Friday, November 21, 2014

Dumb Hidden Assumptions in Drug Abuse Research

The mental health professions these days seem to want to blame their patients' repetitive problematic or self-destructive behavior on just about anything except what is, in the large majority of cases, the primary causes: family dysfunction and adverse childhood experiences (ACE’s). And I mean, they would rather it be almost anything else.

In my post of February 26, 2011, I discussed how a slight increase in aggressive thoughts following the playing of violent  video games by adolescents was translated by researchers into the games being a major risk factor for the development of youth violence. The fact that most compulsive video game players are inveterate couch potatoes who do not get out much never entered into discussions.

Not surprisingly, a recent longitudinal study (Fergus0n et. al., J. Psychiatr Res 2012; 46: 141-146), showed that, by taking other variables into account such as intra-family violence, the correlation between video games and even short-term aggression could no longer be established.  Another older paper from the same lead author (Ferguson and Rueda,  J Exp Criminol, 2009; 5:121-137) showed that aggressiveness in the laboratory, as expected, did not correlate with violent acts in real life.

Focusing on minor targets like video games risks leading social activists and public policy makers to ignore the far more important causes of youth violence like child abuse.

So of course, now that the tide is turning against the insane drug war against  marijuana, which has turned a significant percentage of the population into criminals (who tend to only be prosecuted if they happen to be African American), the folks who refuse to look at reality are now publishing "studies" that attribute a host of problematic behavior almost entirely to the devil weed – while all the while making the most ridiculous hidden assumptions imaginable. 

People who feel the need to be stoned all the time have enough problems; we do not need to make up a bunch of other ones.

In Carl Hart’s book High Price , he recounts his adventures as a reviewer of potential drug abuse studies for funding from the National Institutes of Health. He mentioned that the research agenda was being controlled by the National Institute on Drug Abuse (NIDA). He makes it clear that they were only interested in studies that showed the dangers of street drugs, not on studies which countered the many myths in the field that he had described in the rest of the book. (NIDA also ignores the dangers of the very same drugs they demonize when Pharma sells them for conditions such as "ADHD").

Now comes a study out of Australia and New Zealand: “Young adult sequelae of adolescent cannabis use: an integrative analysis” by Edmund Silins and others. (Lancet Psychiatry, 2014;
1: 286–93). Here is the abstract:

Methods: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765).

Findings: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high school completion (adjusted odds ratio 0·37, 95% CI 0·20–0·66) and degree attainment (0·38, 0·22–0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44–34·12), use of other illicit drugs (7·80, 4·46–13·63), and suicide attempt (6·83, 2·04–22·90).

Interpretation: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefi ts. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects.

Funding: Australian Government National Health

The authors claimed to control for confounding variables, but most of these "controlled" variables were unrelated to ACE’s or ongoing family chaos. They were such things as age, sex, ethnicity, socioeconomic status and mental illness. The authors did control for a few possibly relevant parental variables like alcohol use, tobacco use, divorces, and history of depression. But not for how the parents actually behaved around their children, how they treated their children, child abuse or neglect, how chaotic the home environment was, or how and how consistently the children were or were not disciplined.

What on earth makes people who draw the conclusion that the drug was the primary cause of the lower achievement become so stupid that they don't see that frequent drug use is a sign that the teens already had emotional problems before they even started smoking - and that it was these problems that predate the drug use that were the real cause of both the drug use AND the poor performance?

The authors used exactly one rather vague sentence in their discussion to refer to this possibility, which most readers will miss: “…cannabis use in adolescence could be a marker of developmental trajectories that place young people at increased risk of adverse psychosocial outcomes.” (p. 291). 

Ya think?

Tuesday, November 11, 2014

More to the Story in Tales of Family Dysfunction: How Therapists Get the Whole Picture

She never mentions the word addiction
In certain company
Yes, she tells you she's an orphan
After you meet her family
~ The Black Crowes

In several recent posts (12/27/13, 5/27/14, 10/28/14) I brought up the idea that a story about someone’s family life that one hears from a patient in therapy, in a news story, in a letter to an advice columnist, or directly from friends and acquaintences, is quite often, shall we say, incomplete. The story is true as far as it goes, but it often leaves out details and information about the context in which it occurs.

