Narcissistic & Antisocial Personality in public figures: the role of mental health professionals

The norm in mental health practice has wisely been to stay out of politics for the most part, except when it comes to mental health advocacy.  

It would obviously be problematic if individual mental health experts (such as psychiatrists, psychologists, social workers, nurses, etc.) or groups representing professionals (such as specialist associations, editorial boards from journals, etc.) were to endorse or criticize political figures, with a goal to influence elections.  

But sometimes there needs to be an exception to this neutral policy.  

Mental health professionals have a great deal of experience recognizing and dealing with individuals who have behavioural and relational problems such as narcissistic and antisocial personality.  And the most valuable experience mental health professionals bring to this issue is work with patients whose partner, spouse, close friend, parent, boss, or other family member has narcissistic or antisocial traits.

Narcissistic personality traits or disorder include selfishness, self-absorption, boastfulness, need for admiration, arrogance, exploiting others, and lacking empathy.   Antisocial traits or disorder include disregard for others, frequent lying, impulsiveness and poor self-control, aggressiveness, lack of remorse, and criminal behaviours.  While we should always have an attitude of attempting to help people with these traits, it is first necessary to ensure that people with these problems are not in a position to harm others.  It is especially dangerous when a person in authority, such as a parent, boss, or political leader, has moderate or severe traits of this type.  In some ways it is comparable to allowing a small child who has behaviour problems access to a piece of dangerous machinery or weapons. 

If a patient is in a close relationship with someone having narcissistic or antisocial traits, there can be many reasons why the patient has a hard time escaping the relationship.  The relationship may be all they have known for many years.  The relationship may initially have been exciting, passionate, and positive, perhaps an escape from some other adversity, before the narcissistic and antisocial problems showed themselves.   Other people in the patient's life, including important figures such as family or church leaders, may insist or encourage that they stay.  The patient may not recognize or frame the problems in the relationship as abuse, and may instead normalize the behaviours they suffer or which they observe.  Others may be trapped in relationships of this type for economic reasons.  They may fear leaving, due to concerns not only about risk of violence, but also of social or economic isolation.  Others may experience periods of being cared for at times by their narcissistic or antisocial partner, and/or cared for by the social network which supports this relationship, despite the overall toxicity of the situation.   

Sometimes people with antisocial personality lie so often to the people around them, that everyone starts to believe the lies are actually truth, through sheer repetition.  

These factors are similar to the cognitive biases I have described in other posts -- interpersonal or group affiliations can be so strong that they keep people locked into certain choices or behaviours due to group or "status quo" loyalty, even when the experiences they are having are very harmful to themselves and others.  In such entrenched situations, people will selectively attend to data that supports the status quo, and reflexively reject information that encourages change, even if there is a very strong and compelling level of evidence.  

At present, there are important choices in global elections coming up, and a shocking proportion of people appear willing to vote for a person whose behaviour is laden with very serious and dangerous problems.  Not only are there severe narcissistic traits, shocking mean-spiritedness, and vitriolic, hateful, divisive language evident on an almost daily basis for many years, there are frank antisocial traits including criminal behaviour in multiple domains, as well as other very troubling features including an obvious lack of intellectual skills, fund of knowledge, interpersonal warmth, humour (except for mockery),  patience, balanced capacity for judgment, or intellectual curiosity.  There is often frank thought form disorder evident during orations.  Furthermore, there will be a team of other people supporting or working with this person who share similar traits, behaviours, and attitudes, in an ever more exaggerated way compared to 5-10 years ago.  

Other problems in this case include a lack of fundamental cognitive or intellectual skills, a lack of emotional self-regulation, and a lack of principles that might guide wise, effective, or compassionate decision-making.  Instead, I suspect that this person's decisions would often be guided by vindictiveness and attempted self-aggrandizement rather than the good of the country or the world.  Attachment to policies supported by particular groups, such as church groups, would only be used as a tool to advance himself.    Some individuals with narcissistic or antisocial personality can suppress or hide the narcissistic behaviours quite well, and therefore sneak into positions of power before others have a chance to detect the problems.  But in this case, there is a frank display of narcissism almost every time the person speaks, and perhaps a lack of insight or care about it.  Most disappointing and shocking to me is that there is such a large segment of the population that laps this awful behaviour up, makes excuses for it, minimizes it, or disregards it as unimportant.  

