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.
Tuesday, February 7, 2017
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.
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.
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.
Tuesday, November 15, 2016
Healing Divisions: Empathy, Filter Bubbles, and Free Speech
There is a lot of conflict and division in the world. The recent U.S. election is just one of many examples of this.
What can be done to mend the conflicts?
I found a relevant TED talk a few days ago, featuring a social psychologist named Jonathan Haidt. He discusses the psychology of political difference, and also some ideas of what we can all do to help mend the divisions.
One of the simple challenges he poses to us all, is to practice empathy. It is easier to empathize with a person who has suffered in a way that we can understand or relate to. He points out that it may be much harder for any of us to empathize with someone whom we strongly disagree with. This lack of empathy with our intellectual or political opponents consolidates division, dislike, disrespect, and even hatred.
A very important obstacle to empathy in the modern world is a technical one: people who espouse a particular viewpoint may, through social media, or through other information sources, only expose themselves to those who already share the same views or opinions or backgrounds. Some services, such as Facebook, may deliberately filter information to be attuned to your interests and opinions. This "filter bubble" phenomenon leads to a reduction in empathy between opposing groups, and therefore magnifies division.
I encourage all of us to have a practice of learning why people feel or believe the way they do, even if they have very different opinions, feelings, or backgrounds. You may still strongly disagree at the end of this exploration, but at least there will hopefully be less enmity, and more understanding. You may discover that despite many differences, that there are unexpected areas of common ground. Such common ground can lead to peace instead of war.
A foundation required for this process to work is freedom of speech...I am very troubled by processes in which communication is suppressed. Even in the seemingly warm-hearted area of mental health care reform, I have seen processes of change in which dissenting voices were not welcome...the human tendency to suppress opposition in the name of efficiency or progress is universal. We must always take steps to protect our freedoms. This requires a certain bravery to express ourselves, even when your voice is a lone voice of dissent in a crowd...but it also requires a deliberate commitment to empathize, to strive to understand the feelings, thoughts, and motivations of those who disagree with you. Such empathy must be practiced as a basic discipline of life.
Another recommendation I have is to be aware of the "filter bubble"and to step out of it regularly. Read widely, from as many different sources as you can. This doesn't mean you need to agree with positions you find objectionable, but at the very least it does require you to be more aware of personal stories that you might not have been aware of before.
Addendum (in response to a message about this post): I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice! And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all. In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one. I think of some of the great voices in history, such as Martin Luther King's.
Addendum (in response to a message about this post): I am not meaning to suggest some form of passivity or tacit acceptance of situations which are alarming or wrong -- in fact, I strongly encourage using your voice! And there may often be a need for voices of protest or anger...but I also believe that strong leadership is needed to mend conflicts, which includes a voice that can speak to all. In large-scale human dynamics, people have a tendency to veer gradually towards extreme positions...for those who are drifting towards extremism of any kind, I think that an empathic voice can be much more effective to reverse an extremist trend, compared to an angry one. I think of some of the great voices in history, such as Martin Luther King's.
Monday, November 14, 2016
Grit in Psychological Health and Illness
I've recently finished reading a book called Grit, by Angela Duckworth. The author is a research psychologist who is part of the faculty at Harvard University. She also has a background and interest in childhood education, which is very relevant to her other work.
It is a good overview of the research that has been done about the factors that lead to success and achievement in various domains of life, such as in a profession, in athletics, and in the performing arts.
The author's thesis, in a nutshell, is that "grit", which she defines as perseverance over a long period of time, the practice of being undeterred by failures or disappointments, and the maintenance of long-term purposeful goals, is a much stronger factor leading to success, compared to hereditary factors or "talent."
While this may seem like an obvious truth, it is important to realize that the educational system, and the culture as a whole, tends to value the idea of "talent" more strongly than the idea of "persistent hard work." In one interesting study, an identical performance was judged more highly if the observers were told that the performer was "talented" compared to being told that the performer had "worked really hard."
How is this relevant to mental health?
Here are some of Duckworth's ideas, applied to mental health management:
1) if you are working on mental health, consider that it is necessary to work on this for years. Duckworth's research shows that successful endeavours in almost all spheres of life require a commitment of at least 2 years' time. During this time, it is necessary to have diligent, daily practice. This is not unlike the routines needed by a musician or athlete. This work needs to be guided by a long-term meaningful vision. The work may at times be difficult or even painful, and the work may be interrupted by periodic failures. The disappointing times must be accepted without allowing them to interrupt the work. In fact, it is necessary to learn from the disappointments rather than be derailed by them.
2) Duckworth ponders the unresolved question of whether the daily disciplined work needed for success must be "enjoyable." A lot of the work, in athletes for example, shows that the workouts needed for excellence are not, or cannot be, truly "enjoyable." The required work must challenge the status quo of your body's physiology and reflexes, and this is never easy to do. In this sense, a recipe for excellence is a tolerance for discomfort, which could be nurtured through practice. But I think this view could be reframed: the hard work needed may in the moment be uncomfortable, but provided there is an overarching sense of meaning and joy which guides the process, the periods of intense work would then fit into a paradigm of balanced health. I also believe that a good therapist, teacher, or coach, should always strive to make hard work as enjoyable as possible. Therapy itself may sometimes be quite joyful, and need not always be emotionally taxing.
