Monday, March 13, 2017

Helping Patients with Schoolwork

In my clinic, I mainly see university students.  I believe it is important, and therapeutic, to invite students to bring their schoolwork to their psychiatry appointments, so that we can sometimes look at it together and discuss it.

Last year, I mentioned this practice to a reviewer, and I suspect it was considered an inappropriate use of time in a medical appointment, and a waste of resources -- a psychiatrist "helping with homework."

I would like to make a case for why "helping with homework" is useful, and part of a good therapy relationship:

Understanding


In order to help with a mental health issue, it is good to understand what your client, patient, or friend is doing with their time.   University students often spend thousands of hours studying, writing, and thinking about academic subjects.  Sometimes this work is experienced as a joy of life, a passion, or as a source of meaning.  For others, the work can be experienced as a burden, a chore, or as meaningless "jumping through hoops."   In many cases, a student's academic work is a reflection of health status (both mental and physical),  For many students, academic performance affects self-esteem:  low grades can cause a person to feel like a failure.  Perfectionism in schoolwork can cause almost any grade to feel like a sign of failure or inadequacy.

In order to understand another person's emotional life, it is very important to learn about how he or she is spending time.   Is the schoolwork a meaningful life pleasure?  Is it only a chore, a burden, or a stress?

It deepens understanding of this issue to explore it in more than a superficial way.  I believe it is valuable for understanding and rapport to encourage patients to show their notebooks, textbooks, and assignments, to talk about them a little bit.  Often this leads to a much better understanding of a whole range of other issues, including mood, attention, motivation, anxiety symptoms, learning disabilities (often never previously recognized), relationship problems, and existential uncertainty about direction in life.

Shared Interest


Many students I have seen have been passionately engrossed in their studies for many years, including at a graduate level.  But sometimes, they have almost no social conversation about their studies, with a person who shows interest.  The academic study becomes an insular, lonely experience, rather than a source of potential social interest.  Sometimes this lack of social sharing is due to an entrenched habit...the therapy setting can be a place to change this.    Not only does such a conversation boost rapport, it is also a practice for the patient to be able to converse with other people about their work, for the benefit of their social life.

Also I believe it is psychologically beneficial for a patient or client to have an experience of sharing their own expertise, and learned scholarship, rather than only being on the "receiving end" of such expertise.  It is a humble and respectful position for the therapist to take, which can only improve a therapeutic alliance.


Diagnosis


All mental health issues affect cognitive functioning and academic performance.  A direct discussion about academic matters is relevant to the assessment of overall mental health.  Sometimes cognitive and academic function is good, but a person's feelings about this functioning is very negative.  In this case, looking together at academic work leads to a very direct focus on an active set of symptoms.

What do Notes Look Like? 

The manner in which a person might keep notes, or organize essays, or surf the internet doing research, gives us better understanding of psychological health.    Are notes tidy, meticulous, or disorganized?  Do the notes fluctuate a lot from one week to the next?  Are the notes clear for someone else to read and understand?  Are there gaps where notes are missed entirely?  Is writing fluent once started, but just difficult to start?  Is there evidence of tremor or other neurological symptoms manifest in handwriting?

Cognitive Testing

If cognitive testing is to be done, it is most useful to refer to subject matter that the person is actually interested in, and experienced with.  A mathematician or engineer might not show any decrement on a simple arithmetic test (such as "serial sevens") despite having significant cognitive problems.  It would be more appropriate to ask them to solve a complicated mathematical problem having to do with their current work.    A literature student might not show any decrement on a simple verbal test (such as memorizing words, or reading a sentence) but might have difficulty describing the themes or dynamics of a current novel on the curriculum.    Another benefit to "testing" this way is that it can highlight unusual strengths and talents, which can then be a subject of positive feedback and encouragement.

Practical Therapy


Cognitive therapy is a type of "academic" process:  it requires note-taking, reflection, analysis, and homework.  Many students might not have time for diligent cognitive therapy.  But they do have time for their schoolwork!   Cognitive therapy can take place while doing schoolwork!  It could be rewarding in a therapy session for a patient to have a successful experience of completing an academic task, while having a chance to reflect on the emotional changes or barriers happening at the same time.   A creatively constructed regime of cognitive therapy could involve combining it with academic study.

Behaviour Therapy for performance anxiety

Many students have anxiety about sharing their work, being called on by a professor, speaking out loud in class, presenting in front of others, etc.  The therapy session is a chance to directly practice these things, in a supported setting.  It is a simple CBT exercise!


