Friday, May 31, 2013

Nothing is funny to a psychiatrist...

...or to a clinical psychologist. This recent New Yorker cartoon makes a strong point about the potentially infantilizing effects of being medicated. But by suggesting that the goal of combined treatment (psychotherapy + medication) is being "happy," the cartoon is discordant with Freud's contention that the purpose of psychoanalysis is to transform uncommon misery into "common unhappiness." If the patient is "happy," why are they still in treatment? I like to think that a psychoanalyst would be more likely to see the patient's "happiness" as a medication effect (e.g., feeling more energized) and would thus want to titrate her off her meds and then get down to her core issues.

The cartoon made me wonder how many psychoanalysts also prescribe medication to their patients. It turns out that up to 90% of psychoanalysts also prescribe medication and that medication is used in about 30% of supervised training cases. From Gabbard (2005):

"The patient must be viewed simultaneously as a disturbed person and as a diseased central nervous system. The former view requires an empathic, subjective approach, whereas the latter demands an objective, medical model approach. The clinician must be able to shift between these two modes gracefully while remaining attuned to the impact of the shift on the patient" (p. 151).
Gabbard notes that patients sometimes feel like their doctors are "giving up on them" when they recommend medication. He also notes that clinicians and patients often disagree about the relative contributions of psychotherapy and medication. In my experience, patients are often too eager to attribute positive treatment gains to pharmacological effects. The psychological effects of medication are especially clear when patients report significant improvement within a day or two after starting SSRIs, or after taking homeopathic doses of their prescribed medications, or when they say that they "only take my Wellbutrin when I'm having a bad day."

Some quibbles: The doctor's chair is too far forward; his shoes are in the patient's peripheral vision and he should be completely out of view. (That way she will feel more free to say whatever comes to mind -- free associate -- without concern over his reactions.) There shouldn't be a painting in the patient's line of sight, either, because it will influence the free association. I do like how the facial tissues are just out of reach -- this isn't supportive therapy, bucko. And nice touch with the antimacassar.

From the excellent website of the American Psychoanalytic Association:

In psychoanalysis, the patient typically comes four times a week [!], lies on a couch, and attempts to communicate as openly and freely as possible, saying whatever comes to mind. These conditions create the analytic setting, which enables you to become more aware of aspects of your internal experience previously hidden. As you speak, hints of the roots of current difficulties that have been out of your awareness gradually begin to appear – in certain repetitive patterns of behavior, thought and emotion, in the subjects which you find hard to talk about, in the ways you relate to the analyst. The analyst helps to identify these patterns, and together you and the analyst refine your understanding of the patterns that limit you or cause you pain, and help you elaborate new and more productive ways of feeling, thinking and behaving. During the years [!] that an analysis takes place, you wrestle with these insights, going over them again and again with the analyst and experiencing them in your daily life, fantasies, and dreams. You and the analyst join in efforts not only to modify crippling life patterns and remove incapacitating symptoms, but also to expand your freedom to enjoy intimate relationships and professional and personal pursuits. Gradually, you will change in deep and meaningful ways; you may notice changes in your behavior, relationships and sense of self.

Thursday, May 30, 2013

The moral burden of war

Sebastian Junger, the author of A Perfect Storm, A Death in Belmont, and War, had a nice piece in the Washington Post, Friday, May 24, 2013.

Some excerpts:

Perhaps war is so obscene that even the people who supported it don’t want to hear the details or acknowledge their role. Soldiers face myriad challenges when they return home, but one of the most destructive is the sense that their country doesn’t quite realize that it — and not just the soldiers — went to war. The country approved, financed and justified war — and sent the soldiers to fight it. This is important because it returns the moral burden of war to its rightful place: with the entire nation. If a soldier inadvertently kills a civilian in Baghdad, we all helped kill that civilian. If a soldier loses his arm in Afghanistan, we all lost something.

The growing cultural gap between American society and our military is dangerous and unhealthy. The sense that war belongs exclusively to the soldiers and generals may be one of the most destructive expressions of this gap. Both sides are to blame. I know many soldiers who don’t want to be called heroes — a grotesquely misused word — or told that they did their duty; some don’t want to be thanked. Soldiers know all too well how much killing — mostly of civilians — goes on in war. Congratulations make them feel that people back home have no idea what happens when a human body encounters the machinery of war.

...the obscenity of war is not diminished when that conflict is righteous or necessary or noble. And when soldiers come home spiritually polluted by the killing that they committed, or even just witnessed, many hope that their country will share the moral responsibility of such a grave event.

Their country doesn’t. Liberals often say that it’s not their problem because they opposed the war. Conservatives tend to call soldiers “heroes” and pat them on the back. Neither response is honest or helpful. Neither addresses the epidemic of post-traumatic stress disorder afflicting our veterans. Rates of suicide, alcoholism, fatal car accidents and incarceration are far higher for veterans than for most of the civilian population. One study predicted that in the next decade 400,000 to 500,000 veterans will have criminal cases in the courts. Our collective avoidance of this problem is unjust and hypocritical. It is also going to be very costly.

Sebastian Junger, Combat Outpost Restrepo, Korengal Valley, Afghanistan

Civilians tend to do things that make them, not the veterans, feel better. Yellow ribbons and parades do little to help with the emotional aftermath of combat.


Typically, [tribal] warriors were welcomed home by their entire community and underwent rituals to spiritually cleanse them of the effect of killing. Otherwise, they were considered too polluted to be around women and children. Often there was a celebration in which the fighters described the battle in great, bloody detail. Every man knew he was fighting for his community, and every person in the community knew that their lives depended on these young men. These gatherings must have been enormously cathartic for both the fighters and the people they were defending.

End excerpts


Wednesday, May 29, 2013

During questioning, FBI kills suspect tied to Boston Marathon bombing

Some excerpts from the Wall Street Journal, Thursday, May 23, 2013.

ORLANDO, Fla.—One of the brothers accused of carrying out the Boston Marathon bombing is also now believed to have committed a grisly triple murder in 2011, U.S. law-enforcement officials said after a man believed to be his accomplice was gunned down here Wednesday by a federal agent who was questioning him.

