יום רביעי, 30 בנובמבר 2011

Partnership, Chomsky Audio Book

This is more of a personal post, or at least non scientific.

In the morning I met Shlomi, we were discussing the development of a smartphone based mental health app, specifically for OCD management. I felt like he had good product development understanding, and that he quickly learned a field I was mapping out slowly in this blog. I also felt like I had good answers to a lot of his questions, as I've done my mapping well and could provide insight. I feel like this cooperation is driving me forward, and that's cool.

I was riding my bicycles to school today, and I was listening to a Chomsky lecture recording about linguistics and philosophy. He said something that Isaac Newton disproved the idea of a mechanical world, by showing how gravitational forces, can make objects that are not in contact influence each other. Chomsky says that instead of exorcising the ghost from the machine, he exorcised the machine and left the ghost mystery in tact. This made me feel maybe I was not thinking in a high enough philosophical level, that my academic level was no high enough, and that I wish I could study at MIT. Afterwards, I thought maybe this was a weird argument. 

יום שני, 28 בנובמבר 2011

Visual Effects of OCD

I've been looking at the visual effects of OCD in psycnet, and found the following recent studies:
In a glimpse, it seems OCD has a visual aspect.

יום ראשון, 27 בנובמבר 2011

What's the risk in these psychotherapy apps?

Today I was asked what are the risks about these psychotherapy apps I've been posting about. I counted the following risks for my OCD Manager app:
  1. It could pathologize, by becoming part of a neurotic OCD ritual.
  2. Corporate technology that I may ask to ride on, may lead to profit driven abuse of privacy. (PS, a week later, NICE Systems, which I wish to work with as a CRM developer, appears in WikiLeaks as a dangerous surveillance technology developer.)
  3. Without a humanistic restraint, it could be an app that sets to delete subjectivity itself.
  4. A few hundreds of bucks could be lost from my pocket.
I feel that these risks are out of my control. The only reason I feel free to keep on developing this direction is that I feel like it is ready to be developed by anyone, and it better be me, giving a damn.

This little reverie is after watching Grapes of Wrath, with a Tom Joad kind of tragic motivation.

יום שני, 21 בנובמבר 2011

Existential View of OCD

In his 1917 essay, "Art as Device" about the dialectic dynamic that drives the development of artistic form, Vicror Shklovsky quotes a passage from the great Tolstoy's journal from 1897 in which Tolstoy reports that he cannot remember whether he dusted the sofa or not. Tolstoy is horrified that habit has consumed so much of his conscious life: "...if the whole conscious life of many people passes by unconsciously, then it is as if that life has never been... So life disappears, turning into nothing. Automatization consumes things, clothes, furniture, one's wife and fear of war," and Tolstoy vows never to lose life to a habitualized loss of consciousness. 

Shklovsky holds that art's function is revitalization of consciousness, to cancel the habituation of our consciousness to things, make them new and unfamiliar so we can experience them as they happen, making the stone we pass in the garden stony again. Art does so by showing reality in an unfamiliar way. Art becomes reality as we habituate to it, and then art evolves again, to show reality in an unfamiliar way. That is the driving force and the governing logic for the development of new art forms.

It was in class last year, in Prof Dar's seminar on OCD as a meta cognitive disorder, that I suggested to look at OCD as an attempt to defamiliarize reality. More specifically, we discussed the updating nature of OCD rituals, and the fact that rituals are only helpful as long as they keep the OC person unhabituated to his or her action. Once a ritual becomes automatic, it no longer serves the OC person, and it must be developed further. I told the class of Shklovsky's idea of defamiliarization, and suggested that the same could apply to OCD rituals.

The comparison of OCD rituals evolution to art evolution could lead us to the following ideas:
1) Suggest an existential explanation to OCD, a lack in the sense of being in the world, similar to Tolstoy's concern. This would lead us to treat OCD with existential means, such as the fear from freedom, and the search for meaning.
2) Suggest OC people art as a ritual. Locking the door in multiples of 13 is meaningless and maladaptive (makes you miss the bus). Writing a haiku (a very strict short poetic form) about locking the door is quite cool. Yes, cool. We do many great things that could be considered meaningless and maladaptive, but are rather considered cool, many of these are art. 

