network analysis of groups, which I would like to learn more about.  I consider this to be in the mathematical discipline of “graph theory,” another nice example of pure mathematical concepts and modern data science allowing us a deeply insightful view of aspects of human nature.     I consider this type of analysis especially important in this age of online connectivity, which has the potential to amplify or distort connectivity phenomena, leading to powerful forces of social change, leadership, and spread of ideas or culture.  

After finishing this, I am motivated to finally start Christakis’ next book, Apollo’s Arrow, which is about  the COVID pandemic, again studying it through the lens of sociology and group dynamics.  

A general takeaway point from this book, from my perspective as a psychiatrist, would be to even more strongly value an understanding of social and group dynamics in a person’s life, to understand the nature of connections, connections of connections, group memberships, friendships, communication, and community, in much greater detail, as a component of understanding psychiatric phenomena and strategizing about therapeutic help, rather than stopping at the level of individual psychology only.  

Wednesday, March 23, 2022

The Urge: Our History of Addiction, by Carl Erik Fisher

The Urge: Our History of Addiction, by Carl Erik Fisher is a good book about the history of addiction, weaved together with a story of the author's own alcohol use problems and rehab.  

The original use of the word "addiction," as Fisher shows us, was more general or broad, referring to situations we might now consider "behavioural addictions," habit problems, or just very strong preferences.    This usage of the word, despite objections from some addictions specialists, may be most accurate from a neurobiological point of view, according to recent evidence.  

He emphasizes many times how addictive phenomena lie on a continuum of severity in different people and within the same person at different points in time, and are influenced strongly by social, economic, and political circumstances.   For some people addiction is a symptom of, or a means of coping with, horrible environmental circumstances.  For others, it is a trap leading to loss of control even when environmental circumstances have improved or are normal.  

Understanding and helping addiction problems has had an interesting history, with some compassionate medical and community help approaches evolving since the 1800s, but often interrupted or negatively influenced by social factors such as stigma or criminalization.  

I agree with his conclusions, that addiction treatments need to be individualized, and that there can be various different causes or problems which underlie addiction for different people.  AA or other 12-step groups can be valuable for many people, but this is not the only effective approach.  Other group styles, such as the "SMART" program, can be preferred.  Abstinence-based models of treatment may be preferred or necessary for some people, but for others it is effective to aim only for moderation without abstinence.  Some people do not want or need peer or group support, and prefer one-on-one counseling.  Others may prefer to manage their addictive problems alone; Fisher cites data showing that many people with addictions can recover without any therapeutic treatment at all.   There are medications that can help, such as naltrexone.  

Fisher acknowledges the importance of loss of control in addiction, and of the phenomenon of denial which delays or prevents many people from seeking help.  

There have been big problems in addiction management that must change.  First, there needs to be much more availability of addiction treatment programs for those who desire or need them.  There should not be economic biases causing some groups to have less access than others.  For opiate addiction in particular, there needs to be easier availability of methadone or buprenorphine maintenance for those who would like to try this approach.  Harm reduction strategies in general have a very strong evidence base.  

Second, public health interventions can be simple and effective, such as restricting the advertising or marketing of addictive products (such measures have been useful for reducing tobacco use in the population).  There is still a big corporate influence on policy (from the alcohol or gambling industries, for example), which should not be allowed to continue.   Third, there should be less focus on prohibition and criminal punishments, which in general have often made addiction problems worse, particularly by focusing expensive social resources on law enforcement rather than on community improvement and rehabilitation.  


Friday, December 10, 2021

Recommended Reading 2021: an updated book list

 Updated list of interesting books that I encourage checking out:


Steven Pinker: Better Angels of Our Nature: Why Violence has Declined  (2012)

Steven Pinker: Enlightenment Now (2019)

Hans Rosling: Factfulness (2018)


These three books, aside from being enjoyable and informative to read, also give a message of hope, that there are things actually getting better in the world, thanks to science, reason, and progress in justice, despite the world's many ongoing gravely serious problems.   They do not discount the gravity of ongoing problems, but are a nice antidote for the resignation or despair that can set in when faced with an onslaught of depressing daily news about politics, environment, disease, war, etc.  

