Friday, December 30, 2022

Supplements for Mental Health, Part 3: Omega-3 Fatty Acids & Vitamin D

Omega-3 supplements and Vitamin D have seemed very promising for years, to help with general health, depressive symptoms, cognition, or bipolar symptoms.  

But there was a very large randomized controlled trial, of over 18 000 people,  with an incredible treatment duration of 5 years.  Amazing study!  Recipients received a typical good dose of omega-3 (about 1 gram total of EPA+DHA), plus 2000 IU daily of vitamin D.   

The study showed no effect of the supplement compared to placebo.  There were no significant differences in depression rating scales, suicides, overall death rate, cancer rates, or heart disease rates.  Other findings from this study suggested some possible benefits from Omega-3 for cardiovascular health particularly for people with low dietary fish intake.  

A limitation would be that the study population comprised healthy adults.  It may be that using omega-3 supplementation in the treatment of people with established illnesses such as major depressive disorder or bipolar disorder would be more useful.  

One recent study suggested that omega-3 supplementation may have small but significant benefit in postpartum depression.  Another recent small meta-analysis suggested some benefit in treating residual depressive symptoms in bipolar disorder.   Yet, another good year-long RCT in bipolar patients showed no benefit.  

In ADHD, recent research also showed no benefit from omega-3 in a year-long study.  

In terms of other general health issues, though, there may be benefits from omega-3 and vitamin D supplementation.   The same large RCT mentioned initially (the VITAL study) showed about a 15-20% reduction in autoimmune diseases in the omega-3 or vitamin-D supplemented groups.  There is other evidence that omega-3 supplements could help in other diseases such as macular degeneration.  

So, in conclusion, omega-3 and vitamin D appear to be quite underwhelming in terms of potential mental health benefits.   But there may be some small general health benefits, for particular categories of disease such as autoimmune conditions, for people who may be at risk for deficiencies, such as those of us without much sun exposure, or for those of us who don't eat very much fish.  

Addendum: another study, published by Lavigne & Gibbons in February 2023, showed strong associations between vitamin D supplementation and a lower risk of suicide, in male U.S. veterans, with a stronger association among those with lower vitamin D levels to begin with.  But this is a retrospective cohort study, always much weaker than an RCT, and subject to potential non-causal associations.   Once again, supplementation with a standard daily dose of vitamin D is reasonable and safe; there is negligible risk of harm, with some suggestive data implying potential benefit in autoimmune conditions and mood symptoms, particularly in those who might have been deficient.   


Okereke, O. I., Vyas, C. M., Mischoulon, D., Chang, G., Cook, N. R., Weinberg, A., Bubes, V., Copeland, T., Friedenberg, G., Lee, I.-M., Buring, J. E., Reynolds, C. F., III, & Manson, J. E. (2021). Effect of Long-term Supplementation With Marine Omega-3 Fatty Acids vs Placebo on Risk of Depression or Clinically Relevant Depressive Symptoms and on Change in Mood Scores: A Randomized Clinical Trial. JAMA, 326(23), 2385–2394.

Mocking, R. J. T., Steijn, K., Roos, C., Assies, J., Bergink, V., RuhĂ©, H. G., & Schene, A. H. (2020). Omega-3 Fatty Acid Supplementation for Perinatal Depression: A Meta-Analysis. The Journal of Clinical Psychiatry81(5), 13281.

Kishi, T., Sakuma, K., Okuya, M., Ikeda, M., & Iwata, N. (2021). Omega-3 fatty acids for treating residual depressive symptoms in adult patients with bipolar disorder: A systematic review and meta-analysis of double-blind randomized, placebo-controlled trials. Bipolar Disorders, 23(7), 730–731.

McPhilemy, G., Byrne, F., Waldron, M., Hibbeln, J. R., Davis, J., McDonald, C., & Hallahan, B. (2021). A 52-week prophylactic randomised control trial of omega-3 polyunsaturated fatty acids in bipolar disorder. Bipolar Disorders, 23(7), 697–706.

Abdullah, M., Jowett, B., Whittaker, P. J., & Patterson, L. (2019). The effectiveness of omega-3 supplementation in reducing ADHD associated symptoms in children as measured by the Conners’ rating scales: A systematic review of randomized controlled trials. Journal of Psychiatric Research, 110, 64–73.

Prokopiou, K., Kolovos, P., Tsangari, H., Bandello, F., Rossetti, L. M., Mastropasqua, L., Mohand-Said, S., & Georgiou, T. (2022). A prospective, multicentre, randomised, double-blind study designed to assess the potential effects of omega-3 fatty acids supplementation in dry age-related macular degeneration or Stargardt disease. Investigative Ophthalmology & Visual Science, 63(7), 377-F0208.

Lavigne, J. E., & Gibbons, J. B. (2023). The association between vitamin D serum levels, supplementation, and suicide attempts and intentional self-harm. PLOS ONE, 18(2), e0279166.

Wednesday, December 28, 2022

Supplements for Mental Health, Part 2: Zinc

 Zinc is a metallic element, and an essential nutrient.  

It is toxic if ingested in excess, with various side effects such as nausea, headache, and diarrhea.  High-dose supplementation can cause copper deficiency, typically at doses greater than 100 mg/day.  The maximum recommended dose is 40 mg/day, with the standard daily requirement being around 10 mg/day.  

The prevalence of zinc deficiency in North America is about 7.5 %  In cases of deficiency, it is obviously beneficial to use supplements.  But what about supplementation above a baseline, normal dietary intake? 

There are some positive studies, including RCTs, typically using doses of about 25 mg per day.  But a few groups have shown negative results, including a major study of using several nutritional supplements, including zinc, all at once. (Sarris et al, 2019).  This group showed that placebo did considerably better than supplements, for treating depression.   

There is in particular no evidence of benefit from zinc supplementation in the treatment of COVID.  

Overall, the research is variable, often low-quality.  It is clear, once again, that zinc supplementation is very helpful in situations in which there could be nutritional deficiencies.  

But the risk of supplementing with zinc in a 25 mg per day range would be very low.  It could be on a list of things to try, as an adjunct for the treatment of depression or ADHD.  It would best be done on a randomized basis, for example to set up your own personal study to take either zinc or placebo for 6 weeks (with the truth of what you were actually taking unknown to you until the trial was over) then with repeated randomized 6-week trials several times, to assess any consistent change in symptoms between placebo and zinc trials.  


