Mental Health Reform: reflections & ideas for change

On February 1, 2020 I began work as a psychiatrist at my own private office.  

Before then I worked at a large academic institution for about 20 years, and was the leader of the psychiatric team there for 13 years. I have always loved my work very much.  I have been very privileged and lucky to have had such a job, during those 20 years.  It has been meaningful and enjoyable, for the most part, to care for my patients over the years.  And there were many wonderful colleagues and other staff at my clinic, who made our work more enjoyable, safe, and helpful.  We worked very, very hard.  There was a sense of community, like a type of family.  But I feel incredible relief to have left this position.  Now, after 15 months away from it, I feel I can have a gentle reflection upon some of the problems which developed there over the years. 

I would like to describe some instances of what I think can go wrong during a well-meaning effort to plan for change in community mental health care.  I do not want this post to be understood as a ranting complaint from a disgruntled person, but rather I would hope to simply tell the truth, from my point of view, about some events that happened, with reflections on ways to prevent such problems in the future.   I am happy and grateful for my present and my past, but I do feel there are a few things to be said.  

Mental health reform became a big issue in the community where I worked, over the last 5 years or more.  A lot of extra money appeared in the budget for this, and some care was wisely taken to plan for how to spend it. 

Many meetings took place, to discuss mental health care reform.  

A team of consultants from another country was hired, and flown over several times to assess the situation. I presume this occurred at quite considerable expense.   Their recommendations and presentations appeared to be a very polished lobbying effort.  During these presentations, which included some academic citations to support their positions, there was never actually any room for debate about the research they were citing or for the positions they were advocating, despite the presence in our academic community of many experts.  

A plan eventually developed, devoted to the idea of collaboration among different helping disciplines.  

The meetings would tend to begin with a lot of self-congratulation about progress, followed by lengthy, repetitive monologues, laden with jargon.  I was usually the only psychiatrist present in all of these meetings.  I was always very concerned that I never come across as arrogant or disrespectful of others, given my own privileged position.   I abhor professional arrogance,  so I aimed to remain quiet, to be calm, to try to listen respectfully. 

But eventually, after many hours of such meetings, I realized that major decisions were being made about health care planning, with a lot of money involved, with almost no debate or critical challenge.  These changes affected my patients, my colleagues, my morale, the group's morale, and my own philosophy of practice.    Almost none of the money was directly helping my clinic.  I personally did not have any voice in these meetings: my comments or input were not welcomed, and I think I actually was considered difficult or uncooperative because I didn't seem to go along with the plan.   On several occasions I was told, very directly, to discontinue my comments.   When I gathered feedback from professional colleagues (who otherwise had no voice in all of this), and summarized their comments in a brief written document (as was requested of me),  the document was rejected, and never submitted, because it was deemed not positive enough.  

The foundations of my own philosophy of practice are simple:  make time for patients, listen to them, be available, be gentle, be kind, build trust, be humble, try to honour a patient's wishes.  I believe that good care cannot be rushed.  Mental health care can sometimes be done with great efficiency and speed, but more often it takes a lot of time and patience.  Almost everyone I have ever seen in my career has been tired of seeing people for help who did not really have time for them.  

In terms of larger-scale, organizational philosophy, my foundation would also be simple: take care of the staff!  Everyone, including cleaning staff, clerical workers, nurses, GPs, and specialists, should feel safe, respected, cared for, and heard, in a healthy organization.  Be on the lookout for "burnout" especially when a system is strained by high demand.  Policies that seem efficient on the surface may be quite deeply harmful, if they lead to a type of "assembly line" experience for either the staff or for the people trying to access the system.    

Some tools of efficiency, such as computerized records systems, may seem efficient, and may have many uses, but they may be expensive, inconvenient, slow, prone to error, time-consuming, obstructive to rapport with patients, and very heavily marketed by software companies which are earning a lot of money, often trying to sell impressive-sounding features which are actually unnecessary (I feel very fortunate to have found a perfect electronic records system myself, called "Jane," which is far superior, and much less expensive, than the system used at my previous workplace).   

 One reason I wanted to speak out, even at risk of sounding "difficult" or uncooperative, was to advocate for my patients. I was responsible for the care of patients with the most severe, chronic mental illnesses, yet my input about mental health was not allowed, or was met with rolled eyes and even direct requests that I stay quiet.  Furthermore, none of my psychiatric colleagues were ever present or allowed to contribute to these meetings, beyond a couple of occasions in several years. These colleagues were never officially on the payroll, they always worked privately and paid overhead to be in our group. In fact, my psychiatrist colleagues were always a free service from the point of view of the institutional budget--they actually earned money for the institution by paying overhead.  They earned less money than most other psychiatrists in the community, but stuck with the group due to their love of the work.  These colleagues never had any voice in the institution's mental health care policy.  I felt that I had to speak for this group as well. 

This went on for years. Patient care suffered.  I was the only person in all of these meetings able to do psychiatric consultations for people with severe illness who had been waiting for months, yet I was sitting in redundant, lengthy policy meetings in which I was not even allowed to contribute.  I thought of my patients, which led me to try to speak up, even at risk of sounding "difficult."  

One of the themes of the new policy was "collaboration."  But ironically, because of the policy meetings, the actual collaboration meetings which I and my counselor colleagues had enjoyed for years, in which we would discuss mental health care in general, as well as immediate, serious clinical issues about specific students, were cancelled.

One summer, there was a series of meetings devoted to drafting a formal care algorithm for treating depression.  This was yet another absurd journey.  The subject was the foundation of what most of the counselors in the group had studied for years, in graduate school.  The subject was arguably the focus of my entire 20-year career.  Yet, once again, I and other experienced professional colleagues were mostly silenced, and assigned into small groups to prepare some kind of treatment "algorithm" in an essay-like form. I thought of all the patients who were not seen while we were doing this.  

This was especially troubling, as I found the whole process more and more ethically objectionable.  We should begin by ensuring that people are assessed well, are respected, are heard, and their wishes about their own care honoured to the best of our ability.  Many algorithmic branches should be negotiated by a well-educated caregiver and the patient or client, not dictated by a flow chart.  Good care requires deep attention to building a trusting, caring relationship, empathy, understanding, and a therapeutic alliance.  Furthermore, restricting any "algorithm" to only consider depression is inappropriate, since most people coming for help have various other problems other than depression, which would all have to be considered together. 

During another meeting the entire group of 100 or so people was asked in advance to fill out a Myers-Briggs questionnaire.   The entire group was subdivided according to their Myers-Briggs personality type, and made to sit at separate tables.  Some Myers-Briggs types are more rare, while others are more common.  Many tables were full.  A few tables had only one person.   

The Myers-Briggs personality assessment has very limited validity.  It can lead to fallacious polarization of traits which actually lie on a continuum.   But in any case, personal testing data about psychological traits or symptoms is intimate:  it is arguably in a similar league as any other medical test.    It is inappropriate to have to share such information in a group setting.  There were a few people in the less common personality categories who ended up sitting alone.   To divide the group up like this was an example of what NOT to do with mental health labeling: to actually separate people on the basis of differences, leaving some people alone.  It was introducing new labels, stigma, and separation, needlessly.  To top things off, it surely would have cost money, going to a company making large profits,  to purchase these tests.  In addition to the cost of paying everyone's salary for this, there was also the cost of room reservation and catering.  Most importantly, there was once again the cost of severely ill patients who were not being seen.  