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Thomas Picketty: Capital in the Twenty-First Century (2017)

This is a masterpiece, a historical analysis of wealth disparity and taxation, making an extremely compelling moral and economic case for introducing a better progressive system of wealth, income, and estate taxation.  This is not "socialist" as Picketty does not advocate state control of the market, but does advocate for fair regulation and progressive taxation in order to prevent regression to a pre-20th century societal style of wealthy aristocrats idly owning an increasing majority of national wealth, while most others work hard to hover near the poverty line, with little chance to progress beyond that level.  I find this issue of great importance as a psychiatrist, because it touches on the issue of managing poverty and fairness, permitting access to personal and community growth, in a way that is grounded in freedom and justice.  

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Richard Prum: The Evolution of Beauty (2018)

Almost every book or documentary I've seen dealing with evolutionary biology has emphasized natural selection as the main force of evolutionary change, while often only mentioning sexual selection in passing.  This book deals with sexual selection, a phenomenon first described by Darwin but relatively neglected in the next century.  This is of interest because Prum argues that sexual selection leads to a type of "co-evolution" in which esthetic choices lead to changes in culture which often improve autonomy, especially for females.  As a psychiatrist I think it is interesting as another emphasis of the cultural and biological foundations of esthetic choice-making in humans.  At the very least, interesting ideas to think about.  

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Daniel Kahneman: Thinking: Fast and Slow (2013)

Daniel Kahneman: Noise: A Flaw in Human Judgment (2021)


Kahneman's books are must-reads for any person.  His 2013 book is a masterpiece, an introduction to the subject of biases which influence human judgment.  I can't emphasize enough how important this subject is in the modern world, where our judgments are constantly influenced by factors within ourselves, and from external sources, which we are not aware of.  It is of relevance in psychiatry or mental health because of the importance for wellness to make healthy, well-informed, unbiased judgments, and because of the exaggeration of biases caused by depressive or anxious states.  

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Jonathan Haidt: The Righteous Mind: Why Good People are Divided by Politics and Religion (2013)

This is an incredibly important book, of the greatest relevance for the problems we face in the world in the past few years.  It is a compassionate look at the psychology underlying political, ideological, and religious difference, with recommendations of ways we can mend these differences and reduce polarization.  


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Paul Bloom: Against Empathy: The Case for Rational Compassion (2016)

This is a nice application of the psychology of bias, as described by Kahneman and others, to the practice of altruism and of caring for other people.  Bloom is a brilliant Yale psychologist, initially from Montreal, who has shown that typical reflexive emotional biases can cause our altruistic behaviour to be surprisingly misdirected, or unfair to those who need it most.  I don’t agree with all of his points, but I think this book is essential reading for a person interested in fairness, compassion, altruism, and justice.  

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Nicholas Christakis, Blueprint: The Evolutionary Origin of a Good Society (2019)

Nicholas Christakis, Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way we Live (2020)

I'm pleased to have discovered Christakis.  Blueprint is a great sociological study of group dynamics-- interesting descriptions of groups surviving on their own in remote locations or after shipwrecks; or groups separating themselves from the rest of society, including small religious enclaves, and an interesting introduction to the mathematical structure of group dynamics in communities.  

Apollo's Arrow is a nice review of the sociology of pandemics, including those from long ago as well as Covid since 2020.  The only critique is that it was published in late 2020, which is only about halfway through the Covid story as we know it today.  

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Robert Sapolsky, Behave: The Biology of Humans at our Best and Worst (2017)

Of course, on a psychiatrist's reading list, pretty important to include a title on neuroscience!  This is a great, detailed but readable introduction to how the brain works, with a particular focus on neuroanatomy and neuroendocrinology.  There are a few shortcomings, but overall highly recommended.  Everyone should be introduced to this subject matter.  

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Maria Konnikova, The Confidence Game: Why We Fall for it, Every Time (2017)

Konnikova is a psychologist who has studied con artists.  This book is an entertaining story of spectacular con artistry over the past century, with some commentary on the psychology of con artists and their victims. This subject is incredibly important today, because we are not only prone to being conned by financial scams, online fraud, etc. but also in choice of political leaders, as we have seen beginning in 2016.   We see that con artists can often be so persuasive that even after they are exposed and prosecuted, victims sometimes still support them, because of how effective the con was, and how humiliating it could be for a victim to admit or understand what happened.  Once again, we see this in particular political leaders since 2016.  

