I read this recently and wondered if it explains a lot of what’s wrong with much of the treatment provided in the U.S.

Kakonomics is the strange — yet widespread — preference for mediocre exchanges insofar as nobody complains about. Kakonomic worlds are worlds in which people not only live with each other’s laxness, but expect it: I trust you not to keep your promises in full because I want to be free not to keep mine and not to feel bad about it.

How often does the subtle bigotry of low expectations play out in both directions?

Kakonomics is not always bad. Sometimes it allows a certain tacitly negotiated discount that makes life more relaxing for everybody. As one friend who was renovating a country house in Tuscany told me once: “Italian builders never deliver when they promise, but the good thing is they do not expect you to pay them when you promise either.”

I won’t ask much of you and you don’t ask much of me.blank sign

It’s not just addiction treatment. I remember about 7 years ago, I had my first cholesterol test. A few weeks later, I received an envelope in the mail with lab results. A few numbers were circled with “too high” or “too low” next to them. There was also a note to fill the enclosed prescription for a statin. I wasn’t crazy about being on a statin for 50 years (I was 35 years old), so I asked for an appointment and asked about diet and exercise. The response I got was  shrug and something like, “Sure. You could try that, I guess.”

I felt like I had violated some norm. Here I was, a patient who was looking, not just to reduce a symptom, but to take action to improve my global health and reduce the risk of all sorts additional health problems and I felt like I was being viewed as non-compliant in some way.

These kinds of norms pop up in lots of places. At what cost?

But the major problem of Kakonomics — that in ancient Greek means the economics of the worst — and the reason why it is a form of collective insanity so difficult to eradicate, is that each Low-quality exchange is a local equilibrium in which both parties are satisfied, but each of these exchanges erodes the overall system in the long run. So, the threat to good collective outcomes doesn’t come only from free riders and predators, as mainstream social sciences teach us, but also from well-organized norms of Kakonomics that regulate exchanges for the worse. The cement of society is not just cooperation for the good: in order to understand why life sucks, we should look also at norms of cooperation for a local optimum and a common worse.

What does this look like in treatment, and what does it do to the hope and motivation in a patient with a stigmatized chronic illness? Especially when we know that expectancy impacts outcomes?

UPDATE: What’s interesting about this to me is that while both parties want the mediocre exchange, the addict’s desire for the mediocre exchange is the result of loss of hope from iatrogenic damage. So while the exchange may be consensual, you have problems of power differentials and asymmetrical information. This combination gives one party power over not just what the patient gets, but also what the patient wants and thinks is possible.