This study explores the extent to which a one-week nursing rotation for medical students changed the interprofessional attitudes of the participating nurses and students. Third-year medical students worked with nurses before starting clinical rotations. Pre- and post-experience surveys assessing perceptions of mutual respect, nurse-doctor roles, and interprofessional communication and teamwork were given to 55 nurses and 57 students. The surveys consisted of qualitative questions and a Likert scale questionnaire that was analyzed using qualitative and quantitative content analyses. The response rate was 51/57 (89%) students and 44/55 (80%) nurse preceptors. Nurses reported that students met nurses’ expectations by displaying responsibility, respect, effective communication, and an understanding of nursing roles. Medical students’ narratives demonstrated two significant changes. First, their views of nurses changed from that of physician helpers to that of collaborative patient-centred professionals. Second, they began defining nursing not by its tasks, but as a caring- and communication-centred profession. Responses to Likert-scaled questions showed significant differences corresponding to changes described in the narrative. A one-week immersive clinical nursing rotation for medical students was a transformative way of learning interprofessional competencies. Learning in an authentic workplace during a clinical rotation engendered mutual respect between nurses and future doctors. Students’ view of the role of nurses changed from nurses working for doctors with patients, to working with doctors for patients. Healthy interprofessional relationships are vital for effective team-based patient care, for reducing medical errors, and for improving patient outcomes –4. When The 2015 Institute of Medicine (IOM) report on IPE acknowledged the variety of IPL that occurs between a myriad of health and social care professionals and students in a variety of clinical, classroom, and community settings . DespiteIn its report, the IOM suggests using a modified Kirkpatrick framework for measuring the impact of IPL on students and professionals. The IOM called for research into the modification of attitudes, perceptions, and actual behavioural changes between interprofessional groups ,14. SystAt the undergraduate level, choosing precisely what type of IPL to do, with whom, and when, is critical . CurrentIn the past decade, however, robust IPL in the clinical workplace between practicing nurses and medical students has been increasingly reported. This aligns with the evidence that authentic clinical learning opportunities are most beneficial . To dateTo follow on the IOM report suggestions, we developed a nurse-shadowing rotation for junior medical students in South Asia. This study took place at the Patan Academy of Health Sciences (PAHS) in Nepal. PAHS was founded in 2009 with the socially accountable mission of graduating medical students from all socioeconomic backgrounds with broad competencies including compassion, empathy, professional respect and responsibility, leadership and teamwork. Prior to this study, PAHS faculty held workshops on interprofessional communication skills where the key concerns expressed by nurses were identified as the lack of respect and poor attitudes of doctors towards nurses. The strong hierarchy amongst health professionals often left nurses feeling disregarded, poorly understood, or held in low esteem by their physician colleagues. The nurse-shadowing rotation was designed as a transformative learning experience in which students could be safely uncomfortable in a real-world setting. The goal was to improve students’ understanding of, and respect for, the role of nurses on a healthcare team. The aim of this study was to describe junior medical students’ attitudes towards nurses and collaborative practice before and after a clinical nursing rotation.To address the issue of interprofessional respect and understanding, PAHS faculty designed and implemented a one-week nursing rotation for all third-year medical students before they began clinical clerkship. As part of the preparation for the rotation, the director of nursing (RR) and the lead physician (KB) met with the senior nurses in the hospital to discuss what the objectives should be. Each ward’s head nurse was asked to discuss their desired objectives for the medical students. This was an essential step in engaging the nurses. An agreed set of objectives for the rotation, incorporating both technical and non-technical skills, and several attitudinal objectives was produced . There wIn 2012, all fifty-seven students of the third-year class were assigned by convenience to one of five hospital wards: pediatrics, internal medicine, general surgery, obstetrics and gynecology, and emergency. There they worked for one week as part of the nursing team, both observing and assisting in nursing duties. The nurses supervised one or two students at a time and had no other learners from other disciplines.This was a pre- and post-intervention survey designed to explore the impact of the nursing rotation on medical students' attitudes towards nurses and knowledge of nursing roles. Following a literature search and consultation with an educationalist (SR), we created a specific survey tool to answer the key research questions. The researchers held serial discussions about survey question content and usability to refine the face validity of the questions. Content validity was confirmed by our experts who reviewed the literature and consensus discussion  led to the final design of the pre- and post-questionnaires for nurses and students.The nurses’ questionnaire was intended to assess their current experience of doctor-nurse relationships and their expectations of students, using a four-point anchored Likert scale. In addition, we expanded the questionnaire with written narrative to explore the impact of this experience, asking the nurses open-ended questions such as: ‘What changes do you want this rotation to make in your communication, interaction or teamwork with these students?’, ‘What was the most valuable thing the students learned from this rotation?’ and ‘How will this rotation change your communication, interaction or teamwork with these students in the future?’. A similar pre- and post- questionnaire was designed for medical students, to assess their attitudes towards interprofessional relationships, using a similar Likert scale. As with the nurses, the student survey was expanded with written narrative to explore students’ experience and the impact of the rotation with questions such as: ‘What is the nurses’ role on the ward?’, ‘What was the most valuable thing you learned from this rotation?’ and ‘How will this rotation change your communication, interaction or teamwork with the nurses in future?’.All 57 third-year medical students  and all of their 55 supervising nurses  were invited to participate in this survey. This was the first opportunity nurses had to work with medical students in our new medical school. Informed consent of all participants was obtained, and their participation in the study remained confidential. All survey responses were coded for anonymity, and at no time did any of the students’ assessors, nor any of the nurses’ supervisors, have any access to identifiable survey data. The research ethics board of the Patan Academy of Health Sciences granted approval for this educational program evaluation.All nurses working on the wards and all medical students received questionnaires before the rotation, and again within one week of completing the rotation. The coded surveys allowed linking of pre- and post- data for individuals. The linking codes were known by only one of the researchers (TM).Survey data from Likert-scaled questions was analyzed using 2-tailed T-tests. Answers to the open-ended written questions were analyzed by one research assistant (TM) who worked with two of the physicians  to complete the content analysis. Themes were identified and pre-post comparison was carried out independently by three authors . These three authors then met and came to consensus about the presence and significance of the themes evident in the students’ and nurses’ writings.Response rates for the questionnaires were 89% (51/57) for students and 80% (44/55) for nurse preceptors. Following the rotation, nurses were more likely to “strongly agree” with 2 statements, 2 and 11 . StatemeStudents were more likely to “strongly agree” with questions 2, 3, 4, 6, and 7 after the rotation . All of Both nurses and students wrote extensive responses to the open-ended questions. A thematic analysis of the written content told a more complex and complete story. Responses were analysed together, rather than question-by-question, as there was significant overlap in the themes expressed. The themes are presented below.Prior to the rotation, the nurses hoped for three main outcomes: that the students be professionally responsible, respectful, and good communicators. The post-rotation narratives give depth to how these three areas were manifested.First, nurses felt the students were professional—which expressed itself in their responsibility to the patients, to learning, and to the team.Nurses stated the students learned to provide “nursing care for patient(s) according to their need, counseling to patients and health education” (Nurse 22). Their “attachment to patient(s) is the main theme they learn from this rotation” (Nurse 33) as was their “development of confidence” (Nurse 28). Students’ enthusiasm for learning was echoed by many nurses.Second, the nurses identified respect as a distinct quality. This was expressed in how students learned “how much our nursing job is valuable” (Nurse 34), “the importance of (the) nursing role in the patient care” (Nurse 52) and learned to “develop good interpersonal relationships which will help to develop their sense of team spirit and positive attitude toward nurses (Nurse 3). This left nurses hopeful that “they will be nice to us in coming future when they'll really become doctors” (Nurse 17).Third, improved communication manifested in several ways. The “importance of recording and reporting and documentation” (Nurse 52) was noted in “vital signs recording and reporting” (Nurse 13), and “proper handover and takeover of patients” (Nurse 55).However, the relational aspects of communication–both colleague- and patient-centeredness–were dominant. “The most valuable thing the students learned from rotation is the relationship between doctor and patient and staffs” (Nurse 17). “It will help to build (the) trust of the staff and work as a team member to provide efficient and quality care” (Nurse 7). Nurses repeatedly noted that students demonstrated “the capacity… to maintain interpersonal relationships with staffs, patients and visitors” (Nurse 9), “total patient care in (a) real situation and how to communicate, interact and work as (a) team member in teamwork” (Nurse 42).Overall only four nurses noted unprofessional behaviours in the students and these all related to either failing in responsibility to the patient or the team. “Some of them feel ashamed and hesitate in doing minor jobs like bed making, position change but they should know it means great (things) in well-being and (in the) progress of patient” (Nurse 17). Several comments suggested that the nurses felt empowered to address issues of unprofessionalism with their medical