I would like to test the following questions:
1) Do OC people have a different relation to art than non OCs?
2) Does art help reduce OC distress?
3) Is OC related to a sense of being in the world?
4) Do therapy methods that focus on sense of being in the world help OCD?

I would appreciate any ideas on how to test this, and of any mediating variables I didn't take into account.

Online Therapy Privacy Concerns

Freud puts patient privacy and the development of the science in conflict. If a patient does not trust that his or her unprocessed thoughts and emotions are kept secret, the patient may censor them by what can harm his or her reputation. If abstract findings are not shared with a scientific community, the ability of a therapist to help a specific patient diminishes. 

1)  The patient needs the therapist to be the hub of many secrets, and the therapy to based on experience with other people's secrets. In this sense the patient agrees to a scientific study of the anonymous abstractions from the private therapy sessions of many patients. Then anonymity becomes the issue, not privacy.

2) People already share so much online, and right now they do it for facebook's advertisers to be able to deliver them with better ads. The same behavior that is encouraged by consumer culture can be used for good, with the patient's benefit in mind.

So, in my view:
1) Shared psychotherapy information should be anonymous. Not easy as it sounds.
2) Current technological standards should be adopted, as long as the ethical question is "how to help the patient?".

Bertha Pappenheim, was Breuer disguised as Anna O in his case study essay.

יום שבת, 22 באוקטובר 2011

Facebook Clinical Research

This post is a summary of pubmed abstracts:
My conclusion: if I'm going to research OCD on FB, then I should compare to narcissism and extrovert characers, which currently explain the variance of FB usage.

Of course, clinical research is scarce.. I'll see what professional SMM magazines have to say in the future..\


See more silly ideas on psycho meme

Facebook & OCD - Research Proposal

The following proposal refers to the hypothesis that people with OCD rely on external cues and proxies to compensate for a deficiency in subjective conviction (according to Dar and Liberman's ISF proposal from 2007, available by request). This is to suggest that obsessive-compulsive individuals develop proxies – external indicators of internal states – to compensate for the attenuation of direct experience. 

Virtual Experience
A common incidence of people using external indicators of internal states in order to compensate for the attenuation of direct experience could be seen in virtual experiences. These experiences are the lot of those who interact with computer games and social networks, as they would interact with real people in real life.
For example, on the social network Facebook, a person can befriend others. The subjective experience of friendship, with all its timid sensitivity, search for mutual signs, the low commitment joint lunch or unnecessary phone calls on mundane issues, and later trust and mutual good times that might constitute friendships in real life, are substituted with an algorithm based suggestion of possible friends, a profile picture, a friendship suggestion message, a confirmation and a mutual news feed of mundane online activities. Diffused experiences are emulated by concrete virtual events.
In such a virtual realm, people exchange subjective opinion by pressing a "Like" button, they visit places by checking in to them with a GPS based application, or by tagging their pictures. These actions are compiled into their profile, which represents their virtual self. Virtual profiles become the proxies by which people constitute their subjectivity – they represent what they like, what they wish for, and who they are.
The virtual experience as an emulator of real experience is not the opposite of real experience. Virtual is not false, it is unreal – it takes over the real in a way that makes us question what is real. This is exactly the playing field in which proxies replace direct experience.

It would be my suggested hypothesis, that people who have more OC characteristics, would also rely more on virtual experiences to replace direct experiences. Specifically, that people who score high on OCI-R would also be more active on Facebook.

Participants will be sent a link to subscribe for a Facebook personality quiz application. In order to subscribe the users will give permission to access their Facebook profile information. The participants will fill out the OCD quiz (actually OCI-R). The participants will approve the terms of conditions and submit the quiz. After submitting the participants will receive feedback on their OCI scores.

100 participants should be recruited online, via link to the Facebook application page. The participants will be motivated to fill the forms by promise of OCI score feedback. Participants may be familiar with the experimenter as Facebook friends. In the terms and conditions, the participants will be guaranteed that their name, contact details and any indentifying data will not be used in any public forum, and that quiz is sponsored by the Tel Aviv University for research purposes, and sanctioned by the Helsinki committee.

