Sunday, June 30, 2013

Resumé -- Dorothy Parker

Dorothy Parker
Dorothy Parker (1893-1967)
Razors pain you;

Rivers are damp;

Acids stain you;

And drugs cause cramp.

Guns aren’t lawful;

Nooses give;

Gas smells awful;

You might as well live.

Saturday, June 29, 2013

The Wheel -- Grateful Dead

I suppose this is a fitting Saturday music post, given that I posted about John Perry Barlow last week and the Wheel of Fortune this week:

Boston Garden, May 7, 1977.

The wheel is turning
and you can't slow down
You can't let go
and you can't hold on
You can't go back
and you can't stand still
If the thunder don't get you
then the lightning will

Won't you try just a little bit harder?
Couldn't you try just a little bit more?
Won't you try just a little bit harder?
Couldn't you try just a little bit more?

Round round robin run around
Gotta get back where you belong
Little bit harder, just a little bit more
Little bit farther than you than you've gone before

The wheel is turning
and you can't slow down
You can't let go
and you can't hold on
You can't go back
and you can't stand still
If the thunder don't get you
then the lightning will

Small wheel turn by the fire and rod
Big wheel turn by the grace of God

Everytime that wheel turn round
bound to cover just a little more ground

The wheel is turning
and you can't slow down
You can't let go
and you can't hold on
You can't go back
and you can't stand still
If the thunder don't get you
then the lightning will

Won't you try just a little bit harder
Couldn't you try just a little bit more?
Won't you try just a little bit harder?
Couldn't you try just a little bit more?

Words by Robert Hunter; music by Jerry Garcia and Bill Kreutzmann

An annotated version is here.

Friday, June 28, 2013

Taliban kills mountaineers on Nanga Parbat

From the Associated Press, via the Denver Post online.

ISLAMABAD — Islamic militants disguised as police officers killed 10 foreign climbers, including an American, and a Pakistani guide in a brazen overnight raid against their campsite at the base of one of the world's tallest mountains in northern Pakistan, officials said Sunday.

The Pakistani Taliban claimed responsibility for the attack at the base camp of Nanga Parbat. The mountain is more than 26,250 feet tall and is notoriously difficult to summit. It is known as the "killer mountain" because of numerous deaths in the past.

The attack took place in an area that has largely been peaceful, hundreds of miles from the Taliban's major sanctuaries along the Afghan border.

The Taliban began the attack by abducting two local guides to take them to the remote base camp in Gilgit-Baltistan, said Pakistani Interior Minister Chaudhry Nisar Ali Khan. One of the guides was killed in the shooting, and the other has been detained for questioning. The attackers disguised themselves by wearing uniforms used by the Gilgit Scouts, a paramilitary force that patrols the area, Khan said.

About 15 gunmen attacked the camp about 11 p.m. Saturday, said the Alpine Club of Pakistan, which spoke with a local guide, Sawal Faqir, who survived the shooting. They began by beating the mountaineers and taking away any mobile and satellite phones they could find, as well as everyone's money, said the club in a statement.

Some climbers and guides were able to run away, but those that weren't were shot dead, said the club. Faqir was able to hide a satellite phone and eventually used it to notify authorities of the attack.

Attaur Rehman, the home secretary in Gilgit-Baltistan, said 10 foreigners and one Pakistani were killed in the attack. The dead foreigners included three Ukrainians, two Slovakians, two Chinese, one Lithuanian, one Nepalese and one Chinese-American, according to Rehman and tour operators who were working with the climbers.

Matt Boland, the acting spokesman at the U.S. Embassy in Islamabad, confirmed that an American citizen was among the dead but could not say whether it was a dual Chinese national.

Pakistani Taliban spokesman Ahsanullah Ahsan claimed responsibility for the attack, saying its Jundul Hafsa faction carried out the shooting as retaliation for the death of the Taliban's deputy leader, Waliur Rehman, in a U.S. drone attack May 29.

"By killing foreigners, we wanted to give a message to the world to play their role in bringing an end to the drone attacks," Ahsan told The Associated Press by telephone from an undisclosed location.

The U.S. insists the CIA strikes primarily kill al-Qaeda and other militants who threaten the West as well as efforts to stabilize neighboring Afghanistan.

Pakistani Prime Minister Nawaz Sharif, who wants to pursue peace talks with militants threatening his country, has insisted the U.S. stop the drone strikes. Sharif responded to the attack on the camp by vowing "such acts of cruelty and inhumanity would not be tolerated and every effort would be made to make Pakistan a safe place for tourists."

Thursday, June 27, 2013

The Wheel turns...

"The wheel of fortune turns round incessantly, and who can say to himself, I shall today be uppermost?"

- Confucius

If you prefer a Western version, there's the Rota Fortunae, which is featured prominently in Orff's Carmina Burana.


Why am I thinking about this? Check out these stories from yesterday's paper:

1. "Former Prime Minister Silvio Berlusconi was sentenced Monday to seven years in jail and banned for life from public office by an Italian court that convicted him of paying for sex with an underage woman and then abusing his power in trying to cover it up."

2. "Pakistan's newly elected leader said treason charges would be brought against the former army chief who ousted him in a coup 14 years ago, a potentially risky move that aims to solidify civilian control and deter future interventions by the military.
Pakistan's prime minister said Monday that the government plans to put Pervez Musharraf, seen above in an election banner, on trial for treason, setting up a possible clash with the country's powerful army.
Prime Minister Nawaz Sharif told parliament on Monday that retired general and ex-President Pervez Musharraf had violated Pakistan's constitution, calling him the "last dictator" of a country that has been ruled for half of its existence by the military.

