Narcissistic & Antisocial Traits in Public Leaders: Part II

 This is a sequel to my last post (https://garthkroeker.blogspot.com/2024/09/narcissistic-antisocial-personality-in.html)

It is possible for a charismatic person with narcissistic and antisocial traits to gain widespread popularity, and ultimately to gain positions of public leadership.   There are many psychological causes for this, which I've discussed in other posts:

https://garthkroeker.blogspot.com/2023/05/foolproof-by-sander-van-der-linden.html

https://garthkroeker.blogspot.com/2022/07/how-minds-change-by-david-mcraney-book.html

https://garthkroeker.blogspot.com/2022/03/belief-bubbles-delusions-and-overvalued.html

https://garthkroeker.blogspot.com/2021/09/conspiracy-theories-vaccine-hesitancy.html

https://garthkroeker.blogspot.com/2023/08/the-power-of-us-by-jay-van-bavel.html

Here are likely consequences for the nations that must suffer under such leadership, and for the world: 

1) "Greatness" will decline, for many reasons.   By "greatness" I mean cultural, moral, technological, and economic leadership.   If such a country is of sufficient size (in terms of population and economy) the whole world will be adversely affected.  

2) Other nations will take over the world's moral, cultural and technological leadership.

3) I am reminded of Shakespeare's insights about the impact on a nation of corrupt leadership.  When the king is corrupt, the whole nation becomes corrupt.  The leader can define the character of the entire country, in the eyes of the world, and in the eyes of its own citizens.  Other corrupt forces in a country are emboldened.  Corruption becomes a norm.  When a bully is the leader, other bullies all over the country become more powerful as well.  Other bullies and tyrants across the world will rejoice.  A cloud of gloom and fear is cast upon the entire country.  We see this as a common theme in the most popular novels and movies, such as "Lord of the Rings."  

4) In this case, a mitigating factor in the past was incompetence, which was oddly protective.  The world was dealing with an almost cartoon-like figure, who lacked the intellectual skills, curiosity,  or fund of knowledge to do too much damage.  It was like a middle-school bully came to be in charge of flying a jumbo jet.  But in the past there were robust protective factors, such as the plane's automated systems, the other staff on the plane, the preoccupation of the bully with playing on his phone rather than playing with the plane's throttle, etc. As a result, the plane survived the trip, even though the pilot was unstable, mean-spirited, and incompetent.    In this case, the bully is now 8 years older, and has been learning the ways of bullying all this time.  And the bully is now angry and vindictive, with added health and cognitive issues due to age.   The bully will have fired or replaced the plane's staff.  The bully will have gathered around him a team of other bullies, who are more extreme and unstable than ever before.  Scientists who designed the plane's safety systems will have been fired or will have resigned to find jobs in more stable countries.  And most alarming of all is the fact that the plane in this case is now flying into very dangerous, stormy conditions requiring the expertise of a good pilot; 8 years ago, through pure luck, the plane was flying in comparatively calm conditions.

5) Medical care will be severely damaged, since health policy leadership will be taken over by individuals who have bizarre beliefs unhinged from scientific progress or wisdom.  It will be demoralizing to health care professionals in this country, and also other professionals across the world.   One aspect of the nation's "greatness" was the capacity to attract the most brilliant people from all over the world; this attractive quality will fade.  Not only will the nation's leadership in technology fade, but others would not want to live there anyway, due to the atmosphere of gloom and even the overt risk of violence.  

6) The nation's and the world's environment will be damaged, since policy will likely reverse or impede progress to reduce pollution.  

7) If there are religious groups that have supported such a leader, the moral and religious leadership of these groups will steeply decline.  It is jarring for a religion whose sacred texts teach values involving love, compassion, redemption, integrity, honesty, forgiveness, wisdom, peace, respect for outsiders, etc. to devolve into support for a villainous figure who has no interest whatsoever in any of these values.  Many stories or lessons in religious texts warn that people of faith can be led astray -- into a desert if you will -- causing terrible harm to themselves and to others.  

8) Political groups that have supported such a leader will lose their association with previous noble values, associated with justice, law & order, dignity, family values, loyalty to global allies, and personal freedom.  

9) For individual young men who have supported this leader, they will likely see a decline in their happiness and prosperity.  If such young men desire to be attractive to women, or to have a satisfying relationship life, this has a much lower chance of happening for them, since support for bullies, and becoming a bully oneself, is not an effective strategy for finding or attracting a mate.  Thankfully, the vast majority of young women do not support narcissistic or antisocial leaders.  

10) One of the typical features of bullying that we can expect in coming years is mockery or frank persecution of people who disagree with or are suffering under the coming leadership.  Bullies and those who support them will mock or belittle those who disagree with them, and even enjoy observing the distress of perceived opponents, even if these opponents are their fellow citizens, doctors, technological experts, musicians, artists, or loyal coworkers. 