It would be quite straightforward to evaluate this person's intellectual capacity.  He is a person who boasted about passing a dementia-screening test as though he thought it was a measure of intelligence.  A simple high-school level fund of knowledge test would be interesting, even to identify places on a map of the U.S. or of the world (such as "where is Poland?" or "where is Nebraska"), or to say a little bit about the cultures or histories of different U.S. states or cities or different countries in the world.  A short quiz about how the economy works, or about even the most basic science (such as "what is gravity" or "what is electricity" or "what is the air made of") would be quite revealing.   A standarized situational judgment test, such as the Casper, often a requirement for applicants to professions requiring interaction with people as part of the work, would be really interesting in this case.   My prediction about these things is that the person in question would score a shockingly low percentile on all of these things, and if this was publicized he would as usual surely blame this somehow on the testing being unfair or stacked against him or a product of "cheating" etc.  

Another frequent egregious and alarming behaviour in this case is something I've described before:  projection.  A rhetorical tactic almost always is to use extreme language to denounce other people, or accuse them of some horrible thing, lying all the way through, yet very often the very things he is accusing others of are obvious features of his own behaviour, character, and history.  

It is especially shocking that certain groups whose personal and group culture is devoted to devout faith, moral purity, law & order, and personal freedom, would double down in their support for this person whose behaviour is in extreme contradiction to these values.   In many religious stories or scriptures, a recurring theme has to do with people of faith being misled or enamored by dark forces--there are many stories where the faithful have lost their way, figuratively or literally, but without having insight or the willingness to change until a lot of harm had been done.  These texts encourage people to humbly reflect and be willing to refocus themselves on their values.    In this case, I think many people including those with strong, honourable moral values and faith,  have very much lost their way in their support of a dangerously unfit leader who is poised to do great harm to their country and the world, in service to himself.  

Of course, it is true that unless a detailed assessment were to be done, we could not have the confidence to make a formal psychiatric diagnosis. But in the realm of narcissism and antisocial personality, most of the actual evidence for such diagnoses comes from collateral information of the patient's behaviour.  In an actual interview, particularly a single individual interview, many people with problems of this type can present themselves in a seemingly normal way (though in this particular case I think there would be many simple ways in an interview to demonstrate some of the problems unequivocally, especially intellectual weaknesses and almost cartoon-like unsuppressed narcissism).   

In any case, this situation reminds me of trying to help a patient (i.e. a large segment of the public) who is in a dangerously abusive relationship with a partner, yet who insists on staying and who might get angry or upset at the suggestion that they could or should think about leaving.  The "patient" in this case is a group numbering 40% or more of the population in certain areas.  

The role of a mental health professional with a "patient" of this type would involve compassionate and empathic exploration of the history, help with treating symptoms of pain or suffering, but also there would need to be movement towards encouraging change or leaving the relationship, warning about the risks of staying, but with a message of hope for a better, happier, more prosperous, more peaceful future after leaving.    Here, a motivational interviewing framework would be needed, since simply encouraging or pushing for change could be very counterproductive if the person does not desire this.  Other ideas for helping include tactics similar to what is described in David McRaney's book "How Minds Change."  (see my post about this book).  

One of the most compelling agents of change or healthy persuasion in this case is to emphasize the role of ingroup members who are speaking out.  In this case, there are many examples.  When an ingroup member speaks out, people are less likely to dismiss the concerns as simply being the product of political opponents.  

Another role of mental health professionals could be to discuss the issue of narcissism, antisocial behaviour, and abusive relationships in a public setting, as an educational endeavour to help people recognize and avoid such relationships in the first place, to be informed about how to get out of such a relationship safely, and to be in a position to help others.  

