Psychiatry & Psychotherapy Podcast - Free Will In Psychiatry & Psychotherapy Part 3

Episode Date: July 23, 2020

In this final part of the free will series, we take a look at the relationship between the concept of free will and mental health. Is free will altered in those suffering from schizophrenia? How is well-being related to free will? Thinking about these questions and the rise of neuroessentialism within psychiatry allows us to recognize the influence of our environment on our decision-making. The debate is far from settled, but a belief in free will clearly affects daily life and the practice of psychiatry. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. All right, welcome back to the podcast. I am joined with Matthew Higley. I hope that you've had a chance to listen to Part 1 and 2. I think they all three stand alone so you can jump in whatever episode.

But in Part 1, we really talked about the why, the history of it, the definition, some of the controversy. In part two, we talked about the importance of the belief in free will. We talked about some of the evolutionary sort of aspects of why it's important. and I think it was a really, it's been really interesting. I think it's expanded my understanding. I was just talking with Matthew before and I asked him, what have you really learned or how have you changed your viewpoint since doing all the digging that you've done?

And I think we both agree that one thing that we feel very strongly about after doing this digging is the importance of having this conversation because of how linked good things are with a, a stronger belief in free will. So even if it's going to be neurologically impossible to determine if free will exists, there's a little bit of a double use of the word there, and it's going to be impossible to show neurologically that determinism exists. So there's this existential almost, you know, place that we're left, which is also an existential sort of viewpoint, right, that free will exists. And this existential place is that there's value in the way that we communicate to not

make things overdetermined when they're not and to leave room for people to make decisions and to not be solely influenced by their genes environment. Now, in this episode, we're going to finish talking about the importance of belief in free will. We're going to be talking about some of the different mental illnesses and how free will might be influenced by them. And we're going to talk about sort of this seductiveness, that neuro-essentialism or, you know, that we are our brain and our brain is us. And we are like solely determined by our brain. You know, like this sort of seductive aspect of how we view ourself has permeated psychiatry. And we're going to talk about some of the challenges to that viewpoint.

Okay. And, you know, I teach a class on the history of psychiatry. And we talk about there's kind of like the three domains, the psychological, the spiritual, and the like the biochemical, right? And that these three kind of things throughout history have been, leaned on one more than the other. And coming out of the last like 10 years, we definitely have leaned more into the biology and the brain and chemicals and neurotransmitters. And, you know, this, this has been winning. You know, should it be winning to the level it's winning in the way

that people view themselves and the way that psychiatrists think? You know, so we're going to talk about that. Yep. And I think it's also permeated outside of the professional realm just into to public conversation about neuroessentialism. They might not use those words, but there is a big push that describing mental illness in terms of neurotransmitters or, oh, it's, you know, my brain's problem, that that's supposed to reduce stigma in some way. And so I think it also has a practical application, just even public conversation at large.

Yeah, and that's kind of a myth as well, that it reduces stigma. And honestly, there is a moment where if someone truly has, like, bipolar and they've been doing things, which they feel a ton of shame about, you know, to explain like, hey, you're struggling with bipolar, this, there's, there's aspects of this that are biological. You know, if you explain into those terms, the patient, like, has a decrease experience of shame. I've experienced that. And so there's there is this kind of like draw to be able to say that, but is that true, right? And does that have side effects that may be, you know, it makes people see themselves as I am bipolar. You know, I have a lot of patients that come in. The first thing I tell me is like, I am bipolar. It's like in the men program, we try to get people away from describing themselves as their illness.

You know, maybe I am Jane and I struggle with bipolar. I am Jack and I struggle with bipolar illness. You know, that's different than I am bipolar. But a lot of people, when they first introduce themselves in group therapy, what we find is that they introduce themselves with a bunch of illnesses. And that's become their identity. And that's part of why they are stuck. So part of what we do in our program is we help people sort of see themselves for what their

strengths are. We give the strengths energy. So let's let's jump into this. This is this is, let's talk about some of these studies on static belief and free will. Yeah, let's do it. As you mentioned, just a brief summary of the previous episode, we relied heavily on a specific definition of free will taken from one of those papers that uses it as a blanket term, including components like self-control, planning behavior, rational choice, and then sort of in a more simpler form, free will as self-regulation. So we discussed that and used that definition throughout. We want to pull that definition into this final episode as well. And surprisingly, despite all the studies we listed, there are still a few more that we didn't get to.

A few studies that didn't manipulate the belief in free will, but focused on belief in free will at a static point. So they still used the same tools to assess it, but didn't try and manipulate it in any way. So a study from 2016 by Feldman and others found that a static belief in free will is associated with better academic performances, even though a belief in free will does vary

a little bit across cultures. This is a portion of the study we cited previously with university students from Hong Kong, mainland China, and other international students. And they found, quote, the relationship between the belief in free will and spell checking performance was significant. Participants who reported a stronger belief in free will correctly identified more spelling mistakes and did so in less time. They also conducted another study on the GPA, so overall performance of those students, in a specific class. and they found that, quote, the belief in free will exhibited a positive correlation with the final course grade

and a similar effect for the overall GPA of the semester. The belief in free will was positively correlated with trait self-control and negatively correlated with implicit theories such as intelligence. Yeah, and so some of these correlations are on the lower, side like implicit theories. It's only like a negative 0.12, so that's a very small correlation. Intelligence. 0.24, but still statistically significant. A final study about belief in free will found that a static disbelief and free will is associated with reduced helping behavior.

So if you score lower on your belief in free will, you are less likely to help of This was with undergraduate students, which were asked to rank how many hours they would be willing to donate helping a classmate who was in distress. They found, quote, belief in free will was positively associated with helping behavior. Results showed that disbelief in free will predicted a lower number of hours for which participants volunteered. Treating helping as a dichotomous measure yielded similar results, disbelief in free will was associated with a lower tendency to volunteer any help at all. These findings suggest that chronic disbelief in free will relates to a lower likelihood of helping another person. These effect sizes are not huge.

Point three is a mild effect size. But it's interesting that all of these effects point in the direction that are the same. So I don't see any studies that are showing that a belief in free will hurts you in some way. Right. Correct. That's interesting to me. So all of them are pointing towards more positive outcomes with a belief in free will.

And it seems to be the helping behavior and non-antisocial behavior is kind of linked with the free will. Which fits well with previous discussions about its societal value in the idea that self-regulation, allows for interaction in society and mutual benefits. Transitioning then to the last main topic we're going to talk about in this series is the relationship between free will and mental health. Do they interact? Any interaction between free will, belief in free will, and mental health is not as easily tested or readily published, but some connections do exist.

At the outset, it's important to distinguish... free will from other terms common to psychiatry and mental health. Psychiatrists are often asked to determine decision-making capacity. However, conflating this with free will can lead to a determination that those suffering from schizophrenia or severe depression, for example, may not only lack decision-making capacity, but also free will itself. Renato Ramos takes this concept one step further by explicitly arguing for the free will of schizophrenic patients through the use of the concept of self-organized criticality.

