A (very) critical "review" of CBT: mindfulness

In previous posts I told you that I did an inpatient CBT program for depression. I described the activity planning group here and the relaxation classes here. Today I’d like to share my experiences with the mindfulness group.

I doubt that these classes were according to any protocol, so I don’t want to extend my opinion on it to everything that’s called mindfulness. In the beginning of (almost) every class we were told the mindfulness or pleasure rules: Pleasure needs time, needs to be allowed, is individual… and the rest I don’t recall despite all the repetition. After that we had to focus on one sense, seeing, hearing, tasting, touching, and smelling. For example we were given an item in the hand with closed eyes and had to touch it to see how it feels, or we had to walk through the room and focus on the different colors we could see. I hope you get the point.

Now, I think it this *may* be *some* distraction, but it doesn’t really help. The mechanism by which it should help is not clear to me. When I’m feeling well, this would probably be an interesting task, but when I’m not it’s not. When I’m fine I like a lot of little things, an accidental splash of color on my water bottle, packaging foil (the sounds and looks of it), trees (they just look interesting and come in so many different forms), and lots, lots more. But part of depression is loss of pleasure and it doesn’t come back with just seeing things you might otherwise find beautiful or interesting. I can well describe the sensations (the roughness or softness of a material, the temperature of it, etc.) but it doesn’t mean anything. Chocolate tastes different than cardboard, but it is the same feeling. It’s just not nice. It’s effort. In some way I think the focus on what should be nice but isn’t is quite depressing in itself. It is like they try to tell you “but look, the world is nice, you’ve just to focus on that” but it doesn’t feel, look, take, sound nice.

Having a story to tell...

In a TV-documentary I once saw there was a prosecutor who basically said (smiling): “Yeah, I know that he fitted the criteria for insanity, everyone knew, it was so obvious. I didn’t think we’d succeed with our strategy but we had to build this *narrative* that he was sane.” And she seemed to be totally fine with it, she did her job and won, so that’s something to celebrate, isn’t it? Well, I don’t know. While she succeeded in her job, shouldn’t trials be about evidence and justice instead?

In science, I think this is even more complicated because there isn’t necessarily a representative for every side of an argument. While there of course is peer-review (which serves that purpose), peer-reviewers (most of the time) can’t know what is not reported, what is not part of the narrative that the authors tell. They don’t go and dig failed preliminary studies or replications out of the authors’ file-drawers; they don’t search for evidence against the authors claims.

Therefore I think that in research it is even more important that the full story, not just the prettiest element of it is told. However, that is not what we are taught. In 2015 I attended a Summer School for PhD-students. It was very interesting and I learned a lot, however we also were told that we have to tell a story, report the aspects that are most convincing and interesting to tell. While I understand and agree with some parts of that (data can be shown in confusing or less confusing ways) I think that this advice is mostly understood (and probably meant) as “out of the many things you could tell about your study/your data, you’ve to pick the most interesting part and choose the aspects of the data that support it, while ignoring the rest”. I think that this is wrong.

Who's responsible for flawed studies?

In his blog post about case of data-fabrication in which the (alleged) fabricator was not included as an author, Neuroskeptic notes that „Authorship means responsibility“. I agree!!

In this case, the grad student who collected and manipulated the data remained (so far) unnamed, because he is, rightly or not, not listed as an author. But while it should be clear that authors have to take responsibility for what is published under their name, I think that responsibility reaches further.

In any complex study naturally a lot of people are involved. Of course it’s not the fault of the person at Siemens who wrote the scanning sequence if we then go and use it incorrectly and – in my opinion – neither is it the fault of a supervisor if their PhD-student “cleverly” manipulates the data.(1) After all it’s not kindergarten; not everything can be checked.

But it should be (though I know that it not always is) by “surprise” if an aspect of a study turns out to be problematic after publication: You shouldn’t be able to know prior to publication that, say, the statistics are somewhat dubious; papers with fishy statistics shouldn’t be published. However, it might turn out later on that “consistent signals” may just be artifacts produced by the imaging techniques - and the fact that brains need a constant supply of blood. In such cases it would be useful to know which sequence was used and how – exactly - the resulting data were analyzed. To figure that out the people who chose the sequence or did the analyzes should be known – which in the current mess of unregistered studies is much more likely if they are (co-)authors. Of course they also deserve to be on the paper if they had (substantial) work with the study but for them to become important at some point it doesn’t really matter how “scientific” their work was. The purely technical aspects can be just as important: How long did it take before blood was frozen, how (exactly) where the patients immobilized in the scanner, which arm was the blood pressure apparatus on, did the optic cables reliable transfer the signal and how was that made sure, …? One might say, that all these kind of information should be part of the publication but often it isn’t.