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Ellen Peters, Innumeracy in the Wild: Misunderstanding and Misusing Numbers (2020)

Ellen Peters show us the extent to which the majority of people have poor understanding of mathematics, even at a basic level of interpreting simple data.  This is of great importance because so many of the decisions we have to make in the world today, both on a personal and a political level, require clarity of understanding of issues that are best described in a quantified way,  and an ability to understand and question data intelligently.  

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Judea Pearl, The Book of Why (2018)

This is a book about the science of causality, which could be considered a branch of statistics.  This subject is important in order to understand information in such a way as to guide decision making rationally, and to overcome biases.  The first half of the book is most interesting, with a survey of the history of statistics, stories of particular important theorists whose ego unfortunately slowed down progress in the field (a common theme in history!), and with an introduction to thinking of problems through a lens of causality.  There is some discussion of the theory underling AI (artificial intelligence) which is going to be an extremely important area in all of our personal and cultural lives, from this point forward in history.   The second half of the book gets more technical, and in my opinion this material would be better presented in a textbook with worked examples, rather than in an ordinary text.  

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John Kelly, The Great Mortality: An Intimate History of the Black Death, the Most Devastating Plague of All Time (2006)

This is an exploration of a very important historical event, arguably the worst thing ever to have happened in human history.  The Black Death, starting in 1347, killed, quite suddenly, up to 50% of the population.  The scale of this pandemic was hellish beyond anything we can imagine.  It is obviously relevant in the context of our current pandemic.  Even though the Black Death occurred over 650 years ago, we still see the same extremities of human behaviour showing itself during our present pandemic, despite all the wisdom we've accumulated over the centuries.  This includes fanatical groups with bizarre theories of causation about the problem; racist extremists who blamed minority groups for the disease, leading to mass killings; and some heroic figures who tried to help, at tremendous risk to themselves.  

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Robert Cialdini, Influence: The Psychology of Persuasion (2006)

Cialdini is a psychologist who specialized in persuasion, initially by studying the tactics used by successful salesmen.  He identifies six major factors increasing the effectiveness of persuasive communication.  This subject matter is relevant for scientists, community leaders, and health care professionals, in order to convey health information in a way which is more likely to lead to positive change.  Obviously, this is incredibly relevant during the pandemic.  The other reason to be acquainted with this area is to be empowered to identify unwelcome persuasive techniques being used by marketers, politicians, or pundits, to avoid being conned or manipulated.   Unfortunately, I see that Cialdini's subsequent work has been of similar material directed mostly towards businesses and marketers, without further major contribution as a psychologist. But this initial book remains as a must-read.  

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Richard Dawkins: The Selfish Gene (1987)

Richard Dawkins: The Ancestor's Tale (2004) 

Richard Dawkins: The God Delusion  (2006)


Dawkins is one of the greatest science writers.  The subject of evolutionary biology should, in my opinion, be familiar to everyone.   This is not a dry subject--Dawkins' stories of animal life cycles are often fascinating and beautiful, akin to watching an Attenborough nature documentary.   And the scientific thinking is often spectacularly incisive.   In my opinion, Dawkins' often scathing critiques of religion are really critiques of fundamentalism in all its forms, and in my opinion are really just challenges to people of faith to be able to accommodate scientific understanding of the world into a belief system which is not rigid or unjust.  This is relevant for psychiatry and mental health, both because evolutionary factors obviously contribute to the existence of all human traits and problems,  but also because the subject matter itself, and the way in which it has been received by society in the past two centuries, has been impacted by psychological factors including ingroup biases.  

I specifically mention The Ancestor's Tale because at the time I read it, it struck me as my favourite Dawkins book.  

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Steven Pinker: Rationality: What it is, why it seems scarce, why it matters (2021)

This book is nice review of other material that would be familiar if you've read some of the other books suggested here, such as by Haidt, Kahneman, and others.  The genre is extremely important because our country and the whole world has been afflicted by waves of what Pinker calls "my-side-ism" or "motivated reasoning," driven by ingroup biases, tribalism, polarization, magnified by partisan news sources and misinformation.   Pinker is always carefully rational, a pleasure to read, with measured optimism and suggestions of ways we can improve the dire problems we are facing.   

