Sunday, September 17, 2017
As an undergraduate, I had dreamed of being a writer so accomplished that students there would study my work. But when I hatched that fantasy, I didn't envision the work as a memoir assigned in an Abnormal Psych course. (From the Epilogue, p. 445)
Andrew Solomon, resembling a cross between Tobey Maguire and Sheldon from bad sitcom The Big Bang Theory, is a tremendous public speaker and storyteller. He is somewhat of a regular on the Ted talk circuit. You can hearing him holding forth on adversity and identity, as well as parenthood. One of his most interesting talks concerns depression. This talk is a primer for his much more in-depth treatment of this topic in "The Noonday Demon", a modern classic on the subject.
Solomon discusses his own experience of depression in depth, giving a sometimes poetic description of the phenomenology of his depression, and describing clearly how his level of activity was drastically reduced. He gives a warts-and-all account, describing not only his suicidal ideation but also how distorted thoughts led to self-destructive behaviour that must have seemed illogical to Solomon himself with hindsight. A memorable aspect of these accounts is his fear of relapse, and how he seemed to predict one relapse following a physically painful accident (whether it was a self-fulfilling prophecy, we cannot say).
In discussing depression, Solomon highlights the confusion in how we discuss body and mind (e.g. how a "chemical depression" can make some patients feel that it's not their fault, as if it would be their fault were it more "purely" psychological). He follows this controversy and confusion over the mind-body problem back to the days of Ancient Greece, when the more medical model of Hippocrates contrasted with the views of Plato and Socrates, with Aristotle taking the view of a closer interaction between the body and mind.
In a similar vein, when Solomon moves on to the subject of treatment, he wastes no time in attacking a duality between talk therapy "versus" pharmacological treatment. He touches on this in his own continuing use of pharmacological treatment to avoid relapse, where he feels that there is some pressure to come off medication now that he is better. Although no simple cheerleader for dualism himself, to some extent Solomon needs to find some way of distancing from his own experience of severe clinical depression, initially describing it as something outside of himself; indeed, his cross-cultural experiences of depression lead him to praise traditional approaches to treatment that externalise depression by linking it to spirits. Nonetheless, he also harks back to days when it felt the depression may have always been there in the background, waiting to be triggered
The mind-body relationship appears again in Solomon's investigation into the politics of mental health. From meetings in the USA's halls of power, he notes the bipartisan support for funding in mental health. However, as the book was originally published just a few years after the 1996 Mental Health Parity Act, he points the history of differing health insurance policy with regard to mental compared to physical health. Politics again rears its heads in the issue of poverty and depression. Solomon does not shy away from the role that poverty can play in precipitating depression (and childhood abuse, though hardly unique to poorer people, seems to be a recurring theme on this point). Nonetheless, Solomon is also a champion of individual treatment of depression in poorer patients (although what treatments they can/will afford is another issue...)
In discussing suicide within a book about depression, it is positive that Solomon highlights that many suicidal people do not have depression and vice versa. It is on this topic that he is perhaps at his most confessional, outlining how he helped his mother in assisted suicide. Suicide throws up thorny ethical questions about self-determination (as does the question of involuntary institutionalisation), and although Solomon offers an even-handed view he is not afraid to grasp some of these nettles.
Although this book is authoritative in its research and brave in its exposition, it is flawed. Some aphorisms don't come off quite so strong: Solomon prefaces some statistics with "...it is a mistake to confuse numbers with truth" (mind = blown, man). Notwithstanding that the book was written over 15 years ago, it seems a bit off that exercise is listed as an "alternative" treatment for depression when religion is in the same chapter (on mainstream treatment) as psychotherapy and psychopharmacology. As for listing homeopathy as a "serious" alternative-Jesus wept. Nonetheless, Solomon is at pains not make empty promises about relief from depression. He is clear that every treatment out there will work for some people but not others, and he warns that relapse is always a possibility.
Indeed, in a new epilogue, included in the 2015 edition, Solomon maintains that a relapse could always be on the horizon for him, though he seems arguably more accepting about it now, feeling that recovery will follow relapse. Solomon updates his account of treatment with an outline of the grandchildren of electroconvulsive therapy, including more precise methods such as transcranial magnetic stimulation and even more precise (though highly invasive) methods such as deep brain stimulation-the development of which (including setbacks and ongoing uncertainty) is laid out with great narrative drive. He also follows up people he interviewed for the main text of the book, and discusses whether stigma surrounding depression (and the treatment thereof) has changed; well-known reactionary Irish journalist John Waters comes in for a (less than glowing) mention here.
This is a sprawling overview of a deeply complex topic, that goes some way towards conveying how depression is different for everyone it touches, yet still places it within a broader social and political context. I would highly recommend it to anyone looking for a reasonably accessible book on this subject, as long as they are willing to sit with this subject for some time.
I felt a funeral in my brain
Stigma "goes meta"
Saturday, August 19, 2017
"For the older writer, memory and the imagination begin to seem less and less distinguishable. This is not because the imagined world is really much closer to the writer's life than he or she cares to admit (a common error among those who anatomise fiction) but for exactly the opposite reason: that memory itself comes to seem much closer to an act of the imagination than ever before."
Julian Barnes (2008), Nothing To Be Frightened Of (p. 238, paperback edition)
Think of the last time someone annoyed you. If you're like me you might replay the scene over in your mind. You might think of different things you might have said, how you could have got your own back on the person, or conversely how you could have responded with a greater level of calm. This kind of counterfactual thinking is useful in that it can prepare us to respond better if/when such events re-occur. Memories from our past can thus be tied up with how we think about our future.
As I'm planning a new project examining autobiographical memory, I recently picked up a really interesting book on Understanding Autobiographical Memory. One chapter in particular (see reference below) takes a rather interesting perspective on the connections between memory and future thinking. D'Argembeau highlights an interesting case study of a patient who lost not only his ability to remember past episodes from his life, but also to imagine his future; he described his attempts to engage in either form of thinking as leading to a mental blankness.
This is a rather extreme case that may be difficult for the average person to imagine, but in general both autobiographical memory and thinking about the future can be described as forms of "mental time travel" (imagining oneself in a different time, offering oneself the possibility to experience now what one is not experiencing directly from the present moment). They can both draw upon similar knowledge structures in the mind such as episodic detail or social scripts. For example, your knowledge of what happens in a job interview helps both to delineate what did and did not occur during a past job interview (e.g. bumping into one of the interviewers beforehand was not part of the interview, or so you hope) and to think of how to be more successful in similar situations in future (e.g. by responding to a type of question differently). A difference between the two forms of thinking is that spontaneous thoughts about the future tend to be more generic than their remembered counterparts. However, people may draw upon autobiographical memory in order to "flesh out" more generic thoughts of the future with episodic detail.