Another meeting featured a visiting expert, who had some national fame.   I would once again love to know how much his travel expenses and speaking fees were.    He was a charismatic speaker, with remarkable orational skills.  Everyone loved his presentation.  But one thing stood out for me...one of his opinions had to do with what he thought were excessive mental health resources being offered to people with what he considered minor problems.  In a hushed tone, he summarized the problem as being "narcissistic entitlement" on the part of the people seeking mental health care.  I have no doubt that there is a lot of narcissistic entitlement out there, but to dismiss an entire category of people, and to advocate for major policy change in mental health, based on this assumption, is prejudicial.  I have to wonder how often some famous policy-makers actually work with patients in a therapy setting.   Once again, there was no actual debate on this, just discussion groups affirming what had already been said.  

Another meeting was entitled "Stepped Care Anxiety."  It was a presentation led by a local research psychiatrist with a lot of experience in community programs, though someone who spent little time actually seeing or caring for patients at this point in his career.  Once again, clinical care of patients was cancelled in order for staff to attend this presentation.  Initially I thought the meeting would literally be about "stepped care anxiety"-- that is, anxiety induced in caregivers upon being presented with another tiresome trendy catchphrase.   But the title was actually just a product of some difficulties with English, and the meeting was about "stepped care FOR anxiety."  Basically, the idea of stepped care is to offer more care to people who have more severe problems, and less care to people with less severe problems.  As people improve, start to reduce their level of care.  This is a statement of the obvious, of course, and is what all of us would naturally do anyway.  There seemed to be an implicit assumption that psychiatrists in particular would be seeing patients unnecessarily, even if they were well or not in need of further care, and that we needed guidance to step away from this wasteful practice.   I was asked to be well-prepared for this meeting, by reviewing the materials in advance.  But once again there was no real meaningful discussion about this, aside from a review of obvious principles.  A deeper discussion of care would have allowed for the idea of actually spending time to know patients over a longer period of time, regardless of symptom severity, so as to prevent severe recurrences of mental illness, rather than saving our clinical attention only for emergencies.   Stepped care, when applied dogmatically, is yet another ideological system which leads to superficiality of care, a type of fast-food equivalent in mental health provision.  

After a lull in these meetings, the next chapter began with new hiring in the institution.  This time even more money was spent on expensive administrative positions, instead of on badly-needed direct health care.    Some of the administrative positions were filled by clinicians, so in addition to the cost of paying these administrative salaries, an extra cost to the community was of an expert clinician paid to do office work and attend meetings instead of using desperately needed skills to help patients directly.  I think of how many hundreds of thousands of dollars per year were spent on this increase in administrative funding, while actual clinical care languished.  Our clinical unit had barely grown in decades, despite serving a community which had rapidly expanded, perhaps even doubled in size.  Encounters with the administration were negative and morale-depleting.  I dreaded them.  I really just wanted to see and take care of my patients.  My other priority was to take care of my coworkers and colleagues.  But I felt powerless to do anything for them.    

One of the meetings--again arranged by cancelling our actual work with patients--was with a visiting specialist who had invented a new way to see more patients more quickly.  A psychiatrist would join a GP for a 30-minute "mini-assessment."  That way, more people could have psychiatry assessments, there would be shorter wait lists, and the primary care doctors would feel more supported.  Once again, there was no opportunity for any critical discussion, during or after this presentation.    The thing is, such assessments are pretty much the opposite of what I consider to be good psychiatric practice.  Assessments cannot be rushed.   Imagine if you had to see someone for a difficult, very personal problem or issue, and had to discuss it in 30 minutes, with two people in the room, one of whom a stranger, with the understanding that your future care would be guided by the new expert's opinion during this fragmentary discussion.    It is arrogant on the part of psychiatrists to assume that extremely brief visits could lead to diagnostic or therapeutic insights that the other caregivers had not already thought of.    Such brief assessments, and other schemes in mental health care similar to them, tend to bias the conclusions towards medication management, since this is the easiest type of thing to construe in a short assessment, without knowing a patient well.    Assessments and good care take time--there is no avoiding this!  Relationships cannot be rushed.  

Satisfaction surveys following such changes could also be quite biased and misleading, in the same way that taking a survey of people leaving a fast-food restaurant could give a biased view of food services quality in a community.  Many people might be quite pleased to have convenient fast food, but those who would suffer the most from such policy would not be included in the survey, since they would not be using the services.   

I am deeply relieved to have left that place!  But I miss my colleagues, I know they are good people and skilled professionals.   My decades of work there, despite the frustrations at the end, were a labour of love, for which I am deeply grateful.  While I have voiced some complaints above, the years at my previous position helped make me a better person, and taught me a lot about how to be a good doctor. 

Here are some basic ideas, based on my experience, for organizing a program of mental health care reform: 

1) the expenses involved in the reform program should always be transparent, especially in a public institution.   If consultants or experts are brought in to give presentations to the group, it should be clear to everyone, including the public, how much money was spent on their travel expenses and any other compensations.   Catering and room costs should be made clear.  And most importantly of all, if there are 100 helping professionals who spend 3 hours at a meeting, it should be made very clear that this represents a cost of 300 person-hours of  care.  That is, 300 people could have had a 1-hour therapy session or evaluation.  30 people could have had a basic 10-session treatment for depression or an anxiety disorder, which could possibly have saved lives.  

2) critical debate should always be welcomed.  If there are experts in the group, their expertise and experience should be shared.    If a visiting expert is flown in, the group's responsibility is not to simply compliment the visitor, listen politely, and clap -- at a major academic institution, or anywhere else in society, there is a responsibility, a duty even, to engage in vigorous, intelligent debate, especially when there are critical issues about health, well-being, and morality, being discussed.  

3) it should be absolutely unacceptable for anyone working in the system to feel that their voice or opinion would ever be suppressed. 

4) consideration should be given, at a very high priority, to the morale and well-being of the workers, not just to the efficiency of the work.  

5) if there are to be catered lunches and time off given to staff for collaborative meetings, or to bolster group cohesion, then ALL the staff should be included, including the cleaning staff.   Most of us don't even know who the cleaning staff are.  

6) I have a very specific idea about the economics of care provision.  There are many underemployed counselors in the community, who often have to spend a lot of money renting private office space.  Many can't make it, and end up working in some other field.   But there is a lot of office space vacant in large institutions or campuses during evenings and weekends.  This space could be offered at a very low or free lease rate, to increase the number of hours of care available for people in the community.   This would be a win-win situation for underemployed counselors as well as for the community of people in need of more care.   Clinical office space should be provided with a much higher priority than administrative office space, particularly when there is a severe shortage of clinical care.  

For salaried care workers, I think that a blended payment model (that is, baseline salary plus some component of "fee for service") would be very efficient to increase care provision.  Some workers (counselors or doctors) might want to work longer, or less typical,  hours, and I am quite certain that there would be a high demand in the community for these extra hours.  But there would have to be a fair and convenient model of compensation.    Current salary schemes do not allow such flexibility.  


If you are interested in mental health policy, I encourage you to use your voice,  to be aware of changes going on in your community, and to get involved in the reform process. 

COVID-19, Psychiatry, and Politics: an update and reflection on 2020

 COVID-19 update January 2021

I come to this issue as a psychiatrist.  I am not an infectious disease specialist, immunologist, virologist, or epidemiologist.  But I am well-educated in all of these fields, at least to an undergraduate and MD level,  boosted further by my background in mathematics & statistics.  As an undergraduate science student another of my special interests was microbiology. I have always tried to follow developments in general medicine and medical research over the years, alongside developments in psychiatry.  Epidemiology and the science of efficient, valid study design and data analysis are essential components of modern psychiatry.  

