Wednesday, September 1, 2021

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

I initially published this post in September 2021, with some additions or editing every month or two since then. 

If you don't have time for a longer read, I encourage skipping ahead to the end, where I discuss ideas about what we can do about the problem of vaccine refusal. 

Introduction

Political polarization, propaganda, and conspiracy theories have caused the world great harm in the past few years. A related problem has come up recently, with a significant minority of people refusing COVID-19 vaccination, leading to the pandemic lasting much longer, claiming many more lives, depleting and exhausting workers in the health care system, and causing much more economic damage.

Another round of this came up in Februrary 2022, with convoys of protesters rallying supporters to challenge vaccine mandates and other public health measures.  Protests of this sort are demoralizing and infuriating to those who are trying to help.  It is like a town threatened by a giant forest fire, with burning embers blowing into the neighbourhood,  but protesters tired of restrictions intimidating the firefighters, surrounding the fire stations with horns blaring (waking tired families and children trying to sleep nearby), and demanding to reclaim their right to have open fires.  

In this post, I will explore the psychological and social factors contributing to these problems, with suggestions of things that individuals, community organizations, companies, church groups, and governments can do to help. 

For a brief video introduction to this topic, I recommend a recent short Netflix documentary,  The Mind: Explained, the episode called "Brainwashing."  

A highly recommended book about how to communicate effectively with people having extremely polarized or conspiratorial beliefs is How Minds Change by David McRaney (2022).  

Polarization

It has become more common for people to hold extreme political views. There are increasingly hateful and intolerant attitudes towards political opponents.  Many of us are familiar with  the 2014 study done by the Pew Research Center, showing this polarization gradually worsening in the U.S. since 1994.

Propaganda

Propaganda is false, exaggerated, or misleading information spread for political or manipulative purposes. Many large news organizations in the U.S. support a particular political party, leading to unprecedented exposure to biased information consumed by nearly half the population. Social media sites such as Twitter and Facebook often lead people to obtain information only from like-minded others. Not only does this lead to extreme bias, it also builds a community of online friends or followers who "egg each other on," ideologically or personally, while denigrating opponents often in a mocking or hostile way. 

Beginning in March 2022, the world has once again seen the most horrific propaganda of all, that which persuades an entire nation to support a war against its neighbour, while preventing its citizens from seeing or understanding the atrocities being committed.     

Conspiracy Theories

Conspiracy theories have become more common and more bizarre, often associated with ideological positions or a particular political party. While most of us have had a sometimes amused tolerance for people holding these beliefs, conspiracy theorists are now more organized, can magnify and spread their ideas using social media, and have managed to influence public policy to some degree. I am aware of people in public positions who seriously believe that COVID-19 vaccines contain microchips used to track people, and that Bill Gates is somehow responsible for this. Others believe the moon landing was faked, or even that the earth is flat. 

Ideas of this sort are now very prevalent, with social media and other news sources contributing to their spread.  Such misinformation can often be presented in a professional manner, as though it is valid documentary reporting.  This attracts many followers who then continue to spread these ideas.  

Anti-Vaxxers

We are all weary of the COVID-19 pandemic. Millions have died or suffered severe disease, and many others have had severe financial losses. Many more are going to die. Most COVID patients will recover fully, but a significant minority of survivors will have long-term health consequences (so-called "long covid"), with symptoms such as chronic fatigue and respiratory problems.

We have vaccines that can cause large reductions in pandemic-related severe disease and death. The rapid development and mass distribution of vaccines since 2020 is one of the most outstanding scientific achievements in history. We also have other knowledge about control of viral respiratory disease, such as about mask usage, ventilation improvement, frequent home testing, etc. which, together with vaccination, could have brought our countries out of the pandemic much more quickly, with much less economic hardship, with much less psychological or social hardship,  and with much less loss of life.

No vaccine is perfect.  There are small risks of side effects, including some rare serious problems; but these risks are much lower than risks caused by COVID itself.  Also, very few vaccines lead to perfect "sterilizing" immunity.  The main impact of COVID vaccines has been to reduce the probability of severe disease, hospitalization, and death from COVID, while having a much smaller effect to reduce milder disease.  This protective effect also gradually fades over 6-12 months, though probably does not disappear entirely, requiring booster vaccinations at this point, while new COVID waves are continuing.  There is accumulating evidence that the vaccines also reduce the probability of developing "long covid."   Because of high vaccination rates in Canada, especially in older cohorts, we narrowly averted the disastrous hospital and critical care overflow that would otherwise have occurred in the waves before 2023.  Vaccine development, like any other human process, is never perfect either; there may be many steps of the COVID vaccine development story, such as political or economic issues, to criticize in some way.   But this should not distract us from appreciating how these vaccines have saved more lives, prevented more years of life lost, than almost any health intervention in our history.   

But a significant minority of people refuse to be vaccinated, refuse to use masks, and even refuse to acknowledge that the pandemic is a serious problem. Those who refuse are more likely to belong to particular political or religious groups, are more likely to watch particular news channels, and are more likely to have less education.  

Unvaccinated people from 2020-2022 were much, much more likely to require hospitalization, including intensive care.  At this point, recipients of recent vaccine boosters continue to have a much lower hospitalization rate.  From 2020 to early 2022, hospitals all over the world were filled to capacity, and beyond, by unvaccinated COVID patients.  If everyone had been vaccinated, there would still have been hospitalized patients (since the vaccines are not perfect), but there would never have been overflow or a major strain on the health care system.   Because of inadequate vaccination rates, everyone else (vaccinated or not)  had much more limited access to medical services, including elective surgery and ICU.  Because of people who refused vaccination, it became much more dangerous for all of us to have a heart attack or a case of appendicitis.  Furthermore, the staff in the hospitals were overworked to the point of exhaustion, the horror of the situation magnified further by the needlessness of it.  Vaccine refusal caused extreme harm to health care workers all over the world, and  led the health care system itself to the brink of total breakdown.  

A new horrific development following all of this, is the increasing prevalence of refusal to get vaccines against previously eradicated diseases such as polio and measles.  If this continues, it is likely that we will once again see children needlessly paralyzed or killed from preventable infectious diseases, for the first time in decades.  

Anti-vax beliefs and other bizarre beliefs about COVID can be shockingly extreme and unchangeable: we have many examples of people remaining convinced that COVID is a hoax, right up to the moment of their death from respiratory failure in an ICU bed. Medical colleagues of mine, working in rural areas with low vaccine uptake, have described many stories like this during the pandemic. There are horrifying examples of hospital workers being threatened or attacked by people convinced that the medical care is somehow harmful.  There are examples of public health officials who are afraid to advocate for vaccines, due to having received intense harassment and even violent threats.  

Alternative Medicine 

In many cases, bizarre beliefs about COVID are an extension of unusual ideas about health care. The alternative medicine industry has a market size of about $100 billion per year. Parts of this industry harmlessly promote healthy lifestyle habits, nutrition, or evidence-based care, but there are a lot of exaggerated or false claims made in the sales of alternative medical services and products.   Alternative health care can involve bizarre or even delusional beliefs about illness. There can be distrust for evidence-based medical science, and loyal allegiance to the alternative practitioners despite harmful practices.  

I realize it is excessive and unfair to simply condemn alternative medicine.  Many people have had bad experiences of conventional health care.  And many people have experienced kindness, generosity, support, and helpful guidance from alternative practitioners.  Many alternative practitioners have wisdom in particular rehabilitative techniques, and some knowledge of conventional medicine.  Some supplements or alternative remedies do have a reasonable evidence base, sometimes on par with standard treatments.   Conversely,  conventional physicians sometimes recommend treatments including prescription drugs or surgery which in some cases have a questionable foundation in evidence.  

Problems in modern medicine, including expense, access problems, or brief, impersonal clinical encounters, can feed some frustrated people's pursuit of alternative health care providers who may have more time for empathic support or apparent understanding.  Unfortunately, this apparent understanding is often based on fictional beliefs couched in pseudoscientific language that can sound impressive or convincing.

There are frequent examples of misguided beliefs in alternative health care practice, particularly when the practitioners are marketing expensive products, pushing bizarre theories of causation using expensive, unnecessary pseudoscientific testing procedures,  fomenting distrust in conventional medicine, or discouraging patients or clients from seeking proven therapies, including medications or vaccines.  

Con Artistry & Fraud

Many people with strong opinions opposing vaccines, supporting quack treatments for COVID, or supporting particular political leaders since 2016, have been conned -- that is, they have been victims of fraud. They have been sold something that seemed very attractive to them at the time, but the goods they've obtained are worthless or harmful to themselves and others. But many people would feel an embarrassing or humiliating injury to their pride to admit that they were conned; so instead, they double down on their support for con artists (including particular politicians) or quack remedies. 