The planned prosecution is a dramatic reversal of fortunes for a man who led Pakistan for nearly nine years, and a sign of the country's democratic evolution.

As army chief in 1999, Mr. Musharraf was able to oust a prime minister, Mr. Sharif, who had a two-thirds majority in parliament. Now, Mr. Sharif is back in power, following elections in May, and Mr. Musharraf is under arrest. Mr. Sharif's decision to press treason charges could end up sending his nemesis to the gallows."

3. "Yoo Young-bok's worn hands and gnarled fingernails are the only visual clues of his 47 years spent working in North Korean mines.
Mr. Yoo, 82 years old, is one of an estimated 24,000 South Korean prisoners-of-war that North Korea didn't repatriate after the signing of the Korean War armistice, 60 years ago in July. Most were put to work in mines in the north of the country, where many died. A few hundred are thought to still be alive in North Korea.


Mr. Yoo's own story is one of cruel twists of fate and stubborn survival instincts. Trapped in Seoul in June 1950 when the North invaded, he was press-ganged into the North Korean army.

He deserted soon after and spent two years in South Korean prisons because he fought for the North. On his release he was drafted into the South Korean army and posted to a frontline position. Just over a month before the armistice was signed he was captured in an ambush by Chinese troops sent to support the North Korean army.

Along with other POWs, Mr. Yoo was sent to work in mines in North Korea doing jobs such as pushing carts and drilling in treacherous conditions. Deaths from cave-ins, suffocation and exhaustion were nearly daily occurrences, he recalls."


Wednesday, June 26, 2013

Dan Ariely -- Predictably Irrational

I recently signed up with this great email service called delanceyplace. Everyday they send you an email with a short excerpt from a nonfiction book. I don't read every one they send, but the ones I do read I usually find interesting, even to the point of considering reading the entire book. Below is a recent sample from them. It is from behavioral economist Dan Ariely's book, Predictably Irrational. By the way, Ariely's article on "Why we lie" is among one of the best psychology pieces I have read in the popular press in the last couple of years.

In today's selection -- the decoy effect. Suppose, as suggested by psychologist Daniel Ariely, someone is given a choice between two vacations -- a week in either Paris and Rome at the same price with free breakfast each day -- where they are equally likely to choose either one. Then further suppose that a third choice is added -- Rome at the same price without the free breakfast. With that third choice, that same person will become much more likely to select the option of Rome with the free breakfast. That is because relativity helps us make decisions in life -- he or she now has a better basis for assessing the value of the Rome package: "it's the same price plus I get free breakfast so it must be a good deal." This is known as the "decoy effect," and knowledgeable psychologists and marketers realize it extends to most choices in life -- from buying a house to selecting someone to date. It is the same phenomenon that causes some restaurants to include a highly expensive entree on the menu even though few will order it, simply because it results in more patrons ordering the second most expensive entree on the menu:
"I asked [25 MIT students] to pair the 30 photographs of MIT men and the 30 of women by physical attractiveness (matching the men with other men, and the women with other women). That is, I had them pair the 'Brad Pitts' and the 'George Clooneys' of MIT, as well as the 'Woody Allens' and the 'Danny DeVitos' (sorry, Woody and Danny). Out of these 30 pairs, I selected the six pairs -- three female pairs and three male pairs -- that my students seemed to agree were most alike.
"Now, like Dr. Frankenstein himself, I set about giving these faces my special treatment. Using Photoshop, I mutated the pictures just a bit, creating a slightly but noticeably less attractive version of each of them. I found that just the slightest movement of the nose threw off the symmetry. Using another tool, I enlarged one eye, eliminated some of the hair, and added traces of acne. ...
"For each of the 12 photographs, in fact, I now had a regular version as well as an inferior (-) decoy version.

"It was now time for the main part of the experiment. I took all the sets of pictures and made my way over to the student union. Approaching one student after another, I asked each to participate. When the students agreed, I handed them a sheet with three pictures. Some of them had the regular picture (A), the decoy of that picture (-A), and the other regular picture (B). Others had the regular picture (B), the decoy of that picture (-B), and the other regular picture (A). ... After selecting a sheet with either male or female pictures, according to their preferences, I asked the students to circle the people they would pick to go on a date with, if they had a choice. ...
"What was my motive in all this? Simply to determine if the existence of the distorted picture (-A or -B) would push my participants to choose the similar but undistorted picture. In other words, would a slightly less attractive George Clooney (-A) push the participants to choose the perfect George Clooney over the perfect Brad Pitt?  
"There were no pictures of Brad Pitt or George Clooney in my experiment, of course. Pictures (A) and (B) showed ordinary students. ... Would the existence of a less perfect person (-A or -B) push people to choose the perfect one (A or B), simply because the decoy option served as a point of comparison?
"It did. Whenever I handed out a sheet that had a regular picture, its inferior version, and another regular picture, the participants said they would prefer to date the 'regular' person -- the one who was similar, but clearly superior, to the distorted version -- over the other, undistorted person on the sheet. This was not just a close call -- it happened 75 percent of the time (out of a sample of 600). ...
"Let's take a look at the decoy effect in a completely different situation. What if you are single, and hope to appeal to as many attractive potential dating partners as possible at an upcoming singles event? My advice would be to bring a friend who has your basic physical characteristics (similar coloring, body type, facial features), but is slightly less attractive (-you).  
"Why? Because the folks you want to attract will have a hard time evaluating you with no comparables around. However, if you are compared with a '-you,' the decoy friend will do a lot to make you look better, not just in comparison with the decoy but also in general, and in comparison with all the other people around. It may sound irrational (and I can't guarantee this), but the chances are good that you will get some extra attention. Of course, don't just stop at looks. If great conversation will win the day, be sure to pick a friend for the singles event who can't match your smooth delivery and rapier wit. By comparison, you'll sound great. ... 
"Relativity helps us make decisions in life." 
Author: Dan Ariely

Publisher: Harper Perennial
Date: Copyright 2009 by Dan Ariely
Pages: 11-15

Tuesday, June 25, 2013

SEAL sniper Chris Kyle murdered by fellow veteran

Here's a link to a good piece in the New Yorker on the murder of former Navy SEAL sniper Chris Kyle, author of American Sniper.

