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.

Book Recommendation: "Behave" by Robert Sapolsky

Behave is over 700 pages long.  Its size may lead to some potential readers being intimidated, but I found it an engaging, often entertaining review of neuroscience, from the lens of someone who has good experience and understanding not just of brain chemistry, but of social, historical, and psychological influences upon behaviour.

One of Sapolsky's big messages, in a nutshell, is that very few single factors (such as hormone or neurotransmitter effects, genes, or environmental incidents) have a simple, obvious, consistent impact.  These factors have different effects depending on the circumstances.  For example, androgens may only exacerbate aggressive behaviour in someone who is already having difficulties containing aggression in the first place.  This immediately makes me question the generic finding (recently published) that violent video games have no negative impact...perhaps there is a negative impact, but only in those who have violent behavioural tendencies in the first place.

On the one hand, this is a refreshing antidote to the simplistic reductionism that is often presented in discussions of neuroscience or psychiatry.  On the other hand, it does not negate the importance of studying these factors with good scientific depth, so as to work with them therapeutically, on a neurobiologic or societal level.

A criticism I do have about the book is his references to areas of the psychological literature (such as about priming, for example) which are now being questioned:  a lot of findings about priming seem to have failed replication tests, and so I'm not sure what to think about this whole area anymore.  I suspect influences such as priming do exist, but may be more transient or erratic than what the original literature suggested.

I appreciate his balanced analysis of the work of other thinkers, such as Steven Pinker, and other historical figures in psychology such as Zimbardo. 

I most appreciate his message of hope, about the things we can all work on to live more peacefully, in light of the influences (positive and negative) upon our behaviour that we are born into, through our genes, family, and culture.

This is another type of book that I wish students could be exposed to as part of their university education about psychology, medicine, or other areas of the humanities.

Steven Pinker's optimistic new book

I'm a Steven Pinker fan...I really appreciate his optimism about the state of the world, and the future of the world, an optimism which he supports with a lot of engaging evidence.

So I encourage having a look at his book, Enlightenment Now.  It is a sequel to another of his books (Better Angels of our Nature) which I have reviewed earlier on this blog.

I don't agree with everything he says, but I do also embrace a spirit of optimism about things, and an attitude that the many problems we have in our lives, or in the world, can be solved or at least improved with continued care and effort. 

This type of book is a good accompaniment to a study of behavioural economics and social psychology (such as the works of Daniel Kahneman), as well as optimistic data analysts such as the late Hans Rosling.

The strongest section of his book is the middle part, in which the reader is barraged with many graphs showing positive changes in the world over time.  I found the other sections, with a lot of philosophizing about the enlightenment, etc. less important and engaging. 

As to this book's relevance to mental health?  I hope we might all embrace a spirit of optimism about the pathways of our lives.   Past adversity in life does not necessarily predict a guaranteed future life of suffering.  There is work to be done, to build a better, happier life, regardless of the hardships of our origins.

In the cognitive theory of depression or anxiety, we understand that thoughts may specifically focus on pessimistic or even catastrophic interpretations of observations; much information in our modern world is distilled to emphasize catastrophe or adversity (non-catastrophes are less likely to become headlines), so this information is natural fuel to a depressive or anxious state.  An optimistic but highly rational book such as Pinker's could be understood as a type of cognitive therapy for a modern consumer of news.

Progress in the world may also translate overall to improved mental health...but I suspect we would see the most robust improvements in those areas which have the least current services.

A peril of such a strongly optimistic text can be that it fails to empathize sufficiently with those who continue to suffer...or that it can seem insensitive when there continues to be horrible tragedy in the world.  But I think that we are best able to help and heal from tragedy if we are not depleted, pessimistic, or even hopeless about the ongoing problems in our lives or in the world.  So this book is a much-needed infusion of optimism into public debate.

Depression Treatment Guidelines

I encourage having a look at the September 2016 issue of The Canadian Journal of Psychiatry, which summarizes treatment recommendations for major depressive disorder, based on a thoughtful review of the evidence available at the time.  The authors spent many hours of careful work preparing this authoritative set of articles, and I think they did a good job. 

Here is a brief summary:

1) Various antidepressants are beneficial for treating depression.  They may help with an acute episode, and may help prevent relapses if continued.  Some may work better than others, but the differences are small, and there are likely to be individual cases in which a so-called "second-line agent" works better than the first-line choices.    Some things are classified as "second-line" not because they are necessarily inferior, but because they have not been researched as much as the "first line" things.

2) Various types of psychotherapy are beneficial for treating depression.  These, too, can be helpful for acute episodes, as well as for preventing relapses, even after discontinuation.  CBT has particularly strong evidence for being effective. 

3) As to specifics, such as "which medication is best under which circumstances?" or "which type of psychotherapy is best under which circumstances?", the evidence often does not guide us clearly, aside from CBT in general being favoured. 

4) Various other types of treatment, including ECT, TMS, exercise, and light therapy, have evidence supporting their use.

I am concerned that there was not a lot of critical debate about these claims.  Many authors of review articles are proponents of a particular type of therapy (e.g. light therapy, CBT, etc.), and the content therefore may be biased, or at least lacking input or commentary from different points of view.   It could be argued that "the data speaks for itself," but often the verbal conclusions resulting from the data can be coloured significantly by the author's opinion.

There are some useful specific pointers:  for example, there is a lack of evidence that combining two different antidepressants is consistently helpful.  But "augmenting" strategies, such as adding an atypical antipsychotic medication to an antidepressant, are better supported by evidence. 

In general, for me, these guidelines are most useful as a very general introduction, to get an overview of common treatments, and of up-to-date research evidence.

Here are some ideas of my own to add about "treatment guidelines":

A very thorough understanding of a person's history is most important for care.  In many cases what appears to be "major depressive disorder" ends up being a more complicated story, upon spending time learning the history.  Many treatments such as antidepressants can be dangerous if given without thorough understanding of the history (for example, if there is a history of bipolar symptoms).  Obtaining a good history is not necessarily possible with a single visit, with a standardized interview, etc.  It takes time and a good therapeutic relationship to know a person's story.

There is some question about the validity of "major depressive disorder" as a construct.  Eiko Fried has a good summary of this issue on Twitter: https://twitter.com/EikoFried/status/935098850439847937
As I have written before, a great many patients do not have only one diagnosis (assuming we are focusing on a DSM-style diagnostic scheme).   It is therefore limited to focus only on the treatment of depression alone.  I realize that it is a convenience in research to define syndromes in this way, which can then help us to measure the effectiveness of treatments systematically.  But for a given individual, it is often necessary to step away from diagnostic constructs, and help the person in the specific ways they desire or need. 


There are many pathways towards nurturing mental health.  Finally it is reasonable for most people with depression to try various treatments, including medications, provided there is a good understanding of risks and potential benefits.  Psychotherapeutic ideas (such as CBT, but also other styles) are beneficial for most anyone, even those who do not have formally diagnosed mental illness.  Lifestyle and psychosocial factors are very important: exercise, healthy nutrition, healthy social, family, and community development, physical safety, career, education, stable finances, and the pursuit of meaning, should be an invited focus for everyone.    There is relatively little attention given to these issues in most published treatment guidelines (sometimes I get the feeling that some authors in the field are embarrassed to even approach them) yet for many people these issues are the most important of all.

