Biases in Research
Pharmaceutical Research
We are much more familiar these days with biases in pharmaceutical research studies. A clinical study of a medication treatment is more likely to show an exaggerated beneficial effect, if the study is sponsored by the manufacturer. This doesn't mean industry-sponsored research is "bad," and it doesn't mean that pharmaceutical products are "bad," but it does mean that we have to look with a careful, skeptical eye at research results--not just at impressive tables or graphs, but also at the sources of funding for the study, and the authors' past relationships with the manufacturers. There could indeed be overt "badness" if there are examples of flagrant profiteering on the part of people involved. But the more salient issue, in my opinion, is simply the need to question the authority of results from such studies.
Alternative Medicine
This same critical eye is very much needed for looking at research evidence regarding alternative treatments. There are very strong sales tactics used to market supplements, herbal remedies, and other treatments, and the standards of evidence presented are often much lower than those from pharmaceutical studies. For example, simple testimonial accounts are much more common in alternative medication marketing, as are impressive-sounding but clinically irrelevant scientific or pseudo-scientific claims.
Psychotherapy Too!
We may assume that studies of psychotherapy would be relatively free of these biases. After all, there is no big company that is profiting from psychotherapy!
But we must maintain a critical eye even for studies of psychotherapy. Here are some reasons:
1) A positive study of a psychotherapy technique may not bring obvious financial profit to anyone, but it is likely to increase the prestige of the authors. A big part of the "currency" in a Ph.D. researcher's career relates to impressive publications. A study showing a significant treatment effect of a psychotherapy technique is likely to add to the fame and career advancement of the authors. This career advancement is analogous to direct financial gain.
2) Many psychotherapy researchers have spent many years of study devoted to their therapy technique. Imagine if you had spent 10 years studying a particular thing, and that you had strong feelings about it. You could imagine that you might have a bias in favour of the technique that you had studied all those years. You would really want to show that it works! If a study showed that it didn't work so well, it might lead you to question the value of all those years of your career! In Cialdini's terms, this bias would have to do with "consistency." If someone has been consistently committed to a particular thing for a long time, they are biased to maintain support of that thing, beyond what would otherwise be reasonable. Furthermore, if you had worked all those years studying one particular technique, your social and professional community of peers would be more likely to share similar opinions. You might have frequently attended conferences devoted to your area of specialty. You might have even taught students the technique, who appreciated your help and mentorship. This would lead to Cialdini's "social pressure" effect -- since the people around you support your idea, you will be more likely to hold onto the idea yourself, beyond what would otherwise be reasonable.
3) There is more and more direct financial gain related to therapy techniques. We see a lot of books, self-help guides, paid seminars and workshops, etc. Charismatic marketing, including through publishing of research studies, is likely to increase the financial profit of those involved.
4) In the psychotherapy research community, CBT is the most common modality. CBT is intrinsically easier to research, since it is more easily standardized, the techniques themselves involve a lot of measurement, and the style tends to be more precisely time-limited. CBT is more "scientific" and therefore attracts researchers whose background is more strongly analytical and scientific. There is nothing intrinsically wrong with this , but it leads to more bias in the research. Therapy styles other than CBT are studied less frequently. Therefore there will be fewer positive studies of other styles. This gives the impression that CBT is best. It is not because comparative studies have actually shown it is best. New versions or variations of CBT (with different fancy-sounding names) are also frequently marketed, and often show good results in research, but once again this does not really prove that the techniques are best. The research study becomes an advertising tool for those who have designed the technique.
Conclusion
I do not mean to sound too cynical here...I think that CBT, as well as all other therapy techniques, are interesting, important, and helpful. We should all learn about them, and make use of some of their principles. But I do not think that any one style is necessarily "best." We should not allow biases in research, including simple marketing effects, to cause a large change in our judgment with respect to helping people.
I feel that the more important foundation in trying to help people is spending the time getting to know them, and hearing from the person you are with (whether it be a client, a patient, a family member, or a friend) what type of help they would actually like.
Also, different individual therapists have different personalities, interests, experiences, weaknesses, and skills. I think it is unhealthy for a community of therapists or healers to be pushed into offering a very narrow range of techniques or therapeutic strategies. Instead, I think that the individual talents and strengths of each therapist should be honoured, and there should be room in any health care system to allow for this.
Showing posts with label Philosophical Opinions or Beliefs. Show all posts
Showing posts with label Philosophical Opinions or Beliefs. Show all posts
Wednesday, March 8, 2017
Friday, February 24, 2017
Always Question
The freedom to question is a foundation of healthy living.
In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.
For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living. Other issues may seem much more important in daily life. This is especially true if we are struggling with poverty, illness, or other consuming life stresses. Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to. Whole nations may feel the same way.
I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities. This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.
Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman: he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness. His work also suggests ways that we can protect ourselves from being misguided by our biases.
Let's look at an example situation, of a public educational lecture. How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?
Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!
But here are a variety of biases that occur in lectures:
The Focusing Illusion
In order for a lecture to be narratively interesting, it should probably have a "thesis." This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce). If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence. An essayist who vacillates will probably receive a lower grade.
But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion." This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity: if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.
A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion. The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.
Cialdini's Persuasive Factors
Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking b) authority c) social pressure d)consistency e)reciprocity f)scarcity
A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis. An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture. If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.
A speaker who is wearing more expensive clothing, who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests), has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.
If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed. This is due to the factor of consistency. If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity. And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).
Suppression of Counterargument
Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.
If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion. We have seen this phenomenon in political rallies across the world in the past year. When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions. Decision-making under such conditions cannot be rational. It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity. Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.
Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present. It is freedom in word only, not in action--which really is not freedom at all. A lecturer may allow some time for questions or debate, but often only a few minutes near the end. And the old familiar forces, stated above, may subtly suppress debate. Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.
Zimbardo's Heroism
Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.
He calls for us to be "heroic": what he means is that we should truly exercise our freedom, to always question. It is easy to question things when we are strongly invited to do so. It is harder to practice this freedom in an environment where questioning is discouraged.
The Risks of Questioning
If you raise questions, it is possible that you could get criticized by others in the group around you. You might be labelled as being difficult, oppositional, or disloyal. Some people may believe that you are being resistant to change, stubborn, or disrespectful. Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others. The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.
I think this is a risk worth taking. You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic. The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.
I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.
Relevance to Psychotherapy & Mental Health
All mental health problems could be understood, in part, to reflect a lack of freedom. Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.
Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level. This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.
In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression. Rather, the therapy environment should encourage freedom, including the freedom to dissent! It should feel ok to completely disagree with your therapist, without fear of rejection or argument! I think it should be accepted that it would also be ok, or necessary, for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time. But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.
If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question. It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.
Cognitive Therapy
At its best, cognitive therapy is a formal mechanism to question one's own thoughts! Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression. If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.
Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective. Your thoughts may be trying to warn you about potential dangers, based on learning from the past. It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.
These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency." You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your mind...it likes to have the final word...attempts to question it can seem futile
So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning. You can become a civil rights leader in your own mind! I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use. Analogously, in many oppressive political systems, we see one tyrant simply being replaced by another...it is necessary instead to strive for freedom. So I encourage your work in cognitive therapy to be an exercise in compassionately developing and asserting your freedom, through courageous questioning of your self-talk.
I am not meaning to encourage reflexive defiance, however. Sometimes, after a period of debate, it is time to make a decision, and to move forward with that. It can be unhelpful to debate every step of the way in every change process or learning event. But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making. I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.
In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.
For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living. Other issues may seem much more important in daily life. This is especially true if we are struggling with poverty, illness, or other consuming life stresses. Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to. Whole nations may feel the same way.
I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities. This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.
Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman: he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness. His work also suggests ways that we can protect ourselves from being misguided by our biases.
Let's look at an example situation, of a public educational lecture. How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?
Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!
But here are a variety of biases that occur in lectures:
The Focusing Illusion
In order for a lecture to be narratively interesting, it should probably have a "thesis." This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce). If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence. An essayist who vacillates will probably receive a lower grade.
But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion." This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity: if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.
A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion. The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.
Cialdini's Persuasive Factors
Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking b) authority c) social pressure d)consistency e)reciprocity f)scarcity
A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis. An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture. If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.
A speaker who is wearing more expensive clothing, who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests), has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.
If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed. This is due to the factor of consistency. If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity. And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).
Suppression of Counterargument
Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.
If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion. We have seen this phenomenon in political rallies across the world in the past year. When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions. Decision-making under such conditions cannot be rational. It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity. Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.
Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present. It is freedom in word only, not in action--which really is not freedom at all. A lecturer may allow some time for questions or debate, but often only a few minutes near the end. And the old familiar forces, stated above, may subtly suppress debate. Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.
Zimbardo's Heroism
Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.
He calls for us to be "heroic": what he means is that we should truly exercise our freedom, to always question. It is easy to question things when we are strongly invited to do so. It is harder to practice this freedom in an environment where questioning is discouraged.
The Risks of Questioning
If you raise questions, it is possible that you could get criticized by others in the group around you. You might be labelled as being difficult, oppositional, or disloyal. Some people may believe that you are being resistant to change, stubborn, or disrespectful. Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others. The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.
I think this is a risk worth taking. You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic. The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.
I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.
Relevance to Psychotherapy & Mental Health
All mental health problems could be understood, in part, to reflect a lack of freedom. Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.
Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level. This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.
In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression. Rather, the therapy environment should encourage freedom, including the freedom to dissent! It should feel ok to completely disagree with your therapist, without fear of rejection or argument! I think it should be accepted that it would also be ok, or necessary, for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time. But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.
If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question. It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.
Cognitive Therapy
At its best, cognitive therapy is a formal mechanism to question one's own thoughts! Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression. If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.
Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective. Your thoughts may be trying to warn you about potential dangers, based on learning from the past. It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.
These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency." You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your mind...it likes to have the final word...attempts to question it can seem futile
So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning. You can become a civil rights leader in your own mind! I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use. Analogously, in many oppressive political systems, we see one tyrant simply being replaced by another...it is necessary instead to strive for freedom. So I encourage your work in cognitive therapy to be an exercise in compassionately developing and asserting your freedom, through courageous questioning of your self-talk.
I am not meaning to encourage reflexive defiance, however. Sometimes, after a period of debate, it is time to make a decision, and to move forward with that. It can be unhelpful to debate every step of the way in every change process or learning event. But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making. I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.
Wednesday, February 1, 2017
Compassion vs. Empathy: Reflections on Paul Bloom's Book
Paul Bloom, in his recent book called Against Empathy, challenges us to question the role of empathy as a vital ingredient of goodness or morality. Bloom believes that kindness, guided by thoughtfulness, is the supreme guide to morality, while empathy is often morally neutral or even negative.
Bloom's definition of Empathy
By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling. Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems. Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.
Bloom clearly is not talking about "understanding." He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully. A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state. Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour. With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:
Problems with Empathy
1) Empathy does not correlate with kindness. Many people who behave cruelly have a lot of empathy for their victims. In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty. A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.
Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all. People who perform daring rescues often do not empathize before they act. Having an empathic reaction in an emergency could delay a life-saving action.
One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney. People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!
Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive. A caregiver who is highly, reflexively empathic is at greater risk of burnout. Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm. Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.
2) Empathy as a moral guide can cause us to behave in a biased or unfair manner. If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently. Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer. This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.). It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.
Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies. He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone. This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.
My Thoughts
I see Bloom's thesis as an extension of Kahneman's insights about psychological biases. Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.
Empathy, in my opinion, is a quality similar to eyesight or one of the other senses: it does not, in itself, have a moral quality. It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions. Having highly developed empathy does not make you more moral any more than does having sharp eyesight. If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions. This does not mean we should not cultivate our senses, including eyesight or empathy. They are important talents and skills, and they deserve attention and practice. It is just that we should not rely on them by themselves as moral guides.
Taming Empathy
I do believe that empathy is important, however. It just needs to be "tamed." I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust. A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold. Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment. A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity. But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not be helpful! It would probably frighten or disturb the patient, and would also lead to burnout in the therapist. A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.
Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide. Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.
Empathy for the Therapist!
Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction: if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.
Empathy could work this way in therapy as an example of social learning therapy combined with CBT: if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to follow...in this way the therapist would truly be an emotional guide. I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.
The Importance of Listening and Showing Understanding
I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy. I usually use the term empathy in a broader sense. When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen. Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away. And they may be frustrated if the other person starts to discuss their own similar problems. It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved. This reflection and demonstrated understanding is what I mean by empathy, most of the time. A typical example could be saying something like, "you had an exhausting day..." When giving this reflection, I would not normally feel exhausted myself! Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.
Bloom's definition of Empathy
By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling. Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems. Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.
Bloom clearly is not talking about "understanding." He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully. A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state. Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour. With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:
Problems with Empathy
1) Empathy does not correlate with kindness. Many people who behave cruelly have a lot of empathy for their victims. In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty. A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.
Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all. People who perform daring rescues often do not empathize before they act. Having an empathic reaction in an emergency could delay a life-saving action.
One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney. People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!
Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive. A caregiver who is highly, reflexively empathic is at greater risk of burnout. Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm. Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.
2) Empathy as a moral guide can cause us to behave in a biased or unfair manner. If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently. Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer. This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.). It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.
Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies. He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone. This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.
My Thoughts
I see Bloom's thesis as an extension of Kahneman's insights about psychological biases. Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.