In therapy, as the therapist gets to know the patient, listens carefully, and employs certain techniques to help patients get past their shame, guilt, denial, and protection of family members, the whole story gradually emerges. As I mentioned before, the plot thickens. The added information puts everything the patient told the therapist before in a whole new light.

This more complete information allows the therapist to do something called pattern matching. The full story will remind an experienced therapist of common dysfunctional family patterns that may apply to the patient’s situation, and about which the patient would have no way of knowing.

The therapist can then mention that in other similar cases such and such explained similar family behavior that was otherwise inexplicable and confusing to the patient, and inquires if this is what might be going on with the patient and his or her family. This in turn may allow the patient to understand many things in ways they never thought of before.

Before describing a commonly-used psychotherapy technique (which is a version of the facetiously named Columbo style of questioning, named after a famous TV detective, described in the post of 3/13/12), I would like to refer back to a previous post, popular among readers, about parents pretending to be clueless about why their adult children are no longer speaking to them.

In that post, another reader wrote in and mentioned some possibile details that perhaps the aggrieved parent may have conveniently left out.

A more recent letter to advice columnist Amy Dickenson (10/14/14) is a bit more revealing. The cut off parent initially attributes the cut off to what she readily admits was a rather trivial argument. However, as the letter goes along, the parent reveals additional information that shows that she was not so clueless after all, and the advice columnists calls her on it:

Dear Amy: The last time I spoke to my adult daughter was five years ago. I hosted a first birthday party for her son at my home and she severed ties with me after a petty argument. Since then, she has given birth to additional children, and for several years, I sent cards and gifts in the hopes of reconciling. I stopped giving because the only response I received was through secondary sources; she never responded directly to my e-mail or letters. I feel I had every right to be angry that day long ago. Both she and her husband were upset over my choice of party decorations (among other things). Post-fight, it came out that she felt unsupported during my marriage to my abusive ex-husband. And although I divorced him many years ago, it was evidently still acutely painful for her… — Wronged Mother

Dear Mother: You have chosen this space to try to restate your original gripes against your daughter… I can't help but wonder, however, about your daughter's feelings. In the midst of all the detail you supply, you mention your marriage to an abusive ex-husband. Is it possible that this estrangement is based on your daughter's anger over your inability to protect her from an abusive situation?...

Now in this case the mother had moved on from attributing the cut-off to the argument over party decorations and started getting into the important issues involved. But as mentioned, some patients in therapy or who are interviewed in news stories act like their initial explanation is the totality. It’s their story, and they are sticking to it.

So how do therapists help patients give them the relevant details necessary for the therapist to make an educated guess about what is really going on covertly during repetitive dysfunctional family interactions? The technique is a simple one in principle but difficult in practice, because it requires a therapist to remember everything the patient has said since the very beginning of psychotherapy.

My memory is unfortunately not that good, so I take extensive notes after every session. Just prior to the following session, I do a quick overview of all of my previous notes to refresh my memory.

As patients talk about what’s on their mind concerning ongoing issues, they will often mention something in passing which seems to contradict something they told me earlier in therapy. This usually happens while they are discussing seemingly unrelated matters.  (I just happen to be paying closer attention to what they said than most people).

As therapy progresses, they often mention the same or analogous contradictory information again. Some time later, when several examples of such ambiguities have arisen, I politely ask them to clarify for me how seemingly contradictory statements they have made fit together. I do this without accusing them of trying to obfuscate issues or to confuse me. In fact, I ask them to help me understand this from a position of my being confused, and perhaps just too thick to understand it (this was the technique Columbo used to get perpetrators to confess to crimes).

This is when patients start to admit that they had not been completely candid with me at the beginning of therapy. The amount of detail, internal consistency, and new information that starts to come out shows me that they are not making things up to please me. If and when that happens, their story begins to fall apart.

Another technique that helps clear up plot holes involves the responses the patient makes to any observation the therapist may make. This involves not only whether the patients are agreeing or disagreeing with what the therapist has observed, but what then follows.

Back in the day when psychoanalytic therapies were king, we were taught that there were four possible patient responses to any observation or interpretation a therapist makes. First, the patient agrees with the therapist, and then a bunch of brand new information begins to come out. That’s obviously the best outcome.

The second best outcome is that the patient disagrees with the therapist, but a whole bunch of brand new information nevertheless comes out. This usually means one of two things: 1. That the therapist is partially correct, but is missing something important. 2. That the therapist is bringing up something prematurely, before the patient is quite ready to admit to certain things for any of a variety of reasons.