I have felt that the mental health community has not spoken out appropriately about the current public figure issue I have been alluding to.  I understand the principles behind the reserve, i.e. staying neutral in politics, but this is such an intensely important issue impacting individual and public well-being that something needs to be said about it.  Also, professionals, professional organizations, and editorial boards from journals need not spell out specific opinions about a particular case or a particular person, rather they could simply speak out about recognizing narcissism, antisocial behaviour, entrenched attachment to abusive relationships, the extreme dangers to well-being involved with such situations, the psychological factors preventing change, and things we can all do about it, without spelling out any particular individuals.  

I wish there could be psychiatric journals for the month of October where the issue would be devoted to a review of the research and current state of knowledge about recognizing and dealing with narcissistic and antisocial personality traits in relationships with loved ones, bosses, or community leaders.  In the absence of this, I at least encourage people to explore the issue themselves at a library or online.  

Links: 

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

Garth Kroeker: Political polarization, propaganda, conspiracy theories, misinformation, and vaccine hesitancy: a psychiatric approach to understanding and management

"Spent" by Geoffrey Miller -- a discussion of evolutionary psychology

 "Spent" is a good book by evolutionary psychologist Geoffrey Miller, looking particularly at consumer behaviour, including purchasing and marketing, through the lens of evolutionary psychology, concluding with some recommendations for a healthier, happier life based on his insights.  

There are parts of this book where he gets carried away, or makes what I thought were absurd suggestions, but overall I find him an important author and scientist to be aware of.  

Some of the content here reminded me a little bit of a book I previously reviewed called "The Case Against Education" by Bryan Caplan.  In this book, Caplan, an economist, argues that much post-secondary education provides only "signaling value" rather than tangible skills, expertise, or even enjoyment.  In this way, education can become akin to a peacock's tail -- offering a sign to employers or peers that you are intelligent or capable or "fit."  This may indeed be an accurate sign of fitness, but Caplan argues that it is a needlessly expensive one, in terms of time, money, effort, and emotional investment.  The time spent labouring to get your degree could have been spent doing something you found more enjoyable, productive, meaningful, or lucrative.  The intelligence it required to finish your degree could theoretically have been measured before you did your degree, allowing you entry to your career destination without wasting several years of your life in a program you didn't find useful or enjoyable.   Finally I disagreed with Caplan, since he goes too far in his condemnation of post-secondary education, but I have to acknowledge that he is at least partially right, that many of us pursue post-secondary courses that are more "hoops to jump through" to get a degree rather than providing any sort of benefit that we would use for any esthetic or job-related purpose later on.  

Miller looks more broadly at signaling, particularly with respect to consumer behaviour.   Many of the products we buy are chosen not because of their objective utility, but because they have a signaling value of some sort.   That is, they demonstrate either personality traits, or some intrinsic attractive characteristic such as health, stability, capacity to be caring, or humour, that would be desirable or compatible in a relationship partner.  For example, owning a luxury car would be a signal of financial well-being, which would often be found attractive in a a mate.  Different brands of car are more likely favoured by people with different personality traits, hence brand choice could advertise your personality style.  A degree from a prestigious university would advertise intelligence, and perhaps also stability and financial wealth, which are attractive features in a partner.  A diamond ring demonstrates financial stability and the willingness to sacrifice for your partner.  But the business of diamond rings for weddings is a relatively novel human cultural invention, leading to people sacrificing months of their income, further magnified by group norms about this, just to demonstrate a character trait that both partners should have known about each other just through the time they spent together.  

Miller's overarching thesis is not necessarily that these signaling phenomena are intrinsically bad, but that they are often needlessly or absurdly "expensive" which then causes harm to individuals or even to the world.  If everyone is chasing after expensive objects just to show that they are stable or a good catch, it is depleting to the world, and it is depleting to people's time and energy and money, often with small special interest groups (such as those in the sordid world of diamond mining) making huge profits.  