An interesting meta-analysis has suggested that a network of brain regions is activated during both autobiographical memory and thinking about the future, in addition to other forms of complex cognition such as theory of mind. Perhaps there is some connection here with creative thought; even though autobiographical memory does not and future thinking about oneself typically should not concern fictional events, both could be described as a forms of imagination. As Ruth Byrne has suggested, counterfactual thinking can be a form of creativity, and when this is applied to our own autobiography, the work of fiction can be how our own pasts may have played out.
D'Argembeau, A., 2012. Autobiographical memory and future thinking. In D. Berntsen & D.C. Rubin (Eds.), Understanding autobiographical memory: Theories and approaches, pp.311-330. Cambridge: Cambridge University Press.
Sunday, August 6, 2017
"Excretion is a universal part of the human experience, but it is veiled in taboo. Psychologists have torn the veil off other taboos, such as sex and death, but they have largely ignored elimination. Nevertheless, it is linked to a rich assortment of intense emotions, mental disorders, personality traits, social attitudes and linguistic practices. From psychoanalysis to neurogastroenterology...the psychology of the toilet offers surprising insights into mind–body connections, culture and gender."
Nick Haslam (2012), The Psychologist magazine
"And I remember...my first memory...I was four years old, and I was standing in front of my parents' house and I was shitting in my pants. I was just shitting a massive, terribly painful shit...the centre of this shit was so wide that I actually came online as a result of the anal pain that I was experiencing. It actually awakened me into AAAAAAAA this stream of consciousness I am now living"
Louis C.K., stand-up comedian
Those interested in the human mind have been interested in how it interacts with our guts since at least the days of Freud and colleagues, although as Haslam implies, interest in this area may have waned with the decline of psychoanalysis within academic and research-driven psychology. However, with an increasing interest in the body within psychology and cognitive neuroscience, research is starting to address how gastrointestinal factors may play a role in human psychology.
The nature of this interaction likely goes well beyond the psychology of elimination habits. Although our central nervous systems may do the cognitive heavy lifting available to consciousness, we have an enteric nervous system within our gastrointestinal tracts. Bacteria can produce neurochemicals that impact upon receptors within this nervous system. Ted Dinan, professor of psychiatry and mentor of mine at UCC, refers to it as a form of "collective unconscious". Although the Human Genome Project has mapped out the genes of human cells, there are a huge host of bacterial cells within us; furthermore, different types of bacteria will appear in different people, so this area is opening up a whole industry of gene sequencing of our microbial tenants. The whole area of gene X environment interactions just became more complex.
A major topic in this area is stress; intuitively, you may have noticed changes in your bowel habit while going through periods of heightened stress. One of the major research findings in this area is evidence of alteration in the gut microbiota in stress-related psychological disorder. Irritable bowel syndrome is the most obvious example, but studies from Ireland, China and Norway have indicated alteration of the microbiota in major depression. However, although these studies use healthy adults as controls, it is still too early to comment on what "the" healthy human microbiome looks like. A greater level of diversity is generally seen as a good thing, but as I mentioned above there is likely to be considerable variation in microbiota between different individuals who are generally healthy, so what "the right mix" is is still up for debate.
Despite this interesting evidence in stress-related disorder, there has generally been a lack of research looking at how chronic levels of stress per se can alter the microbiota. This is regrettable when one considers that following the same individuals over periods of greater or lesser stress could get around the issue of how much difference there is between different individuals.
Conversely, could tweaking the microbiota affect stress? A small study I was working on indicated that administration of a probiotic over four weeks could reduce reported daily stress as well as an acute stress response in healthy volunteers. This would suggest that manipulation of the microbiota can potentially affect psychological outcomes. These effects did not occur using the same assessments with a different probiotic; one would expect that different strains will have different effects, but even trying to combine research on a given strain can be fraught, as pointed out in a recent editorial.
Perhaps one of the more tractable questions in this area is how changes in dietary behaviour may impact upon our microbiota at a relatively broad level. There have been studies that compare a contemporary Western diet to groups of people relatively untouched by such dietary trends, such as the Hazda of Tanzania and children from rural Burkina Faso. Although one might think the easy availability of foods from around the world might increase the Westerner's microbial diversity, some findings suggest that it's actually the other way round. We could, of course, speculate that differences in levels of stress in different populations could also have some impact upon microbial differences (and indeed, our diets may become somewhat more processed during stressful times!).
Needless to say, issues such as diet and stress play out in a broader cultural context. It would be interesting to see more research being done on the social psychology surroundings the taboos and neuroses of our toilet habits and the kind of mishaps described by Louis C.K. However, unravelling the question of just how, and to what extent, the microbiota interact with an embodied psychology is going to be keeping people busy for some time.
Allen, A. P., Dinan, T. G., Clarke, G., & Cryan, J. F. (2017). A psychology of the human brain–gut–microbiome axis. Social and Personality Psychology Compass, 11(4).
Image is a detail adapted from Fig. 1 of the paper cited above. See full text here.
Irritable bowel syndrome
From the depths came the form
Probiotics and stress
Image is a detail adapted from Fig. 1 of the paper cited above. See full text here.
Irritable bowel syndrome
From the depths came the form
Probiotics and stress
Sunday, July 9, 2017
We were guided through intense emotions, like buttons on a TV remote. And the strange thing is, I felt each emotion. Are we so easily manipulated?
I've won via a book thanks to a competition at The Psychologist magazine. It's a thesis on ecstatic experiences by Jules Evans, philosopher and bon vivant (in a broad sense of the term). Although the term "ecstasy" is used to describe religious or sexual experience, Evans highlights that many different forms of activity can be associated with this type of experience, which is not just about extreme happiness or pleasure but a loss of the sense of self.
