Wednesday, September 1, 2021

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

This is an introductory post.  It is about 8000 words long, so could take about 30 minutes to read. I will make editorial changes over the next few months, in an attempt to make it better.  A planned future addition will be about the history of other pandemics, going all the way back to the Black Death—and to look at other evidence of pandemic behaviour from other parts of the world not looked at as frequently in North American research.

If you don't have time for a longer read, I encourage skipping ahead to the end, where I discuss ideas about what we can do about the problem of vaccine refusal.  


Political polarization, propaganda, and conspiracy theories have caused the world great harm in the past few years.  A related problem has come up in the past year, with a significant minority of people refusing COVID-19 vaccination, leading to the pandemic lasting much longer, claiming many more lives, and causing much more economic damage.  

I will explore in this post a variety of psychological and social factors which contribute to these problems, with suggestions of things that individuals, community organizations, companies, church groups, and governments can do to help.    These are severe problems which require urgent attention and large-scale investment.  


It has become more common for people to hold extreme political views. There are increasingly hateful and intolerant attitudes towards political opponents.  Many of us are familiar with  the 2014 study done by the Pew Research Center, showing this polarization gradually worsening in the U.S. since 1994.


Propaganda is false, exaggerated, or misleading information that is spread for political or manipulative purposes.  Many large news organizations in the U.S. are clearly supportive of a particular political party, leading to unprecedented exposure to biased information consumed by nearly half the population.  Social media sites such as Twitter and Facebook often lead people to obtaining information only from like-minded others.  Not only does this lead to extreme bias, it also builds a community of online friends or followers who "egg each other on," ideologically or personally, while denigrating opponents often in a mocking or hostile way. 

Conspiracy Theories

Conspiracy theories have become more common and more bizarre, often associated with ideological positions or a particular political party.  While most of us have had a sometimes amused tolerance for people holding these beliefs, conspiracy theorists are now more organized, are able to magnify and spread their beliefs using social media, and have managed to actually influence public policy to some degree.  I am aware of people in important public positions who seriously believe that COVID-19 vaccines contain microchips used to track people, and that Bill Gates is somehow responsible for this.  Others believe the moon landing was faked, or even that the earth is flat.  


We are all weary of the COVID-19 pandemic.  Many have died or suffered severe disease.  Many others have had severe financial losses.  Many more are going to die.   The majority of those who survive will recover fully, but millions will have long-term health consequences, even after mild illness.

We have vaccines that can bring the pandemic to an end, or at the very least to reduce severe disease and death about 100-fold.   The rapid development and mass distribution of vaccines in the past year is one of the greatest scientific achievements in history. We also have other knowledge about control of viral respiratory disease, such as about mask usage, ventilation improvement, frequent rapid testing, etc. which could bring our countries out of the pandemic much more quickly and with much less loss of life. 

But a significant minority of people refuse to be vaccinated, refuse to use masks, and even refuse to acknowledge that the pandemic is a serious problem. Those who refuse are more likely to belong to particular political or religious groups, are more likely to watch particular news channels, and are more likely to have less education.  

Anti-vax beliefs and other bizarre beliefs about COVID can be shockingly extreme and unchangeable: we have many examples of people remaining convinced that COVID is a hoax, right up to the moment of their death from respiratory failure in an ICU bed.  There are horrifying examples of hospital workers being threatened or attacked by people convinced that the medical care is somehow harmful.  

Alternative Medicine 

In many cases, bizarre beliefs about COVID are an extension of unusual ideas about health care. The "alternative medicine" industry has a market size of about $100 billion per year.  Parts of this industry harmlessly promote healthy lifestyle habits, nutrition, or simple evidence-based care; but there are a lot of exaggerated or false claims made in the sales of alternative medical services and products.  Parts of this industry prey upon people who are suffering and vulnerable, whose care might sometimes fall through the cracks.  Problems in modern medicine, including expense, access problems, or brief, impersonal clinical encounters, can feed some frustrated people's pursuit of alternative health care providers who may have more time for empathic support or apparent understanding.  Unfortunately this apparent understanding is often based on fictional beliefs couched in pseudoscientific language that can sound impressive or convincing, especially to uneducated or gullible people.  Alternative health care can be a lifestyle choice, with bizarre or even delusional beliefs about illness held with almost religious fervor.   There can be feelings of distrust for evidence-based medical science, and a feeling of loyal allegiance to the alternative medical practitioners. 

Con Artistry & Fraud

Many people with strong opinions opposing vaccines, supporting quack treatments for COVID, or supporting particular political leaders since 2016, have been conned -- that is, they have been victims of fraud.  They have been sold something that seemed very attractive to them at the time, but the goods they've obtained are actually worthless or harmful to themselves and others.  But many people would feel an embarrassing or humiliating injury to their pride to admit that they were conned, and to change their position; so instead, they double down on their support for con artists (including particular politicians) or quack remedies.   There is a very interesting research literature on con artistry and fraud.  I would start with  Maria Konnikova's book, The Confidence Game: why we fall for it...every time. Her book is a series of case studies of various types of spectacular con artistry & fraud, with some discussion of the psychology underlying this.  The next scholar to be acquainted with is Brooke Harrington, a Dartmouth College sociologist.  I'm in the midst of reading through this work.  One of her questions has to do with justice:  when should a person who has been conned into doing something harmful be considered a victim requiring compassionate care, as opposed to an offender requiring management in the criminal justice system?  


I see these six issues as closely tied together, fed by the same underlying causes.  Together they are driving people and nations apart; they have caused needless suffering, death, and economic hardship during the COVID pandemic, and have led to an unprecedented threat to democracy in some parts of the world. 

