Treatment vs Accccomodation: Diagnosing the DSM

Teaser from my latest CFN column...

 

“Is there a lot of controversy around diagnosis? Absolutely. Should there be? Absolutely. That is its greatest virtue. It provides opportunity for input from lay people, social workers, and brings us all to the table. We’re dealing with conditions where there is a profound degree of complexity and a profound degree of uncertainty.”

There's an old joke about a patient who goes to see his doctor about a physical complaint. The injury itself doesn't matter - let's say it's typing too much on a blackberry, just for fun.

Patient: "Hey doctor, it hurts when I do this."

Doctor: "So, don't do that."

Buh-doom boom.

Of course, that's not the way it tends to work out in real life, is it? An actual conversation with one's doctor might go like this.

Patient: "Hey doctor, my thumbs are killing me, it hurts to type. You gotta do something."

Doctor: "Have you tried typing less?"

Patient: "Drop the lip, doc - I pay you to fix my problems, so fix this. I've got a report that's due next week and the pain is getting in the way.  Can't you give me some Oxycodone or something to help me get back to work?"

Ouch. No rim shot for that one.

Our healthcare delivery model has changed course over the last century or so into one that’s  consumer-based – health is a service provided, not a lifestyle.  Work, not health, is the focus; instead of trying to improve and sustain health, our medical professionals are being seen more like pit crews. How quickly can you patch up the patient and get them back into the rat race?

Our social/economic model of society is very much a race - competition grows ever steeper and people need to invest more and more of themselves, their time, even their well-being into keeping from falling behind. If you don't have access to the best parts and pit crew, the odds are really stacked against you ever winning. The success of the system comes first - individual benefit is supposed to be an organic byproduct of the free market. 

So, what does this have to do with the Diagnostic and Statistical Manual of Mental Disorders (DSM)?

The DSM is, clearly, a diagnostic tool that is designed to help health practitioners, including those of the mental health variety, identify what's wrong with a person. What's wrong seems to be defined as "that which keeps them from functioning properly within an existing social context."  The goal is to get people back on the line and contributing, after all.  So, the aggressive employer that micromanages staff and stifles productivity is sick. The underachieving welfare recipient is sick. The kid acting up in class - sick. 

This should all sound familiar, because it's the exact same phenomenon we've seen throughout history.  We have a habit of stigmatizing and labeling anyone who is different than what the prevalent voices in society want them to be.  It’s like those differences are a social illness we’re trying to correct.

First Nations people and their insistence on group think and non-Western social customs? That's a problem that needs to be fixed.  Lefties who can't seem to get things done with the tools they're provided? They need to operate from the right if they want to belong.  Women who disrupt the work cycle to have babies and such? Not a good investment in the first place.

See the pattern?

We might like to tell ourselves we're inclusive and really open to supporting people's differences, but when we rest on that opinion, we're deluding ourselves. More often than we realize, we're not accommodating the specific challenges of a person - we're trying to get them to conform.  Even Free Market purists trying to save welfare-state believers from themselves are trying to fix people they see as misguided.

About two years ago I had a chat with a former boss, Leslie Noble (a senior Conservative advisor and Government Relations expert) about top-down management. She was frustrated on behalf of a friend who was Executive Director of a mental health institution. Thanks to a standardized government mandate, the friend was being expected to dedicate allocated funds to solving one problem, when it was a different structural issue that was really threatening her operations. This, Leslie explained to me, was why she is so dead-set against a top-down standardized approach to fund allocation; it stifles people from doing what they need to succeed.

That's at the organization level, but it applies to individuals, too.  Trying to standardize everything is like viewing every problem as a nail – which is what you tend to do, if the only tool in your box is a hammer.  Despite what political hawks try to tell us, you can’t hit your way out of everything.  Of course, the reverse is true, too.  It’s naïve to think you can pass around right-handed scissors and expect everyone to have an equal chance of making the cut, but we do that all the time.  It takes an out-of-the-box thinker to consider the possibility of left-handed scissors, creating not only an innovation that helps lefties succeed on their own terms, but creates an economic opportunity as well.

Not that long ago, I had a great chat with former Attorney General (and genius) Michael Bryant and Sylvia Kim, a wickedly smart social entrepreneur about mental health and social functioning. Michael raised an excellent point - there are probably thousands of "gifted undiagnosed" Einsteins out there who, because they were never exposed to people who knew how to recognize or harvest those gifts and weren't born with an aggressive level of self-confidence and marketing ability, are slowly going mad working in a mail room when they could be curing cancer or solving gridlock.