The second to worst outcome is when the patient agrees with the therapist, but then gets quiet, with no additional information coming forth. This usually means that the patient is agreeing with the therapist only for the purpose of telling the therapist what the therapist seems to want to hear.

The worst outcome is when the patient disagrees with the therapist and then gets quiet. That usually means the therapist is way off, and it is time for him or her to ask for the patient's thoughts, and then shut up and just listen.

Tuesday, November 4, 2014

An Unwarranted Hidden Assumption in Research on Personality Disorders

One of the major reasons I became interested in family systems theory, tribalism, family myths, social psychology, and other manifestations of collectivism was because I noticed a big problem with the major forms of psychotherapy practiced on individuals: psychodynamic and cognitive-behavior therapy, and, though to a lesser extent, humanistic therapies like Gestalt therapy.  

All of these forms of individual therapies pay way too much attention to the way patients are reacting, and not nearly enough attention to what it is they are reacting to.

It’s a bit like looking at someone who is falling apart after recently having personally witnessed their entire family being beheaded by terrorists, and concluding that he or she has “poor distress tolerance coping skills.” Well, maybe not quite that bad, but you get the idea.

Some psychologists talk about something called the fundamental attribution error. According to Richard Nisbett and Lee Ross in their 1980 book, Human Inference: Strategies and Shortcomings of Social Judgment, this is defined as “the assumption that behavior is caused primarily by the enduring and consistent disposition of the actor, as opposed to the particular characteristics of the situation to which the actor responds.”

Richard E. Nisbett, Ph.D.

Of course, internal predispositions, one's past history of learning due to environmental reinforcement, and free will are very important in determining how people are going to respond to a given situation. With people who have personality disorders in particular, however, to say that their living in a family war zone, as frequently described in this blog, is not a huge part of the problem seems to me to be the height of absurdity.

I thought of this issue recently after reading an article entitled “Ecological Momentary Assessment in Borderline Personality Disorder: A Review of Recent Findings and Methodological Challenges” (Santangelo, Bohus, & Ebner-Priemer, Journal of Personality Disorders 28 (4), pp. 555-576). 

Ecological Momentary Assessment (EMA) is a research technique designed to look at behavior and internal processes outside of the confines of what is called retrospective reporting. Retrospective reporting is the subjects' response to questionnaires about the way they normally respond in their daily lives - in hindsight.

People in studies using this technique are given a diary to fill out several times per day at regular, fixed intervals as they live their normal lives. They are instructed to record certain feelings and reactions they are experiencing. In the article’s abstract, it says that EMA is “characterized by a series of repeated assessments of current affective, behavioral, and contextual experiences or physiological  processes while participants engage in normal daily activities.”

As the authors reviewed the results of prior studies using this methodology in subjects with borderline personality disorder (BPD), one of those hidden assumptions I defined in a previous post just jumped out at me. The authors were inherently ignoring issues created by the fundamental attribution error. 

The definition of EMA in the article's abstract mentions “context,” by which I assume they mean the environmental context, but in the studies and in their discussion about them, the issue of environmental context seemed to be missing in action. The subjects were always asked about how they were responding, but almost never asked about what it was that they were responding to!

The authors’ literature review focused on five of the DSM’s (the official diagnostic manual of the American Psychiatric Association) criteria for BPD: 1. Affective instability. 2. Dissociation and transient paranoid ideation. 3. Interpersonal disturbances. 4. Self esteem disturbances. 5. Suicidality.

Now, one legitimate reason for doing these studies is to check on the validity of the diagnostic criteria for BPD, in which case descriptions about how the subjects’ families were behaving would be somewhat irrelevant. Since the diagnostic criteria were used to establish the diagnosis of BPD before the studies were even done, if the studies seemed to indicate that the criteria are turning out to be invalid, that would have to mean one of two things:
  1.       Patients with BPD have been invariably lying through their teeth - on an impossibly consistent basis - in giving even superficial descriptions of their personal symptoms and experiences during diagnostic interviews ever since the syndrome was first recognized, or 
  2.      The experimenters in the various earlier studies were lousy diagnosticians and were not applying the criteria in a valid manner.
Now, since I would assume that neither of these things was generally true, a finding that the subjects did not experience these symptoms would be most surprising. Of course, generally the subjects did experience the symptoms, although perhaps in some cases not quite in the generally accepted way. This sort of a conclusion is very close to being a tautology – that is, “a rose is a rose.”

