Month: October 2014

…wait a second

We all know most genetics v. environment* research is done using a mix of monozygotic (identical twins), dizygotic (fraternal) twins , and non-twin siblings, reared apart or together.   The idea was that monozygotic twins share 100% of their DNA, and dizygotic and non-twins shared 50%, so you could tease out the difference between environment and genetics that way.

The first problem was that identical vs. not identicalness was originally assessed based entirely on looks.  But not all genetically identical twins look alike, and not all twins that look alike are genetically identical.  Mislabeling this makes genetics look less influential than they are.

The second problem is that this discounts nine months in utero as an environment, when it is probably the most influential environment you will ever be in.  Some (though not all) studies use dizygotic twins. vs non-twin siblings to measure the affect of a shared uterus, but there’s a lot of confounding variables there.  Worse, 75% of monozygotic twins are monochronic (sharing a placenta), and an exceptional few are monoamniotic (share an amniotic sac) (dizygotic twins never share a placenta or amniotic sac).  Monoamniotic pregnancies are rare and dangerous so we don’t know much about the twins, but monochronic twins are more alike than dichronic-monozygotic twins, despite the fact that sharing a placenta is more like to result in unequal distributions of blood, which can have huge effects.

The third problem is that not-identical -> 50% shared genetics was a reasonable assumption to make in the 1950s, or even the 1980s, but it’s not true. You have a 50% chance of sharing any given chromosome with a full sibling, which means your average relatedness is indeed 50%, but the total percent in common could be anything between 0 and 100**.  With genetic testing as cheap as it is, there’s no excuse not to test study subjects for exact relatedness.

*A stupid framing to begin with

**With complications from crossing over between chromosomes.  The probability math on this is straightforward but the actual calculations are so ugly because it depends on which chromosome crosses over and where.

Depression in video games

Okay, apparently psychology and video games is my niche and I should just accept that.

If you ask most gamers for a game about depression they’d say Depression Quest*, partly because it has depression right in the name and possibly because one of the designers, Zoe Quinn, has been targeted for massive harassment.  DQ is the world’s most morose choose your own adventure novel.  The descriptions of depression and they choices it leaves you are very accurate, but I left the game thinking “Boy, I am good at fighting depression.  Why don’t actual depressed people do as well as I did on this game?”  Which is of course massively unfair, and I assume not what the developers were going for.  I know other people who have liked it a lot, and it’s short and free, so certainly give it a go if you’re at all interested, but I don’t have much to say about it.

And then there is The Cat Lady.

The Cat Lady is a horror game.  If you hate being scared, or don’t want to see violence, sexualized violence, and gore, you should not play it.  I found it well done, artistically merited, and not exploitative, but it is pretty gruesome.

I like horror video games but no genre misses its mark more often.  Many games are never scary.  Of those that are, most rely purely on jump scares, which make me twitchy but not scared- the opposite of what I want.*  The best part of being scared is when it is over.  Of games that are successfully atmospherically scary at first, most are not by the end. You’re too used to the mechanics, you’ve acclimated to the monsters, your brain has noticed none of this is actually happening.  This can ruin the experience.

BEGIN SPOILERS (not scary)

The tempo of The Cat Lady can roughly be described as spooky-creepy-CREEPY-creepy-TERRIFYING-weird-scary-spooky-….and then every scene is less creepy than the one before.  You could call this a failing, in the pattern of many horror games before it.  Or you could call it a brilliant use of the mechanics of a game to induce a particular psychological state in the user,** in this case with the goal of demonstrating the improvement in the main characters psychological state as the game goes on.  The game starts with her suicide.  It ends with her finding her voice, making a friend, and standing up for what she thinks is right.  It felt very organic.  The player is given a lot of choice in Susan’s dialogue.  At the beginning I chose the most withdrawn and passive options, and at the end I chose the most active and courageous ones, because it felt like that’s what the character would do.  The lessening of terror felt like Susan coming into her own.