What is the role of psychiatry with regard to this issue? 

There will be a lot of depression, anxiety, and even traumatic experience that people will suffer as a result of these political changes, so mental health professionals will have to prepared.  Many of the people who will suffer most are those who supported and voted for the bully in the first place.  

I continue to be upset that the psychiatric community did not organize itself to warn the public about these issues.  Finally I find it a failure in duty to serve and inform.  This did not have to involve talking directly about any particular individual or political group, etc.  But there should have been frequent discussion and urgent efforts to warn about the dangers of narcissistic or antisocial personality traits in positions of power.  This could have started with discussion of personal or family relationships of this type (a phenomenon most psychiatrists would see clinically in the course of an average day), but also discussion of the psychology of persuasion, false information, tribalism, internet use & addiction, and propaganda.   Other peripheral issues could have been discussed as well, such as how to evaluate cognition or competence.  All the major journals and conferences could have frequently addressed this theme in the past year.  Unfortunately, as a professional community psychiatrists more or less stood by and did next to nothing.  I hope that in the future there will be more education and advocacy coming from the professional community about this.  Companies involved with news or social media also did not do enough to address or improve these problems, despite having the technological tools and competent leadership to do so. 

One interesting policy idea in the future could be to require neuropsychological testing for political leaders, at the very least to determine intellectual competence.  It would be useful to know if a major political leader had shocking deficiencies in basic fund of knowledge about the world, capacity to learn new information efficiently, severe attentional problems or tendency to have extreme fluctuations in intellectual capacity determined by a volatile emotional state.  

As always, there will be forces of kindness and good which will ultimately prevail.  We see the spirit of this in many of our favourite movies, such as "The Lord of the Rings."    In that movie the heroic characters struggled a lot, had many losses, and were often tempted to give up.   So we will likewise have a difficult journey ahead.

Narcissistic & Antisocial Personality in public figures: the role of mental health professionals

The norm in mental health practice has wisely been to stay out of politics for the most part, except when it comes to mental health advocacy.  

It would obviously be problematic if individual mental health experts (such as psychiatrists, psychologists, social workers, nurses, etc.) or groups representing professionals (such as specialist associations, editorial boards from journals, etc.) were to endorse or criticize political figures, with a goal to influence elections.  

But sometimes there needs to be an exception to this neutral policy.  

Mental health professionals have a great deal of experience recognizing and dealing with individuals who have behavioural and relational problems such as narcissistic and antisocial personality.  And the most valuable experience mental health professionals bring to this issue is work with patients whose partner, spouse, close friend, parent, boss, or other family member has narcissistic or antisocial traits.

Narcissistic personality traits or disorder include selfishness, self-absorption, boastfulness, need for admiration, arrogance, exploiting others, and lacking empathy.   Antisocial traits or disorder include disregard for others, frequent lying, impulsiveness and poor self-control, aggressiveness, lack of remorse, and criminal behaviours.  While we should always have an attitude of attempting to help people with these traits, it is first necessary to ensure that people with these problems are not in a position to harm others.  It is especially dangerous when a person in authority, such as a parent, boss, or political leader, has moderate or severe traits of this type.  In some ways it is comparable to allowing a small child who has behaviour problems access to a piece of dangerous machinery or weapons. 

If a patient is in a close relationship with someone having narcissistic or antisocial traits, there can be many reasons why the patient has a hard time escaping the relationship.  The relationship may be all they have known for many years.  The relationship may initially have been exciting, passionate, and positive, perhaps an escape from some other adversity, before the narcissistic and antisocial problems showed themselves.   Other people in the patient's life, including important figures such as family or church leaders, may insist or encourage that they stay.  The patient may not recognize or frame the problems in the relationship as abuse, and may instead normalize the behaviours they suffer or which they observe.  Others may be trapped in relationships of this type for economic reasons.  They may fear leaving, due to concerns not only about risk of violence, but also of social or economic isolation.  Others may experience periods of being cared for at times by their narcissistic or antisocial partner, and/or cared for by the social network which supports this relationship, despite the overall toxicity of the situation.   

Sometimes people with antisocial personality lie so often to the people around them, that everyone starts to believe the lies are actually truth, through sheer repetition.  

These factors are similar to the cognitive biases I have described in other posts -- interpersonal or group affiliations can be so strong that they keep people locked into certain choices or behaviours due to group or "status quo" loyalty, even when the experiences they are having are very harmful to themselves and others.  In such entrenched situations, people will selectively attend to data that supports the status quo, and reflexively reject information that encourages change, even if there is a very strong and compelling level of evidence.  

