Negative Feedback and Simulacra

Part 1: Examples

There’s a thing I want to talk about but it’s pretty nebulous so I’m going to start with examples. Feel free to skip ahead to part 2 if you prefer.

Example 1: Hot sauce

In this r/AmITheAsshole post, a person tries some food their their girlfriend cooked, likes it, but tries another bite with hot sauce. Girlfriend says this “…insults her cooking and insinuates that she doesn’t know how to cook”. 

As objective people not in this fight, we can notice that her cooking is exactly as good as it is whether or not he adds hot sauce. Adding hot sauce reveals information (maybe about him, maybe about the food), but cannot change the facts on the ground. Yet she is treating him like he retroactively made her cooking worse in a way that somehow reflects on her, or made a deliberate attempt to hurt her.

 

Example 2: Giving a CD back to the library

Back when I would get books on CD I would sometimes forget the last one in my drive or car. Since I didn’t use CDs that often, I would find the last CD sometimes months later. To solve this, I would drop the CD in the library book return slot, which, uh, no longer looks like a good solution to me, in part because of the time I did this in front of a friend and she questioned it. Not rudely or anything, just “are you sure that’s safe? Couldn’t the CD snap if something lands wrong?.” I got pretty angry about this, but couldn’t actually deny she had a point, so settled for thinking that if she had violated a friend code by not pretending my action was harmless. I was not dumb enough to say this out loud, but I radiated the vibe and she dropped it.

 

Example 3: Elizabeth fails to fit in at martial arts 

A long time ago I went to a martial arts studio. The general classes (as opposed to specialized classes like grappling) were preceded by an optional 45 minute warm up class. Missing the warm up was fine, even if you took a class before and after. Showing up 10 minutes before the general class and doing your own warm ups on the adjacent mats was fine too. What was not fine was doing the specialized class, doing your own warm ups on adjacent maps for the full 45 minutes while the instructor led regular warm ups, and then rejoining for the general class. That was “very insulting to the instructor”.

This was a problem for me because the regular warm ups hurt, in ways that clearly meant they were bad for me (and this is at a place I regularly let people hit me in the head). Theoretically I could have asked the instructor to give me something different, but that is not free and the replacements wouldn’t have been any better, which is not surprising because no one there had the slightest qualification to do personal training or physical therapy. So basically the school wanted me to pretend I was in a world where they were competent to create exercise routines, more competent than I despite having no feedback from my body, and considered not pretending disrespectful to the person leading warm ups.

Like the hot sauce example, the warm ups were as good as they were regardless of my participation – and they knew that, because they didn’t demand I participate. But me doing my own warm ups broke the illusion of competence they were trying to maintain.

 

Example 4: Imaginary Self-Help Guru

I listened to an interview where the guest was a former self-help guru who had recently shut down his school. Well, I say listened, but I’ve only done the first 25% so far. For that reason this should be viewed less as “this specific real person believes these specific things” and more like  “a character Elizabeth made up in her head inspired by things a real person said…” and. For that reason, I won’t be using his name or linking to the podcast.

Anyways, the actual person talked about how being a leader put a target on his back and his followers were never happy.  There are indeed a lot of burdens of leadership that are worthy of empathy, but there was an… entitled… vibe to the complaint. Like his work as a leader gave him a right to a life free of criticism.

If I was going to steel- man him, I’d say that there are lots of demands people place on leaders that they shouldn’t, such as “Stop reminding me of my abusive father” or “I’m sad that trade offs exist, fix it”. But I got a vibe that the imaginary guru was going farther than that; he felt like he was entitled to have his advice work, and people telling him it didn’t was taking that away from him, which made it an attack.

 

Example 5: Do I owe MAPLE space for their response?

A friend of mine (who has some skin in the meditation game) said things I interpreted as feeling very strongly that:

  1. My post on MAPLE was important and great and should be widely shared.
  2. I owed MAPLE an opportunity to read my post ahead of time and give me a response to publish alongside it (although I could have declined to publish it if I felt it was sufficiently bad).

Their argument, as I understood it at the time, was that even if I linked to a response MAPLE made later, N days worth of people would have read the post and not the response, and that was unfair.

I think this is sometimes correct- I took an example out of this post even though it required substantial rewrites, because I checked in with the people in question, found they had a different view, and that I didn’t feel sure enough of mine to defend it (full disclosure: I also have more social and financial ties to the group in question than I do to MAPLE).

I had in fact already reached out to my original contact there to let him know the post was coming and would be negative, and he passed my comment on to the head of the monastery. I didn’t offer to let him see it or respond, but he had an opportunity to ask (what he did suggest is a post in and of itself). This wasn’t enough for my friend- what if my contact was misrepresenting me to the head, or vice versa? I had an obligation to reach out directly to the head (which I had no way of doing beyond the info@ e-mail on their website) and explicitly offer him a pre-read and to read his response.

[Note: I’m compressing timelines a little. Some of this argument and clarification came in arguments about the principle of the matter after I had already published the post. I did share this with my friend, and changed some things based on their requests. On others I decided to leave it as my impression at the time we argued, on the theory that “if I didn’t understand it after 10 hours of arguing, the chances this correction actually improves my accuracy are slim”. I showed them a near-final draft and they were happy with it]

I thought about this very seriously. I even tentatively agreed (to my friend) that I would do it. But I sat with it for a day, and it just didn’t feel right. What I eventually identified as the problem was this: MAPLE wasn’t going to be appending my criticism to any of their promotional material. I would be shocked if they linked to me at all. And even if they did it wouldn’t be the equivalent, because my friend was insisting that I proactively seek out their response, where they had never sought out mine, or to the best of my knowledge any of their critics. As far as I know they’ve never included anything negative in their public facing material, despite at least one person making criticism extremely available to them. 

If my friend were being consistent (which is not a synonym for “good”) they would insist that MAPLE seek out people’s feedback and post a representative sample somewhere, at a minimum. The good news is: my friend says they’re going to do that next time they’re in touch. What they describe wanting MAPLE to create sounds acceptable to me. Hurray! Balance is restored to The Force! Except… assuming it does happen, why was my post necessary to kickstart this conversation?  My friend could have noticed the absence of critical content on MAPLE’s website at any time. The fact that negative reports trigger a reflex to look for a response and positive self-reports do not is itself a product of treating negative reports as overt antagonism and positive reports as neutral information.

[If MAPLE does link to my experience in a findable way on their website, I will append whatever they want to my post (clearly marked as coming from them). If they share a link on Twitter or something else transient, I will do the same] 

 

Part 2: Simulacrum

My friend Ben Hoffman talks about simulacra a lot, with this rough definition:

1. First, words were used to maintain shared accounting. We described reality intersubjectively in order to build shared maps, the better to navigate our environment. I say that the food source is over there, so that our band can move towards or away from it when situationally appropriate, or so people can make other inferences based on this knowledge.

