Indistractable, by Nir Eyal, is an instruction manual, teaching us how to make healthy choices with our attention and activities, in the midst of the many addictive distractions of the internet age.
It is a good book, but most of its content could be acquired through a brief surfing of the net.
Eyal wrote another book in 2014 called Hooked: How to Build Habit-Forming Products. Ironically, this earlier book uses his knowledge of persuasion and behavioural psychology to foster the very addictive distractions that Indistractable tries to rescue us from. In some ways I guess we could compare that to the management of a casino organizing its own addiction treatment program for customers.
The book itself is well-written, and its format is an example of how to keep a reader engaged: the chapters are short, the language is simple and clear, and the main points are summarized at the end of each chapter, then once again at the end of the book. There is even material provided to get started on a CBT-style program to become "indistractable." The "indistractable" language is based, I'm sure, on a marketing idea of encouraging an identity-based slogan as a motivational tool. If one were to wear a t-shirt with the "indistractable" logo it might help motivationally.
The book itself is a product, and I suspect that it will lead to profits for the author.
Yet, the ideas contained within are useful, and worth knowing about. Aside from simple behavioural techniques (e.g. decluttering your home screen, scheduling in advance, etc.) there is appropriate attention given to identifying the emotions accompanying distracted behaviour, and to identifying core values (e.g. of being a good parent or a good friend) as a primary motivating force to choose relationships or meaningful work rather than surfing Twitter, playing a distracting video game, or having a text conversation.
This is another example of how therapists or physicians can learn important lessons from people who have expertise in marketing. It often requires an inspiring persuasive message to help someone who is struggling with depression, anxiety, addictions, or other problems to make positive, sustained engagements with meaningful life change.
Monday, October 7, 2019
Saturday, September 21, 2019
Review: "The Coddling of the American Mind" by Lukianoff and Haidt
The Coddling of the American Mind: This is another book I recommend as an important, timely review of contemporary issues relating to modern culture, parenting, free speech, and university education.
I respect what I think Haidt is trying to do, as a persistent theme in his career: to be a peacemaker, to encourage intelligent, harmonious, respectful dialogue among people with different viewpoints or political leanings, and to reduce or mend hostile polarization. This theme comes across once again in this book. I could not support this goal more strongly. Haidt is probably one of the few psychologists who would have a respectful audience among people right across the political spectrum.
But there are many areas where I disagree.
Safetyism -- A Culture of Fragility
The initial section discusses how in a well-meaning quest for "safety" we can create a culture in which people are weaker, less capable, and more fragile. For example, if we are so afraid of a child falling down and getting hurt, we might not allow bike riding, climbing, gymnastics, etc. But this lack of exposure to challenging, slightly risky activity would lead to a failure for the child to develop normal physical skills, and might also lead to the child learning to fear and avoid challenges, rather than to face them and master them.
Ironically, this would sabotage the goal of improving safety.
Intellectually, according to the authors, if we teach fear, avoidance, or suppression of disagreeable ideas and of the people who express them, it may likewise lead to a failure to develop normal resilience or problem solving, and may foment unnecessary, destructive societal conflict.
So the authors are saying that just as we must allow children to try riding bikes or climbing, even though there is a risk of falling, we must encourage a cultivation of resilience and respect when exposed to disparate ideas, including those which offend us.
Cognitive-Behavioural Therapy (CBT) as an approach to modern life
The authors make frequent mention of cognitive-behavioural therapy (CBT) ideas, as a model for approaching these social and political issues. The principles of CBT call for us to study our thoughts, assess them for possible distortions, be open to challenge them and test them behaviourally, and also to face our fears.
Extreme Examples, Case Studies
They describe a variety of unsettling stories of extreme cases, where so-called "safetyism" led to excessive negative consequences for scholars, for free speech, even for university culture in general. The authors argue that these conditions cause intellectual freedom to be dampened, replaced by an atmosphere in which some professors may be reluctant to speak their minds or share their research, for fear of causing offense and a resulting protest or scandal.
A decline in teen and young adult mental health?
The authors move on to describe their theory that teen and young adult mental health is declining, and that a combination of "safetyism," overprotective parenting and internet use (especially social media) are responsible. One of their prescriptions for this (which they advise strongly near the end) is for parents to encourage so-called "free play" with a restriction of internet or smart phone use for children.
Misgivings
Here are some of my misgivings:
As is often the case, one can make a general prescription for a cultural change based on knowledge or experience with a limited group (sometimes a group of just one, when we recommend to everybody what worked for us individually). Haidt is a respected, famous academic leader who has a fair bit of influence. His book is marketed extensively, as I suspect are the public lectures across the world. It would be consistent with one of the better themes of this book to welcome some balanced and thorough debate about it. One insight from social psychology is that once a person has publicly announced a position or opinion (especially in the form of a well-selling book) they are more likely to be biased in favour of this position, despite contrary evidence.
It may well be true that cultivating intellectual resilience through exposure to disparate intellectual ideas, exposure to risk, free play, etc. are in general good things, which would be reasonable public health measures or aspects of a healthy policy about parenting or education. But such cultivation may require a different approach for different people, just as cognitive-behavioural therapy would need to be approached differently depending on where the individual person is at.
In CBT, as with any therapy, the process cannot be pushed if the person does not consent to it. Exposure therapy (e.g. exposure to fears, challenging safety behaviours) cannot occur without informed consent, otherwise it would often be traumatic and counterproductive. And exposure usually needs to occur in a controlled, gradual manner, which is quite different from the way stress occurs in the environment (such stress outside of a therapy room is usually random and uncontrolled). And not every mental health problem is amenable to exposure therapy; in some cases exposure makes things worse. Humans are not always "antifragile."
One of the reasons why I think there is more stress about conflictual issues on university campuses is not because the students are less resilient at all. I think it is because universities in general have become more accepting and accommodating to individuals whose concerns would have been more dismissed and marginalized in previous years and decades.
It is possible now to attend university while having more serious mental health problems, and most modern universities are more accommodating than they were in the past.
There are also movements for previously marginalized groups to speak out, and insist on their rights. Such insistence, as we see from all previous civil rights advances through the ages, often does not happen without social stress and conflict.
So actually I think students are at least equally, if not even more, resilient, courageous, and brave than they were in the past. They are not merely "coddled."
It is not clear to me that there is a large change in rates of mental illness, over a long span of time. There may be, but it is debatable. There can be transient ups and downs over the span of years or decades. Causes for these changes are probably complex, regionally variable, and multifactorial. Economic factors, such as poverty, are probably very important and underappreciated. Different rates may be due to different rates of reporting, more awareness in the population, different trends or fashions of diagnosis, etc.
And if there is a change in the prevalence of mental illness, it is by no means clear to me that internet or social media use is responsible (there are some important recent studies disputing the impact of the internet on youth mental health). There are good alternative viewpoints--here's a link to one good article: * Przybylski, an Oxford researcher, has published a recent study worth reading on this subject: **
It is certainly not clear that parental "coddling" is responsible for changes in teen or young adult mental health. There is evidence on both sides of this. Common sense would dictate that, just as with any other human behaviour, we should be careful with our habits, our parenting, and with how children are spending their time.
I do more strongly agree about one of the authors' points about modern parenting: it is not healthy for children to be overscheduled, to lack free time, and to be forced at a young age to start academic preparations for admission to a prestigious university. Childhood should be a time of relationship development, play, and freedom. However, some individual children may greatly enjoy and appreciate extra academic focus instead of more "free play" -- I know I was one of those children myself.
About "coddling." The authors include this word in the title of their book. It is meant as a pejorative of course. I don't like it. "Caudle" is a thick, sweet, warm drink which is meant to be digested easily or enjoyed by someone who is unwell. The authors use the word to mean that we are overprotective of others, including our own children, to the point that we are causing harm, as though feeding "caudle" to people who aren't ill.
I agree that such overprotection can occur. But many children actually do need more protection and parental supervision. "Caudle" is often useful and good. Different kids develop at different rates. Some individuals, for various reasons, never attain, and are unable to attain, the full set of skills they need (physically, emotionally, or socially) to function independently, despite maximal "CBT." Such individuals have often been neglected, left behind, and excluded by the majority. One cannot just make a blanket prescription to "let the kids play more." As a specific example, various types of learning disorders and developmental variants (such as autism-spectrum phenomena) are permanent, and they cannot be resolved simply by pushing the students to face their fears; remedial help and accommodation are needed (I guess we could call this "coddling"). Social anxiety disorders, which are extremely common, should be approached using CBT techniques, but it is unlikely that any therapy can "cure" social anxiety -- we also need to accommodate ("coddle") and value shyness, rather than just try to "treat" it. ***
"Safetyism" should not be criticized too much. Accidents and injuries are among the most common causes of death and permanent disability for children and young adults. Basic improvements to safety are an obvious, reasonable societal advance. People complaining about "coddling" as an impediment to healthy development might criticize safety features at playgrounds, or of signs recommending safe practices or rules for games. I don't think these things deserve criticism. Safety features and play instructions can be helpful for many people. For those of us who don't want or need these safety features, we can just ignore or defy them, unless they are incorporated into law (such as regarding seat belt or helmet use).
With respect to parenting, the most common situation I see in my clinical practice is of people who have not been "coddled" too much, but who have been neglected or mistreated by their parents. This has nothing to do with how much "free play" has occurred.
A common cause of such neglect is of a modern lifestyle where parents are too busy or disconnected to play with their children. The causes for this phenomenon include cultural trends in work and parenting; economic stress; and mental illness. Most children can accommodate to this, and even thrive, but some cannot. Some children would find endless hours of free play to be a torment. It need not be considered some kind of parenting triumph to allow your child to walk to school alone at an early age. (I do not consider walking alone to be risky--the authors are correct in observing that risks of abductions, etc. are extremely low, and should not rationally lead to walking children to school just for their physical safety.) But physical safety is not the point. Enjoying time and relationship with your child is the point! If you have the opportunity to play with your child, or walk him or her to school, this is not some kind of harmful "coddling"! It is one of the joys of life, leading to memories that both of you will savour for the rest of your lives. And some children may need to be walked to school, to help them negotiate their anxiety or build their social strengths alongside a trusted adult. This is ok too, and is not "coddling" except in the best sense of the word.
I in general support the authors' recommendations for being open to hearing and respecting opposing points of view, as opposed to shutting down opposing voices using angry protest. However, perhaps this recommendation deserves some questioning as well. For example, if one has signed up to learn genetics, and if there is a space and time for a visiting lecturer once per week, I think most would consider it bothersome to reserve this precious lecture time and student attention on entertaining speakers who deny the existence of genes or DNA. Free speech may not require that every point of view should have equal access to a reputable and influential public forum. Of course, this would lead to a question of who has the power to decide who gets access to this forum. A default answer would be to say that in a democracy, it is the people who would decide, hopefully guided by the wisdom of experts. But sometimes the experts could be wrong. Or sometimes population trends could be unreasonable. In these cases, I do agree very much with the authors in affirming a principle of calm, reasonable openness to dissent to be enshrined as a guiding principle, as it is in many nations' constitutions. And it is also reasonable for everyone in the population to be acquainted with rational techniques for self-questioning, such as CBT.
I actually do find that CBT ideas are so prevalent now, that many college students are aware of the theory already. Young people are intelligent and well-informed, for the most part.
My own recommendations:
First of all, I question my right to make any sort of recommendation. I think it is better to be a little more humble and admit that there is quite a bit of uncertainty about all of these things.