At present, there are important choices in global elections coming up, and a shocking proportion of people appear willing to vote for a person whose behaviour is laden with very serious and dangerous problems.  Not only are there severe narcissistic traits, shocking mean-spiritedness, and vitriolic, hateful, divisive language evident on an almost daily basis for many years, there are frank antisocial traits including criminal behaviour in multiple domains, as well as other very troubling features including an obvious lack of intellectual skills, fund of knowledge, interpersonal warmth, humour (except for mockery),  patience, balanced capacity for judgment, or intellectual curiosity.  There is often frank thought form disorder evident during orations.  Furthermore, there will be a team of other people supporting or working with this person who share similar traits, behaviours, and attitudes, in an ever more exaggerated way compared to 5-10 years ago.  

Other problems in this case include a lack of fundamental cognitive or intellectual skills, a lack of emotional self-regulation, and a lack of principles that might guide wise, effective, or compassionate decision-making.  Instead, I suspect that this person's decisions would often be guided by vindictiveness and attempted self-aggrandizement rather than the good of the country or the world.  Attachment to policies supported by particular groups, such as church groups, would only be used as a tool to advance himself.    Some individuals with narcissistic or antisocial personality can suppress or hide the narcissistic behaviours quite well, and therefore sneak into positions of power before others have a chance to detect the problems.  But in this case, there is a frank display of narcissism almost every time the person speaks, and perhaps a lack of insight or care about it.  Most disappointing and shocking to me is that there is such a large segment of the population that laps this awful behaviour up, makes excuses for it, minimizes it, or disregards it as unimportant.  

It would be quite straightforward to evaluate this person's intellectual capacity.  He is a person who boasted about passing a dementia-screening test as though he thought it was a measure of intelligence.  A simple high-school level fund of knowledge test would be interesting, even to identify places on a map of the U.S. or of the world (such as "where is Poland?" or "where is Nebraska"), or to say a little bit about the cultures or histories of different U.S. states or cities or different countries in the world.  A short quiz about how the economy works, or about even the most basic science (such as "what is gravity" or "what is electricity" or "what is the air made of") would be quite revealing.   A standarized situational judgment test, such as the Casper, often a requirement for applicants to professions requiring interaction with people as part of the work, would be really interesting in this case.   My prediction about these things is that the person in question would score a shockingly low percentile on all of these things, and if this was publicized he would as usual surely blame this somehow on the testing being unfair or stacked against him or a product of "cheating" etc.  

Another frequent egregious and alarming behaviour in this case is something I've described before:  projection.  A rhetorical tactic almost always is to use extreme language to denounce other people, or accuse them of some horrible thing, lying all the way through, yet very often the very things he is accusing others of are obvious features of his own behaviour, character, and history.  

It is especially shocking that certain groups whose personal and group culture is devoted to devout faith, moral purity, law & order, and personal freedom, would double down in their support for this person whose behaviour is in extreme contradiction to these values.   In many religious stories or scriptures, a recurring theme has to do with people of faith being misled or enamored by dark forces--there are many stories where the faithful have lost their way, figuratively or literally, but without having insight or the willingness to change until a lot of harm had been done.  These texts encourage people to humbly reflect and be willing to refocus themselves on their values.    In this case, I think many people including those with strong, honourable moral values and faith,  have very much lost their way in their support of a dangerously unfit leader who is poised to do great harm to their country and the world, in service to himself.  

Of course, it is true that unless a detailed assessment were to be done, we could not have the confidence to make a formal psychiatric diagnosis. But in the realm of narcissism and antisocial personality, most of the actual evidence for such diagnoses comes from collateral information of the patient's behaviour.  In an actual interview, particularly a single individual interview, many people with problems of this type can present themselves in a seemingly normal way (though in this particular case I think there would be many simple ways in an interview to demonstrate some of the problems unequivocally, especially intellectual weaknesses and almost cartoon-like unsuppressed narcissism).   

In any case, this situation reminds me of trying to help a patient (i.e. a large segment of the public) who is in a dangerously abusive relationship with a partner, yet who insists on staying and who might get angry or upset at the suggestion that they could or should think about leaving.  The "patient" in this case is a group numbering 40% or more of the population in certain areas.  

The role of a mental health professional with a "patient" of this type would involve compassionate and empathic exploration of the history, help with treating symptoms of pain or suffering, but also there would need to be movement towards encouraging change or leaving the relationship, warning about the risks of staying, but with a message of hope for a better, happier, more prosperous, more peaceful future after leaving.    Here, a motivational interviewing framework would be needed, since simply encouraging or pushing for change could be very counterproductive if the person does not desire this.  Other ideas for helping include tactics similar to what is described in David McRaney's book "How Minds Change."  (see my post about this book).  

One of the most compelling agents of change or healthy persuasion in this case is to emphasize the role of ingroup members who are speaking out.  In this case, there are many examples.  When an ingroup member speaks out, people are less likely to dismiss the concerns as simply being the product of political opponents.  