Lai, J., Moxey, A., Nowak, G., Vashum, K., Bailey, K., & McEvoy, M. (2012). The efficacy of zinc supplementation in depression: Systematic review of randomised controlled trials. Journal of Affective Disorders, 136(1), e31–e39.

Duncan, A., Yacoubian, C., Watson, N., & Morrison, I. (2015). The risk of copper deficiency in patients prescribed zinc supplements. Journal of Clinical Pathology, 68(9), 723–725.

Estimating the Global Prevalence of Zinc Deficiency: Results Based on Zinc Availability in National Food Supplies and the Prevalence of Stunting. (2012). PLOS ONE, 7(11), e50568.

Yosaee, S., Clark, C. C. T., Keshtkaran, Z., Ashourpour, M., Keshani, P., & Soltani, S. (2022). Zinc in depression: From development to treatment: A comparative/ dose response meta-analysis of observational studies and randomized controlled trials. General Hospital Psychiatry, 74, 110–117.

Sarris, J., Byrne, G. J., Stough, C., Bousman, C., Mischoulon, D., Murphy, J., Macdonald, P., Adams, L., Nazareth, S., Oliver, G., Cribb, L., Savage, K., Menon, R., Chamoli, S., Berk, M., & Ng, C. H. (2019). Nutraceuticals for major depressive disorder- more is not merrier: An 8-week double-blind, randomised, controlled trial. Journal of Affective Disorders, 245, 1007–1015.

Thomas, S., Patel, D., Bittel, B., Wolski, K., Wang, Q., Kumar, A., Il’Giovine, Z. J., Mehra, R., McWilliams, C., Nissen, S. E., & Desai, M. Y. (2021). Effect of High-Dose Zinc and Ascorbic Acid Supplementation vs Usual Care on Symptom Length and Reduction Among Ambulatory Patients With SARS-CoV-2 Infection: The COVID A to Z Randomized Clinical Trial. JAMA Network Open, 4(2), e210369.

Supplements for Mental Health, Part 1: Folic Acid

The nutritional supplement industry has a global market size of over 300 billion US Dollars annually.   This is comparable to all the money spent in the world on fresh fruit and vegetables.  

People generally take supplements with the idea that they will improve health or vitality, or prevent disease.  

What is the current evidence that supplements could help improve mental health?  I'll start by looking at vitamin and mineral supplements.  

The vitamin with the most recent attention in the literature is folic acid.  This is a B vitamin found in leafy green vegetables, oranges, and other healthy foods.  It has been established for many years as an essential supplement for pregnant women, to help reduce the risk of birth defects.  

Supplementation of folic acid during pregnancy may modestly reduce the risk of post-partum depression, but there is a lack of rigorous randomized controlled trials (RCTs) to prove this.   

The most compelling recent study was published in JAMA Psychiatry in 2022, finding a strong association between folic acid supplementation at doses at 1 mg daily, and a substantially reduced risk of suicide.   

But a major negative study was published in 2018: this was an RCT showing no reduction in depression risk with high-dose folic acid supplementation over an amazing 7 years of follow-up.  But this study did not specifically look at using folic acid as an augmentation in the treatment of people who already have depression or other mental health problems.  

A 2015 meta-analysis found no significant benefit for short-term use of folic acid as an augmentation for treating depression.  

So in conclusion, there is some evidence of folic acid being useful in treating depression or reducing suicidal ideation, but the findings are by no means definitive, and there are negative studies in RCTs.  As with many of these issues, there should be better RCTs with standardized doses (probably 1 or 2 mg daily) and longer durations, looking at using folic acid as an augmentation in people with established mental health symptoms.  In the meantime, there is negligible risk to supplementing with folic acid 1 mg daily, so it is ok to do so.  


Nutritional Supplements Market Size Report, 2030. (n.d.). Retrieved 28 December 2022, from

Global Marketing Associates (2021, March 8). Global fruit and vegetable market: Export opportunity analysis. Global Marketing Associates.

Jin, X., Cheng, Z., Yu, X., Tao, Q., Huang, R., & Wang, S. (2022). Continuous supplementation of folic acid in pregnancy and the risk of perinatal depression–A meta-analysis. Journal of Affective Disorders, 302, 258–272.

Gibbons, R. D., Hur, K., Lavigne, J. E., & Mann, J. J. (2022). Association Between Folic Acid Prescription Fills and Suicide Attempts and Intentional Self-harm Among Privately Insured US Adults. JAMA Psychiatry, 79(11), 1118–1123.

Okereke, O. I., Cook, N. R., Albert, C. M., Denburgh, M. V., Buring, J. E., & Manson, J. E. (2015). Effect of long-term supplementation with folic acid and B vitamins on risk of depression in older women. The British Journal of Psychiatry, 206(4), 324–331.

Almeida, O. P., Ford, A. H., & Flicker, L. (2015). Systematic review and meta-analysis of randomized placebo-controlled trials of folate and vitamin B12 for depression. International Psychogeriatrics, 27(5), 727–737.

Monday, December 26, 2022

Reflections on COVID management 2022

 The COVID pandemic has been one of the most impactful world events of our lifetime.  Aside from the disease itself, the community response to the disease has been intense and unprecedented.  We have never before seen such prolonged, mandated restrictions and economic shutdowns in response to a global emergency.  

The pandemic has brought out some of the best and worst of humanity.  On the best side, we have seen many people working very hard, at great risk to themselves, to help or save others.  We have amazing feats of scientific innovation, in particular the vaccines and other medical treatments developed so quickly.  We have communities that came together in support.  Governments enacted radical measures to support the population economically during periods of reduced employment.  On the negative side, we have seen misinformation, propaganda, hatred, the escalation of the anti-vax movement, and violence.  These phemenona are expected in pandemics; there are good authors to follow on this subject, such as Christakis (see Apollo's Arrow), or Taylor (The Psychology of Pandemics).  

The pandemic and the community response to the pandemic has affected different people in different ways.  For some people the disease itself was devastating, either causing death, critical illness in hospital, or similar devastating effects in loved ones.  The majority of people have had a case of COVID, followed by full recovery, most of whom with no perceptible damage to their health, but a large minority of people have varying degrees of disability following acute recovery, in the form of so-called "long COVID."    