Ibragim Todashev was shot dead at an Orlando apartment after he lunged at and cut a Federal Bureau of Investigation agent, who with two Massachusetts state troopers had been questioning him about the murders in Waltham, Mass., two law-enforcement officials said, citing preliminary reports from the scene. The agent was taken to the hospital with injuries that weren't life-threatening. The FBI said it was reviewing the incident.

The trail looked to have gone cold in the killings of Brendan Mess, 25, Erik Weissman, 31, and Raphael Teken, 37, whose throats were slashed on Sept. 11, 2011, in a Waltham apartment. Their bodies were found a day later, covered in marijuana and cash. No arrests were made, but the probe gained steam in recent weeks.

The FBI initially questioned Mr. Todashev weeks ago because he was a friend of Tamerlan's, the U.S. official said. He had been cooperative and canceled a planned trip to Russia, in part to continue voluntary interviews with the FBI, according to the official.


A friend, Umar Taramov, said he and his younger brother accompanied Mr. Todashev to meet investigators Tuesday but left because the meeting was lasting hours. He said his younger brother returned and was shocked to find Mr. Todashev had been shot.

"The Ibragim I know is a very normal guy," said Mr. Taramov. "This isn't someone who would have done something crazy."


Mr. Taramov said he wanted an explanation of what exactly transpired between investigators and Mr. Todashev. "They can say anything. The person is dead. Now they can blame him for anything," Mr. Taramov said.

End Excerpts

So, two FBI agents and two Mass. cops meet the friend of one of the Boston Marathon bombers in "an Orlando apartment." Not the nearest FBI office or a local police station. A safe house.

According to the story, after hours of "voluntary" questioning, his friends leave. Then the guy "lunges" at one of the FBI agents with a knife, inflicting non-life threatening injuries, and is shot dead by the agent he sliced.

At best, the Feds and the cops failed to search this guy and let him bring a knife to the interview. Or else they conducted the interview in an apartment in which knives were readily accessible. At worst, well -- it's just not cool to bring a guy in for questioning and then shoot him dead while he is in your custody. You're kinda supposed to be in control of the interview situation.

If you were the guy's father, you might even think that he was murdered.

Tuesday, May 28, 2013

Speaking of SIM-therapists...

Thanks to my friend Bruce who hipped me to this clip from George Lucas's THX 1138 (1971). That's Robert Duvall in the lead role.

Monday, May 27, 2013

Cognitive-bias modification (CBM)

A great article from The Economist, which has great science coverage. I don't know much about this CBM business, but I will look into it.

THE treatment, in the early 1880s, of an Austrian hysteric called Anna O is generally regarded as the beginning of talking-it-through as a form of therapy. But psychoanalysis, as this version of talk therapy became known, is an expensive procedure. Anna's doctor, Josef Breuer, is estimated to have spent over 1,000 hours with her.

Since then, things have improved. A typical course of a modern talk therapy, such as cognitive behavioural therapy, consists of 12-16 hour-long sessions and is a reasonably efficient way of treating conditions like depression and anxiety (hysteria is no longer a recognised diagnosis). Medication, too, can bring rapid change. Nevertheless, treating disorders of the psyche is still a hit-and-miss affair, and not everyone wishes to bare his soul or take mind-altering drugs to deal with his problems. A new kind of treatment may, though, mean he does not have to. Cognitive-bias modification (CBM) appears to be effective after only a few 15-minute sessions, and involves neither drugs nor the discussion of feelings. It does not even need a therapist. All it requires is sitting in front of a computer and using a program that subtly alters harmful thought patterns.

This simple approach has already been shown to work for anxiety and addictions, and is now being tested for alcohol abuse, post-traumatic-stress disorder and several other disturbances of the mind. It is causing great excitement among researchers. As Yair Bar-Haim, a psychologist at Tel Aviv University who has been experimenting with it on patients as diverse as children and soldiers, puts it, “It's not often that a new evidence-based treatment for a major psychopathology comes around.”

Don't talk about it, just do it

CBM is based on the idea that many psychological problems are caused by automatic, unconscious biases in thinking. People suffering from anxiety, for instance, may have what is known as an attentional bias towards threats: they are drawn irresistibly to things they perceive to be dangerous. Similar biases may affect memory and the interpretation of events. For example, if an acquaintance walks past without saying hello, it might mean either that he has ignored you or that he has not seen you. The anxious, according to the theory behind CBM, have a bias towards assuming the former and reacting accordingly.

The goal of CBM is to alter such biases, and doing so has proved surprisingly easy. A common way of debiasing attention is to show someone two words or pictures—one neutral and the other threatening—on a computer screen. In the case of social anxiety these might be a neutral face and a disgusted face. Presented with this choice, an anxious person instinctively focuses on the disgusted visage. The program, however, prods him to complete tasks involving the neutral picture, such as identifying letters that appear in its place on the screen. Repeating the procedure around a thousand times, over a total of two hours, changes the user's tendency to focus on the anxious face. That change is then carried into the wider world.

Emily Holmes of Oxford University, who studies the use of CBM for depression, describes the process as like administering a cognitive vaccine. When challenged by reality in the form of, say, the unobservant friend, the recipient of the vaccine finds he is inoculated against inappropriate anxiety.
In a recent study of social anxiety by Norman Schmidt of Florida State University and his colleagues, which involved 36 volunteers who had been diagnosed with anxiety, half underwent eight short sessions of CBM and the rest were put in a control group and had no treatment. At the end of the study, a majority of the CBM volunteers no longer seemed anxious, whereas in the control group only 11% had shed their anxiety. Although it was only a small trial, these results compare favourably with those of existing treatments. An examination of standard talk therapy carried out in 2004, for instance, found that half of patients had a clinically significant reduction in symptoms. Trials of medications have similar success rates.

The latest research, which is on a larger scale and is due to be published this month in Psychological Science, tackles alcohol addiction. Past work has shown that many addicts have an approach bias for alcohol—in other words, they experience a physical pull towards it. (Arachnophobia, a form of this bias that is familiar to many people, works in the opposite way: if they encounter a spider, they recoil.)