In the 102 pages of this journal, which are devoted to approaching and treating depression--a disease of emotional and often existential suffering, loneliness, joylessness, and a crisis of meaning--here is a tally of individual words used in these pages:

1) love:  0 times.  The search engine found a reference to the author J. Glover as the only occurrence of "love"
2) compassion: 1 time
3) nutrition: 1 time
4) cooperation: 0 times, except as part of 7 references to an agency (the "Asia Pacific Economic Cooperation") which gave money to one of the authors
5) healing: 1 time
6) friendship: 0 times
7) encouragement: 1 time
8) pets: 0 times
9) nature: 1 time (referring to "nature of risk")
10) joy: 0 times
11) humour, laugh, laughter, smile, happy, happiness:  0 times for all
12) art, hobby, hobbies: 0 times
13) patience: 0 times
14) drug: 86 times
15) intervention: 91 times


While I love science (my alternative career would have been a mathematician or a statistician!) it is necessary in mental health care to also discuss issues or words that do not fit neatly into a science or data-based analysis.  These issues include compassion, meaning, love, and patience.  Another issue is finding ways to cope with, live with, or accept unremitting chronic illness or pain, while continuing an evidence-based, but uncertain and frustrating, search for relief or cure.  Algorithms and guidelines tend not to help very much with this existential struggle.    Educationally, I think it is more valuable to present case studies, with group engagement, perhaps with references made to treatment protocols, rather than to make the protocols themselves the subject of the lesson.   

I prescribe a lot of medication.  In some cases the medication appears to be incredibly helpful.  In many other cases, there is a small but significant benefit.  And in others still, there is not much benefit at all despite many, many trials of different medication.  And in a few cases, the medications are harmful.   Many of my patients benefit most from medications that are considered "second line." I can't think of any examples in my practice where guidelines of this type have been useful in determining the most helpful course, aside from being a very general roadmap to remind us of available options or the occasional new finding in the research.   But this roadmap would already be very familiar to most mental health professionals, part of an academic focus over years of training.   Specific treatment issues (such as choosing the best medication or psychotherapy combo etc.) are part of professional development: this requires ongoing familiarity with the broad research literature, and with experience in clinical practice, rather than reliance upon review articles.    Review articles of this type are  authored by research experts, whose work deserves respect; however, the authors represent a limited subset of expertise within the population of mental health workers.

My therapeutic style has included more and more ideas based on CBT, over the past 15 years.   Many of my patients work on structured CBT elsewhere as well.  As with medication, this is incredibly helpful for some, slightly helpful for many, and has little or no effect for a few others.  Arguably, some CBT groups could even be harmful for a few, if there is a large mismatch between what the person desires and needs and what is actually offered.   In many cases, people are familiar with these therapy styles, but have not yet really done the work necessary to derive benefit from them.  This lack of work is usually due to the depression or the psychosocial situation itself, but also can be due to a lack of continuity of care.  It can be a little bit like trying to learn a foreign language, and dabbling in it for a few months, learning a bit of grammar and vocabulary, but never really gaining fluency due to a lack of immersive focus,  and a lack of someone to speak the language with on a regular, long-term basis.


Many people, I think, simply benefit from knowing that they are being cared for, by a person or system which has time and attention for them as they need and desire, sometimes on a long-term, open-ended basis.  It is helpful for mental health care providers to be well-versed in a wide variety of therapeutic techniques, and to be able to adjust or tune the care to what each individual patient or client wants or needs.   Within a system, it is good to value the unique styles and abilities of different individuals within the group, rather than compelling everyone to follow an identical protocol.  Some caregivers are better-suited to using a CBT style, while others are naturally suited to IPT, meditation, or psychodynamic styles.    Some psychiatrists have a particular expertise and interest in medication management.  Most research protocols do not look at this issue in groups or systems.  These individual variations should be respected, but I do think it is also good for everyone to come together to learn from each other.  For example, psychodynamic therapists can adopt interesting, useful ideas from CBT therapists, and vice-versa.

Most of my patients would say that it was not some medication combo or therapeutic style or adherence to guidelines that ended up helping them, but was a combination of many factors, in conjunction with a system of care (such as a therapist, psychiatrist, or other support network) which was stable, consistent, compassionate, and long-term.

Compassion vs. Empathy: Reflections on Paul Bloom's Book

Paul Bloom, in his recent book called Against Empathy, challenges us to question the role of empathy as a vital ingredient of goodness or morality.  Bloom believes that kindness, guided by thoughtfulness, is the supreme guide to morality, while empathy is often morally neutral or even negative.

Bloom's definition of Empathy

By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling.    Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems.  Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.

Bloom clearly is not talking about "understanding."   He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully.    A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state.  Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour.   With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:

Problems with Empathy

1) Empathy does not correlate with kindness.  Many people who behave cruelly have a lot of empathy for their victims.  In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty.  A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.

Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all.   People who perform daring rescues often do not empathize before they act.  Having an empathic reaction in an emergency could delay a life-saving action.

One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney.    People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!

Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive.  A caregiver who is highly, reflexively empathic is at greater risk of burnout.  Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm.   Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.

2) Empathy as a moral guide can cause us to behave in a biased or unfair manner.  If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently.    Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer.  This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.).   It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.


Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies.  He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone.  This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.


My Thoughts

I see Bloom's thesis as an extension of Kahneman's insights about psychological biases.  Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.

Empathy, in my opinion, is a quality similar to eyesight or one of the other senses:  it does not, in itself, have a moral quality.  It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions.  Having highly developed empathy does not make you more moral any more than does having sharp eyesight.  If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions.  This does not mean we should not cultivate our senses, including eyesight or empathy.  They are important talents and skills, and they deserve attention and practice.  It is just that we should not rely on them by themselves as moral guides.

Taming Empathy

I do believe that empathy is important, however.  It just needs to be "tamed."  I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust.   A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold.  Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment.   A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity.   But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not  be helpful!  It would probably frighten or disturb the patient, and would also lead to burnout in the therapist.   A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.

Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide.   Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.

Empathy for the Therapist! 

Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction:  if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.

Empathy could work this way in therapy as an example of social learning therapy combined with CBT:  if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to follow...in this way the therapist would truly be an emotional guide.  I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.

The Importance of Listening and Showing Understanding

I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy.  I usually use the term empathy in a broader sense.    When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen.   Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away.  And they may be frustrated if the other person starts to discuss their own similar problems.   It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved.  This reflection and demonstrated understanding is what I mean by empathy, most of the time.  A typical example could be saying something like, "you had an exhausting day..."  When giving this reflection, I would not normally feel exhausted myself!  Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.  

Feeling Trapped in a Life You Don't Want: Hopelessness & Chronic Depression

I originally published this post in March, 2009.  I was just looking at it again today, while browsing through my blog...I thought I would re-publish this, and maybe work on adding to it.   I have been reviewing treatment guidelines for mental illness, and have been asked to help prepare some official guidelines for my workplace...while I find this task, of preparing "guidelines,"  meaningful or useful in some ways, with some worthwhile observations and tips to be discovered in the existing research, I finally find the task a great source of weariness and frustration.  This particular post really represents something that is much, much closer to the "core" of who I am, or who I want to be, as a psychiatrist.  And it reflects more deeply--than any "guideline" could-- my beliefs about caring for people who are suffering.   


This post is in response to a comment on my previous post "What to expect from an antidepressant".

What is the purpose of a life?

What needs to be present in a life to make it worthwhile?

If a life is like a work of art, a giant canvas that you have been working on for decades--what if you feel that the canvas has already been wrecked? The damage may have been caused by "bad genes" (e.g. an inherited tendency to be depressed, etc.), which in the canvas metaphor might mean the canvas itself is fragile, thin, easily damaged, doesn't hold pigment very well, etc.

Or the damage may have been caused by "bad environment" (e.g. a traumatic childhood, lack of support, lack of opportunity, natural disasters, war, poverty, etc.), which in the canvas metaphor might mean the canvas itself has been damaged by others, or by environmental adversity, causing it to be very difficult or painful to work with in the present.

Or the damage may have been caused by your own past efforts (e.g. a history of spending years trying to develop oneself-- in school, in relationships, in work, etc.--but where these efforts have ended in failure, pain, breakups, sorrow, regret, guilt, or a sense of having burned your bridges--and where the past failures obstruct future opportunities, e.g. via a poor academic transcript, work record, etc.). In the canvas metaphor this might mean there is a lot of paint on the canvas, but none of it is what you want, none of it is where you wanted it to be, none of it you actually like, it all looks like a collection of mistakes. If it was a literal canvas, you might feel like the best action would be to just throw the painting away, and either start fresh, or give up painting altogether. You might feel like you never wanted to paint in the first place, that the task was forced upon you by the fact of your birth, and by the social expectation that you are supposed to live out your life.

