Potentially Dangerous Biases in Policy Planning Meetings

Administrative meetings are are a common part of many people's professional lives.  Teachers, academics, health care workers, engineers...we all at times are required to attend meetings, some of which have a theme of planning for the future, and of changing the way things are done.


Quadrant 4
The importance of reflective, proactive planning is very high.  I often refer--with my patients-- to the four "quadrants" described by Stephen Covey (1989) in his very popular book, The 7 Habits of Highly Effective People.  He wisely points out that many people are devoted to what I call "quadrant 1", which is taking care of short-term, important tasks.  For many workers this could be answering calls, or dealing with emergencies.   While quadrant 1 is important, it often consumes so much time and energy that there is nothing left for long-term planning.

 It is an obvious problem when people are spending too much time in quadrants 2 and 3:  short-term or long-term unimportant tasks (such as engaging in unhealthy habits).

 But Covey's simple but great point of wisdom is that the highest priority ought to be setting aside time for "quadrant 4":  long-term, important tasks.  Many of us are too busy with the urgent matters of the day to make time for these things.   If more attention was given to long-term, creative, imaginative planning, the short-term important tasks could often be taken care of much more efficiently, leaving more time for deeper, higher quality, more meaningful work. 

So, reserving time for meetings, in order to plan for change, can be vitally important, even if they take us away from our important daily work.  

Meetings have Costs
However, meetings have costs!   Many meetings are unproductive and boring.    The cost of the meeting is not only financial (i.e. to pay for the salaries of those in attendance, plus any costs of using the space, or getting food, etc.), but more importantly there is a cost in terms of the work that could have been done if the meeting did not take place.   If there are 40 health care workers in a 3-hour meeting (which is really 4 hours, if we consider the time to get to the meeting place and back), this represents 160 patient-hours of health care which was not provided.   For some types of brief psychotherapy, which consist of 8 sessions over a 2-month period, the meeting has a cost of 20 suffering people not receiving help.    An added cost could be a decrement in morale caused by wasted, unrewarding, unproductive time.  


Cognitive Biases & Heuristics in Meetings
One of the biggest problems with meetings, in my opinion, has to do with the manner in which they occur.  Daniel Kahneman, the Nobel-laureate psychologist and behavioural economist, has written about the strong cognitive biases that occur in group interactions such as meetings.

If a meeting begins with a number of presentations which the rest of the group watches, then these presentations are likely to have more influence than is rationally expected.  This is particularly true if the presenters are seen as "experts."  This is in keeping with other social psychology work, such as that of Cialdini, looking at factors heightening pursuasion.  These six factors have strong, often unrecognized power to manipulate decision-making.  The factors are natural phenomena, and not necessarily "bad"--in fact, as Kahneman points out, these phenomena (heuristics) can help us make important decisions more quickly, because they are "cognitive short-cuts."  For example, if we have a trusted expert educating us about the use of a new technique, it may spare us from having to take a much longer time researching and learning about the technique on our own.  But unfortunately, these persuasive factors are also used manipulatively by marketers, and may also enchant us so much that we do not do the necessary critical thinking about ideas that are presented persuasively to us.  Furthermore, even if those involved with the heuristics do not have any negative or manipulative motive, the biases exist nevertheless.  They cause a potential harmful impairment in rational decision-making, even without anyone being aware of it! 

Cialdini's Elements of Persuasion
Here are five of Cialdini's six elements of persuasion, as manifest in a typical professional meeting:

1) Reciprocity (we are more likely to be persuaded if someone has just given us something of value, since we are likely to feel grateful and indebted):  meetings may begin with tasty snacks & coffee.  We may get our own personalized name tag, which makes us feel valued and important.  We may be entertained by a friendly, humorous, engaging presenter.  It makes us primed to cooperate!  Because we have invested time and effort to come to the meeting, we are probably more apt to be "receptive" to the ideas presented, so as to compensate ourselves for the effort.   This mechanism has been well-researched before in other studies of how people form allegiances to groups via strenuous tasks necessary to join, such as in fraternities or the military.

2) Consistency & Commitment (if we have already agreed to a certain component of an idea, we are more likely to be persuaded to go farther with it in the future, otherwise we could feel as though we are contradicting ourselves or being inconsistent).   This can happen when there are repeated meetings, perhaps spaced out weeks or months apart.  If people have agreed to certain aspects of a plan, they are much more likely to continue agreeing with the same plan, and to go farther with it, even though the plan may at this future point be inappropriate or worthy of questioning.  In sales, if you can convince someone to sign a petition, and to wear a sticker touting some kind of apparently wholesome idea, you are much more likely to be able to convince that person to contribute their time and money to the cause later on, even if that person would otherwise have had a lot of doubts about the plan.  In intimate relationships, if you have said "yes" to someone a number of times previously, it can be harder to say "no" to a similar future request; this often leads to people staying in an undesired relationship, or tolerating negative relationship behaviours, which they regret afterwards. In political movements, initial commitment to a group's policies can have an "inertia" which makes members go along with the group's subsequent negative actions (extreme examples of this phenomenon can be found in various political movements of the past century). 

3) Social Pressure (if other peers are conforming to an idea, we are more likely to as well).   Fellow members of the meeting may be smiling and nodding at the presenter's ideas.

In one meeting, in which electronic gadgets were discussed as a therapeutic modality (not only therapy apps, but also things such as covert monitoring of online activity to monitor health), one could notice that many people in the room had their heads buried in their laptop screens (an irony, speaking to the interpersonal detachment caused by electronic devices!)    Murmurings could be heard from nodding heads, of "yes, yes, therapy apps, yes, what a good idea!"   An objection to the idea of using electronic gadgetry this way would be perceived by the group as a jarring and unwelcome dissonance or even a disrespectful action. 

Also, another tactic in policy presentations can be to show that other large groups across the world are adopting the idea in question.  We may be shown that professional peers, perhaps in Australia, Germany, or Japan, have adopted some new policy, and are thriving with it.   It makes us feel like joining in, or even catching up to our Australian friends!  In an environment with a lot of social pressure, one would feel deterred from objecting to an idea, because of a concern that it might offend our friends, or that it might cause us to look reactionary or old-fashioned!  Clearly, it is important to learn about what our peers are doing, but the problem is when the social pressure becomes a biased cognitive short-cut, leading us to not question or think critically about the matter in question. 

4) Liking.  If the presenter is friendly, likable, humorous, and kind, we are more likely to be persuaded by his or her ideas.  Many salespeople and presenters are indeed friendly, likable people, which gives them a big persuasive advantage!  The trouble is, supposing we had some very shy or less social people in the group, who might have a more abrupt or chilly manner.  Yet, suppose these people had very, very good ideas to contribute to the discussion.  These voices would carry much less persuasive power because of the influence of this factor.    Sometimes quite harmful ideas have been "sold" to groups, because of the likable, engaging demeanour of the person presenting them.  Once again, one does not have to look far in political history to find unsettling or even frightening examples.  

5) Authority.  At the beginning of most presentations, we are usually shown a lengthy list of qualifications that the presenter has.  This might include degrees from major universities, academic awards, publications, etc.  Such a list conveys that the person we are listening to is an "expert," and that we should perhaps trust more strongly what is said.  Often, this is a useful cognitive short-cut.  But in many other situations, the qualifications may have nothing at all to do with the message being conveyed in the meeting.  I can think of some highly-paid professional experts who have much to say about clinical care of patients--but their area of expertise relates to extensive publication of research articles, and extensive attendance of international meetings.  The "expert" may actually have much less experience with clinical care than a humble colleague-- who lacks the impressive credentials-- in the next office, who spends his or her day seeing patients, while not publishing or attending meetings at all.   Qualifications should be respected, but we need to watch out for the impressiveness and "authority" of a presenter causing irrational biases and influence in our decision-making.   Another manifestation of the authority bias has to do with the sincere well-meaning nature of many presenters.  They may be very excited about their new idea.  They may be asked to give speeches and presentations about it across the country, and may even be getting famous as a result.  Their work may be grounded in a passion and commitment for their work, and also the enjoyment of getting acknowledgment and respect professionally.   The trouble is, this very excitement, ambition,  and the existence of professional credit and fame, could lead to a bias in which the presenter becomes overly attached to their ideas, and too eager to push the ideas without critique.  The audience may also really respect the presenter, and the integrity of the presenter's motives, but as a result may be too willing to agree respectfully with the ideas, instead of questioning them rationally. 

Behavioural Economic Biases

Other biases in meetings:  some of these biases are described in behavioural economics.

6) Joint vs Single comparison bias:  in many policy discussions, there may be a presenter excitedly showing results based on a new system or technique.  The results may be very positive.  But very often, there is no fair control group.  When we look at just one thing without comparing, it causes our assessment to be distorted.  Kahneman's classic example is of how people would value  sets of dishes:  in one set, there could be 10 plates in perfect condition, plus an eleventh plate which is defective.  In another set there would be just 10 plates in perfect condition, without the eleventh plate.  If people assess these two sets at the same time, they would value them identically, since they both contain 10 good plates.  But if people assess the sets individually, without comparison, they would give the first set a much higher value than the second.  The existence of the defective plate would make it seem like the whole set has something wrong with it.   In presentations, we often see only "one set of plates."