This study, conducted by Reinout Wiers of the University of Amsterdam and his colleagues, attempted to correct the approach bias to alcohol with CBM. The 214 participants received either a standard addiction treatment—a form of talk therapy—or the standard treatment plus four 15-minute sessions of CBM. In the first group, 41% of participants were abstinent a year later; in the second, 54%. That is not a cure for alcoholism, but it is a significant improvement on talk therapy alone.
Many other researchers are now exploring CBM. A team at Harvard, led by Richard McNally, is seeking volunteers for a month-long programme that will use smart-phones to assess the technique's effect on anxiety. And Dr Bar-Haim and his team are examining possible connections between cognitive biases and post-traumatic-stress disorder in the American and Israeli armies.

Not all disorders are amenable to CBM. One study, by Hannah Reese (also at Harvard) and her colleagues, showed that it is ineffective in countering arachnophobia (perhaps not surprising, since this may be an evolved response, rather than an acquired one). Moreover, Dr Wiers found that the approach bias towards alcohol is present in only about half of the drinkers he studies. He hypothesises that for the others, drinking is less about automatic impulses and more about making a conscious decision. In such cases CBM is unlikely to work.

Colin MacLeod of the University of Western Australia, one of the pioneers of the technique, thinks CBM is not quite ready for general use. He would like to see it go through some large, long-term, randomised clinical trials of the sort that would be needed if it were a drug, rather than a behavioural therapy. Nevertheless, CBM does look extremely promising, if only because it offers a way out for those whose answer to the question, “Do you want to talk about it?” is a resounding “No”.

Sunday, May 26, 2013

Lincoln's Second Inaugural Address

This is well worth committing to memory and reciting weekly.


AT this second appearing to take the oath of the Presidential office there is less occasion for an extended address than there was at the first. Then a statement somewhat in detail of a course to be pursued seemed fitting and proper. Now, at the expiration of four years, during which public declarations have been constantly called forth on every point and phase of the great contest which still absorbs the attention and engrosses the energies of the nation, little that is new could be presented. The progress of our arms, upon which all else chiefly depends, is as well known to the public as to myself, and it is, I trust, reasonably satisfactory and encouraging to all. With high hope for the future, no prediction in regard to it is ventured.
On the occasion corresponding to this four years ago all thoughts were anxiously directed to an impending civil war. All dreaded it, all sought to avert it. While the inaugural address was being delivered from this place, devoted altogether to saving the Union without war, insurgent agents were in the city seeking to destroy it without war—seeking to dissolve the Union and divide effects by negotiation. Both parties deprecated war, but one of them would make war rather than let the nation survive, and the other would accept war rather than let it perish, and the war came.
One-eighth of the whole population were colored slaves, not distributed generally over the Union, but localized in the southern part of it. These slaves constituted a peculiar and powerful interest. All knew that this interest was somehow the cause of the war. To strengthen, perpetuate, and extend this interest was the object for which the insurgents would rend the Union even by war, while the Government claimed no right to do more than to restrict the territorial enlargement of it. Neither party expected for the war the magnitude or the duration which it has already attained. Neither anticipated that the cause of the conflict might cease with or even before the conflict itself should cease. Each looked for an easier triumph, and a result less fundamental and astounding. Both read the same Bible and pray to the same God, and each invokes His aid against the other. It may seem strange that any men should dare to ask a just God's assistance in wringing their bread from the sweat of other men's faces, but let us judge not, that we be not judged. The prayers of both could not be answered. That of neither has been answered fully. The Almighty has His own purposes. "Woe unto the world because of offenses; for it must needs be that offenses come, but woe to that man by whom the offense cometh." If we shall suppose that American slavery is one of those offenses which, in the providence of God, must needs come, but which, having continued through His appointed time, He now wills to remove, and that He gives to both North and South this terrible war as the woe due to those by whom the offense came, shall we discern therein any departure from those divine attributes which the believers in a living God always ascribe to Him? Fondly do we hope, fervently do we pray, that this mighty scourge of war may speedily pass away. Yet, if God wills that it continue until all the wealth piled by the bondsman's two hundred and fifty years of unrequited toil shall be sunk, and until every drop of blood drawn with the lash shall be paid by another drawn with the sword, as was said three thousand years ago, so still it must be said "the judgments of the Lord are true and righteous altogether."
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.


Saturday, May 25, 2013

Soave Sia Il Vento -- Mozart

From a brief piece by Alexander McCall Smith:

"[T]here is one piece of music above all others that inspires me in my work and that I listen to a great deal when writing. This is the trio "Soave Sia Il Vento" from Mozart's "Così Fan Tutte."
It is a morally disturbing opera. Two young women are saying goodbye to lovers who are about to deceive them in a way that will reveal the women's own weakness. Nasty and cynical things are about to happen, yet Mozart graces a grubby tale of deception and inconstancy with a score that soars effortlessly above the libretto's limitations.

Not only is this one of the most beautiful pieces of music ever composed, but the words are extraordinarily peaceful, generous and resolved. "On your voyage, may the winds be gentle; may the waves be calm; may all the elements respond to your desires…" What more can we wish anyone setting off on life's journey? I listen to this several times a day; I never tire of it. It is music suffused with the greatest possible sympathy and humanity. It expresses what I want to feel about the world. It is the deepest truth."

Three minutes of peace and beauty, from Mozart's Cosi Fan Tutte:

Friday, May 24, 2013

How to Fix College (with a Dress Code?)

Harvey Mansfield, professor of government at Harvard, usually has something interesting to say. This article isn't his finest hour, but it does contain a noteworthy paragraph:

Bowdoin’s curriculum lacks the academic standards of excellence that conservatives mostly and mainly defend in academia with little or no help these days from liberals. It is conservatives who deplore and resist the brazen politicization of the classroom, the loss of the great books, indeed the disregard of greatness in general, the corruption of grade inflation, the cheap satisfactions of trendiness, the mess of sexual license, the distractions of ideology, the aggrandizement and servility of administrators, the pretense and dissembling of affirmative action, the unmanly advice of psychologists, the partisan nonsense of professional associations, and the unseemly subservience everywhere to student opinion.