The community response to COVID has had variable effects as well.  Many people have suffered loneliness, mental health problems, worsened physical health problems, and economic hardship due to restrictions.  Many children have had significant disruptions in social and educational development.  Those living in abusive homes were more stuck in these harmful situations.  Most of us were not able to visit ailing or dying loved ones.   The negative impacts have affected some people much more than others.  But there have also been positive effects of public health restrictions.   Many of us have found ways to connect, work, and learn remotely.  Many introverts have been unaffected by restrictions, or have enjoyed them.  Many schoolchildren were spared the bullying and other adversity due to school attendance, and actually experienced a reduction in suicide risk. (see Hansen et al., 2022).  Some have had bonding time with loved ones or family, living in the same household, that they would never otherwise have had.   And many of us have developed a greater engagement for working together as a community, each doing our part, to solve a major world problem.      

I have in the past compared COVID to cigarette exposure, just as an analogy, not as a literal equivalence:  a case of COVID, assuming survival and acute recovery, could be compared to the health effects of 10-20 pack years of smoking (that is, a pack a day for 10-20 years), with a full series of vaccinations with boosters reducing this number substantially.  Most people in the population are lucky--they can tolerate 10-20 pack years of smoking without any obvious health damage.  As a result, a contrarian data scientist could argue that smoking is not very harmful, and should not be restricted (this in fact did happen up until recent decades).  But most people with a 10-20 pack year smoking history would have a measurable decrement in many health metrics--they would be less healthy than they would have been had they not smoked.  Some of these effects may become more obvious only after decades of time, with higher rates of heart disease, emphysema, reduced exercise tolerance etc.  Some people with such smoking history will develop lung cancer, and die, sometimes after a long delay.  Children and young adults are even less likely to show acute adverse effects from 10-20 pack years of smoking, since, of course, they are younger and healthier!  But of course we can all agree that it would be preposterous to suggest that we should allow children to smoke!  Just because children have a much higher survival rate of a harmful agent doesn't mean it is ok for them to be exposed.   Similarly, it should never have been assumed that the low COVID death rate in children is a reason to be unconcerned about mass spreading in younger age groups.  

The overall mortality rate from COVID has always been in a medium range, initially a much higher mortality rate than most strains of influenza, but much lower than a disease such as Ebola.  At this point the mortality rate is more similar to that of influenza, as a result of mass immunization and infection-induced immunity.  But of course, these rates are subject to change (up or down) as new variants are developing as we speak.  Unlike seasonal influenza, COVID cases and deaths are simmering, with recurrent waves lasting a few months each, throughout the entire year, over years of time, rather than settling down after the season is over.  The mortality rate has always been very strongly dependent on age, with elders having very much more severe effects and a much higher death rate than children or young adults. 

 The restrictions and mandates of the past 3 years helped reduce the total number of COVID deaths.  They bought time to allow better treatments to be developed, and to allow a mass vaccination campaign.  They also reduced surges of hospitalization and ICU use.  Despite the restrictions, critical care usage was often right at the brink of overflow.   The restrictions prevented a health care catastrophe that would have been much, much worse. 

To this day, I feel that many analysts of this topic don't fully acknowledge or understand how exhausting and frightening it was for workers in critical care medicine in the past 3 years.  We were dealing with near overflow situations, especially during the case surges.  If we had been more lax about public health restrictions we would have had patients dying in the hallways waiting for ventilators, and other patients without COVID (including heart attack or cancer patients, post-surgical patients, or victims of accidents)  dying due to lack of care.   The stress, and often trauma, imposed on the exhausted medical staff has not been adequately understood outside this niche community of experts.  Critical care experts have been too busy saving lives these past 3 years to busy themselves talking to journalists or trying to engage in public information campaigns.   

A curse of successful public health intervention is that it can cause people to question afterward whether any of it was necessary, rather than have some gratitude that a much, much worse disaster did not happen.  

A contrarian argument based on analysis of death rates in developed countries is a small and potentially misleading component of understanding this issue.  There have definitely been excess deaths -- of course -- due to COVID, but the magnitude of this increase has not been shockingly high compared to rates and changes over the past decades, particularly in areas where there were good public health measures and high vaccination rates.  In many ways these data are evidence of the effectiveness of the interventions, rather than a sign that we did too much, unnecessarily.  Furthermore, death rates alone are the tip of the iceberg regarding health damage, just as a look at mortality rates does not tell the full story regarding the health dangers of smoking.  

Most of us in the medical and public health/epidemiology community have closely followed data on the issue of COVID almost daily over the past 3 years.  The epidemiology community in particular has been deeply involved in this analysis.  

Rather than share my own analysis of data right now, I think it's preferable to cite some of the many other experts in mathematics, statistics, microbiology, virology, and epidemiology who have devoted much of their professional focus over the past three years to studying the pandemic.  I choose the references below because they represent people and groups with years or decades of established expertise, highest levels of educational achievement from top universities, extensive peer-reviewed publications, no significant biases due to financial profit motives etc., and a balanced, moderate point of view:  

1) the website "Our World in Data" has been a wonderful source of information, not only about the pandemic, but about a wide variety of other issues going on in the world.  I strongly recommend this site, as one to follow regularly.  They have curated excellent data about the pandemic.  I recommend following all their COVID data, but here is one link in particular, looking at excess deaths:

2) for some local BC experts, I encourage following the UBC Covid-19 Modelling Group.  Check out the monthly slide presentation from their website; they also have regular video presentations summarizing their findings.  Members include Stanford-trained Ph.D. mathematical biologist Dr. Sally Otto, mathematics professor Dr. Eric Cytrynbaum, Stanford-trained Ph.D. physics professor Dr. Dean Karlen, engineer Dr. Jens von Bergmann, mathematics Ph.D. with specialty in infectious disease modeling Dr. Caroline Colijn, computational biologist Dr. Ailene MacPherson, mathematics professor Dr. James Colliander, statistics professor Dr. Daniel McDonald, mathematician and infectious disease modeler Dr. Dan Coombs, and mathematical biologist Dr. Elisha Are.   These are people with years of expertise in data analysis and epidemiological statistics.  Before doing one's own personal dive into the data, consider whether this group has already done the work at a more sophisticated level.

3) Dr. Isaac Bogoch is a well-known Canadian infectious disease specialist who has worked hard to inform the public about COVID-related issues.  Highly recommended.  Can follow on Twitter: @BogochIsaac. 

4) Dr. Eric Topol has also been a great educator about COVID-related issues.  He was the chair of cardiovascular medicine for 13 years at the Cleveland Clinic, and has since become a leader in medical research and education.  Can follow on Twitter: @EricTopol.  