I also have personal experience with this issue.  A close family member nearly died of COVID-19 and most likely will have long-term serious health consequences despite having survived.  One family member works on an acute COVID ward.  Four other family members are physicians or nurses working in acute care medicine and are in close proximity to this issue in their practices.  Another close family member is a virologist, part of a Canadian team that studies COVID-19 and is developing another vaccine.  An increasing number of colleagues, friends, and patients have been affected by the virus.  

This bears no similarity whatsoever to any other infectious disease epidemic that I have seen in my lifetime.  It is nothing like the seasonal flu. 

COVID-19 is the worst public health catastrophe to have befallen the world since the great pandemic of 1918.  

There have been about 2 million deaths due to COVID-19 in the world so far.  This is a tiny fraction of the number of deaths that would have occurred if we had carried on as usual, as though this were an ordinary outbreak of the flu.  

Let’s imagine that we had not introduced any significant public health measures, and that we had treated COVID-19 like any other seasonal flu outbreak: 

The current understanding of COVID-19 mortality risk, of about 1% overall, would imply a total anticipated worldwide death count of 50 million if no public health measures had been taken to slow the spread of the disease, mostly over the course of one year.     That represents over 500 million years of life lost, equivalent to all the years of life lost from murders and other violence in about 20 years of time.  

But these 50 million deaths do not even begin to estimate the other impacts on the population that would have happened: 

Hospital wards and intensive care units would have been overflowing for a year or more, leading to many more deaths: people with other diseases and injuries would have been unable to access care, forcing healthcare professionals to let many people die without the curative treatments that otherwise would have been available.  Unfortunately we see this going on right now in many places of the world, including in Canada, despite the strong public health measures we have taken.   

Dealing with such devastating trauma would have caused many healthcare workers post-traumatic illness, in many cases for the rest of their lives.  Many workers would have had to leave their careers.  Many would have died by suicide.    For such workers, it would be equivalent to working on the front lines of a major war on a daily basis for an entire year.  Unfortunately, this is going on in many areas of the world, despite the measures taken.  

And, unlike other epidemics of viral respiratory disease, COVID-19 has a clear propensity to cause lasting tissue damage, not only to the lungs, but to other organs including the brain.  There would have been a much higher burden of  lasting or permanent disability as a result, if the disease had been allowed to spread unchecked through the population.  

For people who have shockingly had doubts about the severity of the situation, I have wished that they could visit the many patients in agonizing, suffocating respiratory failure on their journey to a nightmarish ICU stay.  Ironically, the good public health measures in many places have limited ICU overflow, so that relatively few people in these places know any friends or neighbours who have suffered this way—but because of this success, many poorly-informed people do not have a realistic understanding of the horror of the situation. 

The strict measures we have taken have absolutely been necessary to prevent the present catastrophe from being a hundred times worse.  

But the measures were not nearly enough, except in a few countries.  

It is fair enough to observe that if a vaccine, massive-scale testing,  or effective acute treatments had been impossible to achieve, it would have made sense to just let the disease gradually run its course, with just enough public health intervention to prevent the hospitals from overflowing.  

But most of us were optimistic enough to anticipate that a vaccine and other treatments would be developed over the space of months to years, therefore it was imperative to slow the spread as much as possible, not only to delay deaths and suffering, but to prevent them entirely and allow a return to full normality.  

Here are some thoughts of other measures that I think would have been necessary or helpful:  

1) One of the unique aspects of COVID-19 is its very strong age-dependent morbidity and mortality characteristics.  In young, healthy adults under 30, it is indeed usually (though not always) a mild or even trivial viral infection.  But with every advancing year of the victim's age, the disease becomes more deadly.  

This fact, in my opinion, could have been used to design some very simple basic research studies.  It would involve healthy young volunteers, fully informed of risk, to be exposed voluntarily to the virus in a quarantined, medically-supported setting.  The risk would be comparable to that of volunteers for military service. 

This would have allowed research to determine the exact effect size of measures such as mask usage, mask type, ventilation effects, and inoculum size, in determining rate of spread and severity of ensuing disease.  We would know exactly the likelihood of airborne spread, fomite spread, and direct contact spread, therefore guiding us about optimal preventive measures.  

Right now we have very good evidence about the usefulness of masks to reduce viral spread, but a prospective, controlled study in humans would show, beyond the shadow of a doubt, with the highest standards of scientific reliability, the exact effectiveness of widespread or solitary mask use.  When equipped with the unequivocal study data, governments could then have invested appropriately in mask manufacturing for the whole population (including high-grade N95 masks if needed).  

I suspect the results would have shown a significant but modest benefit of masks, with better effectiveness for higher-grade medical masks.  This could have generated a massive government intervention to supply such masks and mandate them for the whole population, using war powers of the government to compel industrial production.  

Such studies would also have shown, with absolute proof, the degree and length of immunity conferred by prior COVID infection, and also whether disease severity would be impacted by inoculum size.  If a smaller inoculum led to milder disease, this would be another reason to mandate mask use.    

Such studies would also have been ideal to quickly test treatment strategies.  The whole hydroxychloroquine fiasco, which the world saw earlier this year, could have been dealt with and resolved within a month or so, allowing us to move on more quickly to find other treatments that could have been more effective.  As it was, hydroxychloroquine became yet another issue tainted by propaganda, misinformation, and mind-numbing ignorance about how to conduct valid medical research.  

Such studies could have demonstrated the degree to which major ventilation improvements in indoor settings (such as with MERV-13 or HEPA filtration at a high number of air changes per hour) could have reduced the risk of viral spread, particularly when combined with modest distancing measures.   This would have allowed us to determine effective safety protocols for settings such as classrooms and restaurants, possibly allowing all of these establishments to operate more safely during the pandemic.  Alternatively, the data might have shown that safety would not improve much with these measures, requiring that such settings be at least temporarily shut down.  

The studies would also have had the benefit of most likely producing an increased number of immune individuals, thereby preventing participants in the study from ever spreading the virus to anyone else. 

A modification of this study approach, which should still be done, and is uncontroversial, is to do more substantial animal studies to demonstrate airborne spread characteristics and the effect size of ventilation improvements.  

2) Ventilation

Thankfully, mask mandates have become much more a norm, though this should have been done many months sooner.  

A relatively neglected issue, which could be simply addressed, concerns improvements to interior ventilation, given evidence that COVID is spread at least in part through airborne transmission.  If every classroom, workplace, restaurant, and home, had simple ventilation improvements (open windows, HEPA filtration, etc.) there could be a significant reduction in the risk and rate of spread. 

Each individual method (distancing, limitation of the size of groups and time spent in group spaces indoors, masks, ventilation, disinfection) has a limited effect size, but in combination, if done consistently, lead to much more substantial protection.   

3) Mass testing

The development of population scale rapid, frequent virologic testing could also have led to a rapid end to the pandemic, while allowing much more freedom to work & socialize.  If every person in the population was tested daily or weekly, every positive person could have isolated for a few weeks; this would rapidly have limited cases.  This approach alone could theoretically lead to the extinction of the virus.  I do not know what type of technological limitations impeded this approach, but it seems to me an area that was never developed as fully as it could have been.  I suspect the vast resources of the US science, technology, and manufacturing community could have led to big developments in this area, if the government response had been more normal.  