Therapy for Procrastination

Procrastination is one of the most common problems faced by almost all students.  This is often much worse when there are other mental health issues going on.  The increased stress, and decreased grades, caused by procrastination, often cause further worsening of mental health symptoms.  Procrastination is sometimes even a critical part of a deteriorating cascade of events, leading to leaving school unsuccessfully.    The core necessity in treating procrastination is to do the procrastinated thing as soon as possible!  In a therapy session, if this subject comes up, I believe it is optimally therapeutic for the patient to have an opportunity to do the procrastinated activity right in the session, immediately!   It is an incredibly simple way for a therapy hour to be directly helpful.  Otherwise, sometimes visiting a therapist can be yet another way to procrastinate work, and feel even worse!   If a patient of mine does agree to do some procrastinated schoolwork during a session, it is my goal to help the patient enjoy the activity, feel supported and encouraged, and to have an experience of success.

Study Techniques

Many students work or study inefficiently, which is an underlying cause of worse academic stress, then leading to worse mental health.  Discussion and practice of better studying techniques is directly relevant to mental health therapy.  I like to discuss various memory and time-management techniques with patients, and try them out right in the session.  These ideas are applicable to other life activities, including CBT exercises.

Reading and Oration

It has been remarkably common to find students who have trouble reading.  Often they have other cognitive strengths, which have allowed them to manage with this reading difficulty all their lives, while still doing well in school.  But in advanced academics, a reading difficulty can greatly slow down the rate at which a student can study.  Reading textbooks becomes a gruelling chore.   Reading out loud, or giving presentations, can become a source of dread.

The most effective therapies for reading difficulties are very similar to therapies for mental health issues:  it involves practice, in a safe setting, with tasks that are easy enough to be enjoyable and easily mastered, but challenging enough to foster growth.    Reading out loud is very literally an exercise to strengthen one's voice.  Such voice-strengthening is a metaphorical cornerstone of all progress in psychotherapy.  Practicing this literally, in a psychotherapy session, is simple, relevant, enjoyable, diagnostically informative, and therapeutically useful, often in a very immediate way.

Study as Mood Therapy

I believe that studying and other intellectual work can be intrinsically therapeutic for mood.  It can be a meditative and meaningful experience, and a healthy coping technique or psychological defense.  But some students have study practices which are far from meditative.  The therapy session can be a chance to help people regain a sense of meaning and meditative joy in study, to recapture "flow."

Oliver Sacks

I am reminded of the famous neurologist, Oliver Sacks.  He spent time really learning to know his patients well, and in doing so became not only a great therapist and physician, but also a wise and insightful scholar about the ways of the mind.   Part of his technique was to always engage deeply with his patient's work and study interests.   In doing so, often he would discover phenomena that would never have otherwise been noticed or attended to.   I would hope to be a clinician more like him.


Other Work (not just study)


I think it is important to discuss other areas of work, with patients, and to be willing to look together at the work very directly at times, if desired.  I like to see examples of some of the work my patients do, and I think this relates to health in a similar way.


Benefit for the therapist


If a therapist takes sincere interest in a patient's work, study,  and other activities, it is also beneficial for the therapist.  What a delight it is to vicariously be part of an educational journey!   The therapist's health will therefore also be better.  This, in turn, will improve care within the system as a whole.  And this goodness will "bounce back" to the clients or patients, and continue a cycle of interpersonal positivity.

Wednesday, March 8, 2017

Biases in Psychotherapy Research

Biases in Research 


Pharmaceutical Research

We are much more familiar these days with biases in pharmaceutical research studies.  A clinical study of a medication treatment is more likely to show an exaggerated beneficial effect, if the study is sponsored by the manufacturer.  This doesn't mean industry-sponsored research is "bad," and it doesn't mean that pharmaceutical products are "bad," but it does mean that we have to look with a careful, skeptical eye at research results--not just at impressive tables or graphs, but also at the sources of funding for the study, and the authors' past relationships with the manufacturers.  There could indeed be overt "badness" if there are examples of flagrant profiteering on the part of people involved.  But the more salient issue, in my opinion, is simply the need to question the authority of results from such studies.

Alternative Medicine

This same critical eye is very much needed for looking at research evidence regarding alternative treatments.  There are very strong sales tactics used to market supplements, herbal remedies, and other treatments, and the standards of evidence presented are often much lower than those from pharmaceutical studies.  For example, simple testimonial accounts are much more common in alternative medication marketing, as are impressive-sounding but clinically irrelevant scientific or pseudo-scientific claims.

Psychotherapy Too! 

We may assume that studies of psychotherapy would be relatively free of these biases.  After all, there is no big company that is profiting from psychotherapy!

But we must maintain a critical eye even for studies of psychotherapy.  Here are some reasons:

1) A positive study of a psychotherapy technique may not bring obvious financial profit to anyone, but it is likely to increase the prestige of the authors.  A big part of the "currency" in a Ph.D. researcher's career relates to impressive publications.  A study showing a significant treatment effect of a psychotherapy technique is likely to add to the fame and career advancement of the authors.   This career advancement is analogous to direct financial gain.