And Ramos is further supported by another author, Willem Martens, who uses a more traditional approach to the concept of free will to claim that psychosis is not always incompatible with free will. So important definitions then. We talked about decision-making capacity. And this is often defined as the ability to express a choice, understand information, appreciate personal relevance, and reason logically. Now, schizophrenia or severe depression can alter the ability to express a choice

or understand the personal relevance of information. These pathologies can also alter the perception of self to such an extent that the individual feels no continuity with their former desires and is unable to express long-held beliefs. These changes do make decision-making capacity very challenging, since they affect some of the core criteria that we have established for decision-making capacity. However, being a different person does not necessarily violate free will. If an individual inherits an entirely new set of desires or changes their priority, they ascribe to certain motivations, they are not precluded from understanding and acting on these desires.

They can still possess free will, even though they lack decision-making capacity for many possible decisions. That makes sense to me because if you think about like someone of schizophrenia, they may be operating from delusions, right? So the delusions may be influencing their thoughts about how the world is structured, but they're making choices based on those inputs. And those choices are things that they're still deciding to make. So they're deciding to not eat the food in the psychiatric hospital because it's been poisoned.

They're operating under some false beliefs, but they're still operating and making a decision not to eat it. Exactly. Yeah, okay. Whereas their decision-making capacity is not present, right? Because if you talk to them about, okay, here are the reasons to take the medication, here are reasons not to take the medication. You know, can you explain to me the risks and benefits?

They may not be able to explain the risks and benefits. because the psychotic sort of inputs may be too much to sort of register what the real risks are, what's really going on, because of the delusions and because the internal representations of reality that aren't there. And I think an interesting argument in support of this, what we've been talking about is one from Ramos that we just mentioned using the idea of self-organized criticality. Basically, it's a type of mathematical law that explains the non-random variation of a given event over space or time. Now, I did not understand this on the first run-through. Thankfully, he gives a helpful example. Basically, if you consider an hourglass or a pile of sand on its own, if you're dropping grains of sand onto this pile, you cannot necessarily predict the movement of each of these grains of sand. However, you can predict

how the pile of sand overall will act. You can predict the slope, you know, when it gets too steep, you'll have some sand sliding down, various things like that. So basically just saying that there are some variations that we can't predict on an individual level, but taken collectively, we can make some predictions. Now, this is interesting because he moves this concept, one step further and says that such systems that have this self-organizing criticality need to have a self-similarity within each object. Quote, self-similarity in terms of human behavior means that although very agitated individuals show intense variations in their behavior, in terms of social interactions,

for example, in comparison with depressive individuals who are less socially interactive and absolute terms, the probability of observing small or bigger variations in their behavior in relation to their basal levels is the same. So in other words, if you have someone who's very agitated or someone who's very sedate, both of those things are off their normal baseline. However, if you take their current states of either agitation or sedation, you can still see some variation within those new normals or those new baselines. He went on to support this concept with a limited study using 40 inpatient psychiatric patients and 34, quote, normal individuals, and then rated the psychiatric patients on a scale for

their psychomotor activity and then rated the control subjects, quote, normal individuals. on a self-rating scale of well-being. And the results were really interesting. Quote, even exhibiting different absolute values, the curves obtained from each group, i.e. the inpatient and outpatient, expressing their behavioral variability and percentage in relation to themselves,

can be superimposed over the curves obtained for all of the groups. So you'll be able to see this graph in the additional material that will be posted, but basically saying that in-group variations were similar in both groups. And this is an interesting concept because the idea of this self-organizing criticality does not depend on any external or centralized control. The author then says, quote, therefore, my proposal is that the free expression of desires, judgments, and decisions about how to behave is sufficient to generate such patterns. So he's linking the idea that someone with free will will generate these types of patterns,

will generate these types of small variabilities off of their baseline, even if their baseline is drastically altered. You know, this kind of makes me think about some of the evidence for, violence in patients with things like schizophrenia, bipolar. For example, in this bipolar study, they looked at those who use substances had an odds of committing violence of 6.4 times the average, whereas those without substance use, the odds ratio was only 1.3. Okay, so it's very low odds if you take away the substance use. And then if you compare the bipolar. patients with their siblings, the odds ratio goes down to 1.1. So it kind of, reading that,

it kind of made me think, well, even in the midst of the bipolar illness, it's not like they're more violent, compared to their siblings. 1.1 is very nominal. The same thing was found in schizophrenia. Substance abuse was 8.9. Those without substance abuse was 2.1. So, a little bit increased. But I think if you were to look at their siblings, it would be decreased even more. Same thing was found in people with TBIs. The odds ratio was higher unless you compared it with the siblings. Then it went down to like an odds ratio of two.

So it doubled a rate. But still not a huge, huge increase. Anyways, this going to show that like, you know, how we think about, people with mental illness is we often think like oh they're violent why do we think that because of movies because of movies like you know Batman where like all of the criminally insane are incredibly violent right um all these movies i watch now on Netflix where they have like people with mental illness who are very violent i'm just like oh my gosh this is like it's horrible i mean the same thing can be said about race you know there's studies that have shown

that black people on the news are shown to be more violent than they are in real life. That influences culture after a while. That influences and seeps into people's implicit bias about something. So, okay, interesting. It is. One last quote I'd like to pull from this article, but I found especially interesting because it takes the perspective of a person who is, you know, currently psychotic, is the author's claim here, considering that I feel these different versions of myself, i.e. the psychotic, the depressed, as still me,

I can describe free will as the cognitive experience of having made an autonomous decision despite not being fully aware of all interactions between my brain-mind process and the external information necessary for an adequate contextualization of this action. You know, I find it, the patients that I have who are schizophrenia and bipolar, and they go into episodes, even being on medications at times, they will still trust you if you have developed a good rapport with them over years. Even in their psychotic illness, even in their psychotic states, the therapeutic alliance will be what gets them to take the medication.

So I think this kind of humanizes these patients a little bit in my mind, like thinking like, okay, they still have this like sense of free will. I don't think it's an on or off switch. I think we'll get to that eventually in this episode. I don't think like it's like all of a sudden you go from like free will to no free will. But it's probably a gradient. But by and large, like we showed with the violence, it's not like there's huge increase odds in doing behaviors that are very foreign, right?

Okay. And I think that's why the idea of this gradient, I think, is why it's important to distinguish this concept of free will from decision-making capacity. Because even though that's moved to more of a gradient concept, I think as it should, you know, someone might not have decision-making capacity for some life-altering decision, but they could have decision-making capacity to decide about what they want to eat for lunch. There is a gradient there as well, but I still think that there are some hard cut-offs in the concept of decision-making capacity. Because you're asking, can they make this decision? yes or no. And I think the idea of free will needs to be distinguished from that as more nuanced and having more gray areas even within that. Yeah. In a similar vein, there's another article here by Martens published in 2007, talking about the idea that free will is not categorically incompatible with psychosis. So Martins does not quite go as far as Ramos in their definition of free will, but they do make some interesting claims. They describe, free will as having free will is to have what it takes to act freely. When an agent acts freely, when she exercises her free will, what she does is up to her. She is an ultimate source or

origin of her action. Martens then provides different examples of how psychoses can be functional in their fulfillment of internal needs, such as the need to survive, to belong, to have power, have freedom and to change or transform. A couple examples to survive, using psychosis for coping with unbearable circumstances to belong. Erotomania, using that to fulfill that need. Power is seen in grandiose delusions. Freedom, psychosis as a break from obligations, or transformation. Psychosis has a higher openness to feedback associated with greater delusion-proneness.

and therefore makes the argument that some psychosis can be based in the fulfillment of these needs. Martens also believes that a narrowly defined set of psychotic patients may qualify as having free will. However, there's a very specific definition for this range of psychotic patients. They must be motivated to change, have insight, mild symptoms, have self-correction, coping skills. They need to obtain effective therapy, have optimal support, and have limited life stress overall. This definition might be a little bit too stringent, especially in comparison to Ramos' definition, but it does show that even looking at this from a more traditional lens, you can make arguments for the existence of free will, even if you don't want to claim free will exists in these extreme cases.