There is a fascinating research literature on this subject. I would start with Maria Konnikova's book, The Confidence Game: why we fall for it...every time. Her book is a series of case studies of various types of spectacular con artistry & fraud, with some discussion of the psychology underlying this. The next scholar to be acquainted with is Brooke Harrington, a Dartmouth College sociologist. I'm in the midst of reading through this work. One of her questions has to do with justice: when should a person who has been conned into doing something harmful be considered an offender requiring management in the criminal justice system, instead of only a victim requiring compassionate care?

I see these issues as closely tied together, fed by the same underlying causes. Together they are driving people and nations apart; they have caused needless suffering, death, and economic hardship during the COVID pandemic, and have led to an unprecedented threat to democracy in some parts of the world.

These are not new problems: they have been with us throughout history. Many of us associate propaganda with World War II or the Soviet Union, not modern-day western democracies. Many of us associate bizarre or erroneous beliefs about health with previous centuries, in which people attributed disease to evil spirits, "excesses of bile," or an excess of blood in the body requiring treatment by bloodletting. Unfortunately, bizarre beliefs about health are alive and well in modern society.

It is crucial to understand and study these problems, to know why they happen and what can be done to improve the situation. A thorough analysis requires input from many fields, including from historians, political scientists, sociologists, public health experts, and psychologists. 

Myside Bias and Motivated Reasoning

The most powerful factor, in my opinion, driving extreme political difference, extreme contrarian views about the pandemic, and "anti-vax" ideas, is what Steven Pinker, in Rationality: What it is, why it seems scarce, why it matters (2021), calls "myside bias," which then gives rise to so-called "motivated reasoning."   This is the tendency to selectively attend to evidence which supports your pre-existing opinion, and to discount or ignore evidence which refutes your opinion.  We are all prone to this.   Your opinions, ideas, and beliefs about almost any issue can become associated with your identity, or your group, or your "side," with differences of opinion or contrary evidence representing some kind of a threat to your identity or values.  Contrary evidence could even bolster your initial opinion further, almost as though your ideas are like a family or village being attacked by outsiders, leading to the community rallying and strengthening itself in response.    Myside bias and motivated reasoning are greatly magnified in groups, and are caused or fueled by many of the factors which I will describe below.  

Haidt: The Righteous Mind

I recommend reading Jonathan Haidt's book, The Righteous Mind: Why Good People are Divided by Politics and Religion--an excellent introduction to the psychological factors which drive ideological differences. Haidt presents himself as a moderate, or even a right-leaning moderate, which I think at the very least should increase the readership and acceptance of this book across a wider swath of the political spectrum.

        Group Loyalty, Tribalism & Ingroup Bias

Haidt concludes that there is a human trait of feeling loyal to groups; those groups with stronger or more frequent loyalty traits among members will have advantages in survival and prosperity. These groups will be more cohesive and better able to defend themselves against outsiders. Some individuals value group loyalty above all other values; this is partially a heritable trait. While loyalty is a virtue, it can also lead to group members continuing or even fanatically increasing their loyal devotion when the group is engaging in destructive or corrupt behaviours, even when such behaviours are causing suffering to the group members themselves. The most extreme examples of fanatical group loyalty are seen in cults, but variations of this phenomenon are seen in daily life--in our families, our communities, our sports teams, our religions, our political groups, and our nations.

We have seen groups with extreme opposition to COVID vaccination harassing exhausted health care workers outside hospitals. Other groups participated in 2021 in an unprecedented mob attack on a world capital. Yet members of these groups previously may have valued ethical principles, such as fairness, hospitality, helpfulness, and the rule of law. Fanatical group allegiance can cause members to stray towards behaviour that is contrary to the group's previous fundamental values.

Groups containing devoutly loyal individuals are likely to have higher hostility to outsiders. Loyalty is a good thing, but in the setting of polarization, propaganda, conspiracy theories, and vaccine hesitancy, such unthinking, rigid loyalty is destructive to others and destructive to the group members themselves.

One of the suggestions Haidt has about improving the problem of polarization is to maintain open dialogue, value the principle of respectful debate, and foster friendships between people and groups with different views. This would involve cultivating friendships between those on the "left" and "right" of the political spectrum, rather than devolving into hostility and becoming "enemies." But this approach is not very helpful for dealing with fanatical or extremist groups; at that point, friendly debate and social warmth will not be possible.

Unfortunately, many people holding anti-vax beliefs and other strongly polarized positions have become too extreme to allow respectful social connection. Yet there are many others whose positions are moderate or ambivalent on these issues, including friends, relatives, and neighbors of extremists. These are the people most amenable to friendly engagement. 

The psychology of Conspiracy Theories

        Lack of feeling in control, need for certainty

According to psychologists studying this area, such as Van Prooijen and Douglas, conspiracy theorists often feel a lack of agency or control, a need to make sense of complex or confusing situations going on in life or in the world, a desire for being respected (but not feeling that such respect is being given), and a need for certainty. Like other delusions or overvalued ideas, conspiratorial thinking can give rise to a feeling of relief, since there is an explanation about why a problem is happening, even though the beliefs are fictional. The explanation, and the excitement of being part of a select group of fellow believers, can give back some feeling of control or certainty, a new sense of purpose. Other people's skepticism could be perceived as a noble challenge to be faced. 

In helping this problem therapeutically, people trapped in conspiracy beliefs need to be shown personal respect and empathy, before any attempt to challenge or refute the false beliefs.  

        Past Psychological Adversity or Trauma 

Prior psychological hardship can sometimes drive people into a fearful, angry, hateful, distrustful, or even paranoid state, with relief of ongoing psychological stress found in narrow or rigid ideologies. Others, including refugees, may have understandable reasons not to trust authorities or the government.  Neuroscientist Nafees Hamid has shown that experiences of social exclusion or discrimination contribute to radicalization.  In some cases, people with a history of trauma or social rejection will find comfort, support, and belonging in groups, such as churches and other community organizations, or extremist fringe groups, even if these organizations are engaging in extreme polarization or conspiracy beliefs. Members of these groups will naturally feel protective and loyal towards the group and the group's beliefs, even if these beliefs are causing harm to others. Therefore, some people develop anti-vax beliefs as a result of their past trauma. 

The possibility of past trauma should always be kept in mind when dealing with someone who is trapped in a conspiracy theory mindset, with compassionate support offered, while always challenging the false beliefs.  

        Personality Disorders

Personality disorders are common, affecting several percent of the population, with milder symptoms affecting many more. They cause lifelong disruption in relationships, behaviour, and emotional stability; people with personality disorders often lack insight that they have a problem. They are caused by a combination of hereditary factors and long-term environmental adversity, such as childhood abuse.

Many conspiracy theorists have narcissistic personality: they believe they are better, more insightful, more informed, and more intelligent than other people, and that other people's skepticism or rational arguments are signs of stupidity or inferiority. They are unable to tolerate critical feedback. A softer type of narcissism is due to unmet psychological needs to feel unique. When extreme narcissism is present in a major world leader (as was the case starting in 2016) the entire group of followers can adopt a narcissistic attitude, even if these traits would normally be abhorrent, or entirely at odds with the group's previous religious or ethical standards.

Another factor is obsessive-compulsive personality. Here, there is a rigid understanding of moral issues, a tendency to be quickly and firmly judgmental, and a tendency to favour a polarized view of issues. Again, such character traits would generally be difficult to tolerate, but when present in a charismatic leader, they become endorsed by the group itself.

Schizotypal and paranoid personality disorders can also lead to conspiracy theory beliefs. With these personality variants, people have low-grade delusional beliefs, magical thinking, superstitions, and mild paranoia.

Finally, there is antisocial personality, which leads to criminal behaviour, a lack of empathy, callous disregard for others' suffering, manipulative behaviour towards others, and compulsive lying, despite showing superficial charm. We have seen this factor in a major political leader since 2016 and in many con artists profiting from the pandemic. 

It should be noted that many conspiracy theorists do not have personality disorders.  They have been swept into false beliefs due to misinformation and group allegiances, but are otherwise mentally well, sometimes well-educated and intelligent.  

In order to help people who have personality disorders, compassionate understanding is required.  There are various therapeutic systems that are useful, including CBT and DBT.  Motivational interviewing techniques are also likely valuable.   Sometimes medications could be of some modest help, at least to reduce specific symptoms such as anxiety, irritability, or low-grade paranoia.  But in order for there to be any possibility of therapeutic help, there would need to be a safe, stable therapeutic frame.  If a person is angry, volatile, or behaving dangerously, therapy is impossible unless there can be strict boundaries guaranteeing safety.   For some people, these boundaries can be difficult or impossible to negotiate.  Furthermore, many people suffering from personality disorders lack insight about their problems, and lack the desire to work on personal change in a therapy setting.  The first step, in these cases, is often to impose limits on negative behaviour.  This is why antisocial personality, for example, usually needs to be dealt with in the justice system.  