students. “The main thing is that if any (poor) behaviour is seen then we can consult with each other rather than side talk” (Nurse 33). This refers to the common practice of gossiping and grumbling about poor behaviour without actually addressing it directly.A final theme that arose in the written comments described the nurses’ roles as teachers. None of the nurses had ever taught medical students before, and there was minimal faculty development prior to this rotation. In this context only a minority of nurses expressed confidence in teaching. “This rotation provide(s) us a chance to share our ideas, knowledge and experience with each other as well as increase our learning habits, so helped us in good communication, interaction and work as good team creating a good working environment” (Nurse 42). “Sometimes student behaviour may change but we have (the) power to handle it” (Nurse 37).The summary of the students’ view of nursing roles could perhaps be described as follows: nurses went from working for the doctors and with the patient, to with the doctors and for the patients. The student perception of the role of nurses underwent two large shifts: nurses went from being physician helpers to having independent professional roles; and they went from being task-oriented to patient- and communication-oriented.The first change in student perception was clear. Before the rotation, nurses were described by a majority of students as being subservient to, and dependent on, doctors. While some students described nurses’ “teamwork with doctors” (Student 17), which “complement(s) doctors’ care” (Student 21), most did not. Nurses were clearly perceived to “assist,” “report to,” “inform,” “help” “discuss with,” “make things ready for,” “follow,” and “call” the doctor (multiple students). They are to “do whatever the doctor directs” (Student 34). Even positive statements that nurses “provide care to the patient…” is only “… as instructed by the doctors” (Student 22).After shadowing the nurses, the majority of students commented on the independent roles of nurses, and their collaborative management of patients. Nurses are the only ones “there for the patient 24/7” (Student 7), and are “as important as, at times much more important, than doctors” (Student 20). The importance of nursing care was highlighted specifically as: “integral”, “holistic”, “vital”, and “helping in every difficulty” as the nurses pursued “spiritual and emotional care”, “team work”, “good communication with a cheerful face” (multiple students). Witnessing the empathy of nurses who were “feeling the pain of the patients by themselves” (Student 27) prompted students to “know that the role of nurses is much greater in caring and curing of the patients” (Student 48).The second evolution in students’ view of their nursing colleagues appears to be one that puts the role of communication ahead of the technical tasks of nursing. Prior to the rotation students understood that nursing duties included “comforting” and “educating” the patients as well as “managing beds, giving medications”, “sending investigations, collecting reports”, “maintaining hygiene” and “measuring vitals”. The balance of comments shifted after the rotation. Following their shadow experience, students spoke more often, and with greater depth about non-technical nursing skills. The “job of nurses” in the students’ eyes became much more than “daily duties” and “technical” tasks. Nurses were seen as “more approachable to patients than doctors” (Student 17). Students learned “ethical concern” (Student 18), and empathy: patients “want to be touched by us and given assurance” (Student 45). The empathy students felt for patients extended to the nurses whom they thought were often overworked.Respect was not only for patients but also with the whole team who all have “an equal part to play”. As one student put it “I felt respected by almost all the nurses, they were helpful and co-operative in every way” (Student 20). Another noted respect from doctor to nurse: “I actually noted a senior doctor actually asking medical advice of one of the nurses on a procedure” (Student 46). As one student summarized: “(I learned) to work as a team, to understand and internalise the troubles and difficulties faced by the nursing staffs, to provide holistic care to the patients, to better meet the patient's physiological, spiritual, emotional, social needs” (Student 52).Finally, our surveys gave room for comment on iterative improvement of the rotation. The majority of both nursing and student cohorts requested that the rotation be increased in duration. None requested that it be shorter, nor discontinued. A significant minority requested a clearer orientation to students regarding ward duties, and orientation for nurse preceptors regarding student objectives and expectations. Finally, some nurses who found teaching while they were working to be difficult requested dedicated teachers for the students. Many students noted that nurses were hesitant to provide formative feedback.The findings of this study are encouraging: students and nurses each demonstrated significant changes in their attitudes towards the other professional group following a simple immersive rotation. This is important considering the attention given to defining IPL, and the challenges experienced in best achieving it ,30. ThisFor an answer to why this authentic workplace IPL experience may have improved understanding and respect, we looked to transformative learning theory. According to O’Sullivan, “transformative learning involves experiencing a deep, structured shift in the basic premises of thought, feelings, and actions. It is a shift in consciousness that dramatically and irreversibly alters our way of being in the world. Such a shift involves our understanding of ourselves and our self-locations; our relationships with other humans and with the natural world; our understanding of relations of power in interlocking structures of class, race and gender, our body awareness, our visions of alternative approaches to living; and our sense of possibilities for social justice and peace and personal joy” . TransfoMany of these factors are present in our setting at the Patan Academy of Health Sciences. In many ways, this rotation was an intercultural immersion for the medical students. And while the student-teacher gradient was not necessarily flat, it was of a low gradient. Possibly because both medical students and nurses share a position below physicians in the hierarchy of the hospital, there was a comfort each with the other. Nurses had a unique opportunity to teach and influence future doctors; and students got to learn from professionals who make up the team they may ultimately be asked to lead.The results of this study may encourage changes to how IPL is best delivered. Indeed, we managed to overcome many of the barriers believed to be obstacles to effective IPE in both developed and developing countries . ClinicaThe timing of IPE may be critical . IdeallyThis study had several limitations. The largest of these is the potential for participants writing down the “right answer” even if it does not reflect actual beliefs or practices. We are not convinced that the anonymity of the surveys was adequate to completely counteract this cultural practice amongst our students and nurses. However, this social desirability bias is likely to have affected both pre- and post-surveys.Inherent to the methodology, this was a student-centric study that did not focus on the learning of the nurses as new preceptors. The placement of students in heterogeneous environments may make some of the comparisons unequal, and we did not analyze each separate nursing ward to see if there were obvious differences between the settings. Unlike many classroom-based IPE programs, we did not evaluate a common curriculum delivered to all students, but rather the set of individual experiences in the workplace. The next step of this research may be to use objective measures to assess ongoing behaviours of collaborative practice between these nurses and students over time.A one-week clinical nursing rotation for medical students was an authentic way of learning interprofessional competencies around collaboration, communication, and professionalism. It enhanced respect for the nursing profession in students and engendered respect for the students by nurses. Even this brief rotation resulted in transformative learning, where students recognized nurses as independent health practitioners within the health care team and identified nurses as holistic patient-centred communicators.S1 FileThis file contains the surveys used in the study.(DOCX)Click here for additional data file.S2 FileThis file contains the complete compiled study data.(XLS)Click here for additional data file.


However, I believe that, if it is true thatindividual akrasia is, in the long run, harmful for those who entertain it, this iseven more so in social contexts. I will illustrate this point by drawing on varioussmall group settings, and explore a number of socio-psychological mechanismsunderlying collaborative irrationality, in particular groupthink. Specifically, Isuggest that in collaborative cases there is what I call a spiraling ofpractical irrationality at play. I will argue that this is typicallycorrelated and indeed partly due to biases in individual members’ affectcontrol and eventually the group’s with whom the members identify.The present paper proposes an integrative account of social forms of practicalirrationality and corresponding disruptions of individual and group-level emotionregulation (ER). I will especially focus on disruptions in ER by means ofcollaborative agential and doxastic akrasia. I begin by distinguishing mutual,communal and collaborative forms of akrasia. Such a taxonomy seems all the moreneeded as, rather surprisingly, in the face of huge philosophical interest inanalysing the possibility, structure, and mechanisms of  People not only have emotions, they also regulate them. In regulating emotions, weselect and adjust the situations of affective import, or modulate our attention orbehavioral responses . It is wThe present paper aims to fill this gap by focusing on social forms of practicalirrationality. Specifically, I will concentrate on two potential disruptions in ER,namely social forms of agential akrasia (AA) and doxastic akrasia (DA). On a firstapproximation, AA consists of acting against one’s own better judgment or againstsome relevant set of values, norms or reasons, or in performing an action that runscounter to one’s intention. Doxastic akrasia, a variant of self-deception, occursif one believes something against one’s own better reasons or epistemicstandards, or ‘in the teeth of evidence.’individual practical irrationality, with little exception concerningself-deception  First, I will argue thatspecific collaborative forms of AA and DA are possible, and propose a novel model toanalyze them. This seems to be a crucial task. After all, in the face of greatphilosophical interest in analysing the possibility, structure and mechanisms ofeception  and eveneception , there ave cases . (2)Sec1 In this section, I resumethe issue of dysregulation and focus on the corruption of group-level ER. Here, I willalso discuss some further socio-psychological mechanisms, which account for theemergence of SI in deliberative groups, notably group-polarization, choice shift and thepooling of unshared information . Finally, I