Another role of mental health professionals could be to discuss the issue of narcissism, antisocial behaviour, and abusive relationships in a public setting, as an educational endeavour to help people recognize and avoid such relationships in the first place, to be informed about how to get out of such a relationship safely, and to be in a position to help others.  

I have felt that the mental health community has not spoken out appropriately about the current public figure issue I have been alluding to.  I understand the principles behind the reserve, i.e. staying neutral in politics, but this is such an intensely important issue impacting individual and public well-being that something needs to be said about it.  Also, professionals, professional organizations, and editorial boards from journals need not spell out specific opinions about a particular case or a particular person, rather they could simply speak out about recognizing narcissism, antisocial behaviour, entrenched attachment to abusive relationships, the extreme dangers to well-being involved with such situations, the psychological factors preventing change, and things we can all do about it, without spelling out any particular individuals.  

I wish there could be psychiatric journals for the month of October where the issue would be devoted to a review of the research and current state of knowledge about recognizing and dealing with narcissistic and antisocial personality traits in relationships with loved ones, bosses, or community leaders.  In the absence of this, I at least encourage people to explore the issue themselves at a library or online.  

Links: 

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

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

Education for gifted teens

I'm uncomfortable with the term "gifted" since it implies that some people have "gifts" while others do not.  Really, everyone is gifted, and it should be a project in life to help all people cultivate their gifts and be acknowledged and appreciated for them.  

But admittedly, there are some students who whose talents and abilities allow them to be doing university-level academic work, or advanced work in performing arts,  by mid-childhood.  Leaving these children in the regular educational system could be boring or stifling for them, both intellectually and socially.  

There are various sources of data about the value of various educational programs, including those catering to students with unusual talents.  Testimonial accounts from the students and teachers are obviously an important source of data.  There could be very glowing accounts of particular programs, or perhaps also scathing critiques, from different individuals, during or after their exposure to the programs.    These are bound to influence subsequent policy.  Or there could be "before" and "after" data, showing that most students in these programs do extremely well by some measure (unfortunately the measures often do not look at long-term psychological health).  

But using data from testimonial accounts or "before/after" studies is fraught with problems.  Students gifted in mathematics or other sciences should understand this very well -- it is a foundation of understanding treatment effects in medical statistics.  If there are many students who give glowing accounts of a particular academic program, or entire cohorts who do well compared to their previous state, what does this really mean?  It could mean that the program itself is excellent and should be continued.  But another possibility is that gifted students are likely to thrive because of their giftedness or intelligence, and they would have thrived regardless of what type of program they were in.  It is possible that the particular program was actually harmful to them compared to some conventional alternative, but they still gave a positive review because of their innate tendency to thrive adaptively.  Similarly, negative reviews of a particular program could be caused by a bad program, or it could be caused by character traits in the reviewers, such as perfectionism, narcissism, or depressive symptoms. 

Some positive reviews could be inaccurate judgments, skewed by other factors such as pride or narcissism.  For example, graduates from an ivy league university may give inflated reviews of their educational experience because of the pride of being associated with such an elite institution.  They may have had a similarly good undergraduate experience at a small local college.  Of course, it is not an "either-or" issue.  Ivy league education is indeed probably better in many ways, but not as much better as people believe it is.  

In order to really determine the effectiveness and healthiness of a gifted program, one would have to do sufficiently powered randomized controlled studies, with both subjective and objective short and long-term assessments looking broadly at social and psychological well-being as well as academic achievement or career success.     Testimonial data is useful but not sufficient.  Jargon-laden theorizing by educational scholars is particularly meaningless and tiresome unless grounded by controlled data.   

Aside from the need to have policy grounded in RCT data, there are a few features that need to be present to have a healthy, effective educational program for gifted children: 

1) there should be specialized teaching to fully develop the students' capacities, otherwise they would be bored and understimulated.  For some students, "teaching" per se is not required -- the students can teach themselves, and an external didactic teacher, especially one trained to be a high school teacher, could often just get in the way.  But there should be adult mentors who are at least supporting and guiding the students' progress, and forming a warm personal connection with the students.  For technical subjects, there should be access to advanced laboratory materials.  And probably there should be access to experts such as university professors who can interact with and challenge the students at their level.  

Some teachers who specialize in teaching gifted children may simply load the students with an enormous quantity of material.  This leads to a risk of harming the children. 

2) it is most likely of benefit for gifted children to be in a group of peers who have comparable abilities.  This is one of the stronger arguments for a "gifted program."   However, this could be achieved in other ways, such as through clubs, in a regular high school or community.   For some gifted students--though not all--the regular high school social environment would be an oppressive chore to deal with

It should be noted that such peer affiliation may not always be positive.  It could foster elitism in some cases, or interfere with social skills.  Or ironically, for some gifted kids, a special program would take them away from peers rather than bring them closer.  Peership is not necessarily about mutual expertise in mathematics or some other academic subject--it could have to do with character or shared interests.  There could be a lot of variation between individuals with respect to this.  