As you can tell from this blog, there is at least one psychologist standing who believes passionately in the great books. Naturally, because it is my ox being gored, I would like to know just what "unmanly advice" he supposes that psychologists are providing. I don't think that he is referring to the fact that most American psychologists are women, nor do I believe that he is asserting that psychologists are necessarily wimps. He is faulting some specific, psychologically-informed policies, and I just wish I knew what they were. If he is referring to the ill-starred self-esteem and "social promotion" movements, then I agree with him.

Former classics professor and historian Victor Davis Hanson also indicts psychology in the destruction of American education:

The K-12 public education system is essentially wrecked. No longer can any professor expect an incoming college freshman to know what Okinawa, John Quincy Adams, Shiloh, the Parthenon, the Reformation, John Locke, the Second Amendment, or the Pythagorean Theorem is. An entire American culture, the West itself, its ideas and experiences, have simply vanished on the altar of therapy.

The point is, I gather, that rather than expect students to learn that which is worth knowing, we are overly concerned with making sure that they feel good about themselves (and that involves giving them ludicrously inflated grades). Hanson has a remedy for the state of American education, one that is well worth contemplating:

Four years of high-school Latin would dramatically arrest the decline in American education. In particular, such instruction would do more for minority youths than all the ‘role model’ diversity sermons on Harriet Tubman, Malcolm X, Montezuma, and Caesar Chavez put together. Nothing so enriches the vocabulary, so instructs about English grammar and syntax, so creates a discipline of the mind, an elegance of expression, and serves as a gateway to the thinking and values of Western civilization as mastery of a page of Virgil or Livy (except perhaps Sophocles’s Antigone in Greek or Thucydides’ dialogue at Melos). After some 20 years of teaching mostly minority youth Greek, Latin, and ancient history and literature in translation (1984-2004), I came to the unfortunate conclusion that ethnic studies, women studies—indeed, anything “studies”— were perhaps the fruits of some evil plot dreamed up by illiberal white separatists to ensure that poor minority students in the public schools and universities were offered only a third-rate education.

If you complete four years of high school Latin, there is no doubt that you have learned the most important academic skill of all -- How to Study.

Here's a link to a great report on "How to Fix College," with some of the highlights here:
Will Fitzhugh, Founder, The Concord Review“It would be great and interesting for all concerned if every college student had to present a one-hour talk on some topic on which he had recently done research…”

Joseph Epstein, Author, most recently of Essays in Biography
“The condition of undergraduate education strikes me as so sad, so wildly screwed up, and so heavily screened off from reality that no single sweeping reform is likely to help. A number of small reforms, though, might make for a beginning. Two I suggest are a dress code and a rigid protocol of address. I suggest these not for students, but for faculty…”

George Dent, Professor of Law, Case Western Reserve University School of Law
“Big-time sports are corrupting higher education. They should be abolished…”

Andrew Gillen, Research Director, Education Sector
“As college costs continually rise, students are increasingly concerned with the impact attending college will have on future jobs and earnings. Yet virtually no data exist to help inform this important decision…”

Charles Mitchell,
Vice President and Chief Operating Officer, Commonwealth Foundation
“Five words: mandatory physical labor, every student…”

Charles Murray
, W.H. Brady Scholar, American Enterprise Institute
“Pass a federal law that no teacher in a college or university that receives federal funds shall be allowed to award an A to more than 7 percent of the students in any course…”

Bradley C. S. Watson
, Philip M. McKenna Professor of Politics; Co-Director, Center for Political and Economic Thought, Saint Vincent College
“Rely on primary sources exclusively. This can be done readily in most social sciences and humanities disciplines. Even most natural science disciplines could assign more primary source readings to good effect…”
Tom Wolfe
, Ph.D., American Studies, Yale, 1957; Author, Back to Blood
“1. Cut undergraduate education from four years to two…
2. Limit the curriculum, over the two years, to remedial education and core subjects…
3. Male students will have a dress code requiring long-sleeved cotton shirts (ties optional) and conventionally cut jackets—e.g., no jacket collars wider than the lapels—whenever they are on campus. Female students will abide by a dress code that, without saying so, makes it impossible to dress in the currently highly fashionable (among young women) slut style.
If the students complain that these codes make them look different from most other people their age, the reply is, ‘Now you’re catching on.’”

See the full article at the National Association of Scholars website.

Thursday, May 23, 2013

The DoD wants to use Sims to screen for mental disorders?

The basic idea is this: Soldiers will interact with a computer simulation of a therapist, which has been programmed to encourage the interaction (with well-timed "uh-huhs", etc.). While the soldier is speaking to the sim-therapist, the computer records their body movements, eye gaze, vocal tone, etc. Then, the sample of the soldier's "body language" is compared to a database of body language prototypes for various patient groups (e.g., combat traumatized, depressed, suicidal, psychotic) and a normal prototype. Soldier's whose body language is similiar to one of the patient prototypes is "red-flagged" and follow-up is conducted with a human clinician.

It is a very interesting idea, but only as a screening device (before the soldiers has seen a clinician), or as a backstop for incompetent mental health clinicians. The suggestion that this technique will yield an "objective measure" (like a blood sample) to inform diagnosis is poppycock. It could possibly distinguish distressed from nondistressed people, but no better than those people could do themselves. What would be great if it could discern suicidal intent in non-disclosing people. If it could, it could be used prior to discharge from psychiatric hospitals. But I won't wait up nights for those findings to come in.


Under the wide screen where Ellie's image sits, there are three devices. A video camera tracks facial expressions of the person sitting opposite. A movement sensor — Microsoft Kinect — tracks the person's gestures, fidgeting and other movements. A microphone records every inflection and tone in his or her voice. The point, Rizzo explains, is to analyze in almost microscopic detail the way people talk and move — to read their body language.