END SPOILERS

The negatives are mostly mechanical- for an atmospheric narrative game, the lack of autosave is puzzling.  The inability to manually save during dialogue, which can go 15 minutes at a stretch, is unacceptable.  The lack of even quicksave, meaning I must hit three buttons and then type the name of a new save, and do it compulsively because you never know if I’m about to crash or hit another 15 minute unsavable section, would be unforgivable even if the game hadn’t crashed twice at the same spot.***  The game is very talky, and it’s paced badly.  It was a very poor choice to block saves between chapters, and then start every chapter with a bunch of exposition, because it meant I was leaving the game in medeas res, rather than at natural down beats.  The talky bits were sometimes very interesting but sometimes very painful to get through- a lot of plumbing through dialogue trees to get the option you already know you’re going to use.

Would I recommend this to a person who wanted to know what depression felt like?  Only very a specific person.  You’d have to be a horror fan or you’d never get past the second chapter.  And if you don’t naturally get the genre I’m not sure it would have the same effect.  Would I recommend it to a depressed person looking to see their experiences reflected in art?  Same caveats, with possibly a wider net, since depressed people will more naturally get the depression in the beginning.  The writer/designer apparently has personal experience with depression, and it shows.  Would I recommend it to someone who likes horror games?  Yes, definitely, without reservation.  It is so good.

As a side note, I think is another piece of evidence for my evolving hypothesis about women and horror stories.  I don’t what the statistical distribution is because I watch a very nonrandom subset, but in a world where most major movies don’t even pass the Bedschel test, horror films address a lot of “women’s issues”.  Ginger Snaps and Jennifer’s Body are about female competitiveness as they come into sexual power, Mama is about being raised by a mentally ill parent, and Drag Me To Hell is about an eating disorder.  And now The Cat Lady is about depression, and the way depressed middle aged women are treated by society.

*There is a very slight chance they’d say Shadow of the Colossus, which is an excellent game, but any connection to depression is buried deep in metaphor.

MORE SPOILERS

*I discovered something interesting when I played Condemned.  Originally the contrast on my TV was so  bad I couldn’t see enemies (which, for maximum discomfort, are crazed homeless people) until they’d actually attacked me.  This was startling, but not scary at all.  I then upped the contrast so it was theoretically possible for me to see enemies ahead of time, although they were still mostly hidden.  This was much scarier.  It’s like I don’t feel fear unless something is preventable through my own actions.  Ironically the fact that The Cat Lady is a puzzle game, and thus you are never on a clock and can only die when the story says you’re definitely going to die, makes it easier for me to be scared.

**Papers, Please is the only other game I think of that does this.  It takes the mundanity of a lot of casual games and makes it a manifestation of working a soul crushing job.  I was impressed with them too.

***Non-gamers: I know it sounds like I’m overreacting, but I’m not.  Imagine if you had to walk to another room to save your place in a book on every page.

Book Review: The Child Catchers

I’ve used the words “calling” or “purpose” a few times on this blog now.  I’m not Christian, but I was raised in a Christian home in a Christian culture, and my concept of a calling is clearly steeped in that tradition.

So for me, reading The Child Catchers (Kathryn Joyce) was mostly a cautionary tale about letting a Call override the rest of your brain.  Step by step, Joyce takes you through how a large group of people who fervently believed they were doing not only the right thing, but the best thing, the thing they had been called by their God to do, destroyed the lives of countless children and ripped about whole societies.  Some of it came from privilege/White Man’s Burden beliefs, but some of it was just that they had bad or insufficient information.

On a practical level, non-foster-care adoption seems to have the trouble as the pharmaceutical industry: we wanted something (lifesaving medicine, care for abandoned children) but didn’t want to pay for it, so we handed the bill to the deepest pocket around (pharma companies, adoptive parents), and then we got mad when the system inevitably bent towards their point of view.  A lot of the problems in adoption stem from that most systems match a parent with a specific child and then start verifying if the child is available to be adopted.  Or the adoptive parents start picking up the mother’s expenses before birth.  The very impulse that will make these prospective parents good parents- the belief that this is their child– is incredibly destructive at this stage, and the fact that they’re required to invest a lot of money makes it worse.  It inevitably leads people to view searches for biological extended family as obstacles, or pressure a birth mother to “keep her word” and surrender the infant.  Even if they haven’t bonded with that specific child (which I would find worrying), they may not have the money to try again.  That’s just not fair.