2. The breakdown of naive intersubjectivity – people start taking the shared map as an object to be manipulated, rather than part of their own subjectivity. For instance, I might say there’s a lion over somewhere where I know there’s food, in order to hoard access to that resource for idiosyncratic advantage. Thus, the map drifts from reality, and we start dissociating from the maps we make.

3. When maps drift far enough from reality, in some cases people aren’t even parsing it as though it had a literal specific objective meaning that grounds out in some verifiable external test outside of social reality. Instead, the map becomes a sort of command language for coordinating actions and feelings. “There’s food over there” is perhaps construed as a bid to move in that direction, and evaluated as though it were that call to action. Any argument for or against the implied call to action is conflated with an argument for or against the proposition literally asserted. This is how arguments become soldiers. Any attempt to simply investigate the literal truth of the proposition is considered at best naive and at worst politically irresponsible.
But since this usage is parasitic on the old map structure that was meant to describe something outside the system of describers, language is still structured in terms of reification and objectivity, so it substantively resembles something with descriptive power, or “aboutness.” For instance, while you cannot acquire a physician’s privileges and social role simply by providing clear evidence of your ability to heal others, those privileges are still justified in terms of pseudo-consequentialist arguments about expertise in healing.

4. Finally, the pseudostructure itself becomes perceptible as an object that can be manipulated, the pseudocorrespondence breaks down, and all assertions are nothing but moves in an ever-shifting game where you’re trying to think a bit ahead of the others (for positional advantage), but not too far ahead.

If that doesn’t make sense, try this anonymous comment on the post

Level 1: “There’s a lion across the river.” = There’s a lion across the river.
Level 2: “There’s a lion across the river.” = I don’t want to go (or have other people go) across the river.
Level 3: “There’s a lion across the river.” = I’m with the popular kids who are too cool to go across the river.
Level 4: “There’s a lion across the river.” = A firm stance against trans-river expansionism focus grouped well with undecided voters in my constituency.

In all five of my examples, people were given information (I like this better with hot sauce, you might break the library’s CD, these exercises hurt me and you are not qualified to fix it, your advice did not fix my problem, I had a miserable time at your retreat), and treated it as a social attack. This is most obvious in the first four, where someone literally says some version of “I feel under attack”, but is equally true in the last one, even though the enforcer was different than the ~victim and was attempting merely to tax criticism, not suppress it entirely. All five have the effect that there is either more conflict or less information in the world.

 

Part 3: But…

When I started thinking about this, I wanted a button I could push to make everyone go to level one all the time. It’s not clear that that’s actually a good idea, but even if it was, there is no button, and choosing/pretending to cut off your awareness of higher levels in order to maintain moral purity does you no good. If you refuse to conceive of why someone would tell you things other than to give you information, you leave yourself open to “I’m only telling you this to make you better” abuse. If you refuse to believe that people would lie except out of ignorance, you’ll trust when you shouldn’t. If you refuse to notice how people are communicating with others, you will be blindsided when they coordinate on levels you don’t see. 

But beating them at their own game doesn’t work either, because the enemy was never them, it was the game, which you are still playing. You can’t socially maneuver your way into a less political world. In particular, it’s a recent development that I would have noticed my friend’s unilateral demand for fairness as in fact tilted towards MAPLE. In a world where no one notices things like that, positive reviews of programs become overrepresented.

I don’t have a solution to this.  The best I can do right now is try to feed systems where level one is valued and higher levels are discussed openly.  “How do I find those?” you might ask. I don’t know. If you do, my email address is elizabeth – at – this domain name and I’d love to hear from you. You can also book a time to talk to me for an hour. What I have are a handful of 1:1 relationships where we have spent years building trust to get to the point where “I think you’re being a coward” is treated as genuine information, not a social threat, and mostly the other person has made the first move. 

The pieces of advice I do have are:

  1. If someone says they want honest feedback, err on the side of giving it to them. They are probably lying, but that’s their problem (unless they’re in a position to make it yours, in which case think harder about this).
  2. Figure out what you need to feel secure as someone confirms your worst fears about yourself and ask for it, even if it’s weird, even if it seems like an impossibly big ask. People you are compatible with will want to build towards that (not everyone who doesn’t is abusive or even operating in bad faith- but if you can’t start negotiations on this I’d be very surprised if you’re compatible).
  3. Be prepared for some sacrifices, especially in the congeniality department. People who are good at honesty under a climate that punishes it are not going to come out unscathed.

Literature Review: MDMA

Introduction

MDMA (popularly known as Ecstasy) is a chemical with powerful neurological effects. Some of these are positive- the Multidisciplinary Association for Psychedelic Studies (MAPS) has shown very promising preliminary results using MDMA-assisted therapy to cure treatment-resistant PTSD. It is also, according to reports, quite fun. But there is also concern that MDMA can cause serious brain damage. I set out to find if that was true, in the hope that it wasn’t, because it sounds awesome.

Unfortunately the evidence is very strongly on the side of “dangerous”. Retrospective studies of long term users show cognitive deficits not found in other drug users, while animal studies show brain damage and inconsistent cognitive deficits. The one bright spot is the MAPS study, which reported no drop in cognitive function after a therapeutic dose of MDMA, but we’ll talk about the problems with that later. There was a single study showing mitigations may be effective.

I was a little inconsistent with citing my sources in this post when I was relying on a number of studies to inform a general point. If you want to follow up or check my work, you can see my notes here.

Background

MDMA’s primary effect is to release massive amounts of serotonin at once. In particular it works on the 5-HT(2B) receptor, which affects the brain, appetite, gut motility and, in a nice bit of poetics, the heart.

MDMA also has significant hormonal effects, causing an increase in DHEA (a cortisol precursor), cortisol (the long-term stress hormone) and prolactin (best known for inducing lactation, but also a counter to dopamine and sex hormones). Curiously, higher cortisol correlates with higher enjoyment of MDMA. At first this surprised me because cortisol is thought of as indicating stress, but then I remembered that the only thing worse than cortisol is needing it and not having it (which may be the chemical underpinnings of burn out). It may be that cortisol contributes to an “energized” feeling, which is interpreted positively due to the flood of serotonin and dopamine.

The Damage

Retrospective Studies

Studies looking at the brains and behavior of long term recreational users are the least trustworthy to me, because it’s so hard to distinguish what else the subject might have taken, deliberately or mixed with their supposed MDMA. If you did want to listen to those studies, the news is awful, with participants showing problems with:

[Note that some of those links are to the same study and should not be taken as independent confirmation]

In some cases, MDMA-users were compared to users of other street drugs and performed worse, providing something of a control. In other cases, only a combination of MDMA and alcohol inhibited performance.

