Garth Kroeker: Books and Reading

Showing posts with label Books and Reading. Show all posts

Monday, April 22, 2024

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

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

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

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

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

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

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

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

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

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

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

Tuesday, March 26, 2024

"Determined" by Robert Sapolsky

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

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

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

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

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

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

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

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

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

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

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

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

Friday, August 4, 2023

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

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

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

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

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

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

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

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

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

Friday, May 26, 2023

Foolproof, by Sander van der Linden: a recommendation, review, and analogy with psychotherapy

I strongly recommend a new book by Cambridge psychologist Sander van der Linden, entitled Foolproof: why misinformation infects our minds and how to build immunity.

I have followed van der Linden's research for several years, alongside other experts who are studying the psychology of persuasion, misinformation, and propaganda. This area has been an interest of mine for many years, after discovering psychologists such as Cialdini and Kahneman.

This is a subject that everyone needs to learn about! Persuasive techniques (for good and for bad) have always been with us through history; the power and influence of these techniques will only continue to escalate, thanks to the internet era, and now the era of artificial intelligence (AI).

I have discussed these issues in other posts, such as:

Garth Kroeker: How Minds Change by David McRaney: a book review and discussion (August 18, 2022)

and

Garth Kroeker: Political polarization, propaganda, conspiracy theories, misinformation, and vaccine hesitancy: a psychiatric approach to understanding and management). (September 1, 2021)

and

Garth Kroeker: "GroupThink" (October 6, 2016)

Van der Linden reviews the history and scope of misinformation. Among the many current examples are conspiracy theorists impacting public opinion and policy, political influencers attempting to sway elections, propagandists from other countries defending violent or oppressive policies or sowing discord among their opponents, and of course the anti-vaccine community.

There are a couple of acronyms he introduces: the word CONSPIRE can help us to recognize some of the common features of conspiracy theories:

C = contradictory. Most conspiracy theories feature contradictions. For example, there could be a belief that some awful event is a hoax, but then also a belief that the awful event is real but was caused by evil conspirators.

O = over-riding suspicion. A sense of general distrust that goes beyond the topic of the conspiracy theory, particularly a distrust of official or mainstream explanations.

N = nefarious plot. A belief that there is a shadowy group of evildoers, such as government officials, corporations, or (at worst) a particular racial or ethnic group, who behind the scenes have caused some bad thing, perhaps with a motive to advance themselves.

S = "something's wrong." The belief that regardless of any acknowledged or corrected fact about an event, there's something going on that isn't right.

P = persecuted individual. The belief that someone is being deliberately harmed (most commonly, the believers in the conspiracy theory).

I = immune to evidence. Presentations of evidence often have little or no effect to change the opinion of people having conspiracy theory beliefs, in fact evidence could even "backfire" and cause the conspiracy theorist to become even more entrenched, or to believe that you or your sources of evidence are all biased or part of the conspiracy. Such immunity to evidence is common among people who have limited expertise or knowledge about science, but could also be present in some highly educated people. A conspiracy theorist who does have more scholarly expertise may understandably deploy statistical or psychological terminology to defend their beliefs; for example, by accusing other scholars of having psychological biases (such as confirmation bias).

Re = reinterpreting randomness. This is creating a false causal story about random, unrelated events. Humans in general are prone to doing this.

It's interesting as a psychiatrist to reflect on the "CONSPIRE" factors above. They are very often present in frank psychotic states, or in milder variants such as paranoid personality. The tendency to have paranoid thoughts exists as a trait on a continuum in the population. This trait has various environmental causes, but also has a high heritability. It is a typical psychotic symptom to believe that there is a special, often ominous explanation behind pseudorandom events.