5) Dr Akiko Iwasaki is a Yale immunobiologist, one of the top specialists in this area in the world.   She has done extensive work on the pathophysiology of COVID and long COVID.  Amazing scientist and an amazing person.  Can follow on Twitter: @VirusesImmunity.  

6) Dr. Trevor Bedford is a professor of biostatistics & computational biology at the Fred Hutch Cancer Centre in Seattle.  Can follow on Twitter: @trvrb

7) Dr. Zeynep Tufekci is a sociologist, with excellent commentary about many aspects of the pandemic, ranging from epidemiologic analysis, to political factors.  Can follow on Twitter: @zeynep

8) Dr. Michael Mina, a Harvard epidemiologist, pathologist & immunologist, has an expertise in mathematical modeling, and during the pandemic has been a leader advocating for better use of rapid testing.  Can follow on Twitter: @michaelmina_lab

9) Dr. Linsey Marr is a Harvard-trained environmental engineer and aerosol scientist, who has been a leader in the research concerning ventilation and mask effectiveness in the containment of respiratory pathogens.  I have felt that the improvement of ventilation has been a neglected area in pandemic and overall infectious disease management; such improvement would likely be broadly accepted by most people, regardless of their political leanings or other beliefs.  Can follow on Twitter:

10) Dr. Nicholas Christakis is a Yale sociologist and physician with expertise in the mathematics of social networks.  He is the author of a good introductory book about pandemics in general, and COVID in particular  (but this book is in need of a sequel, since it was published only one year into the pandemic).  He has vast wisdom and experience in the analysis of pandemics and associated social behaviour.  Highly recommended to follow.  Twitter: @NAChristakis

11) Dr. David Boulware is a professor of medicine and infectious disease specialist at University of Minnesota Medical School.  He has been an advocate for better randomized-controlled studies of COVID treatments.  Such RCTs have been incredibly important, and in my opinion, should have been done on a much larger scale over the past 3 years, to clear up various uncertainties about optimal COVID management.  Such good RCT data showed that treatments such as ivermectin and hydroxychloroquine were ineffective, while some other possible alternative treatments such as metformin, are likely to be useful.  I feel that many more RCTs should have been done, and should still be done, to replicate and elaborate current findings.  

12) Dr. Marc Veldhoen is an immunologist, a professor of immunology in Lisbon, with training in London, working at Cambridge 2010-2016.  I appreciate his clear, authoritative, balanced, erudite efforts to educate the public about immunology in general, and COVID in particular.  Twitter: @Marc_Veld

I have referred to Twitter links above, but also note that Twitter itself is deteriorating due to serious problems in its leadership, so it may be necessary to find the researchers mentioned above in other ways online or in publications.  

The list above is, of course, a tiny slice of the huge, top-notch worldwide COVID research community.  The scientists in this area have done excellent work in terms of genomics, pathophysiology, treatment innovation, epidemiology, and data science, as well as looking at social, psychological, and political factors.  

I recommend checking out the leading medical, epidemiology, and other relevant scientific journals, such as Nature, Science, the JAMA Network journals, the New England Journal of MedicineThe LancetEpidemiology, and The American Journal of Epidemiology .  The American Society for Microbiology is an excellent resource for detailed virology research, and also has some public education resources. When you look at these websites, I encourage browsing through the past year or so of issues, pausing to look at the abstracts of interesting or relevant articles, and choosing a few of the best articles to read in depth.  You can search the website to look for articles specifically about COVID.   If you have access to a university, you can get full articles from these sites, otherwise you can at least read the abstracts.  One of the general takeaways from this perusal of journals should be to understand and appreciate, with some degree of gratitude and awe, the depth and sophistication of the research.   

I also encourage checking out some of my previous posts about COVID over the past few years (though some of them are a bit outdated or may need some corrections).  I consider my major post about polarization & propaganda to be very important:


Links to Journals: 
COVID-19. (n.d.). ASM Journals. Retrieved January 7, 2023, from
Science | AAAS

Books & Articles: 
Hansen, B., Sabia, J. J., & Schaller, J. (2022). In-Person Schooling and Youth Suicide: Evidence from School Calendars and Pandemic School Closures (Working Paper No. 30795). National Bureau of Economic Research.

Christakis, N. A. (2020). Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live. Little, Brown.

Taylor, S. (2019). The Psychology of Pandemics (1st edition). Cambridge Scholars Publishing.

Twitter Links: 
Timothy Caulfield, an expert on health misinformation & propaganda: Timothy Caulfield (@CaulfieldTim) / Twitter
Dr. David Boulware, infectious disease physician & researcher: David Boulware, MD MPH (@boulware_dr) / Twitter
Dr. Nicholas Christakis, physician, sociologist, expert on the social dynamics of pandemics: Nicholas A. Christakis (@NAChristakis) / Twitter
Dr. Linsey Marr, engineer, expert in aerosol transmission of viruses: Linsey Marr | (@linseymarr) / Twitter
Dr. Michael Mina, immunologist, epidemiologist, focus on virus testing: Michael Mina (@michaelmina_lab) / Twitter
Dr. Zeynep Tufekci, sociologist with expertise in the political, social,  and psychological dynamics of the COVID pandemic: zeynep tufekci (@zeynep) / Twitter 
Dr. Trevor Bedford, biostatistician, his lab focuses on epidemiology & virology: Trevor Bedford (@trvrb) / Twitter
Dr. Akiko Iwasaki, Yale immunologist: Prof. Akiko Iwasaki (@VirusesImmunity) / Twitter
Dr. Eric Topol, cardiovascular medicine expert, curator of COVID information: Eric Topol (@EricTopol) / Twitter
Dr. Isaac Bogoch, Canadian infectious disease physician, excellent source of general information about the pandemic: Isaac Bogoch (@BogochIsaac) / Twitter
The BC Covid-19 Modelling Group: a team of mathematicians, biostatisticians, and epidemiologists doing excellent, sophisticated quantitative analysis of pandemic data:
Dr. Marc Veldhoen, Immunologist:

Thursday, August 18, 2022

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

David McRaney, in his new book called "How Minds Change" (2022), reviews our understanding of why people can form tenacious beliefs which are resistant to change, leading to political polarization, conspiracy theorists, hate groups, cults, anti-vax groups, climate change denialism, etc.  