Controlled Animal Experiments

It’s abundantly clear in autopsies that MDMA changes neurochemistry and damages nerves. But only some studies showed this to translate to any actual cognitive deficit. My best guess is this is either because some studies give their rats way more drug than is reasonable, or because the brain is able to work around deficients. I worry that these work arounds are temporary, and as age does its work it will reveal damage done long ago.

Most of the animal studies used very high doses of MDMA, or many repetitions in a short period. I think this is a reasonable shortcut to determining the effects of long term use, but it does leave the possibility the brain is able to heal from damage, if given enough time.

Controlled Human Experiments

These are thin on the ground, and the ones I did find often didn’t do cognitive tests, focusing instead on things like serum levels and temperature (which MDMA raises). The one exception was a study by MAPS, which reported no “significant” cognitive deficits, but declined to share the actual scores on the RBANS test they used. This makes me extremely suspicious.

Is it worth it? This meta-analysis found only ⅓ of MDMA-for-PTSD studies demonstrated statistically significant improvements. This study didn’t even find an improvement in mood. I was going to make fun of this study for specifying that “subjects liked MDMA”, but actually very few studies bothered to note the subjective enjoyment effects, so good on them for getting it on the record.

Mitigations

Folk wisdom has a number of remedies for the post-MDMA crash, including 5-HTP, tryptophan, and SSRIs. These are all aimed at the depletion of of serotonin that occurs after MDMA wears off; if that depletion is the primary cause of brain damage, they might reasonably intervene. If on the other hand the damage is primarily caused by the initial flood of serotonin I would expect them to have no effect.

This very small study (treatment groups of size 8) nonetheless found that single treatments of 5-HTP and tryptophan prevented large drops in serotonin and its metabolite 5-HIAA, and large drops in the number of binding sites. 5-HTP and tryptophan actually increased serotonin or sensitivity in certain brain areas. This is a smaller study than I want to trust my brain to, but nonetheless very interesting.

Conclusion

These studies are likely heavily biased by the US government’s hatred of fun. They’re often quite small, so it would be easy for publication bias to sweep positive reports under the rug. To really answer this question I’d need to do similar literature reviews for other substances and see how they compared. I don’t have that kind of time (if you would like to buy the time for me, contact me at elizabeth at this domain name), but I did find MDMA’s wikipedia page much scarier than LSD’s or marijuana’s. On the other hand, all of the evidence points in one direction, and it would not be shocking if a sudden massive release of neurotransmitters, followed by a prolonged deficit, was damaging.

MDMA is risky, and you probably shouldn’t use it, although a handful of times with the right therapeutic environment might be worth it if your problems are bad enough. There are promising but unproven mitigations. If you do decide that MDMA is worth the risk to you, at least be careful to hydrate properly, in a cool environment to prevent overheating, and definitely don’t mix it with anything else. In other words: a rave is the last place you should be doing E.

 

This post supported by Patreon. Thanks to Justis Mills for copyediting.

 

Cost Effectiveness of Mindfulness Based Stress Reduction

The Problem

The WHO estimates that depression and anxiety together account for 75,000,000 DALYs annually, making up ~5% of total DALYs. In “Measuring the Impact of Mental Illness on Quality of Life”, I argue that there is good reason to think that the system used to generate these estimates severely underestimates the impact of mental illness, and thus the true damage may be much higher. To try to get an estimate on the harms of mental health and the benefits of alieviating mental health problems, I did a preliminary cost-effectiveness analysis of Mindfulness Based Stress Reduction (MBSR).

The Intervention

MBSR is an eight week class that uses a combination of mindfulness, body awareness, and yoga to improve quality of life and perhaps physical health for a variety of conditions.

MBSR was created by Jon Kabat-Zinn at the University of Massachusetts in the 1970s, but has spread widely since then. The exact extent of this spread is hard to measure because no official registration is required to teach mindfulness and many classes and books claim to be mindfulness inspired. For the purpose of this evaluation I looked only at things that were officially MBSR or adhered very closely to the description.

Cost of MBSR

Herman, et al. (2017) estimated the marginal cost of an MBSR class participant at $150. The first three hits on google (run in an incognito browser but suspiciously near the location from which I ran the search) for MBSR listed a cost of $395-$595, $275-$425, and $350. The difference between the top of the range and the marginal cost indicates that the high end of that range probably covers all of the costs involved with MBSR (space rental and instructor time for eight weeks of classes plus one eight hour retreat) and then some, so I will use $600 as the ceiling on costs and $150 as the floor.

MBSR has an unusually high time ongoing cost (one hour per day). To model this, I included a range of DALYs as a cost, ranging from 0 (indicating no cost) to 1/24 (as if the participant were dead for that hour). It is unclear how the one hour duration was chosen and I could not find any studies on the comparative impact of different lengths of meditation; it’s quite plausible one could get the same results in less time. For the purpose of this document I used the official program, because it was the most consistently studied.

Cost Effectiveness Analysis of MBSR

Both depression and anxiety are measured with a variety of clinical surveys. To estimate impact, I assumed that the top score on each survey caused a DALY loss equal to severe depression/anxiety, as estimated by the World Health Organization, and that a drop of N percentage points led to a drop of disability weight * N. For example, a drop of 8 points on an 80 point scale of anxiety (disability weight of severe anxiety: 0.523) causes a gain of .0523 DALYs.

For a survey of papers showing potential impact, see this spreadsheet. The estimates range from 2% to 11%, clustered around 7%.

I have created a Guesstimate model to estimate the impact of MBSR. Results were quite promising. On a randomly selected guesstimate run, the average cost was $290/DALY, with a range from $43/DALY to $930/DALY. This is close to but better than Strong Mind’s $650/DALY and overlaps with estimates of antimalarial treatment ($8.15-$150/DALY). Note that the MBSR estimate may understate the impact due to systemic biases in how DALYs are calculated. However it may also overstate the impact, as medical studies tend to overstate intervention impacts for a variety of reasons.

The model makes no attempt to account for co-morbid disorders. Individuals with depression and anxiety would likely see higher benefits, since the same hour of meditation would impact both.

This model makes the rather optimistic assumption the benefits persist for life. This assumes that the participant would have been counterfactually depressed forever without treatment.  In reality the average depressive episode lasts six months, and of people who have suffered at least one episode, the average lifetime number of episodes is four. If we assume the participant gets two years of benefit out of treatment the cost becomes $1200 to $14,000/DALY, with an average of $5200/DALY.

Caveats

All of the effectiveness studies cited were done on developed world citizens with only mild to moderate mental illnesses. Most were middle aged, and access to MBSR implies a minimum SES bar. It is possible that more severe depression is not amenable to MBSR, or that it is amenable and shows a larger absolute change because there is farther to improve.

I could find no studies on MBSR in the developing world, although since mindfulness meditation was originally created before there was such a thing as the developed world, there is a higher than typical chance that its usefulness will survive cultural translation.