A Facebook application will be created to administer OCI-r to participants, and receive data on their Facebook activity. The application will be advertised by banner, and a caption that call participants to fill out a personality quiz. Alternatively the application could also be reached via link which will be passed to possible participants via Facebook messages and posts.
See an illustration of a banner that would lead a user to the application:

See an illustration of the participant consent to provide the application with profile details:

See an illustration of the web format of the OCI-R test:

See an illustration of participant feedback:

Results are expected to show that high OCI is in correlation with the number of parameters the user specifies in the profile, and the frequency in which these parameters are updated. Specific parameter values will also be tested to see correlations with OCI scores and provide insight for future studies.

If the results show that indeed high OCI is in correlation with high elaboration level and frequent updates of Facebook profile, it would allow suggesting that virtual experiences serve people with OC tendencies more than they serve the easygoing characters.
As Facebook applications are not commonly used in academic research, Facebook profile parameters are not yet researched as valid constructs of human psychology.  This point is the major weakness of this proposal, but also the greatest prospect of it, as the first voyage to uncharted territory is a significant one because it is plotted with uncertainty.

יום שני, 17 באוקטובר 2011

Matrioshka Matrioshka Matrioshka Ay-ay

Mr Keuner came across two wise men arguing about the contents of the ultimate matrioshka doll. It is infinitely small like a black hole, said one. It is a finite point of subjectivity like god, argued the other. Mr Keuner saw nothing. He was ashamed, cried and felt worthless. Well don't cry, said the first, and the other added: it's just a matrioshka...

יום שבת, 15 באוקטובר 2011

How It All Should Be: Prelude to Psychoanalytics

In 3 days I will be 30 years old. I still have no children that I know of, I have not written a great book, and nor have I launched a successful app. 

Still, I believe I am about to write here, the stuff that will change the world. In a sunny October afternoon, just before seeking a hefty student loan, I will post all my secrets and hope for them to return to me with a bounty.

Here goes:

I see mental health as a personal experience that is influenced by  a lot of aspects. Psychotherapy helps, so it seems, but a lot of factors determine how much it helps, and a lot of other stuff like Yoga can help just as well. 

I was at my first year of literature studies, when we compared self psychology and Lacanian psychoanalysis. My teacher of psychoanalytic reading said how the same warmth of the self psychology approach could sometimes be experienced as poisoning and undermining independence. About Lacanian psychoanalysis, she commented that in certain situations it could be experienced as unsettling and brutal, while in others it is liberating and much more alive than its cuddly competitors.

Well maybe competition is the point. There is no need for competition. Sure there is, if we're looking at psychotherapy as a product where you want to create market value. But there isn't, if you look at psychotherapy as something that really helps and you want to find a way to pass it around.

I have the fortune of studying clinical psychology in Tel Aviv University. My teachers, as one would imagine the pantheon gods maybe, are not perfect, and do not contend to be right. Each of them comes from a different school of psychotherapy, and together they make up a respectable bunch of skilled and knowledgeable researchers practitioners. Although I may offend 1-4 of them right now, I feel they lack an impartial Zeus to manage their faculties by specific context. The same I feel about psychotherapy itself.

How do you know when to use CBT, when Yoga, and when to call your mom more often. There is empirical research you say, CBT for phobias, psychoanalysis for Oedipus. As a thumbs rule, this is very helpful. But how do you know, after spending 30% of your income on therapy for a period of 3 months, that your therapist is not undermining your dependence, but actually abusing your trust? "It's a process" is a dangerous hideout for contra productive efforts. Even if you have Oedipus, you might also be anemic, with bad karma, and ADD. You personally, unlike other Oedipal category members, might be helped more by a female therapist, good sleep and a student loan. How would you know this?

Psychology should exactly be about that, the human sensitivity that translates a categorical array of thumb rules into an idiosyncratic, personal disarray. That's a psychotherapist's job. Assuming you need a therapist and not an acupuncturist. 

Usually, articles I read have a good handle of what's wrong, and then spin off in a very bad direction when they start suggesting a better replacement. I am considering whether I should stop here. I think instead I will do it as Jesus did, and then logoff and let you pray for the next post.

There is an urban myth about the Dalai Lama actually being a robot. Once, as he was oiling his hinges, a disciple came into his quarters and was surprised to learn that his master was a robot. The Dalai Lama paused his hinge oiling and said, "and to learn that I am human would make you less at awkwardness?"