2) Many psychotherapy researchers have spent many years of study devoted to their therapy technique.  Imagine if you had spent 10 years studying a particular thing, and that you had strong feelings about it.  You could imagine that you might have a bias in favour of the technique that you had studied all those years.  You would really want to show that it works!  If a study showed that it didn't work so well, it might lead you to question the value of all those years of your career!  In Cialdini's terms, this bias would have to do with "consistency."   If someone has been consistently committed to a particular thing for a long time, they are biased to maintain support of that thing, beyond what would otherwise be reasonable.   Furthermore, if you had worked all those years studying one particular technique, your social and professional community of peers would be more likely to share similar opinions.  You might have frequently attended conferences devoted to your area of specialty.  You might have even taught students the technique, who appreciated your help and mentorship.  This would lead to Cialdini's "social pressure" effect -- since the people around you support your idea, you will be more likely to hold onto the idea yourself, beyond what would otherwise be reasonable.

3) There is more and more direct financial gain related to therapy techniques.  We see a lot of books, self-help guides, paid seminars and workshops, etc.  Charismatic marketing, including through publishing of research studies, is likely to increase the financial profit of those involved.

4) In the psychotherapy research community, CBT is the most common modality.  CBT is intrinsically easier to research, since it is more easily standardized, the techniques themselves involve a lot of measurement, and the style tends to be more precisely time-limited.  CBT is more "scientific" and therefore attracts researchers whose background is more strongly analytical and scientific.  There is nothing intrinsically wrong with this , but it leads to more bias in the research.  Therapy styles other than CBT are studied less frequently.  Therefore there will be fewer positive studies of other styles.  This gives the impression that CBT is best.  It is not because comparative studies have actually shown it is best.   New versions or variations of CBT (with different fancy-sounding names) are also frequently marketed, and often show good results in research, but once again this does not really prove that the techniques are best.  The research study becomes an advertising tool for those who have designed the technique.

Conclusion

I do not mean to sound too cynical here...I think that CBT, as well as all other therapy techniques, are interesting, important, and helpful.  We should all learn about them, and make use of some of their principles.  But I do not think that any one style is necessarily "best."  We should not allow biases in research, including simple marketing effects, to cause a large change in our judgment with respect to helping people.

I feel that the more important foundation in trying to help people is spending the time getting to know them, and hearing from the person you are with (whether it be a client, a patient, a family member, or a friend) what type of help they would actually like.

Also, different individual therapists have different personalities, interests, experiences, weaknesses, and skills.  I think it is unhealthy for a community of therapists or healers to be pushed into offering a very narrow range of techniques or therapeutic strategies. Instead, I think that the individual talents and strengths of each therapist should be honoured, and there should be room in any health care system to allow for this.

Friday, February 24, 2017

Always Question

The freedom to question is a foundation of healthy living.

In our nation, we experience this freedom in the form of constitutional rights to express ourselves, and in the form of enjoying a free press.

For many of us, these freedoms may nevertheless seem fairly abstract, and maybe not that pertinent to daily living.  Other issues may seem much more important in daily life.  This is especially true if we are struggling with poverty, illness, or other consuming life stresses.  Sometimes there may not seem to be time to protect our freedoms, when there are other urgent matters to attend to.  Whole nations may feel the same way.

I would like to make a case that this type of freedom must be exercised, on a daily basis, in a wide range of daily activities.  This is not just a matter of protecting fundamental human rights, but it is a matter of thinking clearly and rationally about daily, practical decisions, so that we may make these decisions in a way which guides us towards better health and happiness, and education.

Once again, I would like to refer to the work of the great psychologist and Nobel laureate, Daniel Kahneman:  he showed us how the human mind is deeply prone to cognitive biases, which affect all of our decisions, often outside of our conscious awareness.  His work also suggests ways that we can protect ourselves from being misguided by our biases.

Let's look at an example situation, of a public educational lecture.  How do biases occur in such a setting, and how can we exercise our freedoms in a healthy way as audience members?

Most of us would understand a public scholarly lecture to be an entirely benign educational event, in which we could all expand our minds...this would be especially true if the speaker were articulate, expressive, passionate, and experienced with giving lectures!

But here are a variety of biases that occur in lectures:

The Focusing Illusion

In order for a lecture to be narratively interesting, it should probably have a "thesis."  This is not unlike a well-written essay (actually, this is one of the ethical problems of the conventionally encouraged format of essays that most students are called upon to produce).  If the speaker is vacillating between several positions, the audience may view him or her as weak-minded or lacking confidence.   An essayist who vacillates will probably receive a lower grade.

But in order to propose a single thesis, we already are at risk of a bias called the "focusing illusion."  This is akin to experiencing a salesman trying to sell you a used car, or a vacation package, or a set of encyclopedias, or an opportunity to contribute to a charity:  if we are presented with one single thing, whether it be a consumer item or an idea, we are more likely to accept it, compared to being offered a variety of options, each given equal time and persuasive effort.