For parenting, I think different children have different needs. For some it is ok or necessary to "coddle." For others, it is best to encourage a lot more "free play." For many kids it probably doesn't make a whole lot of difference either way, and there could be leeway to simply choose the strategy that is possible for you, and that you and the kids enjoy the most. I am a big fan of spending a lot of time with one's children, to cultivate a close relationship, to build strong, positive, happy memories. Such memories are, in my opinion, strongly protective of lifelong mental health, and one of the most powerful sources of resilience that experience can offer (other sources of resilience are inherited, and have nothing to do with parenting). They are also very satisfying for a parent, and probably are associated with healthier, happier aging. In many cases, though, the memories have nothing at all to do with mental health per se. They are just memories of time together. In general, I prefer to have them rather than not.
I respect what I think Haidt is trying to do, as a persistent theme in his career: to be a peacemaker, to encourage intelligent, harmonious, respectful dialogue among people with different viewpoints or political leanings, and to reduce or mend hostile polarization. This theme comes across once again in this book. I could not support this goal more strongly. Haidt is probably one of the few psychologists who would have a respectful audience among people right across the political spectrum.
But there are many areas where I disagree.
Safetyism -- A Culture of Fragility
The initial section discusses how in a well-meaning quest for "safety" we can create a culture in which people are weaker, less capable, and more fragile. For example, if we are so afraid of a child falling down and getting hurt, we might not allow bike riding, climbing, gymnastics, etc. But this lack of exposure to challenging, slightly risky activity would lead to a failure for the child to develop normal physical skills, and might also lead to the child learning to fear and avoid challenges, rather than to face them and master them.
Ironically, this would sabotage the goal of improving safety.
Intellectually, according to the authors, if we teach fear, avoidance, or suppression of disagreeable ideas and of the people who express them, it may likewise lead to a failure to develop normal resilience or problem solving, and may foment unnecessary, destructive societal conflict.
So the authors are saying that just as we must allow children to try riding bikes or climbing, even though there is a risk of falling, we must encourage a cultivation of resilience and respect when exposed to disparate ideas, including those which offend us.
Cognitive-Behavioural Therapy (CBT) as an approach to modern life
The authors make frequent mention of cognitive-behavioural therapy (CBT) ideas, as a model for approaching these social and political issues. The principles of CBT call for us to study our thoughts, assess them for possible distortions, be open to challenge them and test them behaviourally, and also to face our fears.
Extreme Examples, Case Studies
They describe a variety of unsettling stories of extreme cases, where so-called "safetyism" led to excessive negative consequences for scholars, for free speech, even for university culture in general. The authors argue that these conditions cause intellectual freedom to be dampened, replaced by an atmosphere in which some professors may be reluctant to speak their minds or share their research, for fear of causing offense and a resulting protest or scandal.
A decline in teen and young adult mental health?
The authors move on to describe their theory that teen and young adult mental health is declining, and that a combination of "safetyism," overprotective parenting and internet use (especially social media) are responsible. One of their prescriptions for this (which they advise strongly near the end) is for parents to encourage so-called "free play" with a restriction of internet or smart phone use for children.
Misgivings
Here are some of my misgivings:
As is often the case, one can make a general prescription for a cultural change based on knowledge or experience with a limited group (sometimes a group of just one, when we recommend to everybody what worked for us individually). Haidt is a respected, famous academic leader who has a fair bit of influence. His book is marketed extensively, as I suspect are the public lectures across the world. It would be consistent with one of the better themes of this book to welcome some balanced and thorough debate about it. One insight from social psychology is that once a person has publicly announced a position or opinion (especially in the form of a well-selling book) they are more likely to be biased in favour of this position, despite contrary evidence.
It may well be true that cultivating intellectual resilience through exposure to disparate intellectual ideas, exposure to risk, free play, etc. are in general good things, which would be reasonable public health measures or aspects of a healthy policy about parenting or education. But such cultivation may require a different approach for different people, just as cognitive-behavioural therapy would need to be approached differently depending on where the individual person is at.
In CBT, as with any therapy, the process cannot be pushed if the person does not consent to it. Exposure therapy (e.g. exposure to fears, challenging safety behaviours) cannot occur without informed consent, otherwise it would often be traumatic and counterproductive. And exposure usually needs to occur in a controlled, gradual manner, which is quite different from the way stress occurs in the environment (such stress outside of a therapy room is usually random and uncontrolled). And not every mental health problem is amenable to exposure therapy; in some cases exposure makes things worse. Humans are not always "antifragile."
One of the reasons why I think there is more stress about conflictual issues on university campuses is not because the students are less resilient at all. I think it is because universities in general have become more accepting and accommodating to individuals whose concerns would have been more dismissed and marginalized in previous years and decades.
It is possible now to attend university while having more serious mental health problems, and most modern universities are more accommodating than they were in the past.
There are also movements for previously marginalized groups to speak out, and insist on their rights. Such insistence, as we see from all previous civil rights advances through the ages, often does not happen without social stress and conflict.
So actually I think students are at least equally, if not even more, resilient, courageous, and brave than they were in the past. They are not merely "coddled."
It is not clear to me that there is a large change in rates of mental illness, over a long span of time. There may be, but it is debatable. There can be transient ups and downs over the span of years or decades. Causes for these changes are probably complex, regionally variable, and multifactorial. Economic factors, such as poverty, are probably very important and underappreciated. Different rates may be due to different rates of reporting, more awareness in the population, different trends or fashions of diagnosis, etc.
And if there is a change in the prevalence of mental illness, it is by no means clear to me that internet or social media use is responsible (there are some important recent studies disputing the impact of the internet on youth mental health). There are good alternative viewpoints--here's a link to one good article: * Przybylski, an Oxford researcher, has published a recent study worth reading on this subject: **
It is certainly not clear that parental "coddling" is responsible for changes in teen or young adult mental health. There is evidence on both sides of this. Common sense would dictate that, just as with any other human behaviour, we should be careful with our habits, our parenting, and with how children are spending their time.
I do more strongly agree about one of the authors' points about modern parenting: it is not healthy for children to be overscheduled, to lack free time, and to be forced at a young age to start academic preparations for admission to a prestigious university. Childhood should be a time of relationship development, play, and freedom. However, some individual children may greatly enjoy and appreciate extra academic focus instead of more "free play" -- I know I was one of those children myself.
About "coddling." The authors include this word in the title of their book. It is meant as a pejorative of course. I don't like it. "Caudle" is a thick, sweet, warm drink which is meant to be digested easily or enjoyed by someone who is unwell. The authors use the word to mean that we are overprotective of others, including our own children, to the point that we are causing harm, as though feeding "caudle" to people who aren't ill.
I agree that such overprotection can occur. But many children actually do need more protection and parental supervision. "Caudle" is often useful and good. Different kids develop at different rates. Some individuals, for various reasons, never attain, and are unable to attain, the full set of skills they need (physically, emotionally, or socially) to function independently, despite maximal "CBT." Such individuals have often been neglected, left behind, and excluded by the majority. One cannot just make a blanket prescription to "let the kids play more." As a specific example, various types of learning disorders and developmental variants (such as autism-spectrum phenomena) are permanent, and they cannot be resolved simply by pushing the students to face their fears; remedial help and accommodation are needed (I guess we could call this "coddling"). Social anxiety disorders, which are extremely common, should be approached using CBT techniques, but it is unlikely that any therapy can "cure" social anxiety -- we also need to accommodate ("coddle") and value shyness, rather than just try to "treat" it. ***
"Safetyism" should not be criticized too much. Accidents and injuries are among the most common causes of death and permanent disability for children and young adults. Basic improvements to safety are an obvious, reasonable societal advance. People complaining about "coddling" as an impediment to healthy development might criticize safety features at playgrounds, or of signs recommending safe practices or rules for games. I don't think these things deserve criticism. Safety features and play instructions can be helpful for many people. For those of us who don't want or need these safety features, we can just ignore or defy them, unless they are incorporated into law (such as regarding seat belt or helmet use).
With respect to parenting, the most common situation I see in my clinical practice is of people who have not been "coddled" too much, but who have been neglected or mistreated by their parents. This has nothing to do with how much "free play" has occurred.
A common cause of such neglect is of a modern lifestyle where parents are too busy or disconnected to play with their children. The causes for this phenomenon include cultural trends in work and parenting; economic stress; and mental illness. Most children can accommodate to this, and even thrive, but some cannot. Some children would find endless hours of free play to be a torment. It need not be considered some kind of parenting triumph to allow your child to walk to school alone at an early age. (I do not consider walking alone to be risky--the authors are correct in observing that risks of abductions, etc. are extremely low, and should not rationally lead to walking children to school just for their physical safety.) But physical safety is not the point. Enjoying time and relationship with your child is the point! If you have the opportunity to play with your child, or walk him or her to school, this is not some kind of harmful "coddling"! It is one of the joys of life, leading to memories that both of you will savour for the rest of your lives. And some children may need to be walked to school, to help them negotiate their anxiety or build their social strengths alongside a trusted adult. This is ok too, and is not "coddling" except in the best sense of the word.
I in general support the authors' recommendations for being open to hearing and respecting opposing points of view, as opposed to shutting down opposing voices using angry protest. However, perhaps this recommendation deserves some questioning as well. For example, if one has signed up to learn genetics, and if there is a space and time for a visiting lecturer once per week, I think most would consider it bothersome to reserve this precious lecture time and student attention on entertaining speakers who deny the existence of genes or DNA. Free speech may not require that every point of view should have equal access to a reputable and influential public forum. Of course, this would lead to a question of who has the power to decide who gets access to this forum. A default answer would be to say that in a democracy, it is the people who would decide, hopefully guided by the wisdom of experts. But sometimes the experts could be wrong. Or sometimes population trends could be unreasonable. In these cases, I do agree very much with the authors in affirming a principle of calm, reasonable openness to dissent to be enshrined as a guiding principle, as it is in many nations' constitutions. And it is also reasonable for everyone in the population to be acquainted with rational techniques for self-questioning, such as CBT.
I actually do find that CBT ideas are so prevalent now, that many college students are aware of the theory already. Young people are intelligent and well-informed, for the most part.
My own recommendations:
First of all, I question my right to make any sort of recommendation. I think it is better to be a little more humble and admit that there is quite a bit of uncertainty about all of these things.
For parenting, I think different children have different needs. For some it is ok or necessary to "coddle." For others, it is best to encourage a lot more "free play." For many kids it probably doesn't make a whole lot of difference either way, and there could be leeway to simply choose the strategy that is possible for you, and that you and the kids enjoy the most. I am a big fan of spending a lot of time with one's children, to cultivate a close relationship, to build strong, positive, happy memories. Such memories are, in my opinion, strongly protective of lifelong mental health, and one of the most powerful sources of resilience that experience can offer (other sources of resilience are inherited, and have nothing to do with parenting). They are also very satisfying for a parent, and probably are associated with healthier, happier aging. In many cases, though, the memories have nothing at all to do with mental health per se. They are just memories of time together. In general, I prefer to have them rather than not.
Sunday, June 9, 2019
Review: "The Righteous Mind" by Jonathan Haidt
I recommend this book.
In The Righteous Mind, Jonathan Haidt shows that different people have different foundations which underlie their moral judgments or beliefs.
On the "left," the foundations of fairness and charity are more prominent. On the "right," the foundations of loyalty and "purity" are more prominent.
These styles or foundations may be propagated in culture or family upbringing, but also are partly influenced by heredity (genes). In the middle part of the book, Haidt argues that each of these moral foundations can convey improved survival or natural selective advantage to whole groups. For example, a group which values loyalty very strongly as a moral foundation is more like to be cohesive, and therefore more resilient to various stresses, including warfare or internal discord.
Haidt concludes his book with a strong message that we should empathize with people or groups which have different moral foundations, rather than simply fight with them or view them as enemies. He espouses the goal of befriending opponents, including those who have different political or religious beliefs or moral foundations. Such friendship would then reduce extremes of polarization and conflict, and allow groups to move forward more peacefully.
