The sources that have most influenced my philosophical framework

7/7/21

There have been a number of books, podcast, and other media which have significantly changed the way I see the world. These books have given me a set of thinking tools which help me separate signal from noise in the therapy world. I think they’ll help you too.

Books.

1. Fooled by Randomness -Nassim Taleb: This book taught me that much of what we think is skill is actually luck. Worse, the human brain is not wired to see the roll of luck in our lives.
2. The Black Swan -Nassim Taleb: This book is about how rare events, black swans, are what move human history. However, I really enjoyed it because it really helped me to think statistically, which is hard for humans to do. Our minds just aren’t wired that way.
3. Antifragile -Nassim Taleb: This book got me through a personal hard time. This book is all about how to live in a random world, and even prosper in it. I love it because it taught me that many of the things that happened to me were not my fault.
4. Peak -Anders Ericsson and Robert Pool: My first big takeaway from this book is the speed of learning is the speed of feedback. In situations where we get clear feedback, humans learn very quickly. In situations where feedback is delayed or unclear we humans hardly learn at all. My second big takeaway is the importance of deliberate practice in learning anything. If you want to learn anything well, you need to practice.
5. Sources of Power/ Intuition at Work -Gary Klein: After reading Taleb’s work you realize intuition is often wrong. The question then is “when is our intuition right?” This question is what Klein answers beautifully in his work. Sources of Power is an academic text, while Intuition at Work is the same book but for lay people.
6. Noise - Daniel Kahneman: This book is all about how inconsistent we are. Turns out we’re so inconsistent we don’t even agree with ourselves. Given the same information doctors will give one diagnosis in the morning and another in the afternoon. We’re so inconsistent that simple models and checklist often perform better than we do, simply because they are more consistent.

Book Chapters.

1. Thinking Fast and Slow (Chap 16–22)-Daniel Kahneman: Nassim Taleb talks a lot about cognitive biases in Fooled by Randomness (thinking traps). I always wondered where he learned about thinking traps. It turns out he got them from Kahneman’s Thinking Fast and Slow which is all about flaws in decision making. In chapters 16–22 Kahneman systematically goes through the thinking traps that trip experts, and shows how most experts actually don’t outperform lay people. In other words, he shows we have lots of gurus but few experts.

Articles

1. Neil Jacobson - The Overselling of Therapy: Neil Jacobson is a lost treasure. He was one of the first to popularize the idea of “clinical change” in psychotherapy. See it’s not enough to show that therapy has an effect. Therapy has to have enough of an effect that is brings relief. Turns out this only happens 20% of the time, according to Jacobson.
2. Kristen Syme and Ed Hagen - Mental health is biological health: Why tackling “diseases of the mind” is an imperative for biological anthropology in the 21st century: I love this article for numerous reasons. You just have to read it. However, I cite this article a lot because it’s this one that states rate of mental health disorders haven’t changed in 20 years. While every other industry has improved, mental health has been stagnant for at least 20 years. That’s a problem.
3. H. Strupp and S Hadley - Specific vs nonspecific factors in psychotherapy. A controlled study of outcome: This is a landmark study showing that paraprofessionals/ lay counselors often produce results just as good as professional counselors. UPDATED 9/14

The results of this investigation were consistent and straightforward. Patients undergoing psychotherapy with college professors showed, on the average, quantitatively as much improvement as patients treated by experienced professional psychotherapists. The greatest amount of change occurred during the treatment period (individual sessions on a twice-a-week basis for up to 25 hours over a period of three to four months) and it was maintained to the follow-up assessment about a year after intake…Although some form of treatment appeared to be superior to no treatment, the study, on the whole, lent no support to the major hypothesis that, given a benign human relationship, the technical skills of professional psychotherapists produce measurably greater therapeutic change (pp. 1134–1135)

Videos.

1. The Evolution of Psychotherapy: An Oxymoron-Scott Miller. I’ve heard Scott Miller speak several times and this is the best summary of his field of research. He’s one of the most underrated psychologist of our day. He’s done a lot of the heavy lifting of showing that no therapy model outperforms another, that most therapist help 50% of their clients, and that therapist are as effective today as we were 40 years ago. The question is why? Why despite new models and new theories and new research has the field plateaued? Because much of outcomes are random (Taleb), thinking traps give us the illusion of expertise (Khaneman) and because we don’t practice or train for skills (Ericsson and Klein).
2. The Science of Feeling Safe-Stephen Porges. Porges’ Polyvagal theory is the foundation of how I view therapy. In a nutshell humans heal and grow when we feel safe. If we don’t feel safe we divert all resources to defending ourselves. This is the foundation of ALL human behavior. If a kid isn’t learning in school, they probably don’t feel safe. If your mother in law isn’t respecting your boundaries, she doesn’t feel safe. If you feel anxious and depressed, you don’t feel safe.

Podcast.

1. Bold Conjectures — Most surgeries are ineffective. One of my favorite podcast ever. I learned that the same forces which corrupt psychotherapy are present in other fields. The problems of psychotherapy are not unique to us.
2. Bold Conjectures — How we do science determines what we discover. This podcast has had the most impact on my recent thinking. The biggest idea I took from this is we need robust solutions which work in real world environments. So what’s an example of a robust or weak solution? A strong solution for contraception is a vaginal ring. You put it in once and forget about it for a month. A weak solution is a condom. You have to have one on you, you have to make sure it’s not old or has a hole, you have to make sure you partner is okay with using it, etc. Both work, but in the second there’s just too much room for human error. Too often in therapy we train clinicians to provide weak solutions.
3. The Knowledge Project- Todd Simkin. A few days ago I finished writing a post about how my thoughts on therapy have been heavily influenced by the field of investing. Then today I stumbled upon this podcast all about how good investors think. This is a perfect example of everything I was trying to say in the upcoming article- investors know how to make good decisions under uncertainty and therapist could learn a lot from them. UPDATED 9/14/21
4. Afford Anything-The Radical Invention of the Index Fund, with Robin Wigglesworth. First, I’m a fan of history and investing, so this episode on the history of index funds was riveting. The biggest reason it’s on this list, though, is because of what it teaches us about innovation. Oftentimes we know the solution, at times its simple, but we just can’t bring ourselves to use it. Until we’re forced too. It’s stories like this which leave me wondering “what great psychological insight is laying in plain sight?” UPDATED 1/10/22

So how does this all fit together?

If I had to sum up all of the above media I’d say:

We overestimate our effectiveness as therapists. Therapy outcomes haven’t improved in 40 years. Rates of mental illness have been stagnate for 20 years. When we do help people only 20% of people recover. Most “expert” therapist aren’t experts but think they are because of cognitive biases. Randomness plays such a big roll in life that some problems we can’t fix. Either way, if we want to move the field forward we need to move away from head knowledge and get clinicians to engage in deliberate practice of robust interventions with clear feedback. Only then will therapy improve. We don’t know as much as we think we do, but we do have a starting point. The human body needs safety in order to heal. Let’s start there.