        Low Education, Innumeracy, & Lack of knowledge about the world

Many conspiracy theorists have lower levels of education, lower levels of intelligence, and a desire for accuracy or meaning but a lack of the cognitive tools to find this rationally.

Innumeracy, a lack of scientific knowledge, a lack of statistical knowledge, and a general lack of knowledge about the world (for example, about history, culture, geography, or economics) are significant factors contributing to poor personal and political decisions. Even relatively intelligent people who are not broadly educated and informed are more prone to ingroup biases and conspiracy theories. 

Ellen Peters' book Innumeracy in the Wild: Misunderstanding and Misusing Numbers is a detailed account of poor mathematical skill in the population. She shows that only a small minority of people have the skills needed to accurately interpret data, and to correctly guide decision-making. As a result, most people either make erroneous conclusions about data, or are dependent on others to interpret the data for them. This makes people vulnerable to political influence from people who misconstrue data. These influencers may have a deliberately manipulative goal, or may be inadvertently misleading because they are also innumerate.

Without aptitude in science, critical thinking, and reason, verbal ability alone does not protect against being drawn into ingroup biases or conspiratorial thinking. Brittany Shoots-Reinhard, Ellen Peters, and others have done a lot of work over the past decade looking at the relationship between intellectual ability and decision-making. They recently published an article showing that people with higher verbal ability are more likely to have polarized responses to COVID-19, and to consume more polarized media. Numerical skill did not predict higher polarization.  

This suggests that people often use verbal intelligence, not to improve their reasoning or judgment, but to more efficiently gather information that supports their pre-existing views, often ideological and determined by ingroup biases. This is especially problematic at a political level, since verbal intelligence is a more important skill than numerical or scientific intelligence for a politician to be successful, or for a celebrity to be influential. Therefore, we have people who are more likely to have polarized beliefs holding positions of influence in society.

If we see studies looking at the effects of education on various psychological phenomena, beliefs, or ideologies, we need to look at the type of education, with a particular look at numeracy, logic, and reasoning skills, as well as the degree to which the education contains subject matter about global issues, such as history, geography, environmental science, economics, etc. 

It should be noted that some individuals swept into conspiratorial thinking are intelligent and well-educated, and may have good analytical skills.  They are influenced in their misinformation journey by other factors such as group allegiances.   They may use their intellectual skills to spread misinformation more effectively, or even become seen as experts in their communities.  

        The internet and news-bubbles

The internet provides a medium in which people with extreme beliefs can easily form a community, which in conjunction with traits for group loyalty, leads to them forming a strong identity, an "us vs. them" mentality, and a resistance to rational evidence from outside the group.

It is not enough to address this problem on a one-on-one basis. There are political, economic, and educational factors that are likely to help, on an individual and societal level. I'll come back to this later. 

Polarized News Sources & Propaganda

Major news networks in various parts of the world are deliberately propagating conspiratorial thinking and fomenting polarization, catering to entrenched members of particular ingroups. These networks have a profit motive, but the owners of the networks are also driven by ideological beliefs to push this to further extremes. They are popular and tend to have high ratings, especially when they are denigrating ideological opponents in a dramatic way. These news networks lack any form of regulation that prevents or limits harm (particularly in the U.S., after the removal of the FCC fairness doctrine in 1987).

Unfortunately, this has led to a steep decline in the quality of news information that many people are consuming. Fans also form an ingroup loyalty to the news service itself, such that mainstream news may be deemed "fake" or biased. Many fans normally value kindness, civility, education, politeness, the rule of law, balanced debate, and religious beliefs rooted in love and compassion. But due to powerful ingroup loyalty effects, the fans of these news services can embrace leaders or pundits who are unstable, mean-spirited, and bullying.

It is important not to underestimate how powerful and destructive propaganda can be; we have to realize that the freedoms we have enjoyed in modern democracies can be quickly eroded under the influence of powerful and well-financed propaganda efforts.

 Cognitive Biases 

Cognitive biases are "shortcuts" of thinking which allow us to make decisions more quickly. These shortcuts can be useful, since we don't always have the time to analyze every issue in our life in detail. But they can cause massive errors in judgment, especially when we are not even aware of them. For an introduction to this area of psychology, I recommend reading Daniel Kahneman: he is the one psychologist to have won a Nobel Prize.  His book Thinking: Fast and Slow is fun to read and a summary of Kahneman's masterful research.  I'd like to review some of the more common cognitive biases which perpetuate conspiratorial thinking, political polarization,  and ideological extremism:  

    Reactance

Reactance is the urge to do the opposite of what someone wants you to do to resist a perceived constraint upon your freedom. This has been one of the driving factors causing resistance to pandemic-based public health restrictions and vaccinations, and which drives political polarization more generally. A component of the reason many people are refusing vaccination or defying pandemic restrictions is reactance or defiance, because they don't like being told what to do, especially by people who they may see as outside their ingroup.

    Reactive Devaluation

Reactive devaluation is the tendency to devalue an idea or a proposal, only because the idea comes from an opponent. So almost any idea coming from a political opponent is reflexively devalued and opposed, regardless of whether it is rational, correct, or helpful. If the same idea had come from an ingroup member, it would be approved enthusiastically. Reactive devaluation is profoundly self-destructive, not only to individuals, but to entire nations. Unfortunately we see this daily in U.S. politics. Once again, this is a reason many people oppose advice about vaccination or public health measures.

    Projection

Projection is attributing to other people the feelings or problems that you have yourself. For example, you may feel angry with someone, but in a conversation you may have a strong belief that it is the other person who is angry at you. While projection is not typically considered a cognitive bias, it is a common psychological mechanism among those with personality disorders, and among con artists. In the former group, projection is often "unconscious"-- that is, people project without even realizing they're doing it. It would be an issue to be addressed in psychotherapy. In the latter group, it is used deliberately and consciously as a manipulative technique. A well-known political leader after 2016 could be seen to engage in both forms of projection every week--accusing others of bad qualities or behaviours that were obviously his own.

In a conversation with someone holding fanatical anti-vax beliefs, you may encourage the person to be more informed of evidence. But that person will project: they will claim that it is you who are not aware of the evidence! They will deny being conned themselves, but will claim that it is you who have been conned! Many anti-vaxxers are calling people who follow public health guidelines "sheep," while it is the anti-vaxxers who are often passively swept up in mindless herd behaviour. 

    The Availability Cascade

The "availability cascade" and the "illusion of truth effect" refer to the tendency to believe a statement simply because it has been repeated frequently, or because it is easy to understand, even though the statement is false. Many beliefs about the pandemic, including those from conspiracy theorists or those from the "anti-vax" groups, seem more believable simply due to frequent repetition. The staggering daily abundance of frank lies emerging from a major world leader from 2016-2020 were often not perceived to be lies by many people, due to the frequency of exposure and the cognitive ease involved in processing such statements. Or sometimes people did not care that they were lies. Sometimes hateful speech is unfortunately too easy to process cognitively; it may appeal to some deep, primitive component of our brains that is excited by rage and deprecating others. 

    Confirmation Bias

Confirmation bias is the tendency to only look selectively at evidence which supports a previous position. This is driven partly by powerful ingroup loyalty. Even when there is overwhelming evidence to support a contrary position, people suffering from confirmation bias will often remain stubbornly insistent that their own narrow, outdated, or invalid research findings are correct.

    Anchoring

Anchoring is the tendency to stick with an initial position or estimate, or to be swayed by it strongly. If you have started having a particular belief, there is a tendency to maintain it. This is particularly true if there are personality traits valuing consistency, commitment, and loyalty more strongly than traits valuing rationality, compassion, or wisdom. One can become irrationally "loyal" to initially-held ideas (such as about perceived harms of vaccines. or about supporting a political leader who proves to be dangerously unstable) even if these ideas are self-destructively inaccurate and contrary to other values.

    The Dunning-Kruger Effect

The Dunning-Kruger effect and the "overconfidence effect" refer to a tendency for unskilled people to overestimate their ability. We see this with many people making strong claims about specialized areas (such as about epidemiology or virology during the pandemic) despite minimal expertise. Unfortunately, such people can be quite persuasive, not because of their expertise, but because they may be popular and have a loud or persistent voice. On the other hand, many experts may have a rather modest voice, and therefore their accurate messages are under-amplified.

        Present Moment Bias

"Hyperbolic discounting" or present moment bias, is the preference for immediate payoffs relative to later payoffs. On an individual level, this reflects a lack of self-control when faced by temptations. On a community level, it leads to neglect of long-term societal needs, such as health, environmental integrity, and education, in favour of immediate profits, even if such profits cause severe long-term pollution, economic damage, or health damage. We see this in the pandemic management as well--many are unwilling to make a short-term sacrifice (such as maintaining social distancing or mask use) even though such small sacrifices would lead to much larger longer-term gains in health, prosperity, and survival for themselves, their families, and their communities.