But I digress. The authors clearly mention that some of the symptoms they are looking at occur in response to stress, but generally the subjects are not asked to describe the actual stresses to which they are responding. For instance, they say that subjects with BPD were found to be “more prone” to experience stress than controls. 

The problem with this is that it that assumes that the stressors that the controls are responding to are of equal frequency, severity, and nature as the stressors to which the subjects are responding. But no descriptions of those essential factors are presented. Perhaps if the controls were living in a more stressful environment, they would experience the stresses in a fashion more similar to that of the BPD subjects. 

Why are the subjects not also asked in their diaries to describe the stressors to which they are reacting? Is it all in their heads?  (It’s All in Your Head was the original title of my last book. Damn those academic publishers who thought that title was too colloquial). Or is it because therapists, like a lot of people these days, don’t want to look at what is actually going on in families?

Another issue is that, even if the diaries did ask about stressful interactions with intimates, and even if patients described them honestly and included their own behavior in their descriptions, the experimenters would still be in the dark about how severely stressful they were. That is because these interactions have subtexts, as I described in my post The Obvious Secret of Interpersonal Interactions Within Families. 

Words and behaviors during family interactions take on additional shades of meanings within the context of all prior interactions, and these meanings can significantly add to the stress level of the involved parties. In fact, without knowing the entire history of the patient's family interactions, the experimenter's judgments about the severity of the stress would by necessity be extremely flawed. 

As far as I know, there is only one method by which a mental health professional can obtain this data: long term psychotherapy with the involved individual. This should also include occasional conjoint sessions with the patient and family members, to get their sides of the story. The stressors of every single patient have qualities that are unique to them.

Without any descriptions of the nature of the stressors, we can not really come to valid conclusions. Of course, a possible assumption that should be made is this: people who are under severe stress are undoubtedly more likely to respond with more severe reactions than people who are under far less significant stress. 


Tuesday, October 28, 2014

Victimhood and Self-Destructive Behavior

"Taking responsibility for something and self-blame are horses of two entirely different colors. The former is empowering; the latter is paralyzing." ~ John Rosemond, Ph.D.

"You cannot see red flags while wearing rose-colored glasses" ~ Jim Woods, M.D.

Whenever I get into discussions online about people whose behavior is self destructive and which therefore exposes them to dangerous situations, the same old argument comes up again and again. It is sort of the inverse of the argument that comes up when I discuss parental misbehavior.  I am accused of “blaming the victim” or “bashing parents” as the case might be. 

Of course, there are an infinite number of situations in which people are victimized or during which other bad things happen to them, and they bear absolutely no responsibility of any sort for what happened to them. That goes without saying, but I guess I have to say it anyway. (Lets see how many readers totally ignore what I said in this paragraph).

But those are not the situations under discussion.

Alternately, I may be accused of “condemning” those whose behavior I am discussing, rather than just describing it and elucidating its consequences and origins.

I guess I am being critical in the sense that I don’t think self-destructive behavior or bad parenting practices are good things. Does anyone?  But even if I am being critical, that’s a long way from “condemnation.” In fact, 
I have a lot of empathy for the reasons why people behave in self-destructive ways. But it is actually very unempathic to pretend that their behavior is not self destructive. That would be a lie known even to them, and lying is not an empathic thing to do.

Part of the reason these sorts of issues come up is quite understandable. In many cases in which people have been victimized even though they have done nothing to put themselves in harms way, victimizers have a long and storied history of accusing their victims of somehow having invited the abuse they received, and blaming them for it. This is easily seen in the history of the legal defenses used by rapists, for example.  “She was wearing provocative clothing.”  “She was just playing hard to get and wanted it.” And way too many sexist juries bought into this bullcrap.

I absolutely agree that these kinds of accusations are heinous, lame excuses, and/or completely bogus. They are usually outright lies.

Again, not the issue that is the subject of this post.

There was the situation in the news not long ago where a high school girl got so drunk at a party that she completely passed out. The party was attended by fellow students from the football team. She was gang raped while she was unconscious.  Somehow, pointing out that perhaps she bore some responsibility for putting herself in harm’s way is suddenly translated into “You are excusing the rapist.”

