Carrots and Sticks

24 01 2010

Our future human resources

I got up early yesterday to drive these two daredevils to their ski-race camp. And, it got me thinking about how we, both as parents and as a society, choose incentives and disincentives to manage our human resources, ie. carrots and sticks. In this case their parents, who are friends of mine, have found Franny (left) and Kristina are willing to lift weights, dry-land train, get up early in the morning and hurtle their growing bodies down icy slopes, in exchange for the rewards associated with competitive ski-racing. They do it, because they love it. That seems like a progressive way of steering kids into healthy pursuits.

In contrast, it occurred to me that we as a society are regressing.  A new Angus Reid public opinion survey found 62 per cent of respondents favour capital punishment for murderers. This is a significant increase since 2004, when 48 per cent favoured capital punishment. The survey, conducted last fall in Canada, the United Kingdom and the United States, reveals the shared belief by many that even though mandatory minimum sentences can be unfair, they are an indispensable tool, a good stick, that helps deter criminals from committing crimes.

Unfortunately despite the average Canadian’s experience with punishment as a way of deterring behaviour, experts in criminology have shown that neither mandatory sentences nor capital punishment have ever been shown to deter crime.

As a recent letter to the editor of the Globe and Mail by Jim Hackler, author, Canadian Criminology: Strategies and Perspectives, Victoria documented: both California and Texas offer case studies of how politicians used “get tough” policies to deceive voters who respond to simple-minded slogans about crime. For several decades, these states built prisons to accommodate an ever-increasing number of convictions. Funds for education and child care, which provide a positive return for society, were cut. Funds for prisons, which provide a negative return, were increased. Why not spend taxpayer money on things that actually reduce crime?

Negative consequences do deter crime, unfortunately not in most criminals. There are some good neurobiological reasons for this. Let’s take a moment to review the neurobiology of reward and punishment.

Humans have a reward circuit. It’s a dopamine circuit and it runs from the brainstem to a place called the nucleus accumbens, aka, the reward centre. But dopamine does not only communicate reward, it also is the neuro-chemical for at least four other circuits. The five main dopamine circuits are:

Reward Dysfunction here is manifested as being easily bored, feeling diminished pleasure, reward or satisfaction from normal stimuli.

Attention Dysfunction here is manifested as poor attention to detail, careless mistakes, difficulty listening, losing things.

Executive function Dysfunction here is manifested as difficulty with commitment, difficulty sticking to task, difficulty self monitoring, poor planning/ organization, poor problem solving.

Motor control Dysfunction here would manifest as fidgeting, inner restlessness, difficulty sitting through meals, meetings, movies.

Impulse control Dysfunction here would cause distractibility, impulsivity,  excessive talking, blurting things out, being impatient and interrupting others. One of the most obvious deficits associated with poor impulse control is the difficulty making choices between competing priorities.

You can see in the italicized text, that many common criminal traits are associated with dopamine circuit dysfunction. It’s no surprise then that the likelihood of finding ADHD and addiction, two disorders associated with dopamine dysfunction, is very high in criminals.

This is not my opinion or some excuse that bad people use to avoid responsibility for their bad behaviour. This can be shown on SPECT scans of criminals, gamblers, adulterers, liars, thieves, rapists, murderers, you name it. When they are in the heat of the moment, the part of the brain that usually lights up in normal people when they are weighing the consequences of a potential action, DOES NOT LIGHT UP. Simply put, in most cases they WERE NOT thinking through the consequences of their actions. Now before you jump down my throat and label me soft on crime, hear me out.

  • I am not saying criminals do not know wrong from right. They do.
  • I am not saying that criminals have not pre-meditated their crimes. Ususally they have.
  • I am not saying that criminals should not be responsible for the consequences of their actions. They should.

What I am saying, is that most criminals have poor impulse control and don’t show much foresight. They know the consequences, they just don’t weight them properly. They know logically that their actions will have negative consequences, they just don’t value those consequences at the point of performance. Like a kid who launches his skateboard down a steep hill without a helmet. He “knows” the danger. He just values the reward, higher than the risk.

And who do you think becomes a criminal in our society? People who are willing, on multiple occasions, to choose actions with huge potential negative consequences, because they undervalue the risk. Criminals are essentially compulsive gamblers. And all the research we have ever done on pathological gamblers show that they do not have a normal risk evaluation system. That is their illness. That is why mandatory sentences including capital punishment are excellent deterrents for normal people, they just don’t work on criminals, because there is such a thing as a criminal mind.