    The Sunk Cost Fallacy

The "irrational escalation" fallacy or sunk cost fallacy is the tendency to continue investment in a decision that was made previously, despite new evidence that the decision was wrong. Basically, it can be humiliating or injurious to pride to change one's mind, so it can feel easier to hold onto one's mistaken views or decisions rather than change them. 

    Normalcy Bias

The normalcy bias is the refusal to plan for or react to a disaster which has never happened before. If you live in an earthquake zone, but have never seen or experienced an earthquake, you are less likely to consider how to survive an earthquake or protect your home. It is much less likely that you would undertake expensive large-scale disaster preparations. This phenomenon has happened with COVID. Many experts were well-prepared; there were even organized national preparations for pandemics, but some leaders of major governments dispensed with all of this. The same problem is likely to happen on a much worse scale regarding the ongoing degradation of the earth's environment (disappearance of forests, mass extinctions, degradation of fisheries, loss of wildlife habitats, and climate change). Once a disaster is already underway (such as a house fire or earthquake or flood or pandemic or climate change) it is much, much harder to reverse the situation; it becomes much, much more expensive if not impossible to find a solution. Prevention is much, much more affordable and efficient than expensive disaster management.

     The Ostrich Effect

 The ostrich effect is the tendency to ignore an obvious negative situation. Once again, we saw this in a major country upon the outbreak of COVID, and we see this with the environmental & climate change problems. On a personal level, we see this in the tendency for people not to seek medical help when they notice a serious problem, just hoping that it will go away on its own. It is driven by some combination of fear (in this case fear of the truth and fear of how difficult the treatment might be), and magical thinking (i.e. somehow believing that if you don't look at a problem, then it will go away).

    What to Do About Cognitive Biases

Daniel Kahneman, the world's leading expert on cognitive biases, is doubtful that we can eliminate cognitive bias.  Even people who are very well-educated about this issue are still prone to bias, just like everybody else.  The best we can do is educate ourselves about this, be watchful for bias in ourselves and others, collaborate together to make better judgments, and be open to feedback from others on this issue.  Whole communities should be open to critique from other communities, and not try to shut down debate or discussion.  

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Similarity to Addictions 

Ideological bias and conspiracy thinking have a lot in common with addictions, since they are harmful to individuals and communities, but hard to escape. People often dabble with polarized or conspiracy-based ideas a little bit at first, often influenced by psychological adversities, family or peer culture, and genetic risk factors, then become more and more drawn into problematic behaviour over time; in this way, it is like someone trying cocaine with their friends a few times per year at parties, then escalating gradually towards weekly, then daily use, all the while justifying the behaviour as harmless, enjoyable, or a cultural norm.  

Addictive behaviour can cause deep satisfaction or relief in the moment; moving away from addictions can be challenging and painful; people often cannot do it without external help. Furthermore, many people with moderate to severe addictions deny they have a problem, and do not see any reason to change. They may see their addictive behaviour as simply a lifestyle choice, enjoyed by many friends, with any problems lying with other people who criticize them.

Addictions are strongly entrenched by a peer group of fellow addicts. Moving away from addictions often requires that people let go of their current social network, leading to feelings of loss, loneliness, boredom, and a lack of meaning. This is one of the reasons that we have to offer social and community support to people if we would like to help them move away from entrenched polarization or ideological biases. 

Biases & Educational factors beginning in childhood

Many biases and educational factors causing people to be trapped in a narrow or hostile ingroup begin during childhood, with parents, family, and community members teaching and influencing the children. Many people believe things only because their parents, teachers, and peers believed them. After childhood, people will be more likely to associate with, befriend, marry, or have children with others who are similar; this further entrenches previous beliefs and makes differing belief seem strange or wrong.  

Heredity

There is a hereditary influence on the tendency to be dogmatic or stubbornly adherent to ideologies, and on general intelligence. But hereditary predispositions are never absolute, and are never purely good or bad. Hereditary factors, if channelled through a healthy environment, can lead to good individual lives and a healthy community. 

Refusal to admit mistakes

One last huge psychological factor is refusal to admit mistakes. Many people would rather carry on with a previous decision even if it is leading to disastrous results. They would be embarrassed, ashamed, or would not "save face" if they had to admit they made a terrible mistake, or if they had to reverse their position on an important issue.

This stubbornness can be an extremely powerful factor; it could be a psychological defense, a way of protecting a person against the need to feel intense shame and regret for past decisions which caused terrible harm. This phenomenon is fed by some of the biases listed above, such as the sunk cost fallacy, anchoring, and ingroup biases. Instead of owning up to a bad decision, people will go through a remarkable feat of denial, to persuade themselves that they didn't make any mistake at all. Many people hold onto strong anti-vax beliefs or conspiracy theories for this reason. They might be willing to change their mind, but the cost of admitting a big mistake is too high.  

 Well-funded corporate groups & "think tanks"

Wealthy corporate donors with strong ideological positions are funding marketing campaigns and employing the small cohort of contrarian scientists to push policies opposing vaccination, public health measures, environmental protections, and other public policy ideas they see as relevant to their ideologies or profits. These corporate groups or "think tanks" have members who are part of the political or religious ingroups described above. Their biases are not just individual, but organized, powerful, and very well-funded, often with billions of dollars of financial support. 

Oxford-trained Duke University public health scholar Gavin Yamey has warned us about the influence of such groups, and has compared their tactics to those used in past decades by the tobacco industry: denying or twisting health risk data, to plant seeds of doubt in the population, in order to maintain profits of a multi-billion dollar industry despite the terrible harms it caused.  

External Political Interference

Other nations with antagonistic relationships with our own are attempting to propagate conspiracy theories and extremist groups, mainly using social media, in an attempt to disrupt or weaken our nations. This is a national defense issue. 


What to do about it

There is a lot that can be done about this problem:

1) How Minds Change 

David McRaney, in his 2022 book How Minds Change: The Surprising Science of Belief, Opinion, and Persuasion, describes techniques to communicate with people who have strongly entrenched beliefs.  I strongly recommend this book.  The ideas are based on showing respect, empathy, establishing rapport, sharing personal stories, searching for higher principles in common, gentle inquiry about the person's sources of evidence for their belief, and honest exchange of your own view, but without arguing or showing anger or contempt.  

2) Inoculation against Misinformation

Van der Linden et al. have shown that so-called "inoculation" techniques can protect people from misinformation.(see link).   This involves exposure to videos explaining how misinformation techniques work.  They have even devised an online game called "Bad News"  (see link) which helps people see how powerful misinformation techniques can be, in a gamified form.  This technique is similar to the best ideas from CBT (cognitive-behavioural therapy): the therapy requires exposure, following informed consent, to the heart of the problem, in order to overcome it and be protected from future adversity.  

 3)  Massive campaign to provide information & counter misinformation

According to MIT post-doc Ben Tappin, people differing due to an ideological divide are still persuadable using reasoned arguments. A major reason ideological divides lead to such tenacious resistance to change is the lack of exposure of ingroups to such reasoned argument, and the extreme prevalence of ingroup exposure to false arguments. Therefore, it makes sense to keep up our efforts to provide accurate information, and not give up or become resigned, believing that anti-vaxxers or other ingroup members are not persuadable.

We cannot only have health experts, such as government health officers, speaking to the public. Many anti-vax people will not be persuaded at all by a public leader. We need to have spokespeople in the information campaign representing ingroups associated with the anti-vax movement. We need to have right-wing political leaders, religious leaders, celebrities, sports stars, people with different levels of education, and people from different employment groups, all involved in this marketing and information campaign.

We specifically need to hear from people who were formerly part of the anti-vax movement, who have changed their mind. We need to hear directly from people who are severely ill in hospital, preferably with video.

Consideration should be given to prosecution of those spreading misinformation.

4) Addressing Myside Bias by emphasizing unity

Polarized differences and myside bias can be reduced by emphasizing that we are all on the "same team."  Such a principle of unity, of treating all fellow humans with equal respect, regardless of nationality or culture, is consistent with the laws or constitutions of most countries, and with the principles of most religions.   We all want to prosper, to live a healthy, happy life, to live in peace, and to have freedom while also acknowledging the need for cooperation.   We have a shared humanity despite the existence of national or cultural borders.   Unity between divided groups often improves if the groups need to work together to solve a larger external threat.  In this sense, it is unfortunate that the pandemic (a worldwide threat) has not led to a greater degree of unity between nations.  Environmental degradation is another massive looming threat of this kind.  Disagreement about the nature of such threats, and about the type of action needed, is part of the problem.  