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Astronomy Today 

Steven Hawking; A Brief History of Time (1998)

I include these books here, because I just think everyone should know something about astronomy and cosmology.  It's a foundation of understanding the universe and its history, it's wonderfully interesting, and as a psychiatrist I find that it helps us to cultivate a sense of awe and wonder about nature, the world, and reality, in a way which is deeply enlivened by the science, and which does not require superstitions or mystical thinking.   In my opinion, it is an example of how scientific understanding rather than pseudoscience deepens our experience of the world, of nature, and of our humble role as humans in the universe around us.   I think it's pretty important to know what the sun is made of, how far away it is, how old it is, what will happen to it in a few billion years, how far away the stars are, where they came from, etc.  For me it is an intersection of the existential with the scientific, something of great importance to psychological well-being.  

I would like to add similar titles relating to science subjects such as quantum mechanics, relativity, chemistry, paleogeology, and pure mathematics, as I think these are also sublimely interesting, in the same way that astronomy is, with similar existential impacts on mental health and well-being.  

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Video Documentaries

All of David Attenborough’s nature documentaries are, in my opinion, essential as part of enjoying nature and understanding the world.  Starting with Planet Earth, in 2006, the photography is spectacular.  A great way to learn, to be inspired, to enjoy nature, and hopefully to be motivated to do more to protect our world’s environment.  I consider an appreciation and personal experience with nature to be an important component of maintaining good mental health.  Another reason to watch Attenborough is because he is one of the great people, one of the great souls, of the past hundred years, in terms of character, integrity, values, and intellect. 

Neil deGrasse Tyson’s 2014 remake of Carl Sagan’s Cosmos series is another great documentary looking at the history of science, with a particular personal look at interesting people, many of whom you might never have heard of, who made great contributions to understanding and improving the world.  

The Mind, Explained is a good series of short documentary episodes (20 minutes each) looking at particular aspects of how the mind works (including subjects such as anxiety, focus, attention, etc.).  I’m impressed how much information they are able to pack into such brief episodes.  They might not always give a full picture of each issue, but are a great introduction.  

Thursday, May 20, 2021

Review: Sex at Dusk by Lynn Saxon

I read this book a second time recently.  

I appreciate that such a scholarly and well-researched text was written by an amateur scientist.  It was written as a critique of a more popular book with a similar title.  This other book attempted to make a case that humans in the pre-agricultural era (i.e. over 10 000 years ago) had a much more promiscuous lifestyle, which for them was supposedly healthier and more peaceful--then with the implication that we should try to emulate this in modern society.  

Saxon's book looks at almost every claim made by the other authors, and shows how their analysis was biased, incomplete, or just completely wrong, in terms of historical and anthropological data, as well as genetics and evolutionary biology.  Saxon shows that the authors of the other book particularly do not address the very dark side of almost every case study described.  The areas of focus in both books include social and sexual behaviour in primate species most closely related to humans (chimpanzees, bonobos, and gorillas), as well as cultures of remote present-day groups, such as those living in the Amazon.   A particular emphasis is the genetic basis (through natural selection) of behavioural traits.  

The subject of the genetic foundations of animal behaviour, and of the mechanism of evolution through natural selection, should be part of everyone's common knowledge.  Books by naturalists, biologists, or geneticists on this subject are not only informative from a scientific point of view, but are fascinating in the same way that watching a good nature documentary would be:  most of us are unaware of the life cycles and behavioural patterns of most of the species with whom we share the earth.  The stories, often about species that many of us have never heard of, but also sometimes about familiar species, are almost always interesting, but sometimes shocking or disturbing or intensely dramatic.  The best science writer in this genre is Richard Dawkins -- whether or not you like his philosophical point of view, it is essential and often entertaining reading to learn about other species, with the eye of a great naturalist.  