All of the studies referenced had small sample sizes. They all show a consistent effect, but it’s possible publication bias is keeping negative studies out of view.

Official MBSR has an unusually high time cost compared to medication and therapy. The costs are high both upfront (eight weeks of classes and an all day retreat) and ongoing (one hour of meditation/day). Some patients may be able to get the benefits of MBSR with less time; others may not be able to practice at all due to the time demands.

 

For more on this see my shallow review of mental health .

Measuring the Impact of Mental Illness on Quality of Life

Introduction

I am currently evaluating multiple interventions aimed at mental illness. In order to compare these to each other and interventions in other areas, it is important to make an estimate of severity of the problem and of the impact of interventions. Several standard systems for evaluating health interventions exist, each of which has strengths and weaknesses. How accurate/useful are these systems for mental illness?

Death Rate

Mental illness has a death toll (primarily from suicide and overdoses) that can be compared to deaths from physical ailments. Death has the advantage of being a binary state subject to very little measurement error or differing definitions across culture. However it is an imperfect proxy for suffering inflicted by mental illness. Depending on culture one country may have a higher depression rate but lower suicide rate. A country with better medical services may have a worse drug problem but fewer deaths from overdoses. Cause of death is subject to manipulation. Mortality is also a very poor measure of anxiety, since anxiety is almost never the immediate cause of death (although it may shorten lifespan).

Disability Adjusted Life Years

Disability adjusted life years (DALYs) are an attempt to use a single number to express the health of a population. The calculation method can vary from study to study; for purposes of this post I will be referring only to the methods used in the Global Burden of Disease 2010 (hereafter GBD 2010) study.

Aggregated DALYs for a population are calculated by multiplying the [disability prevalence] x [disability weight] x [years until remission or death]. Some surveys (but not all) include further discounts for age, assuming that a year lived as a 70 year old is less valuable than a year lived as a 25 year old. This is known as age-weighting. Disability weight is calculated by asking individuals to compare two scenarios and rate which person seems “healthier.” GBD 2010 surveyed approximately 14,000 individuals from five countries (Bangladesh, Indonesia, Peru, the United Republic of Tanzania and the United States of America) and offered a web based survey as well, which was eventually taken by approximately 16,000 people. Previous versions of the GBD exclusively used the evaluations of health care practitioners.

Because they are only are a measure of health, DALYs are not a good measure of suffering. For example, a loved one dying is an obvious cause of suffering via grief, but has no impact on the DALY metric of the survivors. DALYs also deliberately exclude the availability of mitigations: vision impairment has the same DALY cost regardless of the availability of corrective lenses (Voight & King, 2010). These choices make DALYs highly legible and comparable, at the cost of excluding many things one might care about. Additionally, “Healthy” is a highly ambiguous term, which many cultures consider to refer only to physical health. This suggests that if one cares about suffering, or includes mental health in their definition of health, DALYs are likely to severely underrate the impact of mental illness.
Quality Adjusted Life Years

QALYs are explicitly designed to evaluate quality of life, not just health. Instead of choosing which of two individuals is healthier, survey participants may choose which situation they would rather live in (e.g., five years of blindness or four years of deafness), what risk of death they would accept in order to cure an ailment (e.g. 10% risk of death for surgery to restore function to your leg), or “how bad does this sound to you on a scale of 1-100?”

QALYs are noticeably better than DALYs for measuring the impact of mental illness, in that everyone agrees mental illnesses lower quality of life. However there is still concern that they underestimate the impact because people are bad at imagining themselves in different situations, and bad at imagining mental illness in particular. Dolan (2008) argues that any rating based on trade-offs is inherently weak, because humans are so bad at remembering the past and anticipating the future. He favors using ratings of subjective well being from people currently suffering from a condition. Brazier, et al. (2008) cites data that the general public rates mental health issues as less important than physical health, less so than those who suffer from mental illness (Brazier (2008), which if true would lead to an underestimate of the cost of mental illness. Meanwhile De Wit, Busschbach, and De Charro (2000) argue that people underestimate their ability to adapt to situations, and thus all QALY cost estimates are overestimates. Michael Plant argues that this applies only to physical ailments, and that this leads people to underestimate the severity of mental illness relative to physical illness.

Issues Comparing DALYs/QALYs for Mental Illness with Other Illnesses

The cost-effectiveness estimates for malaria nets are based solely on the averted physical suffering. In order to truly compare malaria QALYs with depression QALYs, we must take into consideration the mental health toll of malaria. This turns out to be a very complicated question that can’t be answered without getting into moral ontology, which is beyond the scope of this document.

For a very, very crude idea of the effect on bednets on suffering, see this guesstimate model, which lets you estimate the mental illness cost of malaria from mourning and mental-health related side effects. Ultimately the DALY/$ (guesstimated in the range of 10^-3 and 10 ^-5) are insignificant next to the DALY/$ gain from deaths averted (in the range of 10^-1).

Financial Cost

Illness (mental or physical) can exact an enormous physical toll on sufferers, in both cost of treatment and lost productivity. Productivity loss is more difficult to measure than death and thus not as precise a metric, but it is significantly more objective and comparable across ailments than DALYs or QALYs. For more information on the productivity costs of mental illness, see this post.

A second issue is that using productivity loss as a metric will bias interventions towards people with higher potential incomes, which is the opposite of most people’s instincts.

Conclusions

None of these measurements met my goals of being easy to measure and capturing the entire impact of mental illness. This is not surprising, since even the impacts of physical ailments are hard to measure. The only clear conclusion is that QALYs are better than DALYs for any purpose I can think of. Of the options available, death and financial cost are the most objective, easiest to measure, and easiest to compare to other ailments, but lose a lot of data around suffering. QALYs capture that data, but are still of questionable suitability for comparing to other ailments.

Impact of Depression and its Treatment on Productivity

Introduction

One argument for prioritizing treatment of mental illness is that the secondary effects (such as higher productivity and improved health-related behavior) may be especially impactful. Illnesses like depression and addiction are incredible drains on productivity, which can be reversed with treatment. In this essay I investigate the productivity cost of untreated (or unsuccessfully treated) mental illness and the impact of treatment on productivity.

How Bad is it?