Yeah, I mean, I think this comes back to number one. Free will doesn't mean you're making freely good decisions. You can make freely bad decisions. I think that when someone's acutely psychotic and they're believing that they're, you know, Jesus or Mother Mary, you know, and they believe that they have a mission to cure the world, obviously we're going to do what's in their best interest in these times to get them psychologically stable. that being said i have a lot of patients who are in remission who go on and live surprisingly adaptive lives where you would never know if you met them you know and you would potentially

seek them out to be a professional that would take care of you you know so i think the psychotic stage i think there probably is a decrease in the ability to choose things that would be adaptive for them to move forward in life they're still going to to make choices based off of delusions and based off of errors of like this author said that there's desires that are amplified so like a desire for control maybe a desire for power may be translated into a delusion of you know i am the head gangster of l.a you know and so they're walking around as a homeless person thinking that they're like the top gangster or like i have the ability to just look at someone and later they're going to die, you know, or something like that.

So they may have these sort of delusions or magical beliefs. And these are rooted in prior desires that they had prior to their psychotic episode. And they just get amplified. Their desires that we all have. We all have desires for control. We all have desires for some sense of power. And, you know, no one wants to be powerless. We all have desires for sex, unless maybe.

Maybe you're on huge amounts of medication. You can have decreased desire for it. But even then, you still have some remnant of desire usually. And so some of these delusions become sort of that extending further. So we can hopefully empathize with the underlying themes that we see. That's good themes, you know. Like, hey, it's good that you want a sense of control and power. I want to help you accomplish that.

Okay. Well, I like your distinction that you made there at the beginning saying that free will doesn't mean that you're making good decisions. I think this author might link recovery with improvement in free will, which we can talk about later. But I do like that you made that clear distinction that just because there are bad decisions being made doesn't mean that free will doesn't exist. to we might differ a little bit with Martin's interpretation of it. Yeah. Moving on then to another section here, talking about how free will relates to mental health in a broader way. And this you might have guessed from previous episodes,

but free will can relate to mental health in a broader way because it promotes good things in life, such as meaning in life, true self-knowledge, and even potentially some association with the concept of passionate love. These relationships are not as direct as a connection between free will and depression, per se, but they do still provide some useful examples, and the lack of those articles linking free will and depression,

provides an opportunity for future research, potentially. Yeah. And we could, I mean, we'll list out these articles if you want to jump in any one of these topics in further detail, but maybe for the purposes. of the podcast. Let's keep going. Yeah, those are there as resources and have some similarities to other articles that discussed. But finally, as we mentioned earlier, the most significant and practical connection between free will and mental health is the concept of neuroessentialism, which claims a full

determinism. This concept is advocated by Sam Harris, among others, and is not rare in the realm of neuroscience. Neuroessentialism has importance for both patients and physicians, giving it practical value. So as a definition, a Schultz in a 2018 article laid out a helpful definition here, neuroessentialism is the view that the definitive way of explaining human psychological experience is by reference to the brain and its activity from chemical, biological, and neuroscientific perspectives. For instance, if someone is experiencing depression, a neuroessentialistic perspective would claim

that he or she is experiencing depression because his or her, her brain is functioning in a certain way. Now, the reason that this, or part of the reason that this term came to prominence is because this biological approach has been hypothesized to accomplish a reduction in stigma by saying that the individual is not responsible for the development of his or her psychological disorder. Instead, their biology is responsible. So the lack of the lack of, this lack of responsibility an individual might have for their disorder, when explained from a biological perspective, can be, quote, outweighed by the adverse effects mediated by perceived differentness and dangerousness respectively, end quote. So even though the goal was to say,

all right, you're not responsible for it, therefore there should be less stigma surrounding this. In some examples, they are finding that when you have less responsibility for it, you are seen more as other or as having greater difference and therefore perceived as being more dangerous by some. Yeah. And there's, so there's studies that show that it actually increases stigmatizing attitudes to believe that it's all biological, which is interesting because like I said, like when you are talking to a page, it can initially reduce their sense of like personal responsibility and therefore decrease their shame right if if you say like look you're having an episode of you know xyz and this is because there's this biological misfiring in your brain and just for clarity like there's there's a couple theories out there that we just know are not true anymore they they get propagated because there's simplistic

ways of explaining things, like depression is because you have low serotonin in your brain. That's just not true. It's a whole lot more complicated than that. You could probably show 20 or 30 things that are going on in the brain during depression. Inflammation, like initially I thought, oh, depression was inflammation. Well, it turns out not all depression has inflammation. Maybe one third has some increased inflammation markers in the brain. So there's like all of these things that are going on in the brain when there is depression, but is, is the causal relationship because of a biological thing that's going on in your brain? So that's kind of where neurosensualism would point. Neurosensualism would say, yes, you are having this because

of this biological issue. Yeah, yeah, and good motivations behind presenting this to patients, presenting this to the public. It's not. to knock the motivations and there are some benefits even if they are shorter term. But yeah, it doesn't really seem to help in all cases. Well, and let me take this to the common parallel that's like diabetes. Like, oh, depression is like diabetes. If you have diabetes, you get medications because you have diabetes because you have low insulin. Or you have insulin resistance.

Well, you know, it's interesting. I've seen a lot of diabetic patients who can't control their glucose, no matter how much insulin they get put on. And once they reduce their stress in their life, all of a sudden, it's easier to control their diabetes. Why is that the case? Well, because stress produces other stuff like cortisol and stuff like that, which makes diabetes a whole lot harder to control.

So what is the underlying cause, you know, what is the underlying thing that you you have to put your energy at fixing. If someone has a structured sleep apnea, we can find a whole lot of changes in the brain that say that this is not a happy brain right now, but you can't go to the brain to change the brain. You have to go to the breathing in the middle of the night to change the brain.

That's going to change the brain. And sometimes you have to go to some weight loss as well. You know, these are harder things to fix. And that's part of the problem is, you know, you come into psychiatry thinking like, oh, I'm going to help people start to change their diets and lifestyle. And then after a couple months, you're just like depressed because no one changes their diet and lifestyle.

It's like, that's really hard to change, right? So sometimes the cause of the illness is so much harder to untangle. Like I was saying, like the belief in the illness can actually influence the illness. right so people seeing themselves as ill getting connection from other people from being ill self propagates their illness narrative right now they see themselves as ill and it kind of like and their their partner may get benefit from being the martyr of taking care of someone who is who is ill right and so how do you disentangle and help this family unit you have to do family therapy essentially because you help the person see themselves as not as ill. They go back to their

family structure and their husband wants them to be ill because that's how he got his narcissistic needs met from being the rescuer, you know? So it's kind of like there's this environment that's malfunctioning that is self-propagating because it's adaptive in some way. And, you know, is that a medication issue? No. You know, I mean, it will medication help a little bit? Yeah, sometimes a little bit. but the effect size isn't going to be that huge. And that's what we see with some, with a lot of psychosomatic illnesses, actually, is that medication is not that huge of an effect size, you know. It is so much more complicated, as you're saying,

to deal with untangling all these parts and backing up exactly what you're saying. This article also talks about the idea that the increase in direct-to-consumer advertising for antidepressants is related to rising prescription rates. And this is partially because these advertisements talk about depression as a biological medical condition that can be treated, you know, almost exclusively with medications. And so these rises then are not necessarily explained by dramatic increases in the, you know, rates of depression, but because consumers are buying into this, and patients, I should say, are buying into this concept of the purely biological depression and therefore are leading to an increase in prescriptions for these medications.