He argues that simple, wholesome signaling is the best and healthiest way to go.  If you would like to signal your personality traits, it is best to simply have sincere conversations with people so they can get to know you.  In conversation, you don't have to boast about yourself, you just have to "be yourself."    You don't have to demonstrate your character through the purchase of a car, or organic produce, or an Apple computer, or designer shoes.  A better signal about character integrity might come from activities, such as the manner in which you conduct relationships with your friends or family, or volunteering, or taking care of a pet.   

Some types of signaling that are meant to be "deceptive" could backfire.  Spending vast sums of money on cosmetic procedures to make yourself look younger and healthier, could in some extreme cases show others that you are overly preoccupied or insecure or "lying" about your appearance.  But wholesome and enjoyable and sincere self-care that is consistent with your interests and personality would always attract the people who are best for you, since it is honest, uncomplicated, non-deceptive signaling.  

In a concluding section, he makes the point that much of human evolution occurred over hundreds of thousands of years during which we lived in small groups surrounded by wilderness.  Effective signaling would have mostly required conversation, simple daily social or individual actions in the community, acts of work or service that would be seen and appreciated by others, demonstrations of particular interests or talents true to our character, and negative social or community consequences for people who behaved badly.  

Instead of buying expensive objects as gifts, Miller argues that it is more meaningful and authentic, healthier for society, and also more effective signaling, to do personalized activities as gifts, such as making someone something using your own efforts and creativity, or taking them on a special outing.  

Activities we would see as daily features of early human communities, such as playing with children, spending time with the elderly, preparing food, doing simple home maintenance for self and others, going for walks in the forest and identifying the bird calls and the plants by name, and managing the duties of daily life with warmth and humour rather than complaint, is a good foundation for a happy and healthy life and a good source of esteem from others.   Demonstrating skill and prowess and enjoyment in these areas would be a universally attractive thing, and hence is much more effective "signaling" than buying an expensive car or obtaining fancy credentials.  I'm a big fan of recommending such simple activities as a foundation of maintaining good mental health.  

Education for gifted teens

I'm uncomfortable with the term "gifted" since it implies that some people have "gifts" while others do not.  Really, everyone is gifted, and it should be a project in life to help all people cultivate their gifts and be acknowledged and appreciated for them.  

But admittedly, there are some students who whose talents and abilities allow them to be doing university-level academic work, or advanced work in performing arts,  by mid-childhood.  Leaving these children in the regular educational system could be boring or stifling for them, both intellectually and socially.  

There are various sources of data about the value of various educational programs, including those catering to students with unusual talents.  Testimonial accounts from the students and teachers are obviously an important source of data.  There could be very glowing accounts of particular programs, or perhaps also scathing critiques, from different individuals, during or after their exposure to the programs.    These are bound to influence subsequent policy.  Or there could be "before" and "after" data, showing that most students in these programs do extremely well by some measure (unfortunately the measures often do not look at long-term psychological health).  

But using data from testimonial accounts or "before/after" studies is fraught with problems.  Students gifted in mathematics or other sciences should understand this very well -- it is a foundation of understanding treatment effects in medical statistics.  If there are many students who give glowing accounts of a particular academic program, or entire cohorts who do well compared to their previous state, what does this really mean?  It could mean that the program itself is excellent and should be continued.  But another possibility is that gifted students are likely to thrive because of their giftedness or intelligence, and they would have thrived regardless of what type of program they were in.  It is possible that the particular program was actually harmful to them compared to some conventional alternative, but they still gave a positive review because of their innate tendency to thrive adaptively.  Similarly, negative reviews of a particular program could be caused by a bad program, or it could be caused by character traits in the reviewers, such as perfectionism, narcissism, or depressive symptoms. 