7) misuse of statistics.  There are many ways to misuse and misrepresent statistics (either deliberately or inadvertently) which ends up unfairly favouring a policy agenda.  A couple of simple, common examples occur to me, pertinent to mental health care:

a) no control group for self-limiting phenomena.    This type of data gathering often occurs in emergency services.  A person in crisis may present to an emergency room.  A symptom questionnaire is administered, showing very high symptom scores.  In the emergency room, the person may be lying on an uncomfortable stretcher in a noisy hallway for hours, be interviewed five or six times by nurses, ER physicians, residents, and then a psychiatrist.   Perhaps a different psychiatrist the next day.  The whole ordeal could be frightening, very uncomfortable, or even frankly traumatizing.    Yet, after three days, the same symptom questionnaire could be administered again, showing a dramatic reduction in symptom scores.  The person would be discharged home, and the data would appear to show that the emergency service was functioning very well.

 In this case,  the person improved mainly because of the passage of time.   Possibly the emergency room offered some measure of safety, and perhaps even some empathic support.  But mainly, it would have been the passage of time for an acute crisis to settle down.   Many of the features of the emergency room stay could have been frankly harmful, yet the data would not show this.   In order to show whether the emergency service was indeed helpful, one would need to have a comparison group, offering a different type of experience (for example, a comfortable, cozy, supportive, community-based environment which had rooms for people to stay overnight).    Probably, the alternative service would show better results, and also a much lower risk of severe adverse effects (such as a patient feeling traumatized).

b) short-sightedness.   Many treatment trials are short term, leading to rapid improvement in symptoms.  If we use potent sedatives to treat insomnia, for example, we are likely to see almost instantaneous improvement in symptom scores.  But if we follow this medicated group for a year, we would most likely see that the medication group was doing no better, or often worse, than a control group.   We see this type of bias all over our culture.  Evidence about the dangers of greenhouse gasses or other pollutants in the atmosphere require data spanning decades.  Short-term data may lull us into believing that there is no risk, or that a harmful policy is benign or beneficial.      In psychotherapy, there is indeed evidence that psychotherapy (of all types)  can have long-term beneficial effects for many people.  But a short-term view would unfairly discourage the use of longer-term psychotherapy.  It is technically easier to gather short-term data, and such data have less technical error (due, for example, to fewer patients lost to follow-up, etc.).   But just because some types of data are easier to gather, and appear to show a positive result, we should not be biased into thinking that long-term approaches are invalid. 

 Zimbardo's Work on the Social Causation of Negative Behaviour
 There are dramatic analogies to be made, looking at historical events.   Philip Zimbardo has written extensively about the manner in which disasterous, or even "evil" events can occur, due to the dynamics of a group context.    In groups, if there is a pre-existing majority position, the meeting can become a time in which the majority position becomes "celebrated" and pushed further, due to contagious group enthusiasm, particularly if the group features a type of hierarchy or a power differential.    A dissenter in such a meeting could be viewed as "negative" or "difficult," and there would be social pressures which discourage contrary points of view.  If one of themes in the meeting is "collaboration," then any comment which seems negative or "non-collaborating" may be seen to be violating the group ethos, even though the comment may be of high ethical import.     This phenomenon occurs in all human groups, including those in which the members are highly intelligent, sophisticated, and "civilized."   The decision making in groups leading to some of the world's great wars of the past centuries have often involved contagious enthusiasm from a strong majority view, in which dissenters were initially suppressed due to social pressure alone, then later due to threat of punishment.


The Brainstorming Myth

Another common event in policy planning meetings is "brainstorming."  This may be a process in which the attendees are split into groups of 5-7 people, and asked to freely, imaginatively, constructively express positive ideas for change, perhaps building on the ideas of others, with notes being taken, and with no criticisms allowed.  But more recent evidence has shown that brainstorming techniques could be inefficient in a variety of ways.  The same social dynamics outlined above could subvert the process, discourage dissent, and discourage a challenge to authority.   It could be much more fruitful, in a group dynamic, not to have "brainstorming," but rather to make strenuous efforts to permit a truly free debate, in which members have fully adequate time to prepare in advance.  In some meetings, there may be opportunity for debate, but the members have had no time to prepare.  This would be like having a court hearing for an important case, in which there would be ample opportunity for debate, but in which one side would be allowed weeks of preparation, while the other side would have to improvise on the spur of the moment with no preparation at all! 



Making Meetings Better


What can be done to improve meetings and to reduce unwelcome cognitive biases?

1) participants in meetings can be asked to contribute ideas before the meeting begins, perhaps anonymously.

2) free questioning, with uncensored feedback, must not only be encouraged, but the right to offer such feedback must be fiercely protected.   This is the foundation of a free society, and of a modern educational process as well. 

2) I do not believe that a decision-making meeting should feature educational presentations at all.  It is simply not possible for a group to critically appraise educational material in an unbiased fashion in the space of only a few hours.   If important group decisions are to be made in a meeting, the presence of a presenter causes very strong influence on this.  We assume that the presenter has good intentions, may be very wise, etc. -- but if there is no opportunity for detailed critical appraisal or debate, then the presenter is given automatic power to influence the group, through various mechanisms of psychological bias.

 Imagine attending a family meeting to decide on a vacation spot, or on a new school for the children, in which there is a presenter advocating some strong point of view on the matter who introduces and leads the meeting, complete with video display and free pastries! There is already a conflict of interest if a group facilitator already has a specific change agenda in mind.  The facilitator is then not really a facilitator anymore, but is a lobbyist.  It is especially harmful if the people attending the meeting assume that the facilitator is neutral, without knowing that there is a strong lobbying effect going on. 

The presenter in our hypothetical family meeting might argue a very convincing case for boarding schools, or home schooling, or on the wonderful possibilities of vacations in Mexico!   But would we want family decisions to be influenced by such a presentation?  My point here is not that presentations are bad -- in fact, they could be very useful and informative -- but the problem is when single presenters have the power to influence a group's decision-making agenda, without fair opportunity for critical analysis, and for other points of view to be fairly and thoroughly explored.   It is not enough to allow an hour during the meeting itself for critical debate!  Many of the arguments presented by a sophisticated lobbyist could require weeks to study.

One of the strengths of the modern legal system is of allowing a fair opportunity for free debate before a decision is made about a legal or ethical matter.  We would never have a situation in a legal proceeding in which the person running the meeting (e.g. the judge!) would give a sales presentation encouraging a particular decision, with no opportunity for the different groups to study the proposal in detail (usually, with weeks to prepare), before decisions are made. 

3) In many cases, meetings do not need to occur at all, as the cost of them (as outlined above) may greatly exceed the benefits.

4) Great care should be taken to minimize bias of all types, and to encourage any marginalized or "hidden" voices to be heard.  In mental health care debates, there are many with strong opinions on the matter.   In many public health analyses, there could be broad population surveys to decide upon future policy.  This is reasonable.  But in many cases, those who have actually accessed and benefited from long-term therapy are not heard from at all in the surveys.   This is analogous to making major decisions about cardiovascular health care by interviewing thousands of random members of the public, while not interviewing those who have actually had heart surgery.   People could conclude from such a survey that a rapid-access, short-term exercise program is what people really want for cardiac health, and that a heart surgery program is far too expensive and inefficient.  But this conclusion would be the result of numerous layers of bias, as well as from an inadequate understanding of the experiences of everyone involved intimately in the issue.  

5) "Pre-mortem"  Another of Kahneman's good ideas about decision making, particularly in group settings, is to have a "pre-mortem."  This means imagining that a particular decision has been made, but imagining further that the decision has led to very negative or even disastrous results in the future.  The exercise is to describe ways in which this negative result could have come to be.  The advantage of a pre-mortem could be to use the group's energy not simply to drift enthusiastically into contagious cognitive biases favouring a particular decision, but to work at exploring hidden risks which the group's enthusiasm would previously have been blind to. 

6) "Non-meeting" meetings:  I think it is a great idea to set aside and pay for times in which employees and colleagues can engage in structured healthy activities, such as an exercise class, a walk in the forest, a fine arts class, or a concert.  While this could seem wasteful and expensive, I think that the benefits for morale, group cohesiveness, enjoyment of work, reduced absenteeism, and work efficiency, could be substantial.  Also this would be an example of self-care on a group level, which I think is an important model for our patients to follow.  If we are doing healthy and enjoyable self-care activities as professionals, it is more likely that our patients will be willing to do the same.

5) Heroism.  Zimbardo concludes his thesis about negative group dynamics by calling for each of us to be a "hero."  The type of heroism he means is to be boldly willing to challenge authority, to speak up freely, even when there is a risk to doing so.  One of the best and strongest aspects of American culture is a respect for free speech (and certainly a respect for heroism).    But this wonderful cultural foundation needs to be constantly nurtured, exercised, and practiced, in order to prevent it from being eroded by other cultural forces.    Be heroic :  speak up!