World Health Organization Data

Alonso, et al. (2011) surveyed workers to determine how many days they missed work due to a variety of chronic illnesses, including depression and anxiety. Their sample included 63,000 people spread across 24 countries, with a range of cultures and income levels. Across all countries, the following disorders caused the average person with that disorder to lose the following days of work. Note that comorbidity is common and days-missed are additive- e.g. a person with depression and generalized anxiety in a lower income country would miss 26.6 days of work.
Days of Productivity Lost to Illness

Lower income countries Medium income countries Higher income countries All countries
Additional days Additional days Additional days Additional days
Mean s.e Mean s.e. Mean s.e. Mean s.e.
Depression 13.1 5 14.7 4.1 4.1 3.2 9 2.5
Bipolar disorder 36.5 15 23.2 9.6 9.6 5.8 17.3 4.9
Panic disorder 24.3 12.9 17.7 5.5 11.7 4.1 14.3 3.5
Specific phobia −6.6 5.2 4.2 4.7 6.7 3.3 3.9 2.5
Social phobia 5.7 10 9 8.4 7.5 2.9 7.3 2.8
GAD 13.5 9.1 24.6 8.4 7.6 4.9 7.7 3.6
Alcohol abuse −2.8 7.2 8.2 5 −0.3 4.5 1.9 3.2
Drug abuse 14.7 13.9 3.9 12.2 1.2 5.5 2.5 4
PTSD 15.3 11.3 −1.1 9.5 16.2 4 15.2 3.5
Insomnia 5.7 5.3 4.6 5.4 9.4 3.2 7.9 2.7
Headache or migraine 10 3.6 6.5 3.3 4.5 2.1 7.1 1.5
Arthritis 6.1 4.4 0.8 5 1.8 2.4 2.7 1.8
Pain 0.9 3.1 11 2.4 19.6 2.1 14.3 1.5
Cardiovascular 2.7 6.7 1 3.6 7.2 2.7 5.7 2.1
Respiratory 10.7 3 −1.1 2.6 0.9 1.4 2.6 1.3
Diabetes 4 6.4 0.5 5.6 9.6 3.8 8.6 2.8
Digestive −4.3 4.8 −0.4 4 16.6 4.8 7.6 3
Neurological 33.7 23 18.6 7 15.3 7.4 17.4 5.8
Cancer 19.4 17.9 −4.2 12.9 6.9 3.6 5.5 3.5

 

[Note that negative numbers mean the condition is associated with an increase in number of days worked.]

Alonso, et al (2011) did not attempt to measure workers who attended work but were less productive due to illness (presenteeism), or control for average number of days of work for a given country.

Chrisholm, et al. (2016) attempted to estimate the economic impact of depression and anxiety, including the cost of lost productivity, using primarily the data above. They estimate that treatment for depression leads to a 5% increase in attendance (in any country) and 5% increase in productivity while present. This implies a normal worker has 180 working days in high income countries and 260 in low income countries, which is low (see OECD data), meaning the 5% estimate for absenteeism is too high. However I believe their estimate for presenteeism is much too low. Just the diagnostic criteria of depression suggests more than a 5% drop in productivity.

 

Comparison to Sleep Deprivation

The effects of depression can be similar to sleep deprivation, in part because depression can cause either insomnia or a need for excess sleep, and in part because both produce a “brain fog” (weirdly, sleep deprivation may also treat depression). Given the paucity of information on the relationship between depression and productivity and the abundance of information on the relationship between sleep and productivity, I turned to sleep deprivation as a model for the effects of depression on productivity, contingent on a given a worker making it to their job. The following are mostly small studies but unsurprisingly all show sleep deprivation having a large negative impact on productivity.

 

Kessler, et al. (2011) estimate that insomnia causes presenteeism equivalent to 7.8 days of missed work per year, an estimated financial loss of $2,280 per person. This used the WHO Health and Work Performance Questionnaire, which relies entirely on workers self-reports of their productivity relative to co-workers. It is also designed only to measure whether someone is more or less productive than average, not the magnitude of the difference.

 

Gibson & Shrader (2014) estimated that a one hour increase in average nightly sleep led to a 16% increase in wages (on average, $6,000). I will use that as my lower bound for the benefits of treating depression. I assume the actual increase productivity is larger than the increase in wages, because some of the benefit is captured by the employer. If we assume the employer and employee capture equal value, this implies an actual productivity increase of 32%. And if we assume depression is equivalent to 2-3x the cost of missing one hour of sleep, that is almost a halving of productivity (note that for actual sleep, the costs of missed sleep probably increase exponentially). This study is especially promising because it is rather large and used a natural experiment (distance from timezone line) to establish study conditions.

 

What Does Treatment Accomplish?

Strong Minds

[When not otherwise stated, data comes from Strong Mind’s 2015 report.]

Strong Minds is an NGO in Africa that runs 12 week group therapy classes in Uganda. Their three month month program produces a noticeable drop in depression.

Strong Minds monitors its effect on depression using a modified version of the PHQ-9 (Patient Health Questionnaire- 9). The scale of this test is unknown, making it hard to evaluate the absolute improvement, but lower scores are relatively better (less depression) than higher scores. This questionnaire is an accepted tool for monitoring severity of depression.

Of women participating in Strong Mind’s 12 week pilot program, 92% had reduced scores on the PHQ-9; 11% of the control group had reduced scores. Most of the other effects reported in Strong Mind’s report are given in absolute terms, with no reference to the control group. Based on the reduction in PHQ-9 scores, I will assume 88% of any result is due to participation in the program. Key results:

  • 15 percentage point increase in participation in primary occupation (79% -> 94%).
  • 40 percentage point reduction in families going 24 hours without a meal (53% -> 13%).
  • 17 percentage point reduction in medical care visits (58% -> 41%). This is likely to understate the improvement in health, as some participants probably had physical problems they had previously been too depressed to treat.
  • 18 percentage point increase in families sleeping in protected shelters (65% -> 83%).
  • 10 percentage point increase in school attendance (33% -> 43%).

Income is not reported in this study. The authors do not say this explicitly, but it is common in developing world studies to examine consumption, because income is so variable.

Qualms about data: the study recorded 46 variables, of which less than 10 were reported in their report (not all of which made it into this report). The report included different metrics from phase one studies (eating 3 meals/day, ability to save any amount of income).  Given that it appears this data was still collected in phase two, the absence of results in the report raises concerns about cherry picking. I included this study despite my qualms because so little data was available about the effect of treatment of depression in developing countries.

Cost: $240/12 women in the program = $20/person. This is almost certainly an underestimate of even the marginal cost of the program.

Schoenbaum, et al.

In The Effects of Primary Care Depression Treatment on Patients’ Clinical Status and Employment, researchers reported that six months after their intervention (treatment for depression by a primary care physician, in the USA), 24% (vs 70% in control group) were depressed, and 72% (vs 54%) were employed.

Summary

Translating these productivity impacts into dollars is difficult because we can’t assume they hit all incomes equally, however the WHO estimates that in aggregate depression and anxiety together cost one trillion dollars US/year in lost productivity worldwide, slightly more than 1% of total GDP. On an individual level, there is no satisfying answer here. Depression has a very broad definition: the worst cases can destroy all productivity. The typical case destroys somewhere between 5% and 50% of productivity. Treatment of depression can restore that lost productivity in some but not 100% of participants.  