5)  Friendship, Diplomacy, and Trade between opponents

 We should strive to develop friendships and trade relationships between members of opposing groups.  Steven Pinker emphasizes this point in his book on the history of violence in society,  Better Angels of Our Nature: Why Violence has Declined

This principle could be objected to, using extreme examples: most of us would not consider it appropriate or helpful to have cultivated friendships with Nazis during World War II. But most members of opposing groups are not extremists; they are moderates. It is necessary to denounce extremism, but this does not mean denouncing almost half of the entire population on the other side of an ideological divide. If there is to be anyone influencing or learning from each other, there has to be ongoing friendship. 

6)  Experiential Education

 Direct experiential education is extremely important. People need to take tours through overflowing intensive care units, meet the burned out but highly compassionate and expert staff, and be aware of the suffering patients there. There will be many patients who are members of their very own ingroup. I think this will be very persuasive, but this has barely been done at all during the pandemic. Of course, there are technical, ethical, and privacy-related barriers to having such tours, but these barriers could be overcome with good planning. At the very least, there should be embedded journalists in these environments, just as embedded journalists have been allowed access to war zones.

7) Vaccine Education

Specific education about vaccine-preventable diseases (such as polio, measles, or smallpox) is important and helpful. Many people don't understand how severe these diseases were, and how remarkably effective vaccines have been to spare hundreds of millions of people (mostly children) terrible suffering and death.

Specific education about how vaccines work is important. Many people simply do not know these things. 

8) Ingroup leaders as educators and influencers

Members of ingroups (most likely moderates) will be much more influential as sources of education and information, than members of outgroups, who will most likely be dismissed if they are even heard at all.

In the case of the pandemic, encouragement of vaccination from religious leaders and right-wing moderates will be useful to persuade others in this community to be vaccinated. Leaders of these ingroups must denounce extremism and violent behaviour. 

9) Emphasis on underlying values

The importance of emphasizing underlying values is a point made by Haidt. People on the right-wing of the political spectrum tend to value loyalty, family, and purity. Issues such as environmental protection and vaccination are consistent with values of loyalty and purity. It is loyalty to country, loyalty to one's own children (looking after their present and future well-being, enjoyment, and prosperity), and loyalty to God (who would want to care for all people, to encourage peace on earth, to care for the place we live, and to help people help one another). The idea of purity is well-served by plans to protect the environment and to protect the body from a devastating infection. 

10) Stop funding propaganda outlets

Steps should be taken by individuals and corporations to stop financial support for propaganda outlets, and to support independent, unbiased journalism. In general, we would not want our news sources to be influenced by wealthy donors or political parties. 

11) Beware of partisan "think tanks"

Good investigative journalism is needed to show financial and political influences coming from partisan think tanks and corporate lobby groups. I hope that if people can become more aware of these issues, there could be organized efforts to oppose such groups, and legislation to limit their power.

National security efforts are critical, to prevent other nations from contributing to propaganda and extremist groups in our countries. Investigative journalism is essential, as is monitoring of "bots" and fake social media accounts, etc. Government action is likely to be necessary. 

12) Reduce social media polarization

Steps should be taken, on a personal and political level, to reduce the tendency for social media platforms such as Twitter and Facebook to produce "news bubbles" and to foment division or extremism. This could involve persuading social media companies (through individual and government intervention) to adjust the algorithms on their sites, to help reduce exposure to extremist positions or false information, and to help "fact check." On a personal level, one of the options is simply to reduce or stop using social media. 

13) Psychiatric techniques

As a psychiatrist, it is often impossible to challenge entrenched biases with a patient unless there is a very strong therapeutic alliance, rapport, and trust. Even then, the amount of change to expect is very limited and slow, especially in the short term.

It is possible to encourage education, to help patients expand their horizons a little bit.

If there are low-grade psychotic symptoms underlying belief in conspiracy theories, an antipsychotic medication could be useful, but most people with this issue would not be willing to try this.

If past trauma or adversity is driving involvement with conspiracy theories or destructive ingroup behaviour, then compassionate, empathic trauma-informed treatment could be helpful.

Cognitive-behavioural therapy (CBT), in principle, could help people to recognize and change cognitive distortions or biases, but the nature of longstanding ideological bias is less amenable to change, in part due to a lack of insight on the part of those having these problems, and in part due to powerful resistances to change that people have developed over a lifetime, maintained or magnified by like-minded family and peers. 

Motivational interviewing is another set of techniques that would be useful to engage with someone having problems due to polarization, conspiracy theories, ideological propaganda, or anti-vax ideas. This is a style of therapy used to help people with addictions. Its foundation has to do with acknowledging a spectrum of insight and willingness/readiness to change for people with addictive problems, and to match the treatment with the level of readiness. While motivational interviewing is a suitable therapeutic style, it is also to some degree a pretty obvious, common-sensical approach. In any case, I encourage checking out a workbook about motivational interviewing, or some YouTube videos teaching the basics. 

14) Empathy with honesty 

In a conversation or debate with a person espousing a conspiracy theory or following some type of propaganda, empathy is needed for the conversation to continue. In conversing with someone who has a delusional belief, it is important that the person you're talking to knows your honest position on the issue, and knows that you are prepared to back up your position with good evidence, but it is essential that you show understanding of their feelings about the matter, and that the discussion does not deteriorate into a shouting match or into personal attacks.

As stated in number 8) above, it could be useful in a debate or conversation with conspiracy theorists, anti-vaxxers, etc. to find examples of prominent people within their ingroups who have changed their mind and moderated their position, while still endorsing and supporting the ingroup. This could include examples of politicians, religious leaders, and celebrities your debate partner might support or admire, who are now endorsing vaccination or other relevant policy issues.  As of December 2021, I am aware of one notorious member of this ingroup, a major U.S. political leader, who is now supporting vaccinations. 

 15) Possible need to end the conversation or relationship

Open dialogue requires safety and fairness. It is impossible to have a productive discussion with someone shouting at you, threatening you, or monopolizing the conversation. If the person you are talking to cannot behave in a physically safe and respectful manner, then it is necessary to end the discussion.

It may be necessary to end some relationships altogether, because continued contact may prove to be too aggravating and stressful over time, distracting us from more positive and helpful engagements or relationships. But if the conversation or relationship does end, I encourage people to remain polite, gentle, and civil, maybe with the possibility of re-establishing the relationship in the future, if the situation improves.  

16) Social Pressure & celebrity influence

It can be helpful to make use of media to show that public health measures such as vaccination & mask usage--and environmental measures such as recycling, reducing carbon emissions, and ecological protection--are attractive, fashionable, and cool. Conversely, media can help show that being an anti-vaxxer or a polluter is very unattractive. This type of work could involve the help of celebrities, sports stars, "influencers" and models.

17) Justice

In order to deal with con artists or fraud, we usually need to involve the criminal justice system. For a person who willfully neglects safety behaviour, and causes harm to others, there would be legal consequences.  For example, almost everyone, regardless of political orientation, would agree that we should prosecute drunk drivers, especially if they harm someone on the road. Rehabilitative treatment should be offered as well, for example to treat alcoholism.   There is a continuum in our society between debatable contrarian opinion on one side, fraud and frank propaganda on the other.  Obviously we shouldn't suppress contrarian opinion using the power of the legal system, but there should be consideration of prosecution in cases where frank lies are causing substantial harm to individual and public health, especially when the perpetrators are profiting financially.  

For con artists who are successfully prosecuted, it can often be the case that the victims who were conned, sometimes leading to severe financial or physical harm, will still insist that they were not victims at all. They may continue to support the con artist even after prosecution and conviction. Such is the tenacious power of people's need to "save face" -- admitting they were conned by someone they and their family and friends have admired for years as a hero can be embarrassing and humiliating. In order to make this process easier, it is necessary for fellow con victims to come forward and admit the truth. We see a few examples (though not enough) of this happening with previous supporters of a well-known political leader since 2016, which hopefully will lead the way to broader positive change. 

18) Be politically involved!  Vote! 

Some extremist or fanatical groups have been organizing protests, frightening and obstructing health care workers and patients at hospitals in recent days.  Others are threatening the foundations of democracy itself.  

It is necessary to become more politically aware and involved. In an age where democracy itself is under threat, it is essential to use your right to vote, and to help & encourage others to vote as well. If people become so discouraged or cynical about the present state of affairs that they don't even bother to vote, then our nation's and our world's problems will be dealt with by people who are very ill-equipped to solve them. 


Selected Readings & References

Armstrong, Karen. The Battle for God: A history of fundamentalism. (2001)

Brashier, N. M., Pennycook, G., Berinsky, A. J., & Rand, D. G. (2021). Timing matters when correcting fake news. Proceedings of the National Academy of Sciences, 118(5).