I respect his thesis very much, of cultivating understanding and empathy for people or groups which have different moral, religious, or political beliefs than one's own. In a psychotherapy environment, such empathy is required in order for progress to occur, even when the therapist may object strongly to aspects of the patient's behaviour.
But I have some criticisms of Haidt's thesis:
Haidt seems to disparage the importance of reason or rationality. In a type of "straw man" argument, he suggests that "reason" without other moral foundations such as loyalty, is insufficient or even pathological. He uses a metaphor of a person or a mind being like an elephant, a powerful creature guided by instincts and passions, with the "rider" of the elephant being our "reason" or logical faculties. The "rider" is described as a recent evolutionary development, intended to serve the elephant, rather than rule over it.
He anticipates in the book that some people will disagree with him on this. I certainly do. I do not disagree that the development of sophisticated reason or rationality is a recent development in evolutionary history, that it indeed did develop in service to the "elephant," and that there are strong selective advantages for "non-rational" qualities, which remain prevalent in nature. But the evolutionary presence of traits is not evidence of their high moral value.
Modern rationality is the foundation of the justice system. Imagine a court system, a scientific lab, a factory producing safety equipment, or a spacecraft agency such as NASA, which would not hold reason as the highest foundation in its decision-making, but instead would consider "loyalty" or "purity" as most important. Such foundations would, and often have, led to disaster.
I realize that some applications of reason may in retrospect prove not so "reasonable" after all. Reason is always fallible, and can be the foundation of huge mistakes--not just technical failures due to mistaken ideas that were apparently well-supported at the time (e.g. the belief in medical remedies such as bloodletting), but also moral catastrophes. But the process of reason requires it to be flexible, to monitor itself for mistakes, to be willing to make corrections when new information arises. This differs from "loyalty" which is by definition resistant to change despite the arrival of new information.
"Loyalty" could be considered a component of "reason" which requires a waiting period before acting on new ideas. It could be like electing a senator for a 6 year term, with other representatives elected for 2 year terms. The senators would be more resistant to rapid or erratic whims of a capricious populace, while the representatives would be poised to act more quickly; the two chambers would ideally lead to an effective equilibrium, sensitive to change, but not impulsively so.
I am not saying that "loyalty" or "purity" are unimportant, but they cannot be viewed as morally equivalent to reason, on some kind of equal footing, such that differences between people can be understood simply as cultural variation.
I was bothered in Haidt's book by his passing disparaging reference to "new atheists" such as Richard Dawkins, more or less dismissing the value of their ideas without acknowledging their wisdom or contribution. There are major problems with these thinkers which warrant fair criticism, but they do deserve respect and attention. This is ironically contrary to Haidt's best conclusion, which is to have some empathy and respect for viewpoints different from one's own.
I am more allied to scholars such as Steven Pinker or Paul Bloom, who are "rationalists" in their approach to psychology and morality. But I have to admit that Jonathan Haidt is an important thinker as well, and deserves respect and attention.
Any author of a book has a tendency to have some inflexibility in their position afterwards, due to several psychological biases. If you have publicly asserted a position, and have become famous for it, you are more likely to maintain it in order to appear consistent, even if there are good arguments against it. There can be some degree of ego involved as well--people don't like to admit that they are wrong. I wish there was a little bit more humility when scholars or experts assert positions on these issues.
I am not an author (except for this modest blog), but I know that I have an ego as well, and I would have a tendency to defend positions that I have asserted, even when they may need to be changed or adapted. I need to watch this tendency in myself, as we all do in ourselves.
In some cases, it may not be possible to have a friendly, empathic dialogue in a setting of conflict, oppression, or injustice. Haidt does not explore this type of scenario adequately. Friendship and empathy are neglected in the management of conflict and polarization, but it is important to acknowledge as well that some of the necessary forces of positive change and justice can be rather more difficult and conflict-ridden.
In The Righteous Mind, Jonathan Haidt shows that different people have different foundations which underlie their moral judgments or beliefs.
On the "left," the foundations of fairness and charity are more prominent. On the "right," the foundations of loyalty and "purity" are more prominent.
These styles or foundations may be propagated in culture or family upbringing, but also are partly influenced by heredity (genes). In the middle part of the book, Haidt argues that each of these moral foundations can convey improved survival or natural selective advantage to whole groups. For example, a group which values loyalty very strongly as a moral foundation is more like to be cohesive, and therefore more resilient to various stresses, including warfare or internal discord.
Haidt concludes his book with a strong message that we should empathize with people or groups which have different moral foundations, rather than simply fight with them or view them as enemies. He espouses the goal of befriending opponents, including those who have different political or religious beliefs or moral foundations. Such friendship would then reduce extremes of polarization and conflict, and allow groups to move forward more peacefully.
I respect his thesis very much, of cultivating understanding and empathy for people or groups which have different moral, religious, or political beliefs than one's own. In a psychotherapy environment, such empathy is required in order for progress to occur, even when the therapist may object strongly to aspects of the patient's behaviour.
But I have some criticisms of Haidt's thesis:
Haidt seems to disparage the importance of reason or rationality. In a type of "straw man" argument, he suggests that "reason" without other moral foundations such as loyalty, is insufficient or even pathological. He uses a metaphor of a person or a mind being like an elephant, a powerful creature guided by instincts and passions, with the "rider" of the elephant being our "reason" or logical faculties. The "rider" is described as a recent evolutionary development, intended to serve the elephant, rather than rule over it.
He anticipates in the book that some people will disagree with him on this. I certainly do. I do not disagree that the development of sophisticated reason or rationality is a recent development in evolutionary history, that it indeed did develop in service to the "elephant," and that there are strong selective advantages for "non-rational" qualities, which remain prevalent in nature. But the evolutionary presence of traits is not evidence of their high moral value.
Modern rationality is the foundation of the justice system. Imagine a court system, a scientific lab, a factory producing safety equipment, or a spacecraft agency such as NASA, which would not hold reason as the highest foundation in its decision-making, but instead would consider "loyalty" or "purity" as most important. Such foundations would, and often have, led to disaster.
I realize that some applications of reason may in retrospect prove not so "reasonable" after all. Reason is always fallible, and can be the foundation of huge mistakes--not just technical failures due to mistaken ideas that were apparently well-supported at the time (e.g. the belief in medical remedies such as bloodletting), but also moral catastrophes. But the process of reason requires it to be flexible, to monitor itself for mistakes, to be willing to make corrections when new information arises. This differs from "loyalty" which is by definition resistant to change despite the arrival of new information.
"Loyalty" could be considered a component of "reason" which requires a waiting period before acting on new ideas. It could be like electing a senator for a 6 year term, with other representatives elected for 2 year terms. The senators would be more resistant to rapid or erratic whims of a capricious populace, while the representatives would be poised to act more quickly; the two chambers would ideally lead to an effective equilibrium, sensitive to change, but not impulsively so.
I am not saying that "loyalty" or "purity" are unimportant, but they cannot be viewed as morally equivalent to reason, on some kind of equal footing, such that differences between people can be understood simply as cultural variation.
I was bothered in Haidt's book by his passing disparaging reference to "new atheists" such as Richard Dawkins, more or less dismissing the value of their ideas without acknowledging their wisdom or contribution. There are major problems with these thinkers which warrant fair criticism, but they do deserve respect and attention. This is ironically contrary to Haidt's best conclusion, which is to have some empathy and respect for viewpoints different from one's own.
I am more allied to scholars such as Steven Pinker or Paul Bloom, who are "rationalists" in their approach to psychology and morality. But I have to admit that Jonathan Haidt is an important thinker as well, and deserves respect and attention.
Any author of a book has a tendency to have some inflexibility in their position afterwards, due to several psychological biases. If you have publicly asserted a position, and have become famous for it, you are more likely to maintain it in order to appear consistent, even if there are good arguments against it. There can be some degree of ego involved as well--people don't like to admit that they are wrong. I wish there was a little bit more humility when scholars or experts assert positions on these issues.
I am not an author (except for this modest blog), but I know that I have an ego as well, and I would have a tendency to defend positions that I have asserted, even when they may need to be changed or adapted. I need to watch this tendency in myself, as we all do in ourselves.
In some cases, it may not be possible to have a friendly, empathic dialogue in a setting of conflict, oppression, or injustice. Haidt does not explore this type of scenario adequately. Friendship and empathy are neglected in the management of conflict and polarization, but it is important to acknowledge as well that some of the necessary forces of positive change and justice can be rather more difficult and conflict-ridden.
The Psychology of Meetings
What does psychology teach us about the components of an effective or positive meeting?
Daniel Kahneman described psychological dynamics in meetings, such that those who contribute first or most vocally tend to bias the discussion excessively.
Quieter members of a group may have important contributions, but they are never heard.
A majority view can tend to prevail. Dissenting positions are often suppressed by peer pressure.
People can be afraid to express themselves, due to fear of consequences.
Many speakers or presenters in meetings are lecturing about information that is already well-known to most or all of the members, therefore this type of lecture is arguably a very inefficient use of everyone's time.
Suppression of dissent or counterargument is the most powerful and morally troubling bias in persuasion and group dynamics.
Overt bias in group dynamics and suppression of dissent can occur in overt ways, such as with an authoritarian meeting style. But there can be subtler mechanisms, such as when a presenter is charming, articulate, humourous, rhetorically skilled, and equipped with attractive visuals. Good food probably helps as well. We all enjoy such presentations, but it is important not to let our enjoyment cause us to shut down our critical thinking. Otherwise, a presentation can be more like a marketing campaign, a revival meeting, or a political rally.
One tactic to reduce this effect can be to ask members to offer their opinions or questions, anonymously if necessary, before the meeting begins, so that opinions are not suppressed by the social dynamics in the group itself. It can be helpful if the leader of a group is the last person to speak, rather than the first.
A related bias in many presentations is the "focusing illusion." Here, a single idea, plan, or thesis is presented, perhaps with good rhetorical style, nice visuals, and strong supportive evidence. This leads to a strong persuasive effect. But if there is only one single idea, plan, or thesis, without presentation and fair discussion of alternatives, the audience will be unduly persuaded towards the single plan they hear about. In some extreme cases, what may seem like a reasoned, balanced, presentation may instead be more similar to a sales pitch or a political rally. To prevent the focusing illusion, it is important to allow time in presentations for debate, counterargument, and alternative ideas. Audience members should be strongly encouraged to think for themselves, to question, and to debate. Many audience members might be reluctant to do this, even if it is allowed, because they may feel it is rude or disrespectful to the presenter.
Another big problem in meetings has to do with the efficient use of time. Sometimes an hour is spent on a subject which could have taken just a few minutes of focused attention. In other areas of our lives, such as when we are listening to music, or watching a TV program, or reading a newspaper, we would rapidly divert our attention to something else if the activity was not useful or enjoyable. But in most meetings you are stuck there, with no capacity to change the activity.
I find that the "cost" of meetings is often not acknowledged. By cost, I do not mean the direct financial cost, which could often be zero (though not always, if there is rented space, catered food, or lost income). I mean the cost in terms of the other activities that could have been done instead. For example, if the meeting is attended by 24 psychotherapists, the total cost of a one hour meeting is 24 "person-hours" of psychotherapy time. The value of "24 person-hours" of psychotherapist time is equal to the treatment of 4 depressed patients with a course of CBT for 6 sessions each. We should acknowledge the costs, and keep these 4 untreated depressed patients in mind as we sit through the meeting.
Another cost of a meeting is of psychological well-being of the attendees. Many professional activities are psychologically neutral. Others could be beneficial, because they lead to better group cohesion or social connection. But others still could be demoralizing, depleting, or frustrating, if they have a negative dynamic. They could add to the stress of the day, since other work would have to be done later. If the meeting is psychologically depleting then it would be harder to keep up with other work.