A lecture, even if it is being given by a famous, experienced, wise scholar, is quite possibly biased due to the focusing illusion.  The audience is more likely to accept the message of the speaker, beyond the acceptance that would be reasonable based on rational thought alone.

Cialdini's Persuasive Factors

Cialdini described the following elements which magnify persuasive power, beyond the rational content of any message or appeal:
a) liking  b) authority c) social pressure d)consistency e)reciprocity f)scarcity

A public speaker's persuasiveness will be bolstered by a wide variety of elements which have nothing to do with the accuracy or content of the thesis.  An enthusiastic or passionate speaker who is a well-liked and respected authority (or who at least seems to be), will have greater power to persuade an audience, irrespective of the content of the lecture.    If many others in the audience are enchanted with the speaker, and are smiling, nodding, or applauding, then you as an audience member will be more likely to go along with this spirit of approval, through social pressure.

A speaker who is wearing more expensive clothing,  who physically looks more like you, or has some other coincidental common background (such as hometown, ethnic heritage, or cultural interests),  has a more attractive video presentation, with more attractive fonts, elements of humour, and perhaps musical accompaniment, is more likely to be persuasive.

  If you have already agreed, particularly in a public way, or through agreements made in previous meetings, to elements of what you are hearing in a current lecture, you are more likely to go further with what the lecturer is saying, even if you would have otherwise disagreed.  This is due to the factor of consistency.  If you are served snacks and coffee during the lecture, and if the speaker gives you warm compliments, you will be more persuaded by the speaker's message, due to reciprocity.   And if the speaker is heavily booked across North America, and if it was hard to even get a ticket to attend the lecture, then you will be more persuaded, since the lecturer will seem more rare and special (scarcity).


Suppression of Counterargument

Kahneman and others have made the case that the most powerful persuasive bias of all is caused by suppression of counter-argument.

If you are attending a lecture, a presentation, a meeting, or a political rally, in which opposing views are not allowed, then this is a strongly loaded environment for biased persuasion.   We have seen this phenomenon in political rallies across the world in the past year.  When dissent is discouraged, suppressed, or even forbidden, then we as individuals, and we as a society, have lost our authority to make free decisions.  Decision-making under such conditions cannot be rational.  It would be like a court case in which only the prosecutor or defense would be allowed to speak, rather than allowing both sides an equal opportunity.  Or, imagine a NASA team designing a new space station, in which it was not encouraged for engineers or technicians to express concerns about design flaws or safety issues.

Sometimes counter-argument seems to be encouraged, but the actual time and space for this to occur is not actually present.  It is freedom in word only, not in action--which really is not freedom at all.  A lecturer may allow some time for questions or debate, but often only a few minutes near the end.  And the old familiar forces, stated above, may subtly suppress debate.  Most audience members would consider it impolite to express disagreement with the speaker, especially if dissenting comments would receive negative non-verbal feedback from fellow audience members.

Zimbardo's Heroism

Philip Zimbardo, another great psychologist of our generation, has made it part of his life's work to study negative behaviours that occur in groups, in conjunction with the types of social psychological dynamics (such as group persuasion) that we've discussed above.

He calls for us to be "heroic":  what he means is that we should truly exercise our freedom, to always question.   It is easy to question things when we are strongly invited to do so.  It is harder to practice this freedom in an environment where questioning is discouraged.

The Risks of Questioning

If you raise questions, it is possible that you could get criticized by others in the group around you.  You might be labelled as being difficult, oppositional, or disloyal.  Some people may believe that you are being resistant to change, stubborn, or disrespectful.   Some might even think you are being narcissistic, as though you are aggrandizing your own opinions while devaluing the opinions of others.  The fear of such group disapproval, or of receiving such labels, often deters people from speaking out about things that need to be said.  

I think this is a risk worth taking.  You can show in other ways that you are not difficult, oppositional, disloyal, disrespectful, stubborn, or narcissistic.  The process of freely questioning actually prevents such problems...because freedom of speech, particularly when used in the service of ethical principles and practical problem-solving, causes a growth and strengthening of healthy character traits, both in the individual, and in the group.

I have experienced this type of dynamic, to my surprise and dismay, this past year, and I have decided to try to use this blog as a vehicle to practice and encourage free speech in this way.

Relevance to Psychotherapy & Mental Health

All mental health problems could be understood, in part, to reflect a lack of freedom.  Symptoms, such as anxiety or depression or insomnia or fatigue, may limit our freedom to experience life in a meaningful, enjoyable way.

Practicing our freedom of expression is an integral part of cultivating mental health, on a personal level.  This freedom could occur, for example, in the form of being able to initiate a conversation which was previously suppressed due to social anxiety or low self-esteem.