Evans does not simply wish to sit at the sidelines but rather engage in some of the kinds of experience he discusses in the book. Sometimes he draws on past personal experiences, at other times he engages in new activities as research for the book (his attempts to dip his toes back into organised religion veer between endearingly awkward and slightly off-putting, as congregants and preachers hungry for young blood latch on to him or try to use him as a mouthpiece). Unsurprisingly, when dabbling in these various activities Evans often fails to become ecstatic. However, he draws on characters from the past who have abandoned themselves to ecstasy more than Evans himself, from sexualised cult leaders to preachers who found ecstasy in the natural world.
Indeed, like many philosophers, Evans has a healthy interest in history. He traces much of the reaction against ecstatic experience (or most ways of seeking ecstasy) to the Enlightenment. He posits that at this time an increasingly materialist worldview was increasingly hostile towards ecstatic experiences where sense of self (and therefore self-control) is lost. I mention "most ways of seeking ecstasy" above, as the ecstatic appreciation of the natural world may be a form of ecstasy less antagonistic to Enlightenment values; people from Dawkins to Tim Michin have highlighted how we shouldn't need God when we could be happy and in awe of the wonder of the Natural World. Evans himself insists that he remains agnostic about religion, although he does seem to want the skeptical reader to consider the spiritual realm.
In delving into the world of ecstasy, a recurring theme is the danger underlying the loss of self. Besides the hazards of dangerous drugs, Evans highlights the negative reaction some people have to meditation. He even suggests there is a dark side to the seemingly innocuous ecstatic appreciation of the natural world; there is a risk of reading an excessively benevolent intention into Nature. However, Evans also suggests a further risk is that ecstasy in nature could distract from a higher power/transcendence (his nudging the reader towards the spiritual again?) This counterbalance serves as a useful rejoinder for the tendency of many self-help types to give an uncomplicated view of phenomena from romantic love to peak experience and flow.
Perhaps the boldest chapter is that which highlights war as a means for searching for ecstasy. Evans mentions Malthusian philosopher John Gray's reference to war as being a major part of the human psyche. Evans does not go as far as Gray in suggesting war as a universal drive, but he does delve deeper into suggesting a number of different reasons why war and violence can be a means to annihilate the self, such as a loss of self to a "greater cause". Of course, with war, unlike most other ecstatic pursuits, when the pleasure fades, you have not just temporarily annihilated the self, but permanently destroyed the other.
This book will raise more questions than answers, which is almost inevitable for a book that deals with a relatively under-explored phenomenon from such a wide-ranging perspective. Is there anything wrong with a life of modest happiness, rather than overwhelming ecstasy? Why is it that ecstatic experience can be turned on/off for many people engaging in quite diverse activities? Why, for so many people, is the self a burden that needs to be shed?
Book Review: "The Stress Test" by Ian Robertson
Mindfulness: In defence of sometimes being in the moment
Sunday, July 2, 2017
Today this supremely beautiful landscape seemed to me to be almost unreal in its perfection. It produces a tonic effect on me…I felt a kind of aesthetic exhilaration, a mental exuberance and keenness of perception, a complete environmental euphoria. (John Fowles, “The Journals: Volume 1” p. 168)
The knot is tied. Daniela and I are honeymooning on a Greek island-Karpathos. I am reading the journals of a favourite writer (I had just recently picked these up in Cardiff, having previously planned to re-read his famous novel with a Greek island setting, The Magus). In his early twenties, John Fowles’s initial resentment and self-absorption in England change to a more outward focus on the extravagant characters he encounters when he takes up a teaching job on the Greek island of Spetsai-possibly the most extravagant of which is the landscape of the island itself.
From visiting the in-laws in Italy, I am by now used to the fairly urban Verona and Bergamo airports. Landing in Karpathos airport, one is struck by the almost alien landscape. It is a little bit like a grey/deep green version of Red Rocks in Denver. Although the sun takes the temperature into the high twenties, the island is windy, with enough of a breeze to make it feel like low twenties much of the time.
We are honeymooning with an Italian tour operator (Irish tourists are a novelty on the island) who take us from the airport to the Aegean Hotel, Amoopi. A polite yet brilliantly deadpan Serbian waiter attends to us at dinner. We dine a few times at a taverna down the road. The highly extroverted husband & wife proprietors engage their patrons/audience not only with cuisine that often incorporates their mini-farm by the taverna, but also with anecdotes and conversation, the hijinks of their dog, a chance to hold newly-born chicklets etc. They also do a mean Greek coffee.
Our first excursion with the tour operator is to Olimbus. The various shops sell bespoke items, and the keepers call to the tourists as they stroll past to check their wares. (I look the archetypal tourist in shorts, T-shirt and a Karpathos baseball cap). In one place we pick up a necklace made up butterfly eggs. Another shopkeeper, who sells us a mug she made herself, is as comfortable discussing her life as an architect in Athens outside of the tourist season as she is asking us what age we are.
We hire a small car. I have never driven on the right before, and by force of habit I frequently reach left for the gearbox. In comparing our relative levels of stress when I am driving versus when Daniela is driving, I decide that I should stick to acting as navigator more often than driver. The car is used to travel to various beaches around Karpathos. Starting from the beach outwards, the water starts transparent, then aquamarine, then azure, then a deep blue. Most of the beaches are enclosed by cliffs or hills reaching down to the outskirts of the water. When swimming I tread water to admire the landscape, feeling a touch of Fowles's "aesthetic exhilaration".
Our second excursion with the tour operator is to the island of Saria, the tiniest bit North of Karpathos. Although some people travel out on a semi-regular basis, when the boat pulls in the island it is quite deserted apart from three mules observing us from the rocky beach. We then walk up a steepish ascent under direct midday sunlight (some of the people on the tour are older-I have to wonder how everyone manages). On the descent we take slight divergence from the way up; there is a dead sheep lying on the path. I was reminded about a reference to travel research I made in an Irish Indo piece highlighting how satisfaction tends not be higher during the initial part of travelling, when one is actually doing the travelling to the place you want to get to!
Towards the initial high point of Saria we encounter a beautiful small church. There seem to be very numerous Orthodox churches dotted all over the island, although they also tend to be either small or very small (a few of them would struggle to accommodate a full family, were they Catholic churches of yesteryear). The churches usually have a similar style in terms of the icons depicted. One less small church we visit elsewhere is besides a large floor mosaic, much of which has been lost in time.
Following Karpathos, we return to Verona, Italy for a few days, for some quieter time in Italy post-wedding excitement, when we can settle some debts and run around with the niece and nephew. Then the return to Ireland and relative normalcy-assembling a wardrobe for our apartment and gearing up for more research at work. The honeymoon is not just another holiday. There's an expectation of creating memories that one holds on to for good. I don't think I'll forget the sunset view from the Aegean Hotel at dinner, overlooking the footpath to the hills that stretched to the sea.