These are not new problems:  they have been with us through all of human history.  Many of us associate propaganda with World War II or with the Soviet Union, not with modern-day western democracies.  Many of us associate bizarre or erroneous beliefs about health with previous centuries, in which people attributed disease to evil spirits, "excesses of bile," or an excess of blood in the body requiring treatment by bloodletting.  Unfortunately, bizarre beliefs about health are alive and well in modern society.  

It is important to understand and study these problems, to know why they happen and what can be done to improve the situation.   A thorough analysis requires input from many fields, including from historians, political scientists, sociologists, public health experts, and psychologists.  

Haidt: The Righteous Mind

I recommend reading Jonathan Haidt's book, The Righteous Mind: Why Good People are Divided by Politics and ReligionIt is a great introduction to the psychological factors which drive ideological differences.  Haidt presents himself as a moderate, or even a right-leaning moderate, which I think at the very least should increase the readership and acceptance of this book across a wider swath of the political spectrum.   

        Group Loyalty, Tribalism & Ingroup Bias

Haidt concludes that there is a human trait of feeling loyal to groups; those groups with stronger or more frequent loyalty traits among members will have advantages in survival and prosperity.  These groups will be more cohesive, and will be better able to defend themselves against outsiders.  Some individuals value group loyalty above all other values; this is partially a heritable trait.  While loyalty is obviously a virtue, it can also lead to members of a group continuing or even fanatically increasing their loyal devotion when the group is engaging in destructive or corrupt behaviours, even when such behaviours are causing suffering to the group members themselves.   The most extreme examples of fanatical group loyalty are seen in cults, but variations of this phenomenon are seen in daily life--in our families, our communities, our sports teams, our religions, our political groups, and our nations.  

We see current groups with extreme opposition to COVID vaccination harassing exhausted health care workers outside hospitals, even while members of their own groups lie dying inside. Other groups participated this past year in an unprecedented mob attack on a major world capital.  Yet members of these groups previously may have valued ethical principles, such as fairness, hospitality, helpfulness, and the rule of law.  Fanatical group allegiance can cause group members to stray towards behaviour that is contrary to the group's previous fundamental values.  

Groups containing devoutly loyal individuals are likely to have higher hostility to outsiders.  Loyalty is a good thing, but in the setting of polarization, propaganda, conspiracy theories, and vaccine hesitancy, such unthinking, rigid loyalty to a group is destructive to others and destructive to the group members themselves.  

One of the suggestions Haidt has about improving the problem of polarization is to maintain open dialogue, to value the principle of respectful debate, and to foster friendships between people and groups having different views.  This would involve cultivating friendships between those on the "left" and "right" of the political spectrum, rather than devolving into hostility and becoming "enemies."  But this approach is not very helpful for dealing with fanatical or extremist groups; at that point friendly debate and social warmth is not going to be possible.  

Unfortunately, many people holding anti-vax beliefs and other strongly polarized positions have become too extreme to allow respectful social connection.  Yet there are many others whose positions are moderate or ambivalent on these issues, including friends, relatives, and neighbors of extremists.  These are the people most amenable to friendly engagement.   

The psychology of Conspiracy Theories

        Lack of feeling in control, need for certainty

According to psychologists studying this area, such as Van Prooijen and Douglas, conspiracy theorists often feel a lack of agency or control, a need to make sense of difficult or confusing situations going on in life or in the world, a desire for being respected (but not feeling that such respect is being given), and a need for certainty.  A conspiracy belief, like other delusions or overvalued ideas, can give rise to a feeling of relief, since the belief provides an explanation for why a problem is happening, even though the belief is fictional.  The explanation, and the excitement of being part of a select group of fellow believers, can give back some feeling of control or certainty, a new sense of purpose.  Other people's skepticism could be perceived as a noble challenge to be faced. 

        Past Psychological Adversity or Trauma 

Prior psychological hardship can sometimes drive people into a fearful, angry, hateful, distrustful, or even paranoid state, with relief of ongoing psychological stress found in narrow or rigid ideologies.  Others, including refugees, may have understandable reasons not to trust authorities or the government.   Most people who suffer trauma do not follow this pathway.  And the majority of those who become extremists do not have histories of trauma.  But in some cases, people with a history of trauma will find comfort, support, and belonging in groups, such as churches and other community organizations, or in extremist fringe groups, even if these organizations are engaging in extreme polarization or conspiracy beliefs.   Members of these groups will naturally feel protective and loyal towards the group and the group's beliefs, even if these beliefs are causing harm to others. Therefore, some people develop anti-vax beliefs as a result of their past trauma.  The possibility of past trauma should always be kept in mind when dealing with someone who is trapped in a conspiracy theory mindset.   

        Personality Disorders

Personality disorders are common, affecting several percent of the population, with milder symptoms affecting many more.  They cause lifelong disruption in relationships, behaviour, and emotional stability; people with personality disorders often lack insight that they have a problem.  They are caused by a combination of hereditary factors and long-term environmental adversity, such as childhood abuse.  

Many conspiracy theorists have narcissistic personality: they believe they are better, more insightful, more informed, and more intelligent than other people, and that other people's skepticism or rational arguments are signs of stupidity or inferiority.   They are unable to tolerate critical feedback.  A softer type of narcissism is due to unmet psychological needs to feel unique.  When extreme narcissism is present in a major world leader (as was the case starting in 2016) the entire group of followers can adopt a narcissistic attitude, even if these traits would normally be abhorrent, or completely at odds with the group's previous religious or ethical standards.

Another factor is obsessive-compulsive personality.  Here, there is a rigid understanding of moral issues, a tendency to be quickly and strongly judgmental, and a tendency to favour a polarized view of issues.  Here again, such character traits would normally be difficult to tolerate, but when present in a charismatic leader, they become endorsed by the group itself.  