3) educators should be aware of the phenomenon of eager parents pushing their children, driven by the parents' pride or ego or perhaps well-meaning but misguided notions as to what is best or healthiest.   

4) Regardless of whether children are in a gifted program or not, and regardless of these kids' talents, their academic program during childhood should allow for a balanced, healthy lifestyle.  There should never be so much homework that kids would not have time for sleep.  Lengthy commutes to and from some special school program, taking 1-2 hours of time daily, should be understood to have a negative impact on a teenager's mental and physical health -- these are hours that could have been spent playing or exercising or socializing or sleeping or studying.  

5) Rushing children through 5 years of high school in just 2 years, even when the kids are very capable intellectually to do this, necessarily will narrow the academic breadth of learning, even for the brightest of children.    Consideration should be given of broadening what is offered, over a longer period of time, rather than narrowing over a short period. 

6) For particular subjects such as literature, it will not be possible to introduce as much breadth of content in a confined period, whether the students are gifted or not.  Furthermore, many gifted programs are so oriented towards students who are destined to study engineering or other hard sciences, that English is glossed over.  In some cases the program may be engaging in some degree of grade inflation regarding literature courses, so that the students end up spuriously receiving good enough English grades to get university admission, even though their actual performance is mediocre or poor.    Mind you, this touches on the subject of university admission criteria--a genius-level student in mathematics perhaps should not be expected to have high grades in English or history in order to gain admission to an advanced university math program.  Demanding high grades across the board for university entrance discriminates against those who have focal areas of excellence but also focal areas of academic weakness.  However, giving high grades in English to students who lack literary skills is unfair to those who have true excellence in literature, and demeans the subject.  

The converse problem is often present in university-level literature courses.  There is a tradition of professors giving very low grades in university English courses, often with the highest grade being in the mid 80's, very few students earning an A, and very few students actually able to change their grade through a term by following any type of constructive feedback from the instructors.   I suspect that if student essays in these courses were objectively and blindly graded by a panel of professional writers and journalists, we would not see good correlations with the professors' grading.  I suspect that adherence to what Steven Pinker called "academese" is unfortunately rewarded, rather than good writing.  This issue may also be amplified by insecurity within this academic community, giving a false sense of importance of the subject by giving low grades to most students.  

7) For scientific subjects, cramming students through high school level courses quickly may well facilitate successful early university entrance, into engineering or physics programs etc.  But often the curriculum offered is narrow.  A gifted program could instead offer greater breadth rather than only greater speed of traversing curricula.  For example, adjunctive courses in statistics would be tremendously useful for any science prodigy, but this material is usually neglected, in favour of advanced calculus or computer science etc.  An enjoyably broad survey of scientific subjects would also be possible for gifted students, to gain a basic understanding of astronomy, geology, meteorology, climate science, ecology, botany, evolutionary biology, etc.   

8) Arts subjects are often neglected in gifted programs.   Breadth in arts and literature could involve studying a wider range of contemporary and historic literature, including a survey of world literature outside the usual western focus.   Many gifted programs tragically do not have robust opportunities for students to participate in performing arts or fine arts activities such as dance, theatre productions, or visual arts.  

9) It is absolutely unacceptable for children not to have regular physical education.  This doesn't necessarily require sports teams, etc. (although this should probably be an option), but a culture of regular, daily fitness is a foundation of a mentally and physically healthy lifestyle.   It is one of the things that teachers would definitely be in a leadership position to offer.  

10) Subjects relating to basic well-being, self-care, etc. are often neglected.  This could include courses in nutrition, food preparation, practical life skills, social and conversational skills, psychology (including an introduction to CBT), and personal finance.  

11) Some gifted programs can become an insular niche.   It could be valuable for new staff trainees to rotate through regularly, to prevent such programs from stagnating, and to allow constructive feedback to occur so that staff can maintain or improve skills, perhaps with constructive feedback invited from students, parents, and alumni of the program.  

In assessing programs of this type, it is perilous to gather data only through something like an external review.  Such reviews are often "corporate" style as though one were assessing a factory.  If there were serious problems, often staff would be reticent to discuss them, since they might fear losing their jobs.  The data gathered would be cross-sectional or testimonial in nature.  This could highlight very serious issues with leadership, safety,  incompetence etc.  Once again, in order to guide sound policy on this matter, RCT data would need to be gathered systematically, such as by doing a prospective randomized study of two or three different approaches to help gifted children, compared with a control group, with a sufficient number of participants, repeated over many years of time.   Such data would likely be "noisy" just as it is in psychotherapy research, because often the strengths or weaknesses of a program are strongly impacted by the particular individual teachers, rather than the style or format. 