 

Areas for Further Investigation

I used sleep deprivation to generate heuristics for how damaging depression might be, with the answer being “quite bad”. Those numbers are even more accurate for estimating the effect of sleep deprivation. Because the scope of this paper was limited to economic effects stemming from workplace productivity, I have left out many other costs of sleep deprivation, including health costs and developmental damage to children. Given the costs and prevalence of sleep deprivation, sleep-promoting interventions, especially in children and adolescents, may be a promising area for intervention.

Epistemic Spot Check: A Guide To Better Movement (Todd Hargrove)

Edit 7/20/17: See comments from the author about this review.  In particular, he believes I overstated his claims, sometimes by a lot.

 

This is part of an ongoing series assessing where the epistemic bar should be for self-help books.

Introduction

Thesis: increasing your physical capabilities is more often a matter of teaching your neurological system than it is anything to do with your body directly.  This includes things that really really look like they’re about physical constraints, like strength and flexibility.  You can treat injuries and pain and improve performance by working on the nervous system alone.  More surprising, treating these physical issues will have spillover effects, improving your mental and emotional health. A Guide To Better Movement provides both specific exercises for treating those issues and general principles that can be applied to any movement art or therapy.

The first chapter of this book failed spot checking pretty hard.  If I hadn’t had a very strong recommendation from a friend (“I didn’t take pain medication after two shoulder surgeries” strong), I would have tossed it aside.  But I’m glad I kept going, because it turned out to be quite valuable (this is what triggered that meta post on epistemic spot checking).  In accordance with the previous announcement on epistemic spot checking, I’m presenting the checks of chapter one (which failed, badly), and chapter six (which contains the best explanation of pain psychology I’ve ever seen), and a review of model quality.  I’m very eager for feedback on how this works for people.

Chapter 1: Intro (of the book)

Claim: “Although we might imagine we are lengthening muscle by stretching, it is more likely that increased range of motion is caused by changes in the nervous system’s tolerance to stretch, rather than actual length changes in muscles. ” (p. 5). 

Overstated, weak.  (PDF).  The paper’s claims to apply this up to 8 weeks, no further.  Additionally, the paper draws most (all?) of its data from two studies and it doesn’t give the sample size of either.

Claim:  “Research shows the forces required to deform mature connective tissue are probably impossible to create with hands, elbows or foam rollers.” (p. 5). 

Misleading. (Abstract).  Where by “research” the Hargrove means “mathematical model extrapolated from a single subject”.

Claim:  “in hockey players, strong adductors are far more protective against groin strain than flexible adductors, which offer no benefit” (p. 14).

Misleading. (Abstract) Sample size is small, and the study was of the relative strength of adductor to abductor, not absolute strength.

Claim: “Flexibility in the muscles of the posterior chain correlates with slower running and poor running economy.” (p. 14).

Accurate citation, weak study.  (Abstract) Sample size: 8.  Eight.  And it’s correlational.

[A number of interesting ideas whose citations are in books and thus inaccessible to me]

Claim:  “…most studies looking at measurable differences in posture between individuals find that such differences do not predict differences in chronic pain levels.”  (p. 31). 

Accurate citation.  (Abstract).  It’s a metastudy and I didn’t track down any of the 54 studies included, but the results are definitely quoted accurately.

 

Chapter 6: Pain

Claim: “Neuromatrix” approach to pain means the pattern of brain activity that create pain, and that pain is an output of brain activity, not an input (p93).

True, although the ability to correctly use definitions is not very impressive.

Claim: “If you think a particular stimulus will cause pain, then pain is more likely.  Cancer patients will feel more pain if they believe the pain heralds the return of cancer, rather than being a natural part of the healing process.” (p93).

Correctly cited, small sample size. (Source 1, source 2, TEDx Talk).

ClaimPsychological states associated with mood disorders (depression, anxiety, learned helplessness, etc) are associated with pain (p94).

True, (source), although it doesn’t look like the study is trying to establish causality.

ClaimMany pain-free people have the kinds of injuries doctors blame pain on (p95).

True, many sources, all with small sample sizes.  (source 1, source 2, source 3, source 4, source 5)

Claim: On taking some cure for pain, relief kicks in before the chemical has a chance to do any work (p98)

True.  His source for this was a little opaque but I’ve seen this fact validated many other places.

Claim: we know you can have pain without stimulus because you can have arm pain without an arm (p102).

True, phantom limb pain is well established.

Claim: some people feel a heart attack as arm pain because the nerves are very close to each other and the heart basically never hurts, so the brain “corrects” the signal to originating in the arm (p102).

First part: True.  Explanation: unsupported.  The explanation certainly makes sense, but he provides no citations and I can’t find any other source on it.

Claim: Inflammation lowers the firing threshold of nociceptors (aka sensitization) (p102).

True (source).

Claim: nociception is processed by the dorsal horn in the spine.  The dorsal horn can also become sensitized, firing with less stimulus than it otherwise would.  Constant activation is one of the things that increases sensitivity, which is one mechanism for chronic pain (p103).

True (source).

Claim: people with chronic pain often have poor “body maps”, meaning that their mental model of where they are in space is inaccurate and they have less resolution when assessing where a given sensation is coming from (p107).

Accurate citation (source).  This is a combination of literature review and reporting of novel results.  The novel results had a sample of five.

Claim: The hidden hand in the rubber hand illusion experiences a drop in temperature (p109).

Accurate citation, tiny sample size (source).  This paper, which is cited by the book’s citation, contains six experiments with sample sizes of fifteen or less.  I am torn between dismissing this because cool results with tiny sample sizes are usually bullshit, and accepting it because it is super cool.

Claim: “a hand that has been disowned through use of the rubber hand illusion will suffer more inflammation in response to a physical insult than a normal hand.” (p. 109).

Almost accurate citation (source).  The study was about histamine injection, not injury per se.   Insult technically covers both, but I would have preferred a more precise phrasing.  Also, sample size 34.

Claim: People with chronic back pain have trouble perceiving the outline of their back (p. 109). 

Accurate citation, sample size six (pdf).

Claim:  “Watching the movements in a mirror makes the movements less painful [for people with lower back pain].” (p. 111). Better Movement. Kindle Edition.

Accurate citation, small sample size (source).

Model Quality

Reminder: the model is that pain and exhaustion are a product of your brain processing a variety of information.  The prediction is that improving the quality of processing via the principles explained in the book can reduce pain and increase your physical capabilities.

Simplicity: Good.  This is not actually simple model, it requires a ton of explanation to a layman.  But most of its assumptions come from neurology as a whole; the leap from “more or less accepted facts about neurology” to this model is quite small.

Explanation Quality: Fantastic.  I’ve done some reading on pain psychology, much of which is consistent with Guide…, but Guide… has by far the best explanation I’ve read.

Explicit Predictions: Good, kept from greatness only by the fact that brains and bodies are both very complicated and there’s only so much even a very good model can do.