Yep. I remember one prescription ad. It showed someone with a something attached to their back that you needed to kind of like turn, you know, and this medication would help turn this to help them get up and go a little bit more. Yeah, there's another thought I had is if you look at some of the top people who write psychopharm books. Some of these people are getting paid not by one pharmaceutical company, but by pretty much every pharmaceutical company for consulting. Wow. And it's in the millions of dollars.

So the people writing some of the psychopharm books that don't mention psychotherapy at all, you know, are getting huge, huge amounts of money from every drug company. And, you know, so they're going to be. biased. I mean, hey, if I got a couple million dollars a year from someone, I would be biased to preach their message. There, you know, I mean, you go to one farm dinner and you'll be more, your prescription prescribing habits will change overnight, you know? That's why I don't go to, I don't allow people to pay for meals for me, you know, like these drug companies. I just don't

go to those dinners. I haven't been to one. Maybe when I was a medical student, I went to one, if you look at my records, maybe one. Okay. I was like, so you can look up every psychiatrist and you can see how much these drug companies have given them financially. And I think if you look at my record somewhere in residency, I was given a book. And I didn't even realize I was going to get put on this thing, but I was given a book. And so there, that's the one thing on my list. But some people are given millions of dollars.

This will change prescribing behavior. And I think it's somewhere around 10% of people in America are on an antidepressant. Wow. And for women, ages 40 to 59, 22% are on antidepressants. It's a lot of people. Yeah. That's a lot of people. Significant number.

That being said, I sometimes prescribe medication. So I'm not like anti-farm. I'm just realizing that. that, you know, some people get put on the medications for very low thresholds of reasons. And I would prefer that they're given more to the severe cases and psychotherapy be given to more of the mild, the moderate. It's going to work as well as antidepressants. And it may have longer lasting impact.

Yeah, and this is a discussion mainly about the philosophical or, you know, your own friend. framework behind choosing to prescribe medications, start therapy. And so it's not meant to, yeah, knock medications, as you were saying, but just to think about, okay, what's the philosophical framework that's either driving, that's driving my thought process one way or the other? Yeah, and let's become conscious of the things that are influencing us so that then we can make rational, sober decisions so that we can best help the most people possible. At the end of the day, that's what I'm about.

So, you know, if I can recommend exercise and that actually works for a patient, you know, I know that there's a study at Duke, which is, you know, cardio three times a week in a group is going to be as good as an antidepressant for mild to moderate depression. So, you know, there's options that we have. And so as psychiatrists, we want to just look at the data. we want to understand the data as closely as we can do the truth so that we can make the best decisions for the most people. To go more at the base of these biological only frameworks or concepts, I believe the author makes a really interesting claim here. This is, quote, so to be us ultimately

is to be physically based or realized. This does not mean, however, that each and every activity, state, aspect, or component of us can be exhaustively or completely described in lower-level physical scientific terms. Use as an interesting example. That is, physicists studying a dollar will not find particles that defy the laws of physics, but they also will not find the dollar's market value. And so going fully biological on this and looking at the most basic neurons and those types of interactions, well, of course, there's going to be laws of physics. There's going to be laws of biochemistry. But as you add levels of complexity, these most basic components will not necessarily explain your larger system. Right. And, you know, one example I

have is when I've studied emotion, I looked a lot for like, where's, what can I learn about anger from, you know, brain scans and stuff like that, the more studies I read, the more complex I realized it was. It's not just one area of the brain lighting up. It's like multitudes of different areas and different studies show different things. And so it's like, I don't think I can really learn much about anger. I could probably learn more about anger from the Iliad, you know, learn about Achilles' anger that led to the killing of Hector, you know, that led to a lot of suffering.

and some character growth as well. So, you know, I think there's another example of, there's certain flowers that change color. And so you can look at that, and you can look at the biochemical aspects of, and you could say, okay, this flower is turning from white to red, okay? Or from red to white, and you could look at the biochemical stuff and why it's changing there and the genes involved.

And you could be like, okay, you know, that's a paper. You could write that up, right? that doesn't say why it's changing color. So then you look at the evolutionary study. And lo and behold, by changing color, maybe that flower has the increased chance of not being eaten. But the increase, like, so early on, the color allows for bees to find it and to propagate it, right? Spread the pollen. But then later on, by changing the color, now it's not eaten by certain other bugs.

So studying it from that perspective, like you're never going to learn that perspective unless you understand the evolutionary survival advantage of that. Right. And so you may not have the complete picture until you look at both perspectives on what's going on or how that happened. But I think it's another good example of like we may look in the brain for depression and what's going on, but we may not understand the cause or what to target. with our treatment. And I think the cause or the target may be a lot more nuanced and maybe a lot more difficult to unravel. And it may be very individualistic.

So it's easier just to kind of get into this mindset, okay, it's like a biological thing, throw an SSRI on, you know, and see if I can get a response. And, you know, if they don't, it doesn't respond, maybe I'll try Wobutrin and la-di-da. So I, and I think that with the way that insurance is set up as well to drive shorter and shorter visits, it's like psychiatry as a

whole has been kind of driven into this place where that may be what happens. So I'd like to, I'd like to pull us out to push us the other direction, you know, to think, to get us to think like what might actually be the causes, what might be the actual targets. Definitely. And to think about, you know, maybe going on a little bit of a tangent there as well. But the idea that, you know, okay, you have a shorter visit, so you're going to solve it with an SSRI. Well, that does provide some solution, but I've been working on another paper and just sort of looking at the challenges of even getting off of these SSRIs. So, okay, we can give it to you now, but what happens if we need to transition in the future? There's just a lot of

difficulties that aren't, you know, that are just pushed off. They're pushed off to a further date and taking the time to or having the time to work through some other options instead of medications. Yeah. Yeah. Getting off them can be can worsen the mood acutely, which can make the person think, oh, I really need this. And it can be hard to get through that transition, period, you know. Yeah. It's complex. So we have to weigh these decisions. And we have to weigh them very carefully, right? And so I don't like the haphazard prescription of like medications. Like, oh, okay, you have some neuropathy, let's give you, you know, some balta. It's like, okay, but then let's like really weigh, like, is this the best option for this

particular person? You know, psychotherapy is probably very underprescribed by primary care doctors. Well, I know it is. It's very underprescribed. And that needs to maybe shift the other way. Okay, let's keep going. So then the author took a look at a couple of interesting studies. and basically talking about how patients viewed their own prognosis,

and later on discussed this same thing with mental health professionals, and sort of how the biological or biochemical view affects their own thoughts of their illness. The study found that biochemical or genetic attribution scores were a significant predictor, of longer expected symptoms duration and lower perceived odds of recovery. Which is fascinating. Author also claims that given the increasing prevalence of biomedical conceptualizations of depression, the notion that depressed individuals who hold such beliefs might be more vulnerable to pessimism about the course of their disorder is alarming.