Empathy, in my opinion, is a quality similar to eyesight or one of the other senses: it does not, in itself, have a moral quality. It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions. Having highly developed empathy does not make you more moral any more than does having sharp eyesight. If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions. This does not mean we should not cultivate our senses, including eyesight or empathy. They are important talents and skills, and they deserve attention and practice. It is just that we should not rely on them by themselves as moral guides.
Taming Empathy
I do believe that empathy is important, however. It just needs to be "tamed." I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust. A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold. Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment. A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity. But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not be helpful! It would probably frighten or disturb the patient, and would also lead to burnout in the therapist. A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.
Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide. Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.
Empathy for the Therapist!
Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction: if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.
Empathy could work this way in therapy as an example of social learning therapy combined with CBT: if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to follow...in this way the therapist would truly be an emotional guide. I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.
The Importance of Listening and Showing Understanding
I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy. I usually use the term empathy in a broader sense. When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen. Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away. And they may be frustrated if the other person starts to discuss their own similar problems. It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved. This reflection and demonstrated understanding is what I mean by empathy, most of the time. A typical example could be saying something like, "you had an exhausting day..." When giving this reflection, I would not normally feel exhausted myself! Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.
Tuesday, November 15, 2016
Healing Divisions: Empathy, Filter Bubbles, and Free Speech
There is a lot of conflict and division in the world. The recent U.S. election is just one of many examples of this.
What can be done to mend the conflicts?
I found a relevant TED talk a few days ago, featuring a social psychologist named Jonathan Haidt. He discusses the psychology of political difference, and also some ideas of what we can all do to help mend the divisions.
One of the simple challenges he poses to us all, is to practice empathy. It is easier to empathize with a person who has suffered in a way that we can understand or relate to. He points out that it may be much harder for any of us to empathize with someone whom we strongly disagree with. This lack of empathy with our intellectual or political opponents consolidates division, dislike, disrespect, and even hatred.
A very important obstacle to empathy in the modern world is a technical one: people who espouse a particular viewpoint may, through social media, or through other information sources, only expose themselves to those who already share the same views or opinions or backgrounds. Some services, such as Facebook, may deliberately filter information to be attuned to your interests and opinions. This "filter bubble" phenomenon leads to a reduction in empathy between opposing groups, and therefore magnifies division.
I encourage all of us to have a practice of learning why people feel or believe the way they do, even if they have very different opinions, feelings, or backgrounds. You may still strongly disagree at the end of this exploration, but at least there will hopefully be less enmity, and more understanding. You may discover that despite many differences, that there are unexpected areas of common ground. Such common ground can lead to peace instead of war.
A foundation required for this process to work is freedom of speech...I am very troubled by processes in which communication is suppressed. Even in the seemingly warm-hearted area of mental health care reform, I have seen processes of change in which dissenting voices were not welcome...the human tendency to suppress opposition in the name of efficiency or progress is universal. We must always take steps to protect our freedoms. This requires a certain bravery to express ourselves, even when your voice is a lone voice of dissent in a crowd...but it also requires a deliberate commitment to empathize, to strive to understand the feelings, thoughts, and motivations of those who disagree with you. Such empathy must be practiced as a basic discipline of life.
Another recommendation I have is to be aware of the "filter bubble"and to step out of it regularly. Read widely, from as many different sources as you can. This doesn't mean you need to agree with positions you find objectionable, but at the very least it does require you to be more aware of personal stories that you might not have been aware of before.
Addendum (in response to a message about this post): I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice! And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all. In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one. I think of some of the great voices in history, such as Martin Luther King's.
Addendum (in response to a message about this post): I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice! And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all. In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one. I think of some of the great voices in history, such as Martin Luther King's.
Wednesday, October 26, 2016
The Virtue of Admitting Weaknesses
I think it is a virtue to admit areas of weakness. In our
modern, competitive world, we are encouraged never to admit our shortcomings.
On a résumé or CV, the
standard practice is to provide a list of our accomplishments, awards, and
strengths, but never to discuss weaknesses! In current events today, we
can find many examples of public figures who not only would never admit any
sort of weakness, but who boast about themselves almost constantly!
Admissions of weakness could seem like manifestations of low
self-esteem, low confidence, or proof of incompetence.
I think it is a strength to be able to admit weaknesses! It is a protection against poor decision-making, and a protection against cognitive biases, to always contemplate weaknesses or mistakes in your planning. For example, Kahneman described a technique called a "pre-mortem" which calls for us to anticipate or imagine that our plans had failed badly, and then to imagine the sequence of events that could have led to the failure. Too often, groups are so excited about new plans that they are blinded by "groupthink" and do not consider adverse consequences. While this often happens in business planning, it frequently occurs in our personal lives as well.
In medical training, it can be important to show confidence.
But imagine how dangerous it is for patient care when a trainee is reluctant to
admit a weakness in performing a medical procedure! In this case, it is a
sign of strong professionalism and leadership to admit that you don’t
know. Ironically, it can require great confidence and self-esteem to be
able to convey these weaknesses honestly.
In the spirit of admitting weaknesses, I would like to list
a few things that I don't think I'm very good at, in my professional
life:
1) teaching meditation. I know that meditation skills can be important and powerful. I encourage almost all my patients to learn about meditation, and to consider investing a lot of time practicing meditation skills. I think I am good at philosophizing about meditation...but not really good at meditation itself! Mind you, I do think that my philosophizing has a meditative quality--at least it does for me!
I am willing and eager to learn more about meditation, but I also
know that a good meditation teacher or group would be more effective and
helpful for my patients to learn meditation skills. I feel the same way
about some other related activities such as yoga.
2) being a very organized, methodical teacher (e.g. for CBT exercises). I love intellectual dialogue, and I enjoy trying to give encouraging, creative feedback...but I know that sometimes a good teacher needs to be very organized, consistent, strict, and focused on a task...My style tends to more informal, with variations of focus from week to week, according to my patients’ wishes. Also, I tend to question things a lot, including the process of things, so I think I would find a highly regimented style to be too restricted. Some patients who desire a more strictly regimented approach might get frustrated with me. At other times, maybe I don’t use time as efficiently as I could.
I am willing to learn more about becoming a better and more organized teacher--but I also recognize that I have limitations with those skills, and that there are others who could do a better job than I could.
3) "Networking" with community resources. I have a
tendency to have a bit of a "monastic" style. While I encourage
patients to inform themselves about community resources, and to make use of
them, I tend to prefer spending most of the time working one-on-one with my
patients, instead of spending time developing relationships or engaging
professional peers in other parts of the community. For similar reasons,
I prefer to do a lot of my continuing education activities on my own, through
reading and writing, rather than signing up for conferences.