Useful Predictions: Okay. The testable prediction for the home-reader is that following the exercises in the back of the book, or going to a Feldenkrais class, will treat chronic pain, and increase flexibility and strength.  Since the book itself admits that a lot of things offer short term relief but don’t address the real problem, helping immediately doesn’t prove very much.

Acknowledging Limitations: low. (Note: author disputes this, and it’s entirely possible he did and I forgot).  GTBM doesn’t have the grandiose vision of some cure-all books, and repeatedly reminds you that your brain being involved doesn’t mean your brain is in control.  But there’s no sentence along the lines of “if this doesn’t work there’s a mechanical problem and you should see a doctor.”

Measurability: low.  This book expects you to put in a lot of time before seeing results, and does not make a specific prediction of the form they will come in.  Worse, I don’t think you can skip straight to the exercises.  If I hadn’t read the entire preceding book I wouldn’t have approached them in the correct spirit of attention and curiosity.

Hmmm, if I’d assigned a gestalt rating it would have been higher than what I now think is merited based on the subscores.  I deliberately wrote this mostly before trying the exercises, so I can’t give an effectiveness score.  If you do decide to try it, please let me know how it goes so I can further calibrate my reviews to actual effectiveness.

 

You might like this book if…

…you suffer from chronic pain or musculoskeletal issues, or find the mind-body connection fascinating.

This post supported by Patreon.

Review: The Dueling Neurosurgeons (Sam Kean)

If you like this blog, you might like…

I originally intended The Tale of the Dueling Neurosurgeons for epistemic spot checking, but it didn’t end up feeling necessary.  I know just enough neurobiology and psychology to recognize some of its statements as true without looking them up, and more were consistent enough with what I knew and what good science and good science writing looks like; interrogating the book didn’t seem worth the trouble.  I jumped straight to learning from it, and do not regret this choice.  The first thing I actually looked up came 20% of the way into the book, when the author claimed the facial injuries of WWI soldiers inspired the look of the Splicers from BioShock.*

[*This is true. He used the word generic mutant, not the game-specific term Splicer, but I count that under “acceptable simplifications for the masses”.  Also, he is quicker to point out that he is simplifying than any book I can remember.]

At this point it may be obvious why I think fans of this blog will really enjoy this book, beyond the fact that I enjoyed it.  It has a me-like mix of history (historical color, “how we learned this fact”, and “here’s this obviously stupid alternate explanation and why it looked just as plausible if not more so at the time”*), actual science at just the right level of depth, and fun asides like “a lot of data we’ve been talking in this chapter on phantom limbs about comes from the Civil War.  Would you like to know why there were so many lost limbs in the Civil War?  You would?  Well here’s two pages on the physics of rifles and bullets.”**

[*For example, the idea that the brain was at all differentiated was initially dismissed as phrenology 2.0.

**I’m just going to assume you want the answer: before casings were invented, rifles had a trade off between accuracy and ease of use.  Bullets that precisely fit the barrel are very hard to load, bullets smaller than the barrel can’t be aimed with any accuracy.  Some guy resolved this by creating bullets that expanded when shot.  But that required a softer metal, so when the bullet hit it splattered.  This does more damage and is much harder to remove.]

I am more and more convinced that at least through high school, teaching science independent of history of science is actively damaging, because it teaches scientific facts, and treating things as known facts damages the scientific mindset.  “Here is the Correct Thing please regurgitate it” is the opposite of science.  What I would really love to see in science classes is essentially historical reenactments.  For very young kids, give them the facts as we knew them in 18XX, a few competing explanations, and experiments with which to judge them (biased towards practical ones you know will give them informative results), but let them come to their own conclusions.  As they get older, abandon them earlier and earlier in the process; first let them create their own experiments, then their own hypotheses, and eventually their own topics.  Before you know it they’re in grad school.

The Dueling Neurosurgeons would be a terrible textbook for the lab portion of that class because school districts are really touchy about inducing brain damage.  But scientists had a lot of difficulty getting good data on the brain for the exact same reason, and Dueling Neurosurgeons is an excellent representation of that difficulty.  How do we learn when the subject is immensely complex and experiments are straightjacketed?  I also really enjoyed the exploration of  the entanglement between what we know and how we know it.  I walked away from high school science feeling those were separable, but they’re not.

You might like this book if you:

  • like the style of this blog. In particular, entertaining asides that are related to the story but not the point. (These are mostly in footnotes so if you don’t like them you can ignore them).
  • are interested in neurology or neuropsychology at a layman’s level.
  • share my fascination with history of science.
  • appreciate authors who go out of their way to call out simplifications, without drowning the text in technicalities.

You probably won’t like this book if you:

  • need to learn something specific in a hurry.
  • are squeamish about graphic descriptions of traumatic brain damage.
  • are actually hoping to see neurosurgeons duel.  That takes up like half a chapter, and by the standards of scientists arguing it’s not very impressive.

The tail end of the book is either less interesting or more familiar to me, so if you find your interest flagging it’s safe to let go.

This post supported by patreon

Dreamland: bad organic chemistry edition

I am in the middle of a post on Dreamland (Sam Quinones) and how it is so wrong, but honestly I don’t think I can wait that long so here’s an easily encapsulated teaser.

On page 39 Quinones says “Most drugs are easily reduced to water-soluble glucose…Alone in nature, the morphine molecule rebelled.”  I am reasonably certain that is horseshit.  Glucose contains three kinds of atoms- carbon, oxygen, and hydrogen.  The big three of organic chemicals.  Your body is incapable of atomic fusion, so the atoms it starts with are the atoms it ends up with, it can only rearrange them into different molecules.  Morphine is carbon, oxygen, hydrogen, and nitrogen, and that nitrogen has to go somewhere, so I guess technically you can’t reform it into just sugar.  But lots of other medications have non-big-3 atoms too (although, full disclosure, when I spot checked there was a lot less variety than I expected).

This valorization of morphine as the indigestible molecule is equally bizarre.  Morphine has a half-life of 2-3 hours (meaning that if you have N morphine in your body to start with, 2-3 hours later you will have N/2).  In fact that’s one of the things that makes it so addictive- you get a large spike, tied tightly it with the act of ingestion, and then it goes away quickly, without giving your body time to adjust.  Persistence is the opposite of morphine’s problem.

This is so unbelievably wrong I would normally assume the author meant something entirely different and I was misreading.  I’d love to check this, but the book cites no sources, and the online bibliography doesn’t discuss this particular factoid.  I am also angry at the book for being terrible in general, so it gets no charity here.

Talking about controversial things (discussion version)

There is a particular failure pattern I’ve seen in many different areas.  Society as a whole holds view A on subject X.  A small sub-group holds opposing view B.   Members of the sub group have generally put more thought into subject X and they have definitely spent more time arguing about it than the average person on the street.  Many A-believes have never heard of View B or the arguments for it before.