But of course, some meetings are effective, enjoyable, educational, and socially beneficial for individuals and groups. They could help people and groups work more enjoyably and efficiently, could help solve problems in the work environment, and could help with creative planning for the future. We need to find ways to have more of these!
While I am not normally a fan of using questionnaires extensively with my patients, I have a simple suggestion for meeting management, based on some of the recent trends in psychotherapy research: obtain and measure feedback data from attendees. The absence of feedback can often give the impression that everyone feels ok with the process, and therefore there is no need to change. Such data would need to be qualified, since the data gathering process itself involves a bias. Reviewers of any service may be more likely to rate it more favourably, otherwise they might not have used the service in the first place. For example, if you gather outcome data from customers at a fast food restaurant, you may get very positive reviews. Such data should not be used as evidence that we should have more fast food restaurants in a community! But with this proviso in mind, here is a suggested questionnaire for meeting attendees, to be submitted anonymously after each session, or after each segment of a meeting. Each question could be rated on a scale with 0="not at all" and 5="very much":
1) I learned valuable new information in this meeting, which is likely to improve my work practices.
2) The presenter took too much time. *
3) Everyone's point of view was welcomed and respected.
4) Disagreement, counterarguments, and dissent were encouraged.
5) I got a fair chance to express my point of view.
6) The time spent at the meeting was worth the time, compared to my other tasks and duties which I missed due to attending the meeting.
7) The meeting was a good chance to connect with my coworkers.
8) The presenter was articulate, engaging, and organized.
9) I enjoyed this meeting.
10) I was bored during this meeting. *
11) The process of this meeting was fair and respectful.
12) The meeting made use of time efficiently.
13) I would like more such meetings in the future.
14) There were instances of disrespectful or objectionable content in the meeting. *
15) The presenter, and fellow attendees, could be heard clearly.
16) The presenter and/or visuals could be seen clearly by all.
17) The presentation contained a lot of unnecessary jargon or needless complex terminology.*
18) The meeting began and ended on time, and stuck to the schedule as announced in advance.
19) The cost of the meeting (in terms of money and time) was acknowledged.
20) Personal information was requested of me which felt uncomfortable to share in a work setting.*
The starred items should be reverse-scored. That is, for starred items, if you initially rate something as a "5" then it should be scored as "0." The score could be summed, with a maximum score of 100 (a "perfect meeting" !) and a minimum of 0 (the "worst possible").
I estimate an average score for most meetings in a relatively healthy organization would be about 60-70.
Aside from only looking at the group average scores, it may be very important to look at the range of scores from all individuals, to ensure that outlier data is not just "dissolved" into the group average.
Daniel Kahneman described psychological dynamics in meetings, such that those who contribute first or most vocally tend to bias the discussion excessively.
Quieter members of a group may have important contributions, but they are never heard.
A majority view can tend to prevail. Dissenting positions are often suppressed by peer pressure.
People can be afraid to express themselves, due to fear of consequences.
Many speakers or presenters in meetings are lecturing about information that is already well-known to most or all of the members, therefore this type of lecture is arguably a very inefficient use of everyone's time.
Suppression of dissent or counterargument is the most powerful and morally troubling bias in persuasion and group dynamics.
Overt bias in group dynamics and suppression of dissent can occur in overt ways, such as with an authoritarian meeting style. But there can be subtler mechanisms, such as when a presenter is charming, articulate, humourous, rhetorically skilled, and equipped with attractive visuals. Good food probably helps as well. We all enjoy such presentations, but it is important not to let our enjoyment cause us to shut down our critical thinking. Otherwise, a presentation can be more like a marketing campaign, a revival meeting, or a political rally.
One tactic to reduce this effect can be to ask members to offer their opinions or questions, anonymously if necessary, before the meeting begins, so that opinions are not suppressed by the social dynamics in the group itself. It can be helpful if the leader of a group is the last person to speak, rather than the first.
A related bias in many presentations is the "focusing illusion." Here, a single idea, plan, or thesis is presented, perhaps with good rhetorical style, nice visuals, and strong supportive evidence. This leads to a strong persuasive effect. But if there is only one single idea, plan, or thesis, without presentation and fair discussion of alternatives, the audience will be unduly persuaded towards the single plan they hear about. In some extreme cases, what may seem like a reasoned, balanced, presentation may instead be more similar to a sales pitch or a political rally. To prevent the focusing illusion, it is important to allow time in presentations for debate, counterargument, and alternative ideas. Audience members should be strongly encouraged to think for themselves, to question, and to debate. Many audience members might be reluctant to do this, even if it is allowed, because they may feel it is rude or disrespectful to the presenter.
Another big problem in meetings has to do with the efficient use of time. Sometimes an hour is spent on a subject which could have taken just a few minutes of focused attention. In other areas of our lives, such as when we are listening to music, or watching a TV program, or reading a newspaper, we would rapidly divert our attention to something else if the activity was not useful or enjoyable. But in most meetings you are stuck there, with no capacity to change the activity.
I find that the "cost" of meetings is often not acknowledged. By cost, I do not mean the direct financial cost, which could often be zero (though not always, if there is rented space, catered food, or lost income). I mean the cost in terms of the other activities that could have been done instead. For example, if the meeting is attended by 24 psychotherapists, the total cost of a one hour meeting is 24 "person-hours" of psychotherapy time. The value of "24 person-hours" of psychotherapist time is equal to the treatment of 4 depressed patients with a course of CBT for 6 sessions each. We should acknowledge the costs, and keep these 4 untreated depressed patients in mind as we sit through the meeting.
Another cost of a meeting is of psychological well-being of the attendees. Many professional activities are psychologically neutral. Others could be beneficial, because they lead to better group cohesion or social connection. But others still could be demoralizing, depleting, or frustrating, if they have a negative dynamic. They could add to the stress of the day, since other work would have to be done later. If the meeting is psychologically depleting then it would be harder to keep up with other work.
But of course, some meetings are effective, enjoyable, educational, and socially beneficial for individuals and groups. They could help people and groups work more enjoyably and efficiently, could help solve problems in the work environment, and could help with creative planning for the future. We need to find ways to have more of these!
While I am not normally a fan of using questionnaires extensively with my patients, I have a simple suggestion for meeting management, based on some of the recent trends in psychotherapy research: obtain and measure feedback data from attendees. The absence of feedback can often give the impression that everyone feels ok with the process, and therefore there is no need to change. Such data would need to be qualified, since the data gathering process itself involves a bias. Reviewers of any service may be more likely to rate it more favourably, otherwise they might not have used the service in the first place. For example, if you gather outcome data from customers at a fast food restaurant, you may get very positive reviews. Such data should not be used as evidence that we should have more fast food restaurants in a community! But with this proviso in mind, here is a suggested questionnaire for meeting attendees, to be submitted anonymously after each session, or after each segment of a meeting. Each question could be rated on a scale with 0="not at all" and 5="very much":
1) I learned valuable new information in this meeting, which is likely to improve my work practices.
2) The presenter took too much time. *
3) Everyone's point of view was welcomed and respected.
4) Disagreement, counterarguments, and dissent were encouraged.
5) I got a fair chance to express my point of view.
6) The time spent at the meeting was worth the time, compared to my other tasks and duties which I missed due to attending the meeting.
7) The meeting was a good chance to connect with my coworkers.
8) The presenter was articulate, engaging, and organized.
9) I enjoyed this meeting.
10) I was bored during this meeting. *
11) The process of this meeting was fair and respectful.
12) The meeting made use of time efficiently.
13) I would like more such meetings in the future.
14) There were instances of disrespectful or objectionable content in the meeting. *
15) The presenter, and fellow attendees, could be heard clearly.
16) The presenter and/or visuals could be seen clearly by all.
17) The presentation contained a lot of unnecessary jargon or needless complex terminology.*
18) The meeting began and ended on time, and stuck to the schedule as announced in advance.
19) The cost of the meeting (in terms of money and time) was acknowledged.
20) Personal information was requested of me which felt uncomfortable to share in a work setting.*
The starred items should be reverse-scored. That is, for starred items, if you initially rate something as a "5" then it should be scored as "0." The score could be summed, with a maximum score of 100 (a "perfect meeting" !) and a minimum of 0 (the "worst possible").
I estimate an average score for most meetings in a relatively healthy organization would be about 60-70.
Aside from only looking at the group average scores, it may be very important to look at the range of scores from all individuals, to ensure that outlier data is not just "dissolved" into the group average.
Monday, October 22, 2018
"The Worried Well"
Sometimes, the phrase "the worried well" is used to describe people with problems which are felt to be minor or which would resolve easily on their own.
In one recent lecture, the expert was extremely articulate, intelligent, and inspiring, discussing the importance of educating people about mental illness, as part of a public health campaign. But then, while using terminology such as "the worried well," he finished his sentence in dramatic hushed tones, saying that people who requested, or demanded, more care for what he felt were minor problems were demonstrating "...narcissistic entitlement." To be a member of the "worried well," I guess the view is that seeking external help would be wasteful, unnecessary, and inefficient for the health care system. This speaker was very persuasive, for many reasons. He obviously had a kind heart, a very altruistic disposition, a commanding intelligence, and excellent rhetorical skills.
I agree that people with extreme, incapacitating symptoms and having extreme, harsh living conditions (such as experiencing severe psychosis while living in severe poverty) require very urgent help. The health care system must attend to this type of situation with a very high priority. Mind you, a big part of the health care would be addressing the poverty and other environmental dangers with similar urgency as treating any psychiatric or medical symptoms.
But people who might be described as the "worried well" are not necessarily exhibiting "narcissistic entitlement" to ask for help. Even if there are narcissistic issues, work with an experienced therapist could be difficult and long-term, but of great potential benefit to the person and to the person's community. In some cases, a person with mild or short-term symptoms may not desire or need very much help, but even a little bit of professional attention can make a big difference. Sometimes the help might prevent a failed relationship, a failed term in university, a slide into more severe mental illness, or a disastrous life choice.
In some cases of extreme severity, a long-term complex care regime is often needed (such as a community team involving physicians, social workers, occupational therapists, etc.).
But in other cases of extreme severity, sometimes brief, focused help is adequate, and is all that the person desires or needs.
In cases of "mild" severity (such as a person with relationship stresses and generalized anxiety), sometimes minimal help is really needed...the issues may settle down on their own. Other times, just a few visits with a professional may be sufficient to help the person pass through the situation more comfortably.
But in other so-called "mild" cases, people may benefit greatly from having more ongoing help, such as a course of psychotherapy. Symptoms, as measured on symptom scales, may not lead to alarm bells ringing, and may not even change very much, but timely or ongoing therapy may make a difference between the person succeeding, flourishing, or failing in their schooling, career development, or relationship life. The most common symptom scales do not tend to measure these things directly.
Nowadays, it is hard to discuss such matters philosophically, without dealing with a question such as "but where is the evidence?" or "Are your ideas evidence-based?" The best evidence base for any health care claim would have to involve a prospective, randomized controlled study with very clear outcome criteria. It is expensive and difficult to assemble such studies. Much of what I am talking about above is not based on some specific "diagnosis" (though nowadays it is quite easy to form a list of DSM-V diagnoses) but on a person's subjective wish to have help. Treatment studies, due to technical difficulties and expense, tend to be brief, single diagnosis-based, and based on fairly simple quantitative measurements (such as symptom scale data). For this reason, a strict requirement for evidence-based treatments in mental health care will tend to favour brief techniques which have very clear evidence of reducing acute symptoms quickly as measured by questionnaires. This favouring is not because the evidence is invalid (in fact, the evidence from these studies is informative and excellent), but because most studies will necessarily be short-term in this way. Longer-term studies with more qualitative measures are much more difficult to do, and therefore there is much less published data.