Cialdini, R. B. (1984). The psychology of persuasion. New York: Quill William Morrow.

Covey Stephen, R. (1989). The 7 Habits of Highly Effective People. Simon & Shuster, USA.

Furnham, A. (2000). The brainstorming myth. Business strategy review, 11(4), 21-28.

Kahneman, D. (2011). Thinking, fast and slow. Macmillan.

Zimbardo, P. (2007). The Lucifer effect: Understanding how good people turn evil. New York.

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 3

So, in conclusion, Pinker's book is very important and can be broadly applied not only to understanding and working towards continued reductions in violence, but these ideas can be useful in developing healthier psychological strategies in daily life.

These principles include:

1) continued education, to bolster reason, cross-cultural understanding, communication skills, empathy, historical knowledge, and even economics and statistics (these latter subjects can help combat cognitive biases which impede clear understanding of information pertaining to daily living)

2) foster trade instead of fostering war.  In some recent news examples, this may not be reasonable (e.g. with some extremely violent groups), but at the very least, fostering trade with adjacent communities would be useful to form alliances. 

3) exercise and strive for freedom of speech

4) expand our circles of empathy, to include those in other groups, cultures, and situations.  Ultimately, a global issue is to include the environment itself in our circle of empathy.  In depressive states, one may be directing aggressive thoughts or actions towards oneself.  So the circle of empathy should deliberately also focus on including oneself.

5) be aware of cognitive biases, such as overconfidence in the setting of conflict, underestimation of the risks of conflict, the tendency to deliver vengeful retaliations that would be considered excessive by a neutral observer, and to overestimate the malevolence of an opponent's motives.    This could be applied to an analysis about one's own depressive thoughts about oneself.

6) avail oneself of mediators or peacekeepers (this can be a role of a therapist).

7) move away from authoritarian or tribalist practices or beliefs, and instead focus on inclusiveness, individual rights, and fairness.  For those involved in religion, work toward a more inclusive, peacemaking, ecumenical, humble theology, with room to include modern scientific findings pertinent to morality, fairness, cultural understanding, and justice. 

8) strive for dignity rather than honour

9) work on ways to improve self-control.  This does not mean a renunciation of Dionysian enjoyments, but rather it means never allowing one's impulses or habits or enjoyments to cause harm or to rule one's life.

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 2

The first section of Pinker's book is an exhaustive review of violence rates throughout history.  This even includes looking beyond our own species, to other great apes, to understand aggression in our evolutionary lineage.  He also reviews cultural attitudes towards violence throughout the ages, as manifest in literature and the arts, and also in accounts of daily social and entertainment practices.  It is very disconcerting to learn about the extent to which horrifying acts of cruelty were commonly accepted, or even considered amusements (the events in the Roman Colosseum comprise just one of many, many examples)

Clearly, rates of violence were much, much higher in all previous periods of history.  Today the risk of suffering a violent non-suicidal death (from war or other crimes) is in the order of 1% or less (this is the total risk over an entire lifespan).    In most prosperous areas of the world it is much less than 1%.  Of the 245 000 deaths in Canada in 2012, 543 were due to homicide (0.2 % of the total).link   link2

But in all previous eras of human and pre-human history, these risks were orders of magnitude higher,  according to a variety of streams of evidence which Pinker amasses.  Instead of 0.2%, the rates were 10% or more.    If anything, much of this data may actually underestimate these past rates, since violence was so much a norm in previous periods of history that many violent deaths or even massacres were barely mentioned in historical texts.  Risks of non-homicidal violence were much higher still, such that most everyone in the population would have been traumatized in some way, or would have had a close friend or family member who was severely traumatized. 

Pinker outlines various of the forces which have driven violent behaviour over the ages; here are some of them:

1) predation
2) dominance
3) revenge
4) communalism/tribalism/nationalism
5) sadism
6) isolation
7) authoritarianism
8) ideology
9) lack of intelligence

1)
Predation is described as a simple goal-oriented motive, such as robbery or looting.  Yet this strategy is "zero sum" or "negative sum" in that there is no net gain during a robbery, only a transfer of property, and most likely a destruction of the means to efficiently produce more property (e.g. jewelry may be stolen in an attack, but the infrastructure or morale needed to produce more or better jewelry gets damaged in the process).

With societal evolution, free trade becomes a non-violent alternative to predation, which allows the process to be "positive sum."   In this case, goods could be traded for jewelry, leading to a prospering group of jewelers who can then produce more or better jewelry in the future.  Both parties gain.   In order for free trade to occur, and the ensuing reduction in predatory violence, there must be improved communication, a fairly governed commercial system, and penalties for predation which are agreed upon by both parties.

In a psychotherapeutic milieu, this principle could lead to the idea of improving communication and stable transactional rules between potentially conflicted individuals.  In general, the idea of trading with your enemy instead of fighting your enemy may not naturally occur to people.

Pinker does not adequately discuss some of the problems with trading relationships, and of free-market economics in general.  Such relationships can be imbalanced, exploitative on some level (either directly towards the individuals or nations involved, or towards the environment), or favouring a relatively small elite while having little benefit for the majority.  I think there needs to be more emphasis on "fair" trade, including a strong focus on environmental issues.  This is consistent with Pinker's observations about the need to expand a "circle of empathy."  This circle should expand to include not just trading partners, but the larger communities affected by trade, and the benefits or consequences to the natural environment.  Trade may often benefit the environment, through a simple economic efficiency argument:  the lowest-cost economic solution to a problem is favoured by free trade, which in turn can maximize the available eonomic resources to protect the environment.  But in order for this efficiency to be protective, there needs to be structured safeguards in place to prevent social or environmental exploitation. Another big issue I have found with conventional economic theory is that costs are underestimated (such as long-term environmental damage), and the cross-sectional cost appears to be very low; often those involved are not held responsible for the ultimate long-term costs.  In any case, this inaccuracy in measuring costs distorts the system, and causes it to be short-sighted.  

2)
Dominance contests can be seen in many species, often as part of a competition for mates.  Most often, of course, these are behaviours seen in males.  In humans, this can give rises to meaningless displays of strength or machismo, with an associated culture of "honour" in which small perceived slights can result in excessive aggressive reactions. Associated psychological phenomena include overconfidence, underestimation of the losses associated with the conflict, and of course lack of empathy for the opponent. In celebrating a culture of "glory and honour" there can be an utter disregard for the individuals and families affected by the ensuing violent losses.

If this type of behaviour is selected for in the population, it gives rise to large, aggressive, arrogant, reckless males who are easily provoked.  In other species it can give rise to males having harems with multiple mates, while driving away or killing other male challengers  (we see literal examples of this in human groups throughout history). 

In humans, this type of dynamic can occur in "honour-based" cultures; previous periods of history often featured distinguished gentlemen absurdly fighting to the death in duels, often over trivial conflicts.  But entire nations can behave in this fashion as well.

Improvement in this type of problem comes with greater education, strong emphasis on women's rights and gender equality, and selection pressure:  reckless, aggressive males with poor impulse control are much less likely to be found attractive as mates in the modern era!   Instead, most elements of modern culture favour self-control and a culture of "dignity."  It is no longer cool or attractive to be a bully or a hothead. 

3)
Revenge is an understandable reflexive process, and it is pointed out that some degree of revenge can be a deterrent to subsequent violence (to show no revenge can invite subsequent exploitation).  The problem with revenge, as Pinker shows, is twofold:  first, wronged individuals or states tend to want to deliver more punitive harm than a neutral mediator would prescribe.  The individuals doing the wrong likewise tend to underestimate their culpability or guilt (e.g. a great many convicted felons may have a smaller estimation of the magnitude of their guilt or responsibility for harm than a neutral observer or their victims would conclude).  This leads to a cycle of revenge, in which each group retaliates vindictively against each other, with force that is often out of proportion to the offense, and each wrongdoer underestimates their culpability.   The retaliation is itself therefore felt as an assault by the recipient, rather than as a fair punishment.  The violence therefore continues in an escalating fashion, with each group feeling justified in their actions, egregiously wronged by the other, and with each group inducing future acts of vengeance from their enemies.

The solutions to this predicament include having neutral arbiters--a fair system of policing and justice, empowered by a neutral and fair government which has a motive of minimizing overall harm in its citizens.

On a psychological level, a solution is to recognize the cognitive biases which lead to excessive retaliations and excessive justifications for one's own excesses.  Another solution is to recognize the need for neutral mediation to help resolve ongoing conflicts.

4)
Communalism, tribalism, or nationalism are understandable, common human experiences.  Early human culture required a cohesive sense of protecting one's fellow villagers from attacks from neighbours.  Yet, tribalism fosters patterns of revenge, predation, and dominance-based aggression on a group level.  Having separate tribal cultures, often with language and geographic barriers, is a barrier to empathy for outsiders, particularly if a cycle of warfare has already begun.  We see this type of aggression on a large and small scale, all around us.  In some cases it is playful, as in sports teams from different communities.  Gang behaviour in large cities has a tribal quality, with battles over control, protection, predation of resources, and "honour."   But entire nations behave this way.  We subjectively have an urge to enjoy national identity, but we have to be wary of the violent associations of this mindset.