"We can look at the position of the head, the eye gaze," Rizzo says. Does the head tilt? Does it lean forward? Is it static and fixed?" In fact, Ellie tracks and analyzes around 60 different features — various body and facial movements, and different aspects of the voice.

The theory of all this is that a detailed analysis of those movements and vocal features can give us new insights into people who are struggling with emotional issues. The body, face and voice express things that words sometimes obscure.

"You know, people are in a constant state of impression management," Rizzo says. "They've got their true self and the self that they want to project to the world. And we know that the body displays things that sometimes people try to keep contained."

So, as Ellie gets the person in front of her to ruminate about when they were happy and when they were sad, the machines below her screen take measurements, cataloging how much the person smiles and for how long, how often they touch their head.

Morency says the machines record 30 measurements per second, or "about 1,800 measurements per minute." Literally every wince, pause and verbal stumble is captured and later analyzed.

Ellie was originally commissioned by the U.S. Department of Defense. After all of the deployment in Iraq and Afghanistan, the military was seeing a lot of suicides and wanted to find a way to help military therapists stop them. Soldiers don't always like to confess that they're having problems, but maybe their bodies would say what their words wouldn't.

This is why Ellie is being programmed to produce a report after each of her sessions — it's a kind of visual representation of the 60 different movements she tracks.
"For each indicator," Morency explains, "we will display three things." First, the report will show the physical behavior of the person Ellie just interviewed, tallying how many times he or she smiled, for instance, and for how long. Then the report will show how much depressed people typically smile, and finally how much healthy people typically smile. Essentially it's a visualization of the person's behavior compared with a population of depressed and nondepressed people.

If the person's physical behaviors are similar to someone who's depressed, then the person will be flagged.

The idea here is not for Ellie to actually diagnose people and replace trained therapists. She's just there to offer insight to therapists, Morency says, by providing some objective measurements.
"Think about it as a blood sample," he says. "You send a blood sample to the lab and you get the result. The [people] doing the diagnosis [are] still the clinicians, but they use these objective measures to make the diagnosis."


But Skip Rizzo, the psychologist working on Ellie, genuinely believes these technologies will eventually change the field of mental health. One of the central problems with humans, he says, is that they bring their own biases to whatever they encounter, and those biases often make it hard for them to see what's directly in front of them.

"You can get training to be a health care provider or psychologist," he says, "and try to put those things on hold and be very objective. But it's still a challenge. It's always going to be biased by experience. What computers [like Ellie] offer is the ability to look at massive amounts of data and begin to look at patterns, and that, I think, far outstrips the mere mortal brain."

This summer, Ellie is being tested. She's scheduled to sit down with dozens of veterans from Iraq and Afghanistan.

She'll ask them about their lives, encourage them to open up.

Then, silently, Ellie will measure their answers.

End Excerpts

Wednesday, May 22, 2013

Beach reading for college undergraduates (and everyone else)

This report from the National Association of Scholars quite effectively shows how a fine idea (common summer readings for undergraduates) has misfired in practice (by selecting ideological and trendy titles instead of more worthy books).

The last few pages of the report are what I am hoping you will look at -- the NAS provides a list of 37 books that they feel are actually "appropriate for any college common book program." I don't have a problem with any of the books on their list and I will confess that I haven't read them all but I am certainly looking forward to tackling Darwin's The Voyage of the Beagle and Dickens' American Notes for General Circulation, thanks to their recommendation. I would also like to obtain a decent copy of Stevenson's Eight Years of Trouble in Samoa.

As for beach reading for college undergraduates, two of the titles on the NAS list stand out, I heartily recommend both of them: Tom Wolfe's The Right Stuff, and Robert Penn Warren's All the King's Men. The former examines the heroic, and the latter, well, the true nature of politics.

And for when it's raining while you're at the beach, take the time and carefully read these other NAS recommendations: The Book of Job and The Book of Ecclesiastes (King James Version, of course). You will get tremendous bang for your buck (great wisdom per word ratio). After you finish the KJV, this translation of Job by Stephen Mitchell looks pretty interesting.

Tuesday, May 21, 2013

The Lobotomist

This is a great documentary (and a good book by Jack el-Hai). The young, willing neurosurgeon who collaborated with Walter Freeman was James Watts, a graduate of Virginia Military Institute, who later performed the lobotomy on Rosemary Kennedy, JFK's sister.


Monday, May 20, 2013

The Lethality of Loneliness

This is one of the best psychology-related magazine articles that I have encountered in a long while. It is well worth reading by anyone interested in the field. The scope is remarkable: from Frieda Fromm-Reichmann to the biology of stress to evolutionary psychology to behavioral genetics to MRI studies to Romanian orphans to Harlow's and Suomi's monkeys.

The article does appear in The New Republic, however, so there is some pointless political partisanship added at the end. Science is one thing and public policy is another. Be aware that the findings collectively presented in this article could just as readily support a policy of parental licensing rather than early pre-school interventions (which, despite what it says in the article, don't work).

Some excerpts (but read the whole article):

"To the degree that loneliness has been treated as a matter of public concern in the past, it has generally been seen as a social problem—the product of an excessively conformist culture or of a breakdown in social norms. Nowadays, though, loneliness is a public health crisis. The standard U.S. questionnaire, the UCLA Loneliness Scale [take it!], asks 20 questions that run variations on the theme of closeness—“How often do you feel close to people?” and so on. As many as 30 percent of Americans don't feel close to people at a given time.


Cole figured that a man who’d hide behind a false identity was probably more sensitive than others to the pain of rejection. His temperament would be more tightly wound, and his stress-response system would be the kind that “fires responses and fires ’em harder.” His heart would beat faster, stress hormones would flood his body, his tissues would swell up, and white blood cells would swarm out to protect him against assault. If this state of inflamed arousal subsided quickly, it would be harmless. But if the man stayed on high alert for years at a time, then his blood pressure would rise, and the part of his immune system that fends off smaller, subtler threats, like viruses, would not do its job.
And he was right. The social experience that most reliably predicted whether an HIV-positive gay man would die quickly, Cole found, was whether or not he was in the closet. Closeted men infected with HIV died an average of two to three years earlier than out men


[N]atural selection favored people who needed people. Humans are vastly more social than most other mammals, even most primates, and to develop what neuroscientists call our social brain, we had to be good at cooperating. To raise our children, with their slow-maturing cerebral cortexes, we needed help from the tribe. To stoke the fires that cooked the meat that gave us the protein that sustained our calorically greedy gray matter, we had to organize night watches. But compared with our predators, we were small and weak. They came after us with swift strides. We ran in a comparative waddle.

