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.
Wednesday, March 8, 2017
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.
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.
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