An approach to this issue is to expand our "circle of empathy," and to view those from other groups as partners rather than enemies.   I suspect the healthiest vestige of nationalism that we can safely keep is to have sports teams.  I think this is also a reason to support free, fair international trade.  Protectionist policies must be based on a notion that there is an "us" and a "them".  But it is fair to view everyone in the world as part of "us" at this point.

Nationalist conflict is one of the most devastating factors causing worldwide violent death and suffering through the ages.

It is for this reason that I support the idea of having international sports events -- I believe that this is a symbolic peaceful sublimation of nationalistic conflict, transforming this type of tension into a playful harmless talent show.   The economic indulgence of such events, such as the Olympics, is an understandable complaint, but I think the pursuit of such playful, peaceful activities is very important.

5)
Sadism  may seem like a rarity, relevant only to extreme cases.  But smaller forms of this issue can occur in communities or in one's inner life.  The driving force in sadism is addictive:  repeated behaviours, even if extremely harmful, can lose their aversive or "taboo" character through repetition, and even lead to addictive pleasure, associated with excitement, relief of tension, etc.  This phenomenon can occur in personalities which had previously been quite "normal."    Pinker does point out the likelihood that psychopathic personality--a pathological lack of sympathy for others-- is a risk factor for sadistic behaviour, and that those with this type of personality are more likely to be attracted to occupations in which they could indulge their violent predilections.  In the book, he does not address the environmental or social causes of psychopathy, though alludes to this problem being at least to some degree a neurobiological variant with heritable aspects, and not entirely due to environmental adversity.  In any case, not all psychopaths end up becoming violent sadists, and not all sadists are psychopaths. 

 In depressive states, various forms of physical and figurative self-injury can become sources of relief, and lead to an escalating pattern of violence against self.   This is not "sadism" but it could be considered as arising similarly, as an addictive habit to which the person becomes tolerant and desensitized, leading to a craving for more and more highly destructive behaviour. 

A solution to this issue is to focus on prevention, and to recognize and avoid risk factors.  In a police or military setting, for example, it needs to be recognized that maltreatment of hostile prisoners can occur and escalate through this process.  Abuses of this kind are not some kind of bizarre perversion, but stem from failure to include judicial safeguards adequately to prevent the police or prison guards from getting involved in an addictive habit of maltreating others.  This can be challenging, because many of the prisoners may have behaved in a terrible way themselves (e.g. violent criminals) and so the initial aggressive responses to them may be approved by everyone involved.

In a personal setting, prevention is also important.  Self-injury often begins secretively, without the addictive risks being appreciated, and by the time the problem surfaces to others, it has become an entrenched habit.  At this stage, approaching it as a potentially lifelong addictive risk becomes necessary, with a variety of psychotherapeutic strategies employed.  For those who engage in sadistic behaviour towards others, I think society should be equipped to approach them as permanent risks to others' safety.   This does not necessarily mean longer prison terms, etc. (though this may be necessary in some instances) but I think it does at least mean longer-term societal scrutiny for protection of others.  

6)
Isolation is a risk factor for violence due to a tendency to form a stronger ingroup, view outsiders as a threat, lack the communication or language to resolve disputes peacefully with outsiders, and to lack the advanced education that could bolster diplomacy, empathy, or self-control.

During early human history, groups existed in relative isolation from each other.  Today, groups which are more geographically isolated (e.g. in remote mountainous areas) tend to have much higher rates of violence, as well as less education.  With the advent of modern communication and transportation technology, isolation on this level does not ever have to be as absolute as it has been in the past.  Yet, some groups may deliberately foster isolation, even when they live in large cities.  I think it is important to foster widespread community interactions between isolated groups.  

On a personal level, isolation is likely to magnify suspicion towards strangers, leading to exaggerated negative reactions to others' behaviour.

Psychologically, problems with isolation may be due to social anxiety, depression, or psychotic paraoia, but the isolation itself becomes part of the vicious cycle of symptom exacerbation.

Every person or community may have a certain "set point" for healthy engagement with others, e.g. some people are more comfortably gregarious than others, but I think some type of social practice and engagement is necessary for the health of individuals and communities. 

On a practical level, learning to speak other languages and customs lessens the isolative boundaries between people.  As a strategy of personal development, it could therefore be healthy to learn other languages, to travel to different countries, and to experience and learn respectfully about other cultures.  Treatment of underlying symptoms, such as paranoia or social phobia, can of course be important. 

7)
Authoritarianism evolves naturally from the most ancient origins:  stronger members of a group will dominate and assume leadership powers.  This factor fits closely with the ideological dynamics of aggression.  Those who challenge the authoritarian leadership can be subject to severe aggression.  One of the perpetuating factors for this dynamic includes the cognitive illusion that everyone supports the authoritarian leader or the authoritarian principles.  Even those who quietly dissent may be so fearful of reprisal that they will act to support the leader, and even punish other dissenters to prove it.  An analogous cognitive distortion is the belief among college students that the majority of their peers enjoy binge drinking--this belief normalizes such behaviour, and causes more people to engage in it because they erroneously thought it was an accepted norm.

A protection against this dynamic is fostering a politically open democracy with freedom of speech.  On a personal level, I think it is healthy and protective to question authority as an intellectual norm.  This includes not only teachers and professors, but also religious teachings.  Authoritarianism that is couched in religious dogma can seem so "sacred" that challenging it would seem disrespectful or like a taboo, thus leading to terrible unchecked excesses and distortions justifying violence or other harms and suppressing intellectual growth.

I had assumed that there would be a universal affirmation of the desirability of multi-party democracy throughout the world.  Yet, I have recently been looking at the PewResearch Global Attitudes Project surveys, including a poll done in 2009 (well before the recent conflicts in Russia and Ukraine).  (link)

This survey shows that people in Russia and several former Eastern-Bloc countries such as Hungary, have had a huge reduction in their enchantment with the idea of democratic government, beginning long before the recent conflicts.   Ukrainians gave some of the lowest ratings of all, regarding attitudes towards democracy, freedom of speech, etc.    I suspect that a major reason for this has been that the democratic changes in these countries have been laden with a lot of corruption, instability, and economic problems.

This is reminiscent of what Pinker described in post-colonial African states, which experienced a large surge in violence rates after declaring independence.  This does not at all mean that colonialism was "good," but rather that the benefits of democracy and societal freedom can only come after a state has become stable in terms of economy and political organization.   The period after major political upheavals can be relatively anarchic, and economically harsh, leading to a steep decline in morale for the population. 


8) 
Ideology can lead to extreme violence, through offering a cohesive set of beliefs which bind an ingroup harmoniously, often with a utopian goal, leading to a rationalization to destroy outgroups. Utopian goals can sound attractive, but often the enactment of these goals involve suspension of the other elements of societal growth and non-violence, such as fairness, justice, empathy for outgroup memebers, etc.  Those who commit catastrophic acts of violence within an ideological framework may understand their actions to be normal or just, and may easily dismiss complaints that their actions are wrong.     Our recent history is full of examples of this type, including Nazi Germany.

Unfortunately, there are many examples in history of religious ideologies leading to extreme violence in this way, continuing with examples in today's news.

A prevention for this type of problem includes education, including in the arts and humanities, a commitment to ecumenical approaches in theology (regardless of one's religious orientation), and a commitment to have diplomatic relationships with those having different ideological viewpoints.

I think these preventions apply on a large scale in societies, but also on a personal, individual level.

9)
Intelligence, the greatest talent of humankind, has the power to defuse conflict through negotiation, wise strategizing, and improved empathic understanding of one's opponents.    Cognitive biases are not eliminated by intelligence alone (as Kahneman has shown), but the capacity to employ reason rather than rage to solve problems is enhanced by intellectual training.  Such intelligence has grown over the generations, as Pinker has shown.  This is likely due to better education, and exposure to a more stimulating global cultural milieu.  Unfortunately, many in the world lack access to the basic resources or freedoms to develop their intellect in this way.  Part of global peacemaking must therefore include a strong emphasis on universal access to education.

Intelligence, of course, also permits a higher chance for employment, prosperity, and diverse leisure activities, all of which reduce risks for violence and other harms.

On a more immediate, personal level, intellectual development could be framed as a component of psychotherapy.  This could work not only as a way to focus the brain on activities apart from depressive rumination, but also could strengthen faculties of the mind which could act as skilled "negotiators" to calm the self-injurious impulses which can occur in depression or anxiety.  Some of the CBT literature shows that this type of therapy works better in those who are more highly educated.  Conversely, I suspect that better education and intellectual training can make psychotherapy work better.

The Better Angels of Our Nature: Why Violence Has Declined, by Steven Pinker: A Book Review, Part 1

I have just finished Steven Pinker's book, The Better Angels of Our Nature: Why Violence Has Declined. 

I think it is a masterpiece of scholarship and research, combining the fields of psychology, history, political science, anthropology, economics, and statistics to contribute a hopeful affirmation about the progress the world has made to reduce violence and to improve quality of life.

My favourite scholarship is the type which combines multiple fields in this way!  