Some positive reviews could be inaccurate judgments, skewed by other factors such as pride or narcissism.  For example, graduates from an ivy league university may give inflated reviews of their educational experience because of the pride of being associated with such an elite institution.  They may have had a similarly good undergraduate experience at a small local college.  Of course, it is not an "either-or" issue.  Ivy league education is indeed probably better in many ways, but not as much better as people believe it is.  

In order to really determine the effectiveness and healthiness of a gifted program, one would have to do sufficiently powered randomized controlled studies, with both subjective and objective short and long-term assessments looking broadly at social and psychological well-being as well as academic achievement or career success.     Testimonial data is useful but not sufficient.  Jargon-laden theorizing by educational scholars is particularly meaningless and tiresome unless grounded by controlled data.   

Aside from the need to have policy grounded in RCT data, there are a few features that need to be present to have a healthy, effective educational program for gifted children: 

1) there should be specialized teaching to fully develop the students' capacities, otherwise they would be bored and understimulated.  For some students, "teaching" per se is not required -- the students can teach themselves, and an external didactic teacher, especially one trained to be a high school teacher, could often just get in the way.  But there should be adult mentors who are at least supporting and guiding the students' progress, and forming a warm personal connection with the students.  For technical subjects, there should be access to advanced laboratory materials.  And probably there should be access to experts such as university professors who can interact with and challenge the students at their level.  

Some teachers who specialize in teaching gifted children may simply load the students with an enormous quantity of material.  This leads to a risk of harming the children. 

2) it is most likely of benefit for gifted children to be in a group of peers who have comparable abilities.  This is one of the stronger arguments for a "gifted program."   However, this could be achieved in other ways, such as through clubs, in a regular high school or community.   For some gifted students--though not all--the regular high school social environment would be an oppressive chore to deal with

It should be noted that such peer affiliation may not always be positive.  It could foster elitism in some cases, or interfere with social skills.  Or ironically, for some gifted kids, a special program would take them away from peers rather than bring them closer.  Peership is not necessarily about mutual expertise in mathematics or some other academic subject--it could have to do with character or shared interests.  There could be a lot of variation between individuals with respect to this.  

3) educators should be aware of the phenomenon of eager parents pushing their children, driven by the parents' pride or ego or perhaps well-meaning but misguided notions as to what is best or healthiest.   

4) Regardless of whether children are in a gifted program or not, and regardless of these kids' talents, their academic program during childhood should allow for a balanced, healthy lifestyle.  There should never be so much homework that kids would not have time for sleep.  Lengthy commutes to and from some special school program, taking 1-2 hours of time daily, should be understood to have a negative impact on a teenager's mental and physical health -- these are hours that could have been spent playing or exercising or socializing or sleeping or studying.  

5) Rushing children through 5 years of high school in just 2 years, even when the kids are very capable intellectually to do this, necessarily will narrow the academic breadth of learning, even for the brightest of children.    Consideration should be given of broadening what is offered, over a longer period of time, rather than narrowing over a short period. 

6) For particular subjects such as literature, it will not be possible to introduce as much breadth of content in a confined period, whether the students are gifted or not.  Furthermore, many gifted programs are so oriented towards students who are destined to study engineering or other hard sciences, that English is glossed over.  In some cases the program may be engaging in some degree of grade inflation regarding literature courses, so that the students end up spuriously receiving good enough English grades to get university admission, even though their actual performance is mediocre or poor.    Mind you, this touches on the subject of university admission criteria--a genius-level student in mathematics perhaps should not be expected to have high grades in English or history in order to gain admission to an advanced university math program.  Demanding high grades across the board for university entrance discriminates against those who have focal areas of excellence but also focal areas of academic weakness.  However, giving high grades in English to students who lack literary skills is unfair to those who have true excellence in literature, and demeans the subject.  

The converse problem is often present in university-level literature courses.  There is a tradition of professors giving very low grades in university English courses, often with the highest grade being in the mid 80's, very few students earning an A, and very few students actually able to change their grade through a term by following any type of constructive feedback from the instructors.   I suspect that if student essays in these courses were objectively and blindly graded by a panel of professional writers and journalists, we would not see good correlations with the professors' grading.  I suspect that adherence to what Steven Pinker called "academese" is unfortunately rewarded, rather than good writing.  This issue may also be amplified by insecurity within this academic community, giving a false sense of importance of the subject by giving low grades to most students.  