In the meantime, simple alternatives for students who are much more academically advanced than their peers could include allowing the freedom to take individual university-level courses before having graduated from high school at all.  Each student could possibly have an individualized plan to help them, perhaps with exposure to advanced material in one area of their life, while having an "ordinary" childhood experience in other areas, depending on that student's wishes or needs.  

Another issue with policy that is usually neglected is consideration of the well-being of the teachers and other staff.  If teachers are bogged down by administrative duties such as long, pedantic meetings or obsessively detailed report cards etc., are restricted in their actions through micromanagement or rigid policy, or are simply overworked without time for their own self-care, this is harmful not only to the individual teachers but obviously to the students as well.  One of the roles of a teacher, for any student, gifted or not, is as a stable, healthy, happy, mentor, who can engage in work in a sustainable, enjoyable way.  A teacher who is stressed out, overworked, unhappy, trapped in an unhealthy bureaucracy, etc. is less available and effective for the students.  Gifted students could be particularly harmed by this, since many of them would have a tendency to push themselves too hard, to the detriment of their mental health.  They would need to have adult role models who have balanced lifestyles, and time for personal connection.    A negative environment of this type cannot be hidden: children often have a really good idea about what's going on even when problems are not spoken about.  

As a psychiatrist, with decades of experience working with a university student population, I have seen many gifted young people.  While many young people in this population are outstandingly happy and mentally healthy, often going on to amazing achievements in their personal and professional lives,  there are many mental health phenomena that are more common in this group, such as autism-spectrum symptoms, perfectionism, obsessive-compulsive phenomena (both OCD & OCPD), eating disorders, and sometimes narcissistic traits.  There have been cases of major mental illnesses and suicides.   In general, I have not found that people in this group have been helped dramatically by their high school gifted program, though many of them would have positive things to say about it.    Usually in their accelerated program, they did not have time nor were they offered any compelling help for mental health issues or to simply have the healthy, well-balanced lifestyle that would have benefited them.  Often they had inordinate pressure from parents.  I can think of one very gifted scholar who didn't want to "develop" their gift at all, but felt obligated to because of the high expectations of parents, teachers, and even self.   In many cases, the programs led to these students being in a university too young.  In many other cases, I think these students would have thrived regardless of what type of program they were in during high school.  But they probably would have had more opportunity for exploration, fun, and play had they started university at a more typical age.  

This subject speaks to a broader issue of "giftedness."  Everyone is gifted, in the sense that we have beautiful qualities which need to be cared for or developed.  But development of gifts must occur in a way that is compatible with physical, mental, social, and community health.  Gift development may require special resources, but we should resist the urge to drive this development at the fastest possible pace.  Sometimes such an intensive but well-meaning drive can damage people, and damage their gifts, rather than help them.   

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

and 

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

and 

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

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

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

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

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

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

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

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

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

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

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

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

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

  

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

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

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

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

C - conspiracy theories.  Encouraging conspiracy theory beliefs. 

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

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

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

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

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

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

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

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

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

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

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

References: 

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

Why to get your COVID bivalent booster

The COVID vaccines have saved millions of lives, and spared millions more a frightening hospital or intensive care admission.   Many people may not realize that recovery from a COVID hospitalization will often not be complete; tissue damage from COVID pneumonia may not heal completely, also the psychological effect of respiratory failure should not be underestimated.  Severe respiratory failure (a terrifying, suffocating experience) can often be a cause of PTSD that could affect you psychologically for years afterwards.   The vaccines have caused a huge reduction in such episodes of respiratory failure.  

COVID vaccinations are not perfect, and their protective effect does diminish gradually with time, though does not disappear entirely.  There are indeed rare cases of serious adverse effects, much lower than the rate of similar or worse adverse effects from COVID itself.  Also, vaccination reduces the probability of spreading to other people, thereby multiplying the beneficial effects in the whole community.  Vaccination followed by a mild case of COVID a few months later likely adds robust protection compared to vaccination or infection alone.   But the most effective and safe protection is to have an updated bivalent COVID booster, particularly if your last dose of vaccine and any episode of COVID infection has been more than 2-3 months before present.  Unfortunately, fewer people have had their boosters compared to previous vaccine doses, resulting in thousands of needless hospitalizations and deaths.  

Anti-vaccine misinformation is widespread, with testimonial accounts from people claiming that the vaccines are harmful.  It is important to know that a bivalent booster will lead to a large reduction in risk of severe disease, hospitalization, ICU admission, and death.    Evidence to support this is very, very robust, and unfortunately has not been emphasized strongly enough in current public health information campaigns.  

I encourage perusing the references below.  Aside from reading the studies and assessing the evidence for yourself, I encourage you to look up the authors and verify for yourself that these are incredibly experienced, well-educated researchers from major research centers, with no major biases or profit motives affecting their findings.    The research findings are corroborated and consistent with the  experience of ICU and infectious disease physicians, who on a daily basis in the past months have continued to see much more severe COVID disease and dangerously high hospital occupancy among those who are not up-to-date with their booster vaccinations.  