In therapy, the counselor or psychiatrist is an authority figure, but this force of authority should not be something that suppresses free expression.  Rather, the therapy environment should encourage freedom, including the freedom to dissent!   It should feel ok to completely disagree with your therapist, without fear of rejection or argument!   I think it should be accepted that it would also be ok, or necessary,  for your therapist to sometimes continue a gentle debate with you, rather than simply agree with what you are saying all the time.   But this dialog must occur with kindness, compassion, and respect, in a spirit of true openness.

If you are a student, or a member of the audience for meetings, sermons, or lectures, I encourage you always to nurture your freedoms, and to exercise your right to question.  It will not only be of great benefit to you, but it will be of great service to other members of the audience, and to the educational process.

Cognitive Therapy

At its best, cognitive therapy is a formal mechanism to question one's own thoughts!  Anxiety, depression, trauma, and other adversity give rise to changes in thought, which can often end up causing suffering or oppression.  If your own thoughts are frequently bullying you, putting you down, or telling you that you can't do certain things, then this is akin to attending a biased presentation at a lecture, political rally, sermon, or policy planning meeting.

Negative thoughts often could be understood to have some positive motivations--with many anxious thoughts, there may be a sincere motive to be protective.  Your thoughts may be trying to warn you about potential dangers, based on learning from the past.  It is just that the voice of these thoughts can become too powerful and persuasive, like a demagogue at a political rally.

These negative thoughts are bolstered by the same familiar factors described above:
1) negative self-talk is often presented without comparisons -- leading to the focusing illusion
2) negative self-talk can seem authoritative, which makes it more believable
3) negative self-talk may have been around for a very long time, which bolsters the persuasive factor of "consistency."  You may have even made certain "commitments" to the negative thought, or perhaps have been using them as motivational tools (e.g. studying to avoid guilt, rather than to pursue joy).
4) negative self-talk often does not invite questioning or dialog in your mind...it likes to have the final word...attempts to question it can seem futile

So, cognitive therapy can be framed as a type of personal liberation movement, which requires a practice of active questioning.  You can become a civil rights leader in your own mind!   I think it is important to view cognitive therapy exercises in this way, as the techniques can otherwise seem somewhat oppressive in themselves...the point in cognitive therapy should not be simply to do the exercises your therapist or self-help book is prescribing for you, or to criticize your "cognitive distortions"--this sounds disturbingly like the type of talk yet another oppressor might use.  Analogously, in many oppressive political systems, we see one tyrant simply being replaced by another...it is necessary instead to strive for freedom.   So I encourage your work in cognitive therapy to be an exercise in compassionately  developing and asserting your freedom, through courageous questioning of your self-talk.  

I am not meaning to encourage reflexive defiance, however.  Sometimes, after a period of debate, it is time to make a decision, and to move forward with that.  It can be unhelpful to debate every step of the way in every change process or learning event.  But it is very important to make sure that there is space and time given, in all situations, for freedom of speech, free opportunity for dissent, and for balanced, unbiased decision making.  I encourage you to protect your own freedoms this way, and also to protect the freedoms of others, by practicing a lifestyle of intellectual openness, curiosity, and free questioning.

Tuesday, February 7, 2017

Mediterranean Diet for Treating Depression

Jacka et al. have just published in BMC Medicine (January 30, 2017) the results of a study showing that healthy dietary change leads to significant improvement in depression.

In their "SMILES" study (another astonishing acronym--it stands for "Supporting the Modification of Lifestyle in Lowered Emotional States" !!), they included 67 people with moderate to severe depression, who also had low dietary quality (e.g. they were not eating a lot of vegetables, fiber, fish, and nuts, but were eating a lot of processed foods and sweets).  The participants were randomized to receive 7 sessions of either nutritional counseling, or social support.  The nutritional counseling aimed to encourage a Mediterranean-style diet, including whole grains, nuts, fish, legumes, vegetables, and fruit, while avoiding sweets and processed foods.  The social support involved having neutral conversations or playing games ("befriending").

People in the nutritional counseling group dropped their depression rating scores by about 40%, while scores in the social support group dropped by only 20%, which was statistically different with a p-value of about .03.  That is, the difference in outcome was about 97% likely to be due to the treatment effect, rather than to chance.

Reflection and Conclusion

It goes without saying, in my opinion, that healthy diet must be emphasized for everyone, in order to improve all aspects of physical and mental well-being.  In depressive states, nutrition tends to be less healthy, for a variety of reasons:  people may have less energy to attend to good nutrition; their depression may cause reduced or increased appetite; there may be comorbid eating disorders; there may be medication-induced side effects affecting nutritional behaviour or metabolism; and the depression could be associated with negative economic and social factors, which are in turn related to poor nutrition.

In addition to this, it is possible that there is a direct biological effect of poor nutritional quality causing depression.