"For all the moral complexity of combat, coming home is often a more distressing and disorienting experience. The transition from battle zones and M.R.E.s to parking lots and fast food can unsettle even the most well-adjusted veterans. In a 2008 study, the rand Corporation estimated that P.T.S.D. affected fourteen per cent of those who served in Iraq and Afghanistan. Symptoms of the disorder range from minor insomnia to debilitating flashbacks, and studies of veterans suggest that the likelihood of developing P.T.S.D. increases with each combat deployment."

"The quality of care varies from one V.A. facility to the next. In 2004, the V.A. Inspector General called the Dallas facility the worst in the nation; last year, a Dallas TV station interviewed veterans who alleged that the facility was so poor that it put “lives at risk.” The V.A. tends to be slow, taking an average of nine months to determine if it will cover a veteran’s health claim. And getting a claim approved can be even more difficult if symptoms are not observed at a veteran’s exit physical. Yet P.T.S.D.’s symptoms may not emerge for a while, and they are often accompanied by a cascade of other health problems. Chiarelli, the former vice-chief of the Army, told me that doctors should be “given more latitude” in assessing combat veterans, adding, “But there’s where you get into cost issues.” The V.A. is a sclerotic and overwhelmed bureaucracy; it barely has the resources to maintain its current level of health coverage, let alone expand it."

Depressing story, all around. The "hero" himself was certainly flawed and the "villain" is plainly psychiatrically disturbed. Some more details on Eddie Ray Routh's pre-killings mental health treatment here. I wouldn't be so quick to blame the VA system. It would be an outrage if former Marine Routh is convicted of first-degree murder.

Here is a must-read take on the story which extensively quotes Edna Foa, promulgator (I wouldn't go so far as to say, "inventor") of prolonged exposure therapy for PTSD.

Monday, June 24, 2013

Smart people talk to their babies more than dumb people do!

Here's the summary: Researchers find that children whose parents speak to them more when they are little do better in school years later. It also was found that poor people spoke less to their young kids than rich people. So now do-gooders are trying to get poor mothers to talk to their babies more. You can read the entire New York Times blogpost here, or just the excerpts below:

By the time a poor child is 1 year old, she has most likely already fallen behind middle-class children in her ability to talk, understand and learn. The gap between poor children and wealthier ones widens each year, and by high school it has become a chasm. American attempts to close this gap in schools have largely failed, and a consensus is starting to build that these attempts must start long before school — before preschool, perhaps even before birth.
There is no consensus, however, about what form these attempts should take, because there is no consensus about the problem itself. What is it about poverty that limits a child’s ability to learn? Researchers have answered the question in different ways: Is it exposure to lead? Character issues like a lack of self-control or failure to think of future consequences? The effects of high levels of stress hormones? The lack of a culture of reading?
Another idea, however, is creeping into the policy debate: that the key to early learning is talking — specifically, a child’s exposure to language spoken by parents and caretakers from birth to age 3, the more the better. It turns out, evidence is showing, that the much-ridiculed stream of parent-to-child baby talk — Feel Teddy’s nose! It’s so soft! Cars make noise — look, there’s a yellow one! Baby feels hungry? Now Mommy is opening the refrigerator! — is very, very important. (So put those smartphones away!)
Intelligence, as measured by IQ scores and as demonstrated by academic and occupational achievement, happens to be highly heritable. How smart your child is and how well he does in school is strongly influenced by how smart his four grandparents were. Adopted children resemble their biological parents in intelligence more than they resemble their adoptive parents who raised them from birth. Socio-economic status and intelligence are positively correlated. All of these facts are diligently ignored by the writer of this article.

The mother who speaks to her infant a lot more than the average parent is probably a lot more intelligent than the average parent. When you observe her, you are not identifying a good parenting technique, you are observing a sign of higher intelligence. Her child is probably already smarter than the average toddler, largely as a result of his genetic inheritance. [By the way, if her kid just stared blankly at her when she spoke (e.g., due to a head injury or autism) she would eventually speak to him much less often.]

Many developmental psychologists ignore the heritability of IQ and concentrate instead on environmental effects, like how much a parent talks to her child. But a person (phenotype) is the product of their genetics (genotype) and their environment. You don't get to ignore any element in that G x E = P equation.  People seize upon ideas like, "Talking to your baby more will increase his later school achievement," because they can't bear to says things like, "How well a kid does in school can be predicted by how well his parents did in school."

The heritability of IQ is not only substantial but also totally unfair. The unfairness is aggravated because of assortative mating (smart people tend to mate with other smart people). The increasing complexity of modern life makes higher cognitive capacity ever more advantageous. It is becoming harder and harder for people of lower intelligence to get on as the world becomes more cognitively complex. People on the far right tail of the IQ bell curve should thank their lucky stars -- they won a genetic lottery. They should also realize that they are not morally superior to those on the far left tail. Perhaps, Mr. Smartypants, your unearned position entails some serious obligations towards those less fortunate.