The references below are a preliminary list; I encourage you to continue checking out other references I've included in my previous COVID-related posts.  

References

Watson, O. J., Barnsley, G., Toor, J., Hogan, A. B., Winskill, P., & Ghani, A. C. (2022). Global impact of the first year of COVID-19 vaccination: A mathematical modelling study. The Lancet Infectious Diseases, 22(9), 1293–1302. https://doi.org/10.1016/S1473-3099(22)00320-6

CDC. COVID Data Tracker.  Centers for Disease Control and Prevention. 

https://covid.cdc.gov/covid-data-tracker/#vaccine-effectiveness

https://covid.cdc.gov/covid-data-tracker/#rates-by-vaccine-status

Arbel, R., Peretz, A., Sergienko, R., Friger, M., Beckenstein, T., Yaron, S., Hammerman, A., Bilenko, N., & Netzer, D. (2023). Effectiveness of the Bivalent mRNA Vaccine in Preventing Severe COVID-19 Outcomes: An Observational Cohort Study (SSRN Scholarly Paper No. 4314067). https://doi.org/10.2139/ssrn.4314067

https://www.azdhs.gov/covid19/documents/data/rates-of-cov-19-by-vaccination.pdf?v=2023010

Lin, D.-Y., Xu, Y., Gu, Y., Zeng, D., Wheeler, B., Young, H., Moore, Z., & Sunny, S. K. (2023). Effectiveness of Vaccination and Previous Infection Against Omicron Infection and Severe Outcomes in Children Under 12 Years of Age (p. 2023.01.18.23284739). medRxiv. https://doi.org/10.1101/2023.01.18.23284739

Andersson, N. W., Thiesson, E. M., Baum, U., Pihlström, N., Starrfelt, J., Faksová, K., Poukka, E., Meijerink, H., Ljung, R., & Hviid, A. (2023). Comparative effectiveness of the bivalent BA.4-5 and BA.1 mRNA-booster vaccines in the Nordic countries (p. 2023.01.19.23284764). medRxiv. https://doi.org/10.1101/2023.01.19.23284764

Davydow, D. S., Gifford, J. M., Desai, S. V., Needham, D. M., & Bienvenu, O. J. (2008). Posttraumatic stress disorder in general intensive care unit survivors: A systematic review. General Hospital Psychiatry, 30(5), 421–434. https://doi.org/10.1016/j.genhosppsych.2008.05.006

Tenforde, M.W. et al. (2022). Early estimates of bivalent mRNA vaccine effectiveness in preventing COVID-19-associated emergency department or urgent care encounters and hospitalizations among immunocompetent adults. VISION Network, nine states, Sep-Nov 2022.  Morbidity and Mortality Weekly Report, 71(5152), 1616-1624. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Also, the book does not discuss individual variations in people as a factor affecting tenacity of belief, propensity to conspiracy beliefs, resistance to fact-based arguments, etc.  In my previous post (https://garthkroeker.blogspot.com/2021/09/conspiracy-theories-vaccine-hesitancy.html?m=1) I discuss factors such as past trauma and personality disorders as factors which could cause an individual to hold more rigid harmful or false beliefs.  There would need to be some varability in the approach to conversing with someone about these issues, given these individual variations.  It may be valuable to focus persuasive efforts on those most ambivalent or amenable to change within a strong ingroup.

 

Medical School Admission Criteria: a discussion

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

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

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

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

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

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

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

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

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

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

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

The Elephant in the Brain & The Folly of Fools

 Two more books to recommend:  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Belief Bubbles, Delusions, and Overvalued Ideas

 One of the most important posts that I've written on my blog, in my opinion, has been "Political polarization, propaganda, conspiracy theories, and vaccine hesitancy: a psychiatric approach to understanding and management," initially published on September 1, 2021 but edited and updated numerous times since then.   I check periodically how many people visit my blog, and I see that there are relatively few.  If I could recommend just one of my articles to be published widely, it would be that one, since I think it is so important regarding individual and public mental and physical health issues in the world today.  

The topics in that post focused on misinformation, propaganda, and deluded beliefs regarding the pandemic.    

I frequently see similar issues at play in my daily work as a psychiatrist.  

What causes fixed false beliefs?  When would we call these "delusions" as opposed to overvalued ideas, or simply examples of erroneous thinking?  

In psychotic states, the mind creates delusional beliefs without any reinforcement from a social community.  This is caused by genetic factors, abnormalities in dopamine circuitry in the brain, magnified by psychosocial stress.  As a result of the individual nature of psychotic illness, fellow members of the community can easily recognize the problem, and hopefully attempt to help.  Such delusional beliefs are unlikely to spread in a social network.  

There are examples of "shared psychotic disorders" in which an individual may have a primary psychotic illness, leading to close associates or family members adopting the same beliefs.  But this is a relatively rare phenomenon.  