Monday, May 29, 2017
When Irish voters were about to go the polls for a referendum on gay marriage, something interesting happened. There were certainly people out there who were willing to express their opposition to such marriages, but within the mainstream Irish media, there seemed at times to be less debate about the referendum question itself, and more debate about whether you could voice a “No” opinion without being “labelled a homophobe”. In short:
The foregone conclusion*: full gay marriage should be legal
The controversy: Pfff, just because someone is opposed to this specific issue they are being labelled as prejudiced. Surprise surprise, here come the stereotypes about Catholics…
I wonder if something slightly similar is happening with disclosure of mental disorder.
I daresay most people would voice their opposition to stigma of people with mental disorder (especially when phrased in such general terms as that). And yet…there is a fatigue setting in about certain things. One is famous people disclosing mental disorder. If there’s something about the person that may challenge stereotypes around mental disorder it might get a bit more attention (e.g. Bruce Springsteen is an energetic, strong and successful man of an older generation but has depression; rappers often project a tough exterior but, hey, they can have mental vulnerability as well). However, if A.N. Other Montrose kid with a trendy haircut cries on RTÉ as they disclose that they have suffered from depression, you can bet that some viewers are rolling their eyes.
The foregone conclusion: we do not stigmatise mental disorder
The controversy: here we go, another person “opening up” about how they feel a bit down sometimes and they got prescribed an SSRI by a lazy GP. You should feel a bit down, you’re a vacuous Irish sleb model! Here come the stereotypes about…
Does the analogy become a bit strained here? In the case of mental disorder, who are the perceived stigmatisers who are being stereotyped? Older people? Some ethnic minority group? Of course, I couldn’t be stigmatising people with mental disorder-stigma is bad!
The Diagnostic and Statistical Manual of Mental Disorders generally indicates that the symptoms of mental disorder only become a disorder when it is associated with significant impairment, such as social or occupational functioning. Are we being “labelled as a stigmatiser” because we can’t work around the person who can’t come to work as they have depression? But the fact is, that person with depression is the only person on our current team who can do this specific task, and it needs to be done…
But, sorry, we were talking about public disclosure of mental disorder, not mental disorder itself. Or are we?
“Look, we know now that disorders like depression and anxiety disorders are really quite prevalent. Why do we still need to hear about how some celebrity has it?”
Perhaps we don’t need to hear them say it. But we should let them say it. Because we can’t be sure that the real issue here is freedom of speech, but rather that society has a problem with a certain group of people.
*I realise it was actually not that much of a landslide, the “foregone conclusion” is just the vibe of a foregone conclusion coming from the mainstream media
Tuesday, May 23, 2017
I am back where I did my PhD studies: Cardiff University. The research project I am newly involved in examines memory, dementia and brain imaging employing fMRI. I have come for a trip back to Cardiff for a focused meeting on fMRI and dementia, bringing together researchers and clinicians in the field from the UK and further abroad.
The talks open with some quite technical discussion of brain imaging acquisition and analysis. Although the mathematics and physics are generally beyond my level of comprehension (I’d need to learn more about the applications of complex numbers for a start), it does draw attention to how different algorithms can be used at various stages of the research process.
A big focus of the talks is on predicting who is at greater risk for developing dementia. An interesting talk by Tony Bayer discusses subjective cognitive decline as a precursor of mild cognitive impairment (which in turn precedes dementia). There is a surprising plethora of approaches in this area, although people working in this area have recently got together to try and create some consistency in how this area is investigated.
In terms of work addressing dementia directly, there is much discussion of Alzheimer’s Disease (the most prevalent form of dementia), but it’s also encouraging to see a lot of research in other forms of dementia (e.g. frontotemporal dementia, Lewy Body Dementia and rarer conditions such as posterior cortical atrophy). It’s also nice to see someone venture outside the hippocampus (a classic target for brain imaging in this area) to look at the cerebellum; Michael Hornberger highlighted that he has had trouble convincing reviewers of his research on the role of the cerebellum in dementia, although he did show interesting results from a meta-analysis in this area as well as his own data.
At lunchtime I take a tour of CUBRIC 2; a new brain imaging centre at Cardiff that builds on the success of the first phase of CUBRIC (Cardiff University Brain Research Imaging Centre). In addition to a high-resolution 7 Tesla fMRI scanner, it boasts a rare 3 Tesla connectome scanner, as well as TMS, MEG, EEG and sleep laboratories. It seems to be one of a number of new buildings coming online in Cardiff University, along with a new Innovation Centre nearby (I believe this will be more geared towards humanities and social sciences). One can only hope the Brexit fallout does not hold neuroimaging at Cardiff back from attracting the talent and research funding needed to keep a centre like this operating.
Back at the talks, it was great to see Dennis Chan (who has worked with Nobel Laureate John O’Keefe) outline some of the novel assessments of memory he has been using, including applications of virtual reality. The conference was grounded by a patient who spoke about her own experience of taking part in research. As someone who had been active in writing and teaching as a younger person, she had a great sense of loss of agency when she developed cognitive impairment. She described how taking part in research gave her the sense that she could in some way help others in the future.
The poster section is very small but very focussed and lively. Quite a few posters highlight new developments in methodology.
Next year’s meeting will be held at Cambridge. Given the level of focus, and the potential to meet researchers in the field at a relatively “intimate” meeting, it’s worth going if this is your area.
Saturday, April 29, 2017
As someone who tries to use language precisely, I dislike it when terms stray into inaccuracy. For example, the phrase “making love” has tended to annoy me for years, as it is sometimes used as an all-purpose stand-in term to describe any sexual intercourse. Although I’m sure such inaccuracy isn’t the intention (people just want a euphemism), the term nonetheless seems to imply that sexual activity is somehow inherently loving. However, this pet peeve is a bit flippant compared to a somewhat similar example I’ve noticed more recently.
In my recent work on dementia caregivers, one can end up thinking quite a bit about the best way to use language in describing patients and those who care for them. The majority of dementia carers who aren’t professional carers are either children or spouses of the patient. However, you do see siblings, sometimes nephews/nieces, or even friends or neighbours. “Carer” or “caregiver” (as opposed to “family member”) works fine, as it describes what they do.