For many people who struggle with chronic depression, I think there is some combination of all these three possibilities: genes, external environment, and personal efforts which haven't worked out, all contributing to a state of hopelessness, tiredness, exhaustion. It can feel like a daily struggle just to make it through the day, a yearning for time to pass just for things to be over. Life can feel like a trap, a life sentence to a prison term, a forced existence that you never really wanted, or have long since stopped wanting.

The idea of a medication somehow "treating" this problem can seem absurd. Or the idea of so-called "cognitive therapy" changing this problem can seem insulting. It is like observing a painting you don't like in an art gallery, and then being told that you have to do some exercises to change your thinking, so that you will start to like it, then have it up on your living room wall for the next 60 years. In some ways this dynamic reminds me of salesmanship, in which case it can feel like the therapist, or even the whole external world, is trying to "sell you" the idea that your life is supposed to be worthwhile, when all you see is something you hate and want to get rid of.

I don't have easy answers to this problem.

But here are some of my beliefs about approaching it:


There are people who will care about you, and who will sit with you through your suffering. A role of a therapist in this type of situation, I think, is to sit quietly, to be gently and consistently present.

The world is full of possibility. No matter how bad conditions have been--internally or externally, past or present--growth and change are possible. The brain is a dynamic structure. It is as powerful and consistently active when alive as is the heart. But the brain reinforces its own pathways. If these pathways give rise to feelings of despair, hopelessness, and futility, then every moment of life can become experiences of despair, hopelessness, and futility. If these pathways of thought, emotion, and felt experience, have been trodden for decades, it can be hard to forge new pathways within the mind.

Immense, profound life change is possible, regardless of how severe problems have been, how long they have been present, or how much damage the problems have caused.

Such changes may require an enormous amount of energy and time, and may require a lot of external support.

There are many individual life stories of profound life change, stories of journeys through chronic hopelessness towards meaning, energy, and joy. Historically, some of these stories are of mythical proportion, and are present in literature and the other creative arts. Many religious stories contain themes of this sort.

Contemporary examples include stories of individuals overcoming lifelong addictions which had devastated their previous life histories (here I am not saying chronic depression is an addiction, but that addictions and depression can both be characterized by feeling very stuck in something bleak and hopeless). The lore in addiction treatment has wisdom to share about making radical life change--in "12 step" models, for example, individuals are called upon to admit "powerlessness" over their problem, and to make a set of statements of faith about a "Power greater than ourselves", etc. While I am wary of the potential for dogmatic religiosity in such statements, I also see that if dogma can be set aside, the "12 steps" can be seen as a sort of "leap of faith", a new contract with life, to live--and work-- with the help of a supportive community. It admits, powerfully, that one must reach out to connect with the possibility of change, it is almost impossible to do alone (the "higher power" idea can simply be an admission that one needs external help).

Psychiatric medications in chronic depression usually do not lead to "profound life change" (sometimes they do, but really this is in a small minority of cases). However, often they help a small to moderate amount. Either to relieve some suffering or pain, or to potentiate energy that might then help to effect a new course in living. I do not feel that any effective treatment leads a person to become resigned to an unpleasant status quo, and then to learn how to "accept a bad life". I feel that effective treatments allow unpleasant circumstances to feel more bearable, then to facilitate the hope and actions that are necessary to improve the unpleasant circumstances.

Cognitive therapy can help. The goal, however, in cognitive therapy, cannot be simple "salesmanship". I think the goal has to be building a satisfying life, where there are healthy, stable relationships: meaningful work, meaningful love relationships, and meaningful activities that bring joy or happiness.

With any type of process that causes deep changes in the brain, the pathway may require you to go right back to the simplest foundations.

I'm reading Norman Doidge's book about "neuroplasticity" right now (The Brain that Changes Itself), which incidentally I recommend highly. The evidence he presents is quite convincing, to some degree surprising, but on another level intuitively very obvious--the brain can change itself, sometimes very radically.

But if new paths are to be formed in one's "mental forest" one may need to start with tasks that seem extremely simple, even infantile, perhaps even "insulting" in their simplicity. Cognitive therapy can seem extremely trite, or even a ridiculous exercise in mental manipulation--an exercise to comform oneself to how society as a whole expects you to think or feel, trying to convince you to think good thoughts about a bad situation.

The thing is, though, these seemingly ridiculous tasks (such as cognitive therapy, etc.) can start new paths forming. In conjunction with this, new connections can begin with the external world, in the form of new friendships, new involvements in creative work, new involvements in education, etc.

There may well be burned bridges, but there is a vast energy available to build new bridges, if you so wish. And your past experiences may eventually become more useful to you than they are right now.

Depression can be extremely tenacious. It is so extremely tenacious that in some cases it is almost like a character that wants to perpetuate itself. The depression itself, so to speak, sets up arguments in one's mind about why this or that action (e.g. medication, therapy, life change of other sorts) cannot or should not happen. In the forest path metaphor, it is like the depression not only has become an extremely well-trodden pathway in a dense forest, but it has also put high fences around the pathway, and a deep moat full of crocodiles on the other side of the fence too.

Once again, I emphasize that I have no easy answers. As I look at the above post, I see that it is rambling. Parts of it probably sound preachy or trite. Probably annoying to look at if you are feeling trapped in a depressive state. I think I come off sounding like a salesman myself, trying to convince you to buy that painting you don't really like.

My intention, though, is to convey my belief that change is possible. There is proof that change is possible. I see this proof in my own clinical experience, as well as in the stories of others. Deep change in a chronically unhappy life is possible, but may require a great deal of external help, and may require a type of commitment to change that is extremely difficult or exhausting to initiate. And your depression won't want you to make any such commitment.

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 3

So, in conclusion, Pinker's book is very important and can be broadly applied not only to understanding and working towards continued reductions in violence, but these ideas can be useful in developing healthier psychological strategies in daily life.

These principles include:

1) continued education, to bolster reason, cross-cultural understanding, communication skills, empathy, historical knowledge, and even economics and statistics (these latter subjects can help combat cognitive biases which impede clear understanding of information pertaining to daily living)

2) foster trade instead of fostering war.  In some recent news examples, this may not be reasonable (e.g. with some extremely violent groups), but at the very least, fostering trade with adjacent communities would be useful to form alliances. 

3) exercise and strive for freedom of speech

4) expand our circles of empathy, to include those in other groups, cultures, and situations.  Ultimately, a global issue is to include the environment itself in our circle of empathy.  In depressive states, one may be directing aggressive thoughts or actions towards oneself.  So the circle of empathy should deliberately also focus on including oneself.

5) be aware of cognitive biases, such as overconfidence in the setting of conflict, underestimation of the risks of conflict, the tendency to deliver vengeful retaliations that would be considered excessive by a neutral observer, and to overestimate the malevolence of an opponent's motives.    This could be applied to an analysis about one's own depressive thoughts about oneself.

6) avail oneself of mediators or peacekeepers (this can be a role of a therapist).

7) move away from authoritarian or tribalist practices or beliefs, and instead focus on inclusiveness, individual rights, and fairness.  For those involved in religion, work toward a more inclusive, peacemaking, ecumenical, humble theology, with room to include modern scientific findings pertinent to morality, fairness, cultural understanding, and justice. 

8) strive for dignity rather than honour

9) work on ways to improve self-control.  This does not mean a renunciation of Dionysian enjoyments, but rather it means never allowing one's impulses or habits or enjoyments to cause harm or to rule one's life.