Schizotypal and paranoid personality disorders can also lead to conspiracy theory beliefs.  With these personality variants, people are prone to having low-grade delusional beliefs, magical thinking, superstitions, and mild paranoia. Like the other personality factors above, these problems are thought to run in families.

Finally, there is antisocial personality, which leads to criminal behaviour, a lack of empathy, callous disregard for others' suffering,  manipulative behaviour towards others, and compulsive lying, despite showing superficial charm.   We have seen this factor in a major political leader since 2016, as well as in many con artists profiting from the pandemic.  

        Low Education, Innumeracy, & Lack of knowledge about the world

Many conspiracy theorists have lower levels of education, lower levels of intelligence, and a desire for accuracy or meaning but a lack of the cognitive tools to find this rationally.  

In my opinion, innumeracy, a lack of science knowledge, a lack of statistical knowledge, and a general lack of knowledge about the world are major factors contributing to disastrous personal and political decisions.  A general lack of intelligence is a factor, but even relatively intelligent people who are not broadly educated and informed are more prone to ingroup biases and conspiracy theories.   

Ellen Peters' book Innumeracy in the Wild: Misunderstanding and Misusing Numbers is a detailed account of poor mathematical skill in the population.  She shows that only a small minority of people have the skills needed to accurately interpret data, in order to correctly guide decision making.  As a result, most people either make erroneous conclusions about data, or are dependent on others to interpret the data for them.  This makes people vulnerable to political influence from people who interpret data incorrectly. These influencers may have a deliberate manipulative goal, or may be inadvertently misleading, because they themselves are also innumerate.  

Other research has challenged the notion that lack of intellectual skill always contributes to polarization.  Brittany Shoots-Reinhard, Ellen Peters, and others have done a lot of work over the past decade looking at the relationship between intellectual ability and decision-making. They recently published an article showing that people with higher verbal ability are more likely to have polarized responses to COVID-19, and to consume more polarized media. Numerical skill did not predict higher polarization.  

This suggests that people often use cognitive strengths, especially verbal intelligence, not to improve their reasoning or judgment, but to more efficiently gather information that supports their pre-existing views, which are often ideological in nature, and determined by ingroup biases.   This is especially problematic at a political level, since verbal intelligence is a more important skill than numerical or scientific intelligence for a politician to be successful, or for a celebrity to be influential.  Therefore, we have people who are more likely to have polarized beliefs holding positions of influence in society.  

If we see studies looking at the effects of education on various psychological phenomena, beliefs, or ideologies, we need to look at the type of education, with a particular look at numeracy, logic, and reasoning skills, as well as the degree to which the education contains subject matter about global issues, such as history, geography, environmental science, economics, etc.    

        The internet and news-bubbles

The internet provides a medium in which people with extreme beliefs can easily form a community, which in conjunction with traits for group loyalty, leads to these groups forming a strong identity, an "us vs. them" mentality, and a resistance to rational evidence from outside the group.  

It is not enough to address this problem on a one-on-one basis.  There are political, economic, and educational factors that are likely to help, on an individual and societal level.  I'll come back to this later.   

Polarized News Sources & Propaganda

Major news networks in various parts of the world are deliberately propagating conspiratorial thinking and fomenting polarization, catering to entrenched members of particular ingroups.  These networks have a profit motive, but the owners of the networks are also driven by ideological beliefs to push this to further extremes.  They are popular and tend to have high ratings, especially when they are denigrating ideological opponents in a dramatic way.  These news networks lack any form of regulation that prevents or limits harm (e.g. in the US, after the removal of the FCC fairness doctrine in 1987).   

Unfortunately, this has led to a steep decline in the quality of news information that many people are consuming regularly.  Fans also form an ingroup loyalty to the news service itself, such that mainstream news may be deemed "fake" or biased.  Many fans normally value kindness, civility, education, politeness, the rule of law, balanced debate, and religious beliefs rooted in love and compassion.  But due to powerful ingroup loyalty effects, the fans of these news services can embrace leaders or pundits who are unstable, mean-spirited, bullying, and even verging on frank sociopathy.    

It is important not to underestimate how powerful and destructive propaganda can be; we have to realize that the freedoms we have enjoyed in modern democracies can be quickly eroded under the influence of powerful and well-financed propaganda efforts.

 Cognitive Biases 

Cognitive biases are "short cuts" of thinking which allow us to make decisions more quickly.  This can be useful, since we don't always have the time to analyze every issue in our life in detail.  But they can cause massive errors in judgment, especially when we are not even aware of them.   For an introduction to this area of psychology, I recommend reading Daniel Kahneman: he is the one psychologist to have won a Nobel Prize, and his book Thinking: Fast and Slow is fun to read and a summary of Kahneman's masterful research.  I'd like to review some of the more common cognitive biases which perpetuate conspiratorial thinking, political polarization,  and ideological extremism:  


Reactance is the urge to do the opposite of what someone wants you to do, in order to resist a perceived constraint upon your freedom.   This has been one of the driving factors causing resistance to pandemic-based public health restrictions and vaccinations, and which drives political polarization more generally.  A component of the reason many people are refusing vaccination or defying pandemic restrictions is reactance or defiance, because they don't like being told what to do, especially by people who they may see as outside their ingroup.   

    Reactive Devaluation

Reactive devaluation is the tendency to devalue an idea or a proposal, only because the idea comes from an opponent.  So almost any idea coming from a political opponent is reflexively devalued and opposed, regardless of whether it is rational, correct, or helpful.  If the exact same idea had come from an ingroup member, it would be approved enthusiastically.  Reactive devaluation is profoundly self-destructive, not only to individuals, but to entire nations.    Unfortunately we see this daily in U.S. politics.  Once again, this is a reason many people oppose advice about vaccination or public health measure.  