But in many situations, the benefit from mental health treatments is longer-term, and may be more qualitative than a symptom questionnaire could pick up.
I do not at all mean to disparage the focus on effective, cost-efficient, brief treatment of mental health problems. I also think it is valuable to challenge wasteful or unnecessary expensive practices, especially those which lack any good evidence at all.
But mental health care sometimes requires a steady, longer-term commitment to really take care of people, to make the effort to know people very well for a long period of time, to understand a person deeply, not just in terms of symptom scores. A therapist or psychiatrist need not be simply a "provider" or technician to relieve symptoms. Sometimes this is all a person wants, and that would be fine. But if this the only thing the profession focuses on, then we risk having a health care system which becomes more impersonal, disconnected, and mechanical. For psychiatrists, a very short-term focus will naturally favour simple prescriptive approaches such as medication trials (I am not "anti-medication" but I strongly discourage the practice of prescribing medications without knowing people well, and without addressing other holistic strategies for health care). A more disconnected or impersonal health care system is harmful for patients, and is harmful for the community of therapists and other professionals.
Let's not use phrases such as "the worried well." Let's not diagnose people who are asking for help, with "narcissistic entitlement." While it is important to prioritize urgent needs, let's spend the time trying to understand and care for all people, without judgment.
In one recent lecture, the expert was extremely articulate, intelligent, and inspiring, discussing the importance of educating people about mental illness, as part of a public health campaign. But then, while using terminology such as "the worried well," he finished his sentence in dramatic hushed tones, saying that people who requested, or demanded, more care for what he felt were minor problems were demonstrating "...narcissistic entitlement." To be a member of the "worried well," I guess the view is that seeking external help would be wasteful, unnecessary, and inefficient for the health care system. This speaker was very persuasive, for many reasons. He obviously had a kind heart, a very altruistic disposition, a commanding intelligence, and excellent rhetorical skills.
I agree that people with extreme, incapacitating symptoms and having extreme, harsh living conditions (such as experiencing severe psychosis while living in severe poverty) require very urgent help. The health care system must attend to this type of situation with a very high priority. Mind you, a big part of the health care would be addressing the poverty and other environmental dangers with similar urgency as treating any psychiatric or medical symptoms.
But people who might be described as the "worried well" are not necessarily exhibiting "narcissistic entitlement" to ask for help. Even if there are narcissistic issues, work with an experienced therapist could be difficult and long-term, but of great potential benefit to the person and to the person's community. In some cases, a person with mild or short-term symptoms may not desire or need very much help, but even a little bit of professional attention can make a big difference. Sometimes the help might prevent a failed relationship, a failed term in university, a slide into more severe mental illness, or a disastrous life choice.
In some cases of extreme severity, a long-term complex care regime is often needed (such as a community team involving physicians, social workers, occupational therapists, etc.).
But in other cases of extreme severity, sometimes brief, focused help is adequate, and is all that the person desires or needs.
In cases of "mild" severity (such as a person with relationship stresses and generalized anxiety), sometimes minimal help is really needed...the issues may settle down on their own. Other times, just a few visits with a professional may be sufficient to help the person pass through the situation more comfortably.
But in other so-called "mild" cases, people may benefit greatly from having more ongoing help, such as a course of psychotherapy. Symptoms, as measured on symptom scales, may not lead to alarm bells ringing, and may not even change very much, but timely or ongoing therapy may make a difference between the person succeeding, flourishing, or failing in their schooling, career development, or relationship life. The most common symptom scales do not tend to measure these things directly.
Nowadays, it is hard to discuss such matters philosophically, without dealing with a question such as "but where is the evidence?" or "Are your ideas evidence-based?" The best evidence base for any health care claim would have to involve a prospective, randomized controlled study with very clear outcome criteria. It is expensive and difficult to assemble such studies. Much of what I am talking about above is not based on some specific "diagnosis" (though nowadays it is quite easy to form a list of DSM-V diagnoses) but on a person's subjective wish to have help. Treatment studies, due to technical difficulties and expense, tend to be brief, single diagnosis-based, and based on fairly simple quantitative measurements (such as symptom scale data). For this reason, a strict requirement for evidence-based treatments in mental health care will tend to favour brief techniques which have very clear evidence of reducing acute symptoms quickly as measured by questionnaires. This favouring is not because the evidence is invalid (in fact, the evidence from these studies is informative and excellent), but because most studies will necessarily be short-term in this way. Longer-term studies with more qualitative measures are much more difficult to do, and therefore there is much less published data.
But in many situations, the benefit from mental health treatments is longer-term, and may be more qualitative than a symptom questionnaire could pick up.
I do not at all mean to disparage the focus on effective, cost-efficient, brief treatment of mental health problems. I also think it is valuable to challenge wasteful or unnecessary expensive practices, especially those which lack any good evidence at all.
But mental health care sometimes requires a steady, longer-term commitment to really take care of people, to make the effort to know people very well for a long period of time, to understand a person deeply, not just in terms of symptom scores. A therapist or psychiatrist need not be simply a "provider" or technician to relieve symptoms. Sometimes this is all a person wants, and that would be fine. But if this the only thing the profession focuses on, then we risk having a health care system which becomes more impersonal, disconnected, and mechanical. For psychiatrists, a very short-term focus will naturally favour simple prescriptive approaches such as medication trials (I am not "anti-medication" but I strongly discourage the practice of prescribing medications without knowing people well, and without addressing other holistic strategies for health care). A more disconnected or impersonal health care system is harmful for patients, and is harmful for the community of therapists and other professionals.
Let's not use phrases such as "the worried well." Let's not diagnose people who are asking for help, with "narcissistic entitlement." While it is important to prioritize urgent needs, let's spend the time trying to understand and care for all people, without judgment.
Sunday, September 30, 2018
Medical Education
Medicine is a very strenuous professional program, but potentially full of incredible intellectual stimulation and personal challenge.
Having gone through medical school myself, and having gotten to know numerous medical students over the years, I have a few ideas about the medical education system:
The academic portion of medicine consists of an enormous amount of material crammed into a short period of time. It requires students to prioritize study time with great care, to get the "big picture" of things. Students with a very strong memory would have a huge advantage. As a result, few students really get to savour the academic learning, to really think deeply about these important subjects. For most, it is a stressful but superficial rush through vast areas of subject matter. Students who are good with test-taking gamesmanship would have an advantage here.
Here are some ideas for change:
How about have a course system in medicine which allows people to gradually complete the academic section at their own pace? This could allow people to take their time, master the material, and to enjoy it.
Some subjects in medicine, such as anatomy, are crammed into the first year, but then rarely touched upon after that, unless the student ends up doing a surgery residency, etc. What about having some very basic subjects such as anatomy be reviewed regularly and immersively, with practical applications, so that students would deepen their knowledge and practical skill over time?
Practical skills in medicine, including interviewing, physical examination, and basic procedures, could be gradually introduced much earlier. It is not necessary to understand biochemical pathways or histology, etc., to practice most clinical skills. Many such practical skills improve, and become "second-nature," with years of practice, so why not start sooner? This would make the work more interesting and relevant for the students, and ultimately would be very good for patients, because they would be dealing with medical students with better practical skills.
Having gone through medical school myself, and having gotten to know numerous medical students over the years, I have a few ideas about the medical education system:
The academic portion of medicine consists of an enormous amount of material crammed into a short period of time. It requires students to prioritize study time with great care, to get the "big picture" of things. Students with a very strong memory would have a huge advantage. As a result, few students really get to savour the academic learning, to really think deeply about these important subjects. For most, it is a stressful but superficial rush through vast areas of subject matter. Students who are good with test-taking gamesmanship would have an advantage here.
Here are some ideas for change:
How about have a course system in medicine which allows people to gradually complete the academic section at their own pace? This could allow people to take their time, master the material, and to enjoy it.
Some subjects in medicine, such as anatomy, are crammed into the first year, but then rarely touched upon after that, unless the student ends up doing a surgery residency, etc. What about having some very basic subjects such as anatomy be reviewed regularly and immersively, with practical applications, so that students would deepen their knowledge and practical skill over time?
Practical skills in medicine, including interviewing, physical examination, and basic procedures, could be gradually introduced much earlier. It is not necessary to understand biochemical pathways or histology, etc., to practice most clinical skills. Many such practical skills improve, and become "second-nature," with years of practice, so why not start sooner? This would make the work more interesting and relevant for the students, and ultimately would be very good for patients, because they would be dealing with medical students with better practical skills.
Review: "The Case against Education"
Bryan Caplan, an economist from George Mason University, has written a book called The Case Against Education: Why the Education System is a Waste of Time and Money.
It's quite a title, and quite a thesis, which touches a few nerves for those of us who have spent much of our lives studying and working in the education system.
Summary of the book
Here's my summary of his most important points as I saw them:
1) Degree programs at a university lead to less skill acquisition than what most people think...instead, grades and degrees and attendance at famous schools have mostly a "signaling value." That is, a person with a diploma, a degree, or high grades is thought of more highly, and is therefore more likely to be given a better job or higher esteem in society, even though their actual skills may be no different from a person lacking such credentials. If they did have more skills, it may not have been due to the degree, but rather they had more skills in the first place, and that's why they did the degree. Having a degree could also be an indirect signal of being compliant and obedient, which might be considered attractive by some employers.
2) The social machinery of education therefore causes people to use enormous amounts of time and money for obtaining academic credentials that have mostly "signaling value" but have little use to them or to society otherwise. Employers assess people based on these educational credentials; this inflates their value. Therefore, people who would be otherwise capable employees even without any such credentials must spend years of time, and tens of thousands of dollars, delaying their lives and careers in order to attend classes.
3) It is true that people who are more skilled or apt for some kind of career in the first place, are more likely to obtain these credentials. But Caplan's point is that these same people would or could have been very similarly capable even if they had not spent years of time and money in the academic system.
3) He recommends at the very least that education not be publicly funded.
Caplan does have some good data to support his positions, which he shows in his book.
Areas where I agree:
Here are some areas where I do agree with him:
1) I find it tragic to see students who are bored with their education. Sometimes people have to sit through and struggle through years of classes, competing for grades, trying to complete their degrees, all the while not enjoying the process, not excelling, and not valuing the subject matter. When the course or the degree is over, the experience is relief. Sometimes the subject matter of the degree is never looked at again. The entire experience is aversive or sometimes even traumatic, a repetitive blow to self-esteem with little redeeming value except for the certificate at the end. People do this because it is considered a social norm and a family expectation to obtain a degree or to go to university. And people do this because employers require more and more academic credentials just to be considered for a job.
2) I agree that trades and technical training programs should be valued more highly. Such training opportunities could start earlier in life, such as in high school.
Areas where I disagree:
But here are areas in which I disagree with Caplan:
Caplan points out that people show evidence of having forgotten much of what they learned in university, not long after they finish. But such tests of memory do not prove an absence of permanent learning. Almost certainly, in most cases, people would re-learn the material much faster if exposed to it again. For example, if you took a calculus or Spanish course 5 years ago, but had not used these subjects since then, you would probably score poorly on a test today. But you would probably be able to re-learn the calculus or Spanish much more quickly than someone who had never taken the course at all. Knowledge can sometimes go into a sort of "zip file" in the brain, which can't be used immediately, but can be re-awakened if needed.
Caplan himself shows that while there is a very high amount of signaling vs. skill acquisition in university education, it is not 100% signaling...that is, some true valuable learning has taken place, on average (in some subjects, such as engineering, more than others). In many areas of life, we have such inefficiency, but that does not negate the importance or value of the activity. For example, an exercise regime may only lead to a statistically small improvement in health variables, but such a small effect is still positive and desirable.