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 2

The first section of Pinker's book is an exhaustive review of violence rates throughout history.  This even includes looking beyond our own species, to other great apes, to understand aggression in our evolutionary lineage.  He also reviews cultural attitudes towards violence throughout the ages, as manifest in literature and the arts, and also in accounts of daily social and entertainment practices.  It is very disconcerting to learn about the extent to which horrifying acts of cruelty were commonly accepted, or even considered amusements (the events in the Roman Colosseum comprise just one of many, many examples)

Clearly, rates of violence were much, much higher in all previous periods of history.  Today the risk of suffering a violent non-suicidal death (from war or other crimes) is in the order of 1% or less (this is the total risk over an entire lifespan).    In most prosperous areas of the world it is much less than 1%.  Of the 245 000 deaths in Canada in 2012, 543 were due to homicide (0.2 % of the total).link   link2

But in all previous eras of human and pre-human history, these risks were orders of magnitude higher,  according to a variety of streams of evidence which Pinker amasses.  Instead of 0.2%, the rates were 10% or more.    If anything, much of this data may actually underestimate these past rates, since violence was so much a norm in previous periods of history that many violent deaths or even massacres were barely mentioned in historical texts.  Risks of non-homicidal violence were much higher still, such that most everyone in the population would have been traumatized in some way, or would have had a close friend or family member who was severely traumatized. 

Pinker outlines various of the forces which have driven violent behaviour over the ages; here are some of them:

1) predation
2) dominance
3) revenge
4) communalism/tribalism/nationalism
5) sadism
6) isolation
7) authoritarianism
8) ideology
9) lack of intelligence

1)
Predation is described as a simple goal-oriented motive, such as robbery or looting.  Yet this strategy is "zero sum" or "negative sum" in that there is no net gain during a robbery, only a transfer of property, and most likely a destruction of the means to efficiently produce more property (e.g. jewelry may be stolen in an attack, but the infrastructure or morale needed to produce more or better jewelry gets damaged in the process).

With societal evolution, free trade becomes a non-violent alternative to predation, which allows the process to be "positive sum."   In this case, goods could be traded for jewelry, leading to a prospering group of jewelers who can then produce more or better jewelry in the future.  Both parties gain.   In order for free trade to occur, and the ensuing reduction in predatory violence, there must be improved communication, a fairly governed commercial system, and penalties for predation which are agreed upon by both parties.

In a psychotherapeutic milieu, this principle could lead to the idea of improving communication and stable transactional rules between potentially conflicted individuals.  In general, the idea of trading with your enemy instead of fighting your enemy may not naturally occur to people.

Pinker does not adequately discuss some of the problems with trading relationships, and of free-market economics in general.  Such relationships can be imbalanced, exploitative on some level (either directly towards the individuals or nations involved, or towards the environment), or favouring a relatively small elite while having little benefit for the majority.  I think there needs to be more emphasis on "fair" trade, including a strong focus on environmental issues.  This is consistent with Pinker's observations about the need to expand a "circle of empathy."  This circle should expand to include not just trading partners, but the larger communities affected by trade, and the benefits or consequences to the natural environment.  Trade may often benefit the environment, through a simple economic efficiency argument:  the lowest-cost economic solution to a problem is favoured by free trade, which in turn can maximize the available eonomic resources to protect the environment.  But in order for this efficiency to be protective, there needs to be structured safeguards in place to prevent social or environmental exploitation. Another big issue I have found with conventional economic theory is that costs are underestimated (such as long-term environmental damage), and the cross-sectional cost appears to be very low; often those involved are not held responsible for the ultimate long-term costs.  In any case, this inaccuracy in measuring costs distorts the system, and causes it to be short-sighted.  

2)
Dominance contests can be seen in many species, often as part of a competition for mates.  Most often, of course, these are behaviours seen in males.  In humans, this can give rises to meaningless displays of strength or machismo, with an associated culture of "honour" in which small perceived slights can result in excessive aggressive reactions. Associated psychological phenomena include overconfidence, underestimation of the losses associated with the conflict, and of course lack of empathy for the opponent. In celebrating a culture of "glory and honour" there can be an utter disregard for the individuals and families affected by the ensuing violent losses.

If this type of behaviour is selected for in the population, it gives rise to large, aggressive, arrogant, reckless males who are easily provoked.  In other species it can give rise to males having harems with multiple mates, while driving away or killing other male challengers  (we see literal examples of this in human groups throughout history). 

In humans, this type of dynamic can occur in "honour-based" cultures; previous periods of history often featured distinguished gentlemen absurdly fighting to the death in duels, often over trivial conflicts.  But entire nations can behave in this fashion as well.

Improvement in this type of problem comes with greater education, strong emphasis on women's rights and gender equality, and selection pressure:  reckless, aggressive males with poor impulse control are much less likely to be found attractive as mates in the modern era!   Instead, most elements of modern culture favour self-control and a culture of "dignity."  It is no longer cool or attractive to be a bully or a hothead. 

3)
Revenge is an understandable reflexive process, and it is pointed out that some degree of revenge can be a deterrent to subsequent violence (to show no revenge can invite subsequent exploitation).  The problem with revenge, as Pinker shows, is twofold:  first, wronged individuals or states tend to want to deliver more punitive harm than a neutral mediator would prescribe.  The individuals doing the wrong likewise tend to underestimate their culpability or guilt (e.g. a great many convicted felons may have a smaller estimation of the magnitude of their guilt or responsibility for harm than a neutral observer or their victims would conclude).  This leads to a cycle of revenge, in which each group retaliates vindictively against each other, with force that is often out of proportion to the offense, and each wrongdoer underestimates their culpability.   The retaliation is itself therefore felt as an assault by the recipient, rather than as a fair punishment.  The violence therefore continues in an escalating fashion, with each group feeling justified in their actions, egregiously wronged by the other, and with each group inducing future acts of vengeance from their enemies.

The solutions to this predicament include having neutral arbiters--a fair system of policing and justice, empowered by a neutral and fair government which has a motive of minimizing overall harm in its citizens.

On a psychological level, a solution is to recognize the cognitive biases which lead to excessive retaliations and excessive justifications for one's own excesses.  Another solution is to recognize the need for neutral mediation to help resolve ongoing conflicts.

4)
Communalism, tribalism, or nationalism are understandable, common human experiences.  Early human culture required a cohesive sense of protecting one's fellow villagers from attacks from neighbours.  Yet, tribalism fosters patterns of revenge, predation, and dominance-based aggression on a group level.  Having separate tribal cultures, often with language and geographic barriers, is a barrier to empathy for outsiders, particularly if a cycle of warfare has already begun.  We see this type of aggression on a large and small scale, all around us.  In some cases it is playful, as in sports teams from different communities.  Gang behaviour in large cities has a tribal quality, with battles over control, protection, predation of resources, and "honour."   But entire nations behave this way.  We subjectively have an urge to enjoy national identity, but we have to be wary of the violent associations of this mindset.

An approach to this issue is to expand our "circle of empathy," and to view those from other groups as partners rather than enemies.   I suspect the healthiest vestige of nationalism that we can safely keep is to have sports teams.  I think this is also a reason to support free, fair international trade.  Protectionist policies must be based on a notion that there is an "us" and a "them".  But it is fair to view everyone in the world as part of "us" at this point.

Nationalist conflict is one of the most devastating factors causing worldwide violent death and suffering through the ages.

It is for this reason that I support the idea of having international sports events -- I believe that this is a symbolic peaceful sublimation of nationalistic conflict, transforming this type of tension into a playful harmless talent show.   The economic indulgence of such events, such as the Olympics, is an understandable complaint, but I think the pursuit of such playful, peaceful activities is very important.