I will post about the way technology could help us improve human wellbeing after I conquer my fears of greatness. If I die today you can find enough hints in my past posts.

All the best,

יום חמישי, 16 ביוני 2011

Conversation Analytics

A few weeks ago in class, we discussed a bank of therapy session recordings that was available to us from a past study that was conducted by one of my professors. Unfortunately for the lazy researcher, the recordings were not transcribed. I remembered my days as a research assistant, transcribing interviews, and vowed that I will transcribe no more. 

So I wrote NICE Systems, a company that develops client relations software (among other things). Already 10 years ago I visited a presentation by their R&D department that described their ability to analyze a conversation structurally, and even recognize some words here and there. I am sure the capabilities have improved since.

I wish I could extract quantitative data from such an audio archive and be able to cross that data with therapy results that were measured by questionnaires during the original research.

They say Google Chrome's next edition is going to have speech recognition in Hebrew, that could be a brilliant update... but didn't find anything ready for use right now. Still experimenting with partial stuff I found though.

BTW - Here's something about an app by Madrid Uni about emotions recognition in conversation, based on speech rate and pitch and volume. They used something called fuzzy logic that uses relative values in conditions in order to draw conclusions. 

יום רביעי, 1 ביוני 2011

OCD Manager

I've just finished playing with a free account on MockFlow.com and made a mockup sketch of a diagnostic app for OCD.

Often in class we've talked about people suffering from OCD as lacking a sense of accomplishment for tasks, so they redo them, making a ritual around them to try and make it feel right. My teacher, Prof Dar, would say that in such a case even love becomes a question of accomplishment - how do I know that I love someone? Is it because we're married? Because she makes me laugh? In this way life is reduced to something we would expect to find on The SIMS, Second Life, or our Facebook life - places filled with events that replace authentic feelings. How do you know you love on FAcebook? By your Likes and your relationship status. Well, then maybe people suffering from OCD can benefit from social gaming dynamics in the same way.

The OCD manager is meant to facilitate a common CBT homework assignment - keeping record of rituals and repeating thoughts. It could also help people suffering from OCD manage their rituals, by logging what they've just done, but much cooler would be if reducing life into events, would emulate the lacking sense of accomplishment.

Tell me what you think :)

I saw some guy stole my name for the app and is now selling his understanding of it in itunes. It's not as good as my idea but still, may he die of OCD.

יום שבת, 28 במאי 2011

Mobile psychotherapy study + my wishes for biometrics sensors, behavioral trackers and AI analytics...

I just read this article by Margaret E Morris from Intel's Digital HEalth Group. It describes a study of 5 cases, of patients using mobile phones that assess their moods, offer interventions such as relaxation techniques and questions that help change negative interpretations. With this, once a week the patients/users had an interview in which a therapist reviewed their data with them and suggested routine solutions to recurrent problems. The studied cases showed improvement.

It seems the researchers got a few things very right:
1) Online assessment - If you want to change a person's behavior you need to map it. How to map it is a question of technology. Brick-and-mortar clinics require the patient to report what he remembers of his behaviors and cognitions in retrospect, and such reports, from outside an intense emotional experience, may suffer from distortion of perspective and rationalization.

2) Online Therapy - traditional psychotherapy requires a leap from the sofa to real life. A patient given a relaxation technique must be able to work it when it is relevant in his routine life. The traditional therapeutic idea of here and now, is what we currently refer to as online. Interventions are given when they are needed.

3) Data mining methodology -  As scholastic bible interpretations take in little data and make whole doctrines by it, so do therapists often take single incidents and observations and induce into principles. This situation was forced by time limitations, a patient's unwilingness or inability to tell it like it is, or just the barriers of language. However, in the age of information technology, data is superfluous and analysis usually means a data reduction funnel - making simple conclusions based on a lot of complex data. The described analysis that was described in the research could be viewed as data mining, and could be broadened to take in much more sets of data on the patient.

4) Mapping cause and affect - What the weekly analytic session provided the patients, was a link between events and their emotional effect. These are the two basic components of CBT. If a person could become aware of how events and situations prompt behavioral and cognitive responses, and more importantly that these are contingent with other responses, then a conscience change would be facilitated. In the article, the example was that a man who used to fight with his family when he came back from work noticed his energy dropped right after work, so he was advised by a therapist to take a pause for relaxation before getting out of the car.