Rwanda has chosen a different tactic.  International families go on a waiting list.  The Rwandan government checks all potentially eligible children, which involves looking for biological family who might take in the child and making sure the birth mother wasn’t coerced, or finding an unrelated local family that would like to adopt.  By the time an international adoptive family is contacted, the chances of something going wrong are minuscule.

Callings are important, but they need to be reality checked.  That might be my new Effective Altruism slogan.

Cutting

Cutting/self-harm comes up in crisis chat even more than borderline personality disorder, in part because cutting is common among both BPD patients, depressed teenagers, and depressed/anxious young adults. I have a lot of thoughts on cutting.

First, it is obvious to me that the shame around cutting is a million times worse for cutters than the actual cutting. I talk to so many kids terrified to reach out for help because people have or will judge them, shame them, or commit them for cutting. Even if they hide it perfectly, they know, and they know their support network doesn’t know, and they will never rid themselves of the fear that the support would be withdrawn if they knew.

Luckily my program gets that, and we’re at least allowed to be chill about cutting.  It doesn’t trigger an active rescue call, we’re explicitly supposed to reassure them it’s not shameful and we’re not judging, and we’re even allowed to praise it not as an alternative to suicide*, but as a coping mechanism that removes the necessity of it.

We are not, however, allowed to suggest it as an alternative to other popular coping mechanisms for the same problems, even to visitors already doing both. This confuses me.  Mental illness often leads to self medication through substance abuse**, eating disorders, social isolation, or simple inability to function in the world.  Done safely  (sterile instruments, proper care afterwords, incisions in safe areas- all of which can be taught) , cutting leads to… cuts.  Maybe some scarring if it’s really bad.  Cutters often report greater feelings of cope after cutting, and are able to invest that cope in other therapist approved things, like eating or seeking out a support network.

Not to mention the things you need to do to prevent people from self harming are incredibly intrusive (because everyone has finger nails), at a time when people most need to feel like their autonomy is respected.  Thin is a documentary about an eating disorder clinic, but a lot of the patients had self-harmed in the past (full disclosure: it’s been two years since I watched this and details might be fuzzy).   I’m sure the clinic had the best of intentions, but the section on the methods they used to prevent cutting left me screaming “do you not realize anorexia is about control?  I understand the feeding tube can’t wait till they get better, but is preventing cutting really worth triggering them like that?”.

In my perfect world, bystanders would treating cutting the same way participants do: as an external representation of an inner ugliness.  And then they would work on resolving that ugliness, rather than pushing away the evidence of it.  In a less perfect but still better than this world, cutting would qualify for the same harm reduction plans that drug addiction does, with health facilities providing sterile blades, bandages, and instruction of safe places to cut.  And then people would notice it is way, way less harmful than heroin or methadone*** and it would lose the stigma and now we’re back to my perfect world

*We’re allowed to praise a lot of things as alternatives to imminent suicide, up to and including later suicide.  It’s not often that “Why not see a doctor first and kill yourself if that doesn’t work out?”  is the right thing to say, but it’s not never either.

**Nothing like a depressant to chase the blues away

***Which is in fact significantly more dangerous than heroin, but less fun.

PS: If a patient or loved one of yours is cutting and you don’t know what to say, I have found “For a lot of people cutting is about releasing stored emotions.  Is it like that for you?”  to be a productive question.

The Real Reason Ebola Should Scare You

Ebola is not that contagious.  It’s easier to catch than HIV*, but way less than the flu, or norovirus**, aka stomach flu.  One of the Ebola nurses flew on two planes before she was quarantined, and so far no one has reported catching it.  Do you know how good planes are at transmitting illnesses?  Extremely.  So for me, the scary part of learning that two nurses caught Ebola while tending to a patient is that if their/the hospital’s hygiene was so lax as to allow transmission of Ebola (even after they elevated the hygiene procedures), what the hell else are the transmitting?