So what would happen if one of us wandered off from her little band, or got kicked out of it because she’d slacked off or been caught stealing? She’d find herself alone on the savanna, a fine treat for a bunch of lions. She’d be exposed to attacks from marauders. If her nervous system went into overdrive at perceiving her isolation, well, that would have just sent her scurrying home. Cacioppo thinks we’re hardwired to find life unpleasant outside the safety of trusted friends and family.


A famous experiment helps explain why rejection makes us flinch. It was conducted more than a decade ago by Naomi Eisenberger, a social psychologist at UCLA, along with her colleagues. People were brought one-by-one into the lab to play a multiplayer online game called “Cyberball” that involved tossing a ball back and forth with two other “people,” who weren’t actually people at all, but a computer program. “They” played nicely with the real person for a while, then proceeded to ignore her, throwing the ball only to each other. Functional magnetic resonance imaging scans showed that the experience of being snubbed lit up a part of the subjects’ brains (the dorsal anterior cingulate cortex) that also lights up when the body feels physical pain.
Put an orphan in foster care, and his brain will repair its missing connections. Teach a lonely person to respond to others without fear and paranoia, and over time, her body will make fewer stress hormones and get less sick from them. Care for a pet or start believing in a supernatural being and your score on the UCLA Loneliness Scale will go down. Even an act as simple as joining an athletic team or a church can lead to what Cole calls “molecular remodeling.” “One message I take away from this is, ‘Hey, it’s not just early life that counts,’ ” he says. “We have to choose our life well.”"
End excerpts
 Sorry to always be a downer, but there are biological constraints to human resilience. The Romanian orphans who had suffered deprivation for more than two years rarely showed significant recovery from the experience (foster care didn't help). And I don't think that believe people can simply choose to "start believing in a supernatural being."
I do think that it is madness to propose that the proper response to children being raised without fathers is to increase the subsidizing of single motherhood ("universal pre-school" is an example of this). If you subsidize an activity, you will get more of it, not less of it.


Sunday, May 19, 2013

Untitled poem by Stephen Crane

Wanderer above the Sea of Fog, Caspar David Friedrich (1818)

A man said to the universe:
"Sir I exist!"
"However," replied the universe,
"The fact has not created in me
A sense of obligation."

Stephen Crane (1871-1900)

If William Blake had been an existentialist he might have produced the poems of Stephen Crane.

By the way, The Red Badge of Courage is worth re-reading as an adult, even if they tried to ruin it for you in 7th grade English.

Take an hour right now and read Crane's short story, The Open Boat, which he wrote after having survived a shipwreck.

Saturday, May 18, 2013

Saturday music -- Like a Rolling Stone (Bob Dylan, 1965)

Not the most creative video on YouTube, but the song doesn't need visuals.

Once upon a time you dressed so fine
You threw the bums a dime in your prime, didn't you?
People'd call, say, "Beware doll, you're bound to fall"
You thought they were all kiddin' you
You used to laugh about
Everybody that was hangin' out
Now you don't talk so loud
Now you don't seem so proud
About having to be scrounging for your next meal.

How does it feel
How does it feel
To be without a home
Like a complete unknown
Like a rolling stone?

You've gone to the finest school all right, Miss Lonely
But you know you only used to get juiced in it
And nobody has ever taught you how to live on the street
And now you find out you're gonna have to get used to it
You said you'd never compromise
With the mystery tramp, but know you realize
He's not selling any alibis
As you stare into the vacuum of his eyes
And say do you want to make a deal?

How does it feel
How does it feel
To be on your own
With no direction home
Like a complete unknown
Like a rolling stone?

You never turned around to see the frowns on the jugglers and the clowns
When they all come down and did tricks for you
You never understood that it ain't no good
You shouldn't let other people get your kicks for you
You used to ride on the chrome horse with your diplomat
Who carried on his shoulder a Siamese cat
Ain't it hard when you discover that
He really wasn't where it's at
After he took from you everything he could steal.

How does it feel
How does it feel
To be on your own
With no direction home
Like a complete unknown
Like a rolling stone?

Princess on the steeple and all the pretty people
They're drinkin', thinkin' that they got it made
Exchanging all kinds of precious gifts and things
But you'd better lift your diamond ring, you'd better pawn it babe
You used to be so amused
At Napoleon in rags and the language that he used
Go to him now, he calls you, you can't refuse
When you ain't got nothing, you got nothing to lose
You're invisible now, you got no secrets to conceal.

How does it feel
How does it feel
To be on your own
With no direction home
Like a complete unknown
Like a rolling stone?

Friday, May 17, 2013

Weekend Reading -- Josiah Bunting

Josiah Bunting is the former headmaster of Lawrenceville, the former President of Hampden-Sydney, and the former Superintendent of his alma mater, VMI (Virginia Military Institute). Bunting was the VMI Superintendent who oversaw the integration of women into the Corps of Cadets.

1. An Education for Our Time. This book was published in the wake of the Clinton-Lewinsky scandal. The question posed by the book is central to the survival of the Republic -- where do we find and develop leaders of character? The book consists of a series of imagined letters from a Silicon Valley billionaire to his lawyer. The letters detail the plans for an ideal new college: where it should be located, who should teach there, what should be taught, who should be invited to learn there. You don't have to agree with the entire plan (e.g., every student must serve one year enlisted service in the Army) in order to find much worth thinking about in this book. It could even help you design your own lifelong learning plan. Here is an interesting, critical review of the book, from a Catholic perspective.