provide a conceptual explanation of collaborativeirrationality in terms of group identification. Drawing on the overall rationalintegrity requirement, I claim that what happens is a failure of integratingfirst-person singular and first-person plural rationalpoint of views, while maintaining group identification . I conclude by pointing to some directions forfuture research (see “Conclusion and Future Directions”).The paper is organized as follows: I begin by fleshing out the concepts of AA and DA andpropose three requirements that agents capable of such irrationalities must fulfill (seeSection “Self-deception and Doxastic Akrasia”): the intentionality, theminimal rationality, and the overall rational integrity requirement. Next, I outline thekey mechanisms and  disruptions of ER. In particular, I suggest that DA inhibitscentral features of successful ER: subjects’ clarity about the type and theevaluative or cognitive content of a given emotion, or even their basic awareness ofhaving a certain type of emotion . I then explore practical irrationality in various social contexts andtheir correlation with ER-disruptions. I distinguish mutual, communal and collaborativeforms of social irrationality (SI), and explore especially the collaborative cases. Iwill mainly draw on the case of a clinical smoking therapy group and demonstrate how‘groupthink’ modulateThere has been much debate as to whether synchronous forms of practical irrationalityare possible at all. The question is whether one can synchronously hold contradictorybeliefs as to what would be best to do. The issue poses itself with particular forcewhen it comes to the role of emotions. The issue is neither that an agent, under theinfluence of the emotion at the time of the practical deliberation, changes her viewabout what it would be best to do; nor do we necessarily have to accept the view thatemotions can be so powerful as to directly change the behavior of an agent at the veryinstance of the respective action, or to refer to ‘irresistibledesires’—a notion that some have rightly rejected .Rather,2Thus, we need an account that captures the tension arising from holding synchroniccontradictory beliefs, desires or reasons for action. Such an account is provided bywhat Thus, some have suggested that emotions will only “cloud or bias” thecognitive processes  upon which the agent’spractical deliberation is based, or influence the agent’s rational choice.The—subsequent—irrational action is then due to a (temporary)‘preference reversal’ . As we wHere, then, is what last-ditch AA and DA amount to: Assume a subject S who is anon-pathological rational believer under normal circumstances  whoattends more or less strictly, but given normal epistemic standards, to logical andrational consistency. For now, such an admittedly liberal, rough-and-readycharacterization of rationality will suffice; I will come back to that below,however.(AA) An action A is strictly akratic iff(1)tonly if S judges that A-ing at t is all-things-considered betterthan B-ing at t, and S believes that she can either A or B att ; S is an intentional agent such that S intentionally will A at (2a)t to the effect that all things consideredshe has sufficient reason for her not A-ing at t ; S holds a belief at (2b)t,S decisively judges that it is best not to A at t; Based on the evaluation of A in attaining S’s goal at (3)t. S  A-s at A number of technicalities set aside, and however, differently one might then wish toexplain how rational agents are led from (1) to (3), or how AA is possible at all, thisfairly mirrors the standard picture of what synchronic AA would amount to .Consider now the similar case of DA, sometimes also called “incontinentbelief” . Here, w(DA) S is subject to doxastic akrasia, or holds or retains an akratic belief, iff(1)p and q are incompatible; S believes that (2)p; S has a reason R to believe that (3)∗s, which warrant q ; S acknowledges that R is a stronger reason than an alternative set ofR(4)q. S believes that pand q may be true propositions, whereas according to the standard view,in self-deception, q will be false, and S knows or at least takesq to be false (Note that (DA) shares almost all features with another phenomenon of practicalirrationality, namely self-deception, except for the fact that both be false . But, aspartitioned ordistributed across two or more agents or believers. In markedcontrast, in usual cases, the subject having a true or sufficiently warranted belief andthe subject of self-deception, akrasia or DA are essentially identical: it is anindividual subject. However, many have argued that the best or only possible explanationof how agents can arrive at the conclusion of AA or DA—without leading toirresolvable paradoxes—is to assume a multiplicity of rational centers withinindividuals. The conflicts or inconsistencies are then construed with reference todifferent aspects in terms of hierarchies of values, epistemic imbalances, non-alignmentbetween motivational strength and evaluative judgments, or a gap between conative andrational poles or cognitive subdivisions  The first is a standard requirement of agency, accepted by almost all philosophersof mind and action today, concerning practical and theoretical intentionality. Itamounts to claiming that an  agent capable of any form ofpractical irrationality  must be an intentional agent.The general idea is fairly straightforward. A subject S is an intentional agent, i.e., Sis the bearer of intentional properties. S can over time and under various practical andepistemic circumstances form, hold, and robustly entertain intentional attitudes andbeliefs with propositional or some otherwise specified intentional content, practicalintentions, and/or desires or other motivational, so-called‘pro-attitudes.’ Moreover, it is these intentional properties that figurein folk-psychological explanations of S’s behavior. Call this theMinimal Rationality Requirement. Accordingto this, S will not only have intentional states, but will typically hold relativelyconsistent, or at least non-contradictory, beliefs, aesthetic, moral, etc., attitudes,rank her preferences, and attend to them and their transitivity . S will be sensitive to available meansand options for attaining her goals, form intentions on the basis of such options,preferences, beliefs and desires and in normal circumstances reason and act uponthose.(2) The second requirement builds directly on this ability of agents entertainingintentional states, but infuses them with certain inferential norms or a minimal form ofrationality. Call this the 3 What we needis a requirement that captures the sense in which agents must be sensitive not simply toavailable means, preference rankings, etc., but more robustly be sensitive to an overallcoherence as full-fledged rational agents or persons.Though such minimal rationality is necessary in order to exhibit practicalirrationality, it is not sufficient. This has to do with a distinction between two waysof being sensitive to the normativity of reasons for action andbelief-formation.4) must, and can, fulfill. I shall label this the OverallRational Integrity Requirement. The central concept at stake, the concept ofa rational unified point of view (RPV), was introduced by the socialontologist be that person).What then is an RPV? It is a unified set of reasons, in the light of which S assessesher given beliefs, preferences and intentions, and which, in the course of practicaldeliberation and theoretical reasoning, yields conclusions as to whatall-things-considered S ought to believe or do. In terms of integrityand autonomy, an agent is an autonomous intentional agent if the agent acknowledges anddeliberately endorses the normative practical and theoretical conclusions provided byher own RPV and if necessary modifies her beliefs, preferences or intentionsaccordingly. This will entail not only a structural or instrumental rationality but alsoa form of reflective rationality. It will entail that agents are awareand deliberatively reflect upon the reasons and motivations they have and act not onlyin accordance with but also by virtue of theirnormative force, or else modify them. Thus, having an RPV is dependent on agents havingminimal rationality [hence on (2)], but it furthermore provides the normative force toact in accordance with that structural or instrumental rationality.(3) I want to argue that we need a more robust requirement, which both individual andcollaborating . In more complex,especially institutional, forms of groups there will be some normatively bindingrational meta-standards for integrating the relevant attitudes. This will includenon-contradictory voting procedures and aggregation functions, mechanisms ensuringconsistency with other dispositional attitudes, values or sub-goals of the group,predetermined levels of expertise, or even (non-authoritarian) hierarchies in order torationally evaluate the beliefs in view of group-level goals.In the following sections, I shall suggest that practical irrationality is typicallyenhanced in collaborative contexts, and that this is correlated and indeed partly due todisruptions in ER. So first we need an understanding of what ER exactly is and how itsmechanisms may be disrupted, particularly in social settings.individual ER, or self-regulation, abounds eversince the work of 5. ER involves the ways in which individuals monitor,modulate or change their emotional elicitation, experience or expression. Lesstechnically, it refers to “influencing which emotions one has, when one has them,and how one experiences and expresses these emotions”  situation selection; (ii)situation modification; (iii) change of attentional deployment; (iv) cognitive change orreappraisal; and finally (v), on the response-focused side, response modulation. Theidea can be brought out by way of the following example. Consider the regular commuter,James, a choleric developmental psychologist, who decides after years of frustrationwith traffic jams to take the not too crowded train to the office instead. James thusselects a situation in which the likelihood of his anger and frustration is less likelyto be elicited (viz. i). One evening on his way back from work, James enjoys his glassof wine and a book in the dining car when a mother with her crying baby chooses to sitright next to him. James feels his anger rising; in order to regulate his emotionalupheaval, he might continue to tailor the situation, for example by changing his seat orstarting to talk to somebody on the phone with his earphones plugged in (ii). But thereare surely more subtle ways of modulating his emotions: For one, James might try tofocus his attention on specific perceptual or cognitive features of the situation toalter its emotional impact. He might try to distract himself from the auditory input bylooking out the window, or concentrating more on his book (iii). Another possibility ofER is to tell himself or try to make himself think that the book was boring anyway andit’s actually more interesting to observe how mothers interact with young babiesoutside his university laboratory. Hence, by means of cognitive reappraisal, he mightselect among alternative meanings attached to the situation (annoying noise vs.interesting ‘field-study’) in order to alter its emotional significance(iv). Finally, if all these mechanisms fail, James would still have a last-ditch moveand could modulate the expressive or affective responses and action-tendencies his angerwould elicit. He