I realize that we all need a balance between "alone time" and "group time" in our lives. This applies to professional life as well--different professionals may like or need different amounts of interaction with professional peers. I think it is unhealthy for anyone to be too extreme in this balance, but on the other hand I do think it is important and good to honour your own personal style.
The practice of psychiatry nowadays tends to favour more "community networking" and less of a "monastic" style. I see that this can be valuable, because it could lead to more of an experience of a collaborative therapeutic community. For me, I guess my lack of inclination to network this way is a weakness...but I hope some might find it a welcome strength that I value the one-on-one experience as highly as I do.
4) not empathizing enough. Sometimes I focus too much on
intellectual dialog, on problem-solving attempts, on being calmly attentive,
etc. – but then I don’t say an empathic comment that needed to be said.
Here, I need to be more diligent to work on this, but also maybe to admit that
this happens more often than I care to admit.
I have a variety of other weaknesses. I encourage a practice of being honest about our weaknesses, not in a resigned or self-deprecating way, but in a way which helps us acknowledge our humanity and our fallibility.
Ironically, I am concerned that I might sound boastful -- I am boasting that I can talk about my weaknesses! Maybe my own boastfulness is another weakness, to be worked on.
Also, in conjunction with admitting weakness, I think it is good to acknowledge that some of our strengths actually depend on the weaknesses! Maybe my weakness regarding networking comes along with a strength for valuing one-on-one therapeutic relationships...perhaps some of your weaknesses which you struggle with are part of a larger picture of having strengths which could allow you greater meaning and purpose in life.
With the admission of weaknesses, I think it is also good to be open-minded about working on them. Not necessarily with a goal to become a different person--it is important to "be yourself"--but with a goal of spending a little bit of time and attention on our weaknesses in a constructive way. For me, this means that I need to spend a little bit more time learning about meditation. I need to consciously say more empathic remarks. I need to maybe sign up for a few more conferences. And I need to push myself a little bit to attend more meetings with colleagues in the community. But I can’t let these goals interfere with the aspects of my professional life that I already enjoy and feel comfortable with.
Tuesday, October 11, 2016
Persuasive Factors in Politics
In my previous posts, I was describing some of Cialdini's factors which affect decision-making and persuasion.
It is interesting to look at some of these factors playing out in current news events:
Why do people adhere to a particular political choice?
Many people insist that they support a particular political candidate, simply because that candidate has the best policies, or has the best leadership skills. Or they support an ideological position, or a whole system of values, because they believe, and feel, that they are the best.
But are there other factors at play? Let's look at some of Cialdini's persuasion factors to consider how they affect candidate or political choice:
1) Consistency & Commitment. If a person has already supported a candidate, a political party, or a position, then that person is more likely to maintain their choice, even if circumstances change. We form loyal attachments to our previous choices, even if the attachment is shown to be irrational or harmful. It may seem humiliating, embarrassing, or weak, to bail out on a previous choice. It might feel similar to abandoning a marriage, a job, or a responsibility, just because things are going through a rough patch.
This consistency factor is especially strong if the person has grown up in a culture where consistency or commitments are considered strong points of honour. This culture of honour is to be respected. Loyalty is to be respected! But unfortunately, this loyalty can cause people to keep supporting, for too long, something that is harmful...it can cause people to overlook negatives in their position, and to go along with things that they would never have rationally supported were it not for their previous commitment.
A related cognitive bias is the "sunk cost fallacy": if you have already invested a lot of time, energy, or money into something, you are more likely to continue pursuing it, even if it is irrational to do so, and even if the project is failing disastrously. It may feel humiliating or shameful to change your mind, even if changing your mind could save you from bankruptcy! It can take courage to let a previous commitment go!
Commitment and consistency are bolstered by community and family factors: if most people among your cultural group, family, or coworkers have all been supporting a particular group, idea, or candidate, then it could seem intensely disloyal to disavow your own support or commitment. You might even fear that your peers or family could reject you if you changed your mind.
So, commitment and consistency are powerful, noble forces in decision-making, and in life, but we must not be enslaved by these factors...it is a sign of a much greater character strength to sometimes over-ride this, and to make a deeply moral choice to let go of a previously held commitment.
There are many tragic stories in history, where massive segments of the population of great societies follow disastrous ideas and leaders, partly due to the persuasive force of consistency.
2) Social pressure. If many people continue to support a particular thing, then it is easier to keep supporting it yourself, even when this is irrational. We all have a tendency to follow a trend...sometimes we follow these trends, along with an excited, passionate crowd, even when the crowd is rushing towards the edge of a cliff! Beware of "GroupThink!"
3) Liking & Authority. We form positive emotional connections with candidates or positions we support, and we may also respect their authority...trust and admiration grows with any ongoing relationship, and we may continue to make decisions influenced by this. If we "like" a political candidate, we may support that person long after it makes rational sense to do so. Conversely, it may be difficult to support a candidate we do not personally "like," even if this candidate may offer the best leadership. Some of these factors can be incredibly irrational, such as supporting a person whom we find better-looking or more entertaining!
When these factors have been at play, and we support something, we are likely to invest our time, attention, energy, and money...we may even suffer and struggle for these causes. Our struggles and suffering usually intensify our attachment, and make us even more resistant to letting it go when it is morally right to do so. If you have fought for something, you are much more likely to keep fighting for it, even if your cause is proven to be unjust.
It is our duty as citizens, or as participants in any community, to make wise choices, and to be willing to change our minds after thinking carefully. You need a great strength of character to take an honest, balanced look at both sides of every major issue or position. You are not just born with character strength--you must work at it, and develop it as an essential life skill! In politics, it is important to give sincere attention to multiple sources of information, and not to rely only on a single news source which happens to support your pre-existing point of view.
I am very alarmed about situations--which we see across the world today--in which there is restricted freedom of speech and expression. Many news sources are overtly supporting only one position. In some countries, the government is restricting free debate in the media. Even closer to home, individual news sources are focusing on telling only one side of many stories... We must protect our freedom of expression! It is not only a matter of taking care of our freedoms, it is also a matter of making wise, unbiased decisions! Wise decision-making is impossible unless we fairly attend to multiple points of view, and unless we are willing to challenge our own individual biases.
Cialdini tells an interesting story about the decline of tobacco use in the U.S., associated with a policy called the "Fairness Doctrine" which required equal time to be given to opposing viewpoints. If tobacco ads were always followed by other ads trying to show the harms of smoking, it led the viewer to make a more balanced decision (which, in this case, led to a decline in smoking). Ironically, once tobacco advertising disappeared entirely, smoking rates did not decline as much. Part of an explanation is that tobacco advertising could then occur in more covert forms, perhaps marketed more exclusively to existing smokers, without equal time given to opposing viewpoints. The best decision-making occurs not when issues are suppressed, but when powerful counter-arguments can be presented in a free society, by a free press, where opposing positions can always be clearly shown, side by side.