2. All Loves Excelling. The setting of this novel is a New England prep school. The villians are the careerist parents who have foresworn education for credentialing and marketing. The victim is a heroic, "perfect," teenaged girl slowly dying of anorexia. (It might be more correct to say, "being murdered slowly by means of anorexia.") Not the prep school life I recall, where overt striving was considered, well, lame. O tempora! O mores!

3. The Lionheads. A very different novel of the Vietnam War, about staff officers, by a former Vietnam staff officer. An essential book to help understand the human cost of military plans, and how plans, even those initiated for the worst reasons (e.g., to impress a visiting superior), take on a life of their own.


4. Ulysses S. Grant. I haven't read this one yet (have been waiting, in vain, apparently, for it to come out in paperback). But this series on the American Presidents is excellent and brief biographies are a special favorite of mine. I will discuss Paul Johnson's excellent brief biographies of Socrates, Churchill, and Napolean in another post.

Thursday, May 16, 2013

VIA Character Strengths -- Free online test

When I learned how to administer, score, and interpret psychological tests, my supervisors insisted that I never give a test that I hadn't already taken myself. It is one thing to assure a patient that completing the 567 items on the MMPI-2 will be worth their time and effort; it is another to take the test yourself. I once had a supervisor, a psychiatrist, who always sampled the drugs that he would prescribe to patients, so he could experience the side effects for himself. When patients complained, "You don't know what it's like to be on these drugs!" he could placidly reply, "Yes, I do." Well, I know what it's like to complete the MMPI-2, and the Rorschach, and the WAIS-III, etc.

"This is not a Rorschach Inkblot"

The VIA Character Strengths survey might be the least iatrogenic of all psychological tests. Everything said about you is positive. You can take it here. (Be sure not to pay for any of the reports -- the free version is sufficient).

The idea is to identify your existing strengths and to capitalize on them. Think of 5 ways you use each of your Top 5 strengths (write those down). Then think of 5 new ways you could employ those strengths but are not currently. That yields a 25-point behavioral action plan. Then, and most importantly, start doing those new things.

For example, if your Number One strength is Love of Learning (as mine is), then you might plan to enroll in a class of some kind or arrange an informal apprenticeship with someone who has a skill you wish to develop yourself.

At the risk of iatrogenic injury, I find it useful to look at the Bottom 5 strengths too. Doing so might give you some ideas about how you might moderate the behaviors associated with them. For example, if your Bottom strength is Modesty, you might want to try spending more time celebrating other people's accomplishments and less time trumpeting your own. Modesty will probably remain one of your lower traits, but you might become a bit less obnoxious.



Wednesday, May 15, 2013

Dr. Joyce Brothers is dead

Dr. Joyce Brothers wins $64,000 for boxing expertise

October 27, 1957
Psychologist Dr. Joyce Brothers put her boxing trivia to the test and came away with $64,000 on October 27, 1957. Brothers, who was appearing on the game show The $64,000 Challenge, took the top prize, competing against a team of seven boxers on boxing lore. This was her second time winning the program’s top prize—two years earlier she had claimed her first victory (when the show was called The $64,000 Question), also on the subject of boxing.

Brothers’ winning appearance not only garnered her a substantial prize, but also sparked her career as a talk-show psychologist. After her appearance on Challenge, Brothers was picked to co-host WATV’s show, Sports Showcase. In 1958, NBC offered Brothers her own talk show, The Dr. Joyce Brothers Show. The show, which counseled viewers on childrearing, marriage, and sex, was an instant success and soon became syndicated nationally. Brothers soon became a ubiquitous media presence offering her psychological expertise on numerous talk shows and often appearing as a celebrity guest on a variety of game shows.

In 1963, Brothers began writing a monthly column for Good Housekeeping. She also wrote a daily column that at its height was published in more than 350 newspapers, and has written several books, including What Every Woman Should know About Men (1982) and How to Get Whatever You Want Out of Life (1978). Her most personal and popular work was Widow (1990), which described Brothers’ emotional journey after the death of her husband in 1989 after thirty-nine years of marriage.

What isn't mentioned above is that she presented herself as an expert on boxing because she noticed that the show liked to cast "contrast" contestants, e.g., the butcher who is an expert on classical music. So what better topic area for a "lady psychologist" than boxing? The kicker is that she knew relatively little about boxing prior to being selected for the show. She studied up on it and quickly learned more about the sport and its history than the seven boxing experts she contended against. Having had a minor brush with a trivia show myself, I hugely admire her chutzpah.

[Emphasizing contrasts is a very useful tip, by the way: the football linebacker who practices Japanese flower arranging is going to stand out more in college or graduate school admissions than a football linebacker who is also an all-state wrestler. Think about your contrasts and present yourself accordingly. The (erroneous) impression that people get when they see that you can do two entirely different things is that you can do anything.]

Dr. Joyce Brothers was the "face of psychology" when I was a kid. Unfortunately, nowadays all we have are Dr. Phil (who actually used to be a licensed psychologist) and Dr. Laura (who isn't a psychologist; her Ph.D. is in physiology but she used to be a Marriage and Family Therapist).

Well, I still prefer those two entertainers to the world's most famous psychiatrist and the world's most famous aspiring neuroscientist.

Tuesday, May 14, 2013

Lost in Medication


This piece by psychiatry resident Sarah Mourra appeared in The Atlantic on May 10, 2013.

Begin Excerpt

"In many places psychiatry has become a biological enterprise, with some psychiatrists even introducing themselves as "psychopharmacologists." In no other specialty does a physician define themselves by the medication that they use. As one of my psychiatry professors once commented, "I have never met an oncologist who says "I'm an onco-pharmacologist." Increasingly, we are convinced that medications are what make patients better -- and that if only they would stay on them, if only they would take them as we have prescribed them, if only they were on the right one or the right dose -- they would get better.
In reality the process of getting better is much more complicated. Medications can play a large role, but other factors are enormously important -- environment, sense of purpose and meaning, the person's perception of their illness, and their relationship with the people who treat them. Studies have shown that patients taking placebo who have a good relationship with their psychiatrist have better outcomes than patients taking the active drug who do not have that strong personal connection. In the outpatient setting, a well-trained psychiatrist will follow what's called the biopsychosocial treatment model -- which values the biological, psychological, and social aspects of a person in considering their treatment -- and consider these other parts of the patient's healing process, in addition to medication."