Projection is attributing to other people the feelings or problems that you have yourself.  For example, you may feel angry with someone, but in a conversation you may have a strong belief that it is the other person who is angry at you.  While projection is not typically considered a cognitive bias, it is a common psychological mechanism among those with personality disorders, and among con artists.  In the former group, projection is often "unconscious"-- that is, people project without even realizing they're doing it. It would be an issue to be addressed in psychotherapy.   In the latter group, it is used deliberately and consciously as a manipulative technique.  A well-known political leader after 2016 could be seen to engage in both forms of projection every week--accusing others of bad qualities or behaviours that were obviously his own. 

In a conversation with someone holding fanatical anti-vax beliefs, you may encourage the person to be more informed of evidence.  But that person will project: they will claim that it is you who are not aware of the evidence!  They will deny being conned themselves, but will claim that it is you who have been conned!  Many are calling people who follow public health guidelines "sheep," while it is the anti-vaxxers who are often passively swept up in mindless herd behaviour.  

    The Availability Cascade

The "availability cascade" and the "illusion of truth effect" refer to the tendency to believe a statement simply because it has been repeated frequently, or because it is easy to understand, even though the statement is false.  Many beliefs about the pandemic, including those from conspiracy theorists or those from the "anti-vax" groups, seem more believable simply due to frequent repetition.  The staggering daily abundance of frank lies emerging from a major world leader from 2016-2020 were often not perceived to be lies by many people, due to the frequency of exposure and the cognitive ease involved in processing such statements.   Or sometimes people did not care that they were lies.   Sometimes hateful speech is unfortunately too easy to process cognitively; it may appeal to some deep, primitive component of our brains that is excited by rage and deprecating others. 

    Confirmation Bias

Confirmation bias is the tendency to only look selectively at evidence which supports a previous position.  This is driven partly by powerful ingroup loyalty.  Even when there is overwhelming evidence to support a contrary position, people suffering from confirmation bias will often remain stubbornly insistent that their own narrow, outdated, or invalid research findings are correct.  


Anchoring is the tendency to stick with an initial position or estimate, or to be swayed by it strongly.  If you have started having a particular belief, there is a tendency to maintain it.  This is particularly true if there are personality traits valuing consistency, commitment, and loyalty more strongly than traits valuing rationality, compassion, or wisdom.   One can become irrationally "loyal" to one's initially-held ideas, even if these ideas are self-destructively inaccurate and contrary to other values.  

    The Dunning-Kruger Effect

The Dunning-Kruger effect and the "overconfidence effect" refer to a tendency for unskilled people to overestimate their ability.  We unfortunately see this with many people making strong claims about specialized areas (such as about epidemiology or virology during the pandemic) despite minimal expertise.  Such people can unfortunately be quite persuasive, not because of their expertise, but because they may be popular and have a loud or persistent voice.  Many experts, on the other hand, may have a rather modest voice, and therefore their accurate messages are under-amplified.  

    The Bandwagon Effect

The bandwagon effect is the tendency to engage in "herd behaviour" or "groupthink."  If many other people are following a trend, it increases the chances of joining it yourself.  If these groups primarily contain ingroup members holding an extreme belief system, then neutral bystanders can get drawn in. 

    Present Moment Bias

"Hyperbolic discounting" or present moment bias, is the preference for immediate payoffs relative to later payoffs. On an individual level, this reflects a lack of self-control when faced by temptations.  On a community level, it leads to neglect of long-term societal needs, such as health, environmental integrity, and education, in favour of immediate profits, even if such profits cause severe long-term pollution, economic damage, or health damage.  We see this in the pandemic management as well--many are unwilling to make a short-term sacrifice (such as maintaining social distancing or mask use) even though such small sacrifices would lead to much larger longer-term gains in health, prosperity, and survival for themselves, their families, and their communities.   

    The Sunk Cost Fallacy

The "irrational escalation" fallacy or sunk cost fallacy is the tendency to continue investment in a decision that was made previously, despite new evidence that the decision was wrong.  Basically it can be humiliating or injurious to pride to change one's mind, so it can feel easier to hold onto one's mistaken views or decisions rather than change them.  We see this in political choices that many people made, such as those beginning in 2016.   If there is some kind of belief that the decision in the first place was endorsed by a deity (as though God himself supported or influenced the decision), then it could become even more unlikely that people would recognize they had made a terrible mistake or to make amends.  Other economic examples can be when we continue a financially disastrous investment (either as individuals or groups) because we have made an overly strong or optimistic commitment to it at some previous point in time.  

    Normalcy Bias

The normalcy bias is the refusal to plan for or react to a disaster which has never happened before.  If you live in an earthquake zone, but have never seen or experienced an earthquake, you are less likely to consider how to survive an earthquake or protect your home.  It is much less likely that you would undertake expensive large-scale disaster preparations.  This phenomenon has happened with COVID.  There were many experts who were well-prepared, and in fact there were even organized national preparations for pandemics, but some leaders of major governments dispensed with all of this.  The same problem is likely to happen on a much worse scale, with respect to the ongoing degradation of the earth's environment (disappearance of forests, mass extinctions, degradation of fisheries, loss of wildlife habitats, and climate change).    Once the disaster is already underway (such as with a house fire or earthquake or flood or pandemic or climate change) it is much, much harder to reverse the situation, and finding a solution becomes much, much more expensive if not impossible, compared to the situation where we had just prevented it in the first place.    