might try to influence his behavioral responses, once initiated, bysome props  or expressive behavior  (v).Psychological work on motions” , p. 271.6 But even more intriguingly, negativemodulations, biases or disruptions in both individual and group-level ER-processes arecorrelated to irrational tendencies in collaborative deliberations and actions—orso I shall argue.However, complex the process, the relevant point for present purposes is that all thesedimensions and aspects are robustly shaped by sociocultural factors. Moreover, all thesemechanisms and dimensions are often disrupted precisely by these factors. Ampleempirical research from developmental, social and cross-cultural psychology supports thethesis that interpersonal or small group settings as well as professional and broadersociocultural contexts robustly shape, modulate or even dictate emotional(self-)regulation .Thus, aThus, just like most other socio-psychological processes emotional co-regulation has notonly a bright but also a dark side. Very often it misfires precisely in social,collaborative, intra- and intergroup contexts. And certain collaborative, intra- andinter-group engagements play also a contributing or even constitutive biasing role inentering or maintaining individual as well as group-level practical irrationality.Combining these insights, the guiding hypothesis I begin to explore here is that thenegative impact of collaborative contexts on practical rationality is partly due totheir specifically disruptive role on ER.dysfunctional ER,in an integrative study on the so-called “Difficulties in Emotion RegulationScale,” lack of emotional clarity and, even more seriously, the lack of emotionalawareness has been suggested to be a crucial component   . Thus, iiveness) .clarity about thetype, the evaluative or cognitive content, or themore fine-grained qualitative aspects of a given emotion. Moreover,they may even hinder the subject to have a basic awareness of having acertain type of emotion at all.8 Below, I will argue that these inhibitions and biases aretypically facilitated in collaborative contexts. For now, consider a case illustratinghow emotions come into play in individual practical irrationality andhow practical irrationality eventually disrupts ER.9really jealous.’), or even tomisidentify the very emotion he is experiencing, which he may re-interpret for examplein terms of pride . In either case, and there may of course be combinations thereof,he will not successfully regulate his jealousy, and will behave, for example,increasingly irritated, nervous or depressive when his wife is not at home.10 But how do such irrationally motivatedER-biases spell out in collaboration with others, and how do they eventually enhancepractical irrationality to a point where we are left with what I call a‘spiraling’ of such? This is the question I wish to address in thefollowing section.Building on, further developing or reversing these findings, I want to suggest thatcertain forms of practical irrationality, and especially DA, inhibit precisely these twocrucial features of successful ER, notably distributed across agents or homunculi withinagents. Here, I want to argue against the related claim that all there is to SI areforms of irresolvable conflicts of interest. In contrast, I shall show that there isan intriguing variety of cases in which irrationality is modulated, facilitated oreven triggered by social contexts and collaborative engagements. Before going intoany detail, it should be noted that not only such distinctively social but also theoverwhelming majority of strictly speaking individual forms ofpractical irrationality are socially co-constituted. More often than not, enteringand retaining akratic self-deception or performing akratic actions is facilitated bysome social facts, or reactions, deliberative ignorance, or the witting or unwittingassistance by others ,namely (i) mutual, (ii) communal and (iii)collaborative SI. Far from being a mere exercise in taxonomy,this is crucial in order to get a firm grip on the exact sense in which sociality isor is not involved in modulating the affective and rational life of individuals. Inparticular, it shall help getting clearer about what it means to properly speakingcollaboratively engage in practical irrationality.But leaving aside the issue of the broader social context of practical irrationalitythat is at play in virtually all cases of irrationality, let me now distinguish threetypes of the genera of what I shall call mutual SI. Suppose two individuals A and B who donot engage in any proper collaborative engagement, let aloneshare any common intentions or goals, but just share a more or less ephemeralsituational context. Mutual SI will arise whenever A’s practical irrationalityis wittingly or unwittingly assisted or reinforced by B’s appropriate reactionor vice versa. Imagine a patient–doctor interaction in which a terminal-stagecancer diagnosis looms large. In this affectively highly charged situation one orboth parties might foreclose or defer an otherwise much more painstaking ER procedureby mutually assisting one another in self-deceptive belief formation about the actualstate of affairs. For example, the patient’s self-deceptive report of hisactual condition will be facilitated or unraveled during the meeting by thedoctor’s  display of an (overly)optimistic attitude, or their respective self-deceptive strategieswill be reinforced by the behavior of the other (cf. (i) Consider first ther cf. .Communal SI is similar in structure. The main difference to themutual case is that the participants are either bound together by a more robustframework of communal, though not necessarily shared interests, habits or policies,or cases in which their respective behavior creates a pattern of‘quasi-collective’ behavior, for example due to mechanisms of emotionalcontagion and mutual reinforcement of biasing affects. To illustrate the firstscenario, consider a group of professional cyclist who are befriended and all doping.Here the individual cyclists’ akratic or self-deceptive practices are (maybeeven unwittingly) assisted by some tacit communal method of concealing certain factsor employing certain habitualized strategies: for example by everybody’sover-optimism or euphemistic jargon-talk (‘It’s just a kind ofanti-oxidant.’). Notice that there mustn’t be any explicit communalpolicy or some shared goal that directly motivates SI, as, say for a dopingcycling-team . All there is are some more or less diffusecommunal patterns of behavior or discourse. The important point is that, if theindividuals were not engaged in the given communal context, they would have a muchharder time not just to rationalize but simply to be clearlyaware of what exactly they are doing (beingakratic cheaters) or to fully realize that they deceive themselves about prospects ofbeing caught. Similar deceptive discourses often facilitate individuals’irrational behavior in corporate professional settings ((ii) settings .individual losses.Now, via emotional contagion  So much then for non-collaborative cases. What I now want to dwell upon are12 Let there be three subjects with the followingthree-item preference ranking: S1 prefers A to B to C, S2 B toC to A and S3 C to A to B. Let each individual be fully consistent andsensitive to the transitivity of their own preferences. However, if we aggregate allthe rankings by simple majority vote we end up precisely with equal preferencerankings for all options, and hence non-transitivity: We then have two collectivelyaggregated preferences for A to B, two for B to C, and two for C to A. As Hurley putsthe point, “collective choices may be irrational despite individualrationality” members of a risk management unit of a bank jointly downplayacknowledged high speculative risks, because they individually or collectively aim tomaximize profit. In doing so, each member holds the same type ofakratic action or belief for similar or even the samereasons and by the same or similar means. This mayinvolve a division of labor and hence a differentiation of specific means ofirrational behavior. All members being motivationally biased, they jointly deceivethemselves. Importantly, as in most collaborative instances of SI, such agency willhave more serious negative consequences and result in a negative spiral of lack ofself-control and hypocrisy. Akratic actions and beliefs performed in tandem withothers may become more easily habitualized and more strongly entrenched as inindividual agency, especially when role-models lead by negative examples. But even ifthis is not the case, the practical implications of one’s own irrationalaction are usually magnified in collaboration and joint irrational agency  akrasia. I will draw upon a real-lifesmall group case study, a clinical group of around 30 would-be non-smokers. It wasanalyzed by the social psychologist Irving Janis in terms of a paradigmatic instanceof what he famously coined “groupthink” , pp. 7–8Consider then a clinical therapy group of heavy smokers gathering on a regular basisfor informal conversation, exchanging views about coping with withdrawal symptoms,motivational advice and clinically supervised medication, in the fashion of ananonymous alcoholic group. At one meeting, a member of the group shyly announces thathe succeeded in stopping since the last meeting, an achievement, to wit, that none ofthe others have attained at that time, or at least have not informed the othersabout. Now, instead of congratulating him and getting more confident about their ownprospects, the other members start slowly, but with increasing expressivity, to treat himas an outsider who deviates from group consensus. In particular, two ferociousmembers start a heated discussion and voice the claim that smoking is an almostincurable addiction. The debate soon results in a consensus that this is clinicallyproven. The ‘deviant’ member who has taken issue with the emergingconsensus at first realizes quickly that the others have ganged up against him, andeventually declares:When I joined […], I agreed to follow the two main rules required by theclinic—to make a conscientious effort to stop smoking and to attend everymeeting. But I have learned from experience in this group that you can only followone of the rules, you can’t follow both. And so, I have decided that I willcontinue to attend every meeting but I have gone back to smoking two packs a dayand I will not make any effort to stop smoking again until after the last session, p. 8.Taken at face value, this very sincere, clear-sighted and consistent avowal isfollowed by the others “beam[ing] at him and applaud[ing]enthusiastically” (ibid.). But the member refrains from quitting the group orleaving the actual session or from reflecting more carefully upon his conflictingdesires and emotions , in order to modulate his emotions accordingly. The reason is that hisdeliberative and ER-capacities are overridden by the most salient alternatives andarguments provided by the cohesive social context. Eventually he acts upon these‘corrupted’ capacities and sticks to the group and smoking.14 so asnot to lose the affective value attached to the group sessions, such as mutualdependence and affiliation, or in-group solidarity and bonding. But this clearlycontradicts the members’ individual goal (to quit smoking) as well as whatBut there is another side to the story: (Doxastic) akrasia and groupthink do not stopshort in exerting their powers, top-down, from group-level