So, in order to manage depression, and all other illnesses, it is of course important to encourage healthy dietary change.

But in the case of this study, there are a few ways in which the results may seem to exaggerate the effect of the nutritional change:

First, it seems to me that any substantial positive lifestyle change could have an "active placebo" effect independent of its direct effect on mood.  Changing your diet in the ways suggested is, in my opinion, intrinsically healthy.  But in order for someone to actually make these changes, they would have to frequently make different decisions than usual in the course of their day (for example, they would eat broccoli and fish instead of a fast food burger).  It is clearly healthier to have that broccoli and fish, but the therapeutic impact of this decision may not be exclusively because of the better nutrition--it is also because the person is taking an active, disciplined step to choose something deliberately, in the name of changing their life for the better.  It is this positive intention which may be a significant part of the therapeutic impact.

People in the control group, who had conversations and card games during the 7 sessions, probably did not experience much of a sense of their lifestyle substantially changing.  I think a more interesting activity for the control group would involve something similarly "lifestyle changing" but not following the same nutritional guidelines.  

So I wholeheartedly affirm the practice of making positive dietary changes!  I have seen numerous patients who are feeling better as a result of making similar changes themselves.  But it is also important to question the conclusion of studies like this one...Here's a reason why:  suppose that there was another study which showed that buying an expensive nutritional supplement led to similar improvements in depression scores.  The supplement, in reality, could be inert, or could simply be flavoured water.  But taking the supplement would require a very active commitment on the part of participants, to alter their dietary behaviour in a consistent, disciplined way, with enthusiastic support from people claiming to be experts, over 12 weeks.  In this case, we could agree easily that the therapeutic impact of the apparent nutritional change was due to a change in disciplined habits, combined with positive expectancy, rather than due to the wholesome properties of the supplement itself.  If people were to assume, erroneously, that the supplement (and not the discipline involved to take the supplement) caused the benefit, then people would be at risk of being taken advantage of financially by the supplement manufacturers.
In conclusion,  I strongly encourage that people make positive, disciplined, healthy dietary change.  It quite probably will improve all aspects of health, including mental health.  But be careful not to overvalue the results of studies such as this one, since the same reasoning that would allow you to uncritically endorse this study's conclusions could make you vulnerable to the persuasive efforts of marketers selling products which also require disciplined adherence.

Wednesday, February 1, 2017

Compassion vs. Empathy: Reflections on Paul Bloom's Book

Paul Bloom, in his recent book called Against Empathy, challenges us to question the role of empathy as a vital ingredient of goodness or morality.  Bloom believes that kindness, guided by thoughtfulness, is the supreme guide to morality, while empathy is often morally neutral or even negative.

Bloom's definition of Empathy

By "empathy," Bloom is specifically referring to the phenomenon of experiencing and feeling what another person is experiencing and feeling.    Many of us define empathy more broadly, so as to imply kind consideration for others' distress, a willingness to help, and an intellectual understanding of another person's problems.  Even some of the researchers who study empathy are imprecise in their definition, leading them to include items about kindness or willingness to help on a symptom scale supposedly intended to measure empathy.

Bloom clearly is not talking about "understanding."   He affirms that it is clearly and obviously important to strive towards understanding of another person's problems or situation, in order to be able to best act morally and helpfully.    A variant of empathy, which we could call "cognitive empathy," refers to understanding, but not feeling, another person's emotional state.  Bloom affirms that this cognitive empathy is important and positive as a social skill, but is not necessarily a guarantee of moral behaviour.   With Bloom's specific, narrower definition of empathy (to feel what another person is feeling), he shows us the following:

Problems with Empathy

1) Empathy does not correlate with kindness.  Many people who behave cruelly have a lot of empathy for their victims.  In fact, sometimes the empathy for the victim causes a sadistic person to magnify their cruelty.  A good fictional example is the character of O'Brien (the "Big Brother" agent) from Orwell's 1984, whose emotional and cognitive empathy guided him to personalize and maximize his torment of the main character.

Conversely, some people who behave with the most astounding kindness and altruism are not guided or motivated by empathy at all.   People who perform daring rescues often do not empathize before they act.  Having an empathic reaction in an emergency could delay a life-saving action.

One example is described of a person who chose to give his kidney to a stranger for a transplant, guided by a cooly mathematical observation of the needlessness of having two kidneys for health, while many people would face death without a single kidney.    People, including young children, are usually motivated to do kind things not because of empathy, but because of a wish to be kind or helpful!

Empathy can actually deter people from behaving kindly, or from even being around suffering people, because the experience of feeling another's suffering is painful and aversive.  A caregiver who is highly, reflexively empathic is at greater risk of burnout.  Whole groups of people, such as those who identify as having autistic symptoms, may have much less "empathy" than average, but they are not at higher risk of causing anyone harm.   Violent offenders do not necessarily have "low empathy"-- the psychological factors associated with violent behaviour have much more to do with low self-control than low empathy.