Another point is which responsibilities people involved in research have beyond their specific duties. While I generally think that the responsibility doesn’t extent (much) above ones area of expertise, I do think that everyone does have the responsibility not to knowingly do or support unethical stuff – and any unjustified or flawed study is unethical in my opinion. In this sense funding agencies share a great deal of responsibility and, once known, the media are also responsible for reporting scientific misconduct. However, of course it can be difficult to judge which studies are unethical or flawed.


(1) If the data are manipulated “uncleverly” I do however think that the supervisor has some responsibility because he or she should be able to “see” that.

(Unfortunately English is still not my native language. I'm sorry about that!)

A (very) critical "review" of CBT: activity planning

I have been doing a cognitive behavioral therapy (CBT) program for depression. In yesterdays post I described the relaxation classes we had to do as part of the program. Today I’d like to talk about the “activity planning” group.

The group was based on the notion that actions, feelings and thoughts influence each other. Therefore – we were told – we just had to get doing (pleasurable!) stuff again in order to feel better and have more pleasant thoughts. We were handed a list of over 200 potentially pleasurable activities and had to do one such activity alone and one together with other people for each class. Each such activity furthermore had to be rated on a 1 to 10 rating scale in the dimensions “mood”, “drive” and “ease of mind” before, during and after the respective activity.

While I understand that it is important to get doing stuff – cos otherwise with absence of or low drive you’d just lie in bed and eventually die of thirst (or lack thereof) – I find that it is asked a bit much, that those activities should be perceived as pleasurable. For me, it just made me feel even more like a loser, because I couldn’t get any pleasure out of going for a walk, even though I tried. (“But it’s nice out here… I just have to tell myself… It’s nice… Sun and wind and…. But it sucks so much, why do I have to do this… I don’t have the energy, I’ll never arrive at the other end of the street…. And how do I know if it’s nice, the world is f*cked pretty much. It’s NOT nice. Climate change, and plastic in water, air pollution…. Why do I have to walk here, it’s so exhausting…. And the food we get here is wrapped all in plastic…. Which pollutes the seas….. But the river is NICE…. I’ve to tell myself…… But I don’t want to lie, not to others and not to me…… it’s not nice…. But maybe liars are the better people, at least they make others happy and aren’t such failures….. I hate this.” And so on….).

But what’s more important than that potentially nice activities didn’t seem to work for me is how to group was lead: It was instructed by whichever nurse had duty that day and they seemed to have very different opinions about what constitutes a pleasurable activity (independent of the list). While some accepted everything others had very specific ideas and would even get mad at you if you did an activity which they didn’t find pleasurable, for example tidying up or learning something (as an activity alone) or skyping and chatting or tweeting (as an activity with others). In their mind you had to get a massage or take a bath or color in something as a nice activity alone and an activity with others had to involve more than virtual contact (going to the cinema or a cafe would do). Now, I don’t find tidying up that pleasurable either, but at least something’s done afterwards, i.e. there’s less mess. If I’d get a massage I wouldn’t enjoy it and my place would be just as messy afterwards, so therefore nothing would be gained. Probably I’d feel guilty for spending the money on something I didn’t even enjoy, and like a failure for not enjoying something which should be enjoyed. Therefore I prefer tidying up – it has the better consequences. However, as I said, not everybody shares that opinion and while of course everybody is entitled to theirs I find it unhelpful decry the activities of people who tried their best to do (and enjoy...) them anyways. But of course not every nurse was like that, some didn’t really give a shit (so that the group ended within 5 minutes after everyone had recited their ratings) and others were trying to be helpful and encouraging (e.g. by suggesting in which other situations the said activity could be helpful or how the activity itself could be improved or what could be done instead).

Overall, is it helpful having to be doing a “pleasant” activity? Personally, I don’t think so, because it’s just not pleasurable and not feeling anything nice made me feel bad. *Just* doing some stuff, without any aspiration to finding it pleasurable *might* be helpful: Not eating or not drinking (water ;) ) doesn’t either, nor does not showering or not brushing teeth etc. But, in my opinion, it can be unhelpful to hope for any pleasure doing these things. Because if that’s the point and it’s too far away you might as well just not do it.

A (very) critical "review" of CBT: Progressive Muscle Relaxation

I did an inpatient CBT program for depression (as a patient) and I’d just like to express my opinion about it (because in a lot of ways it sucked … and apparently I’m not well enough to fill out their feedback form, so…). Of course it’s just that, just my personal opinion and just based on personal experiences at one time and at one place. Other people will have different experiences.