I find Caplan's comments about certain areas of study, such as within the arts, inappropriate and offensive. All subjects, all human wisdom, has value...this is part of being human. We should cultivate respect for all forms of knowledge...however I do agree that we need not "force" people to study these things just for the sake of acquiring some signaling item such as a diploma.
Conclusion and personal reflections:
In conclusion, I have always felt that a broad education is valuable for individual lives and for society.
But I believe that educational pursuits should have a stronger focus on joy and meaning, with efforts made to reduce the predominance of signaling effects.
I agree that we should reduce social or economic penalties for people who do not have formal educational credentials, as long as they can show and develop skill or expertise in other ways.
While I agree that we should value trade schools or other technical programs, I think broad education is important for technical students as well, to allow people to be well-informed and to have a greater esthetic appreciation for the arts, fine arts, and other subjects. Of course, going to school is not necessary for esthetic appreciation, but school at its best can introduce people to beautiful areas of life that would not be discovered otherwise.
I would like to see less polarization between arts and sciences programs...I would love to see more overlap.
I think it would be healthy for the activities of students in different faculties, including in the arts, to have immediate relevance and interaction with the community. It would be interesting, for example, to have more outreach programs. And maybe the encouragement for students to have their undergraduate essays published, so that all those hours of work writing would not just lead to a product that would be read one time by a professor or grad student, and then never looked at again.
People who are truly bored and struggling through material should at least have broader choices for their educational development, to favour subjects that truly interest them, so that people's youth need not be wasted in a drudgery of unsatisfying and demoralizing work.
My own experience of education through my life has been very positive and meaningful. There are many esoteric subjects I studied long ago that I may not make much use of, but I consider them to be part of acquiring wisdom, and broad knowledge of the world. In my daily work, a broad education allows me to have better connection with students from many different faculties.
Most of us need some kind of formal structure to motivate us, and maybe some sort of prize at the end, such as a diploma. Free access to education through the internet is a great thing, but this modality does not have such motivational factors. I love learning but I am much more likely to get something out of a learning process if there is a more formal structure to it.
In the arts, Caplan seems to suggest that many subjects are wasteful. Perhaps an example would be the study of Shakespeare. But I can't help but note the local theatre company which produces Shakespeare plays all summer...all of the performances are packed, with people of all ages! I think if we were to reduce exposure to literature in schools and universities, we would see a decline in these types of cultural activities, which would be a loss for us all.
But I do think that Shakespeare, if taught in school, should be made engaging, dynamic, and fun, just like a good theatre production.
I strongly disagree with Caplan's opinion that we should reduce public funding for education. Reduced funding would penalize those with lower income. He suggests some kind of meritocratic system as well, which I favour too, but it seems to me that access to a high-quality, enjoyable public education should be a basic privilege granted to all citizens. I do agree that there could be more educational options though, aside from the conventional, orthodox degree system which has prevailed during this century.
Relevance to mental health:
I bring up this issue in a mental health blog because one of the common environmental factors contributing to unhappiness, anxiety, and depression in young people is frustration with education. Classes may be boring, excessively difficult, lacking in obvious meaning or purpose, or lacking in application to future life goals. Classes are also expensive, causing students to be in a compromised financial state for years, relying upon loans or family support, or upon strenuous after-hours jobs. Grades, if low, can cause demoralization. Even if grades are high, they can drive a perfectionistic or obsessional quest at the cost of other healthy or enjoyable life activities (ironically, including learning). Once a degree program is over, many students still have a hard time finding employment, even after a graduate degree. Sometimes the jobs that are available have only an oblique relationship to the subject matter studied during the degree.
So I think it is good to examine the process of education itself, and to question some of the foundations, as part of helping young people to have good mental health.
It's quite a title, and quite a thesis, which touches a few nerves for those of us who have spent much of our lives studying and working in the education system.
Summary of the book
Here's my summary of his most important points as I saw them:
1) Degree programs at a university lead to less skill acquisition than what most people think...instead, grades and degrees and attendance at famous schools have mostly a "signaling value." That is, a person with a diploma, a degree, or high grades is thought of more highly, and is therefore more likely to be given a better job or higher esteem in society, even though their actual skills may be no different from a person lacking such credentials. If they did have more skills, it may not have been due to the degree, but rather they had more skills in the first place, and that's why they did the degree. Having a degree could also be an indirect signal of being compliant and obedient, which might be considered attractive by some employers.
2) The social machinery of education therefore causes people to use enormous amounts of time and money for obtaining academic credentials that have mostly "signaling value" but have little use to them or to society otherwise. Employers assess people based on these educational credentials; this inflates their value. Therefore, people who would be otherwise capable employees even without any such credentials must spend years of time, and tens of thousands of dollars, delaying their lives and careers in order to attend classes.
3) It is true that people who are more skilled or apt for some kind of career in the first place, are more likely to obtain these credentials. But Caplan's point is that these same people would or could have been very similarly capable even if they had not spent years of time and money in the academic system.
3) He recommends at the very least that education not be publicly funded.
Caplan does have some good data to support his positions, which he shows in his book.
Areas where I agree:
Here are some areas where I do agree with him:
1) I find it tragic to see students who are bored with their education. Sometimes people have to sit through and struggle through years of classes, competing for grades, trying to complete their degrees, all the while not enjoying the process, not excelling, and not valuing the subject matter. When the course or the degree is over, the experience is relief. Sometimes the subject matter of the degree is never looked at again. The entire experience is aversive or sometimes even traumatic, a repetitive blow to self-esteem with little redeeming value except for the certificate at the end. People do this because it is considered a social norm and a family expectation to obtain a degree or to go to university. And people do this because employers require more and more academic credentials just to be considered for a job.
2) I agree that trades and technical training programs should be valued more highly. Such training opportunities could start earlier in life, such as in high school.
Areas where I disagree:
But here are areas in which I disagree with Caplan:
Caplan points out that people show evidence of having forgotten much of what they learned in university, not long after they finish. But such tests of memory do not prove an absence of permanent learning. Almost certainly, in most cases, people would re-learn the material much faster if exposed to it again. For example, if you took a calculus or Spanish course 5 years ago, but had not used these subjects since then, you would probably score poorly on a test today. But you would probably be able to re-learn the calculus or Spanish much more quickly than someone who had never taken the course at all. Knowledge can sometimes go into a sort of "zip file" in the brain, which can't be used immediately, but can be re-awakened if needed.
Caplan himself shows that while there is a very high amount of signaling vs. skill acquisition in university education, it is not 100% signaling...that is, some true valuable learning has taken place, on average (in some subjects, such as engineering, more than others). In many areas of life, we have such inefficiency, but that does not negate the importance or value of the activity. For example, an exercise regime may only lead to a statistically small improvement in health variables, but such a small effect is still positive and desirable.
I find Caplan's comments about certain areas of study, such as within the arts, inappropriate and offensive. All subjects, all human wisdom, has value...this is part of being human. We should cultivate respect for all forms of knowledge...however I do agree that we need not "force" people to study these things just for the sake of acquiring some signaling item such as a diploma.
Conclusion and personal reflections:
In conclusion, I have always felt that a broad education is valuable for individual lives and for society.
But I believe that educational pursuits should have a stronger focus on joy and meaning, with efforts made to reduce the predominance of signaling effects.
I agree that we should reduce social or economic penalties for people who do not have formal educational credentials, as long as they can show and develop skill or expertise in other ways.
While I agree that we should value trade schools or other technical programs, I think broad education is important for technical students as well, to allow people to be well-informed and to have a greater esthetic appreciation for the arts, fine arts, and other subjects. Of course, going to school is not necessary for esthetic appreciation, but school at its best can introduce people to beautiful areas of life that would not be discovered otherwise.
I would like to see less polarization between arts and sciences programs...I would love to see more overlap.
I think it would be healthy for the activities of students in different faculties, including in the arts, to have immediate relevance and interaction with the community. It would be interesting, for example, to have more outreach programs. And maybe the encouragement for students to have their undergraduate essays published, so that all those hours of work writing would not just lead to a product that would be read one time by a professor or grad student, and then never looked at again.
People who are truly bored and struggling through material should at least have broader choices for their educational development, to favour subjects that truly interest them, so that people's youth need not be wasted in a drudgery of unsatisfying and demoralizing work.
My own experience of education through my life has been very positive and meaningful. There are many esoteric subjects I studied long ago that I may not make much use of, but I consider them to be part of acquiring wisdom, and broad knowledge of the world. In my daily work, a broad education allows me to have better connection with students from many different faculties.
Most of us need some kind of formal structure to motivate us, and maybe some sort of prize at the end, such as a diploma. Free access to education through the internet is a great thing, but this modality does not have such motivational factors. I love learning but I am much more likely to get something out of a learning process if there is a more formal structure to it.
In the arts, Caplan seems to suggest that many subjects are wasteful. Perhaps an example would be the study of Shakespeare. But I can't help but note the local theatre company which produces Shakespeare plays all summer...all of the performances are packed, with people of all ages! I think if we were to reduce exposure to literature in schools and universities, we would see a decline in these types of cultural activities, which would be a loss for us all.
But I do think that Shakespeare, if taught in school, should be made engaging, dynamic, and fun, just like a good theatre production.
I strongly disagree with Caplan's opinion that we should reduce public funding for education. Reduced funding would penalize those with lower income. He suggests some kind of meritocratic system as well, which I favour too, but it seems to me that access to a high-quality, enjoyable public education should be a basic privilege granted to all citizens. I do agree that there could be more educational options though, aside from the conventional, orthodox degree system which has prevailed during this century.
Relevance to mental health:
I bring up this issue in a mental health blog because one of the common environmental factors contributing to unhappiness, anxiety, and depression in young people is frustration with education. Classes may be boring, excessively difficult, lacking in obvious meaning or purpose, or lacking in application to future life goals. Classes are also expensive, causing students to be in a compromised financial state for years, relying upon loans or family support, or upon strenuous after-hours jobs. Grades, if low, can cause demoralization. Even if grades are high, they can drive a perfectionistic or obsessional quest at the cost of other healthy or enjoyable life activities (ironically, including learning). Once a degree program is over, many students still have a hard time finding employment, even after a graduate degree. Sometimes the jobs that are available have only an oblique relationship to the subject matter studied during the degree.
So I think it is good to examine the process of education itself, and to question some of the foundations, as part of helping young people to have good mental health.
Friday, September 21, 2018
Helicopter Parenting vs. Free-Range Parenting
There are many items in the news these days, encouraging "free-range parenting" instead of "helicopter parenting."
A "helicopter parent" is one who is overprotective, excessively anxious, perhaps enmeshed, and who does not allow children to cultivate appropriate independence or autonomy.
A "free-range parent," by contrast, is okay with children going off to play by themselves, with the understanding that enjoyment and learning in childhood requires free time, some risk-taking, and figuring out solutions to problems without parental intervention.
But as with so many issues of this type, we have unnecessary polarization. These parenting styles exist on a spectrum. And individual children may differ in how much they might appreciate or need one or the other style. These needs may also change for these individual children over time.
Some children may greatly appreciate a more involved parent, at least at certain points during their lifetime. Other children may greatly appreciate more autonomy and distance from parents. Let's not impose a generalized parenting philosophy while forgetting to take the individual situation of the child into account.
Another angle on this has to do with the enjoyment of parenting. It is one of the great joys of life to play with one's child. And I think it is a great memory for a child to see their parent enjoying time with them. I have seen so many examples of unhappy children playing alone in the park, while their detached, seemingly uninterested parents are sitting on a bench looking at their phones, or are not present at all. Sometimes, to me, it appears like neglect, rather than being wholesome "free-range."