I wish these points would be developed in the future:
1) More tracking and sensor based data - The device described in the study asked the patient/user to assess his own state and reply on diagnotic questions. this takes time and means that the device has to ask at certain time intervals or the user needs to turn to the device for assessment. I wish more tracking and sensor based data was available. If the patient's heart rate variability would indicate his arousal state, or if a phone tracker would would indicate that at a specific moment was talking on the phone with his wife, or even that in the conversation the speakers were interrupting each other's speech or that the trigger words "get milk" were mentioned... well, then there would be a lot more data to use and to relate to. But more importantly, a lot of the data would reflect aspects of the event that are not part of the patient's perception of the event, and may help bring a broader set of data into the patient's attention and help the patient "see it coming" and be prepared for an aversive situation.

2) Artificial Intelligence Analytics - when more data would be available, it would be harder for a human analyst to contain it. Artificial neuron networks can handle such capacities of data and make statisticly predictivve generalizations. What is more important, and will probably be the Nobel worthy discovery in all this post, is that they will rely less on pre concieved hypotheses and more on empirical findings. They may come to conclusions that humans, as sensitive as they maybe, are prone to overlook. Of course machine learning is also prone here or there. 

3) Sharing - Instead of having the therapist providing ideas and solutions, an experience sharing network could be created. People can learn from each other how to solve problems. For example: "67% percent of people of people who are asked to buy milk at lunch feel stressed during the rest of the day, 90% of them felt better by setting a reminder on their mobile, 10% of them got to feel better by having a long open talk with their life partner about personal space." Well, wouldn't you want to know that?


Morris ME, Kathawala Q, Leen TK, Gorenstein EE, Guilak F, Labhard M, Deleeuw W
Mobile Therapy: Case Study Evaluations of a Cell Phone Application for Emotional Self-Awareness
J Med Internet Res 2010;12(2):e10
URL: http://www.jmir.org/2010/2/e10/
doi: 10.2196/jmir.1371
PMID: 20439251

יום רביעי, 27 באפריל 2011

PTSD therapy: computerized text analysis

I liked this presentation's direction.
2 things I would do:
1) Instead of theorizing which linguistic components might predict therapy outcome, just let the system find them. Search engine technology can do much more than just spot future tense and first person, for example, analyzing the semantics to determine the subjects in the text.
2) Effect measurement is not clear. I did not read the full article, but since it is not specified I assume nothing new. I would try to measure the results online - to see a timeline interaction between writing of the texts and well being, and also measure them in indirect ways such as biofeedback and response time to stroop tasks, since self report may interact with personal writing. Even if I am wrong, self report should be crossed with implicit measures.

So cool :)

How to: start an online industry

I'm on my way to work, reading this old article about online therapy by Michael Fenichel* on the bus, and feeling like something is missing here. The writer of the article tries to translate the face to face psychotherapy principles to those that would apply online. For example, he asks whether the font of an online therapy chat could be interpreted as transference. Well I don't know. Really, I guess it depends on many things. But theorizing about it won't give you the answer either.
In my view, online therapy is not the same craft, not the same industry. Applying psychoanalytic techniques is a good way to miss the point.
I think what needs to be done is a theoretic definition of goals (stuff like improve well being), red lines of abuse (privacy etc.), and then, since my bus has arrived at work, a good technical oprationalization of measurements. I mean, ways to check that goals are achieved and red lines are avoided. Anything in the middle, such as font size in therapy chat - that can be measured accordingly.
Gotta go!

*Not  to be confused with Otto Fenichel.

יום שבת, 16 באפריל 2011

From therapy session to online therapy

I believe the idea of a therapy session is a technical one. When Freud had patients of independent means (that have tons of money) he had 5 sessions a week for a few years, when it's part of public health care insurance (poor folks), it's become 30 sessions tops, and the patient is announced that most work is done between sessions. 

Brick and mortar clinics, are rooms with couches and people, that you have to come to, and meet face to face. I believe they act as bottlenecks in a lot of cases, as the question of matching the best specialist to the most needing patient, becomes a financial and geographic matter. Online therapy offers a lot of people access to therapy. 