Of course, sometimes there are explanations for events which differ from the mainstream understanding. Through history there have always been maverick scientists, who demonstrated something new and important, despite the objections or condemnation of their peers. One example that has always bothered me was Alfred Wegener, who in 1912 was the first to propose the theory of continental drift; he was ridiculed and dismissed by his peers, who couldn't believe that entire continents could move across the face of the earth; Wegener tragically died before his theory was proved correct. We have to be open to consider alternative theories. However, maverick scientists, unlike conspiracy theorists, have clear evidence to support their claims; their reasoning does not contain contradictions; they are not immune to evidence, do not reinterpret randomness, and do not have ominous, over-riding suspicious beliefs about persecution.

Van der Linden's next acronym is "DEPICT", to help remember features of manipulative communication:

D - discrediting. The manipulative communicator will portray experts who disagree with them (such as scientific leaders, or even entire communities such as leading scientific journals), as biased, poorly qualified, incompetent, or having some nefarious agenda. It is frustrating to have a scientific debate with someone who is engaging in such discrediting, since any sound evidence you raise with them will be dismissed as invalid.

E - emotional. Using strong emotional language to induce fear, anger, or disgust as a persuasive tool.

P - polarization. Framing issues, and people who have positions on these issues, in a "black or white" fashion, rather than as shades of grey. This leads to a false sense of dichotomy, and encourages the formation of teams of opponents holding increasingly extreme positions, and increasing disrespect for those who disagree.

I - impersonation. Using fake experts to bolster a claim. A variant of this is using an actual expert, but whose expertise has nothing to do with the issue at hand.

C - conspiracy theories. Encouraging conspiracy theory beliefs.

T - trolling. Attacking, insulting, or threatening opponents, usually in an online environment, such as on social media. Such harassment has at times been so intense that scientists or policy experts (including in public health) have been afraid to speak out, fearing for their safety.

Van der Linden's work focuses on how we can best deal with misinformation. He concludes with an analogy: misinformation must be dealt with by "immunizing" ourselves against it.

In order to build immunity against an infectious disease, it is necessary to be exposed to a weakened version of the pathogen, in order to train the immune system, such that future doses of pathogens would be dealt with quickly.

Infectious diseases are much easier to manage, with much less risk of harm or spread, by building immunity, rather than by only relying on treatment after infection.

Similarly, it is much harder to "treat" misinformation after the fact. Tactics to "treat" misinformation would be debate, education, and careful review of evidence. But many people who have fallen into a misinformation "rabbit hole" are difficult to reach or persuade using reasoned debate. Such debate may even cause the misinformed person to become even more angry or stubbornly adherent to their ideas.

It is better to prevent people from falling into the rabbit hole in the first place--not by eliminating rabbit holes (which is impossible) but by teaching people how to identify and manage rabbit holes if they encounter them.

The idea of "vaccination" is presented as an analogy throughout the book. But beliefs and persuasion are not exactly like the body's immune system. It's a very good analogy, but not perfect. Much of the phenomenon van der Linden is talking about is explainable through learning theory: we learn much better if we actually practice "hands on" with things, rather than just passively absorbing theory. If you want to learn mathematics, you actually have to work through a lot of problems, not just read about how to do them. If you want to learn how to ride a bike or drive a car, you have to practice cycling and driving, not just read about those things in a book! As part of the practice, it is best to face challenging situations, and learn through experience how to overcome them.

Similarly, to deal with emergencies, it is imperative to do behavioural practice many times as a preparation. We have to do fire drills to prepare for a potential fire. Pilots need to practice many times in a simulator how to manage engine failure. If you only read about something, or learn about something, without practicing, you can't possibly become proficient, especially under pressure.

To deal with misinformation, we have to practice, hands-on, dealing with misinformation, at first with "easy" examples, then more and more difficult ones.