Hart and Risley were studying how parents of different socioeconomic backgrounds talked to their babies. Every month, the researchers visited the 42 families in the study and recorded an hour of parent-child interaction. They were looking for things like how much parents praised their children, what they talked about, whether the conversational tone was positive or negative. Then they waited till the children were 9, and examined how they were doing in school....
All parents gave their children directives like “Put away your toy!” or “Don’t eat that!” But interaction was more likely to stop there for parents on welfare, while as a family’s income and educational levels rose, those interactions were more likely to be just the beginning. 
The disparity was staggering. Children whose families were on welfare heard about 600 words per hour. Working-class children heard 1,200 words per hour, and children from professional families heard 2,100 words. By age 3, a poor child would have heard 30 million fewer words in his home environment than a child from a professional family. And the disparity mattered: the greater the number of words children heard from their parents or caregivers before they were 3, the higher their IQ and the better they did in school. TV talk not only didn’t help, it was detrimental. 
Hart and Risley later wrote that children’s level of language development starts to level off when it matches that of their parents — so a language deficit is passed down through generations. They found that parents talk much more to girls than to boys (perhaps because girls are more sociable, or because it is Mom who does most of the care, and parents talk more to children of their gender). This might explain why young, poor boys have particular trouble in school. And they argued that the disparities in word usage correlated so closely with academic success that kids born to families on welfare do worse than professional-class children entirely because their parents talk to them less. In other words, if everyone talked to their young children the same amount, there would be no racial or socioeconomic gap at all. (Some other researchers say that while word count is extremely important, it can’t be the only factor.)
Well, we'll see how well this latest fad works out. So far, they found that they might be able to increase the number of words poor women direct at their infants and toddlers. But that is a long way from demonstrating a positive impact on school achievement. Since nothing else* has ever worked to increase school achievement among the poor, I'm guessing that this will turn out the same way. But, like I said, we'll see.

A few years ago, developmental psychologists noticed that kids whose parents read to them did better in school than kids whose parents didn't read to them. So, they tried to get more parents to read to their kids, and even tried to tell them how to read to their kids (asking questions like, "What do you think is going to happen next?").  Well, that didn't work, because there's a reason why some people don't read to their kids -- because you don't read to your kids if reading is difficult or even painful for you. And this person who can't read is much more likely to have a kid who can't read than a parent who reads for pleasure -- whether or not the parent who reads for pleasure ever reads to her kid.

*Here's an excerpt from a study that claims that Head Start improves cognitive outcomes (compared to children who would otherwise be cared for at home by their single-mothers on welfare):
Our estimates of Head Start effects were roughly comparable to those reported in the Head Start Impact Study. For example, when comparing children who attended Head Start with all other children, we found that the effect sizes for PPVT–III and WJ–R Letter–Word Identification from the propensity score matching models (which essentially were treatment-on-treated [TOT] analyses) were 0.19 and 0.16, respectively; while the effect sizes for social competence and attention problems were 0.14 and −0.16, respectively.
Okay. First of all, you made their attention problems worse by sending them to Head Start. But secondly, those effect sizes are puny. If you had a treatment for depression with those kind of effect sizes, by the end of the study you would still have a bunch of depressed patients.

Sunday, June 23, 2013

You must change your life.


Archaic Torso of Apollo
by Rainer Maria Rilke
translated by Stephen Mitchell

We cannot know his legendary head
with eyes like ripening fruit. And yet his torso
is still suffused with brilliance from inside,
like a lamp, in which his gaze, now turned to low,

gleams in all its power. Otherwise
the curved breast could not dazzle you so, nor could
a smile run through the placid hips and thighs
to that dark center where procreation flared.

Otherwise this stone would seem defaced
beneath the translucent cascade of the shoulders
and would not glisten like a wild beast's fur:

would not, from all the borders of itself,
burst like a star: for here there is no place
that does not see you. You must change your life.


Saturday, June 22, 2013

Sheep May Safely Graze -- Bach

Lame video but I like the orchestral arrangement. Aria 4 of Cantata 208.

Friday, June 21, 2013

James Gandolfini, RIP

I'm pretty sure that David Chase, creator of The Sopranos, said at one time that he had had a lot of psychotherapy. Well, he was paying attention during those sessions because the psychotherapy scenes in that series are top notch. This is the best one.

That's from the second season. Got it, viewer? That psychopath you are living vicariously through is an unredeemable monster who is warping the souls of everyone around him. There's no happy ending possible for A.J., Meadow, or Carmela -- they are all damned. Dr. Melfi is wasting her time trying to help Tony because psychotherapy only works if the patient has a soul. (She figured that out in the last season.)

If we had more psychotherapists like Dr. Krakower, the mental health profession itself would be redeemed. Call things what they are, and don't let anyone else do otherwise.

[Begin transcript]

Carmela: Every marriage has problems.

Krakower: Is he seeing other women?

Carmela: "Yeah, you can make that plural. Yes, he sees other women. I sort of look the other way. I want to help him."

Krakower: "Do you? Moments ago you used the word divorce."

Carmela: "I said I was considering divorce. I may be overstepping my bounds here, but you are Jewish, aren't you?"

Krakower: "Is that relevant?"

Carmela: "Well, us Catholics, we place a great deal of stock in the sanctity of the family. And I am not sure that your people--"

Krakower: "I've been married 31 years."

Carmela: "Well, then, you know. How difficult it can be. He's a good man, a good father."

Krakower: "You tell me he's a depressed criminal. Prone to anger. Serially unfaithful. Is that your definition of a good man?"

Carmela: "I thought psychiatrists weren't supposed to be judgmental."

Krakower: "Many patients want to be excused for their current predicament. Because of events that occurred in their childhood. That's what psychiatry has become in America. Visit any shopping mall or ethnic pride parade. Witness the results."