There are surely many examples of excessive "helicopter" parenting. But there are also many examples of parents who are detached, uninvolved, and missing out on enjoying their children's daily lives. Let's aim for a moderate and flexible approach, somewhere between these two extremes, with a willingness to adjust the style according to the individual child's personality and development.
A "helicopter parent" is one who is overprotective, excessively anxious, perhaps enmeshed, and who does not allow children to cultivate appropriate independence or autonomy.
A "free-range parent," by contrast, is okay with children going off to play by themselves, with the understanding that enjoyment and learning in childhood requires free time, some risk-taking, and figuring out solutions to problems without parental intervention.
But as with so many issues of this type, we have unnecessary polarization. These parenting styles exist on a spectrum. And individual children may differ in how much they might appreciate or need one or the other style. These needs may also change for these individual children over time.
Some children may greatly appreciate a more involved parent, at least at certain points during their lifetime. Other children may greatly appreciate more autonomy and distance from parents. Let's not impose a generalized parenting philosophy while forgetting to take the individual situation of the child into account.
Another angle on this has to do with the enjoyment of parenting. It is one of the great joys of life to play with one's child. And I think it is a great memory for a child to see their parent enjoying time with them. I have seen so many examples of unhappy children playing alone in the park, while their detached, seemingly uninterested parents are sitting on a bench looking at their phones, or are not present at all. Sometimes, to me, it appears like neglect, rather than being wholesome "free-range."
There are surely many examples of excessive "helicopter" parenting. But there are also many examples of parents who are detached, uninvolved, and missing out on enjoying their children's daily lives. Let's aim for a moderate and flexible approach, somewhere between these two extremes, with a willingness to adjust the style according to the individual child's personality and development.
Tuesday, May 22, 2018
Book Recommendation: "Behave" by Robert Sapolsky
Behave is over 700 pages long. Its size may lead to some potential readers being intimidated, but I found it an engaging, often entertaining review of neuroscience, from the lens of someone who has good experience and understanding not just of brain chemistry, but of social, historical, and psychological influences upon behaviour.
One of Sapolsky's big messages, in a nutshell, is that very few single factors (such as hormone or neurotransmitter effects, genes, or environmental incidents) have a simple, obvious, consistent impact. These factors have different effects depending on the circumstances. For example, androgens may only exacerbate aggressive behaviour in someone who is already having difficulties containing aggression in the first place. This immediately makes me question the generic finding (recently published) that violent video games have no negative impact...perhaps there is a negative impact, but only in those who have violent behavioural tendencies in the first place.
On the one hand, this is a refreshing antidote to the simplistic reductionism that is often presented in discussions of neuroscience or psychiatry. On the other hand, it does not negate the importance of studying these factors with good scientific depth, so as to work with them therapeutically, on a neurobiologic or societal level.
A criticism I do have about the book is his references to areas of the psychological literature (such as about priming, for example) which are now being questioned: a lot of findings about priming seem to have failed replication tests, and so I'm not sure what to think about this whole area anymore. I suspect influences such as priming do exist, but may be more transient or erratic than what the original literature suggested.
I appreciate his balanced analysis of the work of other thinkers, such as Steven Pinker, and other historical figures in psychology such as Zimbardo.
I most appreciate his message of hope, about the things we can all work on to live more peacefully, in light of the influences (positive and negative) upon our behaviour that we are born into, through our genes, family, and culture.
This is another type of book that I wish students could be exposed to as part of their university education about psychology, medicine, or other areas of the humanities.
One of Sapolsky's big messages, in a nutshell, is that very few single factors (such as hormone or neurotransmitter effects, genes, or environmental incidents) have a simple, obvious, consistent impact. These factors have different effects depending on the circumstances. For example, androgens may only exacerbate aggressive behaviour in someone who is already having difficulties containing aggression in the first place. This immediately makes me question the generic finding (recently published) that violent video games have no negative impact...perhaps there is a negative impact, but only in those who have violent behavioural tendencies in the first place.
On the one hand, this is a refreshing antidote to the simplistic reductionism that is often presented in discussions of neuroscience or psychiatry. On the other hand, it does not negate the importance of studying these factors with good scientific depth, so as to work with them therapeutically, on a neurobiologic or societal level.
A criticism I do have about the book is his references to areas of the psychological literature (such as about priming, for example) which are now being questioned: a lot of findings about priming seem to have failed replication tests, and so I'm not sure what to think about this whole area anymore. I suspect influences such as priming do exist, but may be more transient or erratic than what the original literature suggested.
I appreciate his balanced analysis of the work of other thinkers, such as Steven Pinker, and other historical figures in psychology such as Zimbardo.
I most appreciate his message of hope, about the things we can all work on to live more peacefully, in light of the influences (positive and negative) upon our behaviour that we are born into, through our genes, family, and culture.
This is another type of book that I wish students could be exposed to as part of their university education about psychology, medicine, or other areas of the humanities.
Monday, April 9, 2018
Steven Pinker's optimistic new book
I'm a Steven Pinker fan...I really appreciate his optimism about the state of the world, and the future of the world, an optimism which he supports with a lot of engaging evidence.
So I encourage having a look at his book, Enlightenment Now. It is a sequel to another of his books (Better Angels of our Nature) which I have reviewed earlier on this blog.
I don't agree with everything he says, but I do also embrace a spirit of optimism about things, and an attitude that the many problems we have in our lives, or in the world, can be solved or at least improved with continued care and effort.
This type of book is a good accompaniment to a study of behavioural economics and social psychology (such as the works of Daniel Kahneman), as well as optimistic data analysts such as the late Hans Rosling.
The strongest section of his book is the middle part, in which the reader is barraged with many graphs showing positive changes in the world over time. I found the other sections, with a lot of philosophizing about the enlightenment, etc. less important and engaging.
As to this book's relevance to mental health? I hope we might all embrace a spirit of optimism about the pathways of our lives. Past adversity in life does not necessarily predict a guaranteed future life of suffering. There is work to be done, to build a better, happier life, regardless of the hardships of our origins.
In the cognitive theory of depression or anxiety, we understand that thoughts may specifically focus on pessimistic or even catastrophic interpretations of observations; much information in our modern world is distilled to emphasize catastrophe or adversity (non-catastrophes are less likely to become headlines), so this information is natural fuel to a depressive or anxious state. An optimistic but highly rational book such as Pinker's could be understood as a type of cognitive therapy for a modern consumer of news.
Progress in the world may also translate overall to improved mental health...but I suspect we would see the most robust improvements in those areas which have the least current services.
A peril of such a strongly optimistic text can be that it fails to empathize sufficiently with those who continue to suffer...or that it can seem insensitive when there continues to be horrible tragedy in the world. But I think that we are best able to help and heal from tragedy if we are not depleted, pessimistic, or even hopeless about the ongoing problems in our lives or in the world. So this book is a much-needed infusion of optimism into public debate.
So I encourage having a look at his book, Enlightenment Now. It is a sequel to another of his books (Better Angels of our Nature) which I have reviewed earlier on this blog.
I don't agree with everything he says, but I do also embrace a spirit of optimism about things, and an attitude that the many problems we have in our lives, or in the world, can be solved or at least improved with continued care and effort.
This type of book is a good accompaniment to a study of behavioural economics and social psychology (such as the works of Daniel Kahneman), as well as optimistic data analysts such as the late Hans Rosling.
The strongest section of his book is the middle part, in which the reader is barraged with many graphs showing positive changes in the world over time. I found the other sections, with a lot of philosophizing about the enlightenment, etc. less important and engaging.
As to this book's relevance to mental health? I hope we might all embrace a spirit of optimism about the pathways of our lives. Past adversity in life does not necessarily predict a guaranteed future life of suffering. There is work to be done, to build a better, happier life, regardless of the hardships of our origins.
In the cognitive theory of depression or anxiety, we understand that thoughts may specifically focus on pessimistic or even catastrophic interpretations of observations; much information in our modern world is distilled to emphasize catastrophe or adversity (non-catastrophes are less likely to become headlines), so this information is natural fuel to a depressive or anxious state. An optimistic but highly rational book such as Pinker's could be understood as a type of cognitive therapy for a modern consumer of news.
Progress in the world may also translate overall to improved mental health...but I suspect we would see the most robust improvements in those areas which have the least current services.
A peril of such a strongly optimistic text can be that it fails to empathize sufficiently with those who continue to suffer...or that it can seem insensitive when there continues to be horrible tragedy in the world. But I think that we are best able to help and heal from tragedy if we are not depleted, pessimistic, or even hopeless about the ongoing problems in our lives or in the world. So this book is a much-needed infusion of optimism into public debate.
Tuesday, March 6, 2018
Depression Treatment Guidelines
I encourage having a look at the September 2016 issue of The Canadian Journal of Psychiatry, which summarizes treatment recommendations for major depressive disorder, based on a thoughtful review of the evidence available at the time. The authors spent many hours of careful work preparing this authoritative set of articles, and I think they did a good job.
Here is a brief summary:
1) Various antidepressants are beneficial for treating depression. They may help with an acute episode, and may help prevent relapses if continued. Some may work better than others, but the differences are small, and there are likely to be individual cases in which a so-called "second-line agent" works better than the first-line choices. Some things are classified as "second-line" not because they are necessarily inferior, but because they have not been researched as much as the "first line" things.
2) Various types of psychotherapy are beneficial for treating depression. These, too, can be helpful for acute episodes, as well as for preventing relapses, even after discontinuation. CBT has particularly strong evidence for being effective.
3) As to specifics, such as "which medication is best under which circumstances?" or "which type of psychotherapy is best under which circumstances?", the evidence often does not guide us clearly, aside from CBT in general being favoured.
4) Various other types of treatment, including ECT, TMS, exercise, and light therapy, have evidence supporting their use.
I am concerned that there was not a lot of critical debate about these claims. Many authors of review articles are proponents of a particular type of therapy (e.g. light therapy, CBT, etc.), and the content therefore may be biased, or at least lacking input or commentary from different points of view. It could be argued that "the data speaks for itself," but often the verbal conclusions resulting from the data can be coloured significantly by the author's opinion.
There are some useful specific pointers: for example, there is a lack of evidence that combining two different antidepressants is consistently helpful. But "augmenting" strategies, such as adding an atypical antipsychotic medication to an antidepressant, are better supported by evidence.
In general, for me, these guidelines are most useful as a very general introduction, to get an overview of common treatments, and of up-to-date research evidence.
Here are some ideas of my own to add about "treatment guidelines":
A very thorough understanding of a person's history is most important for care. In many cases what appears to be "major depressive disorder" ends up being a more complicated story, upon spending time learning the history. Many treatments such as antidepressants can be dangerous if given without thorough understanding of the history (for example, if there is a history of bipolar symptoms). Obtaining a good history is not necessarily possible with a single visit, with a standardized interview, etc. It takes time and a good therapeutic relationship to know a person's story.
There is some question about the validity of "major depressive disorder" as a construct. Eiko Fried has a good summary of this issue on Twitter: https://twitter.com/EikoFried/status/935098850439847937
As I have written before, a great many patients do not have only one diagnosis (assuming we are focusing on a DSM-style diagnostic scheme). It is therefore limited to focus only on the treatment of depression alone. I realize that it is a convenience in research to define syndromes in this way, which can then help us to measure the effectiveness of treatments systematically. But for a given individual, it is often necessary to step away from diagnostic constructs, and help the person in the specific ways they desire or need.