to the individual level.As a case of properly collaborative SI, there is a two-way modulation of, orinteraction in, performing akratic belief formation and action. As the exampleclearly illustrates, by the very akratic avowal and behavior of the initially deviantmember, the members of the group consider themselves reassured in their own akraticbelief that it is impossible to quit smoking all of a sudden. Moreover, there is anaffectively motivated irrational tendency of other group members, aggregated on thegroup-level, to exert pressure on individuals to smoke (even more), especially as thefinal session approaches,jointly in pursuing their goalof quitting to smoke. In contrast for instance to the above mentioned case of therisk-management unit or the doping cyclist-team, in this scenario the group does notconstitute a group agent proper and hence there is no shared or common goal either.After all, in an obvious sense, it is not the group that wants tostop smoking. However, given that we deal here precisely with a smoking therapy groupand not just with randomly meeting individual smokers, the framework within whichmembers pursue their individual goals is indeed a collaborative one. This frameworkrepresents precisely the group’s ethos. It is constituted by thegroup’s implicit and explicit rules, shared values and norms, such as the ruleto help other members to quit smoking by all means—viz. disregarding purelyegoistic motives for  success. As Tuomela puts it, a group’s ethosis something that “functions as kind of underlying presuppositional reason forthe participants’ actions” . Thus, groupthink is characterized byIn the following ,I will discuss further underlying socio-psychological and structural dynamics thathelp explain what exactly causes the collaborative irrational belief and behavioraltendencies. But for the present case, I suggest that the core mechanism at play iswhat Janis has described as the phenomenon of groupthink. Janis has shown thatgroupthink reliably occurs in small- and mid-sized, deeply cohesive groups. Asparadigmatic settings for groupthink, he mentions such groups as “infantryplatoons, air crews, therapy groups, seminars, and self-study or encounter groups ofexecutives receiving leadership training” , p. 7.15a mode of thinking that people engage in when they are deeply involved in acohesive in-group when the members’ strivings for unanimity override theirmotivation to realistically appraise alternative courses for action. […]Groupthink refers to a deterioration of mental efficiency, reality testing, andmoral judgment that results from in-group pressures. , p. 9What exactly are the defects of a group engaging in groupthink? Janis mentions sevendefects in “decision-making tasks” (ibid.: 10): (i) limitation of groupdiscussion to a few alternative courses of action, ignoring alternatives; (ii) lackof surveying the goals and objectives and their implicated values; (iii) failure tore-examine the initially preferred actions regarding non-obvious risks and potentialdrawbacks; (iv) failure to re-consider courses of action initially deemedunsatisfactory or to consider non-obvious gains or factors that make the chosenalternative appear desirable; (v) lack of any attempt to gain  expertopinion about alternatives; (vi) similarly, selective bias to available factual orexpert information supporting desirable courses of action and ignorance of externalcritical views against it; (vii) finally, failure to work out contingency plans tocope with various foreseeable setbacks that might endanger the success of the chosencourse of action.structural and situational factorsleading groups to such irrational behavior in the first place? Janis suggests anumber of “structural faults” of groups fostering groupthink (ibid.:248–249): they include the above-mentioned group cohesiveness, strong grouployalty and an increasing need for affiliation, especially when facing a crisissituation or being subject to stress; an insulation of cohesive decision-makingsubgroups from qualified intragroup experts considered as ‘outsiders’or deviants until the decision is taken; the lack of previously establishedorganizational constraints and norms to adopt methodological checks-and-balances orassess critical information; or an alleged or emerging  group norm in favor ofa particular action or decision toward which members would feel obliged.Additionally, one of the key, though neither sufficient nor necessary,“situational factors” facilitating groupthink is high stress induced byexternal factors, such as the “threat of losses to be expected from whateveralternative is chosen and […] low hope of finding a better solution than theone favored by the leader” (ibid.: 250). This explains how groupthink isdirectly linked to emotion-regulative processes. Arguably, immediate threat of lossesor high stress affect not only deliberative but in the first instance affectiveprocesses. On the one hand, despair, threats, need for affiliation or stress areprevalent targets of ER; on the other hand, they are precisely thosetype of affective states that tend to heavily interfere and disrupt successfulER.But what are the lack of emotional clarity oremotional awareness that deeply affects ER. At the same time, thiscognitive-cum-affective corruption leads the members’capacity to assess alternative ways of ER. Here is how Janis describes thismechanism:Now, with a view to the specific focus of this paper, I want to suggest thatgroupthink, viewed as an underlying, cognitive and affective mechanism facilitating(doxastic) akrasia, arises when members’ intragroup affective bonds andsocio-emotional affiliation overrides their motivation or their very ability torationally assess alternative courses for intentions and actions. What is more,strong groupthink may also inhibit to access one’s own emotional arousal oreven some bodily affective states, even those induced by addictive physiologicalprocesses. Here then we have a clear case of what I introduced above (seeSelf-Deception and Doxastic Akrasia) as the [field experiments indicate] that under certain conditions, increased socialcontact among group members increases not only the attractiveness of the group butalso adherence to norms of self-improvement .Under other conditions, however, the informal norms that develop may subvert theoriginal purposes for which the group was formed. , p. 277interpersonal influences on ER . Secondly, it does not negatively affect my main line of argument anyway.Quite the contrary, it adds further ammunition to the claim that even deeplyaffective symptoms, such as (addiction related) anxiety, are, for better or worse,socially mediated or co-constituted.It should be emphasized that group-level phenomena. In other words, are there anygroup-level mechanisms that play the role of ER and eventually has a feedback on theER-tendencies of individuals, or vice versa. As already indicated, ER processes arenot only deeply embedded into socio-cultural contexts; for some tightly coupled pairsof individuals  there are also ER-dynamicsat play that can only be viewed as a dyadic ‘loop’ of emotionalco-regulation , whereas, say, down-regulatingone’s own anxiety might lessen concern for oneself by friends  information.Group polarization refers to the widely observed phenomenon that deliberative groupsregularly and predictably shift toward more extreme views than pre-deliberationmedians, indicated by the members’ pre-deliberation tendencies . ConsideSecondly, another cogent phenomenon has often been observed in deliberative groups,namely a certain pooling of (unshared) information . There iAs should be obvious, these socio-dynamic tendencies resonate well with theirrational biases and tendencies of groupthink. Moreover, when considering the effectthat the salience of views and biased distribution of information has on irrationaltendencies, the role of group polarization and the pooling of unshared information inthe cognitive and attentional aspects of awareness in ER should also be fairly clear.They will have a key role in corrupting the capacity of group members to change theirattentional deployment, and in deficiencies regarding cognitive change orreappraisal. For example, social comparison will push individuals to adjust theirviews to affects voiced by dominant members , and a disproportionate pool of persuasive arguments will also make moreextreme affects regarding certain positions appear more salient. Thus, these biaseswill hinder individuals’ emotional clarity, or even lead to a lack ofemotional awareness about one’s own or group-level emotional preferences. Justlike groupthink, these socio-dynamic processes will significantly modulate or inhibitindividuals’ successful ER.conceptual explanation of what exactly happens in suchcases. This is the task I wish to pursue in this final section.In the previous two sections, I have mainly focused on explaining whichsocio-psychological mechanisms are responsible for collaborative SI. What is stillmissing is a motivated bias—and hence some, if not good,reasons—for the members qua members to act or believeaccordingly. The motivation deploys its force via the above-mentioned mechanisms andstems from the familiar affective and cognitive biases.To begin with, recall the three requirements that agents capable of practicalirrationality must fulfill . I have argued that it is in particular the Overall Rational IntegrityRequirement that is crucial for establishing the possibility of collaborative irrationalagency. According to this requirement agents have a unified rational point of view inthe light of which they assess their beliefs, preferences or intentions and which, inthe course of practical deliberation, yields conclusions as to what,all-things-considered, they ought to believe or do. Now, I want to argue that in genuinecases of collaborative SI—just as in individual cases—the irrationalityamounts to a motivated non-conformity to this overall rational integrity requirement.Importantly, the non-conformity is not simply irrational but there is amutual and collaborative SI. In the first casethe irrational tendencies are also reinforced and facilitated by the interaction withothers, but the irrationality of the action or belief remains on the side of theindividuals alone. The rationality of the agency, values and beliefs they fail toconform to is determined by the respective individual’s own RPV. And thoserespective RPV might of course conflict; that is, A’s RPV mustn’t overlapwith B’s RPV, and might even be opposed to it. And yet, A might‘rely’ on B for assisting her not to conform to her own RPV. This isdifferent in genuinely collaborative cases. The irrationality amounts not simply toindividuals but to individual members not reasoning or acting in lightof their group’s rational point of view. That is, they failas members to integrate their preferences, intentions or beliefsinto the group’s RPV.In order to appreciate this point, consider again the subtle but important differencebetween as their own. Thus, what happens in the cases I am interestedin is an irrationally motivated failure of the individuals qua groupmembers to integrate their own RPV into the group’s RPV—the group’swith which they keep to group-identify, and that means, whose RPV they keep subscribingto, notwithstanding this failure. Arguably, this is irrational because the members haveno good, or no affectively unbiased, reason for both identifying withtheir group’s RPV and their own. But notice that this does not