End quote. Yeah, I mean, this is what I was talking about before, like the disease narrative that some people pick up on, right? This is why, like, I'm very hesitant to say to someone they're bipolar or they're schizophrenic, like, let's really be careful because some of these things are biological labels and the meaning that people place on them. You know, and it's the same reason someone comes in with me with borderline personality disorder and they call themselves bipolar. I may spend that difficult conversation, uh, to tell them that I don't think that they're bipolar.

And that I'm hoping gets them to a place where they see that with the right treatment, they can overcome this. Because like with the mentalization, 85%, after seven years, didn't meet criteria for borderline personality disorder. 85%. That's a big amount. Yeah. And if you look at that study carefully, it's interesting how they decrease the medication

significantly from the beginning to the end of the study as well. So, you know, it's not a good long-term solution to be someone with borderline per size or are in beyond 12 medications. Okay. Same thing is also found with clinicians. Another study found that clinicians believe psychotherapy to be less effective when shown biological descriptions of mental health pathologies. Yeah.

I see this in therapists. I see this in some therapists. In some therapists, when they get a really hopeless encounter, they'll sometimes think that the medications is like the solution. Sometimes it is. But interesting. Tell me the results of this study and what they found. Yeah.

So they took a couple different disorders that these clinicians were looking at, and then they paired them, you know, One had a biological explanation and the other did not, had a different type of explanation. And the results that were across disorders, the biological explanation yielded significantly less empathy than the psychosocial explanation. They also did some additional analysis, and they found that the biological explanations yielded less empathy than the psychosocial explanations among both MDs and non-Ds. on MDs. Well, it's like, what are you empathizing with, right? If someone is not really suffering, if their biochemicals are off, you know, it kind of gives us a little distance, which, you know, maybe allows the person to continue to treat this difficult person, right, or this difficult situation.

or like inpatient doctors tend to be more biologically minded while they're also being exposed to huge amounts of negative affect all day and so maybe that allows them to cope with their reality a little bit better that's an interesting point they also found in another study with these clinicians that biological explanations were given lower clinical utility scores across disorders and And finally, that clinicians perceived psychotherapy to be significantly less effective when symptoms were explained biologically rather than psychologically. And so then just breaking down the difference between some of the disorders, they said, for all disorders except schizophrenia, biological explanations yielded significantly higher medication

effectiveness ratings than did psychosocial explanations. So, I mean, the placebo effect, too, right? Mm-hmm. Like, if you create a narrative and then you give someone a placebo, and the narrative says you have the shortage of this chemical in your brain and you take this drug and it's going to help you, that's going to increase the placebo effect because your belief has increased. Belief influences the way that a placebo will be taken in. So, you know, a pills like antidepressants, we know that even the placebo effect is pretty significant.

I mean, pretty significant. And the benefit of the medication above placebo is a mild to moderate effect size, usually mild. And so, you know, it's interesting to think about this. The schizophrenia didn't change much. the biological sort of explanation. A final quote from this paper that I thought was especially interesting, just sort of summarizing it, they claim, in addition to client expectancies,

clinician expectancies for client improvement, also have a significant impact on treatment outcomes, and thus, conceptualizations of depression that decrease clinician expectancies will likely worsen treatment outcomes. I just thought that was fascinating because if the clinician doesn't believe this is going to work, then chances are it's not going to. Well, I hope I haven't destroyed any of your placebo responses out there if you're listening to this. And you, I mean, it's interesting because, like, there is this sort of event that you go to

and you hear these great psychopharmacologists speak about things and you start believing in. this medication more, you know? And it's like that leads to your medication's working better, right? Because your belief, people feel that belief. If you don't believe that a medication is going to do much at all, like patients are going to be very haphazard in taking it. So the therapeutic alliance is going to change medication effectiveness. Your belief is going to change the effectiveness. And by the way, that's not just for psychiatric medications. That's for like all medications like Parkinson's medications. A placebo will actually increase dopamine in Parkinson's medications.

That's been a proven trial. So, you know, belief changes a lot of things, right? So if your belief in psychotherapy is very high and you do psychotherapy, then your psychotherapy is probably going to work better too. You know, a lot of fear, a lot of anxiety and patients can be decreased by someone with confidence. Yeah, okay, let's keep going. then we have some more studies here that we could just leave and discuss later but basically linking the idea that the diminished importance of psychotherapy among mental health professionals

ascribing to the concept of neuroessentialism is doubly harmful when considering the multiple context in which psychotherapy matches or outperforms pharmaceutical interventions yeah that's interesting i mean we yeah so there's some um there's a a meta-analysis that looked at CBT and how it has advantages over some pharmacotherapy. The problem I have with a lot of these studies is that there is no good placebo for psychotherapy. And what I mean by that, and this is a, on my self-assessment, no one has gotten this question right, so let me explain this for you guys. So as psychiatrists, we have to take these self-assessment questions.

I have some on my website. and one of the questions is comparing an equally, an equal sized effect size of like 0.6 between a therapy trial and a medication trial. And I say which one is more beneficial? And the control for the therapy is like a wait list. And the control for the medication is a placebo. And so the answer is the medication is actually more effective, right? because the effect size is comparing to an active placebo,

and we know that placebos are more effective. So the overall effectiveness from doing nothing from the wait list is going to be quite a bit larger. So we're not comparing apples to apples when we talked about effect size. So that would be the first sort of critique of some of these studies. The second critique is probably for psychiatry that there seems to be an over sort of emphasis on medications and not psychotherapy.

We should have an ongoing conversation to sometimes convince patients to get psychotherapy. And it's true. Some patients will not go see a therapist. And I'll be talking to them about it for like two years. And some patients have had horrible experiences with therapists. It's like, what do you do with that? Well, this patient has very high countertransference. transference and, you know, they have a lot of stuff that kind of gets drawn up and it's hard

to find a skillful therapist that can meet them with that level of, with their level of need. So there's various reasons why therapy hasn't always been helpful for them. So we'll leave this study up on, we'll link the study on the website. You can take a look at it. And let's move on to this next part. All right. Sort of bring things a little bit to a close here before reaching the actual conclusion. Just some more practical questions. How should patients be counseled and free will approached in the clinic? What affects free will itself? Can it be improved or better exercised based on the influence of the environment, thought content, or traditional concepts like willpower?

These are some big questions. We definitely won't answer them all, but sort of trying to move that way a little bit further. One author, which in some ways I disagree with, but provides some interesting arguments, Glannon in a 2011 article, claims that free will may have a physical component to it. And therefore, since it has some type of physical component, there's a potential to improve or influence this free will in some ways. I don't think that the inclusion of a physical component is helpful for the definition of free will, and I'll sort of make some arguments that effect as we go along.

But it does present an interesting case for influencing free will and allowing it to either grow or shrink. I actually think, yeah, I'd like to hear your thoughts. disagree with you on this. Okay, this will be fun. So author takes the definition here. Free will consists in the ability to initiate and execute plans of action. My response to that would simply be to ask if this means that someone who is simply weaker than average also has decreased free will since they have less ability to carry out everyday tasks. So it seems like there's an average. active, he's thinking that there's an active portion, initiate and execute plans of action.