I have discussed a lot of this material in some of my previous posts.   A big focus in McRaney's book is on what strategies are most effective to help with these problems.  He shows that simply presenting facts to a person with entrenched beliefs is usually ineffective, and could even cause the person to become even more entrenched in their beliefs.  Instead, there are several techniques discussed which have much better success.  These techniques are to some degree common-sensical, and are foundations of what might be found in any compassionate interaction, or any psychotherapy scenario.  

He discusses several such strategies, including deep canvasing, the elaboration likelihood model (ELM), street epistemology, and motivational interviewing.  All of these are similar--I'll summarize the core features here: 

1) establish rapport.  Empathize.  The communicator must seem trustworthy, credible, respectful, and reliable.   Obtain consent to talk about the issues at hand.  

2) Ask how strongly the person feels about a particular issue;  repeat back and clarify; identify a confidence level, such as from 0 to 10; ask how they chose that number; ask how they've judged the quality of their reasons for their choice;  summarize; make sure you've done a good job summarizing correctly.  

3) If there are core values influencing the person's opinion, such as about the importance of family, community, safety for children, freedom, loyalty, etc. be sure to empathize, acknowledge, and affirm these.  If there are core values in common, be sure to emphasize the commonality.  

3) If their confidence level was not at an extreme (0 or 10), ask why not?  

4) Ask if there was a time in their life before they felt this way about the issue, and if so what led to the change?  

5) share a story about someone affected by the issue.

6) Share a personal story about why and how you reached your own position, but do not argue.  

7) ask for their rating again, then wrap up and wish the person well, possibly with an invitation to talk again.  

Notably, these techniques do not involve arguing about facts, such as about scientific data.  A person holding strong entrenched beliefs may consider contrary facts or data to be false, biased, or irrelevant.  They may feel like they are betraying their ingroup or their sacred values if they were to change their position.   Yet elsewhere in the book there is an emphasis on facts as well, it is just that there would need to be a tipping point of information frequency within the person's ingroup, beyond which the group opinion starts to change suddenly.  Below that level, facts are easily dismissed, ignored, or even used to ironically consolidate their previous beliefs, while labeling the fact-provider as a misguided or even evil outsider.  

In some of McRaney's examples, he shows, as I have discussed before, that strong ingroups can be the main factors causing resistance to rational changes in belief, even if the ingroup's beliefs are causing great harm to themselves and are contrary to their core values (the anti-vax movement is an example).  He points out that sometimes people need to leave these ingroups for other reasons, before they become amenable to changing their beliefs.  Exiting the ingroup sometimes needs to happen first.  But this can be unlikely to happen.  To facilitate ingroup members being able to leave, there would need to be a kind, respectful, compassionate approach.  If we only show anger and hostility to these ingroups, the members are more likely to rally together, as if protecting themselves from an enemy attack.  

McRaney alludes to many of the practioners of techniques such as deep canvasing having many video examples of the technique, to help others learn and offer constructive feedback about the technique.  I think this would be something to check out online, to see examples of people working in this area lead a successful conversation leading to positive change.  Otherwise, like so many other techniques in health care or in life, we are stuck with just reading about an idea, rather than practicing and learning "hands on" with the guidance and feedback of others.  

The one critique I have of McRaney's book is that he leaves out discussion of many research leaders in the psychology of conspiracy theorists, cults, and persuasion.  Cialdini's work from decades ago is never mentioned.  Psychologists such as Sander Van Der Linden are not mentioned.  There are some other techniques suggested by these other researchers, including a "fake news inoculation" technique, in which you can learn and practice ways to protect yourself from misleading information.  See the website

Also, the book does not discuss individual variations in people as a factor affecting tenacity of belief, propensity to conspiracy beliefs, resistance to fact-based arguments, etc.  In my previous post ( I discuss factors such as past trauma and personality disorders as factors which could cause an individual to hold more rigid harmful or false beliefs.  There would need to be some varability in the approach to conversing with someone about these issues, given these individual variations.  It may be valuable to focus persuasive efforts on those most ambivalent or amenable to change within a strong ingroup.


Sunday, July 31, 2022

Medical School Admission Criteria: a discussion

 It is very difficult to get admitted to a medical school.   At UBC, only about 10% of applicants are accepted.   

This leads to extreme competition.  Students admitted to the program  have average university grades just under 90%, and average standardized test scores (from the MCAT) just under the 90th percentile.  

Even if you have average university grades above 90%, it is no guarantee of admission.  Only 26% of applicants with such high grades are accepted.  

Therefore, there are other factors which increase the likelihood of admission, aside from grades and standardized test performance.  These are so-called "extracurriculars" such as history of volunteering and "leadership activities," reference letters, and performance in a "multiple mini-interview," which involves responding in a desired fashion, within a time limit, to various hypothetical scenarios with a sequence of 10 different interviewers.  

I understand the need to have multiple criteria to judge applicants.  But I would like to make the case here that the current selection process is not particularly efficient or fair, it has a very strong bias against people with particular personality types, despite those people being very well-suited to be excellent physicians, and also leads to years of unhealthy, expensive, and wasteful frenzied competition before starting medical school.  There is also a bias in favour of people from wealthier families, since such people would more easily be able to afford years of volunteering, cultural exploration, club leadership, MCAT prep courses, tutoring, etc. instead of having to work long hours for years near minimum wage to support educational expenses.  

Imagine who the best future surgeons would be.  They would likely have excellent hand-eye coordination, tactile skills, mastery of fine details such as of anatomy, immense patience with meticulous tasks, and ability to remain calm and focused for long periods of time.  Some of them might be not be "neurotypical."   Many of the most talented such people would not necessarily have great social skills, would not be inclined to volunteer at Big Brothers or at nursing homes, would not be on the executive of university clubs, would not have a history of musical or drama performances, would not seem impressive in rapid interviews, and also may not have high grades in biochemistry or English.  I don't believe that any of the relevant surgical talents described above are assessed at all in the medical school admissions process.  

The current medical school admissions process therefore excludes many of the best future surgeons.  For many other future surgeons who are fairly accepted, they would have spent perhaps years of extra time padding their CVs with life activities that they were not really interested in, just to keep up with the pre-med competition game.  This is a waste not only for these individuals, but for society as a whole (we have budding surgeons who have several fewer years of professional life due to them having spent these years doing CV padding activities).  