Reading the state of the art literature on online therapy makes me feel like there's a big lag in the definition of "online" compared to other services. I mean, when you say that you get your news online, do you mean that you get it on your computer screen instead of on paper? Or do you, perhaps, mean that you get it all the time? Or maybe even, that  you are connected with tons of current content updates relevant to where you are, what you buy and what you do?

Same goes for online psychotherapy. It is not only that we can reduce the cost of couches and waiting rooms. Not even that a specialist can be accessible around the world. It's some app that tells you that since you started yoga, your anxiety levels lowered consistently, and that people who benefited from yoga like you, also found similar benefits in calling grandma. All this without a session.

*This is where someone shows me I've missed something great and fantastic in my research.

יום רביעי, 23 במרץ 2011

PTSD, borderline personality disorder, sexual assault, and 30 years of research.

What do we mean when we say PTSD? 
What don't we mean?

According to Paula Schnurr's (2010) "journal of traumatic stress" editorial review of 30 years of publications since the first inclusion of PTSD in American diagnostic manual, the number of publications grew over nine-fold between 1980–1984 and 1995–1999, from a mere 930 to 8,606, giving rise to new journals dedicated to the field, growing with every disaster and war, and though the growth trend has curbed down since then in the US, now, European, Australian and Japanese researchers continue to contribute a growing part of the publications. Schnurr, who is currently the Deputy Executive Director of the Veterans Affairs National Center of PTSD (National Center of PTSD, 2010), does not refer to the research of PTSD as a result of sexual assault.

In their critical essay, Gross and Graham-Berman (2006) claim that PTSD's emergence in 1980's DSM-III was a result of the Vietnam War and the acknowledgement of veteran rights, and that the diagnosis criteria were also constructed for white, middle-class, combat veteran men. They claim that the very diagnosis criteria and scales that were later used in civilian context were lightly adapted from their original purpose to diagnose combat veterans' PTSD, and women who suffered from trauma and did not fit the combat veteran diagnosis would have been diagnosed as dissociative or borderline personality disorders (BPD). 

DSM-IV's (APA, 2000) symptom checklist for BPD overlap greatly with PTSD, but DSM-IV's definition of PTSD does not consider neglect, family violence or sexual abuse in childhood as traumatic. In their study of a general population sample, Pagura et al. showed that PTSD and BPD are similarly prevalent, 6.6% and 5.9% respectively, mutually predictive, as 24% of people diagnosed with PTSD also had BPD and 30.2% of people with BPD also had PTSD, and also referring to research on neuro-physiological similarities between the two disorders. A possible re-constuction of the differentiation could remain on a severity scale only.

DSM-V's personality disorders work group (2010) chose to keep BPD mostly as a personality type, referring to the national medical burden of BPD, they might mean that this is a way to allow people with BPD to retain their insurance benefits. This along with the declared acknowledgement of sexual abuse as trauma and emotions such as anger and shame as symptoms under the diagnosis of PTSD in DSM-V, mean insurance benefits will now also be granted to sexual assault and abuse victims as suffering from a clinical disorder and not only a personality type. So it seems in the future a lot of BPD will be PTSD.

Accepting the inherent neglect in the very definition of PTSD for the past 30 years, it seems there is less research on PTSD as a result of sexual assault when one searches APA's PsycNet. For example, in their meta-analysis of literature from 1998-2010, Yufik and Simms (2010) indeed refer to the same number of articles about combat or terror related PTSD and about interpersonal violence related PTSD (only partly referring to sexual assault victims) research publications, but their cumulative sample size is 8977 for the former and 3020 for the latter, statistical power that implies where research and development funding has been provided, and where it had not been so ample.

Seems like DSM-V reconstruction of PTSD and its neighboring BPD, requires new research and new requirements for construct validity.