Yes. Where you're saying maybe that you can have a choice to not initiate, right? Yeah, the physical act of executing something seems really to be an unnecessary addition because I would feel that, you know, someone who is paraplegic or has some other limited mobility that doesn't necessarily mean that they have any decrease in their free will just because they're not able to execute some of the plans that they would have. Yeah, I think coming back to our definition that I think I would agree with at this point, free will is self-regulation, self-control, planning behavior, rational choice,

all of those things. I think my critique of his definition would be to initiate and execute plans of action. Sometimes we are, I guess, choosing not to, initiate and execute. So is choosing not to move forward also a place of free will? I would say it is. Okay, let's keep going. There are some parts of the definition, though, that I think are really helpful. For instance, the author claims that free will exists along some type of spectrum and that it can be enhanced, which is, I think, what you've been hinting at for a while here throughout the Z episodes. That was one of my initial ideas.

And I'm not surprised that other people have come up with that idea prior to me reading about them coming up with it. There's not much new out there. But yeah, I think that's sort of one of my thoughts that I had coming into this was I bet that free will is on a spectrum where you can lose it or you can gain it. It's not an on or off switch. Yeah, and I would agree. I think there is, you know, some spectrum there. But I wouldn't necessarily use the examples, I believe, that this author uses. For instance, they use another definition here, talking about free will, quote,

we choose and act freely in the absence of coercion, compulsion, and constraint. This requires the mental capacity to respond to reasons for or against certain actions and the physical capacity to act or refrain from acting in accord with these reasons. which once again sort of brings in this physical component that I could sort of see the train of thought where, you know, if you've, there is some lack of control if you can't stop your arm from moving or can't stop certain things from occurring.

But I don't know if that necessarily relates to free will itself. Okay. They use specifically the example of Parkinson's as an example of D. decreased free will where a patient may be able to consent to deep brain stimulation, while also being unable to control tremors. Quote, while one aspect of the will is impaired, another aspect may be intact. I just don't think it's necessary to add these multiple aspects.

I think free will is purely mental by definition, and that adding this physical aspect of the will is unnecessarily complicated. Yeah, and I would add having had a good mentor who died of Parkinson's or died of complications from Parkinson's, even though his face was not flashing emotion, you know, he had Brady Kinesia who was not moving as much, he internally was experiencing things, but it wasn't being represented on his face or represented in his movements as much. but he was internally there. That being said, Parkinson's can develop dementia, severe depression, it can develop other sensorium issues.

One example he gave, which was interesting, was one of the Parkinson's meds actually increases risk of gambling. I don't know if you remember that medication. Dopamine agonists can over-stimulate the reward pathway in the brain's mesolimbic dopamine system can cause compulsive behavior such as gambling. Now, that being said, it's interesting when you talk to someone with Parkinson's

who's on one of these medications, they may say, you know, it's really interesting. I haven't had the desire to gamble, except, and you warn me about this, Dr. Peter, you warned me that I might have this desire. I mean, started this medication, and I started noticing it and observing it, right? So that, but his will didn't go along with it.

it, right? So because he didn't want to lose all his money. So his will decided to come back and talk to me, right? So that's a good example of like having some, you are not the things that are necessarily driving you. And I see free will or the will as like the choice between the different drivers. Do we want to magnify some drivers? Do we want to diminish some drivers? Do we want to you know, operate out of belief when there is no desire or like our, our, the sense of meaning and purpose that we have at a deeper level, okay? So these things can drive us, even in the face of, you know, situations where it would be very unusual for people to have certain behaviors. Coming back to Victor Frankl's, like examples of people who would take care of each other in

the concentration camps and give away a piece of bread to someone who was starving, you know, these sort of self-sacrificial things in the midst of a huge need for self-preservation, a larger need of self-preservation than probably has ever existed for this individual. And yet their belief structure, their meaning led to their actions. That, I think, is a good example of, like, this decision, this free will is being exerted. Definitely. Definitely. And then just continuing with this concept of a,

physical component of free will. The author does provide an interesting example, which I think is important to acknowledge, is that you do need a mind. You need a brain. It is a physical structure in your body that is where this free will occurs. It's where these thoughts and the ability to manipulate thoughts happens. And so in that way, severe brain damage, you know, missing large portions of your frontal lobe, could definitely affect your free will to some extent if you physically have pieces missing that are necessary to this process. So there is some interaction, but I just don't think the outward physical actions should be linked. They use an example of a teacher in Virginia who began displaying pedophilia, which they found was associated with a

meningioma pressing on his right orbital frontal cortex. Removal of the tumor resolved this pedophilia. However, the behavior returned with the growth of a new meningioma in the same brain region and resolved again when the second tumor was removed. And I mean, it's interesting when I hear a case like this. Like, I would want to see what this guy's like penile plus leograph is or whatever it's called where you hook the penis up to the sort of like ability to judge its erectile function, and then you show pictures, right?

And you can show pictures of different rousing situations and see if someone is attracted to young girls or not, right? So, like, was he attracted to young girls and became more impulsive, right? Like, did the pedophilia predate it? Like, I don't know just from listening to this case. because honestly someone's not going to say like what the truth is you know like like patients reveal that stuff after years of being in treatment you know or like with great shame and so that the chance that you would get something like this especially if there's a legal case you would get the truth

is very low one of my thoughts on this was the Swedish study of traumatic brain injury and violence and they showed that in this study it's a large study 22,000 people with traumatic brain injuries, and they compared it to controls, they found that those with TBIs had an odds ratio of 3.3, adjusted odds ratio of committing a violent act. But when they compared them to siblings, the adjusted odds ratio went down to two. Okay. So this is another example. If you look for environmental factors, it's going to further help you understand that the risk is actually lower. So basically a double increase in the risk for violence. Now, that's not actually very huge if you think about it. So there's a lot of cases where people have a TBI and then they do something

violent and then they blame the TBI. I've had patients with TBIs who have had increased violent thoughts or violent, a desire for violence. But I think that there's a danger in feeling like they're determined, it's determinants. or that they could abdicate responsibility. Okay? So I had this one patient, horrible, horrible case, but he was, you know, someone who would commit domestic violence, but he wouldn't hurt her to the point that he would actually get, like, thrown in jail.

And so when I pointed that out to him, he felt like he had no control. And when I pointed that out to him, that he did have control. And I knew that because he didn't kill her and he didn't get her to the place where he would be put in jail. He sobered up. And it actually, I think, helped him stop doing those violent things because he knew that he had the control to stop doing further stuff, even in the midst of feeling like he had blacked out in a black rage, how he initially described it, you know? So I think it's unhelpful to think about this in terms of, like, you are predestined to now be violent if you have a TBI. or you are like this person couldn't resist, like doing these horrible acts, you know?

I think that that's very counter-helpful to these people. And so the narratives that the narratives we believe about ourselves, I think determines our behavior. And we've seen that in a lot of these studies that primed people to believe in a more deterministic nature. They cheated more, they lied more. they went along with social group norms more. They did not pause to stop doing things that they knew.

They were making mistakes. They didn't pause to re-examine how they could do it better. These are important studies. Yeah, I'm not convinced from a couple studies of these people who had these things that were associated. Was it linked or was it not linked? I don't know. And going back to your discussion of, you know,

in a legal context, author quote someone else and makes an interesting point, that there's no objectively verifiable test determining that an accused individuals could not control him or herself or that he or she merely would not. It's an interesting distinction, which I think you were making as well. Yeah. Yeah. And I, you know, I think that there is a place where, like, if they're, let's say they had a TBI and they're on drugs and they're, you know, sleep deprived, and they're taking large amounts of testosterone. It's like, okay, now they've put themselves at huge amounts of risk. So if I explain this to some of my TBI patients, I'm like, look, like you have increased risk of being violent. That doesn't mean you're going to be violent.