It takes a great strength of character to be willing to change our minds, and to make an intelligent, morally-guided choice, in the face of powerful persuasive factors such as consistency, social pressure, liking, and authority. We can all improve this character strength, if we are willing to challenge ourselves, and if we are willing to work hard!
It is interesting to look at some of these factors playing out in current news events:
Why do people adhere to a particular political choice?
Many people insist that they support a particular political candidate, simply because that candidate has the best policies, or has the best leadership skills. Or they support an ideological position, or a whole system of values, because they believe, and feel, that they are the best.
But are there other factors at play? Let's look at some of Cialdini's persuasion factors to consider how they affect candidate or political choice:
1) Consistency & Commitment. If a person has already supported a candidate, a political party, or a position, then that person is more likely to maintain their choice, even if circumstances change. We form loyal attachments to our previous choices, even if the attachment is shown to be irrational or harmful. It may seem humiliating, embarrassing, or weak, to bail out on a previous choice. It might feel similar to abandoning a marriage, a job, or a responsibility, just because things are going through a rough patch.
This consistency factor is especially strong if the person has grown up in a culture where consistency or commitments are considered strong points of honour. This culture of honour is to be respected. Loyalty is to be respected! But unfortunately, this loyalty can cause people to keep supporting, for too long, something that is harmful...it can cause people to overlook negatives in their position, and to go along with things that they would never have rationally supported were it not for their previous commitment.
A related cognitive bias is the "sunk cost fallacy": if you have already invested a lot of time, energy, or money into something, you are more likely to continue pursuing it, even if it is irrational to do so, and even if the project is failing disastrously. It may feel humiliating or shameful to change your mind, even if changing your mind could save you from bankruptcy! It can take courage to let a previous commitment go!
Commitment and consistency are bolstered by community and family factors: if most people among your cultural group, family, or coworkers have all been supporting a particular group, idea, or candidate, then it could seem intensely disloyal to disavow your own support or commitment. You might even fear that your peers or family could reject you if you changed your mind.
So, commitment and consistency are powerful, noble forces in decision-making, and in life, but we must not be enslaved by these factors...it is a sign of a much greater character strength to sometimes over-ride this, and to make a deeply moral choice to let go of a previously held commitment.
There are many tragic stories in history, where massive segments of the population of great societies follow disastrous ideas and leaders, partly due to the persuasive force of consistency.
2) Social pressure. If many people continue to support a particular thing, then it is easier to keep supporting it yourself, even when this is irrational. We all have a tendency to follow a trend...sometimes we follow these trends, along with an excited, passionate crowd, even when the crowd is rushing towards the edge of a cliff! Beware of "GroupThink!"
3) Liking & Authority. We form positive emotional connections with candidates or positions we support, and we may also respect their authority...trust and admiration grows with any ongoing relationship, and we may continue to make decisions influenced by this. If we "like" a political candidate, we may support that person long after it makes rational sense to do so. Conversely, it may be difficult to support a candidate we do not personally "like," even if this candidate may offer the best leadership. Some of these factors can be incredibly irrational, such as supporting a person whom we find better-looking or more entertaining!
When these factors have been at play, and we support something, we are likely to invest our time, attention, energy, and money...we may even suffer and struggle for these causes. Our struggles and suffering usually intensify our attachment, and make us even more resistant to letting it go when it is morally right to do so. If you have fought for something, you are much more likely to keep fighting for it, even if your cause is proven to be unjust.
It is our duty as citizens, or as participants in any community, to make wise choices, and to be willing to change our minds after thinking carefully. You need a great strength of character to take an honest, balanced look at both sides of every major issue or position. You are not just born with character strength--you must work at it, and develop it as an essential life skill! In politics, it is important to give sincere attention to multiple sources of information, and not to rely only on a single news source which happens to support your pre-existing point of view.
I am very alarmed about situations--which we see across the world today--in which there is restricted freedom of speech and expression. Many news sources are overtly supporting only one position. In some countries, the government is restricting free debate in the media. Even closer to home, individual news sources are focusing on telling only one side of many stories... We must protect our freedom of expression! It is not only a matter of taking care of our freedoms, it is also a matter of making wise, unbiased decisions! Wise decision-making is impossible unless we fairly attend to multiple points of view, and unless we are willing to challenge our own individual biases.
Cialdini tells an interesting story about the decline of tobacco use in the U.S., associated with a policy called the "Fairness Doctrine" which required equal time to be given to opposing viewpoints. If tobacco ads were always followed by other ads trying to show the harms of smoking, it led the viewer to make a more balanced decision (which, in this case, led to a decline in smoking). Ironically, once tobacco advertising disappeared entirely, smoking rates did not decline as much. Part of an explanation is that tobacco advertising could then occur in more covert forms, perhaps marketed more exclusively to existing smokers, without equal time given to opposing viewpoints. The best decision-making occurs not when issues are suppressed, but when powerful counter-arguments can be presented in a free society, by a free press, where opposing positions can always be clearly shown, side by side.
It takes a great strength of character to be willing to change our minds, and to make an intelligent, morally-guided choice, in the face of powerful persuasive factors such as consistency, social pressure, liking, and authority. We can all improve this character strength, if we are willing to challenge ourselves, and if we are willing to work hard!
Monday, May 30, 2016
Rhetoric and Jargon in Health Care Policy, Part 2: "Evidence Based"
These days we often hear about how a new treatment, or program, or therapy style, is "evidence based." This gives the listener an impression that the new treatment must be superior in some way.
It is another language construct which has become much more common, especially in mental health care discussions. Recently, its prevalence has tripled in written language, with a steep increase beginning in about 1993, according to the Google NGram viewer.
But was does "evidence based" really mean?
We often hear, for example, that cognitive-behavioural therapy (CBT) is "evidence based." The implication of this statement is that other forms of therapy must not be "evidence based."
It should go without saying that most everything is "evidence based":
An individual's personal account of their experience is a form of evidence.
A randomized controlled prospective trial of therapy supplies another form of evidence.
An opinion from an expert, or from a mystic, or from a random person on a bus, or from a charlatan, is another form of evidence.
Ironically, the introduction of the phrase "evidence based" may stifle debate and free thinking about a matter. It implies that the issue it is describing has already been decided upon.
In psychiatry, the phrase "evidence based" is typically used in the area of CBT research, and in health care policy. But this can bias opinion away from other therapeutic modalities whose practitioners tend not to advertise themselves with this type of language.
I believe that gathering evidence from prospective, randomized, controlled clinical studies is vitally important--so important, in fact, that we must allow such evidence to cause established opinions about care to actually change. There are many cautionary tales in medical history, in which good evidence about something new was dismissed by practitioners who were resistant to changing the style of practice they had grown up with.