Saxon shows that we cannot escape some of the problems which exist in relationship and sexual dynamics in humans, including jealousy.  There is a strong genetic foundation for pair bonding in our species, though not without tensions, jealousies, and strong desires, which differ between the sexes, to have other relationships outside of the pair bond; but such excursions outside of a pair bond cannot occur without a substantial cost, often manifest in behaviour which is in part genetically determined.  

None of these genetic factors justifies a social policy which constrains relationship choices... social and relationship freedoms, as well as guaranteed personal rights, are aspects of social justice that have thankfully grown in our country in the past century; they must be created and legislated, whether or not they have always been favoured in our species through genetic/natural selective forces in the distant past.  



Thursday, May 6, 2021

Review: Capital in the Twenty-First Century, by Thomas Piketty

 Thomas Piketty is a French economist, whose book "Capital in the Twenty-First Century" is a great analysis of the history of wealth, economic inequality, and taxation through the past two centuries, focusing especially on Europe and North America.  


I highly recommend this book.  It is very long and detailed, and much of it is hard to understand fully for a person not experienced in economics or finance.    For a brief introduction to Piketty's work, there is a good documentary with the same title, which is also worth watching.  But the documentary does not contain nearly as much detailed analysis of the problems and proposed solutions, compared to the book.  

This book is important to read, to become familiar with these issues.  We all pay taxes, and most of us complain about them, but few of us understand the history of taxation, and the reasons why taxes are the way they are.  Even for those who are experts in the area, it seems to me that relatively few people (such as economists) have a good understanding of economic history.  


Piketty shows that income inequality was extremely high in the 1800s in Europe, leading to some people with enormous estates, while much of the population lived near or below the poverty line.  Most of the wealth in the society was owned by a very small number of people.   This changed dramatically mainly as a result of the world wars, and the resulting policy changes after the wars.  


Prior to the wars, those with enormous wealth paid very little tax, and this wealth was also passed through inheritance with very little tax either.   After the wars, progressive taxation of income and estates led to a large improvement in this type of extreme inequality, and allowed a much larger number of people (such as those in the middle class) to own a larger portion of national wealth.   


Interestingly, the United States in the 1950s-1970s had one of the most fair and progressive taxation schemes in the world, leading to improvements in economic inequality, before regressing substantially in the 1980s and beyond.  


Piketty shows that there are not only political and social consequences of having a society allowing extreme wealth to accumulate for a small number of people, without those people having to earn this wealth through work, there is also an economic consequence, since economic efficiency is not well-served or incentivized this way.   


His suggested solutions to this problem include having a progressive income tax, a progressive tax on estates & inheritance, and a progressive tax on capital or total personal wealth.  By progressive, he means paying a higher rate for higher levels of income, and a lower rate for lower levels.  At present, there are many examples Picketty shows where the system is not progressive, but regressive--that is, people with extreme levels of wealth actually pay an overall lower marginal rate on their vast incomes, compared to those in the middle class.  


The main barrier to a progressive tax on capital (i.e. a tax on invested fortunes), is that such investments are often hidden; many extremely wealthy people hide their wealth in offshore banks, etc. so it is hard for governments to understand how much wealth there is.  These are so-called "tax shelters."  In order to solve this problem, governments across the world would have to come together and cooperate with sharing banking information, to create a type of global wealth census, or "cadastre."  


How is this relevant to psychiatry?  Economic issues, including poverty, are extremely important in the causation and management of mental health problems.  Universal health care, and universal comprehensive education (including university  college, or other training) is possible in all countries, and can be improved where it currently exists, such as in Canada.  But health care is expensive, and needs to be fairly subsidized.  Taxation issues obstruct the provision of efficient social services, including health care.  


Also, greed in general, without a principle of making social or community contribution, is a factor contributing to declining mental health, and to more social problems including crime.  


I did not find Piketty's analysis or recommendations to be "radical" at all.  They are not in opposition to free-market economics, but rather are supportive of a system where markets could be free for all, without rapidly escalating and uncontrolled excesses.  


Monday, October 7, 2019

Indistractable: Book Review

 Indistractable, by Nir Eyal, is an instruction manual, teaching us how to make healthy choices with our attention and activities, in the midst of the many addictive distractions of the internet age.

It is a good book,  but most of  its content could be acquired through a brief surfing of the net.

