Sunday, September 30, 2018

Review: "The Case against Education"

Bryan Caplan, an economist from George Mason University, has written a book called The Case Against Education: Why the Education System is a Waste of Time and Money.

It's quite a title, and quite a thesis, which touches a few nerves for those of us who have spent much of our lives studying and working in the education system.

Summary of the book

Here's my summary of his most important points as I saw them:

1) Degree programs at a university lead to less skill acquisition than what most people think...instead, grades and degrees and attendance at famous schools have mostly a "signaling value."  That is, a person with a diploma, a degree, or high grades is thought of more highly, and is therefore more likely to be given a better job or higher esteem in society, even though their actual skills may be no different from a person lacking such credentials.  If they did have more skills, it may not have been due to the degree, but rather they had more skills in the first place, and that's why they did the degree.  Having a degree could also be an indirect signal of being compliant and obedient, which might be considered attractive by some employers.

2) The social machinery of education therefore causes people to use enormous amounts of time and money for obtaining academic credentials that have mostly "signaling value" but have little use to them or to society otherwise.  Employers assess people based on these educational credentials;  this inflates their value.  Therefore, people who would be otherwise capable employees even without any such credentials must spend years of time, and tens of thousands of dollars, delaying their lives and careers in order to attend classes.

3) It is true that people who are more skilled or apt for some kind of career in the first place, are more likely to obtain these credentials.  But Caplan's point is that these same people would or could have been very similarly capable even if they had not spent years of time and money in the academic system. 

3) He recommends at the very least that education not be publicly funded.

Caplan does have some good data to support his positions, which he shows in his book.

Areas where I agree:

Here are some areas where I do agree with him:

1) I find it tragic to see students who are bored with their education.  Sometimes people have to sit through and struggle through years of classes, competing for grades, trying to complete their degrees, all the while not enjoying the process, not excelling, and not valuing the subject matter.  When the course or the degree is over, the experience is relief.  Sometimes the subject matter of the degree is never looked at again.  The entire experience is aversive or sometimes even traumatic, a repetitive blow to self-esteem with little redeeming value except for the certificate at the end.  People do this because it is considered a social norm and a family expectation to obtain a degree or to go to university. And people do this because employers require more and more academic credentials just to be considered for a job.

2) I agree that trades and technical training programs should be valued more highly.  Such training opportunities could start earlier in life, such as in high school. 

Areas where I disagree:

But here are areas in which I disagree with Caplan:

Caplan points out that people show evidence of having forgotten much of what they learned in university, not long after they finish.  But such tests of memory do not prove an absence of permanent learning.  Almost certainly, in most cases, people would re-learn the material much faster if exposed to it again.   For example, if you took a calculus or Spanish course 5 years ago, but had not used these subjects since then, you would probably score poorly on a test today.  But you would probably be able to re-learn the calculus or Spanish much more quickly than someone who had never taken the course at all.  Knowledge can sometimes go into a sort of "zip file" in the brain, which can't be used immediately, but can be re-awakened if needed. 

Caplan himself shows that while there is a very high amount of signaling vs. skill acquisition in university education, it is not 100% signaling...that is, some true valuable learning has taken place, on average (in some subjects, such as engineering, more than others).  In many areas of life, we have such inefficiency, but that does not negate the importance or value of the activity.  For example, an exercise regime may only lead to a statistically small improvement in health variables, but such a small effect is still positive and desirable.

I find Caplan's comments about certain areas of study, such as within the arts, inappropriate and offensive.   All subjects, all human wisdom, has value...this is part of being human. We should cultivate respect for all forms of knowledge...however I do agree that we need not "force" people to study these things just for the sake of acquiring some signaling item such as a diploma.

Conclusion and personal reflections:

In conclusion, I have always felt that a broad education is valuable for individual lives and for society.

But I believe that educational pursuits should have a stronger focus on joy and meaning, with efforts made to reduce the predominance of signaling effects. 

I agree that we should reduce social or economic penalties for people who do not have formal educational credentials, as long as they can show and develop skill or expertise in other ways.