5)
Sadism  may seem like a rarity, relevant only to extreme cases.  But smaller forms of this issue can occur in communities or in one's inner life.  The driving force in sadism is addictive:  repeated behaviours, even if extremely harmful, can lose their aversive or "taboo" character through repetition, and even lead to addictive pleasure, associated with excitement, relief of tension, etc.  This phenomenon can occur in personalities which had previously been quite "normal."    Pinker does point out the likelihood that psychopathic personality--a pathological lack of sympathy for others-- is a risk factor for sadistic behaviour, and that those with this type of personality are more likely to be attracted to occupations in which they could indulge their violent predilections.  In the book, he does not address the environmental or social causes of psychopathy, though alludes to this problem being at least to some degree a neurobiological variant with heritable aspects, and not entirely due to environmental adversity.  In any case, not all psychopaths end up becoming violent sadists, and not all sadists are psychopaths. 

 In depressive states, various forms of physical and figurative self-injury can become sources of relief, and lead to an escalating pattern of violence against self.   This is not "sadism" but it could be considered as arising similarly, as an addictive habit to which the person becomes tolerant and desensitized, leading to a craving for more and more highly destructive behaviour. 

A solution to this issue is to focus on prevention, and to recognize and avoid risk factors.  In a police or military setting, for example, it needs to be recognized that maltreatment of hostile prisoners can occur and escalate through this process.  Abuses of this kind are not some kind of bizarre perversion, but stem from failure to include judicial safeguards adequately to prevent the police or prison guards from getting involved in an addictive habit of maltreating others.  This can be challenging, because many of the prisoners may have behaved in a terrible way themselves (e.g. violent criminals) and so the initial aggressive responses to them may be approved by everyone involved.

In a personal setting, prevention is also important.  Self-injury often begins secretively, without the addictive risks being appreciated, and by the time the problem surfaces to others, it has become an entrenched habit.  At this stage, approaching it as a potentially lifelong addictive risk becomes necessary, with a variety of psychotherapeutic strategies employed.  For those who engage in sadistic behaviour towards others, I think society should be equipped to approach them as permanent risks to others' safety.   This does not necessarily mean longer prison terms, etc. (though this may be necessary in some instances) but I think it does at least mean longer-term societal scrutiny for protection of others.  

6)
Isolation is a risk factor for violence due to a tendency to form a stronger ingroup, view outsiders as a threat, lack the communication or language to resolve disputes peacefully with outsiders, and to lack the advanced education that could bolster diplomacy, empathy, or self-control.

During early human history, groups existed in relative isolation from each other.  Today, groups which are more geographically isolated (e.g. in remote mountainous areas) tend to have much higher rates of violence, as well as less education.  With the advent of modern communication and transportation technology, isolation on this level does not ever have to be as absolute as it has been in the past.  Yet, some groups may deliberately foster isolation, even when they live in large cities.  I think it is important to foster widespread community interactions between isolated groups.  

On a personal level, isolation is likely to magnify suspicion towards strangers, leading to exaggerated negative reactions to others' behaviour.

Psychologically, problems with isolation may be due to social anxiety, depression, or psychotic paraoia, but the isolation itself becomes part of the vicious cycle of symptom exacerbation.

Every person or community may have a certain "set point" for healthy engagement with others, e.g. some people are more comfortably gregarious than others, but I think some type of social practice and engagement is necessary for the health of individuals and communities. 

On a practical level, learning to speak other languages and customs lessens the isolative boundaries between people.  As a strategy of personal development, it could therefore be healthy to learn other languages, to travel to different countries, and to experience and learn respectfully about other cultures.  Treatment of underlying symptoms, such as paranoia or social phobia, can of course be important. 

7)
Authoritarianism evolves naturally from the most ancient origins:  stronger members of a group will dominate and assume leadership powers.  This factor fits closely with the ideological dynamics of aggression.  Those who challenge the authoritarian leadership can be subject to severe aggression.  One of the perpetuating factors for this dynamic includes the cognitive illusion that everyone supports the authoritarian leader or the authoritarian principles.  Even those who quietly dissent may be so fearful of reprisal that they will act to support the leader, and even punish other dissenters to prove it.  An analogous cognitive distortion is the belief among college students that the majority of their peers enjoy binge drinking--this belief normalizes such behaviour, and causes more people to engage in it because they erroneously thought it was an accepted norm.

A protection against this dynamic is fostering a politically open democracy with freedom of speech.  On a personal level, I think it is healthy and protective to question authority as an intellectual norm.  This includes not only teachers and professors, but also religious teachings.  Authoritarianism that is couched in religious dogma can seem so "sacred" that challenging it would seem disrespectful or like a taboo, thus leading to terrible unchecked excesses and distortions justifying violence or other harms and suppressing intellectual growth.

I had assumed that there would be a universal affirmation of the desirability of multi-party democracy throughout the world.  Yet, I have recently been looking at the PewResearch Global Attitudes Project surveys, including a poll done in 2009 (well before the recent conflicts in Russia and Ukraine).  (link)

This survey shows that people in Russia and several former Eastern-Bloc countries such as Hungary, have had a huge reduction in their enchantment with the idea of democratic government, beginning long before the recent conflicts.   Ukrainians gave some of the lowest ratings of all, regarding attitudes towards democracy, freedom of speech, etc.    I suspect that a major reason for this has been that the democratic changes in these countries have been laden with a lot of corruption, instability, and economic problems.

This is reminiscent of what Pinker described in post-colonial African states, which experienced a large surge in violence rates after declaring independence.  This does not at all mean that colonialism was "good," but rather that the benefits of democracy and societal freedom can only come after a state has become stable in terms of economy and political organization.   The period after major political upheavals can be relatively anarchic, and economically harsh, leading to a steep decline in morale for the population. 


8) 
Ideology can lead to extreme violence, through offering a cohesive set of beliefs which bind an ingroup harmoniously, often with a utopian goal, leading to a rationalization to destroy outgroups. Utopian goals can sound attractive, but often the enactment of these goals involve suspension of the other elements of societal growth and non-violence, such as fairness, justice, empathy for outgroup memebers, etc.  Those who commit catastrophic acts of violence within an ideological framework may understand their actions to be normal or just, and may easily dismiss complaints that their actions are wrong.     Our recent history is full of examples of this type, including Nazi Germany.

Unfortunately, there are many examples in history of religious ideologies leading to extreme violence in this way, continuing with examples in today's news.

A prevention for this type of problem includes education, including in the arts and humanities, a commitment to ecumenical approaches in theology (regardless of one's religious orientation), and a commitment to have diplomatic relationships with those having different ideological viewpoints.

I think these preventions apply on a large scale in societies, but also on a personal, individual level.

9)
Intelligence, the greatest talent of humankind, has the power to defuse conflict through negotiation, wise strategizing, and improved empathic understanding of one's opponents.    Cognitive biases are not eliminated by intelligence alone (as Kahneman has shown), but the capacity to employ reason rather than rage to solve problems is enhanced by intellectual training.  Such intelligence has grown over the generations, as Pinker has shown.  This is likely due to better education, and exposure to a more stimulating global cultural milieu.  Unfortunately, many in the world lack access to the basic resources or freedoms to develop their intellect in this way.  Part of global peacemaking must therefore include a strong emphasis on universal access to education.

Intelligence, of course, also permits a higher chance for employment, prosperity, and diverse leisure activities, all of which reduce risks for violence and other harms.

On a more immediate, personal level, intellectual development could be framed as a component of psychotherapy.  This could work not only as a way to focus the brain on activities apart from depressive rumination, but also could strengthen faculties of the mind which could act as skilled "negotiators" to calm the self-injurious impulses which can occur in depression or anxiety.  Some of the CBT literature shows that this type of therapy works better in those who are more highly educated.  Conversely, I suspect that better education and intellectual training can make psychotherapy work better.

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 1

I have just finished Steven Pinker's book, The Better Angels of Our Nature: Why Violence Has Declined. 

I think it is a masterpiece of scholarship and research, combining the fields of psychology, history, political science, anthropology, economics, and statistics to contribute a hopeful affirmation about the progress the world has made to reduce violence and to improve quality of life.

My favourite scholarship is the type which combines multiple fields in this way!  