3) In order to facilitate the years of work and discipline needed for growth and change, it is usually necessary to be part of a culture or community of change. Athletes are usually part of a team, whose members motivate each other. Musicians and academics hopefully are part of communities whose actions challenge and maintain growth and practice. It can make a huge difference to have a dedicated teacher or coach who believes in you, who sees your potential, and who challenges you to work hard. In mental health, I think a good therapist can have a "coach-like" or "teacher-like" role in this way. I think a good therapist should strive to be inspiring, motivating, but also challenging.
4) As Duckworth shows, it is necessary to have a sense of purpose in order to be able to commit to years of hard work. In depression, it is often the case that a sense of purpose is weakened or lost. It is of the utmost importance in therapy to address the issue of meaning. Without meaning, the hard work required for change could feel like a terribly draining, pointless chore. But how can we recapture meaning which has been lost? Maybe sometimes it is not so easy, but we can start by at least addressing it in conversation, and exploring possibilities. Often, in depression, meaning can be rekindled through behavioural exploration, in conjunction with relief of symptoms. In other cases, meaning can be recaptured even when other symptoms are at their worst.
5) One of the connotations of this type of work is that short-term models of mental health care are unlikely to lead to mental health "excellence," unless they serve merely as preliminary introductions to new ways of being. Just like in a successful classroom, sports team, or company, the atmosphere of change must allow for a sustained, long-term commitment. But it is an important critique of some longer-term therapy, that it can become too passive, just like the situation in which a teacher or coach becomes resigned to a class or a team which is not thriving. A good therapist, just like a good teacher or coach, must always strive for growth and change, while also helping the process to be as joyful and meaningful as possible.
It is a good overview of the research that has been done about the factors that lead to success and achievement in various domains of life, such as in a profession, in athletics, and in the performing arts.
The author's thesis, in a nutshell, is that "grit", which she defines as perseverance over a long period of time, the practice of being undeterred by failures or disappointments, and the maintenance of long-term purposeful goals, is a much stronger factor leading to success, compared to hereditary factors or "talent."
While this may seem like an obvious truth, it is important to realize that the educational system, and the culture as a whole, tends to value the idea of "talent" more strongly than the idea of "persistent hard work." In one interesting study, an identical performance was judged more highly if the observers were told that the performer was "talented" compared to being told that the performer had "worked really hard."
How is this relevant to mental health?
Here are some of Duckworth's ideas, applied to mental health management:
1) if you are working on mental health, consider that it is necessary to work on this for years. Duckworth's research shows that successful endeavours in almost all spheres of life require a commitment of at least 2 years' time. During this time, it is necessary to have diligent, daily practice. This is not unlike the routines needed by a musician or athlete. This work needs to be guided by a long-term meaningful vision. The work may at times be difficult or even painful, and the work may be interrupted by periodic failures. The disappointing times must be accepted without allowing them to interrupt the work. In fact, it is necessary to learn from the disappointments rather than be derailed by them.
2) Duckworth ponders the unresolved question of whether the daily disciplined work needed for success must be "enjoyable." A lot of the work, in athletes for example, shows that the workouts needed for excellence are not, or cannot be, truly "enjoyable." The required work must challenge the status quo of your body's physiology and reflexes, and this is never easy to do. In this sense, a recipe for excellence is a tolerance for discomfort, which could be nurtured through practice. But I think this view could be reframed: the hard work needed may in the moment be uncomfortable, but provided there is an overarching sense of meaning and joy which guides the process, the periods of intense work would then fit into a paradigm of balanced health. I also believe that a good therapist, teacher, or coach, should always strive to make hard work as enjoyable as possible. Therapy itself may sometimes be quite joyful, and need not always be emotionally taxing.
3) In order to facilitate the years of work and discipline needed for growth and change, it is usually necessary to be part of a culture or community of change. Athletes are usually part of a team, whose members motivate each other. Musicians and academics hopefully are part of communities whose actions challenge and maintain growth and practice. It can make a huge difference to have a dedicated teacher or coach who believes in you, who sees your potential, and who challenges you to work hard. In mental health, I think a good therapist can have a "coach-like" or "teacher-like" role in this way. I think a good therapist should strive to be inspiring, motivating, but also challenging.
4) As Duckworth shows, it is necessary to have a sense of purpose in order to be able to commit to years of hard work. In depression, it is often the case that a sense of purpose is weakened or lost. It is of the utmost importance in therapy to address the issue of meaning. Without meaning, the hard work required for change could feel like a terribly draining, pointless chore. But how can we recapture meaning which has been lost? Maybe sometimes it is not so easy, but we can start by at least addressing it in conversation, and exploring possibilities. Often, in depression, meaning can be rekindled through behavioural exploration, in conjunction with relief of symptoms. In other cases, meaning can be recaptured even when other symptoms are at their worst.
5) One of the connotations of this type of work is that short-term models of mental health care are unlikely to lead to mental health "excellence," unless they serve merely as preliminary introductions to new ways of being. Just like in a successful classroom, sports team, or company, the atmosphere of change must allow for a sustained, long-term commitment. But it is an important critique of some longer-term therapy, that it can become too passive, just like the situation in which a teacher or coach becomes resigned to a class or a team which is not thriving. A good therapist, just like a good teacher or coach, must always strive for growth and change, while also helping the process to be as joyful and meaningful as possible.
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