In these posts I would like to briefly summarize the book, and to reflect about ways to apply some of Pinker's insights to the practice of psychotherapy.

I see there has been mostly strong praise for this book among critics, but predictably there has been some controversy.    Cultural groups which still have strong authoritarian, communal, tribal, sexist, or fundamentalist values may find some of Pinker's conclusions to be critical of their way of life.  Mind you, he does show that in almost all such subcultures, such as conservative groups in the U.S., there have been positive changes, for example towards affirming rights for previously disenfranchised groups.  It is just that these changes usually lag a decade or two behind such changes in the rest of the population.  An attitude about women's rights or gay rights that would have been called "liberal" in 1970 would be considered a norm in many conservative groups today. 

Pinker shows that most elements of religious belief and practice have had negative impacts on rates of violence and war, due in part to causing an ingroup mindset, which tends to undervalue the human worth of non-believers, therefore facilitating maltreatment of those with a different faith.    Also most religions have a type of authoritarian structure, including about the concept of divinity itself.  The notion of an afterlife can not only model infinite punishment ("hell") as a supposedly fair possibility for an individual based on offenses such as "disbelief" but could encourage such an attitude of infinite punishments in approaching other individuals or cultures.  Conversely, with infinite reward ("heaven") in the picture, perhaps with simple criteria such as "belief" to be the ticket of entry, this could be experienced as a license to engage in many destructive acts during life while minimizing the relative value of earthly justice.

Other critics question his statistics, but here I think he has been very impressively thorough.  His statistics do not at all imply that violence has miraculously disappeared in modernity, and very clearly do not imply that the most horrific possibilities of violence -- such as the scale of events which happened in World War II -- cannot happen again.  In fact, his discussion of statistical power-law distributions modeling violent conflict gives rise to great concern:  based on this distribution, one can expect an arbitrarily large and devastating conflict to occur in the future, since this type of distribution is "tail heavy" statistically.  His analysis does give reason to be hopeful, though--the underlying causations and probabilities which become the parameters of these statistical patterns are themselves declining.

An example of a power-law distribution is the length of words that would be generated on a typewriter if one were to type on the keys and the spacebar randomly.  Typing the spacebar would separate individual words.   The length of the word would represent the magnitude of  (or loss of life from) a violent conflict. With this analogy, a conflict happens every time the spacebar is pressed. One could see that short, small conflicts would be most common, but that longer, larger conflicts could happen periodically, though less frequently, in a random pattern.  It is disconcerting that this type of distribution can have an infinite expected value, representing total destruction of the population.  As we know, this is actually a possibility in the nuclear age.

But Pinker's thesis also shows that the parameters of this imaginary typewriter are changing--with time, the typewriter is gaining more and more keys (just like Microsoft keyboards!).  This causes the relative risk of pressing the spacebar to gradually decrease with time   Also, metaphorically, Pinker is showing that the information content of each key is increasing, so to speak, causing fewer keys to need to be pressed at all.    Just as with computer keyboards, we are even developing ways to interact without using keyboards at all (e.g. with mice, or voice commands).  The mechanisms he shows for these changes in risk parameters are increased education, intelligence, an expanding circle of empathy, an expanding force of reason, improved human rights (e.g. for women, racial minorities, and people having different sexual orientations), free and fair trade,  and improved stable government (what he calls the "leviathan").

The obsolescence of paper journals and conferences

I was reading an editorial article the other day, entitled "A word to the wise about ketamine" by Alan Schatzberg (American Journal of Psychiatry, March 1, 2014).  

The article is a brief opinion piece cautioning psychiatrists about the use of ketamine as an antidepressant.  It includes such statements as this:

Without more data on what ketamine can do clinically, except to produce brief euphoriant effects after acute administration, and knowing it can be a drug of abuse, it is difficult to argue that patients should receive an acute trial of ketamine for refractory depression.

Of course, this is an important opinion, a valid point of debate!  If something like ketamine is indeed simply giving people a momentary high, then leading them into a dark pathway of addiction, then we need to acknowledge this risk and sound the warning!

The problem I have with this editorial is the nature of the debate that can take place in response to it.
Each statement in the editorial can be challenged in quite an engaging debate, for example:

 -benzodiazepines, antihistamines, opiates, and even antipsychotics such as Seroquel, are drugs of abuse as well, yet they have well-established medical benefits in many instances, independent of their "brief euphoriant effects."

-severe refractory depression which has not improved with multiple conventional treatments is a devastating condition; it does not seem "difficult to argue" at all, in favour of a simple agent administered weekly, in an office setting, with a drug level of zero shortly after the patient leaves the clinic, and which can produce profound relief and improved function lasting for a week at a time in a significant number of people.

-medications with potentially dangerous long-term side-effects, including lithium and antipsychotics, are routinely prescribed for refractory depression, often one after the other, even when previous similar trials have not helped at all!  An argument could be made that it should be time to stop this repetitive medication loading, after a dozen or more previous similar trials have done nothing except cause side effects!   It is interesting to consider the adverse consequences, psychologically and medically, of repeated ineffective psychotropic medication trials. 

Now, with this response I do not claim that ketamine is some kind of miracle drug.  I think it is promising, and deserves careful consideration.  It is entirely possible (probable, even) that there are risks associated with it that are not well-enough appreciated.  But in a refractory depressed population, the risks of continued symptoms are devastating!

I also do not mean to put down the value of other conventional medical therapies.  Lithium or antipsychotics or multiple conventional antidepressants may indeed be important, valuable, life-saving treatments, and I think we must keep an open mind about trying them, especially if they have not yet been tried in particular patients.  

Back to my main point, though, which is a process-related point:

-editorial writers in a major journal carry a lot of persuasive weight, which is certainly enhanced further by the editor's long list of publications and awards.   But when it comes to making decisions, it is ineffective to simply hear one person's opinion, even if that person is the leading expert in the world!  --especially, I might add, when this opinion comes from a position of obvious bias (for example, towards theoretical conservatism, lack of personal experience with the specific subject matter,  or "expert" status which is based on expertise in other subject areas than the issue at hand).   Every opinion should be heard, of course!  But in order for a productive understanding of an issue to take place, there needs to be debate!

In a journal such as The American Journal of Psychiatry one could certainly engage in a debate, for example by writing a letter in response to an article.  But, first of all, there is a huge time lag involved!  It could be a month or more before any response would be seen.  Even if the response was published, it would be located in the letter section, rather than in the prominent editorial section.  And imagine having a debate with someone professionally, but in a framework in which you could only exchange comments once per month!  I think the quality of the debate would suffer!  And I suspect many observers of such a debate would lose interest! 

We live in an era where it is possible to engage in an instantaneous debate online.  We can do this on most news websites.   Of course, on news sites, etc. a lot of the public commentary features quite extreme opinions, trolling, etc.  But in a professional on-line publication it would be quite easy to limit comments or discussion only to members of the psychiatric community.

It seems a puzzling and unnecessary relic at this point to observe an editorial of this sort, an opinion piece which has a great deal of room for discussion, but where no discussion can take place in a timely manner.  

There are several other reasons why paper journals in the sciences are obsolete:  first, they are a waste of paper!  Second, many advanced techniques of data presentation (for example, see Hans Rosling's work with health statistics) require a computer to be visualized.  A static 2-dimensional graph or photograph on paper conveys only a tiny fraction of the information which could be easily displayed online.  Similarly, I believe the entire data set should always be provided for any published study, so that the reader can conduct an independent analysis of the data.  This further reduces the possibility of bias in presentation, and conversely increases the possibility that another person could see something in the raw data that was missed by the authors!  Third, if one reads scientific papers online, one can instantly look at hyperlinked references to get a much richer and deeper understanding of the paper (including the paper's strengths and weaknesses). 

For many of the same reasons, I think lectures at professional conferences and meetings are obsolete as well, as least in their role as educational loci!  A professional conference may be a good place for social connections, networking, and tourism, or perhaps to attend a workshop to acquire a new hands-on skill, but it is wildly inefficient as a primary source of didactic education!  This is true for many of the same reasons described above for journals:  lectures are much more likely to be condensed opinion pieces on the part of the lecturer, usually without a lot of room for rich intellectual debate.   And another problem with conferences, in terms of persuasion and bias, is that they are designed to be luxurious!  If the experience of learning a possibly controversial or an outdated dogmatic idea takes place during a time which is simultaneously considered a vacation, in fancy hotels, with gourmet meals, in an exotic location, there is a much higher risk of biased persuasion taking place.   Didactic education does not require physical travel, it requires intellectual travel!

"Anti-psychiatry"

I'm just bumping up this post, originally from July 2008, because there have been some new comments.  

There are a lot of strong opinions out there about psychiatry.

Some people are concerned that the practice of psychiatry has caused harm, perhaps by "over-medicalizing" issues that should be considered matters of personal challenge, character, individual choice & responsibility, spirituality, or normal human experience. Other concerns are that psychiatry is overly influenced by large pharmaceutical companies, whose agenda is to earn larger profits by selling more medication. Critics holding these concerns often consider the results of research studies to be biased, since they have often been sponsored by drug companies.