I bring up madness intentionally, because there's a strong correlation between manic genius and diagnoses of “crazy” - look at this list of famous people with mental illness for just a few examples. Do you know any geniuses yourself? Do you find them a bit high-functioning, maybe have or had substance abuse issues or personal relationship challenges? It's surprising just how much staff of high-performers serve a bit like counselors and support workers, helping to keep the genius focused and keep the individual from going off the rails. If you've ever worked in politics, you'll have seen this, a lot.

Now, consider:

Phiona Mutesi is taking the world by storm as a 17 year-old chess genius. Born in an Ugandan slum, not even really certain of when, it was really nothing more than a stroke of luck that she was able to connect with the supports that helped harness her talents and explore her maximum potential. A slight change of circumstance and the world would be missing something.

On the other end of the spectrum, we have people like Greta Hoaken, a 17 year-old dynamo who started her first business at 13 and is destined to do great things. Sorry, not destined – that implies inevitability.  We like to think good things happen to good people, but there’s zero empirical evidence to say that’s a standard.  Greta had the right supports from her family and community as well as the natural drive to succeed; that’s why we’ll remember her name.

We shouldn’t begrudge Mutesi her luck any more than we should envy Greta her fortuitous background. But we all too often do, don’t we?

It’s a race to the top, after all, and their fortune comes at the expense of our ability to get ahead.  The success of someone else is seen as a negative to us, pure and simple - and we get bitter about that. If we can’t afford the better pit crew, we might just decide throwing a wrench in the wheels of an opponent will help us get to the finish line first.

It’s the same rationale behind Ontario PC Leader Tim Hudak’s attack on foreign workers and foreign students – why should we pay to give outsiders an edge over our people? It’s not fair in a strictly free-market sense, nor does it fit with the goal of creating standardized communities.

In free market theory, money is often described as the life-blood of society and the economy, the heart that pumps it. As we’ve already got a health-related theme going, let’s run with that – if society were a body, would you want to dedicate all your resources to cardio-pulmonary health alone? What about the factors that impact heart health - things like exercise, sleep, stress, diet?

People aren’t machines on the line that unfortunately need quick tune-ups to keep working; they’re complex creatures that are part of an even more complex system – society.  Society is more like an organism than a machine – you don’t get to trade in rusted or malfunctioning parts for new ones.  When you neglect one aspect of society (like the poor) the whole system ends up suffering (crime, illness, economic atrophy). 

Oh, and those foreign bodies joining our economy aren’t a virus to be locked up or run out of town – immigration is more like adding diversity to the social gene pool.  After all, that which doesn’t kill you makes you stronger, right? 

If you want an effective model for understanding individual and social health, you should go back to those troublesome First Nations and take a look at the concept of the Medicine Wheel. A holistic view of individual and social health might not be standard; hopefully we can agree that the standard model has room for improvement.

Which brings us back to the DSM.  By defining a median standard for normal cognitive and social behaviour, we’re stigmatizing those who don’t fit in that box as abnormal.  There will be those who consistently and markedly deviate from the standard; these lateral-thinking folk will be seen as disruptive to the economic race and be more likely to spend time in the pit or get removed from the track entirely. 

Do we really want to normalize or sideline future Isaac Newtons, Abraham Lincolns or Ernest Hemmingways because they don’t fit the standard?  What would we lose if we did?

Society keeps benefiting from the outliers (nutty geniuses like Steve Jobs or captivating artists like Catherine Zeta-Jones) but we make it really, really hard for them to reach and contribute their full potential.  You can chalk that up to the nature of competition, but as with Mutesi and Greta, we see a lot of cases where it’s luck of the draw, not competitive advantage, that helps some get ahead.  At the same time, everyone else is suffering from the stigma of the standardized social race, too – rushing madly just to stay in the same place.  It helps explain why we have an unheralded business crisis here in Canada.

Einstein defined insanity as “doing the same thing over and over again and expecting different results.”  Instead of continuing to add more diagnoses to the DSM, perhaps we should step back and consider if we’ve diagnosed the wrong problem.

Teaser for my next CFN Column:

According to the den Tandt article, Team Trudeau and Justin himself have collectively realized that it’s not just the Liberal Party, but the Canadian political process that is at risk of collapse.  That’s the burning platform; that’s the impetus for renewal.  Instead of engaging in old-school politics of Machiavellian maneuvers planned and orchestrated by shadowy, unaccountable operators, Team Trudeau is trying to devise a new approach, one that is more transparent and accessible to the public while equally being more respectful to opponents.  In this, they’re following some wise words: “Never attack the individual.  We can be in total disagreement with someone without denigrating them as a consequence.”