Eyal wrote another book in 2014 called Hooked: How to Build Habit-Forming Products. Ironically, this earlier book uses his knowledge of persuasion and behavioural psychology to foster the very addictive distractions that Indistractable tries to rescue us from.  In some ways I guess we could compare that to the management of a casino organizing its own addiction treatment program for customers.

The book itself is well-written, and its format is an example of how to keep a reader engaged: the chapters are short, the language is simple and clear, and the main points are summarized at the end of each chapter, then once again at the end of the book.  There is even material provided to get started on a CBT-style program to become "indistractable."  The "indistractable" language is based, I'm sure, on a marketing idea of encouraging an identity-based slogan as a motivational tool.  If one were to wear a t-shirt with the "indistractable" logo it might help motivationally.

The book itself is a product, and I suspect that it will lead to profits for the author.

Yet, the ideas contained within are useful, and worth knowing about.  Aside from simple behavioural techniques (e.g. decluttering your home screen, scheduling in advance, etc.) there is appropriate attention given to identifying the emotions accompanying distracted behaviour, and to identifying core values (e.g. of being a good parent or a good friend) as a primary motivating force to choose relationships or meaningful work rather than surfing Twitter, playing a distracting video game,  or having a text conversation.

This is another example of how therapists or physicians can learn important lessons from people who have expertise in marketing.  It often requires an inspiring persuasive message to help someone who is struggling with depression, anxiety, addictions, or other problems to make positive, sustained engagements with meaningful life change.


Saturday, September 21, 2019

Review: "The Coddling of the American Mind" by Lukianoff and Haidt

The Coddling of the American Mind:  This is another book I recommend as an important, timely review of contemporary issues relating to modern culture, parenting, free speech, and university education.

I respect what I think Haidt is trying to do, as a persistent theme in his career:  to be a peacemaker, to encourage intelligent, harmonious, respectful dialogue among people with different viewpoints or political leanings, and to reduce or mend hostile polarization.  This theme comes across once again in this book.  I could not support this goal more strongly.   Haidt is probably one of the few psychologists who would have a respectful audience among people right across the political spectrum.

But there are many areas where I disagree.

Safetyism -- A Culture of Fragility

The initial section discusses how in a well-meaning quest for "safety" we can create a culture in which people are weaker, less capable, and more fragile.  For example, if we are so afraid of a child falling down and getting hurt, we might not allow bike riding, climbing, gymnastics, etc.  But this lack of exposure to challenging, slightly risky activity would lead to a failure for the child to develop normal physical skills, and might also lead to the child learning to fear and avoid challenges, rather than to face them and master them. 

Ironically, this would sabotage the goal of improving safety. 

Intellectually, according to the authors, if we teach fear, avoidance, or suppression of disagreeable ideas and of the people who express them,  it may likewise lead to a failure to develop normal resilience or problem solving, and may foment unnecessary, destructive societal conflict.

So the authors are saying that just as we must allow children to try riding bikes or climbing, even though there is a risk of falling, we must encourage a cultivation of resilience and respect when exposed to disparate ideas, including those which offend us.

Cognitive-Behavioural Therapy (CBT) as an approach to modern life

The authors make frequent mention of cognitive-behavioural therapy (CBT) ideas, as a model for approaching these social and political issues.  The principles of CBT call for us to study our thoughts, assess them for possible distortions, be open to challenge them and test them behaviourally, and also to face our fears.

Extreme Examples, Case Studies

They describe a variety of unsettling stories of extreme cases, where so-called "safetyism" led to excessive negative consequences for scholars, for free speech, even for university culture in general.  The authors argue that these conditions cause intellectual freedom to be dampened, replaced by an atmosphere in which some professors may be reluctant to speak their minds or share their research, for fear of causing offense and a resulting protest or scandal. 

A decline in teen and young adult mental health?  

The authors move on to describe their theory that teen and young adult mental health is declining, and that a combination of  "safetyism," overprotective parenting and internet use (especially social media) are responsible.    One of their prescriptions for this (which they advise strongly near the end) is for parents to encourage so-called "free play" with a restriction of internet or smart phone use for children.