No I’m not. Those are two completely different issues and they are being conflated. The two issues intersect, but they are two different issues nonetheless. Nobody is saying that the rapists should not go to jail and even burn in hell for eternity. But that hardly negates the fact that the victim’s behavior put her in harm’s way. 

It’s almost ironic that people who get upset about discussing the victim’s role in this situation often seem to think that a large percentage of men are pigs who think rape is OK. If that were indeed true, then passing out at a party would be a particularly dangerous thing to do.

If instead of being raped the girl had when she passed out fallen down and cracked her head open on a concrete floor, would we say that the only one bearing any responsibility for what happened was the floor? Sorry, but the argument that no one can talk about what the girl did because some rapist A-hole might be inspired to defend himself by trying to blame his victim is highly problematic. In fact, it’s stupid. If you want to talk about how to handle people that employ manipulate arguments, that's great, but it's another discussion entirely. 

I’m mincing words here. Someday I’ll tell you what I really think.

It’s also bad policy. If we want to help self-destructive adults take better care of themselves, absolving them of any and all personal responsibility for their fate is counterproductive. The first step in addressing a problem behavior like drinking until you pass out is admitting that it is, in fact, problem behavior.

Another highly important point: Taking responsibility for your own actions and acknowledging it is not the same thing as beating yourself up about it. As Dr. Rosemond points out in the quote at the beginning of the post, self-blame is indeed counterproductive. However, conflating that issue with the issue at hand is another argument based on emotion, and not on reason.

How about the issue of whether the girl might have no control over her drinking? People who think alcoholism is a disease may try to advance that point. Unfortunately, this gives the girl the message that she’s just a helpless, ineffectual human being with no intellect or self control. What a great, empowering message to give to someone. If you are helpless to do anything about this issue, why bother to even try to work on yourself?

A version of this whole argument also comes up regarding domestic abuse. If anyone brings up the issue of why someone (particularly a female, but there are also plenty of men who stay in abusive relationships) did not get out at the first moment an abusive pattern was becoming evident, they immediately get accused of blaming the victim. 

Likewise, when someone attempts to look into the psychology of the abusers and what makes them do such horrible things, they immediately get accused of "making excuses" for the abuser. Bull.

Recently there was an article about women whose boyfriends murdered their children. The murderers of course went to jail, but so did the women. They were charged with endangering their children and not protecting them by having made no effort to get out of an abusive relationship. The author of the article was naturally outraged that the mothers would be so "victimized."

The usual argument in this situation is that the abused spouse is afraid to leave because of threats of more abuse, and they or their family members might even get murdered. This argument of course makes the ridiculous assumption that the abuse is not going to escalate and that there is no risk of being killed if they stay. In the cases described in the article, the women did stay, and their children are now dead!

The women who make no effort to get out of a relationship in which they are continually beaten up are indeed afraid to leave because of something. However, that something is obviously not a fear of more beatings.

Another hidden assumption in public arguments is that the woman is so helpless and stupid that she cannot figure out a way to leave. Again, if that is true, why should she even bother to try to get out? Of course leaving is risky, and there are no guarantees that something really bad might not happen. Again, however, there actually IS a guarantee that bad things will continue to happen if they stay. 

Are these people saying that women are just too weak, helpless, and stupid to figure out a way to get out or to get help, especially now that help is far more readily available than it used to be? (And our past history in that regard is indeed a disgrace, so go ahead and pretend I didn't just say that if you must). Is that supposed to make them feel good about themselves? In fact, those things are just what abusers want their victims to think about themselves, so people who worry too much that women will feel "blamed" if someone points this out are in fact aiding and abetting the abusers!

Many women are quite able to successfully leave a bad relationship - but then they go back. And in therapy we see patients all the time who get out of one relationship with an abusive man, and then get involved with another, leave him, and then get involved with yet another one. What's the common denominator in those cases? Are we "blaming the victim" if we look at the woman's pattern of choosing abusive partners?

One other tantalizing clue. If you ask an abused or formerly abused partner why they stayed (at least those that come in contact with therapists), they are far more likely to answer, "Because I love him!" than "Because he threatened to kill me and my family if I left."