I think these concerns need to be heard and respected. There are specific examples about some of the concerns having some validity to them. In the history of psychiatry, as in the history of all other human endeavour, mistakes have been made. Small mistakes and large mistakes. On a systemic level, I think some of the core theories about psychiatry over the past hundred years have been laden with huge inaccuracies, despite the many nuggets of wisdom contained within them (Freud's ideas are one example). Many times, attempts at treatment have not helped, or perhaps have reduced a symptom at a very great expense to other aspects of the patient's life. There have been trends and fashions in treatment, such as the widespread use of anxiolytic drugs in past decades--while only later do we discover that these treatments can cause entrenched problems with addiction.

Conversely, there are some testimonial accounts of individuals who have had long histories of conventional psychiatric therapies, who have gone on to thrive once leaving all of these behind (perhaps pursuing alternative or naturopathic medicine, or making some other lifestyle change).
I think it is important to step back and examine the evidence closely, with a critical eye (in future posts I will refer to some of the evidence). I hold that there is a vast body of evidence about psychiatry to look at. And the evidence shows that the treatments are truly helpful. The evidence also shows that the treatments are not perfect, and that typically 30% of people do not have a good response from a given psychiatric treatment. The evidence also shows that up to 30% of patients respond to "placebo treatments". These facts lead to several criticisms about psychiatric treatment: first, there are many (perhaps in the first group of 30%) who have tried "conventional psychiatry" and have found that it hasn't worked for them. Second, there are those who have tried "non-psychiatric" treatments, and found that these HAVE worked for them (perhaps these people are in the 30% "placebo" group). Both of these groups may have a tendency to criticize psychiatry; yet there is another 40% -- a group whose ailments have resolved as a direct result of their psychiatric treatments.


This has always reminded me a bit of other areas of medicine, such as cardiology or oncology: the treatments in these specialties can be remarkably curative for some, only palliative for others, and may not work at all for others still.

I do agree that we must never "over-medicalize" any human ailment. It is rare for a problem to be truly cured by a pill. Usually, for any human concern or challenge, any therapy that helps has to be accompanied by holistic changes in lifestyle & behaviour. For the cardiac patient, this means rehabilitative exercise, healthy diet, no smoking, etc. For the mind, just as for the heart, there are many lifestyle habits that are healthy, restorative, and protective against recurrent illness.

Yet, very often people are too ill to be able to institute the "healthy lifestyle habits". The cardiac patient may require medication to control blood pressure and angina before being able to safely or comfortably exercise. Similarly, there are medical treatments in psychiatry that can hopefully provide enough symptom relief to allow the patient to energetically change their life for the better.

I have observed that the "anti-psychiatry" group can be very vocal. I could understand that the individuals among this group could have good reasons to hold such strong, forceful opinions. But I don't want this site to be a forum to spend a lot of time on this debate, I would rather focus on my own beliefs about ways to manage the mind's symptoms in the healthiest possible ways.

Intellectual Lineage & the Sources of Therapeutic Ideas

It was hard to think of a title for this post; really, this is a bit of a philosophical ramble.  It's the type of title I might sometimes poke fun at, it sounds like something you might find in an overly serious scholarly journal. To some degree this post is a sequel to my previous one. 

Psychotherapy, while not religious in a dogmatic sense (unless there is some form of religiosity infused into an individual practioner's style), contains many ideas which are dealt with or contemplated by philosophers or theologians.  Many ideas in psychotherapeutic styles are inspired by religious or literary metaphor, which can be rich sources of insight about the human condition.

If there are borrowings from any type of religious thinking, we could in turn say that the religions themselves "borrowed" ideas (such as regarding compassion, altruism, meaning, etc.) from other thinkers or cultural influences of the day.  Most religions finally have quite similar values in this regard, with stylistic variations from one culture to the next (even within the same religion).  Much theological writing and thinking in this era is, in turn, influenced by secular philosophy, including such pragmatic secular philosophies as contained in cognitive-behavioural therapeutic theory.

The history of human creativity is deeply rooted in borrowing, or referring to, creative ideas generated by others.  Mozart or Beethoven did this with music.  Einstein did this in physics.  Shakespeare did this with language.  New religions are substantially influenced by "borrowings" from other religions. Art, architecture, engineering, etc. are all imaginatively influenced by work (either whole pieces of work, or mere fragments of a whole) that others have done before.  There is a type of "family tree" with respect to ideas, in which we can trace the lineage or ancestry of most any creative or intellectual work.  The degree to which a new thinker ought to give overt credit to the ancestry of his or her ideas is open to some debate, I suppose.  Sometimes the ancestry might not even be part of the conscious awareness of the author.

The very language I am currently using has its origins in a type of linguistic family tree, in the Indo-European family of languages.  The shape of the letters of our alphabet derives substantially from Egyptian hieroglyphics (a delightful area to learn about, see http://webspace.ship.edu/cgboer/alphabet.html or  http://www.usu.edu/markdamen/1320hist&civ/pp/slides/17alphabet.pdf or http://members.peak.org/~jeremy/dictionaryclassic/chapters/alphabet.php ):  for example, various letters of our alphabet derived from symbols the ancient Egyptians used, which resembled animals or objects in the environment; the letter A comes from a picture of an ox head; the letter m from waves in water; the letter o from an eye; the letter D from a symbol representing a door, etc.

Yet I do not feel compelled to include footnotes referring to Egyptian hieroglyphics every time I use letters of the modern alphabet.

I find most styles of psychotherapy to be helpful in particular ways, and in particular situations.  One has to acknowledge the strong evidence base showing that CBT, for example, is useful, particularly for the treatment of specific anxiety symptoms.   I find these ideas to be highly recommended in approaching most any life difficulty.  However, I have found CBT on its own to be very unsuccessful in helping people with chronic, treatment-refractory symptoms.  Research studies generating empirical support for CBT are geared towards showing rapid symptom improvement in non-refractory disorders.  In fact, the very lack of success of CBT can magnify the sense of hopelessness and despair in chronic, treatment-refractory conditions.  Tangible benefits in treatment-refractory conditions may sometimes be measurable on mood questionnaires, but many tangible benefits may come from a broader evaluation of finding a reason to live despite unchanging symptoms; such questions about "reasons to live" are rarely present on questionnaires, or at least would often not be weighted highly.  Yet such an issue is often the most integral daily question faced by a person with a severe chronic illness. 

An approach to being present with unremitting symptoms, as a therapist or as a patient, without losing a sense of meaning or connection, is very important, in my experience.  Stories from those who have endured such suffering are relevant in encouraging a hopeful or life-affirming attitude.

Losing at the Olympics

This subject has come up many times in conversation, over the past month.

The comments go something like this:

(referring to someone who has lost at the Olympics, and therefore did not get a gold medal, or any medal at all, etc.):

"What an incredible waste -- a waste of time, a waste of effort, to train all those years, to get all the way to the Olympics, to base your whole life on excelling in your sport, only to lose at the end!"

It seems to me that children or adults who have grown up being involved with athletics, and who have had good coaching over the years, have gained a good understanding of this issue (at best, I think athletic involvement can help considerably with personal growth).  Their response might be something like this:

"It is a joy and an honour to participate in the sport.  To play at all is meaningful.  To train for something is an intrinsic joy.  To be part of a community event, whether at a local community arena, or at the Olympics, is exciting, fun, and meaningful.  The meaning of all those years of training does not depend on winning a medal (although a medal would be nice!) -- all that training was an act of love, my life has been better because of it, regardless of any medals."

Most of the Olympic competitors were very gracious and honorable in their wins or losses.  The occasional individuals who were not gracious were really the only ones who "lost."  

Of course, there are issues about financial compensation, future career opportunities, etc. which may depend on winning, in one form or another.  And it could be deeply disappointing if a particular goal is not reached, and may not ever be reachable again (e.g. to make the Olympic team, to win a medal, etc.).


But psychological health cannot depend on such things.  I don't believe that Olympic athletes experience significant depressions due to losing...because the joy & meaning do not depend on winning or losing, they depend on the process.

Few of us are Olympic athletes, but we all have analogous life pathways...many of us view life success as dependent on some external "win" such as getting high grades, getting into the right school or program, getting the best job, having money, car, house, relationship, being a certain body type or weight,  etc.

Provided that an individual is not in an impoverished state (financially,  nutritionally, neurophysiologically, psychosocially, etc.), I claim that success in life is dependent on process, not on winning anything.  While the pursuit of excellence is itself a healthy and enjoyable process, it ironically cannot proceed if the pursuit of excellence becomes frozen into a pursuit of "winning."  Winning will happen, on multiple levels, if a joy of process is nurtured.

Olympics & Psychiatry

The Olympic games cost billions of dollars to prepare for, and to host. Therefore, it has been a subject of controversy, particularly because so many people (both globally, and in the local communities near the Olympic sites) are suffering with homelessness, poverty, lack of opportunities for therapy, education, recreation, healthy community, etc. There is understandable criticism that those billions could have been better spent addressing these serious social problems directly.