Whatever…

The program consisted of relaxation, activity planning, a mindfulness-group, music (and/or art) an “Info-Group” and of course the CBT itself (in a group and individually with a therapist).

In the relaxation group we did Progressive Muscle Relaxation according to Jacobsen (PMR). There you have to tense a specific muscle (like you hand, your upper or lower arm, your foot, etc.) for a few seconds and then relax it according to instructions. Then you should focus on the difference between the tension and the relaxation as well as the difference between (say) the left and the right hand. This relaxation technique is popular in Germany (I don’t know about elsewhere) however it does not work for me. (I tend to tension and relax my hands/fingers a lot anyways, especially when I'm not well, but I don't do it according to PMR guidelines; so therefore during the lessons I had to (try to) stop that.)  That’s not their fault, obviously, however I had to do the relaxation class during the entire time of my stay there, even though it had – if any – the opposing effect on me. Most of the time the instructor read the instructions from a piece of paper, but occasionally they just played a tape. Still, the fact that you had to go there may be helpful for people for whom the PMR works but who don’t have the motivation to do it on their own, when they are not forced to. (I find it hard to find any empirical evidence that it works for depression, though.) 

However, I think they vastly overestimate the amount of people from whom it works, because they did not accept any kind of negative feedback. At the end of each lesson there was a feedback round where you had to say how you are now and most people stated that they felt more relaxed. However, if you stated that you weren’t relaxed you still had to make up something which supposedly was better (which reminds me of research). My room-mate suggested I’d just say I’d me more relaxed to have my peace (which REALLY reminds me of research).

However, the one thing that was helpful about the PMR for me was having the appointment (where I had to go) itself; it structured the day a bit. But over all, I had preferred if I hadn’t had to go there.

I may or may not describe the other parts as well. 

Don’t know yet.

My dreams 2016

Hope you don't get nightmares...

1.

I have to do an MRI experiment, of course. For that purpose I have to poke my participants with needels, lots of them, cause it’s fun to investigate suffering. But – oh shit, I think - the needels are magnetic. They’ll slice my poor participant into thousand pieces while being scanned. I lean into the MRI-scanner to my screaming participant and try everything to grap as many needels as many needels as I can reach but this hurts my participant even more. 

Versions of this dream include me trying to convince my colleagues that they can’t put the participant in the scanner prior to him being sliced up or added fun with two participants simultaneously. 

2.

My supervisor wants me to build an inside fantasy world on top of the research building. With parks and waterfalls and stuff. And of course an airport, cos s/he is busy so how else should s/he get there. I keep thinking that that’s impossible, an airplane can‘t land inside the top floor of a building. Furthermore the groundplan of that planned top floor is much greater then that of the building itself. I mention that, but my supervisor just says that if I’m too dump for that I shall just ask the experts. Unfortunately I’m having a hard time finding experts on top story fantasy word building. However, to my surprise one day the the site is finished and it looks good. However, I know that it isn’t, I know that it’ll turn into a disaster and of course I’m right. The plane flights through a tunnel, and which is connected to that top floor to land on the airport and first it looks like it might just work out but then there’s a wind or something, the plane bounces from one site of the tunnel to the other and everything falls into pieces. 

Versions of that dream include a lot of stress because the human recouses depart has disabled my card to enter the building and especially the top floor or me going for a check in the fantasy dream world before my supervisor visits and discovering plies of dead (park-) workers in a sideway. 

3.

I try to get somewhere. Home, to work, where ever. But of course I don’t manage to get there. 

I may take a plane, which flies way too low between the buildings of a random city. The plan has a steering wheel and somehow, I’m the one who has to control it and try to avoid hitting any buildings. But it doesn’t react to what I do. Furthermore I have to run back and forth between the uncontrollable steering wheel and the back of the plane where people want something from me, but I don’t understand what, so they get angry and everyone screams at me. It’s windy, too. Sometimes strong winds hit the plane from street canyons, and the damn steering wheel doesn’t react. Eventually the plane crashes, with its nose into the asphalt of a street. People are not pleased with that.