2) Media and Political Issues

I am ashamed to observe that most of the medical community, and in particular the psychiatric community, has not had the courage to comment on political factors which have led to immense, needless, catastrophic suffering for individuals, economies, and the world as a whole.  

Prior to 2021, Canada's southerly neighbour was afflicted by a devastating failure of leadership.  We are afraid to comment, as professionals, about psychopathic and narcissistic traits accompanied by staggering incompetence, ignorance, self-absorption, affective instability, almost continuous lying, and callous disregard, in a major political leader.  It does not require advanced therapeutic insight to see this--the behaviours were in plain view on almost a daily basis for years.   I am reminded of a cartoon or fantasy villain, with a team of minions, not unlike the villain from a "Batman" movie or a Tolkien novel, with just as much power, though with less intelligence or criminal aptitude.   I am also reminded of a caricaturized bully character from film, such as "Biff" from "Back to the Future."  

If similar behaviour had been going on in the partner of one our patients, I am quite certain we would come out and at least speculate directly about this with our patient, with a message of stern warning In this case, the "patient" is an entire nation, and the "partner" is an extremely unstable, abusive leader, but one whose demagoguery and propaganda have allowed a significant segment of the population to remain devoted, as though members of a death cult, sometimes to a fanatical degree. 

There has been a devastating barrage of misinformation and propaganda that has caused a bizarre politicization of simple community health measures.  In part, I attribute this directly to the leader, whose egregious incompetence and callous disregard has allowed what could have been an inspired, ingenious response from one of the world's great countries to devolve into utter chaos, madness, and mass death.  This behaviour has affected not only the US but the whole world.  The world's response to COVID has been set back greatly, because the world's leader in advanced medicine and scientific research has been suppressed, languishing in a cloud of needless chaos.  

The US could have engineered a rapid, massive research response, akin to the Manhattan Project, or the race to land astronauts on the moon,  combined with public health measures, to have emerged an inspired leader in this crisis, leading to decades of respect and appreciation from people all over the world, bolstering its image and authority forever.  Many of the world's greatest virologists and other health experts are American, and I can only imagine what sorrow, anger, and frustration they must have had this past year to see their country's disastrous and frightening response.  Not only has the response been catastrophic, the leadership is so steeped in denial about the gravity of the situation, and probably so ashamed of its incompetence, that it is trying to convince people that it was never a serious problem in the first place, that it was all over-blown.  It is like trying to convince people that World War II never happened (interestingly, the total number of deaths in World War II is comparable to the number of deaths that would be caused by COVID-19 if nothing was done about it).  

There are complex causes for this phenomenon, but one element of the problem is the polarization of news information found online.  It is very problematic when a group of individuals holding extreme or delusional views can all meet together on an internet-based forum or social media, and be exposed only to repetition and escalation of their beliefs.  In this way, it is again very much like the dynamics found in cults.  

What can be done about this?  It is a hard problem, but I hope that companies responsible for such polarization, such as Twitter or Facebook, can take much stronger steps to prevent their sites from magnifying extremism and polarization, while still honouring freedom of expression. 

Experts and leaders need to ensure that the entire population has access to good-quality information, and is not trapped in a "news bubble."  

Leadership change is of course a key requirement for problems of this type to improve.

Twitter and other news sites have had a negative effect on my own morale.  I have found that stopping news and Twitter exposure entirely for several months has been helpful.  I think that it would be sound mental health advice for all of us to severely limit the amount of time we spend watching news or engaging with social media.  Probably one hour per week would be a reasonable maximum.  Exposure to standard news sources, such as major world newspapers, should accompany any exposure to "news bubbles."   

In Conclusion: 

I was always an optimist about this problem.  I thought we should have had much, much stricter measures earlier on, so that we could have followed a course similar to New Zealand.  We still should do this, but it is like a forest fire: it is so, so much harder to control it if you have left it burning for a long time, instead of dealing with it properly at the beginning.  I  anticipated that we would develop better treatments or a vaccine sooner than expected, and I am relieved and delighted that this has come to be.  

But the pandemic is not over yet.  We should be fighting hard, with every possible public health measure, until the population is vaccinated.  Then the war will be won, and we can carry on with a more normal life again.  Despite the devastation, we will have learned a lot, and some of our adaptations and innovations will stay with us forever—for example, I predict many of us will continue to do much more remote or video-based work, often from home.  I hope it can be a time of healing, peace, and reconciliation, with preparations and changes put into place to prevent this type of disaster from ever happening again.  

The Next Crisis: 

The next crisis, or at least one of the big next crises, is an even bigger one, which is inexorably coming (it has been happening already for decades): it is environmental degradation and climate change. Unfortunately some of the same factors which caused catastrophic delays in responding to the COVID pandemic are now causing delays responding appropriately to the environmental crises.  We need to be acting now to do much, much more about this.  A starting point for education on this issue would be David Attenborough's documentary, "A Life on our Planet."  It is both a sorrowful, tearful account of the state of the world's environment, but also contains a message of hope and a call for action. 

There is always hope despite the severity of any problem.  It is important not to allow frustration, cynicism,  or despair to deter us from taking the actions we can to help.   

The Psychology of Meetings

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medical Education

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

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

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

Here are some ideas for change:

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

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

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

Biases in Psychotherapy Research

Biases in Research 


Pharmaceutical Research

We are much more familiar these days with biases in pharmaceutical research studies.  A clinical study of a medication treatment is more likely to show an exaggerated beneficial effect, if the study is sponsored by the manufacturer.  This doesn't mean industry-sponsored research is "bad," and it doesn't mean that pharmaceutical products are "bad," but it does mean that we have to look with a careful, skeptical eye at research results--not just at impressive tables or graphs, but also at the sources of funding for the study, and the authors' past relationships with the manufacturers.  There could indeed be overt "badness" if there are examples of flagrant profiteering on the part of people involved.  But the more salient issue, in my opinion, is simply the need to question the authority of results from such studies.

Alternative Medicine

This same critical eye is very much needed for looking at research evidence regarding alternative treatments.  There are very strong sales tactics used to market supplements, herbal remedies, and other treatments, and the standards of evidence presented are often much lower than those from pharmaceutical studies.  For example, simple testimonial accounts are much more common in alternative medication marketing, as are impressive-sounding but clinically irrelevant scientific or pseudo-scientific claims.

Psychotherapy Too! 

We may assume that studies of psychotherapy would be relatively free of these biases.  After all, there is no big company that is profiting from psychotherapy!

But we must maintain a critical eye even for studies of psychotherapy.  Here are some reasons:

1) A positive study of a psychotherapy technique may not bring obvious financial profit to anyone, but it is likely to increase the prestige of the authors.  A big part of the "currency" in a Ph.D. researcher's career relates to impressive publications.  A study showing a significant treatment effect of a psychotherapy technique is likely to add to the fame and career advancement of the authors.   This career advancement is analogous to direct financial gain.

2) Many psychotherapy researchers have spent many years of study devoted to their therapy technique.  Imagine if you had spent 10 years studying a particular thing, and that you had strong feelings about it.  You could imagine that you might have a bias in favour of the technique that you had studied all those years.  You would really want to show that it works!  If a study showed that it didn't work so well, it might lead you to question the value of all those years of your career!  In Cialdini's terms, this bias would have to do with "consistency."   If someone has been consistently committed to a particular thing for a long time, they are biased to maintain support of that thing, beyond what would otherwise be reasonable.   Furthermore, if you had worked all those years studying one particular technique, your social and professional community of peers would be more likely to share similar opinions.  You might have frequently attended conferences devoted to your area of specialty.  You might have even taught students the technique, who appreciated your help and mentorship.  This would lead to Cialdini's "social pressure" effect -- since the people around you support your idea, you will be more likely to hold onto the idea yourself, beyond what would otherwise be reasonable.