But in mental health care, the evolving evidence is often much less robust than it seems. Most studies are of very short duration. Short-term or superficial care approaches may lead to various symptomatic improvements for many people...but long-term data is often not present. Also, a great deal of evidence supports the efficiency of treatments which work for 60-70% of people, but does not support useful options of how to help the other 30-40%.
Many people may look back and value a short-term course of therapy in some way, but what they really found most valuable and life-changing was something quite different, such as having a dedicated caregiver over a period of many years who didn't practice using modern "evidence-based" methods at all...
It is good to think carefully about evidence, and to be prepared to change our practice accordingly. But the phrase "evidence based" is often just a slogan, a form of jargon, and a construct which can lead to unwelcome biases in thinking. Such cognitive short-cuts can often be very efficient, in order to decide on an important matter quickly, but such short-cuts should never be used to make large policy changes in a system.
It is another language construct which has become much more common, especially in mental health care discussions. Recently, its prevalence has tripled in written language, with a steep increase beginning in about 1993, according to the Google NGram viewer.
But was does "evidence based" really mean?
We often hear, for example, that cognitive-behavioural therapy (CBT) is "evidence based." The implication of this statement is that other forms of therapy must not be "evidence based."
It should go without saying that most everything is "evidence based":
An individual's personal account of their experience is a form of evidence.
A randomized controlled prospective trial of therapy supplies another form of evidence.
An opinion from an expert, or from a mystic, or from a random person on a bus, or from a charlatan, is another form of evidence.
Ironically, the introduction of the phrase "evidence based" may stifle debate and free thinking about a matter. It implies that the issue it is describing has already been decided upon.
In psychiatry, the phrase "evidence based" is typically used in the area of CBT research, and in health care policy. But this can bias opinion away from other therapeutic modalities whose practitioners tend not to advertise themselves with this type of language.
I believe that gathering evidence from prospective, randomized, controlled clinical studies is vitally important--so important, in fact, that we must allow such evidence to cause established opinions about care to actually change. There are many cautionary tales in medical history, in which good evidence about something new was dismissed by practitioners who were resistant to changing the style of practice they had grown up with.
But in mental health care, the evolving evidence is often much less robust than it seems. Most studies are of very short duration. Short-term or superficial care approaches may lead to various symptomatic improvements for many people...but long-term data is often not present. Also, a great deal of evidence supports the efficiency of treatments which work for 60-70% of people, but does not support useful options of how to help the other 30-40%.
Many people may look back and value a short-term course of therapy in some way, but what they really found most valuable and life-changing was something quite different, such as having a dedicated caregiver over a period of many years who didn't practice using modern "evidence-based" methods at all...
It is good to think carefully about evidence, and to be prepared to change our practice accordingly. But the phrase "evidence based" is often just a slogan, a form of jargon, and a construct which can lead to unwelcome biases in thinking. Such cognitive short-cuts can often be very efficient, in order to decide on an important matter quickly, but such short-cuts should never be used to make large policy changes in a system.
Monday, May 2, 2016
Rhetoric and Jargon in Health Care Policy, Part One: "Stakeholders"
Jargon bothers me. It reduces the enjoyment and engagement we have with language. It can be a barrier for others to even understand what is being said.
The term "stakeholder" is part of contemporary jargon in the area of policy development and corporate planning. According to the Google NGram viewer, this word was very rarely used before 1975. Since 1975, its frequency of use in printed language has increased by a factor of 10 000! The words "stakeholder" or "stakeholders" surpassed the prevalence of the word "honesty" in written language as of the year 2000, and since then the prevalence has almost doubled again!
Before 1975 "stakeholder" was primarily used as part of legal jargon, including one definition as follows:
The term "stakeholder" is part of contemporary jargon in the area of policy development and corporate planning. According to the Google NGram viewer, this word was very rarely used before 1975. Since 1975, its frequency of use in printed language has increased by a factor of 10 000! The words "stakeholder" or "stakeholders" surpassed the prevalence of the word "honesty" in written language as of the year 2000, and since then the prevalence has almost doubled again!
Before 1975 "stakeholder" was primarily used as part of legal jargon, including one definition as follows:
"A stakeholder is a person who is or may be exposed to multiple liability as the result of adverse claims."(McKinney, W. M. (1918). McKinney's Consolidated Laws of New York Annotated. West Publishing Company.)
Since 1975, the meaning has evolved to:
"a person or company with a concern or financial interest in ensuring the success of an organization or business" (Oxford English Dictionary)
The
etymology of the word "stake," relates not to its meaning as a sharp
wooden stick, but rather to another meaning, dating back to 1540, as
"the money risked on a game of dice." (Oxford English
Dictionary)
The honourable spirit of the word "stakeholder" has to do with respecting different groups, positions, and points of view while discussing an issue in an organization. It may invite a shared view of complex systemic matters, as though all the different interested individuals figuratively have "money risked on a game of dice." It invites group decision making, rather than a dictatorial approach.
My complaint about this word has to do with its reflexive use as part of jargon. There are connotations of a group of people gathered around in a betting game (which is literally where the word originates). There is an image of wealthy property-holders (with "stakes" in the land) debating about real estate dealings. Another unintended connotation is of a group of people holding sharp sticks, waiting to confront a vampire!
Finally, I wish that people in a discussion could simply be referred to as people, or by name, rather than as "stakeholders."
I believe
that the honourable spirit of respect, intended by using the word “stakeholder,”
is vitally important. But sometimes jargon brings us farther away, rather than closer, to this honourable
spirit. Many policy discussions can be so laden with this, as to be content-free, muddled doublespeak.
I invite us all to express ourselves in an articulate, engaging manner, while letting go of any need to use jargon. Jargon can be a divisive tactic in language and debate: many listeners become inured to it through repetition. The jargon becomes a short-cut to be persuasive, while not leading the listener with any new thought. It becomes "filler" in a dialog, which can distance and bore the audience. This type of rhetoric can fool an uneducated audience into believing that the speaker is bestowing more wisdom than is actually the case. It can also have a suppressive effect on a dissenting voice, therefore stultifying debate and free thinking.
In cognitive therapy, we see that our minds can create various types of "inner jargon," which can perpetuate anxious or depressive states. While cognitive therapeutic theory is laden with its own jargon, one healthy principle it encourages is to practice awareness of our "inner jargon," to "talk back" to it, and to create new, imaginative, constructive, mindful, and reasoned inner dialog or self-talk.
I believe that cognitive therapy doesn't tend to encourage one thing enough: to practice expressing our thoughts, or forming new inner dialogue, in a way which is rhetorically beautiful.
In cognitive therapy, we are encouraged always to garner the courage to offer a dissenting voice! In the case of cognitive therapy for depression, we must bravely speak back, in our thoughts, to a storm of negative, pessimistic, self-critical thinking. Let us make the "speaking back" full of eloquence, poetry, and beauty. Let us step away from using jargon or other forms of empty talk.