Another issue is that some percentage (of course not all by a long shot - I have to spell that out too, I guess) of abused partners are indeed verbally vicious and provocative with their abusive mates. Now, I can say in no uncertain terms that no one has the right to beat up anyone no matter how provocative they are. Again, no argument there, so bringing up this point is yet another diversionary tactic from addressing this point. (Let's again see how many readers seem to miss this last statement). But to pretend that some people do not compulsively poke a stick into a hornet’s nest is to live in Fantasyland.

In an exchange in the comments section in one of my posts on my Psychology Today blog, I mentioned that psychologically healthy women (and men as well - men abused by their wives and partners are not at all uncommon) get out of a budding relationship at the first sign that they are seeing a controlling and abusive partner. Earlier on, the risk that the person leaving might be stalked and killed, while not zero, is much lower than it becomes as the relationship progresses.

I was then drawn into an argument about whether or not people who do get involved with abusers do not realize that this is what they are dealing with until it’s too late.

I again think it’s extremely naive to think that people can’t see what to many people would be obvious. People who are self destructive are frequently “in denial” and lie to themselves all the time.  The old story of the wife insisting that a husband is not having an affair as she washes another woman’s lipstick off his shirt collars while doing the laundry comes to mind. Therefore, accepting someone’s initial description of how idyllic a relationship that later became abusive was at its beginning is probably not wise.

I discussed a frequent occurrence in the therapy of patients who had previously been in abusive relationships: a lot of time patients in therapy will say at first that there were no early signs that their ex-spouse might become abusive. Before long, however, it turns out there were more red flags right from the very beginning of the relationship than one might find at a rally of Chinese Communists, and the patients sheepishly admit that they chose to ignore them. Consciously.

The response I received: “Could this be because the therapist has browbeat them into admitting something that really isn't true--that they didn't know how to recognize them? They don't give out manuals to teenage girls on how to spot abusive guys before they ever go on their very first date.”

I replied: “I guess you'd have to ask my patients if they think I browbeat them, but unfortunately that's not possible. But I don't. And no interpretation is necessary when it's they themselves who are clearly admitting what they were doing and adding relevant details in a highly coherent fashion right on the spot." And I never even accuse them of contradicting themselves, let alone browbeat them. I use a well known and very gentle, non-confrontational psychotherapy technique that's very effective in getting people to open up. I'll describe it in an upcoming post.

Perhaps the patients were all little Dostoyevskys who are able to spin a complex fictional yarn at a moment’s notice that has no plot holes - just to tell a therapist what they think the therapist wants to hear? Without even knowing what the therapist wants to hear?


But of course, you cannot see red flags if you are wearing rose colored glasses, as Dr. Woods pointed out. The question of why some people are attracted to controlling and abusive partners is not answered by saying they are just too stupid to recognize abusive and controlling people. In fact, since they usually grew up with people like that in their families, they are probably better than the average person at recognizing them.

The answer as to “why” lies in the family dynamics discussed throughout this blog.

It is a very wise rule to not jump to any conclusions at all about the role of a victim or apparent perpetrator in any situation until the whole story comes out. And there is almost always far more to the story than you hear at first. The plot, shall we say, has a marked tendency to thicken.

Tuesday, October 21, 2014

The Woeful State of Our Knowledge of the Brain, and the Director of the National Institute of Mental Health

The major theme of this blog is how family systems issues have been denigrated in psychiatry and even psychology in favor of a disease model for everything.  

For this reason, you might think that I would be highly critical of the National Institute of Mental Health and its director, Dr. Thomas Insel. He has led the agency to focus almost entirely on neuroscience to the exclusion of research into family dynamics and other types of social psychological phenomena. Without an understanding of those latter factors, I believe it is impossible to really understand even the neuroscience, let alone human behavior in general.

Dr. Thomas Insel

Insel has been particularly supportive of President Obama’s BRAIN initiative (Brain Research Through Advancing Innovative Neurotechnologies), with its emphasis on such things as bio materials, engineering and nanoscience. He has been critical of the field’s diagnostic manual, the DSM 5, because it is limited to just observable signs and symptoms rather than the causes (etiology) of the various mental disorders.

While I certainly am critical of his neglect of handing out research dollars for social psychological and other such issues in mental disorders, I certainly have nothing against studying the brain in more detail.