Carmela: "What we say in here stays in here, right?"

Krakower: "By ethical code and by law."

Carmela: "His crimes. They are, uh, organized crimes."

Krakower: "The mafia."

Carmela begins sobbing. "Oh Jesus." She dabs at her face with a tissue. "Oh so, so what? So what? He betrays me every week with these whores."

Krakower: "Probably the least of his misdeeds."

Carmela shifts forward, as if to leave.

Krakower: "You can leave now, or you can you stay and hear what I have to say."

Carmela: "Well, you're gonna charge the same anyway."

Krakower: "I won't take your money."

Carmela: "That's a new one."

Krakower: "You must trust your initial impulse and consider leaving him. You'll never be able to feel good about yourself. You'll never be able to qualm the feelings of guilt and shame that you talked about. As long as you're his accomplice."

Carmela: "You're wrong about the accomplice part."

Krakower: "Are you sure?"

Carmela: "All I do is make sure he's got clean clothes in his closet and dinner on his table."

Krakower: "So 'enabler' would be a more accurate job description for you than 'accomplice'. My apologies."

Carmela: "So . . . You think I need to define my boundaries more clearly. Keep a certain distance. Not internalize my--"

Krakower: "What did I just say?"

Carmela: "Leave him."

Krakower: "Take only the children, or what's left of them, and go."

Carmela: "My priest said I should try to work with him. Help him to be a better man."

Krakower: "How's that going?"

Carmela: "I--"

Krakower: "Have you ever read Crime and Punishment? Dostoyevsky. It's not an easy read. It's about guilt and redemption. And were your husband to turn himself him, read this book, and reflect on his crimes every day for seven years in his cell, then he might be redeemed."

Carmela: "I'd have to, uh, get a lawyer. Find an apartment. Arrange for child support."

Krakower: "You're not listening. I am not charging you because I won't take blood money. And you can't either. One thing you can never say, that you haven't been told."

Carmela: "I see. You're right. I see."
[End transcript]

Thursday, June 20, 2013

This American Life -- John Perry Barlow

Ira Glass, the host of the radio show, This American Life, has the makings of a fine psychotherapist. (As does his NPR colleague, Terry Gross). It is probably not irrelevant that Mr. Glass's mother, Shirley Glass, is a psychologist. Anyone interested in becoming a psychotherapist could learn something from listening to interviews conducted by Mr. Glass or Ms. Gross. (Johnny Cash, interviewed by Terry Gross shortly before he died, told her, "You're very good at what you do." I have always interpreted this is to mean that she made him think about himself and his life in ways that he never had before -- psychotherapy!)

I heard this episode of This American Life when it first aired in 1997 and I have never forgotten it. In many ways, it is an excellent analogue to a psychotherapy session. The "patient" is John Perry Barlow, a cyber-libertarian, Wyoming rancher, and former lyricist for the Grateful Dead. The transcript of the show is available here, but you really should listen rather than read or else you will miss the emotional tone. Seriously, the entire episode is worth listening to, but definitely listen to the John Perry Barlow story (Act III, When Worlds Collide). One of the privileges of being a psychotherapist is that people share stories like this with you, stories they have never told anyone else.

John Perry Barlow

Wednesday, June 19, 2013

Your insula knows whether you need Lexapro or CBT?

Here's the original article from JAMA Psychiatry that is making all the headlines recently. The authors suggest that their findings (if replicated) indicate that depressed patients should undergo a $2,000 PET scan test (which involves an intravenous injection of radioactive liquid) in order the decide whether they should receive Lexapro (an antidepressant) or CBT (a psychotherapy) as a first-line treatment for their depression.

The study randomly assigned 82 depressed patients (with the usual exclusion for patients with "current suicidal ideation requiring urgent clinical intervention") to either Lexapro (up to 20 mg qd) or CBT (16 sessions; twice weekly for the first 4 weeks, then weekly). After 12 weeks, 6 of the 30 (20.0%) Lexaprosiacs were still depressed, versus 9 of the 33 (27.3%) of the CBT'rs. (19 participants were excluded or terminated after randomization.)

The researchers the did a two-way ANOVA [treatment (CBT or Lexapro) x outcome (remission or nonresponse)] to identify brain regions in the pre-treatment baseline PET scans that "predicted" (or rather, postdicted) treatment response. They found six such regions: right anterior insula, right inferior temporal cortex, left amgydala, left premotor cortex, right motor cortex, and precuneus. They found the strongest effect size for the insula and thus labelled it a "treatment-specific biomarker candidate."

Just a couple of comments:

1. The authors appropriately state that these findings require replication. This is because this study was a fishing expedition -- they had no idea, and no real reason to believe, that the metabolic rate of the right anterior insula would predict response to a specific treatment. They looked at dozens of brain regions, searching for "significant differences" between the groups and they found one -- just like you always will if you look at enough variables. What are the chances that these findings will be replicated by another group of researchers? Well, when is the last time you saw any study in neuroscience replicated by a second group of researchers? (It's pretty darn hard to replicate somebody else's random findings.)

2. Not having an initial hypothesis as to which brain regions might be involved is par for the course with these types of studies. This should be pretty shocking to anyone who ever got a B or higher in a psychology Research Methods course. The authors present very plausible-sounding reasons for why the right anterior insula is just so great at predicting treatment-specific response, but be aware that they would have come up with equally plausible-sounding reasons had the most significant effect been for the left premotor cortex or the precuneus (or the part of the brain that is involved in blink rate, if anyone knew what that was). Because human beings are very clever and creative, we can come up with plausible explanations for any random phenomenon (this is the pitfall of Freudian dream analysis -- AND of neuroscience).