Another result of the pre-med competition process is that candidates will be well-motivated to pad their academic transcript with easier courses, so-called "grade boosters," while avoiding difficult or challenging courses which tend to have a low class average.   The challenging courses would lead to improved scholarship and wisdom, but people have to avoid them because they could drag their grades down.  Most medical colleges do not take into account the difficulty of the courses that people take.  In any case, one of the advantages of a standardized exam such as the MCAT is that everyone in the world takes the exact same exam, so there is no selective avoidance of difficult material.  

The competition to show extracurricular volunteering and "leadership activities" also creates a bias against introverts.  Many of us are quiet, shy, with relatively solitary habits.  Such gentle, quiet people often would make excellent physicians: people who are calm, good listeners, patient, kind, intelligent, sensitive, and skilled.  But for a person with this personality style, group involvement, group leadership, and many types of volunteering, are just simply unpleasant or impossible.   I am an example of such a quiet, shy, relatively solitary person.  

We should have a selections process that chooses people who are likely to be competent, skilled, and stable.  We should have a process that makes it hard for a psychopathic person to get admitted.  The existing process does select for competence, stability and skill indirectly through grades, even though most of the actual grades have little to do with skills that would be of clinical use during a medical career.   A psychopathic person is less likely to have consistently high grades and a good volunteer record.  But many psychopaths could present themselves very well in cross-sectional interviews, while many non-psychopaths who are simply shy or reserved would bomb the interviews.  

What would be reasonable to change the process?  I don't think there's an easy answer.  I think that grades and MCAT should continue to have a prominent impact on admissions, despite some of the biases involved. Maybe this is unavoidable.   People should be rewarded, rather than penalized, for taking difficult courses that may have lower average grades.  It would seem very reasonable and practical to be rewarded in the admissions hierarchy if you have proven experience or skill in health care work or in relevant skills; for example, people who have worked in nursing or other allied health fields, as a paramedic, in an anatomy lab, as a technician, doing other work requiring long hours of meticulous focus, veterinary work, or psychotherapeutic work.  I think that much less weight should go to performance in a cross-sectional interview process, since this is extremely prone to biases which are not relevant to future medical performance (this reminds me of Kahneman's descriptions of biased and meaningless selection interviews from "Thinking Fast and Slow").  I think that showing "leadership skills" should have minimal impact on admissions, and people should not be penalized in the process for not showing "leadership skills."   Furthermore, those who are most ambitious to show such "leadership" are often the worst leaders.  

Wednesday, May 25, 2022

"The Biology of Desire: Why Addiction is Not a Disease" by Marc Lewis

Marc Lewis explores the neurobiology of addiction in this short book, with proposed approaches to better understanding and helping people who are struggling with addictions.  

He comes across very clearly as a compassionate person, with a good understanding and personal experience in this area.  Probably someone who would be good to have as a therapist or support in the context of addictive problems.   

The book presents several case stories, which is always a compelling style in describing health care issues.  They could be a source of inspiration that could help people in their own journeys through addiction.  But of course testimonial accounts have only limited value in a scientific study, since they can introduce very strong biases in the reader, if not accompanied by references to large controlled studies.    

He has good reasons for disparaging what he calls "medicalization" of addiction, and emphasizing his opinion that addiction should not be considered a "disease."    Many of these reasons involve emphasis on what most of us would consider "bad medicine," i.e. institutional or even punitive treatment, simple remedies such as drug treatments given without addressing social or psychological issues, etc.    He particularly disparages psychiatrists, as though he thinks all psychiatrists enjoy the narrow or excessive brandishing of labels and dispensing of medications without attending to deep understanding, therapeutic compassion, and a biopsychosocial focus, with patients.  

So I found this part of his message to be tiresome.  Excessive narrow "medicalization" of almost any issue is not good medicine.  Almost any health condition, such as type II diabetes, heart disease, hypertension, and certainly conditions such as anxiety or depression, have spectrums of severity or chronicity; there are very important psychosocial factors, often present for years before the onset of the condition, that influence symptoms, severity, and progression.   There are feedback loops involving behaviour which cause spiralling exacerbations or rapidly accumulating harms in all of these conditions.  And treatments for diabetes or heart disease need to involve understanding and help with lifestyle, social, and economic factors affecting these conditions, with long-term goals in mind.    But it is not necessary to avoid calling diabetes a "disease."  Rather, the approach should be, in my opinion, to recognize that any disease state occurs on a continuum.  In many cases, there is no clear-cut line between disease or non-disease.   The word "disease" does not necessarily imply permanence, or need for invasive, narrow,  or institutional treatments.  For example, we could agree that viral pharyngitis is a disease, but is not one which normally requires medical intervention.  Just as in addiction, many conditions uncontroversially considered "diseases" or at least pathological states, such as pneumonia, COVID, migraine, sciatica secondary to disc prolapse, psychotic episodes, or brain injury, can often  recover on their own without any treatment at all; but for some sufferers of these conditions, the symptoms become relentlessly chronic or more difficult to deal with.    Just because something has the possibility of improving on its own, or through lifestyle improvements, after days, months, or years, does not mean that it shouldn't be considered a disease.  Furthermore, the improvements in many conditions can sometimes be associated with improved perspective or lifestyle, but sometimes the improvements are just random.  Many patients I've seen have engaged in all the healthy perspective-taking and good lifestyle habits you can imagine, but are still afflicted by the same tormenting symptoms.  Other patients somehow recover from severe problems without changing their lifestyles much at all.  

Hypertension is a disease, with multifactorial causes, which often requires medication but always requires attention to lifestyle factors.   Simple, overly reductionistic medical treatments can sometimes help with certain disease states (such as repairing a broken limb) but in many or most disease states, medical treatments are only one branch of helping.  The other branches require attention to lifestyle factors, community or social supports, and possibly an existential focus, to help people regain an awareness and passion for long-term goals.  But this multi-pronged focus is what I consider to be normal medical care.  

Lewis argues that because the neurobiology of addiction features entirely "normal" activations of normal brain pathways, akin to learning or falling in love, addiction therefore should not be considered a disease.  But many conditions in medicine feature activation of normal physiologic functions as a component of their pathology.  For example, inflammatory states resulting from infection (this is a major pathology in COVID) are activations of the body's defenses to fight off pathogens, but the inflammation itself ends up causing severe tissue destruction.  The processes are all "normal" but the circumstances of the disease state (germ + host) cause the reaction to be disastrous.  A clear understanding of disease states, mechanisms, and medical interventions to interrupt this cycle, are indicated to save lives and prevent widespread tissue destruction.  