3) There is more and more direct financial gain related to therapy techniques.  We see a lot of books, self-help guides, paid seminars and workshops, etc.  Charismatic marketing, including through publishing of research studies, is likely to increase the financial profit of those involved.

4) In the psychotherapy research community, CBT is the most common modality.  CBT is intrinsically easier to research, since it is more easily standardized, the techniques themselves involve a lot of measurement, and the style tends to be more precisely time-limited.  CBT is more "scientific" and therefore attracts researchers whose background is more strongly analytical and scientific.  There is nothing intrinsically wrong with this , but it leads to more bias in the research.  Therapy styles other than CBT are studied less frequently.  Therefore there will be fewer positive studies of other styles.  This gives the impression that CBT is best.  It is not because comparative studies have actually shown it is best.   New versions or variations of CBT (with different fancy-sounding names) are also frequently marketed, and often show good results in research, but once again this does not really prove that the techniques are best.  The research study becomes an advertising tool for those who have designed the technique.

Conclusion

I do not mean to sound too cynical here...I think that CBT, as well as all other therapy techniques, are interesting, important, and helpful.  We should all learn about them, and make use of some of their principles.  But I do not think that any one style is necessarily "best."  We should not allow biases in research, including simple marketing effects, to cause a large change in our judgment with respect to helping people.

I feel that the more important foundation in trying to help people is spending the time getting to know them, and hearing from the person you are with (whether it be a client, a patient, a family member, or a friend) what type of help they would actually like.

Also, different individual therapists have different personalities, interests, experiences, weaknesses, and skills.  I think it is unhealthy for a community of therapists or healers to be pushed into offering a very narrow range of techniques or therapeutic strategies. Instead, I think that the individual talents and strengths of each therapist should be honoured, and there should be room in any health care system to allow for this.

Always Question

The freedom to question is a foundation of healthy living.

In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.

For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living.  Other issues may seem much more important in daily life.  This is especially true if we are struggling with poverty, illness, or other consuming life stresses.  Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to.  Whole nations may feel the same way.

I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities.  This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.

Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman:  he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness.  His work also suggests ways that we can protect ourselves from being misguided by our biases.

Let's look at an example situation, of a public educational lecture.  How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?

Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!

But here are a variety of biases that occur in lectures:

The Focusing Illusion

In order for a lecture to be narratively interesting, it should probably have a "thesis."  This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce).  If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence.   An essayist who vacillates will probably receive a lower grade.

But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion."  This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity:  if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.

A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion.  The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.

Cialdini's Persuasive Factors

Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking  b) authority c) social pressure d)consistency e)reciprocity f)scarcity

A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis.  An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture.    If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.

A speaker who is wearing more expensive clothing,  who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests),  has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.

  If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed.  This is due to the factor of consistency.  If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity.   And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).


Suppression of Counterargument

Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.

If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion.   We have seen this phenomenon in political rallies across the world in the past year.  When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions.  Decision-making under such conditions cannot be rational.  It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity.  Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.

Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present.  It is freedom in word only, not in action--which really is not freedom at all.  A lecturer may allow some time for questions or debate, but often only a few minutes near the end.  And the old familiar forces, stated above, may subtly suppress debate.  Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.

Zimbardo's Heroism

Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.

He calls for us to be "heroic":  what he means is that we should truly exercise our freedom, to always question.   It is easy to question things when we are strongly invited to do so.  It is harder to practice this freedom in an environment where questioning is discouraged.

The Risks of Questioning

If you raise questions, it is possible that you could get criticized by others in the group around you.  You might be labelled as being difficult, oppositional, or disloyal.  Some people may believe that you are being resistant to change, stubborn, or disrespectful.   Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others.  The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.  

I think this is a risk worth taking.  You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic.  The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.

I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.

Relevance to Psychotherapy & Mental Health

All mental health problems could be understood, in part, to reflect a lack of freedom.  Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.

Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level.  This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.

In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression.  Rather, the therapy environment should encourage freedom, including the freedom to dissent!   It should feel ok to completely disagree with your therapist, without fear of rejection or argument!   I think it should be accepted that it would also be ok, or necessary,  for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time.   But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.

If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question.  It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.

Cognitive Therapy

At its best, cognitive therapy is a formal mechanism to question one's own thoughts!  Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression.  If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.

Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective.  Your thoughts may be trying to warn you about potential dangers, based on learning from the past.  It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.

These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency."  You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your mind...it likes to have the final word...attempts to question it can seem futile

So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning.  You can become a civil rights leader in your own mind!   I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use.  Analogously, in many oppressive political systems, we see one tyrant simply being replaced by another...it is necessary instead to strive for freedom.   So I encourage your work in cognitive therapy to be an exercise in compassionately  developing and asserting your freedom, through courageous questioning of your self-talk.  

I am not meaning to encourage reflexive defiance, however.  Sometimes, after a period of debate, it is time to make a decision, and to move forward with that.  It can be unhelpful to debate every step of the way in every change process or learning event.  But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making.  I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.

Healing Divisions: Empathy, Filter Bubbles, and Free Speech

There is a lot of conflict and division in the world.  The recent U.S. election is just one of many examples of this.

What can be done to mend the conflicts?  

I found a relevant TED talk a few days ago, featuring a social psychologist named Jonathan Haidt.  He discusses the psychology of political difference, and also some ideas of what we can all do to help mend the divisions.  

Here is a link:  https://www.ted.com/talks/jonathan_haidt_can_a_divided_america_heal

One of the simple challenges he poses to us all, is to practice empathy.  It is easier to empathize with a person who has suffered in a way that we can understand or relate to.  He points out that it may be much harder for any of us to empathize with someone whom we strongly disagree with.  This lack of empathy with our intellectual or political opponents consolidates division, dislike, disrespect, and even hatred.  

A very important obstacle to empathy in the modern world is a technical one:  people who espouse a particular viewpoint may, through social media, or through other information sources, only expose themselves to those who already share the same views or opinions or backgrounds.  Some services, such as Facebook, may deliberately filter information to be attuned to your interests and opinions.  This "filter bubble" phenomenon leads to a reduction in empathy between opposing groups, and therefore magnifies division.  

I encourage all of us to have a practice of learning why people feel or believe the way they do, even if they have very different opinions, feelings, or backgrounds.  You may still strongly disagree at the end of this exploration, but at least there will hopefully be less enmity, and more understanding.  You may discover that despite many differences, that there are unexpected areas of common ground.  Such common ground can lead to peace instead of war.  

A foundation required for this process to work is freedom of speech...I am very troubled by processes in which communication is suppressed.    Even in the seemingly warm-hearted area of mental health care reform, I have seen processes of change in which dissenting voices were not welcome...the human tendency to suppress opposition in the name of efficiency or progress is universal.  We must always take steps to protect our freedoms.  This requires a certain bravery to express ourselves, even when your voice is a lone voice of dissent in a crowd...but it also requires a deliberate commitment to empathize, to strive to understand the feelings, thoughts, and motivations of those who disagree with you.  Such empathy must be practiced as a basic discipline of life.  