3. It is really weird/lame that they found no main effect for remission. In other words, there was no brain region that predicted whether you would recover from your depressive episode in 12 weeks (regardless of which treatment you received). They are pretty silent about this non-result in their paper, although they sure seemed to think that they would find something.

4. It seems like the real question here is is not "Which brain region best predicts treatment outcome?" but rather "How do we match patients and treatments for the best results?" A future study should compare whether a clinician (or a psychological test, such as the MMPI-2) could perform the same task they are saying that the insula is doing (i.e., deciding which patients should get which treatment). And let's not lose sight of the fact that 76% of the patients recovered from their depressive episode despite being randomly assigned to either CBT or Lexapro, regardless of their personal preferences.

5. Would you rather have a clinical interview with a psychodiagnostician, complete a 90 minute True or False test, or have a radioactive i.v. followed by a PET scan that your insurance may or may not pay for?

6. My guess is that treatment-specific response has a lot to do with what kind of depression the patients had. We have known for a while now that people with dysthymia respond better to antidepressants than they do to psychotherapy, and people with chronic major depression respond better to combined therapy (AD meds + psychotherapy). How long the patients had been depressed was not noted in the insula study.

7. Any study that looks at psychotherapy efficacy and ignores therapeutic alliance (the strongest predictor of psychotherapy outcome) is courting worthlessness. Therapeutic alliance also influences response to antidepressant medications! If you don't like your psychiatrist (or if he doesn't like you), then you are less likely to get better.

8. Why do people persist in using the crappy little HAM-D as their only outcome measure of depression? Why not use the MMPI-2? If they had, we could have been able to tell the chronic depressives from the acute depressives (and which of the patients had hysteric defenses, paranoia, agitation, etc.).

For the best critiques of brain imaging studies (by an fMRI reseacher), I refer you to Neuroskeptic. As Neuroskeptic says, brain imaging "is a great way to approach neuroscientific questions. It’s a bad (and terribly expensive) way to do psychology." The new book, Brainwashed, by Scott Lilienfeld and Sally Satel, also promises to be well worth reading.

Tuesday, June 18, 2013

Civilization and its Discontents -- Freud


"The element of truth behind all this, which people are so ready to disavow, is that men are not gentle creatures who want to be loved, and who at the most can defend themselves if they are attacked; they are, on the contrary, creatures among whose instinctual endowments is to be reckoned a powerful share of aggressiveness. As a result, their neighbour is for them not only a potential helper or sexual object, but also someone who tempts them to satisfy their aggressiveness on him, to exploit his capacity for work without compensation, to use him sexually without his consent, to seize his possessions, to humiliate him, to cause him pain, to torture him and to kill him. Homo homini lupus."

"That the education of young people at the present day conceals from them the part which sexuality will play in their lives is not the only reproach which we are obliged to make against it. Its other sin is that it does not prepare them for the aggressiveness of which they are destined to become the objects. In sending the young out into life with such a false psychological orientation, education is behaving as though one were to equip people on a Polar expedition with summer clothing and maps of the Italian Lakes. In this it becomes evident that a certain misuse is being made of ethical demands. The strictness of those demands would not do so much harm if education were to say: 'This is how men ought to be, in order to be happy and to make others happy; but you have to reckon on their not being like that.' Instead of this the young are made to believe that everyone else fulfills those ethical demands -- that is, that everyone else is virtuous. It is on this that the demand is based that the young, too, shall become virtuous."


Monday, June 17, 2013

"Always be a gentleman."

A day late for Father's Day, some fatherly advice, passed along by former MLB commissioner Fay Vincent:

"My father was definitely old school. He rarely swore, drank only an occasional beer in the high summer heat, and generally lived the solid decent life of what he called "a gentleman." From him I learned the values of decency, honor and pride.

During his lifetime I occasionally felt he was totally behind the times with his regular injunctions that I do my best and honor the family name. Yet now I realize the value of his legacy, which is summed up in the following set of commandments:

Always be a gentleman. To my father, a gentleman is someone who never offends another person needlessly. He lived that code. He stood when a woman entered the room. He tipped his hat when he wished to pay respect. He even kept his mouth shut even when his calls were challenged while he officiated football and baseball games. His sturdiest reply to insults was "Go peddle your papers."

• Always keep your shoes shined. QED.

Save your money. It will be your best friend. Here my father reflected the Great Depression and his experience of graduating from Yale with every athletic honor—only to discover the sole job available was digging post holes for the local electric utility.

Any week in which you do not put some money aside for a rainy day is a wasted week. This was a corollary to his injunction to save—which he did with religious zeal. He also invested in stocks with some success. But he insisted on receiving dividends and would shun any stock that did not pay him dividends.

A car is the most expensive thing you can own. He told me to try and avoid buying one, reminding me that it falls in value by a huge percent the minute you drive it off the lot.

My father followed his own counsel, and the family did not own a car until I was about 12. He rode the bus and walked just about everywhere. We always lived near a bus line.

• A pension is important. If possible, find a good job with a bank, insurance company or utility where layoffs are rare. A good job is one that is secure and not always the one with the highest pay.

If your boss or employer is not making money on you, you will eventually lose your job. Your work has to permit him to profit on what you produce. If you and the employer just break even you are not being properly productive. Get to work early and stay late if necessary.

It is more important to be able to write and speak well than it is to be able to succeed in athletics. My father was a superb football and baseball player at Yale, but he was certain the language skills he did not possess were the most important ones in any business or professional career.