    The Ostrich Effect

The ostrich effect is the tendency to ignore an obvious negative situation.  Once again, we saw this in a major country upon the outbreak of COVID, and we see this with the environmental & climate change problems.  On a personal level, we see this in the tendency for people not to seek medical help when they notice a serious problem, just hoping that it will go away on its own.  It is driven by some combination of fear (in this case fear of the truth and fear of how difficult the treatment might be), and magical thinking (i.e. somehow believing that if you don't look at a problem, then it will go away).  In recent political extremism, this has led some members of ideological or political ingroups to ignore or minimize very grave problems, since it is more comfortable to do so.  This includes even ignoring or minimizing a violent mob attack in a major capitol city.      

  Similarity to Addictions 

I think that ideological bias, conspiracy thinking, etc. have a lot in common with addictions, since they are harmful to individuals and communities, but hard to escape.  People often dabble with polarized or conspiracy-based ideas a little bit at first, often influenced by psychological adversities, family or peer culture, and genetic risk factors, then become more and more drawn into problematic behaviour over time; in this way it is like someone trying cocaine with their friends a few times per year at parties, then escalating gradually towards weekly, then daily use.  

Addictive behaviour can cause deep satisfaction or relief in the moment; moving away from addictions can be very challenging and painful; people often cannot do it without external help.   Furthermore, most people with moderate to severe addictions deny that they have a problem, and do not see any reason to change; they may see their addictive behaviour as simply a lifestyle choice, enjoyed by many friends, with any problems lying with other people who criticize them.  

Addictions are strongly entrenched by a peer group of fellow addicts.  To move away from addictions often requires that people let go of their current social network, leading to feelings of loss, loneliness, boredom, and a lack of meaning.  This is one of the reasons that we have to offer social and community support to people if we would like to help them move away from entrenched polarization or ideological biases.  If people in these groups change, they will likely experience a lot of strain or loss in their social networks or families, and will need to have ways to manage this stress and loss.   Similarly, it is important to address entire groups regarding addictions, not just approaching the issue on an individual level. 

Biases & Educational factors beginning in childhood

Many biases and educational factors causing people to be trapped in a narrow or hostile ingroup begin during childhood, with parents, family, and community members teaching and influencing the children. Many people believe things only because their parents, teachers, and peers believed them.   After childhood, people will associate more likely with others who are similar, which further entrenches these beliefs and makes differing belief seem strange or wrong.  


There is a hereditary influence on the tendency to be dogmatic or stubbornly adherent to ideologies, and on general intelligence.   

Refusal to admit mistakes

One last huge psychological factor is refusal to admit mistakes.  Many people would rather carry on with a previous decision even if it is presently leading to disastrous results.  They would be embarrassed, ashamed, or would not "save face" if they had to admit they made a terrible mistake, or if they had to reverse their position on an important issue.   

This stubbornness can be an extremely powerful factor; it could be a psychological defense, a way of protecting a person against the need to feel intense shame and regret for past decisions which caused terrible harm.  This phenomenon is fed by some of the biases listed above, such as the sunk cost fallacy, anchoring, and ingroup biases.  Instead of owning up to a bad decision, people will go through a remarkable feat of denial, to persuade themselves that they didn't make any mistake at all.    We see this among some political leaders, scientists, public health experts, and doctors following mistaken decisions about pandemic management.  And many people hold onto strong anti-vax beliefs or conspiracy theories for this reason.  They might be willing to change their mind, but the cost of admitting a big mistake is too high.  

 Well-funded corporate groups & "think tanks"

Wealthy corporate donors with strong ideological positions are funding marketing campaigns and employing the small cohort of contrarian scientists to push policies opposing vaccination, public health measures, environmental protections, and other public policy ideas they see as relevant to their profits.  It may be expensive for a business to reduce or clean up pollution, so some business leaders want to just remove pollution regulations in order to optimize profits!  These corporate groups or "think tanks" have members who are part of the political or religious ingroups described above, and the biases they have are not just individual, but organized, powerful, and very well-funded, often with billions of dollars of financial support.  

Oxford-trained Duke University public health scholar Gavin Yamey has warned us about the influence of such groups, and has compared their tactics to those used in past decades by the tobacco industry: denying or twisting health risk data, to plant seeds of doubt in the population, in order to maintain profits of a multi-billion dollar industry despite the terrible harms it caused.  

External Political Interference

Other nations with antagonistic relationships with our own are likely attempting to propagate conspiracy theories and extremist groups, mainly using social media, in an attempt to disrupt or weaken our nations.  This is a national defense issue.  

What to do about it

There is a lot that can be done about this problem:

1)  Massive campaign to provide information & counter misinformation

There must be an urgent, massively funded campaign to provide accurate information about vaccine safety and effectiveness.   The scale of funding for this has to be much larger than what we see already.  We need to see posters, ads on the sides of buses & bus shelters, and on billboards.  We need to have well-designed commercials from marketing experts on the radio, TV, and internet.  There needs to be a huge social media campaign.  And there must be a huge campaign to specifically warn people about and to counter misinformation and propaganda.  There should be people going door to door providing information and vaccine encouragement.  These people should preferably be respected and well-liked community members, rather than strangers.  

We cannot only have health experts, such as government health officers, speaking to the public.  Many anti-vax people will not be persuaded at all by a public leader.  We need to have spokespeople in the information campaign that represent ingroups associated with the anti-vax movement.  We need to have right-wing political leaders, religious leaders, celebrities, sports stars, people with different levels of education, and people from different employment groups, all involved in this marketing and information campaign.  

We specifically need to hear from people who were formerly part of the anti-vax movement, who have changed their mind.  We need to hear directly from people who are severely ill in hospital, preferably with video.   

Massive funding for this needs to come from government, but also from corporate and individual donations.  Respected companies and businesspeople should come out with their own pro-vaccine marketing campaigns.  