Misgivings

Here are some of my misgivings:

 As is often the case, one can make a general prescription for a cultural change based on knowledge or experience with a limited group (sometimes a group of just one, when we recommend to everybody what worked for us individually).   Haidt is a respected, famous academic leader who has a fair bit of influence.  His book is marketed extensively, as I suspect are the public lectures across the world.  It would be consistent with one of the better themes of this book to welcome some balanced and thorough debate about it.  One insight from social psychology is that once a person has publicly announced a position or opinion (especially in the form of a well-selling book) they are more likely to be biased in favour of this position, despite contrary evidence.


It may well be true that cultivating intellectual resilience through exposure to disparate intellectual ideas, exposure to risk, free play, etc. are in general good things, which would be reasonable public health measures or aspects of a healthy policy about parenting or education.  But such cultivation may require a different approach for different people, just as cognitive-behavioural therapy would need to be approached differently depending on where the individual person is at.

In CBT, as with any therapy, the process cannot be pushed if the person does not consent to it.  Exposure therapy (e.g. exposure to fears, challenging safety behaviours) cannot occur without informed consent, otherwise it would often be traumatic and counterproductive.  And exposure usually needs to occur in a controlled, gradual manner, which is quite different from the way stress occurs in the environment (such stress outside of a therapy room is usually random and uncontrolled).    And not every mental health problem is amenable to exposure therapy; in some cases exposure makes things worse.  Humans are not always "antifragile."

One of the reasons why I think there is more stress about conflictual issues on university campuses is not because the students are less resilient at all.  I think it is because universities in general have become more accepting and accommodating to individuals whose concerns would have been more dismissed and marginalized in previous years and decades.

It is possible now to attend university while having more serious mental health problems, and most modern universities are more accommodating than they were in the past. 

There are also movements for previously marginalized groups to speak out, and insist on their rights.  Such insistence, as we see from all previous civil rights advances through the ages, often does not happen without social stress and conflict. 

So actually I think students are at least equally, if not even more,  resilient, courageous, and brave than they were in the past.  They are not merely "coddled." 

It is not clear to me that there is a large change in rates of mental illness, over a long span of time.  There may be, but it is debatable.  There can be transient ups and downs over the span of years or decades.  Causes for these changes are probably complex, regionally variable,  and multifactorial.  Economic factors, such as poverty,  are probably very important and underappreciated.  Different rates may be due to different rates of reporting, more awareness in the population, different trends or fashions of diagnosis, etc.

And if there is a change in the prevalence of mental illness, it is by no means clear to me that internet or social media use is responsible (there are some important recent studies disputing the impact of the internet on youth mental health).   There are good alternative viewpoints--here's a link to one good article: *   Przybylski, an Oxford researcher, has published a recent study worth reading on this subject: **

It is certainly not clear that parental "coddling" is responsible for changes in teen or young adult mental health.    There is evidence on both sides of this.  Common sense would dictate that, just as with any other human behaviour, we should be careful with our habits, our parenting, and with how children are spending their time.

I do more strongly agree about one of the authors' points about modern parenting:   it is not healthy for children to be overscheduled, to lack free time, and to be forced at a young age to start academic preparations for admission to a prestigious university.  Childhood should be a time of relationship development, play, and freedom.  However, some individual children may greatly enjoy and appreciate extra academic focus instead of more "free play" -- I know I was one of those children myself.

About "coddling."   The authors include this word in the title of their book.    It is meant as a pejorative of course.   I don't like it.  "Caudle" is a thick, sweet, warm drink which is meant to be  digested easily or enjoyed by someone who is unwell.  The authors use the word to mean that we are overprotective of others, including our own children, to the point that we are causing harm, as though feeding "caudle" to people who aren't ill.