A relative stranger shows up at a gathering of the subgroup and begins advocating view A, or just questioning view B.  The sub-group assumes this is a standard person who has never heard their arguments and launches into the standard spiel.  B doesn’t listen, A gets frustrated and leaves the subgroup, since no one is going to listen to their ideas.

One possibility is that the stranger is an average member of society who genuinely believes you’ve gone your entire life without hearing the common belief and if they just say it slowly and loud enough you’ll come around.*  Another possibility is they understand view B very well and have some well considered objections to it that happen to sound like view A (or don’t sound that similar but the B-believer isn’t bothering to listen closely enough to find out).  They feel blown off and disrespected and leave.

In the former scenario, the worst case is that you lose someone you could have recruited.  Oh well.  If the latter, you lose valuable information about where you might be wrong.  If you always react to challenges this way you become everything hate.

For example: pop evolutionary psychology is awful and people are right to ignore it.  I spent years studying animal behavior and it gave me insights that fall under the broad category of evopsych, except for they are correct.  It is extremely annoying to have those dismissed with “no, but see, society influences human behavior.”

Note that B doesn’t have to be right for this scenario to play out.  Your average creationist or anti-vaxxer has thought more about the topic and spent more time arguing it than almost anyone.  If an ignorant observer watched a debate and chose a winner based on fluidity and citations they would probably choose the anti-vaxxer.  They are still wrong.

Or take effective altruism.  I don’t mind losing people who think measuring human suffering with numbers is inherently wrong.  But if we ignore that entire sphere we won’t hear the people who find the specific way we are talking dehumanizing, and have suggestions on how to fix that while still using numbers.  A recent facebook post made me realize that the clinical tone of most EA discussions plus a willingness to entertain all questions (even if the conclusion is abhorrent) is going to make it really, really hard for anyone with first hand experience of problems to participate.  First hand experience means Feelings means the clinical tone requires a ton of emotional energy even if they’re 100% on board intellectually.  This is going to cut us off from a lot of information.

There’s some low hanging fruit to improve this (let people talk before telling them they are wrong), but the next level requires listening to a lot of people be un-insightfully wrong, which no one is good at and EAs in particular have a low tolerance for.

Sydney and I are spitballing ideas to work on this locally.  I think it’s an important problem at the movement-level, but do not have time to take it on as a project.**  If you have thoughts please share.

*Some examples: “If you ate less and exercised more you’d lose weight.”  “If open offices bother you why don’t you use headphones?”, “but vaccines save lives.”, “God will save you…”/”God isn’t real”, depending on exactly where you are.

**Unexpected benefit of doing direct work: 0 pangs about turning down other projects.  I can’t do everything and this is not my comparative advantage.

Unquantified Self

Recently I did a CFAR workshop.  No one has settled on a good description of CFAR, but I think a good one would be “getting the different parts of your brain to coordinate with each other.”  The further I get from CFAR the more positively I view the experience, which suggests that I did the same thing with EA Global, which suggests I overestimated CFAR’s primary flaw (not being EA Global), which makes me view it even more positively.

CFAR suggests you go into the workshop with a problem to solve.  Fortunately but perhaps inconveniently, I went through a personal growth spurt right before CFAR.  It’s not that I was out of problems to solve, but the repercussions of the previous solutions had not yet worked their way through the system so it was hard to see what the next round would be.   Then I solved food.  For those of you who are just tuning in, I have/had lifelong medical issues that made food physically difficult, which made it psychologically difficult, which made the physical issues worse.  Clearing out all the anxiety around food in a weekend is not a small thing.  But to really achieve it’s full power I have to follow it up with things like “how do you choose food based on things other than terror?” and “stoves: how do they work?” So that’s a bunch more work.*

I left CFAR with some new things and some refinement on some old things.  I didn’t want to lose what I’d gotten at the workshop so I tried to do follow ups but I felt… full.  Defensive.  Like it was attempting to take up space in my brain and if it succeeded I would lose a lot of work.

My way of solving problems, which is either what CFAR teaches too or what I extracted from whatever CFAR actually does, is to understand them super well.  Eventually a solution just falls out and application is trivial.**  Some of this comes from focused thought, but there’s a lot of opportunistic noticing.  I store bits of information until suddenly they coalesce into a pattern.  As anyone who’s read Getting Things Done will tell you, storing information in your brain is expensive.  So I decided I needed a way to store all this opportunistic data, plus things from the conscious experiments I was running, to keep it all straight.

This is hard to do.  Take the comparatively simple “go to gym every day”.  There are 400 billion apps that will track this for me and I have never stuck with one of them, because they are boring and seeing the numbers go up doesn’t motivate me for more than a week.  More generally, I’ve never been able to get into quantified self because if I know what data to measure the problem is already solved.  I don’t really care how many calories I burned.  I do care what mental blocks inhibited me from going (bed so comfy, outside is cold, feeling like I stayed in bed too long and now I have to do Real Work) and how I maneuvered things so it didn’t take willpower to fight those (“remember how you feel much more productive after the gym and have an awesome job that doesn’t care when you work?”).  There is no app for that.

Then there are more difficult problems like “New information indicates I handled something 9 months ago really poorly, but I’m not sure what I’d do differently then with only the information I had at the time, without causing other problems.”  Or “My friend triggered an intense premortem that made me realize I’m ignoring information on project X just like I did with project Y last year, but I don’t know what that information is.”  I still don’t know what I’m going to do about the former, for the latter I tracked “things that feel like they’re hitting the same part of my brain” until a pattern emerged.  Tracking patterns for “things you are actively trying not to think about” is not cheap.

So I needed a system that could hold this information for me, that would show me information I didn’t realize was connected as I recorded it.  Without being cluttered.  The closest analogy I could come up with was an old timey naturalist.  They had a bunch of set things they knew they were looking for (what eats this flower), but also wanted to record cool things and then be able to connect to other cool things later (why are all these finches different yet similar?).    I don’t know how old timey naturalists did that with pen and paper because that did not work for me at all.  I tried workflowy and a google docs but just sat there frozen, unable to figure out how to sort the information.

My CFAR partner  Tilia Bell had a really good idea, which was to use a private wordpress blog.  I could give an entry as many tags as I wanted, and read tags when they felt relevant.  Or just the success tag, because winning feels nice.  This was a huge improvement, but wordpress is kind of clunky and annoying.  In particular, the tagging system does not flow at all.

I talked about it with Brian, who suggested a one person slack.  I could use channels for defined projects and tags for observations I wanted to connect later.  To be fair, this idea is three hours old.  On the other hand, in 20 minutes applying it I figured out what piece of information I was ignoring in that problem my brain didn’t want to look at.  I’m not saying it’s the sole cause, I’ve gathered a lot of information this past week.  But since “connecting things I already noticed” is pretty much its point, it seems promising.

*My nutritionist is finding me much easier to work with now.

**I’m exaggerating some but it’s more true than it has any right to be.