Consideration should be given to prosecution of those spreading misinformation.  

 Efforts need to be made, as a country, to provide a broad public education starting in early childhood, with a particular view to understand and reach out to children living in ideologically rigid communities.   Various subjects are particularly important: history, political science, economics, biology (including immunology, virology, and evolutionary genetics), public health, and statistics.  Many of these areas might sound intimidating but they could be introduced starting in elementary school at a level most children would understand and enjoy.   Adult education is also very important. But education alone is rarely sufficient to overcome powerful and often lifelong biases.  

2)  Friendship, Diplomacy, and Trade between opponents

 We should strive to develop friendships and trade relationships between members of opposing groups.  Steven Pinker emphasizes this point in his book on the history of violence in society,  Better Angels of Our Nature: Why Violence has Declined

This principle could be objected to, using extreme examples:  most of us would not consider it appropriate or helpful to have cultivated friendships with Nazis during World War II.  But most members of opposing groups are not extremists, they are moderates.  It is much more possible for moderates to find common ground.  It is necessary to very strongly denounce extremism, but this does not mean denouncing almost half of the entire population on the other side of an ideological divide.  If there is to be anyone influencing or learning from each other, there has to be ongoing friendship.  

3)  Experiential Education

Direct experiential education is extremely important.   People need to take tours through overflowing intensive care units, to meet the burned out but highly compassionate and expert staff and to be aware of the suffering patients there.  There will be many patients who are actually members of their very own ingroup.  I think this will be very persuasive, but this has barely been done at all during the pandemic.  Of course, there are technical, ethical, and privacy-related barriers to having such tours, but these barriers could be overcome with good planning.   At the very least, there should be embedded journalists in these environments, just as embedded journalists have been allowed access to war zones. 

4) Vaccine Education

Specific education about vaccine-preventable diseases (such as polio, measles or smallpox) is important and helpful.  Many people don't understand how severe these diseases were, and how remarkably effective vaccines have been to spare hundreds of millions of people (mostly children) terrible suffering and death.  

Specific education about how vaccines work is important.  Many people simply do not know these things. 

5) Ingroup leaders as educators and influencers

Members of ingroups (most likely moderates) will be much more influential as sources of education and information, than members of outgroups, who will most likely be dismissed if they are even heard at all.  

In the case of the pandemic, encouragement of vaccination from religious leaders and right-wing moderates will be useful to persuade others in this community to be vaccinated.  Leaders of these ingroups must denounce extremism and violent behaviour.  

6) Emphasis on underlying values

The importance of emphasizing underlying values is a point made by Haidt.  People on the right-wing of the political spectrum tend to value loyalty, family, and purity.  Issues such as environmental protection and vaccination are consistent with values of loyalty and purity.  It is loyalty to country, loyalty to one's own children (looking after their present and future well-being, enjoyment, and prosperity), and loyalty to God (who would want to care for all people, to care for the place we live, and to help people help one another).   The idea of purity is well-served by plans to protect the environment and also to maintain physical purity by protecting the body from a devastating infection.  

7) Stop funding propaganda outlets

Steps should be taken by individuals and corporations to stop financial support for propaganda outlets, and to support independent, unbiased journalism.  In general, we would not want our news sources to be influenced by wealthy donors or political parties.   

8) Beware of partisan "think tanks"

Good investigative journalism is needed to show financial and political influences coming from partisan think tanks and corporate lobby groups.  I hope that if people can become more aware of these issues, that there could be organized efforts to oppose such groups, and/or legislation to limit their power.  

National security efforts are extremely important, to prevent other nations from contributing to propaganda and extremist groups in our countries.  Investigative journalism is important, as is monitoring of "bots" and fake social media accounts, etc.  Government action is likely to be necessary.  

9) Reduce social media polarization

Steps should be taken, on a personal and political level, to reduce the tendency for social media platforms such as Twitter and Facebook to produce "news bubbles" and to foment division or extremism.   This could involve persuading social media companies (through individual and government intervention) to adjust the algorithms on their sites, to help reduce exposure to extremist positions or false information, and to help "fact check."  On a personal level, one of the options is simply to stop using various social media, except for some of its initial uses, such as sharing photos with friends, family, and colleagues across the country.  

10) Heroism

Philip Zimbardo's work on evil and heroism is good to be aware of.  Zimbardo's research, such as about the Stanford Prison Experiment, has been strongly criticized in recent years, but some of his ideas about the risk of people devolving into evil behaviour due to group influences, is important to know about, and obviously relevant to the events of today.   I like his idea about heroism, the need to step forward to do what is right, even when the people around you don't agree.  This idea of being a hero I think would have broad appeal across the political spectrum.  

11) Psychiatric techniques

As a psychiatrist, it is often impossible to challenge entrenched biases with a patient unless there is a very strong therapeutic alliance, rapport, and trust.  Even then, the amount of change to expect is very limited, especially in the short term.  

It is possible to encourage education, to help patients expand their horizons a little bit.  

If there are low-grade psychotic symptoms underlying belief in conspiracy theories, an antipsychotic medication could be useful, but most people with this issue would not be willing to try this.  

If past trauma or adversity is driving involvement with conspiracy theories or destructive ingroup behaviour, then compassionate, empathic trauma-informed treatment could be helpful.  

Cognitive-behavioural therapy (CBT), in principle, could help people to recognize and change cognitive distortions or biases, but the nature of longstanding ideological bias is less amenable to change, in part due to a lack of insight on the part of those having these problems, and in part due to powerful resistances to change that people have developed over a lifetime, maintained or magnified by like-minded family and peers.  