What then is the best single collective term to use for those being cared for? “Patient” or “person with dementia” is fine, but doesn’t capture who they are with relation to the carer. “Family members” covers most, but not all, patients with unpaid carers. “Loved ones” looks like a good one -the patient doesn’t have to be a family member of their carer for us to call the patient a “loved one”. And does it not capture the idea of care as loving? I recall seeing a video of an elderly man caring for his wife with a caption along the lines of “If this isn’t true love, what is?”
One afternoon, while speaking with a carer, she took the opportunity to share some of her thoughts and feelings. She had been caring for her husband with dementia for a number of years. After speaking more broadly about caring for her husband, she came to the topic of love and marriage: “You know, sometimes I ask myself whether after x years of marriage, do I still love this man?…And really, the answer is no. Well, you’re a young man-I suppose it’s something you’ll understand when you’re older…”
Another carer (again caring for her spouse) spoke of how she no longer loved her husband at a gathering of carers. She added that it’s not something she felt she could say to her (adult) children. Maybe she just wanted to get it off her chest when speaking to other carers, or perhaps she wanted to see if she wasn’t the only one who felt this way. On hearing what she had said, another carer (caring for a parent) suggested that maybe the first carer didn’t like her spouse any more, but she did love him. The first carer who had spoken of her feelings restated them.
I can see how people might identify with the carer who made the “not liking, but still loving” suggestion. Perhaps there is a temptation not to take these statements about an end of love at face value. We could be suggesting that carers perform love, even if they don’t feel it, if we say things like “If this isn’t true love, what is?” But if we try to downplay these feelings (or lack of feelings), are we not also downplaying how, in some cases, there is great social pressure to stay in the full-time carer role? (Particularly if society at large is not giving them enough help). And are we not more generally downplaying the level of altruism such carers are showing?
If caring for someone you love is heroic, caring for someone you no longer love is more so.
Saturday, April 8, 2017
A man who moralises is usually a hypocrite.
"I consider myself a vegetarian because there is no meat in here." A tongue-in-cheek comment in the 2am queue in McDonald's from some woman I had met an hour or two previously. In an argumentative train of thought and taking her comment a bit too seriously, I nonetheless refrained from voicing aloud the idea that she was doubly hypocritical; firstly for describing herself as a veggie when she eats meat and secondly for dissing McDonald's when clearly about to buy their stuff.
But when is it best to accuse someone of being a hypocrite? It's something I've thought a bit over the past while. Here are some questions to consider:
1. Is the person really a hypocrite?
1a. Do their actions contradict their current stance, or is it just their previous stance/opinion that contradicts their current stance?
To state the obvious, being a hypocrite involves saying/doing something and then doing/saying something else that contradicts that. It's worth thinking clearly about whether the person has really done anything or is just giving one opinion and then opining differently later on. (This may be harder in the case of politicians or more powerful people, where speech acts may have quite tangible consequences).
1b. Do they just have a short memory about something they previously said?
People are notoriously inconsistent about their preferences and opinions, including those about hypocrisy itself, and may at different times believe that something is THE most important aim. "You must respect others' religious views" and "the rights of women should be upheld" may strike the same person as very highly important principles, but depending on the situation one particular view may be more salient than the other. As a result, they may segue from suggesting that westerners should leave religious minorities alone to advocating (or maybe even engaging in) strong intervention if women's rights are in some way compromised by a religious minority.
1c. A question of extent
If a person is vocally against a strong instance of a crime, are they a hypocrite if they commit a much milder version of the same (or very similar) crime? Unfortunately, we all have to live in a physical and practical world. It would be nice to always live up to the standards of a particular view, but this may not always be very practical...
1d. To what extent can they freely choose their actions?
Without wanting to get bogged down in a debate about free will, someone may be pressurised into selling out their views. If someone is threatened with job loss, blackmail, or even harm to their family they may be pushed into actions that contradict their genuinely-held values.
1e. Are their actions as an individual inconsistent with their views on broader societal issues?
The anarchist drawing the dole, the climate change warrior driving their petrol-burning car...If the person is vocally advocating for societal change, do their actions as an individual really have to stand up to what they are advocating for society at large? If someone speaks out against violence against women (a societal issue) but is controlling his wife with threats of violence, that's pretty damn hypocritical. However, the climate change warrior is probably only making a negligible contribution to the problem (whereas one battered wife is in itself a clear wrong). Furthermore, the advocate for societal change still has to exist in a society which may not allow them to function without contributing in some way to climate change (see also 1d above).
2. What's in it for you?
It's worth pausing to think why you want to accuse someone of hypocrisy.
2a. Is your key aim to prove your own point?
Are you using the person's hypocrisy about a matter as a way of "proving" that their stance on an issue is wrong? This is a logical fallacy. Maybe there are better examples, but a topical example in Ireland is that many pro-choice advocates seem to point out the (sometimes glaring) hypocrisy of various pro-life individuals or institutions and just leave it at that, without going on to make their own case for why the freedom to choose to have an abortion/bodily integrity outweighs the preservation of the fetus/embyro/zygote etc.* This can be self-sabotaging, as one misses out on the opportunity to showcase why your point of view makes sense in its own right.
2b. Are you trying to discredit the person, or their argument?
Pointing out hypocrisy may go some way towards undermining your opponent's argument/actions, or at least their rationale for speaking/acting this way. However, is the real agenda here to actually undermine people's perception of your opponent's character?
Given some of the issues raised above, most people with an opinion may come off as a bit hypocritical at some point. In this sense I wonder how much of a character assassination an accusation of hypocrisy really is (unless the really damning thing is some awful act they committed that they're now being a hypocrite about).
In any case, deciding what your key aim really is will help in making a more cogent case.
2c. Do you actually want to get through to the person?
3. How can you get through to the person?
Perhaps you really feel this is a moment where you can show someone the error of their ways, or at least a contradiction in their thought patterns. But consider...
3a. Do they actually care?
The expressed opinion of the person may simply be telling people what they want to hear, before pounding out business-as-usual in their actions.
It can be surprising how often one is fighting a lost cause.
3b. Will they think that you are just trying to discredit them as a person or just using their hypocrisy as a "proof" of your own point-of-view, or defence of your own actions?
If they think you're falling into some of the positions mention above, then they are unlikely to think that they're going to actually pick up anything worth learning by listening to you.
3c. If you're outlining their opinion, are you giving a fair account of what they've said?