A few things in particular bother me about the Olympics: one main corporate sponsor is a soft-drink company; another is a fast food company. These companies, in my opinion, contribute to the health problems of millions of people. It is like having cigarette companies as sponsors. The Olympic torch was preceded by a truck with neon lights and dancers boisterously advertising soft drinks...I think this was contrary to the spirit of the event--certainly in bad taste-- and I hope future Olympic organizers can be more health-conscious in considering whom to allow as corporate sponsors.

Overall, however, my opinion is that the Olympics are very healthy, for the following reasons:

1) In these games we have an opportunity for nations of the world to display a type of excellence, and to come together in serious, spirited, but friendly competition. It is a model of sublimating competitive conflict through sport or play, rather than through war. And it is an opportunity for multicultural celebration, in a setting which encourages sportsmanship, generosity, and hospitality.

2) The ethical problem of spending extravagantly while many do not have basic needs met is a very serious one. Here are a few ideas about this:
-Almost any activity could be considered extravagant spending (in terms of money, time, or attention) : much university education does not address the needs of impoverished, displaced, or other suffering individuals. Much in medicine (e.g. transplantation surgery) could be considered expensive extravagance, benefiting a small number of people while others have inadequate basic health care. A great deal of scientific exploration (e.g. the space program) is very expensive, yet doesn't help directly with poverty or world hunger. Investment of time, attention, or money in the arts (e.g. music, theatre, literature, visual arts) could be considered wasteful, since it does not directly help with poverty or homelessness. People could be directed to stop spending time reading novels, going to plays, going jogging, having pets, etc. because they should better be volunteering to assist with dire social problems.
-Regarding the above examples, I think most would agree that these "extravagant" aspects of human endeavour are healthy...it is part of human nature to strive for excellence and for new frontiers (whether this be in space travel, advanced surgery, mathematics, theatre, or sports): it is part of healthy civilization that we allow our attention, time, and money to be invested in these activities. It would induce a type of global psychosocial impoverishment to suppress these activities. The development of a culture which is advanced in terms of arts, sciences, and sports, and which shares its advances with other cultures, is healthy. While these activities may not directly help with social problems, they are part of building a healthier society, which in turn can address its social problems with greater ease and morale.

This social issue has a metaphorical parallel, I think, in individual cases of depression, anxiety, or other psychological symptoms: in a depressed or anxious state, a much greater portion of energy may be invested to meet basic needs. Energy itself may be in short supply, and it may require most of this energy just to prepare food, or to make it through the day. It makes sense to budget energy in such a way that few "extravagances" are allowed. Yet, if this budgeting practice persists for years, it may lead to a perpetuation of a grey, depressed status quo. "Extravagance" may be a necessary part of energy budgeting in depressive states--this extravagance might take the form of energy expenditures which may not seem affordable (e.g. exercising, taking up a new activity, involving oneself in a new community, socializing, taking time away from a hard-to-maintain work schedule in order to volunteer, etc.)---and indeed, such extravagances may sometimes not work out (e.g. efforts to socialize may fizzle, the new activity doesn't work out due to depressive fatigue, etc.). But allowing for extravagances is a type of balanced risk that can permit growth from a depressive status quo.

Suppose a room-mate invites a whole bunch of people to your home, for a lavish celebration. Suppose you are very opposed to this event, perhaps in the context of your room-mate not having done his share of chores regularly for the past 4 years (etc.) ...But suppose also that the guests are themselves honorable, noble people who come from many lands, who are polite, respectful, talented, and interesting. Perhaps in this context it is healthier to set aside one's differences, and to welcome the guests with a spirit of hospitality and celebration.

I think it is great to have the Olympics in Vancouver: I wish all the athletes and spectators a happy, healthy, spirited few weeks of enjoying our community, of enjoying vigorous competition and good sportsmanship. Afterwards, I hope that all of us in the community may enjoy the resources constructed for the games, and that special effort may be made to include those in greatest need.

A Gene-Environment-Phenotype Surface

I've been thinking of a way to describe the interaction between genes, environment, and phenotype qualitatively as a mathematical surface.

In this model, the x-axis would represent the range of genetic variation relevant to a given trait. If it was a single gene, the x-axis could represent all existing gene variants in the population. Or, the idea could be extended such that the x-axis could represent all possible variants of the gene (including the absence of the gene, represented as "negative infinity" on the x-axis). The middle of the x-axis (x=0) would represent the average expression of the relevant gene in the population.

The y-axis would represent the range of environmental variation relevant to a given trait. y=0 would represent the average environmental history in the population. y="negative infinity" would represent the most extreme possible environmental adversity. y="positive infinity" would represent the most extreme possible environmental enrichment.

The z-axis would represent the phenotype. For example, it could represent height, IQ, extroversion, conscientiousness, etc.

In my opinion, current expressions of "heritability" represent something like the partial derivative dz/dx at x=0 and y=0; or perhaps, since the calculation is based on a population sample, heritability would be the average of derivatives dz/dx over various sampled (x,y) points near x=0 and y=0.

Conventional heritability calculations give a severely limited portrait of the role of genes on phenotype, since it condenses the information from what is really a 3-dimensional surface into a single number (the heritability). This is like looking at a sculpture, then being told that the sculpture can be represented by a single number such as "0.6", based on the average tilt on the top centre of the artwork.

A more comprehensive idea of heritability would be to consider that it is the gradient, a component of which is dz/dx. This gradient would not be a fixed quantity, but could be considered a function of x and y.

It is particularly interesting to me to consider other properties of this surface, such as what is the derivative dz/dy at different values of y and x? This would determine the ease with which environmental change could change a phenotype regardless of genotype.

A variety of different shapes for this surface could occur:

1) z could plateau (asymptotically) as y approaches infinity. This implies that the phenotype could not be changed beyond a certain point, regardless of the degree of environmental enrichment.
2) z could appear to plateau as y increases, but this is only because we do not yet have existing environments y>p, where p is the best current enriched environment. It may be that z could increase substantially at some point y>j, where j>p. I believe this is the case for most medical and psychiatric problems. It implies that we must develop better environments. Furthermore, it may be that for some genotypes (values of x), z plateaus as y increases, but for other genotypes z changes more dynamically. This implies that some people may inherit greater or lesser sensitivity to environmental change.
3) dz/dx could be very high near the origin (x,y)=(0,0), leading to a high conventional estimate of heritability; but at different values of (x,y), dz/dx could be much smaller. Therefore, it may be that for some individual genomes or environmental histories, genetic effects may be much less relevant, despite what appears to be "high heritability" in a trait.
4) dz/dx could be very low near the origin, but much higher at other values of (x,y). Therefore, despite conventional calculations of heritability being low, there could be substantial genetic effects on phenotype for individuals with genotypes or environmental histories which are farther from the population mean.

The idea of x itself being fixed in an individual may also not be entirely accurate, since we now know of epigenetic effects. Also, evolving technology may allow us to change x therapeutically.

In order to describe such a "surface", many more data points would need to be analyzed, and some of these might be impossible to obtain in the current population.

But I think this idea might qualitatively improve our understanding of gene-environment interaction, in ways that could have practical applications (current heritability estimates are typically 0.5 for almost anything you can think of--this fact seems intuitively obvious, but is not very helpful to inspire therapy or change, can sometimes increase a person's sense of resignation about the possibility of therapeutic change, and can distort understanding about the relative impacts of genes and non-genetic environment).

Positive Psychology (continued)

This is a response to a reader's comment on my post about positive psychology:
http://garthkroeker.blogspot.com/2009/10/positive-psychotherapy-ppt-for.html

Here's a brief response to some of your points:

1) I don't think there's anything wrong with focusing on pathology or weaknesses. In fact, I consider this type of focus to be essential. Imagine an engineering project in which structural weaknesses or failures were ignored, with a great big smile or a belief that "everything will be fine." Many a disaster has resulted from this kind of approach. I think of the space shuttle disaster, for example.

The insight from positive psychology though, in my opinion, has to do with re-evaluating the balance between a focus on "positivity" vs. pathology.

In depressive states, the cognitive stance is often overwhelmingly critical, about self, world, and future. Even if these views are accurate, they tend to prevent any solution of the problem they describe. It is like an engineering project where the supervisor is so focused on mistakes and criticism that no one can move on, all the workers are tired and demoralized, and perhaps the immediate, relentless focus on errors prevents a different perspective, and a healthy collaboration, which might actually definitively solve the problem.

2) I believe that pronouncements of the "right or wrong" of an emotional or intellectual position are finally up to the individual. It is not for me, or our culture, to judge. There will be all sorts of points of view about the morality or acceptability of any emotional or social stance: some of these points of view will be very critical or judgmental to a given person, some won't. I suppose there are elements of the culture that would harshly judge or criticize someone who appears too "happy": perhaps such a person would be deemed shallow, delusional, uncritical, vain, etc. I prefer to view ideas such as those in "positive psychology" as possible instruments of change, to be tried if a person wishes to try them. CBT, medications, psychoanalysis, surgery, having "negative friends" or "ditching them", etc. are all choices, change behaviours, or ways of managing life, which I think individuals should be free to consider if available, and if legal, but also free to reject if they feel it is not right for them.