While I agree that we should value trade schools or other technical programs, I think broad education is important for technical students as well, to allow people to be well-informed and to have a greater esthetic appreciation for the arts, fine arts, and other subjects.  Of course, going to school is not necessary for esthetic appreciation, but school at its best can introduce people to beautiful areas of life that would not be discovered otherwise. 

I would like to see less polarization between arts and sciences programs...I would love to see more overlap.

I think it would be healthy for the activities of students in different faculties, including in the arts, to have immediate relevance and interaction with the community.  It would be interesting, for example, to have more outreach programs.  And maybe the encouragement for students to have their undergraduate essays published, so that all those hours of work writing would not just lead to a product that would be read one time by a professor or grad student, and then never looked at again.

People who are truly bored and struggling through material should at least have broader choices for their educational development, to favour subjects that truly interest them, so that people's youth need not be wasted in a drudgery of unsatisfying and demoralizing work.

My own experience of education through my life has been very positive and meaningful.  There are many esoteric subjects I studied long ago that I may not make much use of, but I consider them to be part of acquiring wisdom, and broad knowledge of the world. In my daily work, a broad education allows me to have better connection with students from many different faculties.

Most of us need some kind of formal structure to motivate us, and maybe some sort of prize at the end, such as a diploma.  Free access to education through the internet is a great thing, but this modality does not have such motivational factors.  I love learning but I am much more likely to get something out of a learning process if there is a more formal structure to it.

In the arts, Caplan seems to suggest that many subjects are wasteful.  Perhaps an example would be the study of Shakespeare.  But I can't help but note the local theatre company which produces Shakespeare plays all summer...all of the performances are packed, with people of all ages!   I think if we were to reduce exposure to literature in schools and universities, we would see a decline in these types of cultural activities, which would be a loss for us all.

But I do think that Shakespeare, if taught in school, should be made engaging, dynamic, and fun,  just like a good theatre production.

I strongly disagree with Caplan's opinion that we should reduce public funding for education.  Reduced funding would penalize those with lower income.  He suggests some kind of meritocratic system as well, which I favour too, but it seems to me that access to a high-quality, enjoyable public education should be a basic privilege granted to all citizens.   I do agree that there could be more educational options though, aside from the conventional, orthodox degree system which has prevailed during this century.

Relevance to mental health:

I bring up this issue in a mental health blog because one of the common environmental factors contributing to unhappiness, anxiety, and depression in young people is frustration with education.  Classes may be boring, excessively difficult, lacking in obvious meaning or purpose, or lacking in application to future life goals.  Classes are also expensive, causing students to be in a compromised financial state for years, relying upon loans or family support, or upon strenuous after-hours jobs.  Grades, if low, can cause demoralization.  Even if grades are high, they can drive a perfectionistic or obsessional quest at the cost of other healthy or enjoyable life activities (ironically, including learning).    Once a degree program is over, many students still have a hard time finding employment, even after a graduate degree.  Sometimes the jobs that are available have only an oblique relationship to the subject matter studied during the degree.

So I think it is good to examine the process of education itself, and to question some of the foundations, as part of helping young people to have good mental health.

Friday, September 21, 2018

Helicopter Parenting vs. Free-Range Parenting

There are many items in the news these days, encouraging "free-range parenting" instead of "helicopter parenting." 

A "helicopter parent" is one who is overprotective, excessively anxious, perhaps enmeshed, and who does not allow children to cultivate appropriate independence or autonomy. 

A "free-range parent," by contrast, is okay with children going off to play by themselves, with the understanding that enjoyment and learning in childhood requires free time, some risk-taking, and figuring out solutions to problems without parental intervention. 

But as with so many issues of this type, we have unnecessary polarization. These parenting styles exist on a spectrum.  And individual children may differ in how much they might appreciate or need one or the other style.  These needs may also change for these individual children over time.

Some children may greatly appreciate a more involved parent, at least at certain points during their lifetime.  Other children may greatly appreciate more autonomy and distance from parents.  Let's not impose a generalized parenting philosophy while forgetting to take the individual situation of the child into account. 