I was pleasantly surprised by a recent article about Insel in Clinical Psychiatric News (August, 2014) that showed that he was at least realistic about both the current state of our knowledge about the brain as well as the prospects for our ever really understanding it.

I was particularly pleased about the following facts he emphasized to the newspaper:

“We can get cells to turn into neurons, but getting cells to turn into circuits is still a challenge. We don’t even know what a neural circuit is. We don’t know where it begins, where it ends; we don’t know how big it has to be; we don’t know exactly what the dynamics are.”

“…it may turn out that our brains simply aren’t smart enough to figure out how they work…It may be just a cosmic joke that we’re evolved enough to ask these questions, but not evolved enough to answer them. We’ll have to see.”

And then there’s his comments about the whole issue of emergent properties that characterize anything as complicated as the human brain. As an analogy, think of a car. Is it just a collection of bolts, screws, gears and metal shafts? Well, yes and no. 

It is definitely comprised of those things, but if you just look at those things alone (reductionism), you’d be hard pressed to understand a vehicle which can transport humans and other cargo over long distances. Other properties of the car emerge from the interactions of the parts.

So for the brain:

“…there is this whole body of work now that says, ‘Don’t worry about those hundred cells, or even those individual cells, and don’t even worry about looking at the circuitry because the key activity in the brain that is associated with attention, and thought, and consciousness is very slow oscillatory activity
…these oscillations that go in and out of the cortex create the dynamic of the cortex – some people call these cortical avalanches – seem to be pretty important for the way the mind works.

It would be like saying we want to know what’s on a television screen, and that you actually do better if you step back and get the whole picture, but don’t worry about any given pixel, because the emergent property of that television show is actually the whole thing together.’”

You can say that again!

Tuesday, October 14, 2014

Book Review: How Not to Be Wrong by Jordan Ellenberg

A while back (11/2/11) I reviewed the book Stats.con by James Penston. That book discussed how the statistics used in randomized clinical trials can be highly deceptive. How Not to be Wrong also covers some aspects of statistical misuse, in more detail, and certainly in a much more entertaining way. Some of his comments are funny as hell. 

Jordan Ellenberg

Consider the widespread use of a statistic call the p value, which estimates the probability that the result of a study could have just been a chance coincidence rather than an actual meaningful finding. A study is generally considered positive if the p value is 5% or less.

5% is of course not 0%. There is a one in twenty probability that the study results that are deemed positive were in fact negative. But what happens if journals only publish the positive studies and not the negative ones, when there might be a large number of negative studies, and when the positive study results are not reproduced (replicated) in a second study? Well, people start believing things that are not true, that's what.

The reason for this is because, as the author points out, improbable things actually happen quite frequently. Especially if you do lots and lots of things – like experiments. 

Another issue he mentions is that, if your sample size is too small, the chances increase dramatically that one of your subjects will be an outlier that dramatically but artificially changes the average for whatever characteristic you are measuring. With a small sample, you are more likely to get a few extra prodigies or slackers in a study of people's ability to perform certain tasks. A famous example: if Bill Gates walks into a bar with a few other people, the average guy in the room is a billionaire.  

Here’s how the author starts out a discussion of the p value problem (pages 145-16) :

"Imagine yourself a haruspex; that is, your profession is to make predictions about future events by sacrificing sheep and then examining the features of their entrails...You do not, of course, consider your predictions to be reliable merely because you follow the practices commanded by the Etruscan deities. That would be ridiculous. You require evidence. And so you and your colleagues submit all your work to the peer-reviewed International Journal of Haruspicy, which demands without exception that all published results clear the bar of statistical significance.    
Haruspicy, especially rigorous evidence-based haruspicy, is not an easy gig. For one thing, you spend a lot of your time spattered with blood and bile. For another, a lot of your experiments don't work. You try to use sheep guts to predict the price of Apple stock, and you fail; you try to model Democratic vote share among Hispanics, and you fail…The gods are very picky and it's not always clear precisely which arrangement of the internal organs and which precise incantations will reliably unlock the future. Sometimes different haruspices run the same experiment and it works for one but not the other — who knows why? It's frustrating…
But it's all worth it for those moments of discovery, where everything works, and you find that the texture and protrusions of the liver really do predict the severity of the following year's flu season, and, with a silent thank-you to the gods, you publish
You might find this happens about one time in twenty.
That's what I'd expect, anyway. Because I, unlike you, don't believe in haruspicy. I think the sheep's guts don't know anything about the flu data, and when they match up it's just luck. In other words, in every matter concerning divination from entrails, I'm a proponent of the null hypothesis [that there is no connection between the sheep entrails and the future]. So in my world, it's pretty unlikely that any given haruspectic experiment will succeed.
How unlikely? The standard threshold for statistical significance, and thus for publication in IJoH, is fixed by convention to be a p-value of .05, or 1 in 20... If the null hypothesis is always true — that is, if haruspicy is undiluted hocus-pocus —then only one in twenty experiments will be publishable.
And yet there are hundreds of haruspices, and thousands of ripped-open sheep, and even one in twenty divinations provides plenty of material to fill each issue of the journal with novel results, demonstrating the efficacy of the methods and the wisdom of the gods. A protocol that worked in one case and gets published usually fails when another harupex tries it, but experiments without statistically significant results do not get published, so no one ever finds out about the failure to replicate. And even if word starts getting around, there are always small differences the experts can point to that explain why the follow-up study didn't succeed."