Greg Mitchell doesn’t give an exact answer, but he does have a body count: 2000 people died from hospital acquired infections last week.  So if everyone could redirect their panic from the scary African disease to the nice WASPy ones and start designing emergency rooms that aren’t festering petri dishes, that would be great.

*Although because HIV has a long dormant period, a person with HIV will on average infect more people than a person with Ebola.

**I am still mad at norovirus almost killing me in 2006.

Borderline Personality Week: What success looks like

Around the same time I was reading Buddha and the Borderline, I found a post on reddit by another model graduate of BPD treatment, which provides me another lovely BPD example I can use with violating someone’s privacy.  (To the best of my ability to determine based on self report on the internet…) This woman is doing everything right.  She did all the therapy, she is trying to keep from hurting others, she recognizes she has a problem and that it is her responsibility to make it right.  And what it has gotten her is a relationship in which any disagreement they have is assumed to be her fault, and any feeling she has is a problem.  DBT has let her stop listening to false alarms constantly ringing in her head, at the cost of ignoring the genuine alarms.  So even though her issue (3+ years of dating, woman wants to commit, man dragging his feet) is hilariously cliched on r/relationships, she, and everyone else, view it through the lens of “I must contain my unreasonable desires.”

[It’s also pretty instructive to look at the comments of that post.  It is abundantly clear that for a large subset of commenters, there is nothing she could say after the word “borderline” that would make them take her side.    I can’t prove she’s actually as controlled as she claims she is, but what borderlines do is usually not so much lie as convey their emotional truth, from which you can usually reverse engineer what actually happens.  This woman is objective as hell ]

I see a lot of this in chat as well.  The uncontrolled frequent flyer borderlines get all the attention, but I regularly talk to people who have done all the therapy and been very successful and what it means is that when they dysregulate, they contain the damage.  Which is much better than not containing it, but doesn’t make the dysregulation itself less painful.    Of course, I have a pretty biased sample- maybe lots of people genuinely do get better and I don’t talk to them because they never visit chat- but I would bet money there’s a substantial population like this.  And I hope we eventually find something better for them.

Borderline Personality Week: Making sure you’re not getting too much out of medical care

I’ve already talked about how Van Gelder’s mental hospital wanted to make sure she didn’t enjoy them caring about her too much.  They also wanted to make sure she didn’t get too much out of their long term assistance.  Van Gelder participated in the hospital’s MAP program (outpatient, but you attend therapy for a full workweek), two different Dialectic Behavioral Therapy groups, and a graduate BPD skills class (none of which were directly associated with the hospital).    Participants in these programs are not allowed to make friends with each other, not allowed to provide emotional support in group, not allowed to exchange contact information and keep in touch after the class.

On one hand, I understand why the therapists think this is a good idea.  BPDers friendships with neurotypicals are chaotic, two BPDers is chaos squared.  They don’t want to be constantly interrupting their skills class to deal with interpersonal drama.  On the other hand, people have emotions about people they’re spending a lot of around.  People have more emotions around people they’re doing difficult, vulnerable, things around.  Trying to cut that out seems a lot like the military’s Don’t Ask Don’t Tell policy- it pushes the problem deeper underground and denies people tools for coping with it.  It seems especially cruel to form a group of out of people with abandonment issues and then demand they cut ties at a point you determine.

It’s not just the skills class that is temporary. The Dialectic Behavioral Therapy and then Internal Family Systems therapy Van Gelder gets (which is the gold standard for borderline personality disorder) is very clearly meant to be temporary.  They teach you the skills and then you’re on your own.  It is, like physical therapy after a traumatic injury, meant to be a cure.

Except the same professionals will tell you there is no cure for BPD.  A lot of the benefit of the therapy is that it treats the symptoms by giving people a safe place, with unconditional positive regard and no risk of abandonment.  In that way it is like massage therapy for office workers, or insulin for diabetics:  minimiizng suffering and collateral damage by treating the symptoms, but with the expectation that problem will reoccur if treatment stops.