7) For scientific subjects, cramming students through high school level courses quickly may well facilitate successful early university entrance, into engineering or physics programs etc.  But often the curriculum offered is narrow.  A gifted program could instead offer greater breadth rather than only greater speed of traversing curricula.  For example, adjunctive courses in statistics would be tremendously useful for any science prodigy, but this material is usually neglected, in favour of advanced calculus or computer science etc.  An enjoyably broad survey of scientific subjects would also be possible for gifted students, to gain a basic understanding of astronomy, geology, meteorology, climate science, ecology, botany, evolutionary biology, etc.   

8) Arts subjects are often neglected in gifted programs.   Breadth in arts and literature could involve studying a wider range of contemporary and historic literature, including a survey of world literature outside the usual western focus.   Many gifted programs tragically do not have robust opportunities for students to participate in performing arts or fine arts activities such as dance, theatre productions, or visual arts.  

9) It is absolutely unacceptable for children not to have regular physical education.  This doesn't necessarily require sports teams, etc. (although this should probably be an option), but a culture of regular, daily fitness is a foundation of a mentally and physically healthy lifestyle.   It is one of the things that teachers would definitely be in a leadership position to offer.  

10) Subjects relating to basic well-being, self-care, etc. are often neglected.  This could include courses in nutrition, food preparation, practical life skills, social and conversational skills, psychology (including an introduction to CBT), and personal finance.  

11) Some gifted programs can become an insular niche.   It could be valuable for new staff trainees to rotate through regularly, to prevent such programs from stagnating, and to allow constructive feedback to occur so that staff can maintain or improve skills, perhaps with constructive feedback invited from students, parents, and alumni of the program.  

In assessing programs of this type, it is perilous to gather data only through something like an external review.  Such reviews are often "corporate" style as though one were assessing a factory.  If there were serious problems, often staff would be reticent to discuss them, since they might fear losing their jobs.  The data gathered would be cross-sectional or testimonial in nature.  This could highlight very serious issues with leadership, safety,  incompetence etc.  Once again, in order to guide sound policy on this matter, RCT data would need to be gathered systematically, such as by doing a prospective randomized study of two or three different approaches to help gifted children, compared with a control group, with a sufficient number of participants, repeated over many years of time.   Such data would likely be "noisy" just as it is in psychotherapy research, because often the strengths or weaknesses of a program are strongly impacted by the particular individual teachers, rather than the style or format. 

In the meantime, simple alternatives for students who are much more academically advanced than their peers could include allowing the freedom to take individual university-level courses before having graduated from high school at all.  Each student could possibly have an individualized plan to help them, perhaps with exposure to advanced material in one area of their life, while having an "ordinary" childhood experience in other areas, depending on that student's wishes or needs.  

Another issue with policy that is usually neglected is consideration of the well-being of the teachers and other staff.  If teachers are bogged down by administrative duties such as long, pedantic meetings or obsessively detailed report cards etc., are restricted in their actions through micromanagement or rigid policy, or are simply overworked without time for their own self-care, this is harmful not only to the individual teachers but obviously to the students as well.  One of the roles of a teacher, for any student, gifted or not, is as a stable, healthy, happy, mentor, who can engage in work in a sustainable, enjoyable way.  A teacher who is stressed out, overworked, unhappy, trapped in an unhealthy bureaucracy, etc. is less available and effective for the students.  Gifted students could be particularly harmed by this, since many of them would have a tendency to push themselves too hard, to the detriment of their mental health.  They would need to have adult role models who have balanced lifestyles, and time for personal connection.    A negative environment of this type cannot be hidden: children often have a really good idea about what's going on even when problems are not spoken about.  