Another angle on this has to do with the enjoyment of parenting.  It is one of the great joys of life to play with one's child.  And I think it is a great memory for a child to see their parent enjoying time with them.   I have seen so many examples of unhappy children playing alone in the park, while their detached, seemingly uninterested parents are sitting on a bench looking at their phones, or are not present at all.  Sometimes, to me, it appears like neglect, rather than being wholesome "free-range." 

There are surely many examples of excessive "helicopter" parenting.  But there are also many examples of parents who are detached, uninvolved, and missing out on enjoying their children's daily lives.    Let's aim for a moderate and flexible approach, somewhere between these two extremes, with a willingness to adjust the style according to the individual child's personality and development.   

Tuesday, May 22, 2018

Book Recommendation: "Behave" by Robert Sapolsky

Behave is over 700 pages long.  Its size may lead to some potential readers being intimidated, but I found it an engaging, often entertaining review of neuroscience, from the lens of someone who has good experience and understanding not just of brain chemistry, but of social, historical, and psychological influences upon behaviour.

One of Sapolsky's big messages, in a nutshell, is that very few single factors (such as hormone or neurotransmitter effects, genes, or environmental incidents) have a simple, obvious, consistent impact.  These factors have different effects depending on the circumstances.  For example, androgens may only exacerbate aggressive behaviour in someone who is already having difficulties containing aggression in the first place.  This immediately makes me question the generic finding (recently published) that violent video games have no negative impact...perhaps there is a negative impact, but only in those who have violent behavioural tendencies in the first place.

On the one hand, this is a refreshing antidote to the simplistic reductionism that is often presented in discussions of neuroscience or psychiatry.  On the other hand, it does not negate the importance of studying these factors with good scientific depth, so as to work with them therapeutically, on a neurobiologic or societal level.

A criticism I do have about the book is his references to areas of the psychological literature (such as about priming, for example) which are now being questioned:  a lot of findings about priming seem to have failed replication tests, and so I'm not sure what to think about this whole area anymore.  I suspect influences such as priming do exist, but may be more transient or erratic than what the original literature suggested.

I appreciate his balanced analysis of the work of other thinkers, such as Steven Pinker, and other historical figures in psychology such as Zimbardo. 

I most appreciate his message of hope, about the things we can all work on to live more peacefully, in light of the influences (positive and negative) upon our behaviour that we are born into, through our genes, family, and culture.

This is another type of book that I wish students could be exposed to as part of their university education about psychology, medicine, or other areas of the humanities.

Monday, April 9, 2018

Steven Pinker's optimistic new book

I'm a Steven Pinker fan...I really appreciate his optimism about the state of the world, and the future of the world, an optimism which he supports with a lot of engaging evidence.

So I encourage having a look at his book, Enlightenment Now.  It is a sequel to another of his books (Better Angels of our Nature) which I have reviewed earlier on this blog.

I don't agree with everything he says, but I do also embrace a spirit of optimism about things, and an attitude that the many problems we have in our lives, or in the world, can be solved or at least improved with continued care and effort. 

This type of book is a good accompaniment to a study of behavioural economics and social psychology (such as the works of Daniel Kahneman), as well as optimistic data analysts such as the late Hans Rosling.

The strongest section of his book is the middle part, in which the reader is barraged with many graphs showing positive changes in the world over time.  I found the other sections, with a lot of philosophizing about the enlightenment, etc. less important and engaging. 

As to this book's relevance to mental health?  I hope we might all embrace a spirit of optimism about the pathways of our lives.   Past adversity in life does not necessarily predict a guaranteed future life of suffering.  There is work to be done, to build a better, happier life, regardless of the hardships of our origins.

In the cognitive theory of depression or anxiety, we understand that thoughts may specifically focus on pessimistic or even catastrophic interpretations of observations; much information in our modern world is distilled to emphasize catastrophe or adversity (non-catastrophes are less likely to become headlines), so this information is natural fuel to a depressive or anxious state.  An optimistic but highly rational book such as Pinker's could be understood as a type of cognitive therapy for a modern consumer of news.

Progress in the world may also translate overall to improved mental health...but I suspect we would see the most robust improvements in those areas which have the least current services.