The mental health field seems very determined to make their services a cure rather than a treatment.  You can be on psychoactive drugs for the rest of your life, but not therapy.  The thing is, unconditional positive regard is not that difficult or expensive to provide.  That’s why they let us volunteers do it after 20 hours of training (and providing active listening to BPD sufferers is at times a large part of my work at crisis chat).   There’s also some evidence that’s the benefit of most counseling modalities, regardless of what the therapist says they’re doing.  It would not surprise me at all if there are issues I haven’t thought of that mean giving BPDers low-level therapy for their entire lives is not viable.  But I haven’t heard anyone give one, or even really ask the question.  It’s just assumed that lifelong therapy represents failure.  And I don’t think that’s fair.

Borderline Personality Week: when your desire to kill yourself is an annoyance to others

Jesus Christ I hate the wordpress post management system.  It published my first BPD entry three days early and then ate drafts of two planned posts.  Let’s see what I can recreate.

There are a lot of insights I get from working at the crisis chat center I would like to talk about, but talking about them requires examples, and using the chats as examples would be a huge violation of privacy, both morally and legally.  Lots of health care workers get around this by writing semi-fictionalized or composite characters, but I don’t feel skilled enough to pull that off.  Luckily, Kiera Van Gelder  wrote a book,The Buddha and the Borderline, about her recovery from learning to cope with Borderline Personality Disorder, and there is absolutely no privacy violation in using her as an example.

The first issue I want to discuss is how health care professionals treat BPDers’ threats of suicide.  Van Gelder was committed for short term stays due to suicidality several times- first as a young adult, and then three times in six months around age 30.   BPD can lead to suicide, at about the same rate depression, bipolar disorder, and schizophrenia do (with the exactly number being hard to determine because co-occurrence and misdiagnosis between BPD and the first two of those disorders is so common).  But BPDers are (perceived as) more likely to enjoy their stays.  That is probably because (crudely) depressed people want to kill themselves because they think everything is hopeless, bipolar people because they simultaneously think think everything is hopeless and have the energy to act on that belief, and schizophrenics think the CIA has told the demons where to find them.  Whereas BPDers are often thinking things like “no one cares about me.” and “I’m all alone.”  A hospital stay with kind staff checking to make sure you haven’t killed yourself salves this directly, and as such can be pleasant.  I can’t even judge them for this because even though I don’t think I’d have fun in a mental hospital, I got my IV nutrition + immune support at a concierge medicine place and it was awesome. *

But after two stays in a few months, the hospital was not so nice.  On the second visit, they told her that if she kept this up insurance would force her into the state hospital, which she would “not find so pleasant”.  When she came back a third time anyway they suggest maybe she needs to just learn to live with being suicidal and when she insists she is.  not.  safe.  they put her in a “rapid recovery unit”, which is basically a holding tank for the hospital to prove they did their due diligence vis a vis keeping her from killing herself while expending as few resources as possible.  It is not warm, it is not comforting, no one is demonstrating they care about her.

Perhaps the fear is that BPDers are faking suicidality, or worse, pushing themselves to become genuinely suicidal, to get attention.  I can’t prove that’s not happening.  And if anyone is going to do it, it’s probably borderlines.  But as I said above, the death-by-suicide rate for borderline personality disorder is only slightly lower than that for depression and bipolar disorder.   That doesn’t mean they have the same chance of following through on a given threat (it’s quite possible BPDers threaten more often), but it seems like the safer plan might be to give them more attention without requiring them to resort to suicide, rather than calling their bluff.

Perhaps it is that the act of denying a BPD sufferer admission to the hospital makes suicide more likely, in a way it doesn’t for other mental illnesses.  You might think that that would make admission a better idea, but a consistent thread in the medical treatment of BPDers is trying to make them get less out of treatment.  I’ll talk about that tomorrow.

[ An important note if you’re dealing with a person with BPD: even if they are making the suicide threat “for attention”, ignoring them doesn’t mean it will go away.  Suicide also looks like a viable means of getting attention and/or coping with not getting attention.  This does not obligate you to indulge their every whim when they mention the word suicide, you are in your rights to cut them off, but if you think the threat is credible, alert their support network or emergency services ]

*Have you ever had a nurse be happy to peel an orange for you?  I have.  Having insurance cover treatment at conceirge locations is like getting bumped to first class when you bought a coach ticket.