2) Empathy as a moral guide can cause us to behave in a biased or unfair manner.  If we use only empathy to guide us to help a particular suffering person, it can guide us to help that person before helping someone else who needs the help more urgently.    Furthermore, we empathize more easily with people who are more similar to ourselves, and who live closer.  This may cause us to preferentially help others based on unjust factors (including age, race, ethnicity, etc.).   It is easier to empathize with a suffering animal we find "cute" compared to a suffering animal (who may be in even greater need) who is less photogenic.


Bloom rightly critiques the tendency for empathy to be admired as a type of stellar quality, for all of us to emulate in a quest to become better people, better therapists, or better societies.  He instead encourages us to strive towards kindness and understanding, with our actions guided by reason rather than the narrow, biased focus of emotional empathy alone.  This view is supported by those considered some of the world's greatest altruists, such as the Dalai Lama--in this tradition, it is calm compassion, free of anger, which is felt to be the best guide for moral action, rather than the emotion-swept milieu generated by empathy.


My Thoughts

I see Bloom's thesis as an extension of Kahneman's insights about psychological biases.  Our biases and emotional responses are an intrinsic part of being human, but they easily become experiences which fool us, and cause us to behave irrationally.

Empathy, in my opinion, is a quality similar to eyesight or one of the other senses:  it does not, in itself, have a moral quality.  It can have a narrow focus, which makes it prone to bias, and it can be easily fooled by illusions.  Having highly developed empathy does not make you more moral any more than does having sharp eyesight.  If you believe strongly that your sharp eyesight allows you to understand things better, you may be very prone to others taking advantage of your belief, and you may be very prone to being fooled by optical illusions.  This does not mean we should not cultivate our senses, including eyesight or empathy.  They are important talents and skills, and they deserve attention and practice.  It is just that we should not rely on them by themselves as moral guides.

Taming Empathy

I do believe that empathy is important, however.  It just needs to be "tamed."  I can think of many clinical situations in which an empathic moment--even to the point where I might shed a tear--has helped with my patient feeling a sense of connection and trust.   A therapist who shows no emotional response to a patient's suffering could be experienced as detached, aloof, and cold.  Also, many therapists have a reflexive suppression of their own affect, which is felt to be a part of professionalism, yet which causes an unnecessary and obstructive detachment.   A therapist's practice of allowing their own emotions to flow empathically, and to manifest in the session, can be an aspect of fostering connection and demonstrating sensitivity.   But if this empathy would lead to the therapist suffering with sadness or panic through the hour, at the same time as the patient, then this clearly would not  be helpful!  It would probably frighten or disturb the patient, and would also lead to burnout in the therapist.   A brief moment of deep empathy can be very therapeutic, but after that point, therapy moves away from pure empathy towards cognitive understanding and gentle problem-solving.

Empathy can also be a joy of life to experience, provided it is not understood to be a moral guide.   Empathy can and should be practiced and savoured, just as you would cultivate your other senses--but it should not be granted power as an arbiter of moral decisions.

Empathy for the Therapist! 

Bloom makes a nice point that in a good therapeutic environment, sometimes empathy is most beneficial in the opposite direction:  if the therapist is gently attuned and understanding, but calm and at peace, then the patient's empathy for the therapist may help the patient to attain calm and peacefulness in the midst of painful emotions.

Empathy could work this way in therapy as an example of social learning therapy combined with CBT:  if the patient would see the therapist briefly having a deep empathic moment of "co-suffering," but would then see the therapist gently step back, in a thoughtful, compassionate calm state, this could be an in-the-moment example for the patient to follow...in this way the therapist would truly be an emotional guide.  I think this effect should not be overstated, as the therapist's helping role may usually be much more modest and subtle.

The Importance of Listening and Showing Understanding

I believe it is very important to emphasize that we have been talking about Bloom's very focused definition of empathy.  I usually use the term empathy in a broader sense.    When people are meeting with a therapist or a friend, they often greatly desire to simply be with someone who will listen.   Many people do not desire to have advice or reassurance in response to what they are sharing, at least not right away.  And they may be frustrated if the other person starts to discuss their own similar problems.   It is often very appreciated if the listener at times reflects back what has been said, to convey respectful understanding, of both the situation and the emotions involved.  This reflection and demonstrated understanding is what I mean by empathy, most of the time.  A typical example could be saying something like, "you had an exhausting day..."  When giving this reflection, I would not normally feel exhausted myself!  Sometimes a more elaborate or detailed reflection could be good, but sometimes prolonging these responses for more than a brief sentence can interrupt the person's experience of being gently listened to.  