    Motivational Interviewing 

Another set of techniques that would be useful to engage with someone having problems due to polarization, conspiracy theories, ideological propaganda, or anti-vax ideas is motivational interviewing.  This is a style of therapy used to help people with addictions.  Its foundation has to do with acknowledging a spectrum of insight and willingness/readiness to change for people with addictive problems.  Prescribing a treatment program is not appropriate if the person is ambivalent about wanting any type of change.   A first step can be to gently explore with a person what change might be like, or whether they might like change, but not to push for any sort of treatment until the person is ready.  In the meantime, a lot of the work has to do with establishing trust, empathy, and rapport, while encouraging education.   I encourage checking out a workbook about motivational interviewing, or some YouTube videos teaching the basics.  

12) Empathy with honesty 

In a conversation or debate with a person espousing a conspiracy theory or following some type of propaganda, empathy is needed for the conversation to continue.  In conversing with someone who has a delusional belief, it is not helpful to simply disagree and quote evidence supporting your disagreement.  It is important that the person you're talking to knows your honest position on the issue, and knows that you are prepared to back up your position with good evidence, but it is essential that you show understanding of their feelings about the matter, and that the discussion does not deteriorate into a shouting match or into personal attacks.  

As stated in number 5) above, it could be useful in a debate or conversation with conspiracy theorists, anti-vaxxers, etc. to find examples of prominent people within their ingroups who have changed their mind and moderated their position, while still endorsing and supporting the ingroup.  This could include examples of politicians, religious leaders, and celebrities your debate partner might support or admire, who are now endorsing vaccination etc. 

 13) Possible need to end the conversation or relationship

Open dialogue requires safety and fairness.  It is not possible to have a productive discussion with someone who is shouting at you, threatening you, or monopolizing the conversation.  If the person you are talking to cannot behave in a physically safe and respectful manner, then it is necessary to end the discussion.  

It may be necessary to end some relationships altogether, because continued contact may prove to be too aggravating and stressful over time, distracting us from more positive and helpful engagements or relationships.  But if the conversation or relationship does end, I encourage people to remain polite, gentle, and civil.  

14) Social Pressure & celebrity influence

It can be helpful to make use of media to show that public health measures such as vaccination & mask usage--and environmental measures such as recycling, reducing carbon emissions, and ecological protection--are attractive, fashionable, and cool.  Conversely, lack of support for these things can be demonstrated to be unattractive.  This type of work could involve the help of celebrities, sports stars, models, etc. who people admire for esthetic reasons.  

15) Justice

In order to deal with con artists or fraud, we usually need to involve the criminal justice system.  For a person who willfully neglects safety behaviour, and causes harm to others, we would prosecute them.  For example, almost everyone, regardless of political orientation, would agree that we should prosecute drunk drivers, with severe consequences if they harm someone on the road.  Rehabilitative treatment should be offered as well, for example to treat alcoholism.  Anti-vaxxers are causing harm to themselves and others in a comparable way, and it needs to be a point of discussion to consider legal consequences.  

For con artists who are successfully prosecuted, it can often be the case that the victims who were conned, sometimes leading to severe financial or physical harm, will still insist that they were not victims at all.  They may continue to support the con artist even after prosecution and conviction.  Such is the tenacious power of people's need to "save face" -- admitting they were conned can be embarrassing and humiliating.  In order to make this process easier, it is necessary for fellow con victims to come forward and admit the truth.   We see a few examples of this happening with previous supporters of a well-known political leader since 2016, which hopefully will lead the way to broader positive change.  But it remains to be seen how much longer this phenomenally dangerous con will continue, or whether it could actually grow further.  

16) Be politically involved!  Vote! 

Some extreme or fanatical groups have been organizing protests,  frightening and obstructing health care workers and patients at hospitals in recent days.  Members of such protest groups may create the illusion amongst themselves that they represent many people in the population, or that their views are widely supported.  

To respond to these protests, another type of political involvement would be to show strong public support for health care workers.  I think it could be useful to organize and hold much larger public demonstrations in support of health care, at the same time as the anti-vax protests.   Of course, these demonstrations should occur at a safe distance from hospitals, so as not to disturb or interfere with health care, ambulances, or patients.  

It is necessary to become more politically aware and involved.  In an age where democracy itself is under threat, it is essential to use your right to vote, and to help & encourage others to vote as well.  If people become so discouraged or cynical about the present state of affairs that they don't even bother to vote, then our nation's and our world's problems will be dealt with by people who are very ill-equipped to solve them. 

Selected Readings & References

Armstrong, Karen. The Battle for God: A history of fundamentalism. (2001)

Brashier, N. M., Pennycook, G., Berinsky, A. J., & Rand, D. G. (2021). Timing matters when correcting fake news. Proceedings of the National Academy of Sciences, 118(5).

Briant, Emma Louise (2015). Propaganda and Counter-terrorism. Manchester: Manchester University Press. p. 9.

Christakis, Chris. Apollo's Arrow: The profound and enduring impact of coronavirus on the way we live. (2020)

Dawkins, R. The God Delusion (2006).

Dawkins, R. Outgrowing God (2019). 

  (note: Dawkins is very anti-religious, but I think it is good for any religious person to understand the reasons for this; these books present subject matter that doesn't have to interfere with people's faith or religious community, but rather challenges people to maintain a belief system that has room for modern scientific wisdom.  I mention these books here because they address the subject of how people come to form extremely strong ideological positions, and how people can move away from this.)

Douglas, K. M. (2021). COVID-19 conspiracy theories. Group Processes & Intergroup Relations, 24(2), 270-275.