simply mean thatthe members are sticking to their own preferences, beliefs and intentions, which are inconflict with those dictated by their group’s RPV. Rather, they stick, asgroup-identifying members, to their own RPV—a point of view, however, of whichpart and parcel is precisely the group’s RPV. Their own RPVwould dictate either to quit the group or to stop acknowledging the group’soverall RPV or identifying cognitively and affectively with it. Instead, the individualskeep trying to integrate the group’s RPV into their own, an integration that isdoomed to fail, however. But this failure, as I have tried to show, is itself notimmediately apparent to the individuals, which explains why they keep trying. The reasonfor that is that the individual members’ own emotion regulatory processes, andindeed their awareness of their own desires, intentions, and affectivestates—including their affective attachment to the group—are biased orclouded by the deficiencies of the group’s ER and viceversa.Let me explain this in terms of the familiar notion of group identification as it isemployed in social identity theories . Group isome cases, both theseexplanations seem unable to account for the collaborative nature of irrationality we arelooking at.Now, critics may wonder whether such collaborative cases would not simply amount to acertain internal division or partitioning within deliberative groups, such that we endup with conflicting sub-groups or, to put it bluntly, conflicts between what individualswant and what the group wants. Thus, one might think that we are dealing here with afirst-order  and a second-order (collaborative) case of irrationality. Ifso, we would just re-introduce the partitioning picture on a higher level. But this, asI have argued, would not suffice to capture the sense of irrationality at stake in SI.After all, we would then simply be left with competing reasoning or goals and, at best,a compromise of negotiated reasons and intentions. On an alternative construal, DA wouldeither be based on the model of other-deception, where one individual or subgroupdeceives another, or amount to a mere problem of practically motivated (epistemic)mis-coordination. The latter possibility might be seen as the result of certainepistemological opacities (maybe due to affective biases), which in turn may result innon-cooperative behavior or the members’ poorly executed coordination regarding ashared goal. But however well they may fit complete conformity of theindividual’s overall rational point of view with that of thegroup’s is too strong a requirement for group-membership as such. Putdifferently, does any participation in a collaborative endeavornecessarily requires integrating the individual’s overall RPVinto that of the group on pain of irrationality? This surely seems too hard a bullet tobite in most ordinary cases of collaboration.Relatedly, it might seem that self-deception or practical irrationality), or one subgroupsuccumbing to the irrational tendencies of another subgroup. Rather, there is atemporary disintegration of collaborative reasoning anddeliberation. In other words, what we have here is a motivated, but nonethelessirrational, disruption of group identification and eventuallyof the overall rational unification of the members. The result ofsuch will be a temporary disintegration of the rational-cum-practicaland often affective integration of the individuals, initially bound together by sharedreasons, goals and intentions, or a shared affective life. Specifically, what happens isa failure of integrating one’s own rational point of view into that of thegroup’s rational point of view. But notice again that the failure does not simplyamount to a conflict between two incompatible perspectives. For, again, in genuinelycollaborative cases, in which the members identify cognitively,psychologically or phenomenologically with their group, part and parcel of one’sown RPV is precisely the group’s RPV. Conversely, if collaboration is supposed tobe taken seriously—as in therapy group settings for instance—thegroup’s RPV is supposed to be ‘in line’ withtheir members, and indeed purports to be a more or less practically and affectivelycoherent integration of each and every member’s RPV. So we don’t simplyhave two or more RPVs—the group’s and themembers’—conflicting with each other but a practically irrationaldisintegrating force working among or across the members and ultimatelydisrupting the overall unification of the group as a whole.Against these potential objections, I want to emphasize again that collaborativeirrationality does not amount to a mere problem of an individual and the group or somesubgroups having conflicting reasons or interests. Neither do we have one individual orsubgroup deceiving another goal. Surely, not in all cases in which individuals cannot integrate their RPV into thegroup’s do we have individual akrasia or self-deception at play. It might simplybe that the individual’s norms of rationality are stronger than the ones dictatedby the group or that the group identification of the individual is not strong enough foran irrationality to arise in the first place. In such cases, there is room for“rational deviation” rationality conflicting,but itself be a collaborative conflict of rationality. ‘Relevant’integration here, again, means that the individual must integrate those elements of thegroup’s RPV into her own that concern pursuing a collaborativegoal in which the individual aims to partake herself . So this doesn’t mean that individualcouldn’t at all, or rationally, deviate fromthe group’s RPV. She may still try to weigh both the psychological and cognitiveevidence for what’s best for her to do and what’s bestfor the group .But there are also cases—and these are the ones I have beendiscussing—where one may not have rationally valid excuses or reason (foroneself) not to fulfill the obligations associated with a collectivegoal. Moreover, because the individual is torn not only by her own akratic tendenciesbut also, and more importantly, given her initial group identification, biased byin-group affiliation tendencies or similar dis-regulatory mechanisms, she might simplynot be any more in a position to rationally and also psychologically  adequately assess the available evidences.Viewed from the individuals’ perspective, what goes wrong in the process is thatthe viation”  from thejoint commitment to collective reasons, values and practicalconclusions, which are provided by its rational point of view. That is, not only do allof the above requirements (1)–(3) still hold, such that the irrationality canarise in the first place. What is more, the members acknowledge and also continue to layclaim to their group’s rational point of view, such that its normative forcestill exerts its influence.Similarly, on the group level, the disintegration is not simply a partitioning of thegroup into conflicting subgroups, but rather a dissolution of the normative force of aninitially none of the participants of a certain collaborativeendeavor has a personal commitment to a shared belief or intention,even though they continue to be jointly committed to it. To appreciatethis point, consider Gilbert’s notion of ‘joint commitment.’Gilbert uses this notion as a technical concept to highlight a difference between‘joint’ and ‘personal’ commitments to collective beliefs oractions. In her view, when parties jointly commit themselves to a shared belief orintention, they must see to it “as far as possible to emulate, by virtue of theactions of each, a single body that intends to do the thing in question” personal intentions.Another way to put this, is to point to a certain disintegration or drifting apart ofindividuals’ ‘personal’ intentions, on the one hand, and thegroup’s ‘joint’ intention, on the other. In terms of uestion” , p. 180.I have argued that given three requirements agents are capable of mutual, communal, andin particular collaborative forms of AA and DA. I have provided a conceptual model toanalyze these in terms of a failure to integrate individual members’ rationalpoint of views into the overall rational point of view of the group with which themembers keeps to group-identify. Indeed, I hope to have shown that such social forms ofirrationality are not only real but are also rather common and prevalent phenomena.Moreover, I have emphasized that in collaborative cases there is a two-way modulation, abottom-up, leading from individuals’ irrational tendencies to that of the group,and a top-down, leading from groups’ irrational policies to individuals’irrational action and belief-formation. I have explored this reciprocal, reinforcingdynamics in terms of what I call ‘collaborative spiraling of practicalirrationality.’ Furthermore, I have argued that in some instances collaborativeirrationality is due to a salient deficiency in ER, namely to the socially motivatedmisidentification of one’s own affects. I have suggested that this biasesone’s own affect control and eventually one’s group’s ER.Consequently, I have claimed that various social engagements often play a contributingor even constitutive role in entering or maintaining practical irrationality, and thisis, in turn, partly due precisely to their disruptive role on ER.Now, even if the argument goes through, some may wonder whether there would lurk acircularity at its very dialectical core, and especially when considering the latterclaims: Thus, it might seem that there is a circularity between the claim that somesocial forms of irrationality have a disruptive role on ER, on the one hand, and theclaim that the resulting biases in individual and group-level ER are reinforcingcollaborative irrationality, on the other. Put differently, one may wonder about thedirection of the causal influence regarding the emergence and indeed intensification ofirrational biases: is it failures in emotional (co-)regulation leading to or increasingcollaborative akrasia or vice versa? Or does the influence go both ways? However, Ibelieve that the ‘circularity,’ though in fact real, represents a virtuousand not a vicious circle, which rather than threatens the argument, lends credit to it.For, indeed, there is a certain feedback between disruptions of collaborative andindividual rationality, on the one hand, and disruptions of individual and group-levelER, on the other, and this mirrors the spiraling of collaborative irrationality that Ihave elaborated upon. Typically, in real-life scenarios, once this spiraling is set inmotion, it proves almost impossible to stop the feedback-loop between disruptions ofwhat one or one’s group can emotionally access and regulate, on the one hand, anddisruptions of what one or one’s group is rationally able to do or to think, onthe other.collective andorganizational forms of SI. The subjects of akrasia andself-deception would then not be collaborating individuals but fullyfledged group or corporate agents (Let me close with a remark on a lacuna and the potential direction for future research.In this article, I have concentrated on mutual, communal, and especially collaborativeforms of practical irrationality. However, I contend that given our three requirementsthere is also room for genuinely e agents . But if The author confirms being the sole contributor of this work and approved it forpublication.The author declares that the research was conducted in the absence of any commercial orfinancial relationships that could be construed as a potential conflict of interest.