I agree that such overprotection can occur.  But many children actually do need more protection and parental supervision. "Caudle" is often useful and good.  Different kids develop at different rates.  Some individuals, for various reasons, never attain, and are unable to attain, the full set of skills they need (physically, emotionally, or socially) to function independently, despite maximal "CBT."    Such individuals have often been neglected, left behind, and excluded by the majority.  One cannot just make a blanket prescription to "let the kids play more."   As a specific example, various types of learning disorders and developmental variants (such as autism-spectrum phenomena) are permanent, and they cannot be resolved simply by pushing the students to face their fears; remedial help and accommodation are needed (I guess we could call this "coddling").    Social anxiety disorders, which are extremely common,  should be approached using CBT techniques, but it is unlikely that any therapy can "cure" social anxiety -- we also need to accommodate ("coddle") and value shyness, rather than just try to "treat" it. ***

"Safetyism" should not be criticized too much.  Accidents and injuries are among the most common causes of death and permanent disability for children and young adults.  Basic improvements to safety are an obvious, reasonable societal advance.   People complaining about "coddling" as an impediment to healthy development might criticize safety features at playgrounds, or of signs recommending safe practices or rules for games.   I don't think these things deserve criticism.  Safety features and play instructions can be helpful for many people.  For those of us who don't want or need these safety features, we can just ignore or defy them, unless they are incorporated into law (such as regarding seat belt or helmet use).

With respect to parenting, the most common situation I see in my clinical practice is of people who have not been "coddled" too much, but who have been neglected or mistreated by their parents.   This has nothing to do with how much "free play" has occurred.

A common cause of such neglect is of a modern lifestyle where parents are too busy or disconnected to play with their children.   The causes for this phenomenon include cultural trends in work and parenting; economic stress; and mental illness.  Most children can accommodate to this, and even thrive, but some cannot.   Some children would find endless hours of free play to be a torment.    It need not be considered some kind of parenting triumph to allow your child to walk to school alone at an early age.   (I do not consider walking alone to be risky--the authors are correct in observing that risks of abductions, etc. are extremely low, and should not rationally lead to walking children to school just for their physical safety.)  But physical safety is not the point.  Enjoying time and relationship with your child is the point!  If you have the opportunity to play with your child, or walk him or her to school, this is not some kind of harmful "coddling"!  It is one of the joys of life, leading to memories that both of you will savour for the rest of your lives.     And some children may need to be walked to school, to help them negotiate their anxiety or build their social strengths alongside a trusted adult.  This is ok too, and is not "coddling" except in the best sense of the word.

I in general support the authors' recommendations for being open to hearing and respecting opposing points of view, as opposed to shutting down opposing voices using angry protest.  However, perhaps this recommendation deserves some questioning as well.  For example, if one has signed up to learn genetics, and if there is a space and time for a visiting lecturer once per week, I think most would consider it bothersome to reserve this precious lecture time and student attention on entertaining speakers who deny the existence of genes or DNA.  Free speech may not require that every point of view should have equal access to a reputable and influential public forum.    Of course, this would lead to a question of who has the power to decide who gets access to this forum.  A default answer would be to say that in a democracy, it is the people who would decide, hopefully guided by the wisdom of experts.   But sometimes the experts could be wrong.  Or sometimes population trends could be unreasonable.   In these cases, I do agree very much with the authors in affirming a principle of calm, reasonable openness to dissent to be enshrined as a guiding principle, as it is in many nations' constitutions.  And it is also reasonable for everyone in the population to be acquainted with rational techniques for self-questioning, such as CBT.

I actually do find that CBT ideas are so prevalent now, that many college students are aware of the theory already.  Young people are intelligent and well-informed, for the most part.

My own recommendations:

First of all, I question my right to make any sort of recommendation.    I think it is better to be a little more humble and admit that there is quite a bit of uncertainty about all of these things.

For parenting, I think different children have different needs.  For some it is ok or necessary to "coddle."  For others, it is best to encourage a lot more "free play."  For many kids it probably doesn't make a whole lot of difference either way, and there could be leeway to simply choose the strategy that is possible for you, and that you and the kids enjoy the most.  I am a big fan of spending a lot of time with one's children, to cultivate a close relationship, to build strong, positive, happy memories.  Such memories are, in my opinion, strongly protective of lifelong mental health, and one of the most powerful sources of resilience that experience can offer (other sources of resilience are inherited, and have nothing to do with parenting).   They are also very satisfying for a parent, and probably are associated with healthier, happier aging.   In many cases, though, the memories have nothing at all to do with mental health per se.  They are just memories of time together.  In general, I prefer to have them rather than not.