You have increased risk. You should not put yourself at more increased risk for this behavior. Like you have to keep your mind sober. You cannot go out and get drunk, you know? And yeah, there is no verifiable test to see if someone was in control of him or herself. That's interesting. Well, that segues in well to the discussion of how free will fits in the context of addiction. The author we're working with here, Glannon, claims that the neurobiology of addiction imposes mental constraints on the reasoning and decision-making that are necessary for a person

to control his or her behavior and thus retain free will. Changes in addict's brains from repeatedly taking a drug may compromise these cognitive capacities to such a degree that the addict cannot choose and act freely. The desires resulting from these changes compel the addict to contain in you taking a drug? Yeah. You know, I have one patient that I told the family recently, I think you need to put your daughter into a controlled environment because of the level of risk of this person using drug on the streets

and their inability to likely change without being in a controlled environment. So I think there is some truth in like if this disease progresses far enough, it's going to be very, very hard to resist that next use of that drug. you know, with like methamphetamines, after a while, it's like, you need that meth to feel normal, to not feel completely horrible, you know, and these people come into the psych ward, they get off meth, and for the next three days, they're crashing, they're irritable, they're angry, they're throwing things, they're violent, you know, they're in a horrible state, they feel horrible, and so to just feel normal, they just have to continue. So there's, there is this sort of compulsive nature.

But on the other hand, I think that for a lot of people, I would align with, uh, author Doads, DoD-E-S, he's written some books on addiction. And he talks about how a lot of the times when you really talk to someone who goes out and who decides, okay, I'm going to go out and I'm going to go to the store and get a six-pack of beer and I'm going to take it home. And maybe I haven't drinking in a while, right? So you talk to this person. And the moment they decided going home that they were going to go to the store was when they calmed down. And the moment before they decided they felt overwhelmed by something in life.

And so is it the substance that's actually needing to calm them down? Or is it just the ability to control the feeling of being overwhelmed? And so it's helpful to help people control their feeling of being overwhelmed without drugs. So they feel like they can be competent and in control of themselves. But it's interesting when you think about like how biological we talk. we talk about it, talk about addiction. There's a huge movement in that in the past 20 years. And some of it takes away personal responsibility,

and it's like, oh, this isn't a moral issue, right? And some of that is decreasing the shame that people feel acutely. It helps the family members tolerate maybe. They're family members who had made bad decisions when they were using. But are there other side effects to that belief structure? Yeah, and we just talked about some with the decrease in clinician empathy with a biologic, you know, a more fully biologically explained model. I mean, I don't think they necessarily included addiction among those pathologies they discussed, but in general, it seems they would track. Well, if you felt, if you were a clinician that felt that it was morally reprehensible that they were using, it might actually increase your empathy if you believe that it was.

was purely biological. So I think this is where, like, I would almost look at the individual. Now, I'm not saying that it's one of the other. I think there's actually a third place that this is, you know, there's this in the Republic, when they're looking at what justice is,

Plato, Socrates, arguing with this guy what justice is, he's like, well, if you do something unjust towards someone, is it going to make them more just, or more unjust, probably more unjust. And in the same way, if you shame someone who's using drugs or alcohol, eating excessively, is it going to increase their use or decrease their use of the substance? It probably will actually increase their use.

And that's what studies have shown. Some of the motivational interviewing studies that early on studies of that, in William Miller's book, it shows some studies about how shaming someone, being aggressive to change their behavior actually pushes them further into the addiction. So, you know, it's a tricky place, right? Because I'm saying, like, help the person understand

where they felt overwhelmed, help them feel confident in tolerating their overwhelmed through psychotherapy, that being an alternative solution. and then where and then with the motivational interviewing you're looking at what's their internal motivation to change you're rolling with resistance you're giving empathy these are the powerful techniques that we have

we know that there's not a lot of drugs that change substance use that much the effect size is pretty low that's a good point yeah that is much more complicated than I thought there is a lot of nuance there yeah it's fun it is it's fun and I think it's It's why doing this type of work is exciting because there's just continual areas to learn and grow. You have to grow as an individual. I would say any time you have a strong counter-transference reaction towards a patient, it's very hard to treat that patient.

Even Freud said in one of his letters, like people are healed by love, you know, psychoanalysis cures by love. The patients that he cared for the most probably got the most impact. Okay, let's keep going. All right, just a couple more things. I think it would be interesting to get your reaction to here. Author makes some claims that predisposition is not compulsion. And they also make a claim in the context of addiction that, quote, if their initial choices are informed and free, then their responsibility transfers from the earlier to the later time

even if they cannot act freely at that time. Right. So this is the guilty by, you know, the first use of meth, right? You use the meth and then you go out and you steal. A lot of, a couple of my meth addict patients said that when they used meth, they had this incredible urge to steal something. I didn't quite understand it, but that's a, that's something they experienced. And so, yeah, it's like, yeah, when they chose to initially use that meth,

that was a choice that they had. So I think that's why there's a great amount of energy people have when they initially think about doing something bad, right? And we all have this shadow. We all have this ability to do bad things. And we sometimes push those thoughts into our unconscious. We don't want to have to think about it. I think it's actually much more powerful to bring it into conscious awareness

that we have a potential but can choose not to. right so yeah i kind of agree with that i mean that's like probably an argument for why we should still convict people who do things under the influence that are bad that being said we probably should not convict as many people for smoking marijuana i think those people should probably get out of jail go home be with their families it's pretty sad talk about that in a future episode what would you think um because my initial response to that was that the author seems to be conflating informed consent with free will. Because there's sort of that language of, all right, initially they had a choice and it was

informed and it was free. And I don't know. How would you think? Do you think that that's an overlap of those two concepts there? I think it's where it gets complicated because someone may have freely chosen to drink that alcohol, right? But maybe they didn't get, maybe they didn't realize what the informed consent. for the drinking of that much of alcohol was.

Right? So it's like they may have been more innocent in that choice, so to speak, not knowing that, like, driving home that night, they would accidentally get in a car accident, get a DUI, blah, blah, blah, you know, all these horrible things that happen. So, yeah, I don't know. I think I'm saying it differently than you were thinking, but I think a lot of times people, when they get close to something that is incredibly pleasurable, they're not,

they often blur their mind to like all the negative consequences that may come after. It's hard to see it all at once. Let's talk about psychopathy, because I think that's an interesting one. We've talked about that in this podcast a couple times. Episode three, the episode on 10 Bundy, we talk a lot about psychopathy.

Yeah, this is something that would be really interesting to hear your thoughts on. The author when talking about psychopathy says, quote, also given that psychopaths identify their victims as people they can harm and know that they do harm them, they seem to have some capacity to respond to moral reasons and be at least partly morally responsible for their actions. Going on, they claim, in exploiting others

and disregarding their rights and interests, psychopaths know that their actions are wrong, but they do not care. You know, it's This reminded me of that dirty John podcast on Wonderly. I don't know if you've heard of that one. It's a long podcast into one criminal and how he swindled women. Like he would seduce these women. He would lie about his profession.