African American/Black and Hispanic persons living with HIV (AABH-PLWH) in the U.S. evidence insufficient engagement in HIV care and low uptake of HIV antiretroviral therapy, leading to suboptimal clinical outcomes. The present qualitative study used critical race theory, and incorporated intersectionality theory, to understand AABH-PLWH’s perspectives on the mechanisms by which structural racism; that is, the macro-level systems that reinforce inequities among racial/ethnic groups, influence health decisions and behaviors.N = 37). Participants were purposively sampled for maximum variation from a larger study, and engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach.Participants were adult AABH-PLWH in New York City who were not taking antiretroviral therapy nor well engaged in HIV care  mono-therapy, which was initially prescribed in unacceptably high doses, causing serious side effects, but with only modest efficacy. In this historical/cultural context, aspects of structural racism negatively influenced health care decisions and behavior in four main ways: 1) via the extent to which healthcare settings were experienced as overly institutionalized and, therefore, dehumanizing; 2) distrust of medical institutions and healthcare providers, which led AABH-PLWH to feel pressured to take HIV antiretroviral therapy when it was offered; 3) perceptions that patients are excluded from the health decision-making process; and 4) an over-emphasis on antiretroviral therapy compared to other non-HIV related priorities. We found that although participants were located at the intersection of multiple social categories , race/ethnicity and social class were described as primary factors.Critical race theory proved useful in uncovering how macro-level structural racism affects individual-level health decisions and behaviors. HIV clinical settings can counter-balance the effects of structural racism by building “structural competency,” and interventions fostering core self-determination needs including autonomy may prove culturally appropriate and beneficial for AABH-PLWH. Treatments for HIV infection have improved dramatically in recent years . These aThe literature highlights a number of factors that contribute to AABH-PLWH engaging in HIV care at suboptimal levels and/or to delay, decline, or discontinue ART. This literature to date has focused primarily on barriers at the individual level of influence, such as unsupportive health beliefs, including negative outcome expectancies regarding ART, low self-efficacy to manage ART, and negative emotions, including fear , 14, as Structural barriers are aspects of the larger external environment that limit individuals’ options. These include general social and health-specific policies , aspects of organizations , and/or infrastructure  . Past reTo address this gap in the literature, we conducted a qualitative study informed by critical race theory (CRT), and incorporating intersectionality – complementary trans-disciplinary theoretical frameworks grounded in social justice –32. CRT CRT proceeds from an understanding that while structural racism is less visible than individual racism, it is just as, if not more, influential. Unlike individual racism, structural racism is a systemic, historically rooted form of oppression that cannot be eradicated simply at the level of individual attitudes or behavior. Indeed, the individuals operating within institutions may be, in practice, non-discriminatory, but still operate within a larger structurally racist context. For example, a health care provider may understand him or herself as delivering high-quality care to all his/her patients regardless of their race and backgrounds, but this provider nonetheless operates within an institutional context marked by unequal resources, policies, and practices. Yet as a result of failing to address the ways in which health care providers in particular, and the medical system in general, are perceived by patients who have experienced multiple, overlapping forms of discrimination, many health care providers may nonetheless inadvertently contribute to AABH-PLWH’s experiences of discrimination within health care settings.Through eliciting counter-narratives, CRT guides an exploration of how institutional policies and structures, as well as prevailing cultural norms, work to influence the health care decisions and outcomes among populations of color . The aimThe present study was conducted in New York City (NYC), a location with a large and mature HIV epidemic comprised of approximately 120,000 PLWH, more than 75% of whom are African-American/Black and Hispanic . NYC hasN = 95) to develop interventions to increase ART initiation among those who were medically eligible for ART, but had delayed, declined, or discontinued ART, many of whom were also poorly engaged in HIV primary care. Participants for the larger study were recruited mainly through peer-to-peer referrals in New York City in 2012–2014. For the present qualitative study, participants were purposively sampled from this larger cohort for maximum variation on HIV history  and ART experiences . A total of 37 participants were sampled, approached, and enrolled in the qualitative study, for which participants gave signed informed consent. None of those approached declined to participate. Interviews took place 4–6 months after enrollment in the larger study. Procedures were approved by the Institutional Review Boards at New York University and two collaborating hospital sites. The larger study is described in more detail elsewhere ) and the mean HIV viral load level was substantial . All reported that a health care provider had recommended ART in the past. Half (50.0%) had symptoms of depression at a clinically significant level. Thus participants were diverse with respect to socio-demographic, health, and other background characteristics, in keeping with the sampling approach. A description of the psychometric characteristics of structured measures used to assess the sample are described elsewhere  have all these other assumptions of the drugs, the crime. All these different things, and it’s just a different form to me of racial profiling…Depending on what street you live on makes a big difference between how you’re going to be treated. Soon as [they] find out your address-it changes a lot of things.Further, we found participants reported they were likely to receive lower quality care based on their geographical location and its presumed relationship with race/ethnicity and social class background, especially related to the amount of time that providers spent with them. Marcus, a 46-year-old African American man diagnosed with HIV over six years ago, described his experiences with HIV care institutions as degrading and demoralizing. He understood the dehumanizing and anonymizing way he was treated as based on both his actual and presumed socio-demographic characteristics, all linked to where he lived, a borough in New York City:I think mostly it’s pains that mostly people of color go through. You know it’s a lot of pains. It’s a lot of rejection. Not understanding the person’s, you know, history or what that person’s been through, and trying to find someone that really cares to listen to that person. You don’t get much of that because they tell you, “I don’t have time because I have 50 other thousand people that have worse situations than you,” and so you walk out bitter. … So a lot of people—okay, a lot of African Americans —they are on that pre-judgment.We found healthcare settings were described as emitting “invisible” hostility that resulted in AABH-PLWH being denied individualized attention and treatment. This was exacerbated when participants felt they were perceived as less deserving of quality HIV care on the basis of overt racial/ethnic and class profiling. Darryl, a 60-year-old African American man diagnosed 17 years ago, who had never taken ART, summed up his past health care experiences:Thus while not all participants reported experiences of overt racial/ethnic and/or class-based discrimination on the part of individual staff in health care settings, they nonetheless pointed out “deeper” and more “invisible” experiences of being treated unfairly and as a member of multiple, mutually reinforcing dehumanized stereotyped categories – inequitable aspects of the larger health care environment that could be described as consistent with structural racism.We found the theme of medical distrust was pervasive and powerful, and this distrust had profound effects on engagement in HIV care and uptake of ART. Distrust manifested variously among participants as suspicions they would be “guinea pigs” subject to medical experimentation, or concerns that decisions made by individual healthcare providers were overly influenced by the financial motivations of pharmaceutical companies.cause of death of many PLWH in the early days of HIV treatment. This “legacy” of AZT has been passed down among AABH-PLWH through the decades, indicating, to some PLWH, at least, malicious intent on the part of the pharmaceutical industry, and serving as a warning about the newer antiretroviral medications.Further, distrust was linked to fears that the side effects patients often experience when taking ART – more common in the earlier formulations of the medications – are evidence of its toxicity, and to some, even a form of genocide. For many participants, this specific aspect of distrust of ART is directly linked to the memory, or historical memory, of AZT monotherapy, one of the earliest treatments for HIV prescribed in the late 1980’s, which, as noted above, was prescribed in high doses, leading to serious side effects, but with only limited efficacy. In fact, AZT was commonly cited as the Despite great medical advancements in the treatment of HIV and a significant reduction in side effects experienced by patients, we found a legacy of medical experimentation, non-consensual treatment, and the maltreatment of people of color in healthcare persists, and specific counter-narratives continue to circulate and remain important sources of information guiding individuals’ healthcare decisions. The side effects of HIV medications, in general, remained some of the most easily articulated manifestations of medical distrust among AABH-PLWH within the overall historical context of the memory of past medical exploitation of populations of color.Thus we found that a side effect was not always just a side effect. Indeed, for AABH-PLWH, ART side effects were experienced through a specific historical and cultural lens, often serving as a reminder of the individual’s location in an inequitable society. Indeed, we found ART side effects, or even just the fear of potential side effects, commonly produced major emotional barriers to ART initiation, continuation, and adherence.I believe that they do have a cure out there but it’s gonna be for those that are very rich. Like, I’m gonna tell you, I believe the government made this. And they made it for the less desirables. And they didn’t expect their own kids to wind up (getting) it. And it spreaded. I’m not trying to be prejudiced or anything but they made it for the Blacks, the Puerto Ricans and they made it for the Whites that they didn’t want there.Participants expressed a sense of vulnerability in relation to institutions they perceived as lacking concern for their well-being, or that, in some cases, which they felt sought to harm them. For some, this distrust was described as stemming from the historically documented medical exploitation of poor communities of color, especially poor African American/Black communities. For others, distrust of medical institutions was the result of an indefinable sense of wariness passed from generation to generation. Ramona is a 53-year-old African-American/Black woman who had frequently stopped and started HIV medications over the past 15 years since she was first diagnosed. She related a common, albeit highly disheartening, counter-narrative about an HIV/AIDS epidemic created and perpetuated by the government:So what they basically doing is experimenting. They don’t have it correct yet. That’s why they’ve made so many different types. Sometime it make me feel that it’s not really worth taking.For Ramona, distrust of HIV treatment and the notion of a cure being withheld from the community of “less desirables” were directly related to her personal decisions to interrupt ART and HIV care. Moreover, lack of knowledge and suspected malicious intent on the part of healthcare providers and medical institutions about the efficaciousness and potential dangers of ART contributed to her understanding of taking ART as a type of experimentation, as she noted below:They like to experiment and say, okay, I heard of, what you call them, clinical trial, that’s what clinical trials is, one big guinea pig. That’s for all those guinea pigs. I know I’m a guinea pig, everybody’s a guinea pig.Victoria, an African American woman in her 40’s who had never sought medical care for HIV, expressed similar concerns:I would say my population of people are against medicines because they hear the old AZT, you know, you get fat belly. And you get more sicker. That was my idea at first too you know. Yes, a lot of current information isn’t being put out there so they’re still living on the old regimen medicines, AZT and all these other medicines that really, really got you really sick because they was just, I guess, learning. So a lot of my peers that don’t wanna take the medicines, [it’s] because they don’t want the added side effects of it.Julio, a 50-year-old Puerto Rican man who had frequently interrupted ART due to concerns about side effects, referred to the history of AZT as an example of how gaps in medical knowledge shape social norms of HIV medications among AABH-PLWH in particular:I think it’s [social] class. I think some providers feel, they look down at the person. Not all, not all. I’ve had good providers, bad ones, but I feel like they [think they’re] better than [you], you know. “You come here for services from me? You know, who put you in that situation? You did.” You know what I’m saying? “Now you’re wasting my tax dollar,” you know what