Bergstom, C. and West, J. Calling Bullshit: The Art of Skepticism in a Data-Driven World (2020). 

Briant, Emma Louise (2015). Propaganda and Counter-terrorism. Manchester: Manchester University Press. p. 9.

Christakis, Chris. Apollo's Arrow: The profound and enduring impact of coronavirus on the way we live. (2020)

Dawkins, R. The God Delusion (2006).

Dawkins, R. Outgrowing God (2019). 

  (note: Dawkins is a critic of religion, but I think it is good for any religious person to understand the reasons for this; I mention these books here because they address the subject of how people come to form extremely strong and often irrational ideological positions, and how people can move away from this, while gaining some education about basic science)

Douglas, K. M. (2021). COVID-19 conspiracy theories. Group Processes & Intergroup Relations, 24(2), 270-275.

Douglas, Karen et al, Understanding Conspiracy Theories. Political Psychology 40, Suppl. 1, 2019

Epstein, Z., Berinsky, A. J., Cole, R., Gully, A., Pennycook, G., & Rand, D. G. (2021). Developing an accuracy-prompt toolkit to reduce COVID-19 misinformation online. Harvard Kennedy School Misinformation Review.

Haidt, J. The Righteous Mind: Why Good People are Divided by Politics and Religion (2012).

Harrington, B. (2012). The sociology of financial fraud. In The Oxford handbook of the sociology of finance.

https://theconversation.com/why-people-believe-in-conspiracy-theories-and-how-to-change-their-minds-82514

Johnson DK et al. "Combating Vaccine Hesitancy with Vaccine-Preventable Disease Familiarization" Vaccines 2019, 7. 39

Kahneman, D. Thinking: Fast and Slow. (2013).

Kelly, J. (2006). The Great Mortality: an intimate history of the Black Death.

Konnikova, M. (2016). The confidence game: Why we fall for it. Every Time. New York.

Lewandowsky, S., & Van Der Linden, S. (2021). Countering misinformation and fake news through inoculation and prebunking. European Review of Social Psychology, 1-38.

Marchlewska, M., Green, R., Cichocka, A., Molenda, Z., & Douglas, K. M. (2021). From bad to worse: Avoidance coping with stress increases conspiracy beliefs. British Journal of Social Psychology.

McRaney, David.  How Minds Change: The Surprising Science of Belief, Opinion, and Persuasion. 2022. 

Pennycook, G., & Rand, D. G. (2021). The psychology of fake news. Trends in cognitive sciences.

Pennycook, G., McPhetres, J., Zhang, Y., Lu, J. G., & Rand, D. G. (2020). Fighting COVID-19 misinformation on social media: Experimental evidence for a scalable accuracy-nudge intervention. Psychological science, 31(7), 770-780.

Pennycook, G., McPhetres, J., Bago, B., & Rand, D. G. (2020). Predictors of attitudes and misperceptions about COVID-19 in Canada, the UK, and the USA. PsyArXiv, 10, 1-25.

Peters, Maertens, R., Roozenbeek, J., Basol, M., & van der Linden, S. (2021). Long-term effectiveness of inoculation against misinformation: Three longitudinal experiments. Journal of Experimental Psychology: Applied, 27(1), 1.

Peters, Ellen. Innumeracy in the Wild: Misunderstanding and Misusing Numbers. Oxford (2020). 

Pinker, S. Better Angels of Our Nature: Why Violence has declined (2012). 

Pinker, S.  Rationality: What it is, why it seems scarce, why it matters (2021)

Pretus, C., Hamid, N., Sheikh, H., Ginges, J., TobeƱa, A., Davis, R., ... & Atran, S. (2018). Neural and behavioral correlates of sacred values and vulnerability to violent extremism. Frontiers in psychology, 9, 2462.

Prum, Richard. The Evolution of Beauty: How Darwin's Forgotten Theory of Mate Choice Shapes the Animal World - and Us. Anchor (2018).

Rathje, S., Van Bavel, J. J., & van der Linden, S. (2021). Out-group animosity drives engagement on social media. Proceedings of the National Academy of Sciences, 118(26).

Rutjens et al, "Science skepticism across 24 countries."  Social Psychological and Personality Science 2021. 

Shoots-Reinhard et al. "Ability-related political polarization in the COVID-19 pandemic" Intelligence 88, 2021, 101580

Swire‐Thompson, B., Ecker, U. K., Lewandowsky, S., & Berinsky, A. J. (2020). They might be a liar but they’re my liar: Source evaluation and the prevalence of misinformation. Political Psychology, 41(1), 21-34.

Tappin, B. M. (2021, October 4). Exposure to Arguments and Evidence Changes Partisan Attitudes Even in the Face of Countervailing Leader Cues. https://doi.org/10.31234/osf.io/247bs

Taylor, S. (2019). The psychology of pandemics: Preparing for the next global outbreak of infectious disease. Cambridge Scholars Publishing

technologyreview.com/2020/07/15/1004950/how-to-talk-to-conspiracy-theorists-and-still-be-kind/

Van Bavel, J. J., Baicker, K., Boggio, P. S., Capraro, V., Cichocka, A., Cikara, M., ... & Willer, R. (2020). Using social and behavioural science to support COVID-19 pandemic response. Nature human behaviour, 4(5), 460-471.

Van der Linden, S., Panagopoulos, C., Azevedo, F., & Jost, J. T. (2021). The paranoid style in American politics revisited: An ideological asymmetry in conspiratorial thinking. Political Psychology, 42(1), 23-51.n 

Van Prooijen & Kuijper, "A comparison of extreme religious and political ideologies: Similar worldviews but different grievances", Personality and Individual Differences 159 (2020)

Van Prooijen & Krouwel, "Psychological features of extreme political ideologies."  Current Directions in Psychological Science 2019 28(2) 159-163. 

van Prooijen et al, "connecting the dots: Illusory pattern perception predicts belief in conspiracies and the supernatural."  Aug 21, 2017/ 

van Prooijen and Song, "The cultural dimension of intergroup conspiracy theories."  August 13, 2020. 

Zimbardo, P. (2011). The Lucifer effect: How good people turn evil. Random House.


Friday, June 11, 2021

Mental Health Reform: reflections & ideas for change

On February 1, 2020 I began work as a psychiatrist at my own private office.  

Before then I worked at a large academic institution for about 20 years, and was the leader of the psychiatric team there for 13 years. I have always loved my work very much.  I have been very privileged and lucky to have had such a job, during those 20 years.  It has been meaningful and enjoyable, for the most part, to care for my patients over the years.  And there were many wonderful colleagues and other staff at my clinic, who made our work more enjoyable, safe, and helpful.  We worked very, very hard.  There was a sense of community, like a type of family.  But I feel incredible relief to have left this position.  Now, after 15 months away from it, I feel I can have a gentle reflection upon some of the problems which developed there over the years. 

I would like to describe some instances of what I think can go wrong during a well-meaning effort to plan for change in community mental health care.  I do not want this post to be understood as a ranting complaint from a disgruntled person, but rather I would hope to simply tell the truth, from my point of view, about some events that happened, with reflections on ways to prevent such problems in the future.   I am happy and grateful for my present and my past, but I do feel there are a few things to be said.  

Mental health reform became a big issue in the community where I worked, over the last 5 years or more.  A lot of extra money appeared in the budget for this, and some care was wisely taken to plan for how to spend it. 

Many meetings took place, to discuss mental health care reform.  

A team of consultants from another country was hired, and flown over several times to assess the situation. I presume this occurred at quite considerable expense.   Their recommendations and presentations appeared to be a very polished lobbying effort.  During these presentations, which included some academic citations to support their positions, there was never actually any room for debate about the research they were citing or for the positions they were advocating, despite the presence in our academic community of many experts.  

A plan eventually developed, devoted to the idea of collaboration among different helping disciplines.  

The meetings would tend to begin with a lot of self-congratulation about progress, followed by lengthy, repetitive monologues, laden with jargon.  I was usually the only psychiatrist present in all of these meetings.  I was always very concerned that I never come across as arrogant or disrespectful of others, given my own privileged position.   I abhor professional arrogance,  so I aimed to remain quiet, to be calm, to try to listen respectfully. 

But eventually, after many hours of such meetings, I realized that major decisions were being made about health care planning, with a lot of money involved, with almost no debate or critical challenge.  These changes affected my patients, my colleagues, my morale, the group's morale, and my own philosophy of practice.    Almost none of the money was directly helping my clinic.  I personally did not have any voice in these meetings: my comments or input were not welcomed, and I think I actually was considered difficult or uncooperative because I didn't seem to go along with the plan.   On several occasions I was told, very directly, to discontinue my comments.   When I gathered feedback from professional colleagues (who otherwise had no voice in all of this), and summarized their comments in a brief written document (as was requested of me),  the document was rejected, and never submitted, because it was deemed not positive enough.  