In these posts I would like to briefly summarize the book, and to reflect about ways to apply some of Pinker's insights to the practice of psychotherapy.

I see there has been mostly strong praise for this book among critics, but predictably there has been some controversy.    Cultural groups which still have strong authoritarian, communal, tribal, sexist, or fundamentalist values may find some of Pinker's conclusions to be critical of their way of life.  Mind you, he does show that in almost all such subcultures, such as conservative groups in the U.S., there have been positive changes, for example towards affirming rights for previously disenfranchised groups.  It is just that these changes usually lag a decade or two behind such changes in the rest of the population.  An attitude about women's rights or gay rights that would have been called "liberal" in 1970 would be considered a norm in many conservative groups today. 

Pinker shows that most elements of religious belief and practice have had negative impacts on rates of violence and war, due in part to causing an ingroup mindset, which tends to undervalue the human worth of non-believers, therefore facilitating maltreatment of those with a different faith.    Also most religions have a type of authoritarian structure, including about the concept of divinity itself.  The notion of an afterlife can not only model infinite punishment ("hell") as a supposedly fair possibility for an individual based on offenses such as "disbelief" but could encourage such an attitude of infinite punishments in approaching other individuals or cultures.  Conversely, with infinite reward ("heaven") in the picture, perhaps with simple criteria such as "belief" to be the ticket of entry, this could be experienced as a license to engage in many destructive acts during life while minimizing the relative value of earthly justice.

Other critics question his statistics, but here I think he has been very impressively thorough.  His statistics do not at all imply that violence has miraculously disappeared in modernity, and very clearly do not imply that the most horrific possibilities of violence -- such as the scale of events which happened in World War II -- cannot happen again.  In fact, his discussion of statistical power-law distributions modeling violent conflict gives rise to great concern:  based on this distribution, one can expect an arbitrarily large and devastating conflict to occur in the future, since this type of distribution is "tail heavy" statistically.  His analysis does give reason to be hopeful, though--the underlying causations and probabilities which become the parameters of these statistical patterns are themselves declining.

An example of a power-law distribution is the length of words that would be generated on a typewriter if one were to type on the keys and the spacebar randomly.  Typing the spacebar would separate individual words.   The length of the word would represent the magnitude of  (or loss of life from) a violent conflict. With this analogy, a conflict happens every time the spacebar is pressed. One could see that short, small conflicts would be most common, but that longer, larger conflicts could happen periodically, though less frequently, in a random pattern.  It is disconcerting that this type of distribution can have an infinite expected value, representing total destruction of the population.  As we know, this is actually a possibility in the nuclear age.

But Pinker's thesis also shows that the parameters of this imaginary typewriter are changing--with time, the typewriter is gaining more and more keys (just like Microsoft keyboards!).  This causes the relative risk of pressing the spacebar to gradually decrease with time   Also, metaphorically, Pinker is showing that the information content of each key is increasing, so to speak, causing fewer keys to need to be pressed at all.    Just as with computer keyboards, we are even developing ways to interact without using keyboards at all (e.g. with mice, or voice commands).  The mechanisms he shows for these changes in risk parameters are increased education, intelligence, an expanding circle of empathy, an expanding force of reason, improved human rights (e.g. for women, racial minorities, and people having different sexual orientations), free and fair trade,  and improved stable government (what he calls the "leviathan").

"The Lazy Controller" -- reflections about Kahneman's book

This is the first of a series of posts I've been planning based on Daniel Kahneman's book Thinking, Fast and Slow. 

I found this book to be excellent, an account of how the brain is very biased in its mode of forming decisions and judgments, loaded with very abundant solid research over 40-50 years in the social and cognitive psychology literature.

My purpose of reflecting on this book in detail is hopefully to add ideas about understanding the brain's biases in the context of psychiatric symptoms, and then to propose therapeutic exercises which could counter or resolve the biases, and strengthen cognitive faculties which may intrinsically be weak.

----

The first few chapters of this book are introductions to the idea that the brain can be understood as having two main modes of processing and responding to information; the author calls these "system 1" and "system 2."

System 1 is rapid, automatic, reflexive, and often unconscious.  It is the dominant system in most cases.  It is the foundation of "intuition."  It is built upon deeply engrained memory for similar situations.  It is a foundation of all talent and mastery of skills, in that it permits one to perform a difficult task with ease, without even having to "think" about it (e.g. for a master musician, athlete, surgeon, or really any other occupation).  But system 1 is extremely prone to biases.  Its mode of processing data is based on what it has experienced repeatedly in the past -- so it is a kind of autopilot -- and it can be very easily fooled  (yet, on the other hand, its rich set of past associations may be a fertile ground for imagination, creativity, and inspired insight). 

System 2 is a highly conscious, intellectually analytical mode.  It permits us to systematically solve a multi-step difficult problem of any sort.  It permits us to cope with situations which differ from an overlearned template.  It would be like the true pilot landing a plane in difficult or rapidly changing conditions, instead of letting the autopilot trying to land it.

One of Kahneman's main theses is that system 2 can be easily fooled too!  While system 2 is the only cognitive mechanism which could prevent biased interpretation of information, Kahneman shows that system 2 is intrinsically "lazy."  Because engaging system 2 is effortful -- it demands energy -- we are strongly drawn to intellectual processes which minimize the energy expenditure.  If system 1 has an automatic, "intuitive" answer for us, then we would tend not to engage system 2 at all.  And if a rapid engagement of system 2 appears to be sufficient to get an answer, we will usually not spend extra time or energy.  Thus system 2 can easily lead us to a premature and inaccurate conclusion.

Another of Kahneman's main theses has to do with the nature of phenomena, cause-and-effect, and data in general.  Accurate conclusions about cause and effect often require a type of statistical analysis (even a simple one, employing quite straightforward rules of probability), but Kahneman shows that the brain (both system 1 and system 2) are not intrinsically designed to think in a statistical fashion.  Therefore we tend to greatly distort the likelihood of various types of events.

An area I would want to extend beyond Kahneman's main theses is that I suspect both system 1 and system 2 could be very specifically trained to reduce biases.  Kahneman seems somewhat resigned to conclude that the brain simply can't resist the types of biases he describes (citing, for example, profoundly biased thinking in his psychology student subjects--or even in himself-- whose biases were evidently not reduced by understanding and education).  But I do not see that very much work has been done to very specifically and intensively train the mind to reduce biases -- I think that simply learning about bias is not enough, it is something that must be practiced for hundreds of hours, just like any other skill. (this reminds me of something said in psychotherapy:  "insight alone is not enough to effect change -- it must be accompanied by action.")

I believe this is relevant to psychiatry, in that all mental illnesses (such as depression, anxiety disorders, personality disorders, psychosis, and attention/learning disorders) contain symptoms which affect cognition.  In  cognitive therapy theory, it is assumed that depressive cognitions cause and perpetuate the mood disorder.    Many such "cognitive distortions" could be looked at through the lens of "system 1" and "system 2" problems.    For example, in many chronic symptom situations, system 2 may have developed a very deeply ingrained reflexively negative expectation about a great many situations, with many of these reflexes being unconscious.  These reflexes could possibly have been developed based on childhood experience of parents (consistent with a sort of psychoanalytic model), but I think the most prominent source of such reflexes would simply be due to having had a particular symptom frequently for years or decades at a time, regardless of that symptom's original cause.    Under such conditions the brain would change its expectation about the outcome of many events, based on the repeated negative experiences of the past (which could have been due to poor external environmental conditions, but also simply to the past chronicity of symptoms).

A proposed treatment for this phenomenon could very much be along the lines of cognitive therapy.  But I might suggest extending a specific focus on depressive "cognitive distortions" etc. to work on understanding and countering bias in systems 1 and 2 in general.  I propose that intellectual exercises to minimize biased interpretation of perceptions -- even if these exercises have little directly to do with psychiatric symptoms or depressive cognitions, etc. -- could be useful as a therapy for psychiatric disorders.