I could go on, but I think you get my point.

So why are we building bigger jails and spending more money on lawyers, judges and crown prosecutors? Every bit of data ever collected says this is not only the wrong approach, it is THE MOST EXPENSIVE APPROACH. On the contrary, the data shows that we save $7-10 dollars in the social costs of mental health, addiction and crime for every dollar we spend on youth centres, mental health services, child care, parenting programs, etc.

It is my considered opinion that if we paid more attention to parents and children, we would have to spend much less on crime and punishment. If we improved the use of carrots, we would need to spend less on sticks.

Which brings me back to Franny and Kristina. I’m not saying that were it not for ski-camp, these two would be headed for a life of crime. Ski-camp may not be for everyone. But organized, group-based, outdoor physical activity, whether it is soccer or sailing, provides kids with bevy of physical, emotional, cognitive and spiritual benefits that should be considered highly prized social outcomes. These kids will be fitter, their brains will be more flexible, they will learn to cope with failure and loss, they will learn social skills, they will be more accountable for their actions, they will learn to soothe their fears, they will be more confident and will probably spend less time obsessing about their clothes or possessions, THEY WILL SPEND MORE TIME IN NATURE and LESS TIME AT THE MALL. There is a good chance they will be better stewards of the environment. In short, while there is no guarantee they will fly straight, the chances are in their favour.

It would be simplistic to think that we don’t also need to have negative consequences when people break rules. We do. We need both carrots and sticks. And, we need to be progressive with both. While money invested in youth  does not guarantee good social outcomes, playing to our kid’s strengths and spending at least as much money on parents and kids as we do on jails is in my opinion a preferred human resources management.

Cheers, A

Dr. Anthony Ocana – MSc, MD, CCFP, ABAM – special interest in mental health and addiction – co-founder NorthShore ADHD Clinic

http://www.northshoreadhd.com

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The little voice in your head

8 12 2009

Last week, I finally listened to the little voice in my head. At the time, I was contemplating, “Should ride back down on the road, or should I ride down the trail.”

The trail would have been much more fun. There are roots, rocks, some really steep pitches, lots of fast curves, tricky corners and a series of hairpin turns right before the big drop that delivers you back to the road just above the highway. Usually, by that time my heart is pounding, my legs shaking and my arteries flush from the injection of adrenaline. Then it’s back to the office.

But just then I passed the sign on the road that says, “Are you prepared? If you get lost, does anyone know where you are going? This is not for nothing. Every year, in every season, people die on the North Shore mountains, because they get lost, it get’s dark and they fall of a cliff or succumb to hypothermia. So, just before I pointed the front tire of my new Trek Fuel mountain-bike down that gnarly path, I heard the little voice in my head.

The voice said, ” You know, that might not be such a good idea. It’s Friday at noon on December 4th; there is no one on the trail, nor will there be anytime soon; the trails are super-slick because it has been raining like crazy for the last month; no one knows where you are; you don’t have a cell phone;  and if you fall and need help, it will be dark and cold soon and basically, you’re toast!”

Usually, I would have argued with the voice. I would have said, “Oh, what do you know. It’s a beautiful day; you haven’t ridden this trail in months and you’ve got lots of time. Don’t be a wimp.”

But then I remembered all the near death experiences I have ever had. Three of them, three and a half if you include the time Simon Parker and I got lost in the dark on the back side of Bowen Island. Right before each of them, I had a similar exchange with the voice in my head. And… I remembered that after each of them I promised that I would be more diligent, more careful and I would not ignore the voice of caution.

So this time I listened.

I listened to that voice… no questions asked. I listened because I finally realized that if you get that little voice in your head telling you, “maybe this is not such a  good idea”, that you should bloody well listen, because it is not telling you, it’s not such a good idea, for nothing. It’s telling you, it’s not a good idea, because it is desperately trying to save your bacon. So, listen.

Most anthropologists are pretty clear in saying that humans are not completely rational beings. They point out that humans often act in ways that are contrary to their best interests, when we make emotional rather than rational decisions. Recent research suggests that, it’s not that we are not rational, but rather that we often act before any rational thought has had a chance to influence our behaviour. We are often flying down that proverbial trail and before we know it, we are ass-over-tea-kettle, looking right at the worst possible consequence that we could ever have anticipated, if only we had…anticipated. But we didn’t anticipate. We didn’t think it through. We acted without thinking, again.