Addictive states can lead to similar destruction of bodies, minds, relationships, and careers.  Just because the mechanisms involve activations of normal neural pathways does not mean we should avoid diagnostic language.    Problems associated with pathologizing labels, such as stigma (from others or from self) do not mean we have to avoid such labels entirely, but it may mean that the labels should be used with care and humility, rather than in a pejorative manner.  

There is interesting neuroscience describing addictive processes, but sometimes discussion of this can devolve into making overly strong literal claims (e.g. about neuroplasticity), often based on compelling testimonial accounts, without as much robust statistical evidence to back these up.  This is a pitfall I've seen with other authors touching on this, such as Doidge.  The use of the neuroscientific language then becomes a tool of persuasion, which sounds impressive to most people.  But it is much more important in this area to back up claims, especially those based on case studies or testimonial accounts, with careful reference to large controlled studies.   

Lewis has good ideas and a passion for his subject, but his focus on addiction not being a "disease" is needless--it is to some degree a semantic squabble, which subtracts needlessly from the impact of his book.  

Monday, May 23, 2022

The Elephant in the Brain & The Folly of Fools

 Two more books to recommend:  

The Folly of Fools (2011) by Robert Trivers and The Elephant in the Brain (2018) by Kevin Simler & Robin Hanson are both about the human tendency to engage in deception: not only the deliberate deception of others but the deception of self.  

Trivers approaches this issue from the point of view of genetics (he was the first to characterize the evolutionary biology of reciprocal altruism).  The capacity to deceive can be beneficial to survival, as we see in many species of animals, and in many human examples.   But such deception can only work up to a certain point, an equilibrium point in terms of frequency, otherwise the strategy fails.  If deception was too frequent, the evolved strategies to counter deception would render the deceptive strategy ineffective.  Similarly, cheating can be an evolved strategy, but if cheating occurs too frequently in a population, it would no longer be effective due to widespread awareness and countermeasures in the population.    

Trivers goes on to argue that self-deception is a type of advanced deceptive strategy.  The capacity to effectively deceive others is enhanced if we can deceive ourselves.  If you REALLY believe you can win a fight (despite poor objective evidence), you are more likely to convince your opponent that you can win, and therefore are more likely to actually win, even if you utterly lack fighting skills. 

Unfortunately, self-deception leads to many serious problems in society.  Trivers goes through many examples, showing that horrible accidents, wars, biased research, and religious phenomena, are often driven by self-deceptive factors which end up causing disastrous results.  

His chapter called "religion and self-deception" is particularly recommended.  

While I consider this book important and highly recommended, I did find it often to be quite informal in reasoning, punctuated by forays into humour, but this could be a bit problematic when he is wandering into areas (for example about politics, wars, and religion) that many people could be quite sensitive or easily offended about.  There are bound to be sections in this book which could cause people some offense.  

The Elephant in the Brain is quite a remarkable review of ideas from social psychology and behavioural economics.  There is influence from Kahneman, Trivers (The Folly of Fools is referenced), Haidt, and many other leaders in the research of this area over the past decades.  I think it's astounding that these two authors, who are not specialists in these areas, produced such a comprehensive and compelling summary of this research.  

The thesis of this book is that humans have a powerful motive to signal membership in groups.  The tendency to form ingroups is a powerful human trait, evolved over millions of years.  Group membership allows us to trust and collaborate with our group members, for safety, defence, maintaining a food supply, dealing with illness, finding a mate, and raising children.  But unfortunately, this tendency to form ingroups can become such a powerful motivation, often without our awareness, that it overwhelms reason, fosters needless and often terrible conflict with outgroup members, and can become very destructive or at least inefficient.    And the phenomenon tends to perpetuate itself, since members of ingroups (be it political or religious or cultural) tend to socialize, mate, and have children with fellow ingroup members.  

They refer to Bryan Caplan's argument about education, showing that a great deal of education leads to only an indirect signal of skill or competence.  Most people do not use subject matter they learned in university very often if at all in the work they do afterwards.  Instead, the degree and grades serve mainly as a competitive signal to employers about capacity to achieve work, conform stably to demands, etc.  I have reviewed Caplan's book elsewhere (I do have some disagreements about this).  

The authors show that political and religious membership have powerful ingroup effects.  The tendency to form strong beliefs about elements of religious doctrine can be understood as a badge of group membership; if one can engage in successful self-deception about these doctrinal elements, it is all the more effective as a group membership badge.    The beliefs become shibboleths which can allow some feeling of trust with co-believers, and a sense of distrust or frank dislike of outsiders.  Such belief systems can develop independently of rational moral reasoning.  While all religious systems contain positive insights about morality (e.g. "love your neighbour as yourself", "blessed are the meek", "blessed are the peacemakers," "judge not lest ye be judged", "do unto others as you would have them do unto you," etc.), the moral prominence of these beautiful insights is often lost in a cloud of doctrine that becomes more about maintaining an emblem of group involvement, an "us" vs. "them" mentality.  This mentality is a manifestation of an evolved trait pushing all humans towards group involvement, formation of local communities in which we can feel trust and belonging, but with the unfortunate consequence of having outgroups which we would not trust, and which we would treat with less positivity, warmth, and generosity.  

The same phenomena occur in political beliefs.  While there could be core rational beliefs about positions on a political spectrum, with regard to preferred economic strategy, international affairs, management of public works, etc., a great deal of political involvement involves doctrinaire beliefs that are badges of group membership, and which have nothing to do with any understanding of policy.  Most people don't even know what the policy positions are, exactly, of the candidates they vote for.   Many others support their ingroup's politicians even though the associated policies would be harmful to themselves economically or socially.    We have tragically seen this happen during the pandemic.  Extreme beliefs about vaccines, masks, etc. became emblems of political group membership; many people made decisions about these issues not because of rational evidence (which strongly supported vaccine and mask use, for the protection of everyone's health, including the anti-vaxxers' own health and well-being), but because of the beliefs of fellow ingroup members in political or religious factions.  Masks and vaccines have almost nothing whatsoever to do with religion or politics -- they are simply common-sensical public health measures -- but once these issues became badges of group involvement, the issue spiralled into disaster, to the detriment of everyone.  This is an extreme example of the phenomenon shown in the famous children's study, where kids randomly given shirts of a different colour end up forming hostile ingroups, opposed to each other.  In the case of the pandemic, a great deal of anti-vax belief was simply driven by factors akin to having a different shirt colour, just to show difference from an opposing outgroup.  