There is no such thing as an honest politician. He viewed politicians with the same cynical eye he cast on doctors, lawyers and priests. He accepted the argument there must be some good and decent ones but he was suspicious until solid facts prevailed.

My father valued hard work over brilliance and saw most professions as predatory. As my physician sister left the house every morning his regular admonition was, "Don't charge some poor people today."

• Don't get old. It's no fun. When he could no longer take his customary long walks, referee football games or umpire softball and baseball games, he suffered.

My father had been blessed with a powerful and compliant body and the natural erosion was painful. The day he died at 78, he had been up a ladder painting the outside of his home. When he felt the heat and need to rest, he climbed down and went inside. My sister found him dead in his favorite chair.

• The finest legacies are often not material things. The lessons my father instilled in me are precious because they are so firmly grounded in experience. For that reason and for so many more, he remains with me daily."

 George Sanders, gentleman

Sunday, June 16, 2013

The Young British Soldier -- Rudyard Kipling

When the 'arf-made recruity goes out to the East
'E acts like a babe an' 'e drinks like a beast,
An' 'e wonders because 'e is frequent deceased
Ere 'e's fit for to serve as a soldier.
Serve, serve, serve as a soldier,
Serve, serve, serve as a soldier,
Serve, serve, serve as a soldier,
So-oldier ~OF~ the Queen!

Now all you recruities what's drafted to-day,
You shut up your rag-box an' 'ark to my lay,
An' I'll sing you a soldier as far as I may:
A soldier what's fit for a soldier.
Fit, fit, fit for a soldier . . .

First mind you steer clear o' the grog-sellers' huts,
For they sell you Fixed Bay'nets that rots out your guts --
Ay, drink that 'ud eat the live steel from your butts --
An' it's bad for the young British soldier.
Bad, bad, bad for the soldier . . .

When the cholera comes -- as it will past a doubt --
Keep out of the wet and don't go on the shout,
For the sickness gets in as the liquor dies out,
An' it crumples the young British soldier.
Crum-, crum-, crumples the soldier . . .

But the worst o' your foes is the sun over'ead:
You ~must~ wear your 'elmet for all that is said:
If 'e finds you uncovered 'e'll knock you down dead,
An' you'll die like a fool of a soldier.
Fool, fool, fool of a soldier . . .

If you're cast for fatigue by a sergeant unkind,
Don't grouse like a woman nor crack on nor blind;
Be handy and civil, and then you will find
That it's beer for the young British soldier.
Beer, beer, beer for the soldier . . .

Now, if you must marry, take care she is old --
A troop-sergeant's widow's the nicest I'm told,
For beauty won't help if your rations is cold,
Nor love ain't enough for a soldier.
'Nough, 'nough, 'nough for a soldier . . .

If the wife should go wrong with a comrade, be loath
To shoot when you catch 'em -- you'll swing, on my oath! --
Make 'im take 'er and keep 'er: that's Hell for them both,
An' you're shut o' the curse of a soldier.
Curse, curse, curse of a soldier . . .

When first under fire an' you're wishful to duck,
Don't look nor take 'eed at the man that is struck,
Be thankful you're livin', and trust to your luck
And march to your front like a soldier.
Front, front, front like a soldier . . .

When 'arf of your bullets fly wide in the ditch,
Don't call your Martini a cross-eyed old bitch;
She's human as you are -- you treat her as sich,
An' she'll fight for the young British soldier.
Fight, fight, fight for the soldier . . .

When shakin' their bustles like ladies so fine,
The guns o' the enemy wheel into line,
Shoot low at the limbers an' don't mind the shine,
For noise never startles the soldier.
Start-, start-, startles the soldier . . .

If your officer's dead and the sergeants look white,
Remember it's ruin to run from a fight:
So take open order, lie down, and sit tight,
And wait for supports like a soldier.

Wait, wait, wait like a soldier . . .

When you're wounded and left on Afghanistan's plains,
And the women come out to cut up what remains,
Jest roll to your rifle and blow out your brains
An' go to your Gawd like a soldier.

Go, go, go like a soldier,
Go, go, go like a soldier,
Go, go, go like a soldier,
So-oldier ~of~ the Queen!   


Saturday, June 15, 2013

Our Love is Here to Stay -- Dinah Washington

Some folks prefer Ella Fitzgerald's rendition, but they are misguided.

It's very clear
Our love is here to stay ;
Not for a year
But ever and a day.

The radio and the telephone
And the movies that we know
May just be passing fancies,
And in time may go!

But, oh my dear,
Our love is here to stay.
Together we're
Going a long, long way

In time the Rockies may crumble,
Gibralter may tumble,
They're only made of clay,
But our love is here to stay.

A fascinating anecdote about the lyricist, George Gershwin:

"[I]n 1935, when he was 36 and at the peak of his career, Gershwin lost his usual verve and became severely depressed. He sought help from an esteemed psychoanalyst of the era, seeing him five times a week. During this period, he also set out to write the opera "Porgy and Bess."
The opera is the story of an impoverished African-American community, of hardship and betrayal. The opera’s song "Summertime" reflects a deep sadness. "But the opera’s ‘My Man’s Gone Now’ is unquestionably the most anguished song that Gershwin ever wrote," Kogan declared. "In fact, it is probably one of the most anguished songs of the 20th century."
In other words, the formerly egocentric, not particularly empathetic Gershwin had become much more sensitive to others because of his depression, Kogan explained. His depression gave "Porgy and Bess" a poignancy, a seriousness that his previous works had not possessed. ...
Although "Porgy and Bess" was undoubtedly Gershwin’s greatest work, his life spiraled downward after it was written. When the opera opened in 1935, it met with little success. Months of psychoanalysis also failed to relieve Gershwin’s depression. "No, it was not a psychiatric success story," Kogan lamented.
Further, Gershwin started showing signs of incoordination, smelled what appeared to be the odor of burning garbage during a rehearsal of "Rhapsody in Blue," and experienced an increasing number of headaches that became increasingly painful. His physicians suspected that he had a brain tumor and recommended emergency surgery.
On July 11, 1937, surgeons found a massive tumor in Gershwin’s brain impinging on his olfactory nerve. Although they removed the tumor, he did not survive the operation.
"Yes, Gershwin’s depression was undoubtedly due to his brain tumor," Kogan contends. "While writing ‘Porgy and Bess’ he was dying, but didn’t know it. Nonetheless, I think it was the depression plus dying that informed his ability to write something of such exquisite depth.""
Never give psychotherapy to a brain tumor!