We are "stakeholders" of our own minds! Or, different points of view held in the mind are all "stakeholders" of self. But perhaps we can let go of the "stakes" and simply work with ideas, without using jargon, in a frank, articulate, compassionate dialogue.
In cognitive therapy, we see that our minds can create various types of "inner jargon," which can perpetuate anxious or depressive states. While cognitive therapeutic theory is laden with its own jargon, one healthy principle it encourages is to practice awareness of our "inner jargon," to "talk back" to it, and to create new, imaginative, constructive, mindful, and reasoned inner dialog or self-talk.
I believe that cognitive therapy doesn't tend to encourage one thing enough: to practice expressing our thoughts, or forming new inner dialogue, in a way which is rhetorically beautiful.
In cognitive therapy, we are encouraged always to garner the courage to offer a dissenting voice! In the case of cognitive therapy for depression, we must bravely speak back, in our thoughts, to a storm of negative, pessimistic, self-critical thinking. Let us make the "speaking back" full of eloquence, poetry, and beauty. Let us step away from using jargon or other forms of empty talk.
We are "stakeholders" of our own minds! Or, different points of view held in the mind are all "stakeholders" of self. But perhaps we can let go of the "stakes" and simply work with ideas, without using jargon, in a frank, articulate, compassionate dialogue.
Monday, December 14, 2015
Changes in Psychiatric Culture -- Wait Lists, "Efficiency," and Superficial Care
Psychiatrists are more commonly offering the following services:
1) "Assessment": This is a single 1-hour interview, yielding an obligatory report with diagnostic label, and treatment advice. In some places, this single interview is all the psychiatric input that is offered.
The single assessment has rich prececents in other areas of medicine. For example, a visit to a dermatologist could yield a very accurate and fruitful diagnosis of a specific type of chronic skin disease, leading to a clear set of instructions for safe and effective treatments. In many cases, it would not be necessary to see the dermatologist regularly after this assessment, unless the treatment regime was going very poorly.
But psychiatry and dermatology are quite different! Despite our attempts to have a reductionistic and medicalized diagnostic scheme in psychiatry (e.g. the DSM-V), we see that two different people with the exact same diagnosis frequently do not follow the same pathway of symptom progression. Identical treatments do not work in identical ways with different people.
Furthermore, I believe it is an act of significant hubris to assume that one can effectively "diagnose" someone, with respect to issues touching on a person's entire history of self, character, emotion, and intellect, following a single one-hour visit. The "first impression" from a first interview can be very important to understand a person's life and problems, but as we all know, first impressions can very, very often be inaccurate or incomplete. For some people, it could take weeks, months, or even years, to share their story.
Yet, this pattern of assessments may, on paper, appear to be very efficient. One could "manage" wait lists much more quickly. The problem is that a single assessment is actually not very useful, despite yielding an official-looking report which appears useful. Offering single assessments only is similar to a teacher offering a single day of school to each of 4 000 students, rather than a whole year of daily teaching for a classroom of 20. Another insidious consequence of the apparently "efficient" pattern of doing multiple "assessments" is that the therapist, or teacher, who may have a great joy and talent for deeply helping people in an ongoing collaborative relationship, may instead not really get to help anyone very much, leading to sinking morale and rising cynicism. Burnout would probably follow, much more often. But the paycheque would not go down -- it would actually be higher (in psychiatry, the fees for assessments are about 25% higher than for spending the same length of time offering a follow-up therapy appointment).
Many of the patients I have seen have had an incredible, audible sigh of relief, when they have discovered that I am actually going to make time to see them regularly! There is often some sense of surprise that I do not focus on diagnostic labels. The experience of mental health care, for many, has been one of shuttling between various short-term groups, superficial courses of CBT in a sort of group lecture format, brief one-on-one followup which ends just as a deeper sense of trust is forming, and medication trials with primary care doctors.
2) "Medication management visits": In many cases, psychiatrists do not offer what could be called "psychotherapy." Instead, patients are seen for a few minutes, to discuss medication doses. These visits could possibly be more frequent if the patient is not doing as well. It is understandable to have such visits, for people who are wishing to take medication. In clinics serving those who have major mental illnesses, who are taking complex medication combinations, this type of service is undeniably important. Other types of psychotherapy or health care may be happening elsewhere. But if this is the only style of visit which psychiatrists are offering, it creates a frame in which medication use is implied as a norm. Why would you have a "medication management visit" if you didn't want or need medication? From the psychiatrist's point of view, why discuss other matters, such as relationships, goals, dreams for the future, etc. unless it pertains to the medication management plan? The frame leads to an atrophy of therapeutic skill. I think it is a serious problem if psychiatric visits are framed with an expectation of medication management, particularly when we know what an incredibly, strongly loaded set of biases exist around medication use and marketing. The medication management visit framework is surely designed to "optimize" the use of psychiatry, in a setting of long wait lists and shortages of care, but in setting things up this way we are inviting a possible massive deterioration in the quality of care. I note again, that psychiatrists using the provincial fee schedule receive a large financial gain by seeing larger numbers of patients for briefer, more superficial, medication-oriented visits. The decrement in the quality of care may tragically not be noticed in the short term, because wait lists would be shorter, appearing to be beneficial.
Also, "improved" wait list management may cause an external observer to assume that the system has been "fixed," therefore delaying more substantive systemic changes.
In a further sort of game-theoretical analysis of these evolving trends, I believe that there are even more adverse consequences: because of the changing culture of the type of psychiatric practice which is considered a norm, the profession itself will attract those who are most comfortable offering this style of service. Those wishing to do more psychotherapeutic work, or having more skepticism about medicalized psychiatry, would feel ever more part of an eccentric minority, and might choose not to enter a psychiatry residency in the first place. So psychiatry would become even more "medicalized" with time, in a form of evolutionary selection process.
Ideas for Positive Change:
1) Wait list management.
a) The public health system in Canada, and possibly private insurers elsewhere in the world, could simply fund private non-medical psychotherapists. Therapy visits with a psychologist or other counselor could be covered under the public medical services plan. This could reduce psychiatry wait lists dramatically, while also helping the many psychotherapists who are ironically struggling to make a living, despite there being a massive population need for their services. For a large institution such as a university, if there were extra funds to spend on mental health, these funds could be spent on providing service availability with local therapists, personal trainers, music & art therapists, pet therapists, gym memberships, etc., rather than spending money on expensive new buildings and other infrastructure. People help people. Buildings don't help people much, despite appearing to do so.
b) Non-medical psychotherapists could be allowed to prescribe medication, at least in a very limited way. I am not meaning to suggest this as a way to increase medication use! I suggest this to defuse the power dynamic which currently exists among psychiatrists and other physicians. The basics of psychiatric medication prescription do not require many years of medical education to understand and manage safely. In fact, the many years of education may simply consolidate a culture of medication use as an often unnecessary norm. If there would be less pressure on psychiatrists and other physicians as the sole prescribers of medication, then there could be an opportunity for psychiatrists to be less focused on medication, and therefore more focused on therapeutic alliance.