In terms of the "gimmicky" nature of positive psychology, I agree. But I think most of the ideas are very simple, and are reflected in other very basic, widely accepted research in biology & behaviour. In widely disparate fields, such as the study of child-rearing, education, coaching, or animal training, it is clear that recognition and criticism of "faults" or "pathologies" is necessary in order for problems to be resolved. Yet the mechanism by which change most optimally occurs is by instilling an atmosphere of warmth, reward, comfort, and joy, with a minority of feedback having to do with criticism. The natural instinct with problematic situations, however, is often to punish. Punishing a child for misbehaviour may at times be necessary, but most times child punishments are excessive and ineffectual, often are more about the emotional state of the punisher rather than the behavioural state of the child, and ironically may reinforce the problems the child is being punished for. Punishing a biting dog through physical injury will teach the dog to be even more aggressive. I find this type of cycle prominent in depressive states: there may be a lot of internal self-criticism (some of which may be accurate), but it leads to harsh self-punishment which ends up perpetuating the depressive state. I find the best insights of "positive psychology" have to do with stepping out of this type of punitive cycle, not by ignoring the negative, but by deliberately trying to nurture and reward the positive as well.

3) The research about so-called "depressive realism" has always seemed quite suspect to me. In a person with PTSD (a disorder which I consider highly analogous to depression and other mental illnesses), very often there is a high degree of sensitivity to various stimuli, that may, for example, cause that person to be able to have better vigilance regarding the potential dangers associated with the sound of footsteps in the distance, or of the smell of smoke, etc. Often times, though, this heightened vigilance comes at great expense to that person's ability to function in life: a pleasant walk, a work environment, or a hug, may instead become a terrifying journey or a place of constant fear of attack.

Similarly, in depressive states, there may be beliefs that are, on one level, accurate, but on another level are causing a profound impairment in life function (e.g. regarding socializing, learning, work, simple life pleasures, spirituality, etc.).

With regard to science, I do not find any need to say that "positive psychology" etc. is about a biased interpretation of data. Instead, my analogy would be along the lines of how one would solve a complex mathematical equation:
-a small minority of mathematical problems have a straightforward answer. If one was to look only at precedents in data, one might conclude that there is no definable answer for many problems. A cynical and depressive approach would be to abandon the problem.
-but most complex problems today require what is called a "numerical analysis" approach. This necessitates basically guessing at the solution, then applying an algorithm that will "sculpt" the guess closer to the true answer. Sometimes the algorithm doesn't work, and the attempted solutions "diverge." But the convergence to a solution through numerical analytical methods is the most powerful phenomenon in modern science. It has permitted most every single major advance in science and engineering in the past hundred years. It is basically analogous to positive behavioural shaping in psychology. It is not about biased interpretation of data, it is about using a set of "positive" tools to solve a problem (in the mathematical case, to get numerical solutions; in the psychological case, to relieve symptoms, to increase freedom of choice, and to expand the realm of possible life functions available).

4) Some of the experiments are weak, no doubt about that. I don't consider experiments evaluating superficial cross-sectional affect to be relevant to therapy research. Experiments which evaluate the change in symptoms and subjective quality of life measures over long periods of time, are most relevant to me. I consider "positive psychology" to be just one more set of ideas that may help to improve quality of life, and overall life function, as subjectively defined by a patient.

In my discussion of this subject, I am not meaning to suggest that so-called "positive psychology" is my favoured therapeutic system. Some of the ideas may be quite off-putting to individuals who may need to deal with a lot of negative symptoms directly before doing "positivity exercises." But I do think that some of the ideas from positive psychology are important and relevant, and deserve to be adopted as part of an eclectic therapy model.

The Importance of Two-Sided Arguments

This is a topic I was meaning to write a post about for some time. I encountered this topic while doing some social psychology reading last year, and it touches upon a lot of other posts I've written, having to do with decision-making and persuasion. It touches on the huge issue of bias which appears in so much of the medical and health literature.

Here is what some of the social psychology research has to say on this:

1) If someone already agrees on an issue, then a one-sided appeal is most effective. So, for example, if I happen to recommend a particular brand of toothpaste, or a particular political candidate, and I simply give a list of reasons why my particular recommendation is best, then I am usually "preaching to the converted." Perhaps more people will go out to buy that toothpaste brand, or vote for that candidate, but they would mostly be people who would have made those choices anyway. The only others who would be most persuaded by my advice would be those who do not have a strong personal investment or attachment to the issue.

2) If people are already aware of opposing arguments, a two-sided presentation is more persuasive and enduring. And if people disagree with a certain issue, a two-sided presentation is more persuasive to change their minds. People are likely to dismiss as biased a one-sided presentation which disagrees with their point of view, even if the presentation contains accurate and well-organized information. This is one of my complaints about various types of media and documentary styles: sometimes there is an overt left-wing or right-wing political bias that is immediately apparent, particularly to a person holding the opposing stance. I can think of numerous examples in local and international newspapers and television. The information from such media or documentary presentations would therefore have little educational or persuasive impact except with individuals who probably agree with the information and the point of view in advance. The strongest documentary or journalistic style has to be one which presents both sides of a debate, otherwise it is probably almost worthless to effect meaningful change--in fact it could entrench the points of view of opposing camps.


It has also been found that if people are already committed to a certain belief or position, than a mild attack or challenge of this position causes people to strengthen their initial position. Ineffective persuasion may "inoculate" people attitudinally, causing them to be more committed to their initial positions. In an educational sense, children could be "inoculated" against negative persuasion, such as from television ads or peer pressure to smoke, etc. by exploring, analyzing, and discussing such persuasive tactics, with parents or teachers.

However, such "inoculation" may be an instrument of attitudinal entrenchment and stubbornness: a person who has anticipated arguments against his or her committed position is more likely to hold that position more tenaciously. Or an individual who has been taught a delusional belief system may have been taught the various challenges to the belief system to expect: this may "inoculate" the person against challenging this belief system, and cause the delusions to become more entrenched.

An adversarial justice system reminds me to some degree of an efficient process, from a psychological point of view, to seek the least biased truth. However, the problem here is that both sides "inoculate" themselves against the evidence presented by the other. The opposing camps do not seek "resolution"--they seek to win, which is quite different. Also, the prosecution and the defense do not EACH present a balanced analysis of pro & con regarding their cases. There is information possibly withheld--the defense may truly know the guilt of the accused, yet this may not be shared openly in court. Presumably the prosecution would not prosecute if the innocence of the accused was known for sure.

Here are some applications of these ideas, which I think are relevant in psychiatry:

1) Depression, anxiety, and other types of mental illness, tend to feature entrenched thinking. Thoughts which are very negative, hostile, or pessimistic--about self, world, or future--may have been consolidated over a period of years or decades, often reinforced by negative experiences. In this setting, one-sided optimistic advice--even if accurate-- could be very counterproductive. It could further entrench the depressive cognitive stance. Standard "Burns style" cognitive therapy can also be excessively "rosy", in my opinion, and may be very ineffective for similar reasons. I think of the smiling picture of the author on the cover of a cognitive therapy workbook as an instant turn-off (for many) which would understandably strengthen the consolidation of many chronic depressive thoughts.

But I do think that a cognitive therapy approach could be very helpful, provided it includes the depressive or negative thinking in an honest, thorough, systematic debate or dialectic. That is, the work has to involve "two-sided argument".

2) In medical literature, there is a great deal of bias going on. Many of my previous postings have been about this. On other internet sites, there are various points of view, some of which are quite extreme. Those sites which are invariably about "pharmaceutical industry bias", etc. I think are actually quite ineffectual, if they merely are covering the same theme, over and over again. They are likely to be sites which are "preaching to the converted", and are likely to be viewed as themselves biased or extreme by someone looking for balanced advice. They may cause individuals with an already biased point of view to unreasonably entrench their positions further.

Also, I suspect the authors of sites like this, may themselves have become quite biased. If their site has repeatedly criticized the inadequacy of the research data about some drug intended to treat depression or bipolar disorder, etc., they may be less likely to consider or publish contrary evidence that the drug actually works. Once we commit ourselves to a position, we all have a tendency to cling to that position, even when evidence should sway us.

On the other hand, if there is a site which consistently gives medication advice of one sort or the other, I think it is unlikely to change very many opinions on this issue, except among those who are already trying out different medications.

So, in my opinion, it is a healthy practice when analyzing issues, including health care decisions, to carefully consider both sides of an argument. If the issue has to do with a treatment, including a medication, a style of psychotherapy, an alternative health care modality, or of doing nothing at all, then I encourage the habit of analyzing the evidence in two ways:
1) gather all evidence which supports the modality
2) gather all evidence which opposes it

Then I encourage a weighing, and a synthesis, of these points of view, before making a decision.
I think that this is the most reliable way to minimize biases. If such a system is applied to one's own attitudes, thoughts, values, and behaviours, I think it is the most effective to promote change and growth.



References:
Myers, David. Social Psychology, fourth edition. New York: McGraw-Hill; 1993. p. 275; 294-297.