Applying these ideas to psychotherapy: CBT (cognitive-behavioural therapy) is very important and useful, but at worst it can be too passive. Many people engaging in CBT do a lot of passive learning, they do written exercises in a workbook, but do not really practice deliberate exposure to uncomfortable stimuli. The "vaccine" analogy could be useful to incorporate into CBT for treating depression or anxiety. This is something that I have advocated for many years, mainly an emphasis on the "B" part of CBT. To deal with panic attacks, it is most helpful to actually practice having panic attacks, in safe, controlled conditions! To deal with depressive thoughts, it could be a useful exercise to invent simulated depressive thoughts, at first mild ones, then more challenging ones, to understand the mechanism by which they are created, and to practice facing them without being negatively affected. This exposure therapy is like van der Linden's "vaccine." But most therapists don't emphasize this enough, they only try to teach people to relax or cope with symptoms after they have occurred. One of the purposes of talking about past emotional trauma is to recreate the painful events in the mind, but in a limited, controlled, "virtual" form, within the safe context of a therapy office. In this way talking therapy has a vaccine-like effect.

Linden's book is a must-read, not only for those interested in propaganda or misinformation, but also for anyone wanting a better understanding of the mind itself, with ideas that touch upon managing almost any life adversity, including mental illnesses.

References:

Linden, S. V. D. (2023). Foolproof: Why Misinformation Infects Our Minds and How to Build Immunity. WW Norton.

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 https://www.getbadnews.com/books/english/

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 (https://garthkroeker.blogspot.com/2021/09/conspiracy-theories-vaccine-hesitancy.html?m=1) 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.

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.

Wednesday, March 23, 2022

The Urge: Our History of Addiction, by Carl Erik Fisher

The Urge: Our History of Addiction, by Carl Erik Fisher is a good book about the history of addiction, weaved together with a story of the author's own alcohol use problems and rehab.

The original use of the word "addiction," as Fisher shows us, was more general or broad, referring to situations we might now consider "behavioural addictions," habit problems, or just very strong preferences. This usage of the word, despite objections from some addictions specialists, may be most accurate from a neurobiological point of view, according to recent evidence.

He emphasizes many times how addictive phenomena lie on a continuum of severity in different people and within the same person at different points in time, and are influenced strongly by social, economic, and political circumstances. For some people addiction is a symptom of, or a means of coping with, horrible environmental circumstances. For others, it is a trap leading to loss of control even when environmental circumstances have improved or are normal.

Understanding and helping addiction problems has had an interesting history, with some compassionate medical and community help approaches evolving since the 1800s, but often interrupted or negatively influenced by social factors such as stigma or criminalization.

I agree with his conclusions, that addiction treatments need to be individualized, and that there can be various different causes or problems which underlie addiction for different people. AA or other 12-step groups can be valuable for many people, but this is not the only effective approach. Other group styles, such as the "SMART" program, can be preferred. Abstinence-based models of treatment may be preferred or necessary for some people, but for others it is effective to aim only for moderation without abstinence. Some people do not want or need peer or group support, and prefer one-on-one counseling. Others may prefer to manage their addictive problems alone; Fisher cites data showing that many people with addictions can recover without any therapeutic treatment at all. There are medications that can help, such as naltrexone.

Fisher acknowledges the importance of loss of control in addiction, and of the phenomenon of denial which delays or prevents many people from seeking help.

There have been big problems in addiction management that must change. First, there needs to be much more availability of addiction treatment programs for those who desire or need them. There should not be economic biases causing some groups to have less access than others. For opiate addiction in particular, there needs to be easier availability of methadone or buprenorphine maintenance for those who would like to try this approach. Harm reduction strategies in general have a very strong evidence base.

Second, public health interventions can be simple and effective, such as restricting the advertising or marketing of addictive products (such measures have been useful for reducing tobacco use in the population). There is still a big corporate influence on policy (from the alcohol or gambling industries, for example), which should not be allowed to continue. Third, there should be less focus on prohibition and criminal punishments, which in general have often made addiction problems worse, particularly by focusing expensive social resources on law enforcement rather than on community improvement and rehabilitation.

Friday, December 10, 2021

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.

Garth Kroeker