2) Style of Practice
Here, I think it is very simple: make time for people! Doctors, make time for your patients! Be willing to see them! I am less concerned about what style of psychotherapy or other tactics. I am more concerned about being present, collaborative, empathic, and available. We should be well-informed about medications, and about therapy styles such as CBT, but we should focus most of our attention on very basic matters of building rapport, trust, and working alliance, without fear of the relationship being cut off.
1) "Assessment": This is a single 1-hour interview, yielding an obligatory report with diagnostic label, and treatment advice. In some places, this single interview is all the psychiatric input that is offered.
The single assessment has rich prececents in other areas of medicine. For example, a visit to a dermatologist could yield a very accurate and fruitful diagnosis of a specific type of chronic skin disease, leading to a clear set of instructions for safe and effective treatments. In many cases, it would not be necessary to see the dermatologist regularly after this assessment, unless the treatment regime was going very poorly.
But psychiatry and dermatology are quite different! Despite our attempts to have a reductionistic and medicalized diagnostic scheme in psychiatry (e.g. the DSM-V), we see that two different people with the exact same diagnosis frequently do not follow the same pathway of symptom progression. Identical treatments do not work in identical ways with different people.
Furthermore, I believe it is an act of significant hubris to assume that one can effectively "diagnose" someone, with respect to issues touching on a person's entire history of self, character, emotion, and intellect, following a single one-hour visit. The "first impression" from a first interview can be very important to understand a person's life and problems, but as we all know, first impressions can very, very often be inaccurate or incomplete. For some people, it could take weeks, months, or even years, to share their story.
Yet, this pattern of assessments may, on paper, appear to be very efficient. One could "manage" wait lists much more quickly. The problem is that a single assessment is actually not very useful, despite yielding an official-looking report which appears useful. Offering single assessments only is similar to a teacher offering a single day of school to each of 4 000 students, rather than a whole year of daily teaching for a classroom of 20. Another insidious consequence of the apparently "efficient" pattern of doing multiple "assessments" is that the therapist, or teacher, who may have a great joy and talent for deeply helping people in an ongoing collaborative relationship, may instead not really get to help anyone very much, leading to sinking morale and rising cynicism. Burnout would probably follow, much more often. But the paycheque would not go down -- it would actually be higher (in psychiatry, the fees for assessments are about 25% higher than for spending the same length of time offering a follow-up therapy appointment).
Many of the patients I have seen have had an incredible, audible sigh of relief, when they have discovered that I am actually going to make time to see them regularly! There is often some sense of surprise that I do not focus on diagnostic labels. The experience of mental health care, for many, has been one of shuttling between various short-term groups, superficial courses of CBT in a sort of group lecture format, brief one-on-one followup which ends just as a deeper sense of trust is forming, and medication trials with primary care doctors.
2) "Medication management visits": In many cases, psychiatrists do not offer what could be called "psychotherapy." Instead, patients are seen for a few minutes, to discuss medication doses. These visits could possibly be more frequent if the patient is not doing as well. It is understandable to have such visits, for people who are wishing to take medication. In clinics serving those who have major mental illnesses, who are taking complex medication combinations, this type of service is undeniably important. Other types of psychotherapy or health care may be happening elsewhere. But if this is the only style of visit which psychiatrists are offering, it creates a frame in which medication use is implied as a norm. Why would you have a "medication management visit" if you didn't want or need medication? From the psychiatrist's point of view, why discuss other matters, such as relationships, goals, dreams for the future, etc. unless it pertains to the medication management plan? The frame leads to an atrophy of therapeutic skill. I think it is a serious problem if psychiatric visits are framed with an expectation of medication management, particularly when we know what an incredibly, strongly loaded set of biases exist around medication use and marketing. The medication management visit framework is surely designed to "optimize" the use of psychiatry, in a setting of long wait lists and shortages of care, but in setting things up this way we are inviting a possible massive deterioration in the quality of care. I note again, that psychiatrists using the provincial fee schedule receive a large financial gain by seeing larger numbers of patients for briefer, more superficial, medication-oriented visits. The decrement in the quality of care may tragically not be noticed in the short term, because wait lists would be shorter, appearing to be beneficial.
Also, "improved" wait list management may cause an external observer to assume that the system has been "fixed," therefore delaying more substantive systemic changes.
In a further sort of game-theoretical analysis of these evolving trends, I believe that there are even more adverse consequences: because of the changing culture of the type of psychiatric practice which is considered a norm, the profession itself will attract those who are most comfortable offering this style of service. Those wishing to do more psychotherapeutic work, or having more skepticism about medicalized psychiatry, would feel ever more part of an eccentric minority, and might choose not to enter a psychiatry residency in the first place. So psychiatry would become even more "medicalized" with time, in a form of evolutionary selection process.
Ideas for Positive Change:
1) Wait list management.
a) The public health system in Canada, and possibly private insurers elsewhere in the world, could simply fund private non-medical psychotherapists. Therapy visits with a psychologist or other counselor could be covered under the public medical services plan. This could reduce psychiatry wait lists dramatically, while also helping the many psychotherapists who are ironically struggling to make a living, despite there being a massive population need for their services. For a large institution such as a university, if there were extra funds to spend on mental health, these funds could be spent on providing service availability with local therapists, personal trainers, music & art therapists, pet therapists, gym memberships, etc., rather than spending money on expensive new buildings and other infrastructure. People help people. Buildings don't help people much, despite appearing to do so.
b) Non-medical psychotherapists could be allowed to prescribe medication, at least in a very limited way. I am not meaning to suggest this as a way to increase medication use! I suggest this to defuse the power dynamic which currently exists among psychiatrists and other physicians. The basics of psychiatric medication prescription do not require many years of medical education to understand and manage safely. In fact, the many years of education may simply consolidate a culture of medication use as an often unnecessary norm. If there would be less pressure on psychiatrists and other physicians as the sole prescribers of medication, then there could be an opportunity for psychiatrists to be less focused on medication, and therefore more focused on therapeutic alliance.
2) Style of Practice
Here, I think it is very simple: make time for people! Doctors, make time for your patients! Be willing to see them! I am less concerned about what style of psychotherapy or other tactics. I am more concerned about being present, collaborative, empathic, and available. We should be well-informed about medications, and about therapy styles such as CBT, but we should focus most of our attention on very basic matters of building rapport, trust, and working alliance, without fear of the relationship being cut off.
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