Tuesday, October 23, 2018

Book Review: The Coddling of the American Mind by Greg Lukianoff and Jonathan Haidt

This highly recommended book addresses an extremely important issue: why the current climate we have in the States is characterized by increased and pathological polarization between various groups and subgroups, with each group vilifying the others. The authors also focus on a cultural shift on college campuses that has often led to an environment characterized by political correctness rather than free and open debate between opposing viewpoints. Groups can even turn on their own members for deviating ever so slightly from a “party line.”

The book is almost a textbook about certain processes that are characteristic of groupthink. Groupthink is when a group of people, in an effort to demonstrate harmony and unity, fail to consider alternative perspectives and ultimately adopts a shared narrative about the world which actively tries to keep out opposing viewpoints. 

Haidt, in a previous work reviewed here, pointed out that when groups of people who know each other share goals and values, this enhances “our ability to work together, divide labor, help each other, and function as a team is so all-pervasive we don’t even notice it.” He adds that “Words are inadequate to describe the emotion aroused by prolonged movement in unison that drilling involves.” 

However, sometimes groupthink goes way too far. Even supposedly objective scientists are not immune from overdoing it, which will be the subject of an upcoming book on groupthink in science I am co-editing for Springer.

Group process, in human psychology, is often at odds with our own brain’s ability to be selfish and think about what we want and believe instead of what others want us to want and believe. There is a war between individualist and collectivist tendencies within all of us. This idea is at the heart of my own therapy model, unified therapy. Its roots, in turn, are found in the model of family systems therapy formulated by Murray Bowen. 

His was the first, and is still seemingly the only other, therapy model that recognizes this basic conflict, which is found everywhere in nature. We are biologically programmed to, under certain environmental circumstances, sacrifice our own needs and beliefs – and even our very lives – for our kin or ethnic group.

The book discussed here looks at not only political correctness as an impediment for finding truth in the universe, but what they see as a related issue: why the rates of depression, anxiety, drug abuse and suicide have been rapidly increasing in college aged kids and others over the last few years. He attributes this to the adoption by large numbers of people in the Western world, particularly in the States, of what he calls “three great untruths:”

1.      The untruth of fragility: what doesn’t kill you makes you weaker.
2.      The untruth of emotional reasoning: always trust your feelings.
3.      The untruth of Us versus Them: life is a battle between good people and evil people.

When I was growing up in the 1950’s, all of the children I knew were out riding their bicycles in the neighborhood, wandering freely over significant distances, and spending much of their time engaged in free play. Many of them walked or rode their bikes to school, and baby sitters hired by parents at night could be as young as 12. What a difference from today, when someone might call the police or child protective services on you for letting a 9 year old walk home from school without adult supervision! 

Ironically, the rate of child abductions and crimes against kids was no different then than it is today, but partly because of pictures of missing kids on milk cartons and also because of widespread illiteracy about probability, today’s parents are downright paranoid.

The effect is disastrous. Human beings are, in many but of course not always, what the authors term anti-fragile. Of course, if trauma is severe or frequent, children often become more fragile and fall apart emotionally more easily later on. However, as the authors point out, if they are not exposed to a certain amount of stressors and challenges, they do not seem to learn to tolerate adversity, adapt to stressful circumstances, and grow up. They get weaker. Some stress is good for you! 

This is a good illustration of what I call the “principle of opposite behaviors.” Two opposite but extreme approaches to life and parenting lead to the very same problem. In this case, people who act fragile. Parents who over-protect their children end up harming them and driving their emotional problems.

My view about the interpersonal processes involved here differs somewhat from that of the authors. I do not think these folks are usually as fragile as they might appear. I think they act that way because they believe that their parents need them to be that way so the parents can feel good about themselves.

Over-protective parenting has become epidemic in society. The authors go into several revealing reasons for this phenomenon, although they do not mention as one of these reasons what I believe to be a major contributor: Over the period from 1965 to today, the change in gender role expectations and the need for two career families has led parents to feel guilty about not being there as much for their kids. They make up for it by being overly solicitous. These guilty feeling are exacerbated by today's culture wars.