As argued by Daniel Dennett and others, one should try and develop the best account of what your opponent is really trying to argue, or what the aims of their actions are, before you start criticising them. Going after a straw man is not really the best use of one's time.
Obviously these suggestions are easier to make than to follow. Just earlier I saw an argument online that seemed somewhat contradictory, and I nearly went off on a train of thought whereby I speculated that the person would engage in a number of other hypocritical arguments (that were purely imagined by me at this point). Had I put anything down in writing I'm sure I would be failing to heed a number of points here.
What a hypocrite, ay?
Daniel Dennett book review
Being right wing and doing the right thing
*This is just an example of how someone might frame the debate on this issue; I realise people may have more/less utilitarian stances on this.
Saturday, March 18, 2017
There's a film-making legend that Michael Caine accepted a role in a particular movie immediately after reading the opening line "EXT. South of France. Day". When one sees "Seville, Spain" for a conference, this in itself could be sufficient reason to go. A beautiful city, bike-friendly but not so veggie-friendly (one menu helpfully lists a dish with eggs and fish under "vegetables"). But I'm here for the American Psychosomatic Society's Annual conference. Thanks to the generosity of their Young Investigator Program, I had registration fees written off this year, so with so many interesting talks on it was an offer I couldn't refuse!
At lunch the day before the conference proper began, one researcher was voicing a scepticism with findings from psychological research in general, at least in terms of their ability to translate into tangible outcomes for people in everyday life. Hey presto, here's a slide from the first morning session:
On that note, perhaps some of the difficulty in getting research applied comes down to the replication crisis within psychology and other disciplines. If the research can't be replicated, it's unlikely to be applied, and statistical analysis that leads to false positives may confound the problem. A session on statistics in the post p < .05 era began with some fairly basic 101 on p-values (a tad dull to wade through, although a show-of-hands at the beginning did suggest a lack of understanding of p-values even in a professional audience). More interesting were the suggestions of tips on what to do next, such as using effect sizes rather than p-values for our benchmark for replication.
Larger sample sizes are one way of avoiding replication issues, and a session on the genomics era certainly delved into big data. From my own perspective a talk by Brenda W. Penninx was particularly interesting, as she focused on the genetics of depression. Her work had the interesting approach of both identifying genetic similarities between depression and other conditions, but also delving into the differences within depressive phenotypes (e.g. some people have lower appetite and sleep less, other sleep more and have a higher appetite). It will be interesting if she can show genes that are predictive of treatment response in future analyses.
A talk by David Clark on Friday really brought a focus to a national level, describing Improving Access to Psychological Therapies (IAPT) in the United Kingdom. Although IAPT targets depression as well as a variety of anxiety disorders, Clark grounded things by giving the specific example of social anxiety, and how cognitive therapy can address the thoughts and behaviours that can exacerbate anxiety in people with social anxiety. They've collected a lot of data from IAPT, which has been shown to be cost effective. It made me wonder why we can't do something similar in Ireland.
At the poster sessions, in keeping with trying to gain more replicable and generalisable results, a number of posters on various topics tapped into large cohort/prospective studies. It was also good to see other people covering caregiver research, with researchers from Madrid finding that psychological therapies could reduce blood pressure in dementia caregivers, and a systematic review from researchers in Bath, UK indicating that problem-focused coping in particular was associated with better outcomes in younger carers (aged under 18). Belgian researcher Natalie Michels presented a poster on microbiome research-this is another area of investigation that will be generating large datasets and will again challenge us to avoid false positives. With regard to false positives in abstract screening, my own poster on dementia caregiving was somewhat upstaged by a truly "interesting" poster beside it, manned by 5 or 6 Japanese researchers, which indicated in its rationale that different deities emit different forms of light. Provocative stuff...
In terms of "walking the talk", at least in our own lives, the conference had well-being sessions every day. Mindfulness sessions included mindful walking (which I attended; good fun) as well as loving kindness meditation and T'ai Chi. Un/fortunately, although the Society also strive to have healthy options at their conferences, the venue was rather keen to keep the pastries and treats flowing at the coffee breaks-as well as showing the Sevilla fondness for meat I mentioned above!
All in all this was a forward-thinking meeting, with researchers, clinicians and thinkers who weren't going to let the sunny weather stop them from focusing how to ensure our discipline remain relevant to life outside the academy.
Conference Review: APS 2016
APS 2016: Young Investigator Colloquium
Sunday, February 26, 2017
Gareth Stack, writer/director; Me, critic; Adam Tyrell, actor
Enter Perry Pardo. Successful entrepreneur; envied, rich, a go-getter. He had to work his way to top to become the man he is today, and if you're not willing to come with him, then fine, stay part of the 99.9%. Think of Tom Cruise's character in Magnolia, but instead of women, his conquest (or perhaps his enemy) is everyone else.
Mic Drop, a new play from Gareth Stack, comprises a motivational talk by Perry Pardo, who must contend with indifferent AV staff, an audience that can never be as engaged as he wants, and his own demons to deliver his message of crawling your way to the top by any means necessary. But for all his go-out-there-and-get bravado, Perry is well aware that Ireland, and the world, are not meritocracies.
The script is finger-licking for any actor, and in the words of Pardo, Tyrell takes it and eats it with his f(ck)ng mouth. It's perhaps the most intense one-man performance I've seen since Jonathan Capdevielle's role as a serial killer (and his victims) in Gisele Vienne's production of Dennis Cooper's Jerk. Tyrell struts and frets his half hour on the stage like his life depends on it (no doubt Pardo believes that it does). Modafinilled out of his box, Pardo is itching for confrontation but has to content himself with feeding off the nervous quiet of the audience.
Mic Drop has its final performance tonight as part of the Smock Alley Scene and Heard festival. It is a 30 minute, abridged version of a longer play, but manages to pack more into those 30 minutes than most do in 90. The unabridged version will be worth looking out for.
Theatre Review: Autumn Royal
Saturday, February 11, 2017
Thanks to generous funding from the Health Research Board, we at UCC Dept. Psychiatry & Neurobehavioural Science and the APC Microbiome Institute were able to host an international research seminar. This was a chance for some leading researchers in the areas of caregiving stress to discuss their research and ideas.