A peril of such a strongly optimistic text can be that it fails to empathize sufficiently with those who continue to suffer...or that it can seem insensitive when there continues to be horrible tragedy in the world.  But I think that we are best able to help and heal from tragedy if we are not depleted, pessimistic, or even hopeless about the ongoing problems in our lives or in the world.  So this book is a much-needed infusion of optimism into public debate.

Tuesday, March 6, 2018

Depression Treatment Guidelines

I encourage having a look at the September 2016 issue of The Canadian Journal of Psychiatry, which summarizes treatment recommendations for major depressive disorder, based on a thoughtful review of the evidence available at the time.  The authors spent many hours of careful work preparing this authoritative set of articles, and I think they did a good job. 

Here is a brief summary:

1) Various antidepressants are beneficial for treating depression.  They may help with an acute episode, and may help prevent relapses if continued.  Some may work better than others, but the differences are small, and there are likely to be individual cases in which a so-called "second-line agent" works better than the first-line choices.    Some things are classified as "second-line" not because they are necessarily inferior, but because they have not been researched as much as the "first line" things.

2) Various types of psychotherapy are beneficial for treating depression.  These, too, can be helpful for acute episodes, as well as for preventing relapses, even after discontinuation.  CBT has particularly strong evidence for being effective. 

3) As to specifics, such as "which medication is best under which circumstances?" or "which type of psychotherapy is best under which circumstances?", the evidence often does not guide us clearly, aside from CBT in general being favoured. 

4) Various other types of treatment, including ECT, TMS, exercise, and light therapy, have evidence supporting their use.

I am concerned that there was not a lot of critical debate about these claims.  Many authors of review articles are proponents of a particular type of therapy (e.g. light therapy, CBT, etc.), and the content therefore may be biased, or at least lacking input or commentary from different points of view.   It could be argued that "the data speaks for itself," but often the verbal conclusions resulting from the data can be coloured significantly by the author's opinion.

There are some useful specific pointers:  for example, there is a lack of evidence that combining two different antidepressants is consistently helpful.  But "augmenting" strategies, such as adding an atypical antipsychotic medication to an antidepressant, are better supported by evidence. 

In general, for me, these guidelines are most useful as a very general introduction, to get an overview of common treatments, and of up-to-date research evidence.

Here are some ideas of my own to add about "treatment guidelines":

A very thorough understanding of a person's history is most important for care.  In many cases what appears to be "major depressive disorder" ends up being a more complicated story, upon spending time learning the history.  Many treatments such as antidepressants can be dangerous if given without thorough understanding of the history (for example, if there is a history of bipolar symptoms).  Obtaining a good history is not necessarily possible with a single visit, with a standardized interview, etc.  It takes time and a good therapeutic relationship to know a person's story.

There is some question about the validity of "major depressive disorder" as a construct.  Eiko Fried has a good summary of this issue on Twitter:
As I have written before, a great many patients do not have only one diagnosis (assuming we are focusing on a DSM-style diagnostic scheme).   It is therefore limited to focus only on the treatment of depression alone.  I realize that it is a convenience in research to define syndromes in this way, which can then help us to measure the effectiveness of treatments systematically.  But for a given individual, it is often necessary to step away from diagnostic constructs, and help the person in the specific ways they desire or need. 

There are many pathways towards nurturing mental health.  Finally it is reasonable for most people with depression to try various treatments, including medications, provided there is a good understanding of risks and potential benefits.  Psychotherapeutic ideas (such as CBT, but also other styles) are beneficial for most anyone, even those who do not have formally diagnosed mental illness.  Lifestyle and psychosocial factors are very important: exercise, healthy nutrition, healthy social, family, and community development, physical safety, career, education, stable finances, and the pursuit of meaning, should be an invited focus for everyone.    There is relatively little attention given to these issues in most published treatment guidelines (sometimes I get the feeling that some authors in the field are embarrassed to even approach them) yet for many people these issues are the most important of all.