He would get tons of opiates and use them. And he was very skillful at manipulating. you know and his father actually was a con man himself so it's like he was kind of wired for psychopathy and then he had this belief system that like yeah get away with whatever you can get away with and he kind of went through his life and got what he wanted you know and so in this article he starts by talking about all the biological correlates of psychopathy we know that there are different things that are linked to psychopathy in the brain and low affective embaltive low physiological response to things.

But at the same time, you know, we know that some people who are wired towards psychopathy, it was a famous TED talk by one guy who, you know, studied psychopathy and found out all these MRI changes in psychopath's brain. And then he put himself in the MRI and he found out, lo and behold, his brain looked just like psychopaths. And he knew it, right? He knew it going into it that he was lower affective empathy and, you know, he was a researcher. and he had chosen based on his belief structure to live a life where he was pro-social

and, you know, abided by the laws and did things that were good for humanity like research and stuff like that. And I think that a lot of times the belief structure is so important for people who are more wired towards psychopathy. If they believe in kind of a Nietzschean sort of worldview where you get away with what you can get away with you're you know this like like you you can be like us you know this kind of like um like a self-interest moral theory a self-interest moral theory right where you're um the most just thing is to do things that are in your in self-interest okay if that's what you truly believe at a deep

level then you're potentially going to do things that harm other people and benefit yourself and as a psychopath you're not going to care as much because your guilt is just not there. This is where I think like some of the classical education stuff is so important, like reading Plato and understanding like justice is, his, Plato in book one of the republic argues that justice is doing what's in the best interest of those people you serve. And he argues against someone who says justice is doing the best interest of myself, you know, doing what I can do and getting away with it. And the way that Plato's skillful, argues for this other option is he shows that actually the people may not know what's in their

best interest. And so the most just thing to do to that person would be to do what benefits them the best, right? Even when they don't think that that might be what benefits them the best. So it kind of like blurs the lines of like, okay, but then what is that which benefits them the best? Right. So as doctors, what benefits our patients the most is what makes us a doctor. Like the goal of being a doctor is to not make a lot of money, the goal is to do what's in the best interest of the patients that we treat, right? So we are a doctor in as much as we're able to do that. And so a just doctor treats its patients and treats them and gives them like a fiduciary relationship where he thinks about them and what's in their best interest.

The idea that Plato argues here is that the rulers of the country should be doing what's in the best interest of those people that they rule. And so having a structure of beliefs where you actually believe that mindset would lead to someone who could potentially believe that as an idea. And if they took that to heart, they may resist their own inclination to do what's in their best interest all the time. And I think when you start going down that road of doing what's in your best interest and violating other people in the process, and you get more and more used to that violation of the other people. I think it reduces your guilt.

It reduces your sort of negative feelings that come with that, right? So I don't think psychopathy is purely a biological phenomenon. We know that there are people who are pro-socialally psychopaths, meaning they're wired for psychopathy, but they do pro-social things. They bomb diffusers. They may fight in the military. They may. but they're not doing some of the classically malevolent acts

which violate the personhood of other people. So that's my summary of psychopathy. That's fascinating. Well, we'll have to have more conversations. I'm reading a good book, Reasons and Persons by Derek Parfit, that goes through some of these self-interest moral theories and how they fail and how they interact with others. And that's fascinating.

To think of that is also connected to some. psychopathy as well. Well, you know, and my one other thing on self-interest moral theories is that humans did not evolve for pure self-interest. You put one human in the jungle and we are the biggest prey you've ever met. You know, we are going to get eaten, we're going to get killed, you know, you put 50 humans that are working together collectively in a jungle and we're the biggest predator. What shifts? That ability to work together. So for 10, of thousands of years, humans have evolved that capacity to work together. So we're not just evolve purely for self-interest. We're evolved for collective interest. We're evolved for clan

interest. And then through writing and through learning and through ideas like the Plato stuff, we move from just a pure city state, right, to maybe having self-interest that's beyond that, doing the good of society, doing the good of the world. And I think that's where, where we need our leaders to take gear up towards more in the future. Okay. Well, then you're ready to try and bring this to a close here? Yeah, I think that would be good. All right. Well, we'll see if it's possible. If you're with me right now and you go into the resource library to look at these articles some more, let me know.

I want to know if you got through all three episodes. I'll give you a special award of my congratulations. Okay. All right. Well, we can't summarize everything, but just sort of thoughts here. What have we gained after this long series? Well, hopefully we've provided a helpful context for the entire free will discussion. More importantly, we hope we've produced evidence or provided evidence of the value of a belief in free will for both individuals and society. Also hope to have entered the neuroscience debate by engaging with Sam Harris's work on free will. And finally, we hope to have provided practical examples of how belief in free will can affect mental health care through the concept of neuro-essentialism or assumptions that certain pathologies violate the potential for free will. We've broadly summarized free will as self-regulation and given evidence that a belief in free will can be altered. However, making alterations in free will itself is a much more philosophical topic

with more limited data. The existence of free will has not been proven, but we also believe it has not been disproven as some claim. Moving forward, it's important to acknowledge the influence of our environment and the potential for improving our decision-making processes. Better decisions are an obviously good goal, but the better choices do not necessarily mean free will itself has been influenced. And then how does this all apply in today's culture? We've given some examples of in-cell culture, suffering during this COVID-19 pandemic, and the hope for improving individuals and our relationships with those who are different from us in some way. There are many more applications and hope you will share some of your own discoveries for how

to use this information. That's great. Well, I think my conclusion is I feel very strongly at this point, after looking at this research, that there is a benefit of a conception of belief and free will and that there is overwhelming evidence that that leads to many good things. So we want, we want to believe that we have the choice, right? We want, we want to believe and we want to help other people believe that they are not stuck, okay? And so that would be the first place that I would be enthusiastic about the work that we've done here. The second thing is, I think that there's a gradient of, like,

maybe as our sensorium gets hit, there can be, um, there can be, um, a lessening of our ability to make good choices, some of which comes from maybe some of our more impulsive or self-centered, self-oriented sort of drivers coming up more powerfully. But that doesn't necessarily mean that we give up the ability to amplify maybe some of the softer voices in our sort of our brain, you know,

maybe the drive for group, the betterment of the group. You know, we have to amplify that sometime. or we have to amplify, you know, what is doing the most justice in this particular incident. And the third thing in, I think I would leave off is I think that this is something that gets stronger with practice. So I think making, you know, free will is not just making a good decision. It's making a decision. But I think the decision to, or the practice of making decisions that are beneficial to society, to

to move things forward to help mankind, you know, to help people is something that we can practice. And I think it's necessary to have a small sense of voluntary suffering in the midst of that to maybe come up against our shadow a little bit, right? Our shadow saying like our shadow, the id wants it all, right? We should find socially condonable ways to gratify it at times. but other times we should say no, you know, and I should practice what I preach a little bit when I say no to ice cream. So not that I'm an expert in this by any means, but I think this was a good conversation. I really appreciate the work that you put into it, and I hope you guys appreciate Matthew's work that he's done here,

and I look forward to working with you more in the future. Me too. Thank you for the opportunity. It was a really fascinating. project. So if you write anything nice, either through my website or in a Google review, I will share that with future Dr. Hagley. Higley. And we look forward to hearing your guys' thoughts from this. And we'll leave it there.