As outrageous as it seems, educating oneself about statistics, and practicing statistics problems repeatedly -- may be therapeutic for psychiatric illness!  

I'll try to continue this discussion with more specific examples in later posts.

"Outlier": The causes of high achievement

Outlier by Malcolm Gladwell, is a brilliant book about the causes of success, outstanding achievement, and personal greatness.

Gladwell describes a variety of interesting life stories, of people with outstanding ability or outstanding achievement, then looks carefully at the factors leading to these successes.

He does not claim that "inborn traits" or hereditary factors are unimportant.  But he shows quite convincingly that inborn talents correlate with achievement only to a certain point.  Individuals with extreme talents tend not to achieve more than those with merely "sufficient" talents. A recurring theme in this book, shown through one example after the next, is that the simple stories many people might have, to account for a person's great achievements, are often appealing and believable, but are in fact often inaccurate or at the very least incomplete.

He shows that various situational biases can have a profound, snowballing effect on the course of successfulness in a person's life.  A trite detail such as birthdate can lead to a cascade of advantages or disadvantages for athletes, which then accumulate over many years (his example is of successful hockey players being much more likely to have an early birthday--if you're born in December, this is an instant disadvantage, as you will be a little bit smaller and weaker on average compared to your teammates, therefore the older players will tend to outperform you, leading to a smaller chance of  you being noticed or advanced to a more challenging team, or to be deemed "gifted" and given more ice time, etc.)  

He emphasizes the role of thousands of hours of intensive practice being required to master a skill.  Those who have 10 000 hours of practice under their belt early on in their lives--particularly if some serendipitous quirk of fortune allowed them to be one of the only individuals, or one of the first, to gain this experience-- have a strong chance of succeeding spectacularly in their fields.  He gives examples such as Bill Gates, or the Beatles, or some of the most successful New York lawyers doing a particular type of law. 

One of the psychologists cited in this book,  who has studied the area of "exceptional achievement" is AK Ericsson, who generally argues that "extended, intense practice"  is the primary determinant of elite performance, as opposed to inborn talent.  The ability to do this type of practice, of course, requires or is greatly facilitated by, motivational resources as well as environmental opportunity, parental support, a culture which favours such as endeavour, etc.) Here are some references to articles of his:
http://www.ncbi.nlm.nih.gov/pubmed/17905932
http://www.ncbi.nlm.nih.gov/pubmed/17642130
I suspect that heredity is quite relevant, but may manifest itself in many ways aside from what many people might assume.  Factors that could be considered at first glance to be a disadvantage, either hereditarily or environmentally, may, in the world of successfulness, end up being compelling advantages.

Guillermo Campitelli is another excellent researcher in this field; here's a reference to one of his recent papers: http://www.ncbi.nlm.nih.gov/pubmed/17201516.  The evidence here, looking specifically at chess players as a model of acquiring expertise, affirms the extreme importance of thousands of hours of  practice, but also recognizes that some players improve much more than others with the same amount of practice.  This is probably the influence of inherited talent.  Maybe there could be other hidden variables, including family or cultural factors.   He suggests that the age at which the practice begins is another important variable.  

It should be noted that, in this literature, "deliberate practice" refers to a type of activity which is specifically directed towards performance improvement, is adequately difficult, has feedback about performance, and which has opportunity to correct errors.  This differs from "ordinary" work experience, which may be quite a bit less intense and much less geared towards improving skills.  I suspect that the quality of "deliberate practice" may vary quite a bit, depending on the degree of immersion, concentration, energy, engagement, and meaningfulness there is in the action.  I wonder if enjoyment of the practice is a major variable too, I would be interested to see if some of these researchers would look at this.  If someone finds their 100 hours of practice meaningful and enjoyable, I have to wonder if they might advance much more than someone whose 100 hours were a drudgery.    

Another excellent angle of discussion in Gladwell's book has to do with understanding a person's cultural background and childhood developmental history, as extremely important determinants of success.   This leads to discussions about opportunity, pedagogical technique and policy, etc.  Sometimes cultural or developmental factors cause individuals to lack a certain skill necessary to succeed, or put individuals at risk of recurrent severe problems or frustrations.  Good examples are given, including the story of a profoundly gifted intellect who was never able to share his talents; and of highly trained pilots who were too quietly respectful of authority to be able to proactively use strong assertive social skills to prevent an aviation disaster.

I'll add to this post later on, to expand some thoughts about achievement and success.  In the meantime, I think Outlier is a worthwhile and entertaining read.

Reading Exercises

A common problem I find among university students is difficulty reading quickly or efficiently.  Reading problems can also occur in conjunction with depression.

The best thing to do to improve reading skills is, of course, to read more.  But a phenomenon which often happens when reading any text, but especially longer texts, such as novels, is that you can lose track of what you have just been reading.  Whole sections of the text may end up being skimmed superficially, as part of your attention lapses or wanders, while still maintaining a basic pace of absent-minded reading.  This leads to a lack of enjoyment or feeling of mastery with reading, dampened morale, sapped motivation, contributing further to any depression which had been present, and deterring further reading efforts. 

An approach to this type of problem requires you to stop to reflect or answer questions frequently about what you have just read.  Whenever you test yourself regularly, your learning and retention are greatly increased.  Most good introductory university textbooks are set up this way.  But not very much in the line of non-textbook reading.  

So, I have been trying to find resources to help with reading skill, for adults.  Elementary-school language textbooks or readers seemed like a reasonable thing to check.   I certainly recommend that adults at least periodically read books which have been written for children or adolescents.  The best things I've found online are from ESL (English as a second language) programs.  Even if you are an advanced reader, or have spoken English all your life, I think that ESL exercises could be good for improving reading skill. 

Cognitive-skills training websites tend not to offer very much in terms of language learning or improving reading fluency or retention.  I wish that the cognitive skills website people could develop more along these lines: reading-oriented games don't seem very difficult to imagine or design, compared to other types of games.

Here's a list of a few sites I've found, where you can practice English reading skills:

http://web2.uvcs.uvic.ca/courses/elc/studyzone/
This is an excellent free resource from the University of Victoria (in BC).  For the reading exercises, choose an "English language level"  (beginner to advanced), then follow the links about reading. 

Houghton Mifflin College
This site also offers timed readings with questions afterwards. 


Quizzes Based On VOA Programs (ESL/EFL)

This link goes to a site where you have to read a text a sentence at a time, and fill in the blanks from a list of options, according to what makes sense or is grammatically correct.  While some might find this type of exercise too easy, I think it is a nice way to remain more interactive with the text.  If you do find it easy, you can just try to do it faster, and make it into a game. 

Another useful thing to look for is an online book club which has discussion questions about the book you're reading.  Some sites have questions for each chapter, which is the type of thing I'm recommending, so that you can pause frequently to review what you have just been reading.   I haven't found a single site which has chapter-by-chapter questions for a wide variety of books, but here's an example of a specific site, giving questions about Great Expectations by Charles Dickens (a great book, by the way):
http://www.victorianweb.org/authors/dickens/ge/pva107.html

The Nature of Happiness - book review

The Nature of Happiness by Desmond Morris, is a brief little book describing the author's beliefs about various types of happiness.

I think it's worth including in a list of books to read about happiness, though I find it to be quite a superficial opinion piece.  There are a few interesting observations; some sound, simple advice;  and a collection of nice quotations from famous authors, but otherwise the book really lacks substance.  There is almost no reference to research;  there are many sweeping statements, such as about evolutionary underpinnings of happiness-related behaviour, yet without a rigorous development of these ideas, and perhaps without a sense of understanding the voice or perspective of those to whom he is referring.

It is always surprising to me how a minor text of this type could warrant a glowing review from a major newspaper:
"At last, a highly intelligent, serious exploration of a subject as universal as it is mysterious...an illuminating and fascinating read."  The Times

 

Man's Search for Meaning

Man's Search for Meaning, by Victor Frankl, is one the great books of the past century. 