A much more challenging problem occurs when false beliefs are spread in a social network.  In this case, the beliefs may or may not have anything directly to do with the other beliefs or values within the social network .  For example, extremist anti-vax beliefs are more common in particular religious or political groups, but vaccines have very little to do with theology or ideology.   The process of ideological spreading in these cases is analogous to what Dawkins calls a "meme", though driven not by a natural selection process, but by a process akin to "sexual selection."   In "sexual selection" traits such as peacock feathers propagate together with traits for recognizing and desiring the initial trait.  For example, bird songs or feather colours are sexually selected due to the song or feather itself and the desire of other birds to recognize or value the song or feather.  The song or feather comes to be an emblem of the species itself, rather than having other adaptive or communicative value (bright or decorative feathers do not lead to improved flight).  Many examples of "mass delusion" such as anti-vax beliefs are likely similar; they have become emblems of membership in particular religious or political communities, which are found to be attractive by those within the communities, even though the beliefs are harmful to the group and contrary to the group's positive values.  In this way, they are ironically similar to a virus:  anti-vax dialogue and behaviour has become much more prevalent or even dominant in these religious or political groups, such that the groups' core values or policies are utterly neglected or contradicted.   People from outside these groups would be disgusted by this phenomenon, leading to the groups becoming more insular, decried as hypocritical and immoral by outsiders, and obviously less able to offer charismatic outreach.  In particular, values such as love, care, and freedom are profoundly contradicted by beliefs which decry life-saving public health protections.  

Anti-vaccine and other "anti-public-health" propaganda is extremely harmful to society; it causes needless suffering, death, and economic hardship.  The propagation of such ideas is shockingly dissonant with the core values of many of the groups associated with it.  Disparate groups have endorsed such beliefs, leading to an unusual medley of fundamentalist religious groups, biker gangs, and racist groups joining in protests or defiance against vaccine and public health mandates. 

It is very difficult to address or improve problems of this sort.  When beliefs have been adopted as an emblem of a tight-knit social community, they are strengthened greatly by group association, and group members will defend these ideas from outsiders, almost like people might defend their home or family from invaders.   These ideas become adopted as almost sacred core values,  as though the beliefs (in this case about vaccination, wearing masks, etc.) were enshrined in a sacred religious text such as the Bible.  

As with psychotic illness, there are degrees of severity.  In mild cases of psychosis, affected people may be able to question their beliefs or request help; in more severe cases they have the insight to know that others would see their beliefs as paranoid, so they are able to refrain from discussing their beliefs, even though they still are fully believing their delusions.  In more severe cases, people will start expressing, or casually "slipping in"  the paranoid ideas in casual conversation (even with a psychiatrist) almost as though to test or evaluate the conversational partner, perhaps to seek a kindred believer or to be warned about a "nonbeliever."  As with some examples of religious practice, "believers" may seek to attempt to "convert" others as though expressing the delusion has a sacred value.   

I think it's pretty important as a psychiatrist to gently inform people that there are delusional beliefs going on.  With entrenched delusions this may need to be done with the greatest care and empathy, but I do think it needs to be discussed at least a little bit, otherwise there is a risk of the person feeling their delusions have been endorsed.  In the case of socially-spread overvalued ideas, it's a more difficult process to address in a therapy setting.  In some cases the discussion risks spreading to a focus on ideas concerning religious or cultural beliefs, which are generally off-base.  But when new "contagious" beliefs are spreading in a social network, straddling the boundary between a "cultural belief" and a "delusion," unbridled and harmful spreading is more likely.  This is similar to the epidemiological dynamics of COVID itself:  COVID is deadly, but its death rate is low enough to insert itself into populations in a seemingly harmless way, until a few weeks or months later when hospitals and ICUs are overflowing with severe cases.  Ironically, if the mortality rate of COVID was much higher, it might be easier to control at a community level, because there would be more unity of action.

As I discussed in my "political polarization" post, there are many social actions that can help this situation.  It is most valuable for rational, persuasive pro-vaccine, pro-public-health members of affected social groups (such as religious leaders, truckers, political leaders on both sides of the political spectrum, police, military personnel, alternative health care providers, and people formerly part of the anti-vax movement but who have changed their position) to speak out as educators and leaders.   Scientists and public health officials, etc. should still do their best to offer effective public communication, with efforts to reach out to these groups, but they are less likely to have a substantial impact in these communities, since they will be dismissed or derided as threatening outsiders.   Some of the communicative efforts from scientific leaders could at least involve building a better rapport with disparate communities, so that scientists would not be seen as elitist or part of an "ivory tower," out of touch with the rest of the population.    Meanwhile, there is evidence that the rest of us should continue to do our best to combat the spread of misinformation, and to do our best to speak the truth, rationally, resisting the urge to give up in frustration.