In both books, reference is made to psychiatric theory as an example of self-deception.  Psychoanalytic theory is basically a set of ideas akin to religious doctrine, with a strong ingroup community of "believers" who couch discussion of psychiatric issues through the lens of a theoretical system which is mostly fictional.  As with religions, there are core beliefs in psychoanalysis which reflect deep insight and wisdom.   For example, the idea of psychological defenses came from psychoanalysis, and is ironically an insight into the tendency for humans to engage in self-deception, with the implication that we should try to become aware of our defences, and to be able to set them aside.   Similar insights warning about self-deception can be found in religious texts.  But most of psychoanalytic theory is arbitrary, based on bizarre inferences made from case reports, coloured by the already biased opinions of the therapists.   But as with religious practices, much of the therapeutic value in psychoanalysis has nothing to do with the literal belief system, it has to do with the practice itself.   Visiting a trusted minister or priest, who would most likely be kind, gentle, understanding, supportive, and wise, could be a wonderfully healthy practice, as could a meditative practice of daily prayer, or visiting a congregation of loving friends.   These healthy and possibly healing effects would occur regardless of the belief system held by the group.  Similarly, the practice of psychoanalysis (or psychodynamic therapy more generally) requires frequent visits with a wise, compassionate, gentle, kind therapist who probably has some useful feedback about life problems, and there would be a healing effect of simply having a stable therapeutic relationship over a long period of time, irrespective of the fictional theoretical belief system held, such as strict Freudianism.  

While we can empathize and even endorse the benefits of ingroup membership phenomena, I believe it behooves us to strive for improved rationality, to guide our knowledge and decisions so as to benefit ourselves, our neighbours, and the world in the most effective way.  Societies across the world have improved in this way over the centuries, as Steven Pinker has shown us (see Enlightenment Now), but we have a lot of work to do to continue progress in building a just, peaceful, prosperous society.  

In both books, we are wisely cautioned to look to ourselves for our own self-deceptions.  It is another human tendency to see self-deception or folly in others, while not noticing our own.  In my case, I recognize this will be a work in progress.   I surely have beliefs or practices that are products of my ingroup or other biases; I hope that I will be able to keep working on better awareness of these issues over time, in service to my patients and to myself.   

Monday, April 25, 2022

Review: Shrinking Violets: The Secret Life of Shyness, by Joe Moran

 Joe Moran's book is a nice exploration of various historical figures (such as authors, poets, and musicians) who had what he calls "shyness."  Moran alludes to his own shyness as well.  

A thematic goal of the book is to understand shyness as a part of the tapestry and variety of human life, as opposed to a pathology that requires treatment, or that is even treatable at all.  

Moran is a good writer--he's an English professor, and it is always a delight to read a book in this type of genre written by someone with a mastery of the language.  

This book is interesting as a historical or biographical journey, but I found it quite limited as a serious study of shyness from a psychiatric point of view.  First of all, "shyness" is a very limited term to describe the many varieties of anxiety, introversion, personality styles, and autistic traits likely present in some of his case studies.  

Near the end of the book, Moran encourages a position of gentle acceptance of shyness, but this acceptance seems to disparage the potential value of attempting to help people manage or change their social anxiety or avoidance using therapeutic techniques.  One chapter is even called "The War Against Shyness," which is a pretty strong condemnation of the therapeutic culture.    

There are many shy people, who have what might be considered social anxiety or autistic traits, who might find therapy helpful, to improve social skills, to find ways of facing fears more comfortably, or even to reduce anxiety a notch (including with the help of medication).   We should always have modest or limited expectations of therapy; also we need to take care to affirm an accepting rather than a pathologizing stance, particularly when social behaviour and experience always exists on a spectrum.  Yet the best of modern therapy is affirming and accepting; it just helps people to suffer a little bit less, to help people have a little bit more freedom in their lives to do things they might find meaningful, enjoyable, or essential for survival or prosperity.  

Sunday, April 3, 2022

Review: Blueprint by Nicholas Christakis

 I am happy to have discovered Christakis and his work, in an area I would call “evolutionary sociology” or “mathematical sociology.”  

Blueprint: The Evolutionary Origins of a Good Society is an excellent companion to books by Steven Pinker, Jonathan Haidt, and Richard Dawkins, and even behavioural economists such as Kahneman, looking at issues concerning the genetic components of individual and group behaviour, and the intersection or interplay between “genetic” and “environmental.”     Christakis shares Pinker’s general optimism about human progress, though through a social and anthropological lens rather than a strictly individual, rationality-based one.  Haidt and Christakis both look at dynamics of group differences, Haidt as a psychologist, Christakis as a sociologist.  And Christakis looks at gene-environment interaction on a group level, a continuation or elaboration of Dawkins idea of an “extended phenotype.”  

Near the beginning of the book, there are very interesting case studies presented about small groups that isolated themselves from the rest of society, either through choice (e.g. the Shakers), or through disaster (shipwrecks), then having to develop some means of survival, stability, or happiness.  Some organizational styles were successful, especially when there was some form of effective but not overly rigid leadership, combined with respect for individual differences, and a culture encouraging playful interactions.   Some styles led to failure (a very low survival rate), such as if warring factions developed, “Lord of the Flies” style, or if the community was either too anarchistic, too insular, or too tyrannical.  

Christakis introduces network analysis of groups, which I would like to learn more about.  I consider this to be in the mathematical discipline of “graph theory,” another nice example of pure mathematical concepts and modern data science allowing us a deeply insightful view of aspects of human nature.     I consider this type of analysis especially important in this age of online connectivity, which has the potential to amplify or distort connectivity phenomena, leading to powerful forces of social change, leadership, and spread of ideas or culture.  

After finishing this, I am motivated to finally start Christakis’ next book, Apollo’s Arrow, which is about  the COVID pandemic, again studying it through the lens of sociology and group dynamics.  

A general takeaway point from this book, from my perspective as a psychiatrist, would be to even more strongly value an understanding of social and group dynamics in a person’s life, to understand the nature of connections, connections of connections, group memberships, friendships, communication, and community, in much greater detail, as a component of understanding psychiatric phenomena and strategizing about therapeutic help, rather than stopping at the level of individual psychology only.