Another recommendation I have is to be aware of the "filter bubble"and to step out of it regularly.  Read widely, from as many different sources as you can.  This doesn't mean you need to agree with positions you find objectionable, but at the very least it does require you to be more aware of personal stories that you might not have been aware of before.

Addendum (in response to a message about this post):    I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice!  And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all.  In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one.   I think of some of the great voices in history, such as Martin Luther King's.  

Persuasive Factors in Politics

In my previous posts, I was describing some of Cialdini's factors which affect decision-making and persuasion.

It is interesting to look at some of these factors playing out in current news events:

Why do people adhere to a particular political choice?

Many people insist that they support a particular political candidate, simply because that candidate has the best policies, or has the best leadership skills.  Or they support an ideological position, or a whole system of values, because they believe, and feel, that they are the best.

But are there other factors at play?  Let's look at some of Cialdini's persuasion factors to consider how they affect candidate or political choice:

1) Consistency & Commitment.  If a person has already supported a candidate, a political party, or a position, then that person is more likely to maintain their choice, even if circumstances change.  We form loyal attachments to our previous choices, even if the attachment is shown to be irrational or harmful.   It may seem humiliating, embarrassing, or weak, to bail out on a previous choice.   It might feel similar to abandoning a marriage, a job, or a responsibility, just because things are going through a rough patch.

This consistency factor is especially strong if the person has grown up in a culture where consistency or commitments are considered strong points of honour.   This culture of honour is to be respected.  Loyalty is to be respected!  But unfortunately, this loyalty can cause people to keep supporting, for too long,  something that is harmful...it can cause people to overlook negatives in their position, and to go along with things that they would never have rationally supported were it not for their previous commitment.

A related cognitive bias is the "sunk cost fallacy":  if you have already invested a lot of time, energy, or money into something, you are more likely to continue pursuing it, even if it is irrational to do so, and even if the project is failing disastrously.   It may feel humiliating or shameful to change your mind, even if changing your mind could save you from bankruptcy!  It can take courage to let a previous commitment go!

Commitment and consistency are bolstered by community and family factors:  if most people among your cultural group, family, or coworkers have all been supporting a particular group, idea, or candidate, then it could seem intensely disloyal to disavow your own support or commitment.  You might even fear that your peers or family could reject you if you changed your mind.

So, commitment and consistency are powerful, noble forces in decision-making, and in life, but we must not be enslaved by these factors...it is a sign of a much greater character strength to sometimes over-ride this, and to make a deeply moral choice to let go of a previously held commitment.  

There are many tragic stories in history, where massive segments of the population of great societies follow disastrous ideas and leaders, partly due to the persuasive force of consistency.

2) Social pressure.  If many people continue to support a particular thing, then it is easier to keep supporting it yourself, even when this is irrational.  We all have a tendency to follow a trend...sometimes we follow these trends, along with an excited, passionate crowd, even when the crowd is rushing towards the edge of a cliff!  Beware of  "GroupThink!"

3) Liking & Authority.  We form positive emotional connections with candidates or positions we support, and we may also respect their authority...trust and admiration grows with any ongoing relationship, and we may continue to make decisions influenced by this.  If we "like" a political candidate, we may support that person long after it makes rational sense to do so.  Conversely, it may be difficult to support a candidate we do not personally "like," even if this candidate may offer the best leadership.   Some of these factors can be incredibly irrational, such as supporting a person whom we find better-looking or more entertaining!

When these factors have been at play, and we support something, we are likely to invest our time, attention, energy, and money...we may even suffer and struggle for these causes.  Our struggles and suffering usually intensify our attachment, and make us even more resistant to letting it go when it is morally right to do so.   If you have fought for something, you are much more likely to keep fighting for it, even if your cause is proven to be unjust.

It is our duty as citizens, or as participants in any community,  to make wise choices, and to be willing to change our minds after thinking carefully.  You need a great strength of character to take an honest, balanced look at both sides of every major issue or position.   You are not just born with character strength--you must work at it, and develop it as an essential life skill!  In politics, it is important to give sincere attention to multiple sources of information, and not to rely only on a single news source which happens to support your pre-existing point of view.

I am very alarmed about situations--which we see across the world today--in which there is restricted freedom of speech and expression.   Many news sources are overtly supporting only one position.  In some countries, the government is restricting free debate in the media.  Even closer to home, individual news sources are focusing on telling only one side of many stories...  We must protect our freedom of expression!  It is not only a matter of taking care of our freedoms, it is also a matter of making wise, unbiased decisions!  Wise decision-making is impossible unless we fairly attend to multiple points of view, and unless we are willing to challenge our own individual biases.

Cialdini tells an interesting story about the decline of tobacco use in the U.S., associated with a policy called the "Fairness Doctrine" which required equal time to be given to opposing viewpoints.  If tobacco ads were always followed by other ads trying to show the harms of smoking, it led the viewer to make a more balanced decision (which, in this case, led to a decline in smoking).  Ironically, once tobacco advertising disappeared entirely, smoking rates did not decline as much.  Part of an explanation is that tobacco advertising could then occur in more covert forms, perhaps marketed more exclusively to existing smokers, without equal time given to opposing viewpoints.  The best decision-making occurs not when issues are suppressed, but when powerful counter-arguments can be presented in a free society, by a free press, where opposing positions can always be clearly shown, side by side.  

It takes a great strength of character to be willing to change our minds,  and to make an intelligent, morally-guided choice, in the face of powerful persuasive factors such as consistency, social pressure, liking, and authority.  We can all improve this character strength, if we are willing to challenge ourselves, and if we are willing to work hard!

"GroupThink"

One of my favourite areas of psychology has to do with the study of persuasion, and of the cognitive biases involved with this.

There are two very important researchers who have written extensively about this:  Robert Cialdini (an expert in the psychology of persuasion), and Daniel Kahneman (an expert in the psychology of cognitive biases).   

Cialdini: Persuasion

I highly recommend that everyone be familiar with Cialdini's work, because it relates to making good decisions in the modern world.  Cialdini has spent decades studying the persuasive techniques which are used in sales and marketing, with the rigorous and thoughtful eye of a scientist and experimental social psychologist.  A problem with Cialdini, however, is that his books seem too focused on an audience of business people and marketers. 

Kahneman: Cognitive Biases

Kahneman's work focuses more on the cognitive mechanisms that affect judgment, and this area is an important complement to Cialdini.   Kahneman is the only psychologist to have won the Nobel prize!  His psychological work is very relevant to economics--it is a quantitative look at how human cognitive biases affect all decision making, including small and large economic or financial decisions.  

Why is this Important?

Cialdini -- and probably Kahneman too -- are most appreciated by people in the business community, especially marketers, since their ideas are likely to help any business earn more profit.  But I think these ideas should be part of everyone's knowledge base, since they will help us all to protect ourselves from being influenced by marketing in an unwelcome way.   Not just obvious marketing, such as commercial advertising, but also subtler forms of "marketing," such as experiencing persuasive forces in the workplace, in the media, in politics, and even in our personal or social lives.  