In the 102 pages of this journal, which are devoted to approaching and treating depression--a disease of emotional and often existential suffering, loneliness, joylessness, and a crisis of meaning--here is a tally of individual words used in these pages:

1) love:  0 times.  The search engine found a reference to the author J. Glover as the only occurrence of "love"
2) compassion: 1 time
3) nutrition: 1 time
4) cooperation: 0 times, except as part of 7 references to an agency (the "Asia Pacific Economic Cooperation") which gave money to one of the authors
5) healing: 1 time
6) friendship: 0 times
7) encouragement: 1 time
8) pets: 0 times
9) nature: 1 time (referring to "nature of risk")
10) joy: 0 times
11) humour, laugh, laughter, smile, happy, happiness:  0 times for all
12) art, hobby, hobbies: 0 times
13) patience: 0 times
14) drug: 86 times
15) intervention: 91 times

While I love science (my alternative career would have been a mathematician or a statistician!) it is necessary in mental health care to also discuss issues or words that do not fit neatly into a science or data-based analysis.  These issues include compassion, meaning, love, and patience.  Another issue is finding ways to cope with, live with, or accept unremitting chronic illness or pain, while continuing an evidence-based, but uncertain and frustrating, search for relief or cure.  Algorithms and guidelines tend not to help very much with this existential struggle.    Educationally, I think it is more valuable to present case studies, with group engagement, perhaps with references made to treatment protocols, rather than to make the protocols themselves the subject of the lesson.   

I prescribe a lot of medication.  In some cases the medication appears to be incredibly helpful.  In many other cases, there is a small but significant benefit.  And in others still, there is not much benefit at all despite many, many trials of different medication.  And in a few cases, the medications are harmful.   Many of my patients benefit most from medications that are considered "second line." I can't think of any examples in my practice where guidelines of this type have been useful in determining the most helpful course, aside from being a very general roadmap to remind us of available options or the occasional new finding in the research.   But this roadmap would already be very familiar to most mental health professionals, part of an academic focus over years of training.   Specific treatment issues (such as choosing the best medication or psychotherapy combo etc.) are part of professional development: this requires ongoing familiarity with the broad research literature, and with experience in clinical practice, rather than reliance upon review articles.    Review articles of this type are  authored by research experts, whose work deserves respect; however, the authors represent a limited subset of expertise within the population of mental health workers.

My therapeutic style has included more and more ideas based on CBT, over the past 15 years.   Many of my patients work on structured CBT elsewhere as well.  As with medication, this is incredibly helpful for some, slightly helpful for many, and has little or no effect for a few others.  Arguably, some CBT groups could even be harmful for a few, if there is a large mismatch between what the person desires and needs and what is actually offered.   In many cases, people are familiar with these therapy styles, but have not yet really done the work necessary to derive benefit from them.  This lack of work is usually due to the depression or the psychosocial situation itself, but also can be due to a lack of continuity of care.  It can be a little bit like trying to learn a foreign language, and dabbling in it for a few months, learning a bit of grammar and vocabulary, but never really gaining fluency due to a lack of immersive focus,  and a lack of someone to speak the language with on a regular, long-term basis.

Many people, I think, simply benefit from knowing that they are being cared for, by a person or system which has time and attention for them as they need and desire, sometimes on a long-term, open-ended basis.  It is helpful for mental health care providers to be well-versed in a wide variety of therapeutic techniques, and to be able to adjust or tune the care to what each individual patient or client wants or needs.   Within a system, it is good to value the unique styles and abilities of different individuals within the group, rather than compelling everyone to follow an identical protocol.  Some caregivers are better-suited to using a CBT style, while others are naturally suited to IPT, meditation, or psychodynamic styles.    Some psychiatrists have a particular expertise and interest in medication management.  Most research protocols do not look at this issue in groups or systems.  These individual variations should be respected, but I do think it is also good for everyone to come together to learn from each other.  For example, psychodynamic therapists can adopt interesting, useful ideas from CBT therapists, and vice-versa.

Most of my patients would say that it was not some medication combo or therapeutic style or adherence to guidelines that ended up helping them, but was a combination of many factors, in conjunction with a system of care (such as a therapist, psychiatrist, or other support network) which was stable, consistent, compassionate, and long-term.