CFN - You Can’t Take the Risk Out of War

War isn’t a game, video or otherwise. When a person gets shot, stabbed or blown up, it’s not “hearts” they risk losing – it’s their limbs, lives and ongoing quality of life. Winning is no tonic against injury, either; soldiers who come home still bear the physical and psychological scars of combat. If the war happens on a soldier’s home turf, there’s every risk that they won’t have a physical home to return to, either. I will never forget walking around a bombed-out downtown Sarajevo still littered in rubble and “beware of landmines” signs in 2001, six years after the Bosnian War was supposed to be over. The spoils may go to the victor, but when the spoils are in ruins, what has really been won? 

 

This is why military strategists from Sun-tzu on keep developing new ways to mitigate personnel and infrastructure risks at the same time as increasing chances of meaningful victory. The evolution of warfare has seen the development of increasingly complex offensive and defensive technology and tactics, but it has also included the nurturing of warrior codes of conduct like bushido, chivalry or the Geneva conventions. At its core, diplomacy is really a military strategy designed to mitigate the risk of destructive combat and avoid losses on both sides.

 

Of course, we wouldn’t fight in the first place if there weren’t rewards to be had. Land and resources are of definitive value to expanding populations, which is why so many wars are fought over them. A balance of power might encourage a military code of conduct, but when the balance shifts, we can always find wiggle room. Hawaiian Chief Kamehameha seized on the arrival of European weapons and tactics as an opportunity to tip the balance in his favour and conquer all the Hawaiian islands; Spanish conquistadors might have honestly thought they were doing God’s work in bringing Christianity to native heathens, but this noble quest didn’t stop them from slaughtering innocents and stealing their land and gold.

(CFN) Cognitive Labour: The Mechanics of Innovation by Craig Carter Edwards

“Insanity: doing the same thing over and over again and expecting different results.”

• Albert Einstein

CFN – Whether you blame its loss on globalization or government policy, North America’s manufacturing industry is bleeding out.  Those positions are shipping overseas to countries with cheaper labour and less regulation, like China.  Wherever our leadership sits on the political spectrum, there’s a general acceptance that those jobs aren’t coming back.  Economic policy makers are looking to natural resources for theoretically sustainable revenue or turning to new industries with growth potential to fill the manufactured gap.  At both the national and provincial levels, there’s increased focus on nurturing innovation as part of our broader economic solution.

So, how exactly do you do that?  How do you cultivate creativity?  Faced with new challenges, we instinctively turn to solutions that have proven effective in the past.  The entire industrial economy was built on employers with tools providing financial carrots and sticks to their labourers.  As that worked pretty well it makes sense to rinse and repeat, this time tying bonuses and promotions to innovation – right?  By looking at things like tax cuts, capital cost allowances or red tape reduction as tools to support innovation, this is essentially the approach government is taking.  In speaking to vacation days, equitable compensation and other measures to help the front line be more effective while on the job, unions are taking a different approach to the same concept.  Financial rewards are meant to spark ideation.  But do they?

Here’s the grand irony – traditional carrot-and-stick motivation not only fails to foster creativity – it impedes it.  Experiments have repeatedly demonstrated that while financial incentives might encourage people to work harder at finding innovative solutions, the promise of riches actually impairs creative cognition in much the same way alcohol impairs rational decision-making.  In short – the tools of motivation that worked so well over the past century or so simply aren’t up to the task of nurturing innovation.  Now, you can argue against this all you want (as others have), but before you start calling me a communist, let’s look at the facts.

It is true that the rise of capitalism coincided with a period of increased innovation – but does correlation imply causation?  If employees who came up with new products were richly rewarded for their value-add, wouldn’t every worker have been constantly spinning out new ideas as a way to get ahead?  That clearly hasn’t been the case.  In fact, the most successful people were often not the ones who did things differently, but rather did the same thing more effectively than their peers/competitors.

On the factory floor, that translates into results like more widgets made per hour.  In sales, the more deals you close, the greater your take-home will be.  Carrot-and-stick economics is simple; work hard and produce results, you’ll be rewarded for success.  Slack off or be ineffective, you’ll miss your bonus or perhaps get your walking papers instead.  Don’t like it?  You can rage against the machine all you want; the physical stress of anger (or anxiousness) makes you hungrier, more aggressive and, as a result, can actually help you get ahead.  The same rule applies to competitive sports; the more you focus on a narrow end goal (victory, bonus, promotion) the harder you will physically work to achieve it.