Persuasive Factors

In his initial work, Cialdini described 6 factors contributing to persuasion:

1) Reciprocity.  If someone gives you something, you will be more apt to give something back, including your approval or support!   If you are treated to lunch, you will be more likely to comply with someone's request afterwards!  This is a normal, natural thing, and even part of good social skills...but be careful about this, because sometimes the person giving you a free lunch may have an agenda to change your mind about something that you would otherwise not want to change.  A very troubling example of this in current events is of extremist groups providing free food, shelter, and other care to people in need...while helping people in need is wonderful, it also leads the people receiving this help to be more likely to join the extremist group!   We can address this problem politically by making a big effort to help people in need long before an extremist group does, rather than focusing only on military solutions to such problems!  

2) Consistency. Once you have done a certain action, or agreed to a certain thing, or committed in a small way to a certain thing, you are more likely to go further with that same thing in the future.  If you once joined a particular political party, you will be much more likely to keep supporting it in the future, even if you would otherwise disagree.  If your parents and grandparents have always supported a certain political or religious group, you will be more likely to also support the same group, since it could seem inconsistent, or even a "betrayal," to change your mind or your actions.  This consistency can be a great thing--it is part of maintaining a personal or community culture.  But it can also cause people to be "stuck" with ideas or behaviours which are unhealthy or harmful, yet with a resistance to change.   Marketers use this phenomenon all the time, by encouraging you to become a "member" of a points plan for a particular business, to have consumer "loyalty" programs, by having you formally endorse one of their products, which leads to a long-term tendency to choose the same products again.   

Be careful about this one!  Consistency is good, but not if it prevents us from changing our mind when change is needed.  Some of the most disastrous events in world history happened when people's consistency and commitment led them down a dark path...

3) Social Pressure, or Social Proof.  If you see that something is becoming more popular, you are more apt to support it.  Suppose you are starving in the woods, and you see bushes with berries on them.  You are not sure whether they are poisonous or safe.  If you see other people happily eating those same berries, you will obviously be reassured that they are safe, and you will happily pick some berries for yourself!  In this case, social proof is very useful and protective.  But marketers routinely use information about social proof to push us to support things or buy things.  Even the polls that we see in the media can have this effect:  if someone claims that a particular candidate is soaring in popularity, many people will be more likely to join in and support that person as well.  This effect is especially pronounced if the social proof comes from people who are similar to us in some way.  For example, if you are shown that most people who are around your age, and who come from a similar ethnic background, and who share similar cultural interests, are all supporting a particular political candidate, you will be more likely to be persuaded to support this candidate as well.  

Once again, this is a normal and often efficient way to make decisions in life, by assessing the decisions that similar people are making already.  It is what Kahneman calls a "cognitive short-cut."  

But marketers use this factor all the time, to push us to support things, or to buy things, that we otherwise would not want.   

4) Liking.  If someone you really like asks you to do something, or to change your mind, you are more likely to comply!  This is again a completely normal, understandable, and often useful human behaviour.  But be careful with this one!  Marketers, politicians, and even people in your social circle could sometimes push you to make decisions you otherwise would not make, just by being nice, and by being "likeable."  The stereotype of a "con man" usually includes being physically attractive, charming, and superficially likeable.  Be careful not to let these factors affect your judgment more than you want!  

5) Authority.  This is a huge factor, both in the marketplace and in a professional work environment.  It is another very useful cognitive short-cut to assume that an "expert" has good advice.  Often the expert or authority (such as a famous doctor or researcher) really does have useful advice and wisdom!  But people are easily prone to shutting off their critical judgment if they are told something by an expert.  In many cases, an expert may have a particular agenda for change which is not directly related to their expertise.  And in many cases, a speaker may be granted more "authority" or expert status than is reasonably warranted.  For example, it is a tradition for speakers at a meeting or conference to be introduced with a glowing biographical vignette, summarizing a list of very impressive credentials, degrees, awards, and a publication record.  These facts may be completely accurate, but it is important to know that this introduction will increase the speaker's persuasive influence over the audience...While this is often useful and reasonable, it could also often give the speaker license to influence the audience about all sorts of things that are outside of their expertise!  

I have seen this in my work very often:  a speaker with impressive credentials is greatly respected by the audience.  The speaker's ideas about treatment strategies (e.g. medication or therapy approaches for treating depression) or about health care policy (e.g. how to set up an efficient medical system) are accepted by the audience in a much more uncritical way, with much less reasoned debate, than would be the case if the same ideas were shared without the introductory eulogy about credentials!  

Be careful when you see a commercial featuring an esteemed expert or authority endorsing a product.  The information you hear should be considered seriously, but remind yourself that you may exaggerate the validity of this information, simply because you respect the expert's authority.  Always question authority!  Don't reject it outright, but always question it!  

6) Scarcity.  If you know that something is rare, or disappearing, you are more likely to desire it more.  This factor is routinely used in sales and marketing:  if a particular product is "disappearing fast,"  or if you are told it is your "last chance" then you are more likely to be interested in it.  If you are guided to believe that you have some kind of rare, special, personalized knowledge about something, then you are more likely to act on it. 

In marketing and politics, the fear of loss can have an exaggerated influence on people's decision making.  The fear of loss of security or safety can lead to a greatly increased focus on policies addressing this (e.g. military or policing issues).  While it is reasonable to focus on such things, ironically the fear involved can distract attention away from other policy factors which would ultimately have a much better chance of improving safety (such as enhancing diplomacy, improving education, focusing resources on eliminating poverty, etc.) 

In Cialdini's more recent work, we could add another factor, one which Kahneman has talked about extensively as well.  It is something which all the other 6 factors incorporate to some degree as well:  

7) Guided Attention & the Focusing Illusion

If our attention is guided towards something, we are much more likely to assume that this thing is important, and that it has some causal influence.  A magician or illusionist routinely makes use of this...most magic tricks involve carefully guided attention, so that we don't notice the magician fooling us, right in front of our eyes!   I encourage you to look at some YouTube videos showing clever illusionists using this phenomenon; here's a good example: https://www.youtube.com/watch?v=GZGY0wPAnus

This factor is arguably the most powerful of all persuasive influences.   When a person or a group is focusing on something, we will be guided into thinking that this focus is more important and causal than it really is, and it will prevent the person or group from asking other important questions!  

Cialdini gives a good example of this, having to do with the journalists who were allowed to cover a recent war.  The journalists were given unique, unprecedented "embedded" access to soldiers in their daily lives.  On the one hand, this allowed a valuable transparency about the goings on in the war.  It led to a focus upon the daily dramas in the life of a soldier:  the harsh climate, the food, the camaraderie and bonding with fellow soldiers, and especially the heroism, bravery, and self-sacrifice involved in the battles.   As a result of this focus, the viewers would form an understandable and healthy attachment to the human stories on the battleground, and would form a completely normal and healthy admiration for the bravery and nobility of the soldiers.  But--because of this, the viewer would be less likely to question the strategy of the war itself!   

The manner in which a story is focused upon can distract us from asking other questions about the story, which may need to be asked!  

In a work environment, there could be a new policy scheme, which in some ways could be similar to the example above...it could involve honourable, devoted, intensive efforts from many warm-hearted people, all of whom nobly striving towards making things better.  But once such a plan is in action, the attention of the group becomes focused upon the daily "battles" and human dramas associated with enacting the plan.   The group is much less likely to question the strategy of the plan itself, even if the plan is unhealthy or harmful.  

One can see this in political movements:  supporters of a particular political party or candidate are working very hard, are forming strong social and emotional bonds with the cause...they are motivated honourably, often with strong wishes to make the country better.  There are daily struggles with polls, with debates, with interviews, with criticisms from opponents...these struggles are analogous to a battlefield.  The stories involved with the battles are dramatic and engaging, and the media on both sides of the battle are eager to focus on them.   But because of this, supporters are likely to simply focus on continuing the battle they started, rather than pausing, reflecting, thinking deeply, and being willing to change their strategy or beliefs if necessary and morally right.   