There are many pathways towards nurturing mental health. Finally it is reasonable for most people with depression to try various treatments, including medications, provided there is a good understanding of risks and potential benefits. Psychotherapeutic ideas (such as CBT, but also other styles) are beneficial for most anyone, even those who do not have formally diagnosed mental illness. Lifestyle and psychosocial factors are very important: exercise, healthy nutrition, healthy social, family, and community development, physical safety, career, education, stable finances, and the pursuit of meaning, should be an invited focus for everyone. There is relatively little attention given to these issues in most published treatment guidelines (sometimes I get the feeling that some authors in the field are embarrassed to even approach them) yet for many people these issues are the most important of all.
In the 102 pages of this journal, which are devoted to approaching and treating depression--a disease of emotional and often existential suffering, loneliness, joylessness, and a crisis of meaning--here is a tally of individual words used in these pages:
1) love: 0 times. The search engine found a reference to the author J. Glover as the only occurrence of "love"
2) compassion: 1 time
3) nutrition: 1 time
4) cooperation: 0 times, except as part of 7 references to an agency (the "Asia Pacific Economic Cooperation") which gave money to one of the authors
5) healing: 1 time
6) friendship: 0 times
7) encouragement: 1 time
8) pets: 0 times
9) nature: 1 time (referring to "nature of risk")
10) joy: 0 times
11) humour, laugh, laughter, smile, happy, happiness: 0 times for all
12) art, hobby, hobbies: 0 times
13) patience: 0 times
14) drug: 86 times
15) intervention: 91 times
While I love science (my alternative career would have been a mathematician or a statistician!) it is necessary in mental health care to also discuss issues or words that do not fit neatly into a science or data-based analysis. These issues include compassion, meaning, love, and patience. Another issue is finding ways to cope with, live with, or accept unremitting chronic illness or pain, while continuing an evidence-based, but uncertain and frustrating, search for relief or cure. Algorithms and guidelines tend not to help very much with this existential struggle. Educationally, I think it is more valuable to present case studies, with group engagement, perhaps with references made to treatment protocols, rather than to make the protocols themselves the subject of the lesson.
I prescribe a lot of medication. In some cases the medication appears to be incredibly helpful. In many other cases, there is a small but significant benefit. And in others still, there is not much benefit at all despite many, many trials of different medication. And in a few cases, the medications are harmful. Many of my patients benefit most from medications that are considered "second line." I can't think of any examples in my practice where guidelines of this type have been useful in determining the most helpful course, aside from being a very general roadmap to remind us of available options or the occasional new finding in the research. But this roadmap would already be very familiar to most mental health professionals, part of an academic focus over years of training. Specific treatment issues (such as choosing the best medication or psychotherapy combo etc.) are part of professional development: this requires ongoing familiarity with the broad research literature, and with experience in clinical practice, rather than reliance upon review articles. Review articles of this type are authored by research experts, whose work deserves respect; however, the authors represent a limited subset of expertise within the population of mental health workers.
My therapeutic style has included more and more ideas based on CBT, over the past 15 years. Many of my patients work on structured CBT elsewhere as well. As with medication, this is incredibly helpful for some, slightly helpful for many, and has little or no effect for a few others. Arguably, some CBT groups could even be harmful for a few, if there is a large mismatch between what the person desires and needs and what is actually offered. In many cases, people are familiar with these therapy styles, but have not yet really done the work necessary to derive benefit from them. This lack of work is usually due to the depression or the psychosocial situation itself, but also can be due to a lack of continuity of care. It can be a little bit like trying to learn a foreign language, and dabbling in it for a few months, learning a bit of grammar and vocabulary, but never really gaining fluency due to a lack of immersive focus, and a lack of someone to speak the language with on a regular, long-term basis.
Many people, I think, simply benefit from knowing that they are being cared for, by a person or system which has time and attention for them as they need and desire, sometimes on a long-term, open-ended basis. It is helpful for mental health care providers to be well-versed in a wide variety of therapeutic techniques, and to be able to adjust or tune the care to what each individual patient or client wants or needs. Within a system, it is good to value the unique styles and abilities of different individuals within the group, rather than compelling everyone to follow an identical protocol. Some caregivers are better-suited to using a CBT style, while others are naturally suited to IPT, meditation, or psychodynamic styles. Some psychiatrists have a particular expertise and interest in medication management. Most research protocols do not look at this issue in groups or systems. These individual variations should be respected, but I do think it is also good for everyone to come together to learn from each other. For example, psychodynamic therapists can adopt interesting, useful ideas from CBT therapists, and vice-versa.
Most of my patients would say that it was not some medication combo or therapeutic style or adherence to guidelines that ended up helping them, but was a combination of many factors, in conjunction with a system of care (such as a therapist, psychiatrist, or other support network) which was stable, consistent, compassionate, and long-term.
Here is a brief summary:
1) Various antidepressants are beneficial for treating depression. They may help with an acute episode, and may help prevent relapses if continued. Some may work better than others, but the differences are small, and there are likely to be individual cases in which a so-called "second-line agent" works better than the first-line choices. Some things are classified as "second-line" not because they are necessarily inferior, but because they have not been researched as much as the "first line" things.
2) Various types of psychotherapy are beneficial for treating depression. These, too, can be helpful for acute episodes, as well as for preventing relapses, even after discontinuation. CBT has particularly strong evidence for being effective.
3) As to specifics, such as "which medication is best under which circumstances?" or "which type of psychotherapy is best under which circumstances?", the evidence often does not guide us clearly, aside from CBT in general being favoured.
4) Various other types of treatment, including ECT, TMS, exercise, and light therapy, have evidence supporting their use.
I am concerned that there was not a lot of critical debate about these claims. Many authors of review articles are proponents of a particular type of therapy (e.g. light therapy, CBT, etc.), and the content therefore may be biased, or at least lacking input or commentary from different points of view. It could be argued that "the data speaks for itself," but often the verbal conclusions resulting from the data can be coloured significantly by the author's opinion.
There are some useful specific pointers: for example, there is a lack of evidence that combining two different antidepressants is consistently helpful. But "augmenting" strategies, such as adding an atypical antipsychotic medication to an antidepressant, are better supported by evidence.
In general, for me, these guidelines are most useful as a very general introduction, to get an overview of common treatments, and of up-to-date research evidence.
Here are some ideas of my own to add about "treatment guidelines":
A very thorough understanding of a person's history is most important for care. In many cases what appears to be "major depressive disorder" ends up being a more complicated story, upon spending time learning the history. Many treatments such as antidepressants can be dangerous if given without thorough understanding of the history (for example, if there is a history of bipolar symptoms). Obtaining a good history is not necessarily possible with a single visit, with a standardized interview, etc. It takes time and a good therapeutic relationship to know a person's story.
There is some question about the validity of "major depressive disorder" as a construct. Eiko Fried has a good summary of this issue on Twitter: https://twitter.com/EikoFried/status/935098850439847937
As I have written before, a great many patients do not have only one diagnosis (assuming we are focusing on a DSM-style diagnostic scheme). It is therefore limited to focus only on the treatment of depression alone. I realize that it is a convenience in research to define syndromes in this way, which can then help us to measure the effectiveness of treatments systematically. But for a given individual, it is often necessary to step away from diagnostic constructs, and help the person in the specific ways they desire or need.
There are many pathways towards nurturing mental health. Finally it is reasonable for most people with depression to try various treatments, including medications, provided there is a good understanding of risks and potential benefits. Psychotherapeutic ideas (such as CBT, but also other styles) are beneficial for most anyone, even those who do not have formally diagnosed mental illness. Lifestyle and psychosocial factors are very important: exercise, healthy nutrition, healthy social, family, and community development, physical safety, career, education, stable finances, and the pursuit of meaning, should be an invited focus for everyone. There is relatively little attention given to these issues in most published treatment guidelines (sometimes I get the feeling that some authors in the field are embarrassed to even approach them) yet for many people these issues are the most important of all.
In the 102 pages of this journal, which are devoted to approaching and treating depression--a disease of emotional and often existential suffering, loneliness, joylessness, and a crisis of meaning--here is a tally of individual words used in these pages:
1) love: 0 times. The search engine found a reference to the author J. Glover as the only occurrence of "love"
2) compassion: 1 time
3) nutrition: 1 time
4) cooperation: 0 times, except as part of 7 references to an agency (the "Asia Pacific Economic Cooperation") which gave money to one of the authors
5) healing: 1 time
6) friendship: 0 times
7) encouragement: 1 time
8) pets: 0 times
9) nature: 1 time (referring to "nature of risk")
10) joy: 0 times
11) humour, laugh, laughter, smile, happy, happiness: 0 times for all
12) art, hobby, hobbies: 0 times
13) patience: 0 times
14) drug: 86 times
15) intervention: 91 times
While I love science (my alternative career would have been a mathematician or a statistician!) it is necessary in mental health care to also discuss issues or words that do not fit neatly into a science or data-based analysis. These issues include compassion, meaning, love, and patience. Another issue is finding ways to cope with, live with, or accept unremitting chronic illness or pain, while continuing an evidence-based, but uncertain and frustrating, search for relief or cure. Algorithms and guidelines tend not to help very much with this existential struggle. Educationally, I think it is more valuable to present case studies, with group engagement, perhaps with references made to treatment protocols, rather than to make the protocols themselves the subject of the lesson.
I prescribe a lot of medication. In some cases the medication appears to be incredibly helpful. In many other cases, there is a small but significant benefit. And in others still, there is not much benefit at all despite many, many trials of different medication. And in a few cases, the medications are harmful. Many of my patients benefit most from medications that are considered "second line." I can't think of any examples in my practice where guidelines of this type have been useful in determining the most helpful course, aside from being a very general roadmap to remind us of available options or the occasional new finding in the research. But this roadmap would already be very familiar to most mental health professionals, part of an academic focus over years of training. Specific treatment issues (such as choosing the best medication or psychotherapy combo etc.) are part of professional development: this requires ongoing familiarity with the broad research literature, and with experience in clinical practice, rather than reliance upon review articles. Review articles of this type are authored by research experts, whose work deserves respect; however, the authors represent a limited subset of expertise within the population of mental health workers.
My therapeutic style has included more and more ideas based on CBT, over the past 15 years. Many of my patients work on structured CBT elsewhere as well. As with medication, this is incredibly helpful for some, slightly helpful for many, and has little or no effect for a few others. Arguably, some CBT groups could even be harmful for a few, if there is a large mismatch between what the person desires and needs and what is actually offered. In many cases, people are familiar with these therapy styles, but have not yet really done the work necessary to derive benefit from them. This lack of work is usually due to the depression or the psychosocial situation itself, but also can be due to a lack of continuity of care. It can be a little bit like trying to learn a foreign language, and dabbling in it for a few months, learning a bit of grammar and vocabulary, but never really gaining fluency due to a lack of immersive focus, and a lack of someone to speak the language with on a regular, long-term basis.
Many people, I think, simply benefit from knowing that they are being cared for, by a person or system which has time and attention for them as they need and desire, sometimes on a long-term, open-ended basis. It is helpful for mental health care providers to be well-versed in a wide variety of therapeutic techniques, and to be able to adjust or tune the care to what each individual patient or client wants or needs. Within a system, it is good to value the unique styles and abilities of different individuals within the group, rather than compelling everyone to follow an identical protocol. Some caregivers are better-suited to using a CBT style, while others are naturally suited to IPT, meditation, or psychodynamic styles. Some psychiatrists have a particular expertise and interest in medication management. Most research protocols do not look at this issue in groups or systems. These individual variations should be respected, but I do think it is also good for everyone to come together to learn from each other. For example, psychodynamic therapists can adopt interesting, useful ideas from CBT therapists, and vice-versa.
Most of my patients would say that it was not some medication combo or therapeutic style or adherence to guidelines that ended up helping them, but was a combination of many factors, in conjunction with a system of care (such as a therapist, psychiatrist, or other support network) which was stable, consistent, compassionate, and long-term.
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