Shireen Sindi of the Karolinska Institute in Sweden set the scene for our discussion of stress. She touched on classic work from the late sixties by Mason, highlighting key factors for producing a stress response, such as a stressor's unpredictability, its unfamiliarity and a person’s sense of control (or lack thereof). This work has since been borne out in a large review by Dickerson & Kemeny, who found that release of cortisol tended to be most clearly associated with such aspects of stress.
Dr Sindi made the interesting point that people may often lack insight into their own chronic stress levels, particularly in the case of physiological stress. This raises the question of whether self-report and physiological measures may show less concordance when tapping into more long-term stress. Speaking of long-term stress, she pointed out evidence that chronic stress in childhood may lead to very difficult-to-reverse changes in the amygdala (a region of the brain associated with processing emotion such as fear).
Brent Mausbach from the University of California at San Diego opened by highlighting a classic finding from Schulz and colleagues, indicating that caregivers were at increased risk for mortality at follow-up, specifically those with high levels of caregiver strain. He then discussed some of his own findings, looking at caregivers and whether they had depression and/or distress with challenging behaviours in the patient, with cardiovascular disease (CVD) as the outcome. Those who suffered from both depression and high distress in their caring role had an increased risk for CVD-a rather startling result.
Professor Mausbach went on to discuss some really interesting results from his group following caregivers over time in terms of measures of inflammation and clotting; interleukin-6 and D-dimer were higher in dementia caregivers compared to controls, and also increased at a sharper rate. These biological markers are associated with heightened risk of CVD, so these findings neatly suggest a biological mechanism as to how psychosocial stress can lead to negative health effects over time.
It wasn’t all bad news; he also highlighted promising preliminary data on treatment. The team at San Diego used behavioural activation (getting people to engage more in activities they enjoyed) as a way to treat depression in caregivers, thereby treating CVD risk. This behavioural activation approach, which allowed carers to develop their own tailored intervention, led to greater improvement than a typical intervention (education and support).
Kathryn Lord brought things back to basics, challenging assumptions underlying work in the area of caregiver stress, particularly the concept of “challenging behaviour”. Lord suggested that the classification of a given behaviour as challenging risks ignoring the perspective of the patient, who may act as they have genuine grievances with how they are being cared for. Dr Lord posited that a person-centred approach to care should inquire into the meaning of a patient’s behaviour, and whether they are trying to communicate something about their environment.
Dr Lord also warned of being too ready to attribute any behaviour that causes others difficulty to dementia. Patients with dementia can have pre-existing issues with others that can pre-date the dementia that can nonetheless be missed by care workers (or indeed family caregivers).
Like Brent Mausbach, Dr Lord had some very nice intervention data from a randomised clinical trial for family carers using the START program. This program was developed by the Livingston team at UCL in the US, and Dr Lord’s team adapted this program for a UK population. Although it only lasted 8 weeks, START reduced the risk of depression at follow-up years later in the carers who completed it. It was also cost-effective; interestingly carer’s health costs actually went up in START group (perhaps due to increased health-seeking behaviour), but the patients’ health costs went down by more than the increase seen in the carers.
Noted intellectual-about-town Andrew P. Allen wrapped things up, highlighting similar themes in his own research that chimed with previous speakers, including immune data suggesting increased inflammatory cytokines in carers compared to controls, as well as a positive impact of psychosocial interventions for carers (with cognitive performance as the outcome). He also tied this area in with the brain-gut axis, mentioning evidence of altered microbiota in major depression, evidence from France of increased prevalence of IBS in carers as well as the potential for probiotic supplementation to attenuate stress.
HRB seminar on carer stress
He ain't heavy, he's my carer
HRB seminar on carer stress
He ain't heavy, he's my carer
Sunday, February 5, 2017
We are seated on the stage of the Everyman Theatre, Cork, in just two rows of chairs. Stacks of washing machines form the walls behind them, and the kitchen floor almost impinges on the audience's seats. Although this is a close-up view, when the performances begin, they remain more theatrical than cinematic. While always remaining in character, Siobhán McSweeney and Shane Casey play to the crowd in a manner that is more like unaffected stand-up comedy than self-conscious breaking of the fourth wall.
They play Timothy and May, a brother and sister from Cork who are caring for their ill father. Tim is 36; May is somewhat older. The soundtrack chimes with the ticking of a clock. May and Timothy are aware that they are not getting younger, and they point out that their father could live for years or maybe decades. Banana and peanut butter sandwiches are made at intervals throughout the play, a repetitive task. Days are too slow; years too fast. Boredom is fought with gossip about locals.
One wonders how well references to specific places around Cork city and county will travel, but it wouldn't be true to the characters for them to purely to speak in universal terms that transcend place; Timothy and May are stuck in this particular place. Timothy for example might have more perspective if he could fulfil his pipe dream of travelling to Australia, but for now the siblings are where they are. May is concerned with how the neighbours will respond to them placing their father in a nursing home. The street hems them in as much as the house.
Although much of the comedy is broad, there is a darker tone throughout. As the characters' fantasies stray towards the homicidal, I can't help but imagine an epilogue where an older actor represents the elderly father, challenging the audience on the extent to which they identify with May and Timothy. But like Daphne Du Maurier's Rebecca, we only see the father through the eyes of others (though he is heard clamouring from upstairs). Maybe this isn't one to see with your folks.
Autumn Royal will be playing next at the Project Arts Centre in Dublin 7-11th Feb and at The Dock Leitrim 23rd February. (Both shows are sold out as far as I'm aware)
He ain't heavy, he's my carer
Thoughts on compassion fatigue
Sunday, January 8, 2017
As you may be aware, I have an interest in mindfulness. I both practice mindfulness and research its effects in the context of chronic stress.
A rather disgruntled piece from a couple of months back in the Sunday Review of the New York Times has been getting some ongoing attention on social media. My response to it is a bit delayed, but if you are interested, here is a link to the original article (which I quote at some length in italics in this post):
I’m making a failed attempt at “mindful dishwashing,” the subject of a how-to article an acquaintance recently shared on Facebook. According to the practice’s thought leaders, in order to maximize our happiness, we should refuse to succumb to domestic autopilot and instead be fully “in” the present moment, engaging completely with every clump of oatmeal and decomposing particle of scrambled egg. Mindfulness is supposed to be a defense against the pressures of modern life, but it’s starting to feel suspiciously like it’s actually adding to them.