Tuesday, January 17, 2017

Hallucinogens in mental health

Hallucinogenic drugs such as LSD, psilocybin, and ayahuasca have been used to treat depression and addictions, and to help with the psychological well-being of patients suffering advanced stages of cancer.  

Terminally Ill  Patients

Jan Hoffman's article, published on December 1, 2016 in The New York Times, describes some of the research supporting the use of psilocybin for treating psychological suffering in cancer patients.* 
The most recent major study supporting this was published by Stephen Ross et al. in the December 2016 edition of The Journal of Psychopharmacology.     In this study, 29 cancer patients suffering from anxiety and depressive symptoms were given either 0.3 mg/kg of psilocybin, or an active placebo of niacin.  They received only one single dose!   There were no serious side effects.  The psilocybin doses led to large, sustained relief of anxiety and depression symptoms, following an immediate hallucinogenic, mystical effect which lasted about 6-7 hours.  Response and remission rates for depression and anxiety symptom scores were significantly larger, compared to placebo, than what we would typically see for most other established therapeutic modalities, such as conventional psychotherapy or antidepressants.  And these beneficial effects appeared to persist for up to 8 months.

In another study published in the same edition of this journal, by Griffiths et al., 51 anxious or depressed participants with life-threatening cancer received a low dose (~.01 mg/kg) and a high dose (~0.3 mg/kg)  of psilocybin,  5 weeks apart.    The authors found that the higher dose led to significant relief of anxiety and depression symptoms (final symptom scores were about 30% of the initial scores), which persisted over 6 months of follow-up.  Interestingly, reports outside of the usual depressive symptom score domain also changed in a positive way; for example, there were substantial increases in "positive attitudes about life."  A majority of subjects considered the experience with this therapy to have been very meaningful and significant.   The amount of symptom improvement was correlated with the intensity of the experience on the dosage day.   Once again, there were no severe side effect problems.  Blood pressure increases of up to 20 mm Hg could be expected.

Treatment-Resistant Depression

Here is a reference to another study published in the prestigious journal Lancet Psychiatry by Carhart-Harris et al. in July 2016: ****  This was an open-label study of 12 people with severe, treatment resistant depression.  They received a first dose of 10 mg psilocybin, followed by a second dose of 25 mg one week later.  They did not receive any further doses!    They were followed after this for 3 months.  Remarkably, there was a substantial reduction in depression severity scores which persisted at all follow-up points.  58% of the patients showed a response, and 42% of the patients showed full remission after 3 months.  

Microdoses 

Others have used so-called "microdoses" of hallucinogens on a more regular basis,  typically about 10% of a typical recreational dose every 4 days (e.g. an LSD microdose would be about 10 micrograms).   This is too low to produce a dramatic subjective hallucinogenic effect, but anecdotally can lead to a sustained relief of depression.  Here is a reference to Alex Williams' January 7, 2017 article in The New York Times describing a case example of this practice:  **

Addictions

Hallucinogens have also been used to treat addictions.  Here is a reference to a study showing very good long-term abstinence rates (67% after 1 year) in smokers treated with 2-3 doses of psilocybin (0.3 - 0.4 mg/kg) in combination with CBT:  ***

 In another small study, two doses of psilocybin were given, 4 weeks apart (0.3 mg/kg, then 0.4 mg/kg) to patients with alcohol dependence. *****   The patients were followed for 36 weeks, and had a dramatic, sustained reduction in heavy drinking days (reduction from 40% to about 10-15%).

Conclusion

Hallucinogens remain illegal in most places.  The quality and dose of hallucinogens available on the street might be very uncertain.

I have seen people whose experience with these agents appears to have helped them substantially.

But I have also seen people over the years who have used hallucinogens periodically, yet still suffer from a variety of psychological problems, including depression, anxiety, and addictions.

While the studies mentioned above have been very reassuring about toxicity risks and side effect problems, it would of course be very important to understand better any of the possible risks associated with this type of approach.   Patients with bipolar or psychotic symptoms might be at particular risk of harm from hallucinogens, though I would be interested to see better evidence of such risks.

If hallucinogens do have a role in treating various types of psychological suffering, I think it is likely that  they would have to be used with great care, probably in combination with a very safe, gentle, supportive milieu, and in combination with psychotherapy.  Arguably, some aspects of the benefit might be due to a "catalytic" effect when used in a safe, therapeutic setting, or as an augmentation to psychotherapy.

I would be interested to see more carefully conducted, randomized controlled studies of hallucinogens, so we could understand this issue better.  I think there is some urgency to get going with these studies, since the preliminary evidence seems so very promising.  The most likely dosing schedule for hallucinogens would be very infrequent, which would cause such treatments to be economically very inexpensive.  But as a result, we would not be seeing large-scale corporate funding for research into this!   Also, parts of the research community may have quite orthodox beliefs about non-standard treatment regimes such as this, which might cause delays in setting up good studies quickly.