I’m saying? I can give you a perfect example. “No, I’m not giving you that med that’s too expensive.” Why not? Medicaid’s  paying for it or whatever…but the doctor feels he don’t want to give him that medicine because they’re in bed with the pharmaceutical companies because the provider also get a little incentive. [The pharmaceutical companies say], “Here’s a vacation doc. Here’s a couple hundred dollars, you know, just promote this.” And I, me with my own eyes seen it, like that, the medicine for the belly. I’m in my clinic with my doctor and here comes the representative of this medicine, coming in trying to push it on me.Moreover, Julio spoke extensively about the lack of trust he and his peers have in the information and financial motivations of medical institutions and pharmaceutical companies, which he believed have a disproportionate influence on already overburdened healthcare providers in economically depressed neighborhoods:We found participants were acutely aware of how structural racism and economic inequality take not only the form of outright discrimination or unintended micro-aggressions but, more importantly, operate as over-arching and invisible features of the healthcare industry. Yet in this context, and despite fear and distrust, we found participants were continually evaluating their health care needs, seeking services, trying medications (including ART in some cases), and engaging in health care. We found participants were emotionally torn between, or perhaps immobilized by, the desire to engage in health care and take ART, and their strong desires to avoid negative reactions received from, and elicited by, health care settings and encounters. Thus medical distrust often impeded, but did not necessarily preclude, involvement in health care.when it is right for (them)” was another common and potent theme. This desire for autonomy was often discussed in opposition to the experience of being pressured and even judged by health care providers, who, participants noted, pressed them to immediately begin ART after their initial HIV diagnosis, regardless of other life factors such as treatment anxiety, lack of emotional readiness, fear of stigma, substance use problems, or other health conditions. Moreover, the perceived privileging of medical expertise over the patient’s own knowledge, experience, and immediate concerns caused patients to feel excluded from the ART decision-making process, thereby undermining their sense of self-determination with respect to their health and their body. This contributed to a feeling that providers often doubted whether patients had the capacity to make decisions in their own best interest.We found the need among participants to make confident, informed decisions about initiating ART “Because [in] the emergency room you get Residents that come [in], so it’s like you’re a guinea pig. And it’s frustrating, especially when you know what’s going on with your body, and you’ve been sick, you know. You’ve been positive or have full-blown AIDS for a certain amount of time. And most people know their bodies. So when they go in, they know what to tell the doctor. But if you’re telling somebody new, they’re going to try something else. And like I said, and if you come from [where] I come from in [my neighborhood], they’re going to give you a hard time. The first thing they want you do is take a [drug test] which a lot of people don’t know. They have to tell you that that’s what they’re doing, and it has to be a reason why they’re doing it. So it’s like I said, you have to learn how to advocate for yourself.Marcus (described above) directly connected his social location as an African American/Black man living in government-supported housing for people with HIV to his negative experiences in medical systems:Marcus’s experiences led him to anticipate discrimination and paternalism in health care settings and to understand his provider’s suspicions that he was using illicit substances as an additional factor in denying him his autonomy. While Marcus’ narrative depicts in large part an Emergency Department following standard protocols to provide appropriate diagnosis and treatment planning, it also highlights the widely divergent lenses by which many AABH-PLWH and providers view these interactions, and the mismatch, in many cases, between patients’ needs and the institutional structures where they seek assistance.I feel some places just treat people like pushovers …just cause I’m Black. It’s like, ‘you’re Black,’ you know what I’m saying?… it’s like, [I’m] just treated a certain way all the time. I just get to the point where it’s like I don’t have a voice. I have to do this because they say so… I don’t own myself. Just occupying this, you know what I’m saying? Just using time or something for somebody else’s purpose.Similar to Marcus’ experience, Leon, also described above, felt he is treated as a “pushover” because of his race:All my doctors would beg me to take the medication. They wanted me to do DOT [Directly Observed Therapy], you know, come in, pick up the medication, and I ain't like that at all… I didn't like being told. I wanted my medicine when I wanted to take it, and you know. I want to do what I wanted to do.Subsequently, Leon decided that his best option was to completely disengage from medical care, in order to preserve his autonomy and dignity. Lawrence (described above) also reported feeling pressured by providers to initiate ART since his diagnosis. Indeed, participants described how health care providers rightly promote ART to their patients as their best chance to live longer and healthier lives, and to virtually eliminate the risk of transmitting HIV to others. However, as Lawrence noted:avoid conflict” with him, which Isaac feared would negatively affect his ability to receive treatment for his other medical concerns. For Isaac, it was necessary to cede a certain degree of autonomy in order to receive necessary medical care:Because I didn’t even want to have the conversation of them trying to convince me to do something that I didn’t want to do anyway. Because he was a relatively nice man and I didn’t want to have a conflict with him, because I had to use him for other medical issues as well. So I didn’t want to alienate the process of going to the doctor for my whole body. I might need him to give me some pills for anxiety or for my whatever I am having, my iron pills or may go to in for a colonoscopy and I didn’t want to have the conflict.Isaac was a 63-year-old African American man who had initiated ART, but who withheld his decision to then discontinue ART from his provider in order to “Marcus, Leon, Lawrence, and Isaac all described mechanisms through which their abilities to make autonomous decisions and indeed, control their bodies, was threatened as a result of their identities as low-income, African American/Black men. In the context of structural racism, and health care settings located in a context of structural racism, perceived pressure to initiate ART resonated strongly with participants’ collective knowledge of the history of medical maltreatment of people of color. As a result, patients reported viewing themselves as potential experimental subjects, and medical treatment was treated with suspicion and associated with non-consensual procedures. In this way, medical distrust and the need for autonomy were closely linked.And then that’s what [the doctor] just kept…drilling on that same issue. I’m like, does this guy know anything? … He needs to see the bigger picture here. If you want to help someone, like I said, you got to see the whole picture of what’s going on with this person and the reason why they have waited this long [to take ART]. There has got to be some other things that are going on that you’re not asking these questions. You’re focusing on one thing. It’s good but it’s bad at the same time because it’s not really motivating that person to take their medicine or to start taking medicine. I would walk out of here just as empty as I walked in here. I’m sorry.Within brief health care encounters, participants noted that ART was often prioritized over other concerns. As a result, medical care was characterized as typically lacking a focus on overall quality of life, and attending only minimally to participant’s co-occurring health and social issues. Gerard, a 53-year-old African American man, described feeling as though his provider was either unaware or uninterested in why he had waited so long to initiate ART, which served as a disincentive to initiate HIV medication for him:bigger picture” that providers often missed were participants’ co-occurring medical issues, which were often more burdensome to the patient than HIV. Sam, a 40-year-old Hispanic man, for example, avoided medical treatment for a staphylococcus infection. When he did eventually seek treatment, he experienced providers as ignoring the infection that brought him to the hospital, focusing instead on his decision not to take HIV medication, as he explained:I had not dealt with [the staph infection] before, and I was trying to cure it at home, you know. Doing my own medical cures, you know. Cause I didn’t wanna really go to the doctors and expose all my records and stuff. But it got worse and worse and worse. So I finally went. [But] they weren’t talking about the thing that I came there for. They were more focused on, oh, you’ve had HIV all along, and you don’t take medication, and you should be on pills, and I was like, …I don’t wanna see you anymore. I need somebody at the top. I’ve been dealing with (HIV) for longer than you’ve known me these past 20 hours, and whatever the occasion may be, I know what’s going on here. I need help with (the staph infection). Any questions about HIV, you need to ask me, I have the answers for you.For many participants, one piece of the “While we acknowledge that health care providers may have correctly identified a relationship between Sam’s untreated HIV and the staphylococcus infection, a lack of attention to what he considered his most pressing medical needs served as a source of frustration, and an impediment to his receiving care in a timely fashion, and further, did not appear to move him closer to a decision to initiate ART.Everybody just see the pill. Y’know what I mean? But I’m bigger than the pill. Y’know, the pill is within me, I guess [chuckles]. But the pill is a big thing, y’know what I mean, I don’t know, there’s some kind of way that human got it backwards in their minds, they see the pill as bigger than me.Rose, a 50-year-old African American/Black woman who viewed her own concerns as being subordinated to the imperative of ART initiation, expressed similar concerns to those of Gerard and Sam:Notably, throughout the study we found women in particular were likely to note that while the negative effects of HIV stigma on social relationships were asymmetrically felt by women, and while the disproportionate burden of childcare and other familial responsibilities fell to women, health care providers were often inattentive to these concerns, thus exacerbating what was already perceived to be a paternalistic relationship between patient and provider.feeling like a number,” “a guinea pig,” “a pushover,” or as smaller than “the pill,” participants routinely highlighted the ways that structural racism and its influence on medical settings, along with an overall lack of concern for the ways that social class and gender complicate concerns related to HIV care, appeared to contribute to an understanding among AABH-PLWH of their being seen as a problem in need of a solution, rather than as a “whole person” receiving high-quality medical care.Thus through describing experiences of “A substantial proportion of AABH-PLWH in the United States successfully engage in HIV care, take ART with good adherence, and achieve viral suppression – an important public health achievement . The preOn an institutional level, the effects of structural racism reverberate throughout strained and over-burdened health care systems, as is evident in the dehumanizing manner by which patients often feel treated by health care workers and staff in such settings. There is a growing awareness, in fact, of the structural foundations of health care dissatisfaction. Timmermans and Almeling (2009), for example, described depersonalization of health care and the effects of bureaucratic control as “pathologies” of modern medicine . SimilarPast research has demonstrated the negative effects of discrimination based on race, class, and gender in healthcare settings, especially as it relates to poor ART adherence , 60. We Similar to past studies , we founYet fear and medical distrust, even when prominent, do not necessarily eliminate willingness to participate in health care or medical research, as Westergaard and colleagues have noted . We founOne general limitation of this study is that its purposive sampling method may limit its generalizability to the population of AABH-PLWH as a whole. Yet purposive, rather than a random sampling method, is consistent with the goals of qualitative research, which aims for depth rather than breadth. Further, the sample selected included few younger AABH-PLWH, a gap that future studies on this topic can address. Last, we acknowledge that the primacy of race/ethnicity and social class in the results over other disadvantaged categories may have emerged, in part, from the larger study’s emphasis on this category over others such as gender.The present study yields a number of implications for clinical settings and health care and social service providers. The CRT approach highlights the notion that health care settings are located in a society characterized by structural racism and must adapt to that context. There is growing awareness of the importance of “structural competency” in the health care setting. Metzl and Hansen  argue thAABH-PLWH tend to be insufficiently engaged along the HIV care continuum and evidence worse health outcomes than their White peers. There is growing awareness that structural racism, that is, the macro-level systems that create inequities among racial/ethnic groups , has per


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