As a psychiatrist, with decades of experience working with a university student population, I have seen many gifted young people.  While many young people in this population are outstandingly happy and mentally healthy, often going on to amazing achievements in their personal and professional lives,  there are many mental health phenomena that are more common in this group, such as autism-spectrum symptoms, perfectionism, obsessive-compulsive phenomena (both OCD & OCPD), eating disorders, and sometimes narcissistic traits.  There have been cases of major mental illnesses and suicides.   In general, I have not found that people in this group have been helped dramatically by their high school gifted program, though many of them would have positive things to say about it.    Usually in their accelerated program, they did not have time nor were they offered any compelling help for mental health issues or to simply have the healthy, well-balanced lifestyle that would have benefited them.  Often they had inordinate pressure from parents.  I can think of one very gifted scholar who didn't want to "develop" their gift at all, but felt obligated to because of the high expectations of parents, teachers, and even self.   In many cases, the programs led to these students being in a university too young.  In many other cases, I think these students would have thrived regardless of what type of program they were in during high school.  But they probably would have had more opportunity for exploration, fun, and play had they started university at a more typical age.  

This subject speaks to a broader issue of "giftedness."  Everyone is gifted, in the sense that we have beautiful qualities which need to be cared for or developed.  But development of gifts must occur in a way that is compatible with physical, mental, social, and community health.  Gift development may require special resources, but we should resist the urge to drive this development at the fastest possible pace.  Sometimes such an intensive but well-meaning drive can damage people, and damage their gifts, rather than help them.   

"Determined" by Robert Sapolsky

 Robert Sapolsky is a great scientist with deep wisdom to share about humanity.  His recent book, Determined, is another must-read.  

The first half or so of the book details the many factors causing a given behaviour which are outside of what could be called "free will."  For example, hereditary factors, evolved traits, endocrine factors, social and cultural factors, childhood adversity, abuse, poverty, neglect, or discrimination, or on the other hand extreme enrichment through wealth and having good parents, home, and family; and the environmental conditions of the day or the hour.   Sapolsky reminds us, with evidence to back it up, how influential these factors are.  One chapter is dedicated to the Libet experiments, which demonstrate some degree of neural evidence of a decision before a person is subjectively aware of having decided, therefore calling into question whether our sense of making a decision is something like an illusion.  Other chapters are devoted to physics, such as about quantum mechanics and chaos theory; he argues that free will is not to be found in these areas.  

His strongest thesis, which he states a few times in the book, is that even if free will does exist, it is less influential than we believe it is -- that is, we underestimate the impact of other factors.  But often he strays from this strong thesis, into a state of denying the existence of any free will whatsoever, and then reflecting about the moral consequences of this.  

I think in many areas he is overconfident about findings that are quite debatable.  While the many genetic and environmental factors mentioned above are all indisputable, there could be a lot of debate (which he does not engage in) about the magnitude of some of these particular factors, or about the soundness or biases of the existing studies on these matters.  Just as in his previous book (also a great book), Behave, he quotes study data that really ought to be debated vigorously rather than accepted as the final truth on a matter.  In the current book, he even acknowledges these issues with Behave, but then he proceeds to do the same thing again anyways.  I'm not saying he's wrong about these claims, only that he overstates, at least through insinuation, the certainty of the evidence supporting them.  

 In quantum mechanics, for example, the most common view is that events in the quantum realm take place in a truly random fashion; such randomness eliminates the possibility of deterministic precision.   At the very least, there may be certain deterministic statements that are almost undeniably true (such as that you or I will die in less than 100 years; or that the sun will enter a red giant phase in several billion years), but there will always be a shadow of uncertainty around the specifics, or even the tiniest flicker of uncertainty about the event itself; some of this uncertainty is not due just to incomplete information to make a prediction, it is fundamental to physics itself.     Such quantum events I think are relevant to human events, as for example they could determine whether a particular DNA mutation takes place at a particular time, with very important consequences regarding an individual's survival, disease state, or passage of genes to the next generation.    Mind you, I discovered one group of physicists espousing an idea called "superdeterminism," which accounts for some of the peculiarities of quantum experiments (such as those dealing with Bell's inequality) by positing that apparently random quantum events are all completely determined, thus one cannot actually modify an experiment in a truly arbitrary manner, since the decision about the supposedly randomized experimental manipulation was already completely determined in advance.  Yet, I think we would have to agree that this is far from a settled matter in physics, and we would need to step back from making strong claims about this area.  