Does this sound familiar?

To most of my patients with ADHD and addiction, this is the story of their life. Shoot first, ask questions later. Neuro-biologically, this can be explained as follows…

Normal people have about 4 milliseconds between impulse and action, giving them a brief but adequate window, during which the little voice in their head has just enough time to say, “Hmm, maybe that’s not such a good idea.” This is when normal people put on the brakes, look over the edge of cliff and say, “Phew, that was close.”

On the other hand, impulsive people have about 1 millisecond between impulse and action, which means, by the time their little voice has spoken, they are already at the bottom of the cliff, wheels up, engine billowing smoke, wondering, “What the heck just happened. Maybe I should have hit the brakes.”

For the record, Buddhist monks have about 8 milliseconds between impulse and action, during which they have enough time to have a national debate on whether or not to hit the brakes.

So, as you can see, being impulsive is quite the handicap. Take for example, the patient I saw the other day. Tough kid…  smoked dope at 11; doing lines of coke at 13, dropped out of school at 14; smoking crack and shooting heroin before his sixteenth birthday. So you might think he was stupid, or came from a bad family. That’s the current thinking. But he was an intelligent kid, raised by loving and intelligent parents. Unfortunately, he was also impulsive, a risk taker, a stimulus seeker who found school to be too boring. He was a skilled mountain-biker, dirt-biker, 4×4 truck driver, but what really turned him on was seeing the duffle bag full of $20 bills when he cashed in his first grow. 4000 marijuana plants make a lot of pot and at $2000 a pound, that’s a lot of green. Pretty soon he’s running two grow-ops and starting a third. Money is as addictive as the finest drug.

Long story short, our friend, we’ll call him Jake, is now up for 5 counts of possession with the intent to traffic. So he comes in today to have a little chat. He was diagnosed with ADHD as a child because he was hyperactive and could not focus in school. He was tried on medication, but it made him an introvert and he did not like it and so he stopped.

I explain to him that is a very common outcome, because the medicines in those days were too short-acting; few people knew how to use them and that his experience is caused not by the medicine, but by the medicine wearing off. He and his father both nod as if they understand, but I can see that they both wish there would be could be a way to make it all better.

I explain that right now there won’t be any medication; that we first need to finish our assessment and I remind his father of what he already knows. There will be no more bail-outs. It’s not that we don’t feel any empathy for Jake’s plight. It’s just that protecting Jake from the consequences of his actions is not doing him any favours. So he is  looking at 6 months in jail. He’s made his bed, now he has to sleep in it.

I tell Jake that I am happy to help him, but the first thing he needs to do is to make a commitment to stop using cocaine, because I can’t safely treat his ADHD until he is cocaine free for 4 months. There are a few things we can do in the meantime, so I am not blowing him off, but he has at least to give me his best effort. I say good bye and wish them both luck.

A few hours later, Jake’s dad calls back in a bit of a panic.

As we discussed, Jake’s dad made it clear that there would be no more hand-outs, bail-outs or redemptions. That Jake would have to stay in a shelter and get some kind of temporary job so that he could get back on top again. It so happens that Jake is a highly skilled carpenter who could easily earn $50,000 a year, legally, by applying the skills of his trade. Unfortunately, he sold all of his tools to buy drugs.

Jake, being the master manipulator that all drug addicts are, will have none of it. He wants Dad to take him back. If he doesn’t, Jake says he will commit a few B/Es to get the cash that he needs.

Jake’s dad wants to know what to do. I tell him my thoughts and he thanks me. He just needed to hear it from someone else.

So, do you think Jake will take the time to think through the consequences of his threatened actions? Do you think he will listen to the voice in his head? Do you think he can even hear the voice in his head?

Stay tuned...

Dr. Anthony Ocana

MSc, MD, CCFP, ABAM

Family Physician

Addiction Specialist

drocana@telus.net







What’s your default mode?

29 11 2009

K2 The Savage Mountain

Last week, an old climbing buddy, Eileen Bistrisky, invited me to a presentation by Canadian climber, Don Bowie. K2 – The Ascent of the Savage MountainI was both inspired and horrified as he described his successful ascent of K2 without the use of supplemental oxygen.. At 28,253ft above sea level, K2, located in Northern Pakistan is the world’s second highest peak. It is widely considered to be the hardest and most dangerous mountain on earth to climb. On July 4th, 2007, Don became the 4th Canadian to summit.