I'd probably be flattering myself if I called myself a "thought leader", but I can say that mindfulness is intended to be a non-judgemental awareness of the present moment. The "decomposing particle of scrambled egg" probably ain't aesthetically pleasing to the author, but I guess mindfulness is more about trying to get away from the judgment calls we naturally make. Easier said than done, but mindfulness is a practice, not something one is supposed to get overnight.
The point about mindfulness adding to our pressures is interesting though; I think a point that is implicit here is feelings about our own feelings. If one doesn't start to feel an effect from a practice like mindfulness after a few weeks, there is of course the risk that we might start to think that we are particularly resistant to psychological self-improvement. Some people take longer than others to "get into" mindfulness (and some will naturally give up on the practice over time). This is something a skilled mindfulness instructor should be able to pick up with clients. In any case, good mindfulness materials will be at some pains to reassure novices that they should not beat themselves up if their minds (naturally) start to wander as they engage in meditation (I know my own mind still wanders quite a lot mid-meditation after a few years of practice).
Perhaps the single philosophical consensus of our time is that the key to contentment lies in living fully mentally in the present. The idea that we should be constantly policing our thoughts away from the past, the future, the imagination or the abstract and back to whatever is happening right now has gained traction with spiritual leaders and investment bankers, armchair philosophers and government bureaucrats and human resources departments....
Surely one of the most magnificent feats of the human brain is its ability to hold past, present, future and their imagined alternatives in constant parallel, to offset the tedium of washing dishes with the chance to be simultaneously mentally in Bangkok, or in Don Draper’s bed....What differentiates humans from animals is exactly this ability to step mentally outside of whatever is happening to us right now, and to assign it context and significance. Our happiness does not come so much from our experiences themselves, but from the stories we tell ourselves that make them matter.
Whether or not one is an "armchair philosopher" (capable of identifying "perhaps the single philosophical consensus of our time"), one can indeed take great pleasure from mentally projecting oneself into the past or future (whether or not it is a realistic version of said past or future). However, to use this point to "refute" the way most people use mindfulness meditation is nothing more than the slaying of a straw man. Taking a moment at the end of the day to simply focus on your own breath, your own posture etc. is useful for people who would otherwise be prone to thinking about their anxieties about the future and/or their resentments about the past.
But still, the advice to be more mindful often contains a hefty scoop of moralizing smugness, a kind of “moment-shaming” for the distractible, like a stern teacher scolding us for failing to concentrate in class....This judgmental tone is part of a long history of self-help-based cultural thought policing. At its worst, the positive-thinking movement deftly rebranded actual problems as “problematic thoughts.”...This is a kind of neo-liberalism of the emotions, in which happiness is seen not as a response to our circumstances but as a result of our own individual mental effort, a reward for the deserving. The problem is not your sky-high rent or meager paycheck, your cheating spouse or unfair boss or teetering pile of dirty dishes. The problem is you.
It is, of course, easier and cheaper to blame the individual for thinking the wrong thoughts than it is to tackle the thorny causes of his unhappiness. So we give inner-city schoolchildren mindfulness classes rather than engage with education inequality, and instruct exhausted office workers in mindful breathing rather than giving them paid vacation or better health care benefits.
Truly nothing makes me #triggered like the implication of neoliberalism being thrown at psychology. Never mind that I help to run free mindfulness classes for caregivers. (Okay, okay, I'm taking a broader social point too personally). Of course, if individual therapeutic approaches are treated as if they are going to solve all of society's ills then these ills will remain. We should be vigilant to the very real threat of psychological therapies being seen as a cure-all in this way. But I'm also reminded of Christopher Hitchens's sarcastic remark along the lines of "Oh well, we can't do everything, so let's do nothing". Even in fairer societies people will face challenges, and if a way thinking can help them to build resilience then this is a good thing.
I'm concerned there's an implication here that people think mindfulness will turn people into doormats. Being mindful doesn't mean that you can't recognise that you are being wronged, nor does it mean that you can't act to right this wrong or protect yourself or your community.
In reality, despite many grand claims, the scientific evidence in favor of the Moment’s being the key to contentment is surprisingly weak. When the United States Agency for Healthcare Research and Quality conducted an enormous meta-analysis of over 18,000 separate studies on meditation and mindfulness techniques, the results were underwhelming at best.
Although some of the studies did show that mindfulness meditation or other similar exercises might bring some small benefits to people in comparison with doing nothing, when they are compared with pretty much any general relaxation technique at all, including exercise, muscle relaxation, “listening to spiritual audiotapes” or indeed any control condition that gives equal time and attention to the person, they perform no better, and in many cases, worse.
The meta-analysis Whippman discusses should certainly give pause to anyone who thinks that mindfulness is everyone's "key to contentment". However, the 18,000 studies she mentions are simply the titles that were screened in the systematic review-the conclusions of the article are actually based on evidence from 47 studies. This is still a lot of evidence, but although many studies focused on people with anxiety problems, the evidence came from people with really quite diverse clinical problems (the analysis did not include studies looking at mindfulness in healthy populations). It should also be noted that it is generally quite difficult to show effects that are greater than an active control. In particular, exercise has a strong antidepressant effect, so to suggest for example that mindfulness is "no better than" exercise is weak criticism. Nonetheless, it should be borne in mind that the observed beneficial effects of mindfulness on anxiety and depression were mild-moderate.
I think another point being lost in this quick overview is the strong individual variability in response to mindfulness. As with many other therapeutic approaches, a lot of people benefit but a few will experience negative effects; it should be noted that mindfulness comes with risks (it may be that people prone to panic attacks in particular should exercise caution). More common than an actively unpleasant reaction is the feeling that "mindfulness simply isn't of interest for me". This decision that it "doesn't float my boat" may happen after a few sessions (I suspect Whippman falls within this group) or oftentimes the minute someone hears a brief description of what mindfulness is. And if mindfulness doesn't make someone tick, and other activities do, then good for them.
But perhaps the conclusion I'm most concerned that people will draw from this article is not that mindfulness will have no major effect overall in randomised controlled trials compared to a strong active control (which could happen due to strong individual differences in response), but rather that mindfulness does nothing at all-that it is a kind of homeopathy of the mind, when it fact it can have quite profound effects on the way people think, often for good, but sometimes in more ambivalent or even negative ways as well.
In any case, if the dishes are a pain in the neck, feel free to mentally travel wherever your imagination may take you. And if that is where your mind is at present, try to experience the fun as fully as you can!
Mindfulness and the mind
The breadth and depth of research impact