Douglas, Karen et al, Understanding Conspiracy Theories. Political Psychology 40, Suppl. 1, 2019

Epstein, Z., Berinsky, A. J., Cole, R., Gully, A., Pennycook, G., & Rand, D. G. (2021). Developing an accuracy-prompt toolkit to reduce COVID-19 misinformation online. Harvard Kennedy School Misinformation Review.

Haidt, J. The Righteous Mind: Why Good People are Divided by Politics and Religion (2012).

Harrington, B. (2012). The sociology of financial fraud. In The Oxford handbook of the sociology of finance.

Johnson DK et al. "Combating Vaccine Hesitancy with Vaccine-Preventable Disease Familiarization" Vaccines 2019, 7. 39

Kahneman, D. Thinking: Fast and Slow. (2013).

Kelly, J. (2006). The Great Mortality: an intimate history of the Black Death.

Konnikova, M. (2016). The confidence game: Why we fall for it. Every Time. New York.

Lewandowsky, S., & Van Der Linden, S. (2021). Countering misinformation and fake news through inoculation and prebunking. European Review of Social Psychology, 1-38.

Marchlewska, M., Green, R., Cichocka, A., Molenda, Z., & Douglas, K. M. (2021). From bad to worse: Avoidance coping with stress increases conspiracy beliefs. British Journal of Social Psychology.

Pennycook, G., & Rand, D. G. (2021). The psychology of fake news. Trends in cognitive sciences.

Pennycook, G., McPhetres, J., Zhang, Y., Lu, J. G., & Rand, D. G. (2020). Fighting COVID-19 misinformation on social media: Experimental evidence for a scalable accuracy-nudge intervention. Psychological science, 31(7), 770-780.

Pennycook, G., McPhetres, J., Bago, B., & Rand, D. G. (2020). Predictors of attitudes and misperceptions about COVID-19 in Canada, the UK, and the USA. PsyArXiv, 10, 1-25.

Peters, Maertens, R., Roozenbeek, J., Basol, M., & van der Linden, S. (2021). Long-term effectiveness of inoculation against misinformation: Three longitudinal experiments. Journal of Experimental Psychology: Applied, 27(1), 1.

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

Pinker, S. Better Angels of Our Nature: Why Violence has declined (2012). 

Prum, Richard. The Evolution of Beauty: How Darwin's Forgotten Theory of Mate Choice Shapes the Animal World - and Us. Anchor (2018).

Rathje, S., Van Bavel, J. J., & van der Linden, S. (2021). Out-group animosity drives engagement on social media. Proceedings of the National Academy of Sciences, 118(26).

Rutjens et al, "Science skepticism across 24 countries."  Social Psychological and Personality Science 2021. 

Shoots-Reinhard et al. "Ability-related political polarization in the COVID-19 pandemic" Intelligence 88, 2021, 101580

Swire‐Thompson, B., Ecker, U. K., Lewandowsky, S., & Berinsky, A. J. (2020). They might be a liar but they’re my liar: Source evaluation and the prevalence of misinformation. Political Psychology, 41(1), 21-34.

Taylor, S. (2019). The psychology of pandemics: Preparing for the next global outbreak of infectious disease. Cambridge Scholars Publishing

Van Bavel, J. J., Baicker, K., Boggio, P. S., Capraro, V., Cichocka, A., Cikara, M., ... & Willer, R. (2020). Using social and behavioural science to support COVID-19 pandemic response. Nature human behaviour, 4(5), 460-471.

Van der Linden, S., Panagopoulos, C., Azevedo, F., & Jost, J. T. (2021). The paranoid style in American politics revisited: An ideological asymmetry in conspiratorial thinking. Political Psychology, 42(1), 23-51.n 

Prooijen & Kuijper, "A comparison of extreme religious and political ideologies: Similar worldviews but different grievances", Personality and Individual Differences 159 (2020)

Van Prooijen & Krouwel, "Psychological features of extreme political ideologies."  Current Directions in Psychological Science 2019 28(2) 159-163. 

van Prooijen et al, "connecting the dots: Illusory pattern perception predicts belief in conspiracies and the supernatural."  Aug 21, 2017/ 

van Prooijen and Song, "The cultural dimension of intergroup conspiracy theories."  August 13, 2020. 

Zimbardo, P. (2011). The Lucifer effect: How good people turn evil. Random House.

Friday, June 11, 2021

Mental Health Reform: reflections & ideas for change

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

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

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

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

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

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

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

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

But eventually, after many hours of such meetings, I realized that major decisions were being made about health care planning, with a lot of money involved, with almost no debate or critical challenge.  These changes affected my patients, my colleagues, my morale, the group's morale, and my own philosophy of practice.    Almost none of the money was directly helping my clinic.  I personally did not have any voice in these meetings: my comments or input were not welcomed, and I think I actually was considered difficult or uncooperative because I didn't seem to go along with the plan.   On several occasions I was told, very directly, to discontinue my comments.  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thursday, May 20, 2021

Review: Sex at Dusk by Lynn Saxon

I read this book a second time recently.  

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

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

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

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

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

Thursday, May 6, 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

Monday, January 11, 2021

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

 COVID-19 update January 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The ideal model for dealing with COVID comes from countries such as New Zealand, Taiwan, South Korea, Vietnam, Hong Kong, Australia, and China.  

If the pandemic had been handled with intense focus, very strong leadership, and very strong enforcement, it is reasonable to expect that we could have had an outcome in Canada similar to that of New Zealand.  We could have had very close to zero deaths, and very close to zero disruption in normal life beyond the spring of 2020, had we handled this properly in the first place.  

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

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

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

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

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

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

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

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

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

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

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

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

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

2) Ventilation

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

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

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

3) Mass testing

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

2) Media and Political Issues

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

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

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

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

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

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

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

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

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

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

In Conclusion: 

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

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

The Next Crisis: 

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

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