End Excerpt

Let's stop there for a moment. First of all, check out the Results section of the abstract that she linked to (Mckay, Imel, & Wampold, 2006. Psychiatrist effects in the psychopharmacological treatment of depression. Journal of Affective Disorders):

"The proportion of variance in the BDI scores due to medication was 3.4% (p < .05), while the proportion of variance in BDI scores due to psychiatrists was 9.1% (p < .05). The proportion of variance in the HAM-D scores due to medication was 5.9% (p < .05), while the proportion of variance in HAM-D scores due to psychiatrist was 6.7% (p = .053). Therefore, the psychiatrist effects were greater than the treatment effects."
This is data from a randomized double-blind placebo controlled clinical trial of an antidepressant. The psychiatrists were handing out meds to depressed patients, giving placebos to some and active drugs to others. What is stunning to most people is that the degree of your recovery from depression (as measured by BDI and HAM-D scores) was affected more by which psychiatrist you happened to be treated by than whether he or she gave you "real" or "fake" drugs. However, this study (don't you love how we always write, "studies have shown" and then we only cite one study to support our statement?) doesn't say anything about "strong personal connections" between psychiatrists and patients.

For the most part, the patient encounters in this study consisted of the standard "15 minute med checks." Thus there was scant opportunity to build the "strong personal connections" that Dr. Mourra believes were formed, and which she believes explain the findings. But the quality of the "therapeutic alliance" between doctor and patient was not measured in this study. Therefore, it is just as possible that other factors, also not measured by the researchers, played a role, e.g., whether diplomas and certificates were prominently displayed in the doctor's office, whether or not a male psychiatrist wears a tie, the quality of the magazines in the waiting room, etc. You can't just add this study to the ample literature that shows that therapeutic alliance is the most important predictor of psychotherapy outcome (see here, and here, for recent examples).

So, yes, it matters which psychiatrist you happen to see. Some psychiatrists seem to be more effective than others, and their patients tend to do better whether or not the patient is receiving active or placebo medication. But the reason for this is not necessarily because some psychiatrists have formed "strong personal connections" with their patients while others did not. It could be that some of the less effective psychiatrists were non-native English speakers.


"Now do you understand why you stay awake all night, horrified that you are wasting your life?"

Continue Excerpts

"Often under pressure from insurance companies, inpatient psychiatric units experience a tremendous push to medicate patients quickly and discharge them as soon as possible....Often involving numerous rotating caregivers working in shifts, moonlighters, or trainees on one rotation and off to another, patients often complain, "I only saw my doctor for ten minutes!" ....Overpopulated psych units resulting from hospitals trying to keep out of the red often lead to burned out staff members who would rather silence a psychotic, agitated, or complaining patient with medication than sit down and talk to them. ... I remain baffled by the expectation that patients could easily begin the process of recovery from mental illness on most inpatient psychiatric units....These units are designed to keep patients safe and prevent adverse outcomes like a suicide in the hospital or emergency room. However, the therapeutic value of the physical setting is often overlooked as strapped hospital budgets prioritize other needs.

Fed up with the apparent "mill" of psychiatric hospitalization, a process that seemed to lose the person in the cycle of checkboxes and protocols, I wondered out loud to one of my supervisors whether anything like the old asylums existed. Though these institutions had many flaws, it seems as though things have swung too far the other way. The value of fresh air, therapeutic work, and a community of peers seems to have crumbled away in our quest for quicker and faster discharges and a focus on crisis management.


This isn't to say that people don't need to be on medication -- but this psychopharmacological myopia is dangerous in that most psychiatrists of my generation pay lip service to the "psychosocial" part of the biopsychosocial treatment model while failing to put it into practice. This is no fault of our own. I come from a generation of psychiatrists who will never see someone come into a hospital, be taken off all medications, and get better. And for many in my generation, if you don't see it, you won't believe it's possible."

End Excerpts

The often repeated quip is that psychiatry follows the "bio-bio-bio" model, rather than the biopsychosocial model. One of my recent patients was told by her psychiatrist (she came to me because of her dissatisfaction with her medication treatment) that her depression was "100% biological" and could only be treated with medication. I do not doubt that he believes this. Most psychiatric residents don't get much training in psychotherapy (compared to clinical psychologists) and fewer psychiatrists spend much time practicing psychotherapy (44% of psychiatric office visits involved psychotherapy in 1997 versus 29% in 2005; source). This response by Ronald Pies to this rather damning New York Times article seems rather weak to me, in that the type of "psychotherapy" provided by psychiatrists he is talking about seems to involve occassionally listening to patients talk about their lives ("supportive psychotherapy") and not the type of  focused, consistent (e.g., 16-24 weekly 50-minute sessions) psychotherapy that I and most of my clinical psychologist colleagues practice.

In the comments section of The Atlantic article, someone called bystander sums the situation up even better than the author of the article:

"It's a weird moment in science. On the one hand you have physicists proclaiming to have answered the ultimate questions posed by the universe, human spirituality, etc. etc. On the other hand, psychiatry, which should be the application of all that insight to the problem of healing people psychologically, is floundering from what looks from the outside like the obvious blunder of thinking that a human being is nothing more than a mass of chemical reactions and physical processes. (That's what the near-exclusive reliance on medication means, right? If you think a human being is a mass of chemicals, then a psychological problem is a chemistry problem, and a chemistry problem calls for a chemical solution.)

Here's hoping the scientific and medical communities get a does of common sense and humility and realize that the spiritual and psychological sides of human being are far from having been explained, let alone explained away, by science, physics and chemistry, and that some old-fashioned common sense, empathy, emotional contact and yes, spiritual insight would go a long way to correcting this weird and weirdly arrogant imbalance."
I'll let Abe Maslow have the last word:

I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.
  • The Psychology of Science: A Reconnaissance (1966), Ch. 2, p. 15