The strongest conclusion Sapolsky makes based on his thesis about determinism is that we therefore need to be more empathic and gently understanding about all human behaviour (of course, his thesis really takes away the possibility that we could somehow "choose" to be more understanding, since if this empathy occurred it all would have been determined in advance).  The best we could do to analyze this moral issue, while accepting his thesis of an absence of free will, is to consider an ideal moral code (in some kind of Platonic "realm of forms") which would have optimal fairness and justice.  This is in fact what moral codes, including those in the legal system, strive to do.  But in the light of our knowledge about free will, what changes if any would be best in terms of modifying moral or legal rules?  

He argues that dealing with criminal behaviour in a blaming or punitive manner is not rational, since the causes for crime have been determined not by the individual's "free will" but by genetic and environmental factors outside that person's control.  He similarly argues that praising people or celebrating great accomplishments is irrational, since the accomplishments, or capacity for hard work, etc. were also determined by factors outisde the individual's control.  So basically when we congratulate someone for a great accomplishment,  we are granting the person credit for factors that were really the product of millions of years of prior good luck.  

But of course, is this how we would really want to live?  To stop congratulating people after they do good things?  Or to always be meekly understanding when people do terrible things?  I agree with Sapolsky that improved scientific understanding about causality should prompt us to be more humble, and to be less inclined to reflexively blame or punish bad behaviour while motivated by reflexive emotions.   

But part of normal life involves congratulating people.  Admiring accomplishment is like admiring beauty in nature.   Maybe there should be a little bit of humble acknowledgement of those factors that contributed to the accomplishment outside of one's own "free will."  But this is part of the etiquette in almost any awards ceremony, though most people don't go into remote evolutionary causes for their good fortune--they tend to stop at family, friends, and teachers.  

Sapolsky cites various egregious examples of recklessly excessive violent punishments through history, leading to his own stance of advocating leniency in the justice system.  He has a very admiring tone around Norway's approach to having what most in the world would consider a shockingly lenient prison sentence for a notorious mass murderer.   While there is much to admire in Norway's civilization and justice system, I think this practice of strictly limited sentencing fails to address a massive component of consideration in criminal sentencing, which is the psychological impact of the sentence on victims, and families of victims (who are also victims) of the crime.  A reason to keep a mass murderer in custody permanently is to treat and prevent anxiety and distress among victims or families of victims.  It need not be motivated by our base (but highly evolved) urges to punish, or by irrational overestimation of subsequent criminal risk (scientific estimates of recidivism risk should obviously impact management of criminal offenders, though the accuracy of recidivism risk estimation is way less than 100%). It should definitely be influenced by considerations of the impact of the sentencing on the health and psychological well-being of victims.  

So all in all, a very important and impactful book.  I have to admit I find it disturbing to know that "free will" even if it does exist, is rather less complete in determining behaviour than most of us believe.   But in dealing with scientific findings, we need to be prepared to consider things if the evidence supports them, even if the findings might be disconcerting.

How does this book guide our understanding of mental health, or of therapies for mental health problems?  For one thing, we should be reminded to reflect on our tendency to be reflexively judgmental, or to blame people for what could be seen as failures of will.  If we do engage in judgment or blame, it should be guided by rationality, as to whether this would be helpful to improve the situation for all.  Often such blame or judgment is not actually helpful.  Arguably some forms of blame could be a normal motivational influence in humans, but probably we use this too often and too heavy-handedly.  

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

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

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

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

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

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

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

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

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