The foundations of my own philosophy of practice are simple:  make time for patients, listen to them, be available, be gentle, be kind, build trust, be humble, try to honour a patient's wishes.  I believe that good care cannot be rushed.  Mental health care can sometimes be done with great efficiency and speed, but more often it takes a lot of time and patience.  Almost everyone I have ever seen in my career has been tired of seeing people for help who did not really have time for them.  

In terms of larger-scale, organizational philosophy, my foundation would also be simple: take care of the staff!  Everyone, including cleaning staff, clerical workers, nurses, GPs, and specialists, should feel safe, respected, cared for, and heard, in a healthy organization.  Be on the lookout for "burnout" especially when a system is strained by high demand.  Policies that seem efficient on the surface may be quite deeply harmful, if they lead to a type of "assembly line" experience for either the staff or for the people trying to access the system.    

Some tools of efficiency, such as computerized records systems, may seem efficient, and may have many uses, but they may be expensive, inconvenient, slow, prone to error, time-consuming, obstructive to rapport with patients, and very heavily marketed by software companies which are earning a lot of money, often trying to sell impressive-sounding features which are actually unnecessary (I feel very fortunate to have found a perfect electronic records system myself, called "Jane," which is far superior, and much less expensive, than the system used at my previous workplace).   

 One reason I wanted to speak out, even at risk of sounding "difficult" or uncooperative, was to advocate for my patients. I was responsible for the care of patients with the most severe, chronic mental illnesses, yet my input about mental health was not allowed, or was met with rolled eyes and even direct requests that I stay quiet.  Furthermore, none of my psychiatric colleagues were ever present or allowed to contribute to these meetings, beyond a couple of occasions in several years. These colleagues were never officially on the payroll, they always worked privately and paid overhead to be in our group. In fact, my psychiatrist colleagues were always a free service from the point of view of the institutional budget--they actually earned money for the institution by paying overhead.  They earned less money than most other psychiatrists in the community, but stuck with the group due to their love of the work.  These colleagues never had any voice in the institution's mental health care policy.  I felt that I had to speak for this group as well. 

This went on for years. Patient care suffered.  I was the only person in all of these meetings able to do psychiatric consultations for people with severe illness who had been waiting for months, yet I was sitting in redundant, lengthy policy meetings in which I was not even allowed to contribute.  I thought of my patients, which led me to try to speak up, even at risk of sounding "difficult."  

One of the themes of the new policy was "collaboration."  But ironically, because of the policy meetings, the actual collaboration meetings which I and my counselor colleagues had enjoyed for years, in which we would discuss mental health care in general, as well as immediate, serious clinical issues about specific students, were cancelled.

One summer, there was a series of meetings devoted to drafting a formal care algorithm for treating depression.  This was yet another absurd journey.  The subject was the foundation of what most of the counselors in the group had studied for years, in graduate school.  The subject was arguably the focus of my entire 20-year career.  Yet, once again, I and other experienced professional colleagues were mostly silenced, and assigned into small groups to prepare some kind of treatment "algorithm" in an essay-like form. I thought of all the patients who were not seen while we were doing this.  

This was especially troubling, as I found the whole process more and more ethically objectionable.  We should begin by ensuring that people are assessed well, are respected, are heard, and their wishes about their own care honoured to the best of our ability.  Many algorithmic branches should be negotiated by a well-educated caregiver and the patient or client, not dictated by a flow chart.  Good care requires deep attention to building a trusting, caring relationship, empathy, understanding, and a therapeutic alliance.  Furthermore, restricting any "algorithm" to only consider depression is inappropriate, since most people coming for help have various other problems other than depression, which would all have to be considered together. 

During another meeting the entire group of 100 or so people was asked in advance to fill out a Myers-Briggs questionnaire.   The entire group was subdivided according to their Myers-Briggs personality type, and made to sit at separate tables.  Some Myers-Briggs types are more rare, while others are more common.  Many tables were full.  A few tables had only one person.   

The Myers-Briggs personality assessment has very limited validity.  It can lead to fallacious polarization of traits which actually lie on a continuum.   But in any case, personal testing data about psychological traits or symptoms is intimate:  it is arguably in a similar league as any other medical test.    It is inappropriate to have to share such information in a group setting.  There were a few people in the less common personality categories who ended up sitting alone.   To divide the group up like this was an example of what NOT to do with mental health labeling: to actually separate people on the basis of differences, leaving some people alone.  It was introducing new labels, stigma, and separation, needlessly.  To top things off, it surely would have cost money, going to a company making large profits,  to purchase these tests.  In addition to the cost of paying everyone's salary for this, there was also the cost of room reservation and catering.  Most importantly, there was once again the cost of severely ill patients who were not being seen.  

Another meeting featured a visiting expert, who had some national fame.   I would once again love to know how much his travel expenses and speaking fees were.    He was a charismatic speaker, with remarkable orational skills.  Everyone loved his presentation.  But one thing stood out for me...one of his opinions had to do with what he thought were excessive mental health resources being offered to people with what he considered minor problems.  In a hushed tone, he summarized the problem as being "narcissistic entitlement" on the part of the people seeking mental health care.  I have no doubt that there is a lot of narcissistic entitlement out there, but to dismiss an entire category of people, and to advocate for major policy change in mental health, based on this assumption, is prejudicial.  I have to wonder how often some famous policy-makers actually work with patients in a therapy setting.   Once again, there was no actual debate on this, just discussion groups affirming what had already been said.  

Another meeting was entitled "Stepped Care Anxiety."  It was a presentation led by a local research psychiatrist with a lot of experience in community programs, though someone who spent little time actually seeing or caring for patients at this point in his career.  Once again, clinical care of patients was cancelled in order for staff to attend this presentation.  Initially I thought the meeting would literally be about "stepped care anxiety"-- that is, anxiety induced in caregivers upon being presented with another tiresome trendy catchphrase.   But the title was actually just a product of some difficulties with English, and the meeting was about "stepped care FOR anxiety."  Basically, the idea of stepped care is to offer more care to people who have more severe problems, and less care to people with less severe problems.  As people improve, start to reduce their level of care.  This is a statement of the obvious, of course, and is what all of us would naturally do anyway.  There seemed to be an implicit assumption that psychiatrists in particular would be seeing patients unnecessarily, even if they were well or not in need of further care, and that we needed guidance to step away from this wasteful practice.   I was asked to be well-prepared for this meeting, by reviewing the materials in advance.  But once again there was no real meaningful discussion about this, aside from a review of obvious principles.  A deeper discussion of care would have allowed for the idea of actually spending time to know patients over a longer period of time, regardless of symptom severity, so as to prevent severe recurrences of mental illness, rather than saving our clinical attention only for emergencies.   Stepped care, when applied dogmatically, is yet another ideological system which leads to superficiality of care, a type of fast-food equivalent in mental health provision.  

After a lull in these meetings, the next chapter began with new hiring in the institution.  This time even more money was spent on expensive administrative positions, instead of on badly-needed direct health care.    Some of the administrative positions were filled by clinicians, so in addition to the cost of paying these administrative salaries, an extra cost to the community was of an expert clinician paid to do office work and attend meetings instead of using desperately needed skills to help patients directly.  I think of how many hundreds of thousands of dollars per year were spent on this increase in administrative funding, while actual clinical care languished.  Our clinical unit had barely grown in decades, despite serving a community which had rapidly expanded, perhaps even doubled in size.  Encounters with the administration were negative and morale-depleting.  I dreaded them.  I really just wanted to see and take care of my patients.  My other priority was to take care of my coworkers and colleagues.  But I felt powerless to do anything for them.    

One of the meetings--again arranged by cancelling our actual work with patients--was with a visiting specialist who had invented a new way to see more patients more quickly.  A psychiatrist would join a GP for a 30-minute "mini-assessment."  That way, more people could have psychiatry assessments, there would be shorter wait lists, and the primary care doctors would feel more supported.  Once again, there was no opportunity for any critical discussion, during or after this presentation.    The thing is, such assessments are pretty much the opposite of what I consider to be good psychiatric practice.  Assessments cannot be rushed.   Imagine if you had to see someone for a difficult, very personal problem or issue, and had to discuss it in 30 minutes, with two people in the room, one of whom a stranger, with the understanding that your future care would be guided by the new expert's opinion during this fragmentary discussion.    It is arrogant on the part of psychiatrists to assume that extremely brief visits could lead to diagnostic or therapeutic insights that the other caregivers had not already thought of.    Such brief assessments, and other schemes in mental health care similar to them, tend to bias the conclusions towards medication management, since this is the easiest type of thing to construe in a short assessment, without knowing a patient well.    Assessments and good care take time--there is no avoiding this!  Relationships cannot be rushed.  