Those are the raw stats. But they don’t begin to describe the strength of character of this young man. Not only did Don and his two team mates make it to the top, shortly after watching a fellow climber slide by and disappear over the edge of a cliff forever. But on the way down, in the falling dark, he stopped to help a fellow climber who had collapsed and was lying motionless in the snow. He could have kept walking. In fact, one got the feeling from hearing the story that the large majority of climbers on that mountain, would have done just that.

While helping that guy down to camp four, Don lost his footing and shot down the icy slope. Maybe it was karma, but it seems it was not his time to die, as he slid feet first into a snow-bank and stopped. 10 feet either was and he would have been toast.

The good news was that he was still alive. The bad news was that his toes on one foot were facing the wrong way; down instead of up – He had badly fractured his ankle. However, when you only have one good leg and you are 24,000 feet up a mountain, you might as well  be dead.

Unbelievably, other than his team-mates, no one else offered him any assistance. Don was stunned. Finally, just before the treacherous ice falls, getting impatient with the lack of empathy, he lashed out in frustration. This seemed to have guilted a few of the otherwise oblivious climbers into action and with that, they carried him through the last stretch. As it turns out. Don, did make it to base camp in one piece and with the help a US Army helicopter, he made it the rest of the way home.

In the ensuing Q and A, someone asked why he was willing to help a fallen comrade when he was surely close to total exhaustion himself. (remember, he has been climbing without oxygen) This is where Don really blew me away…

He said, “I train so that when I’m down to my last 5%, and I’m at the end of my rope, that my default mode is kindness”.

Kindness, now that’s an interesting concept. How many of us are even aware that when push comes to shove, when our brain is being hijacked by pain and fatigue that we even have a default mode? And how many of us have been conscious enough, in that storm of emotions, to be able to step back and pay attention to how we feel, how we are behaving and how we are being perceived? Now, take it one step further…How many of us train to control our behaviour in default mode?

I’m going to suggest that that level of self awareness is pretty rare.

Neurobiologically, we are driven into fight or flight mode when our amygdala, the part of the brain that perceives danger, flips the switch triggering the sympathetic nervous system which responding to the amygdala’s wailing siren, prepares us to either put up our dukes, or get the hell out of Dodge.

On the other hand, when we are down to our last 5%, lactic acid coming from our fatiguing muscles sends an inhibitory signal to our sensory cortex that says, “Batten the hatches, we’re going down”. At that point, parasympathetic functions like consciousness, digestion, cognition and the like start shutting down to conserve energy.

That is why you have to train your default mode.

Because, whatever happens at that point had better be automatic or else it’s not going to happen. So, in fact, not only do you have to have an idea of what you want your default mode to be, but you have to practice putting yourself in that situation over and over in order to train yourself to behave the way you want to in default mode.

In my daily work as an addictionologist, I work with people who are precisely those who in their QuestForFire become completely unconscious of the consequence of their actions Their default mode is to use drugs and alcohol as a way of coping with their dysphoria. I’m not saying that in a pejorative way. It’s just the way it is. That’s the definition of addiction. Continued use of drugs or alcohol as a way of managing distress despite evidence of continuing negative consequences.

So that is why I was so impressed with Don Bowie. In his QuestForFire, his mindset is exactly the polar opposite of impulsivity. In fact, it is the essence of impulse control.

And, when you look at the massive social, economic and interpersonal harm that results when we are unable to adequately control our impulses, you can see the amazing value of Don’s ability to ride the horse, instead of letting the horse ride him.

I for one struggle with my impulse control. It may be in my genes as I come from a long line of short-tempered Spaniards who are known to succumb to temptation. I’m not trying to make excuses. It’s just that I often find myself doing and saying things in default mode that make me shake my head.

“What were you thinking”? I wonder to myself. That’s just it. I wasn’t thinking. I was in default mode. So now the challenge is to imagine a more sensible default mode and to see if I can behave differently enough times to crack the mould and hopefully sculpt something I can be proud of.

Next week we’ll talk more about impulse control, what’s behind it neurobiologically and how we can harness it.

Cheers, A

Dr. Anthony Ocana   MD, MSc, CCFP, ABAM                                                               Family Physician, Addiction Specialist                                                     drocana@telus.net