Or, I may try to take a train (maybe a good idea after all these crashed planes, one would think). But of course, it doesn’t work out. Purchasing a ticket can be a complicated matter, especially in (my) dreams. The ticket machine may calculate a ridiculously long journey with several overnight stays at scary rail stations for an actually short distance. Or the ticket machine explodes when I try to purchase my ticket. Or, what could be a nice dream but isn’t, the ticket machine gives me back way too much money. I don’t know what to do with it i.e. how to handle the situation and get the money I falsely received back to its rightful owner(s). I can’t leave it there, because then obviously someone will take it. I can’t take it myself because I don’t have enough pockets and I’m clumsy and drop it everywhere. While I try to pick one coin up again I lose 10 others. People chase me for the money. I forget the rest in the ticket machine. My trains don’t arrive and the prediction on which track they’ll arrive changes constantly. After some chasing over some tracks I decide just to wait on the track I’m at till my train arrives there. (Good plan, no? :D). But police is after me for the money I just wanted to bring to the lost-properties office. (Another great plan, right? …. That reminds me of a real situation in Munich where I found a 50 Euro note in a train (S-Bahn) station on the moving stairs. I was so confused by that, that I turned to the person next to me and asked him if it was his…..). I get arrested, my attempts to explain myself fail.

Alternatively I have a ticket, but I need to bring my little sister with me and like always the announced tracks change constantly. We chase through station hall after station hall without getting anywhere. I realize we need to get underground but the underground part of the station is all flooded. It’s supposed to be like that, it’s just me and apparently my sister who can’t breathe under water. Not only that, but there’s also an underwater obstacle course which we have to solve in order to get somewhere. Unfortunately I fail and my little sister drowns.

I spare you the versions of that dream in which I accidentally kill my grandmother, my father or other random people.

Sleep well.

Bullshitting.

A few weeks ago Richard Morey wrote a blog post^[1] about how undergraduate students in psychology learn to bullshit (i.a.) by criticizing peer-reviewed papers (which are difficult to criticize because they shouldn’t contain any severe and easily detectable errors anymore). 

When I was studying we didn’t have to write any essays or to criticize any studies. So maybe I didn’t learn about the art of bullshitting well enough. However, I believe that the problem that bullshitting is rewarded is even greater than that: Guessing an answer in an exam and bullshitting a bit around is almost always better than stating that you don’t know. 

My first MSc-exam was in Clinical psychology. I think, I had learned really well^[2], but as this was an important – and also basically^[3] my first oral – exam, I was very nervous. The first question the professor asked me was: "Why is the prevalence of major depression increasing?" And I didn’t know! I didn’t even know it was increasing! But if s/he asked that, that must be, right? So I mentally went through all the text-books I’d worked through, searching for the part where they explained *why* more people today are depressed then in the past. I mean, it could be anything, or nothing. More divorces, different foods, more or different industries, different expectations or stressors, different lifestyles? Vaccinations? Exams?^[4] But my professor hadn’t asked for some hypotheses or my opinion but *why* that is. And I didn’t know! So I told him/her so, while I kept searching mentally in the text-books and all my notes. His/her next question was *if* I *knew* the theories for depression. As I was still desperately trying to come up with a better answer than "I don’t know" for his/her first question, I just said “yes”, because, well, I knew. At this point, I think s/he possibly felt pranked, because apparently s/he wanted me to name (or explain) those theories not be told that I knew them. Upon clarification I of course explained the theories to her/him, but I had real trouble understanding what s/he wanted from me throughout the whole exam.

It occurred later, much later, to me that s/he probably wanted to ask a "nice" first question whereby my task had been to bullshit something together, despite not knowing. Who knows *if* and *why* the prevalence truly is increasing and *if so* compared to when? 

I don’t blame that professor for my inability to understand my task correctly, so please don’t take me wrong. Of course I could have said: I don’t know… for this and that reason… one would need to know this and that to answer this question. Certainly that would have been much better, but I thought she wanted an answer to the question and not some justification why I don’t have it. 

A lot of people will say "Yeah, but you have to think beyond the facts and combine all the knowledge you have. Everybody can learn some facts so there’s no value in echoing some books without thinking about it by yourself!" And it's true, it's certainly an advantage to be able to think even during – or especially during – exams. But then at least frame the question like it. (E.g. "I'm interested in your opinion/thoughts. Let’s assume the prevalence of major depression was increasing. What could be possible factors that may – or may not – contribute to that? And how could one test if those factors actually do contribute to an increase in the prevalence? What would possible problems in testing those hypotheses be?") Otherwise it invites to bullshitting.

 

But then, on the other hand, bullshiting seems to be an essential skill in many aspects of life… maybe that is why they select by that….

[Sorry if that post is to bullshitty itself, obviously it’s just my opinion (and experience) and no knowledge… Also sorry for language-errors.]

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^[1]  Link: http://bayesfactor.blogspot.de/2016/04/how-to-train-undergraduate.html 
^[2] Or at least A LOT! Probably much more than what was good for me… 
^[3] Apart from a tiny part of my final school exams. But that was just a tiny part and therefore not nearly as important.

^[4] Not really.