Satisfaction surveys following such changes could also be quite biased and misleading, in the same way that taking a survey of people leaving a fast-food restaurant could give a biased view of food services quality in a community.  Many people might be quite pleased to have convenient fast food, but those who would suffer the most from such policy would not be included in the survey, since they would not be using the services.   

I am deeply relieved to have left that place!  But I miss my colleagues, I know they are good people and skilled professionals.   My decades of work there, despite the frustrations at the end, were a labour of love, for which I am deeply grateful.  While I have voiced some complaints above, the years at my previous position helped make me a better person, and taught me a lot about how to be a good doctor. 


Here are some basic ideas, based on my experience, for organizing a program of mental health care reform: 

1) the expenses involved in the reform program should always be transparent, especially in a public institution.   If consultants or experts are brought in to give presentations to the group, it should be clear to everyone, including the public, how much money was spent on their travel expenses and any other compensations.   Catering and room costs should be made clear.  And most importantly of all, if there are 100 helping professionals who spend 3 hours at a meeting, it should be made very clear that this represents a cost of 300 person-hours of  care.  That is, 300 people could have had a 1-hour therapy session or evaluation.  30 people could have had a basic 10-session treatment for depression or an anxiety disorder, which could possibly have saved lives.  

2) critical debate should always be welcomed.  If there are experts in the group, their expertise and experience should be shared.    If a visiting expert is flown in, the group's responsibility is not to simply compliment the visitor, listen politely, and clap -- at a major academic institution, or anywhere else in society, there is a responsibility, a duty even, to engage in vigorous, intelligent debate, especially when there are critical issues about health, well-being, and morality, being discussed.  

3) it should be absolutely unacceptable for anyone working in the system to feel that their voice or opinion would ever be suppressed. 

4) consideration should be given, at a very high priority, to the morale and well-being of the workers, not just to the efficiency of the work.  

5) if there are to be catered lunches and time off given to staff for collaborative meetings, or to bolster group cohesion, then ALL the staff should be included, including the cleaning staff.   Most of us don't even know who the cleaning staff are.  

6) I have a very specific idea about the economics of care provision.  There are many underemployed counselors in the community, who often have to spend a lot of money renting private office space.  Many can't make it, and end up working in some other field.   But there is a lot of office space vacant in large institutions or campuses during evenings and weekends.  This space could be offered at a very low or free lease rate, to increase the number of hours of care available for people in the community.   This would be a win-win situation for underemployed counselors as well as for the community of people in need of more care.   Clinical office space should be provided with a much higher priority than administrative office space, particularly when there is a severe shortage of clinical care.  

For salaried care workers, I think that a blended payment model (that is, baseline salary plus some component of "fee for service") would be very efficient to increase care provision.  Some workers (counselors or doctors) might want to work longer, or less typical,  hours, and I am quite certain that there would be a high demand in the community for these extra hours.  But there would have to be a fair and convenient model of compensation.    Current salary schemes do not allow such flexibility.  


If you are interested in mental health policy, I encourage you to use your voice,  to be aware of changes going on in your community, and to get involved in the reform process. 





Thursday, May 20, 2021

Review: Sex at Dusk by Lynn Saxon

I read this book a second time recently.  

I appreciate that such a scholarly and well-researched text was written by an amateur scientist.  It was written as a critique of a more popular book with a similar title.  This other book attempted to make a case that humans in the pre-agricultural era (i.e. over 10 000 years ago) had a much more promiscuous lifestyle, which for them was supposedly healthier and more peaceful--then with the implication that we should try to emulate this in modern society.  

Saxon's book looks at almost every claim made by the other authors, and shows how their analysis was biased, incomplete, or just completely wrong, in terms of historical and anthropological data, as well as genetics and evolutionary biology.  Saxon shows that the authors of the other book particularly do not address the very dark side of almost every case study described.  The areas of focus in both books include social and sexual behaviour in primate species most closely related to humans (chimpanzees, bonobos, and gorillas), as well as cultures of remote present-day groups, such as those living in the Amazon.   A particular emphasis is the genetic basis (through natural selection) of behavioural traits.  

The subject of the genetic foundations of animal behaviour, and of the mechanism of evolution through natural selection, should be part of everyone's common knowledge.  Books by naturalists, biologists, or geneticists on this subject are not only informative from a scientific point of view, but are fascinating in the same way that watching a good nature documentary would be:  most of us are unaware of the life cycles and behavioural patterns of most of the species with whom we share the earth.  The stories, often about species that many of us have never heard of, but also sometimes about familiar species, are almost always interesting, but sometimes shocking or disturbing or intensely dramatic.  The best science writer in this genre is Richard Dawkins -- whether or not you like his philosophical point of view, it is essential and often entertaining reading to learn about other species, with the eye of a great naturalist.  

Saxon shows that we cannot escape some of the problems which exist in relationship and sexual dynamics in humans, including jealousy.  There is a strong genetic foundation for pair bonding in our species, though not without tensions, jealousies, and strong desires, which differ between the sexes, to have other relationships outside of the pair bond; but such excursions outside of a pair bond cannot occur without a substantial cost, often manifest in behaviour which is in part genetically determined.  

None of these genetic factors justifies a social policy which constrains relationship choices... social and relationship freedoms, as well as guaranteed personal rights, are aspects of social justice that have thankfully grown in our country in the past century; they must be created and legislated, whether or not they have always been favoured in our species through genetic/natural selective forces in the distant past.  



Thursday, May 6, 2021

Review: Capital in the Twenty-First Century, by Thomas Piketty

 Thomas Piketty is a French economist, whose book "Capital in the Twenty-First Century" is a great analysis of the history of wealth, economic inequality, and taxation through the past two centuries, focusing especially on Europe and North America.  


I highly recommend this book.  It is very long and detailed, and much of it is hard to understand fully for a person not experienced in economics or finance.    For a brief introduction to Piketty's work, there is a good documentary with the same title, which is also worth watching.  But the documentary does not contain nearly as much detailed analysis of the problems and proposed solutions, compared to the book.  

This book is important to read, to become familiar with these issues.  We all pay taxes, and most of us complain about them, but few of us understand the history of taxation, and the reasons why taxes are the way they are.  Even for those who are experts in the area, it seems to me that relatively few people (such as economists) have a good understanding of economic history.  


Piketty shows that income inequality was extremely high in the 1800s in Europe, leading to some people with enormous estates, while much of the population lived near or below the poverty line.  Most of the wealth in the society was owned by a very small number of people.   This changed dramatically mainly as a result of the world wars, and the resulting policy changes after the wars.  


Prior to the wars, those with enormous wealth paid very little tax, and this wealth was also passed through inheritance with very little tax either.   After the wars, progressive taxation of income and estates led to a large improvement in this type of extreme inequality, and allowed a much larger number of people (such as those in the middle class) to own a larger portion of national wealth.   


Interestingly, the United States in the 1950s-1970s had one of the most fair and progressive taxation schemes in the world, leading to improvements in economic inequality, before regressing substantially in the 1980s and beyond.  


Piketty shows that there are not only political and social consequences of having a society allowing extreme wealth to accumulate for a small number of people, without those people having to earn this wealth through work, there is also an economic consequence, since economic efficiency is not well-served or incentivized this way.   


His suggested solutions to this problem include having a progressive income tax, a progressive tax on estates & inheritance, and a progressive tax on capital or total personal wealth.  By progressive, he means paying a higher rate for higher levels of income, and a lower rate for lower levels.  At present, there are many examples Picketty shows where the system is not progressive, but regressive--that is, people with extreme levels of wealth actually pay an overall lower marginal rate on their vast incomes, compared to those in the middle class.  


The main barrier to a progressive tax on capital (i.e. a tax on invested fortunes), is that such investments are often hidden; many extremely wealthy people hide their wealth in offshore banks, etc. so it is hard for governments to understand how much wealth there is.  These are so-called "tax shelters."  In order to solve this problem, governments across the world would have to come together and cooperate with sharing banking information, to create a type of global wealth census, or "cadastre."  


How is this relevant to psychiatry?  Economic issues, including poverty, are extremely important in the causation and management of mental health problems.  Universal health care, and universal comprehensive education (including university  college, or other training) is possible in all countries, and can be improved where it currently exists, such as in Canada.  But health care is expensive, and needs to be fairly subsidized.  Taxation issues obstruct the provision of efficient social services, including health care.  


Also, greed in general, without a principle of making social or community contribution, is a factor contributing to declining mental health, and to more social problems including crime.  


I did not find Piketty's analysis or recommendations to be "radical" at all.  They are not in opposition to free-market economics, but rather are supportive of a system where markets could be free for all, without rapidly escalating and uncontrolled excesses.