One of the odd things going on in college campuses lately stems directly from the parenting changes: the absurd emphasis on “triggers,” “microaggressions” and the need for “safe spaces.” What this means is that both the kids and the adults running the schools think that a kid can be literally traumatized by hearing someone’s conflicting opinion. Not just upset, annoyed or even angry about it, but literally traumatized. Scarred for life!

The professors who don’t believe this to be the case feel intimidated and fearful for their jobs if they challenge this belief, and so they usually remain silent. This has led to something akin to a “speech police.” Speakers are prevented from coming to campus by occasionally violent protesters, and well-meaning professors and administrators have been fired for using the wrong word in something they wrote. The authors give several truly frightening examples.

This culture is completely the opposite of the culture that led to the “free speech movement” at the University of California in Berkeley in the mid 1960’s. Human knowledge advances by the free exchange of ideas as well as challenges to those ideas. That idea used to be at heart of the philosophy of higher education in the United States, but in many cases it seems to have disappeared.

Particularly enlightening – and frightening – is the book’s chapter on witch hunts. These occur when “A community becomes obsessed with religious or ideological purity, and believes it needs to find and punish enemies within its own ranks in order to hold itself together” (p.99). If someone offers any kind of differing viewpoint, they become the enemy. Everything starts to reek of “Us versus Them,” and the idea that people are either good or evil, and everyone seems to assume the worst about almost everyone else.

Thursday, October 11, 2018

Another Pharma Trick for Overstating the Effectiveness of their Drugs: The Will Rogers Phenomenon

Will Rogers

Big Pharma has a number of ways, many of which have been described in this blog, of making their drugs look a lot better than they actually are. And some psychotherapy researchers use the techniques to push their favored school of thought. I recently came across another one of which I wasn’t aware. 

It is easiest to see with drugs used for cancer chemotherapy, but can be applied in other cases.

It is called the Will Rogers phenomenon (and is also called Stage Migration). It is an apparent epidemiological paradox. The Rogers reference comes from a remark made by the famed humorist Will Rogers about migration during the American economic depression of the 1930's: "When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states."

With cancer drugs, it comes from changes over time in the way the severity of the disease is assigned to patients - how the various stages of a disease are determined in each case. (Stage I is when the cancer is smallest, has not spread, and is usually the most easily treated. Stage IV is the most advanced with metastases). The issue comes about because the technology for staging a cancer in a given patient has improved significantly. This can produce spurious improvements in stage-specific prognosis, even though the outcome of individual patients has not changed.

New imaging tools have allowed detection of cancer metastases before they became evident clinically. As a result, more patients are classified into the more severe metastatic disease stage from the less severe single tumor stage. Such a 'stage migration' resulted in an improved survival of patients in both the less and the more severe disease stages. (Multiple sclerosis is another disease where this sort of thing has taken place).

Some studies compare a new treatment to the treatment of so-called historical controls who had received other treatments. This is usually done because carrying out placebo-controlled studies in potentially dying patients is unethical. The Will Rogers phenomenon is recognized as one of the most important biases limiting the use of historical controls groups in experimental treatment trials. 

Essentially, the use of different diagnostic criteria may generate spurious improvements in the medium-term prognosis which then may be wrongly interpreted as treatment effects.

In psychiatry and psychology, placebo controlled studies can be done ethically, but a variation of the Will Rogers phenomenon can still take place because of how rigorously DSM diagnostic processes are applied to patients. When I first started training, the criteria for major depression and mania were rigorously applied in treatment studies; now they are often applied sloppily – on purpose. 

Chronic unhappiness, which may respond very well to cognitive behavioral psychotherapy, is often now misdiagnosed as the more serious major depressive disorder. If you have a bunch of those folks in your psychotherapy outcome study, CBT can be “shown” to be effective in major depression by including people in your study who really don’t have major depression.

The more serious depressions respond better to antidepressant medications. Since most antidepressants are now generic, drug companies who want doctors to use other, more profitable drugs like Latuda can do the same thing to “show” that antidepressants are actually less effective than they actually are. Placebo response rates in antidepressant studies have gone up about 10% every decade, and this is what I believe to be the reason.