Frankl (1905-1997) was an Austrian psychiatrist who developed a style of therapy which he called "logotherapy," a style which focuses upon the identification and nurturance of meaning as a primary therapeutic goal.  While this style affirms the importance of symptom relief, it focuses on the idea that meaning is available even in the context of extreme unremitting symptoms or suffering.

The gravity of his ideas must be taken very seriously, because of Frankl's own personal experience between 1942-1945:  he survived almost three horrific years in Nazi concentration camps including Auschwitz and Dachau.  His parents and wife were killed in the concentration camps, and his only surviving immediate relative was one sister.  So Frankl approaches these questions with the perspective of one who understands the extremity of suffering, profound loss, and domination by oppressive forces outside of one's control.   In this way, Frankl has a deep empathic understanding of what it can be like to experience severe, torturously unremitting psychological illness. 

The first half of Man's Search for Meaning is a description of life in the concentration camps.  The second half is a brief description of the author's meaning-based psychotherapy style.

As a style issue, I do wish there was more attention to gender-inclusive language, as humans are always referred to as "man," and the pronoun "his" is always used instead of "her."    But this is a very small complaint, given the profoundly moving, inclusive, and life-affirming nature of this writing. 

This is another of the books I've read recently, which I really ought to have read 20 years ago...

Book Review: Mad, Bad and Sad

Mad, Bad, and Sad: A History of Women and the Mind Doctors from 1800 to the Present, by Lisa Appignanesi (2007) is quite a good history of psychiatry, particularly regarding the period between 1800 and about 1950.

It was interesting and valuable to look at some of the life histories of individual women from previous eras, and to speculate about what helped them and what did not. Some of the biographical sketches are about famous women such as Sylvia Plath, Virginia Woolf, and Marilyn Monroe.

The author approaches the subject matter with a broad vision to include social and cultural context, and particularly feminist issues such as the role constraints and expectations imposed upon women by the prevailing culture, in communities, in families, and also in the therapeutic relationships (which often had a paternalistic quality, or one which reinforced restrictive cultural stereotypes about women).

Many of the stories are strong critiques against various elements of therapeutic philosophy and practice, especially biological psychiatry.

An important thesis is of the limitations of "therapy": her closing statement is

...the mind doctors--whether they're GPs on the front line, therapists of an increasing number of varieties, psychoanalysts, psychiatrists or psychopharmacologists -- trudge along, doing what they can, which is sometimes all that can be done. The danger, perhaps, comes when we ask them to do too much. (p. 484)

Certainly, through all the stories mentioned, the benefits of therapy were often tangible but limited--some compelling "success stories," others particularly tragic in their ending (e.g. Plath, Woolf, or Monroe).

An underlying thesis seems to be very supportive of psychoanalysis as an important form of therapy, which may nurture a sort of freedom in self-development and personal growth.

I find that she is excessively dismissive of cognitive-behavioural therapy. While I agree that such "shorter term" therapy styles may well be designed to improve symptom scores, such that an insurance company would be more willing to fund this therapy for a short time, then cut people off--I also think that many psychological ailments can be products of simple symptoms which can be treated in a very direct, matter-of-fact way, rather than through years of philosophical rumination on a psychoanalyst's couch. Panic attacks, OCD, social anxiety, etc. can be approached as symptoms which can be mastered through behavioural practice. It could be a tremendous disservice to individuals seeking "freedom" or "liberation" to neglect these practical and philosophically simple techniques.

I do agree that complex existential and relational issues can usually not be addressed in a shorter course of therapy, especially if the therapist is dogmatically attached to a particular style (e.g. in formal CBT, there may be no time to talk about any transferential issue or existential problem). Yet, many people may feel empowered to develop their existential and relational life on their own, provided that symptoms are not obstructing their efforts.

Some of her comments can be quite dismissive, for example:

But what young person doesn't feel depressed?--particularly perhaps after a week of student exams, or a split with a boyfriend, even after a little use of recreational drugs and forgetting to eat...A sense of hopelessness, a teenage irritability, may be a phase, even if one that lasts several years...One of the effects of such tools as the Beck's [sic] Depression Inventory and the DSM's chartable diagnoses is that they can produce the very results they are looking for. (pp. 468-9)

In response to this quote, I would say that we are dealing with semantics to some degree. Actually, most young people do not feel depressed after their exams. They do not have a sustained change in behaviour after relationship disappointments, do not have a prolonged sense of hopelessness, irritability, insomnia, weight loss, suicidality, etc. These feelings may well be "phases," but the question is, should we simply treat these as "normal," (which is a semantic construct itself), and therefore not "do" anything (i.e. not offer companionship, support, advice, mentorship, etc.)? I agree that labeling and medicalization may unreasonably guide people into reflexive and sometimes unhelpful or inappropriate treatments (e.g. if a certain Beck score or life disappointment would automatically necessitate antidepressant drug therapy without any opportunity for dialog).

The author appears to have a particularly narrow view of some psychiatric treatments, such as ECT, which she describes as "barbarism." (p. 480) Perhaps thoracic surgery could be judged barbaric as well--most types of medical treatment were truly barbaric in many previous points of history, and only became less so through understanding and careful research as to how to perform the treatments more safely. Undoubtedly, even today, many people have negative experiences with thoracic surgery--or ECT--but in order to evaluate the humane usefulness of such invasive procedures, we need to do careful research trials. In order to assess whether something is "barbaric" or not, perhaps it is important to examine the stories of those who have had a profound, life-saving experience of something, alongside the stories of those who have had ambivalent or negative experiences.

She attempts to be fair in her analysis of medication treatments, but I think most readers unfamiliar with the issue would read her analysis, and conclude that medications to treat depression are a dangerous sham perpetrated by drug companies, with the collusion of paternalistic and impatient physicians.

There is little discussion of vast areas of research about the human mind: the entire field of academic & research psychology is barely mentioned. This research is so very important in challenging the dogmas associated with various therapeutic theories. Psychoanalytic theorists may have been, and still are, very wise and very talented listeners or shamanic figures, but the theories themselves were, and are, often very weak if taken too literally, and sometimes cultishly dogmatic, with therapeutic gains or inferences being illusions caused by the primitive logic of association leading to an assumption of causation. Also, the field of neuroscience is barely mentioned. The author uses the term "Big Science" as a kind of pejorative epithet, alongside "Big Pharma", a kind of ad hominem style of argument which seems to suggest that research findings from "Big Science" must be biased, and that the lack of research findings which support her position must have to do with the scientists being inadequate, rather than her position in fact being weak. One piece of "Big Science"-style research she does cite, in support of psychoanalysis, is upon closer observation a single study, with no adequate control group, little critical review. Yet she seems to aggrandize these findings in a way similar to how I have seen "Big Pharma" reps market medications based on a single, fairly weak research study.

The strength of this book lies in the biographical stories of suffering individuals, and of the descriptions of how people attempted to help them. Some of the most effective strategies are clearly based on common sense: humane social and community support, minimizing iatrogenic harm, promotion of the greatest degree of freedom possible. She argues effectively that Freudian ideas were quite liberating, permitting discussion of subjects previously held under a veil of taboo in the Victorian era, such as the nature of sexual drives. Also, these Freudian notions tended not to pathologize the drives themselves, but rather considered the drives to be innately normal, hence inviting frank, uncensored dialog as a pathway to greater freedom. The book highlights, importantly, some of harms done to people by misguided therapists and theories. And the book highlights the fact that symptoms generated by the mind can present in different ways, according to cultural influences. She argues that classification schemes can follow a fashion, and that ailments may present to follow the classification scheme, rather than the other way around.

So, in conclusion, a book with some interesting biographical sketches of patients and therapists. And some good discussion about the dangers of over-medicalizing human nature. But she does not convey a good understanding of psychological or neuroscience research, and certainly does not lay out evidence in a balanced or comprehensive way.