There’s a term for this blind focus on achieving a singular goal: functional fixedness.  Like all behaviour, functional fixedness results from your grey matter flexing in specific ways.  Hormones like testosterone and epinephrine (adrenaline) incite you to think and act in an aggressive, intense manner.  The same principle behind alcohol impairing reason applies here.  Adrenaline junkies will hyper-focus on specific goals and ignore physical strain or external obstacles that get in their way because of the behaviour their brains are generating.

It’s a useful ability to have if your goal is to win something or to evade a threat, which is why natural selection developed the capacity for stubbornness in the first place.  At the neurological level, there’s little difference between is such an apt metaphor.

While the ability to dedicate one hundred and ten per cent of your attention to completing a given task is an important one, it’s not the same process as being innovative.  Innovation requires a different kind of cognitive activity – putting existing pieces of information together in new combinations to produce original results.  The reason humans are more innovative than other species has nothing to do with our economic system and everything to do with that part of the brain that’s more developed in us than in any other animals.  It’s by feeding and stimulating the neo-cortex that new ideas are generated.

But that’s not what we’re doing.  In workplaces across Canada (around the world, really) employees are being told to develop new products and services, prove that they involve no financial risk and then bring them to market and close deals, all incented by traditional monetary carrots and sticks.  Even worse, we have social entrepreneurs developing new, creative solutions but, as they don’t have the business background to make one-minute cost/benefit pitches in language investors understand, those ideas are going nowhere.  By relying on traditional methods of motivation that nurture functional fixedness, we are essentially telling employees and social entrepreneurs to push open pull doors and tying their livelihoods to their success.

This approach isn’t opening more doors – instead, it’s burning out employees and frustrating managers.  These cognitive tensions are taking a toll on the health of Canada’s workforce too, leading to more diagnoses of conditions like depression and anxiety.  When 44% of Canadians say they’ve battled with mental illness, that’s not an annoyance – it’s a crisis.  It’s a costly one, too; Canada is witnessing a decrease in productivity and an increasing dependence on health services and pharmaceuticals, neither of which comes cheap.

Not surprisingly, there’s a growing realization among Canadian decision-makers that our innovation gap, our mental health crisis and the unsustainable financial burden being placed on our healthcare system are intertwined.   It’s going to take a multi-lateral, integrated solution to crack this nut – and it has to start with a rethink of how we motivate innovation in Canada’s workforce.  Fortunately, we’re not starting from scratch on this; there are already evidence-based models of cognitive labour motivation out there to crib from.

Innovation leaders like Google have had success in creating the right work environments and providing the right kinds of incentives to help their employees be more innovative.  Canadian companies like Optimus SBR are testing out new models of collaboration and process to support ideation among their team and generate more results.  Social entrepreneurs on the cutting edge of creativity are applying knowledge of how the brain actually works towards reimaging individual support and workplace design.  All that’s missing now are forums and opportunities to link these bold new approaches with decision makers and investors.  Those gaps are being filled right now, though it’s a slow, painful, uncoordinated process.  Government leadership would significantly speed this process up.

It’s becoming increasingly clear the traditional models of work motivation that fueled the industrial economy actually impede the cognitive labour needed to drive success in the 21st Century.  While there’s growing pressure to adopt new approaches of supporting innovation, these models are so counter-intuitive for decision-makers weaned on the financial carrot-and-stick system that they’re being met with resistance.  At the same time, these new models are quietly being adopted by ahead-of-the-curve companies, giving them a competitive advantage.

To tackle the mental health, innovation gap and healthcare cost challenges of today, government would be wise to embrace these bold new approaches, partner with leaders in cognitive labour promotion and start crafting policy that builds on their successes.

In fact, they’d be crazy not to.

CFN - The Politics of Responsibility – From Alaskan Airlines to Adam Carroll

Politics, of course, isn’t about doing what’s right – it’s about doing what it takes to get ahead. The public might decry attack ads, but they will continue to be used because they’re effective. It might frustrate us when partisan groups get the gravy and friends of politicians get appointments, but if we’re not voting, not donating and not engaging in the political process, what else can we really expect? Sir John A. MacDonald used to say “Give me better wood and I will make you a better cabinet” – we can only expect our democracy to represent our interests when we actively participate in the process. But then again, when politicians of all stripes regularly ignore the public trust, how can we possibly expect contributions to have an impact? It’s a chicken and omelette kind of thing.