Cochrane review

This was going to be a post about zinc for colds.  I read many journal articles (fine, abstracts) and wrote many witty analogies.  Than my friend pointed me to Cochrane review, which did the same thing much more rigorously.   Some day I will be grateful for this wonderful resource but right now I am just mad my thunder was stolen

Edited to add: the friend was John Salvatier.

Reality is Broken and how to fix it

I am very into video games.  This does not mean I play many video games- I’m below average for people I know, although that’s a skewed sample.  But I do a lot of reading about video games , because I find economics interesting and the business of video games has a confluence of factors that allow me to understand it.  Plus, it’s going through some interesting transformations on both the monetary and art fronts.  That is why I read Reality is Broken by Jane McGonigal.

Much like researchers of heroin and cocaine before her, McGonical’s approach is to look at something addictive and, rather than declare we’re all weak for liking it, study why it is so addictive/satisfying and what we can do to bring that into our lives in a healthy way.  Her list of things video games provide us- flow, challenge, ownership, accomplishment- read like a list of things my job doesn’t do.  Which I already knew, and has led me to start researching other careers, which led to among other things this blog.  This gave me the idea to start alternating work-type tasks with video games targetted to give the satisfaction of having done work (e.g. Harvest Moon, which is about running your own farm).  For the moment the work type task is “reading books I already wanted to read”, but it nonetheless raised my satisfaction and endurance level significantly, and I’m hopeful it will help when I return to work as well.*

But then McGonigal shifts tacts, and talks about all the ways we can use video games to improve the world.  One example is Foldit, in which players are given the primary structure of a protein and attempt to find the lowest-energy tertiary structure for it.  Scientists actually use these results in their research. **   She also designed World Without Oil, a collaborative fiction game where people brainstormed how to adapt to an oil storage.

She also talked about her prolonged recovery from a concussion.  I identified with this a lot: the lack of tangible progress, the alternation between not having the energy to do what you’re supposed to and being desperate to do something but not knowing what.  In my case there’s also juggling several different problems, and wondering if you’d be happier if you just concentrated on one until it was done, and trying to manage containing the most urgent symptoms and investing in long term solutions.  I responded by writing “this is hard” in my diary.  Jane McGonigal responded by making SuperBetter, a website/service that gamifies convalesence (think fitocracy but for actual health, rather than health-as-codeword-for-skinny).  This was kind of a revelation for me on two levels.  One, it solved a problem I had recently been whining about, and enables me to take better care of myself.  I’ve been using it for a week so far, and while it’s not magic, it is helpful, and it is most helpful when I am least able to act on my own.

Two, it has me thinking about my future.  My volunteer thus far has me very convinced I want to work in adolescent mental health.  I think that is my special talent and while I feel stupid saying it, I genuinely think I could change the world.  I want to do that.  But so far my research has focused on existing career tracks I could jump into (psychiatrist, counselor, etc).  I’d considered programming for a company that made meaningful software but dismissed it, in part because I’d done it before and found it lacking.  But maybe there’s a hybrid.  I could have made SuperBetter.  I mean, the last webpage I made was written in notepad, but I’m capable of learning the skills to make SuperBetter.  Hell, I could probably get a job to pay me to learn the skills to make SuperBetter.  There’s no credential holding me back.  And I think I would be really proud of myself if I did something like that.

MoodGym already exists, so off the top of my head I don’t know what I could create that would add value to the world.  I definitely need more volunteering and reading to find out, and may quite possibly need more formal education.  But my eyes are open to the broader range of possibilities for me to change the world, both now and in the future.

Which is extremely convenient, because the money that would have gone to taking off work and soul searching has gone to taking off work and holding an ice pack to my jaw.  It was a good trade given the circumstances, but it may set formal school back years.  This was an excellent time to acquire hope I can do more in place.

*According to Reality is Broken, this is common strategy among top executives.

**This is how I got through the analytical section of organic chemistry.  I hated all that stuff that was never going to be relevant to me as a behaviorist until I realized it used exactly the same part of my brain as the game Set, which I loved.  I went on to nail that test and enjoyed it more than any other part of orgo.