GroupThink

So, this is what I mean by "GroupThink."  It is going along with what other people are thinking...due to reciprocity, consistency, social pressure, liking, authority, and the focusing illusion...we then risk getting caught up in things that aren't good for us.  

"GroupThink" can often be efficient, to get certain tasks done.  If everyone in a group is constantly stopping, reflecting, and questioning themselves, then the group's actions could be frozen...but we must always at least be aware of how powerful "GroupThink" is, and how it affects all of us.  The antidote for this, the way to keep this force balanced, is to always be willing to question things!  

Be willing to question others, even authorities, even people whom you really like!  Be willing to question yourself!  Just because you have thought, felt, or done a certain thing for a long time doesn't mean you can't change your mind, your feelings, or your actions!   

Be aware that there are powerful persuasive factors in our lives, all around us...we don't have to be afraid of them, but we do need to know that it can be easy to follow these factors passively.  We can live healthier, happier, more satisfying lives if we take some time to step back, think carefully about our decisions, and be willing to speak up!  

Mental Health Care Triage

What is Triage?

"Triage" is a term used in medicine, referring to the process of deciding the order in which patients should be seen and attended to, if many are waiting.

If you are waiting for something, such as for a table at a restaurant,  the first person to arrive is served first.  An even higher priority is also given to people who have made "reservations," or who have arranged their appointments in advance.

In an emergency room, a different system is needed.  Even if you have been in the waiting room for several hours with a broken ankle, a person just arriving with a heart attack must be seen right away, before you!   It generally would not work to make "reservations" at the emergency room, except maybe if you are on your way in an ambulance.

Triage involves not only deciding what order in which patients should be seen, it also involves deciding what type of service should be provided to each person.

If everyone with abdominal pain was sent to a surgeon, it would be inefficient...most cases of abdominal pain do not need surgical treatment.  If these non-surgical cases were all seen by the surgeon, then the surgeon would be too busy to deal with the true surgical emergencies!

In mental health care, it can be efficient to have a triage process.  But how to do this?

Assessment

The most common strategy is to offer some form of "assessment" which then could guide a triage decision.  This usually would involve an interview.  It could involve filling out questionnaires.  Based on the results of the interview and the questionnaire results, a decision could be made about whether some form of counseling might be needed, or perhaps a visit to a physician, a referral to a psychiatrist, or even an urgent trip to the hospital.   In other cases, a bit of simple reassurance, simple lifestyle or self-care advice might be really helpful.

The benefits of an efficient triage process would be that others in the system could then see clients or patients whose particular problems or levels of severity were well-matched to the skills of the particular caregiver.  All caregivers in the system would spend less time dealing with situations that were outside their scope of experience or expertise.

Potential Problems 

What are some of the potential problems of a mental health triage process?


1) The first issue has to do with the reliance on a single interview, and on questionnaire data.  In a great many cases, this is an efficient, helpful process.  But in some cases, an ongoing relationship is needed to understand mental health issues.  People may not be willing to share sensitive issues with someone who will only be seeing them once.  People may not be willing to divulge sensitive information in a questionnaire, which will then be handed in to a stranger.   Some people may have a very clear reason to desire a therapeutic relationship of a particular type, without wanting to explain their reasons in detail to a stranger who would only be seeing them once.

So the triage system, involving interviews and questionnaires, must have the flexibility to accommodate situations of this type.  Basically, it should have strong consideration for patients' or clients' wishes for privacy, discretion, confidentiality, and therapeutic resources, while not being rigidly adherent to questionnaire or interview data.

A simple remedy for this problem can be for individual patients or clients to have the ability to make a direct request for a particular type of care, without having to "jump through the hoop" of a triage assessment visit.  Many people who desire a therapeutic relationship will not benefit from going over their history with a stranger who will not be seeing them in the future.  In fact, the triage step will just add to their stress, and could lead to a feeling of having to negotiate yet another bureaucracy.

2) The second issue has to do with the quality of life of people working in the system.  In my experience, emergency psychiatry is a very stressful area of mental health care.  Practitioners in this area can often become burned out or even cynical over time, if this is the only type of work that they are doing.  The reasons for this are not simply related to the severity of the problems seen in the emergency room:  it is also because emergency workers usually do not follow the patients or clients after their emergency visits.  Therefore, they do not get to see their patients or clients recover!  They may not have the satisfaction or enjoyment of working with someone over a period of time, and seeing their progress.    Furthermore, if they are only doing emergency or triage tasks, their clinical skills for doing other types of ongoing health care will weaken or atrophy.  

I believe that a big part of the joy of being a therapist or a physician, involves getting to know your clients and patients on an ongoing basis, sometimes for long periods of time.  It can be demoralizing and stressful to only be seeing people a single time, or only be seeing people who are severely ill.

There is a simple remedy for this problem:  in any triage system, or emergency care system, it can be valuable for different staff to take turns doing triage tasks.  Each staff person should also have the opportunity, at other times,  to follow some patients or clients for ongoing care.   This would help staff to maintain better morale, and to maintain better clinical skills beyond "assessment."

3) A third issue has to do with the risks of a supposedly "efficient" system becoming more and more like a mechanical or impersonal bureaucracy.   As questionnaire-based systems become more and more prevalent, we may start talking more and more about "PHQ-9" scores, and less and less about a person's story.   Furthermore, score-based assessments in mental health may lead to false conclusions about what is truly helpful.  For example, a person in great distress may enter an emergency room on a Friday night with an extremely high score.  That person might have an unpleasant experience on a stretcher in a noisy hallway on Friday night, then a frightening experience on a busy emergency ward for the next day.  On Sunday afternoon, the symptom questionnaire may be repeated, yielding a greatly reduced score.  The conclusion may be that the emergency room experience was profoundly helpful!   In this case, the symptom score diminished because of the passage of time, and perhaps because of a physical place that was safe in some ways.  Other types of harms may well have been done because of this experience (for example, the person may dread ever having to go to the hospital again), but this harm would not be detected on a cross-sectional symptom scoresheet.   The harm would be apparent, however, if we were to have a conversation with this person rather than just give them a questionnaire.

Symptom questionnaires are very imperfect guides, and should never be the foundation of any type of health care, especially in mental health  (see my previous post about questionnaires: http://garthkroeker.blogspot.ca/2015/11/the-business-of-psychological.html).  I do think they have their role, and people could be invited to use them, but there is a risk of both the patient or client, and the caregiver, paying too much attention to questionnaires, and too little attention to other aspects of care or need.

4) A fourth issue has to do with allocation of health care resources.  While triage could improve efficiency, and allow more people to get the help they need, it could also in some cases be an unnecessary bureaucratic hurdle.  The same money and resources spent on a triage system could instead be spent simply hiring more counselors, who could manage their own triage.  In many private counseling regimes, a person seeking a counseling relationship is already "self-triaging" and can inquire on their own with the therapist about the possible types of care available or needed.  

This issue is similar to the Electronic Health Records (EHR) issue:  an innovative device, triage system, or "model" may be useful in some ways, but it must always be in service of a higher value, which is to provide personal, empathic, attentive, ongoing care to those who desire it, and to allow a healthy, balanced, meaningful work environment for therapists.