Friday, June 14, 2013

Epictetus -- The Enchiridion

Ever wonder about the origins of Cognitive-Behavioral Therapy? First of all, Albert Ellis was first on the scene -- not Aaron Beck, as is commonly believed. Secondly, Ellis plainly stated (as was his wont) that he lifted the ideas for his Rational-Emotive Behavioral Therapy from the Stoic philosophers Epictetus and Marcus Aurelius.

The entire Enchiridion of Epictetus is available online here.

Some excerpts:

5. Men are disturbed, not by things, but by the principles and notions which they form concerning things.

8. Don't demand that things happen as you wish, but wish that they happen as they do happen, and you will go on well.

12. If you want to improve, reject such reasonings as these: "If I neglect my affairs, I'll have no income; if I don't correct my servant, he will be bad." For it is better to die with hunger, exempt from grief and fear, than to live in affluence with perturbation; and it is better your servant should be bad, than you unhappy.

Begin therefore from little things. Is a little oil spilt? A little wine stolen? Say to yourself, "This is the price paid for apathy, for tranquillity, and nothing is to be had for nothing." When you call your servant, it is possible that he may not come; or, if he does, he may not do what you want. But he is by no means of such importance that it should be in his power to give you any disturbance.

17. Remember that you are an actor in a drama, of such a kind as the author pleases to make it. If short, of a short one; if long, of a long one. If it is his pleasure you should act a poor man, a cripple, a governor, or a private person, see that you act it naturally. For this is your business, to act well the character assigned you; to choose it is another's.

21. Let death and exile, and all other things which appear terrible be daily before your eyes, but chiefly death, and you win never entertain any abject thought, nor too eagerly covet anything.

33. Immediately prescribe some character and form of conduce to yourself, which you may keep both alone and in company.

Be for the most part silent, or speak merely what is necessary, and in few words. We may, however, enter, though sparingly, into discourse sometimes when occasion calls for it, but not on any of the common subjects, of gladiators, or horse races, or athletic champions, or feasts, the vulgar topics of conversation; but principally not of men, so as either to blame, or praise, or make comparisons. If you are able, then, by your own conversation bring over that of your company to proper subjects; but, if you happen to be taken among strangers, be silent.

Don't allow your laughter be much, nor on many occasions, nor profuse.

Avoid swearing, if possible, altogether; if not, as far as you are able. [General U.S. Grant!]

Avoid public and vulgar entertainments; but, if ever an occasion calls you to them, keep your attention upon the stretch, that you may not imperceptibly slide into vulgar manners. For be assured that if a person be ever so sound himself, yet, if his companion be infected, he who converses with him will be infected likewise.

Provide things relating to the body no further than mere use; as meat, drink, clothing, house, family. But strike off and reject everything relating to show and delicacy.

As far as possible, before marriage, keep yourself pure from familiarities with women, and, if you indulge them, let it be lawfully. But don't therefore be troublesome and full of reproofs to those who use these liberties, nor frequently boast that you yourself don't.

If anyone tells you that such a person speaks ill of you, don't make excuses about what is said of you, but answer: "He does not know my other faults, else he would not have mentioned only these."

45. Does anyone bathe in a mighty little time? Don't say that he does it ill, but in a mighty little time. Does anyone drink a great quantity of wine? Don't say that he does ill, but that he drinks a great quantity. For, unless you perfectly understand the principle from which anyone acts, how should you know if he acts ill? Thus you will not run the hazard of assenting to any appearances but such as you fully comprehend. [B.F. Skinner!]

50. Whatever moral rules you have deliberately proposed to yourself. abide by them as they were laws, and as if you would be guilty of impiety by violating any of them. Don't regard what anyone says of you, for this, after all, is no concern of yours. How long, then, will you put off thinking yourself worthy of the highest improvements and follow the distinctions of reason? You have received the philosophical theorems, with which you ought to be familiar, and you have been familiar with them. What other master, then, do you wait for, to throw upon that the delay of reforming yourself? You are no longer a boy, but a grown man. If, therefore, you will be negligent and slothful, and always add procrastination to procrastination, purpose to purpose, and fix day after day in which you will attend to yourself, you will insensibly continue without proficiency, and, living and dying, persevere in being one of the vulgar. This instant, then, think yourself worthy of living as a man grown up, and a proficient. Let whatever appears to be the best be to you an inviolable law. And if any instance of pain or pleasure, or glory or disgrace, is set before you, remember that now is the combat, now the Olympiad comes on, nor can it be put off. By once being defeated and giving way, proficiency is lost, or by the contrary preserved. Thus Socrates became perfect, improving himself by everything, attending to nothing but reason. And though you are not yet a Socrates, you ought, however, to live as one desirous of becoming a Socrates.

Adm. Jim Stockdale credited Epictetus for helping him to survive captivity in North Vietnam