The book covers many subjects about which the non-mathematically-inclined can learn to think in a mathematical way in order to avoid coming to certain wrong conclusions and to zero in on correct ones. Many of these, however, are irrelevant to this blog – the chapters on lotteries come to mind. I of course found those parts a bit less interesting. But the chapters relevant to medical studies are so right on.

Another important topic the author covers is known mathematically as regression to the mean. This phenomenon can lead, as examples, to overestimates about the genetic component of human traits and explains why fad diets always seem to work at first but then later on everyone seems to forget about them. As mentioned, when you average any measurement applied to human beings, the averages can be deceptive.  

In addition to the sample size considerations described above, you can get into trouble if you start with a sample that contains people who are higher or larger on average on the relevant variable that the average person in the general population.

If two tall people marry, their progeny will usually be, on average, tall compared to others in the general population. However, they are not all that likely to be taller than their parents. As Ellenberg states, “…the children of a great composer, or scientist, or political leader, often excel in the same field, but seldom so much as their illustrious parents” (p. 301). Their heredity mingles with chance environmental considerations, and pushes them back toward the population average. That is the meaning of regression to the mean.

To understand this, think about those who embark on weight loss diets. One needs to consider the fact that most people’s weight tends to fluctuate a few pounds either way depending on a lot of chance factors, such as their happening by an ice cream truck. And when are people most likely to start a diet? When their weight is at the top of their range! So by the law of averages, they are probably in many instances going to lose weight whether they diet or not. But when they do diet, guess what happens? They attribute the loss to the fantastic new diet!

I can not say for certain, but I wonder if studies on borderline personality disorders (BPD) yield misleading results because of regression to the mean. Long term follow-up studies on patients with the disorder seem to indicate that it seems to go away after a few years in a significant percentage of subjects. This finding is misleading, however, when you look closer. 

To make the BPD diagnosis, the subject needs to exhibit 5 of the 9 possible criteria. Many of the "improved" subjects merely went from 5 criteria down to 4 of them, and were therefore not diagnosed with BPD any longer. Actually, they became just what we call "subthreshold" for the disorder. Their problematic relationships, however, were still pretty much the same.

These results could mean that subjects with BPD may naturally vacillate between meeting criteria for the disorder and being subthreshold, or between exhibiting a high number of the criteria and a lower one. Which would mean that if they qualified for the diagnosis at the beginning of the long term follow-up study, a significant proportion of the long-term study subjects were at their worst. If so, the study results may indicate regression to the mean, and therefore say nothing else significant about the long term prognosis for the disorder.

Other important statistical issues the author discusses clearly and brilliantly include assumptions that two variables are related in a linear fashion when the are not (non-linearity - cause and effect relationships that are not based purely on an increase in one variable always leading to either an increase or decrease in another); torturing the data until it confesses (running multiple tests on your study data, controlling for different things, until something significant seems to pop up); and the following problem inherent in studies designed to see if two things like being married and smoking are correlated: 

"Surely the chance is very small that the proportion of married people is exactly the same as the proportion of smokers in the whole population. So, absent a crazy coincidence, marriage and smoking will be correlated, either positively or negatively."

Any one who is serious about critically evaluating the medical literature owes it to themselves to read this book.