APA. (2000). DSM IV TR online - borderline personality disorder. Retrieved February 18, 2011, from AllPsych: http://allpsych.com/disorders/personality/borderline.html

APA. (2010). Rational of revisions to personality disorders. Retrieved February 18, 2011, from DSM-V proposed revisions: http://www.dsm5.org/ProposedRevisions/Pages/RationaleforProposingFiveSpecificPersonalityDisorderTypes.aspx
Gross, M; Graham-Berman, S A. (2006). Gender, Categories, and Science-as-Usual: A Critical Reading of Gender and PTSD. Violence Against Women , Vol 12 (4) pp. 393-406.
National Center of PTSD. (2010, September 15). Retrieved February 17, 2011, from US governement Department of Veteran Affairs: http://www.ptsd.va.gov/professional/ptsd101/presenters/paula-p-schnurr-phd.asp
Schnurr, P. (2010). PTSD 30 Years On. Journal of Traumatic Stress , Vol. 23 (1), pp. 1–2.
Yufik, T & Simms, L J. (2010). A Meta-Analytic Investigation of the Structure of Posttraumatic Stress. Journal of Abnormal Psychology , Vol. 119, No. 4, 764–776.

יום רביעי, 23 בפברואר 2011

Result based psychotherapy

Soon I will post a few literature reviews that describes the state of the art in diagnosis and treatment of sexual assault related PTSD. The review aim is to examine the viability of a results oriented therapy method for the disorder. Results oriented management is a business practice that gives preference to efficacy over any specific process, no matter how deep and meaningful that process may sound. Or in other words: "why should I talk about my mother now???"

Result oriented therapy requires a well established construction of sexual assault related PTSD and its definition as an object of therapy, representative measures of therapy effect that can be applied continuously through the process of therapy, and a variety of therapeutic methods and technologies that can be applied alternately according to ongoing efficacy feedback from measured results. The underlying assumption is that clinician time is the bottleneck in the therapeutic process, and that methods and technologies that use clinician time more efficiently can increase therapy effect within therapy and in making therapy affordable to more potential patients.

So when a patients asks why talk about mom, while the current answer is "it's a process, it could help", a therapist with any measures of efficacy can answer: "it helps you".

יום שבת, 19 בפברואר 2011

The American Psychiatric Association acknowledges sexual assault as a cause for PTSD in proposed revisions to its diagnostic manual

By definition of DSM-IV (APA, 2000), PTSD always follows a traumatic event which causes intense fear and/or helplessness in an individual. Symptoms are divided into clusters that include re-experiencing the trauma, obsessive thoughts, and flashbacks, avoidance and increased anxiety. The DSM-V work group proposed a few revisions to the definition of PTSD such as specifying sexual assault as a traumatic event, and also to restructure the symptom clusters to highlight negative cognitions and mood as a cluster of its own, and adding to it moods like anger and shame, (to DSM-IV's fear and helplessness) and cognitions such as self blame (APA, 2010). These revisions seem to better describe PTSD symptomatology (Yufik, & Simms, 2010) and to take in the feminist criticism of the PTSD definition being biased against sexual assault related PTSD characteristics (Gross, & Graham-Berman, 2006).


APA. (2000). DSM IV TR online version. Retrieved February 17, 2011, from AllPsych Online: http://allpsych.com/disorders/anxiety/ptsd.html

APA. (2010). PTSD work group. Retrieved February 17, 2011, from DSM-5 proposed revoisions: http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165#

Gross, M; Graham-Berman, S A. (2006). Gender, Categories, and Science-as-Usual: A Critical Reading of Gender and PTSD. Violence Against Women , Vol 12 (4) pp. 393-406.

Yufik, T & Simms, L J. (2010). A Meta-Analytic Investigation of the Structure of Posttraumatic Stress. Journal of Abnormal Psychology , Vol. 119, No. 4, 764–776.

יום חמישי, 17 בפברואר 2011

TeleHealth protocol: treating PTSD with PE via Skype

I like this approach. I am thinking about Therapy on Demand channels,  iphone apps etc...

2 quote from the article:

"when patients had difficulty beginning in vivo exercises on their own, it was helpful for the patients to complete the exercise while talking to the clinician on a cell phone."

"Prolonged Exposure therapy via telehealth technology was associated with large reductions in symptoms of  PTSD and depression for veterans diagnosed with combat-related PTSD. In the current sample, telehealth PE treatment was safe and pragmatically viable. Treatment noncompletion rates, although higher than average for our clinic, were in the acceptable range."

(Tuerk et al., Journal of Traumatic Stress, Vol. 23, No. 1, February 2010, pp. 116–123)

Looks like people are doing it. skype therapy I mean...

יום שבת, 12 בפברואר 2011

Dr Phil is cool

I think Dr Phil is cool because:

His intro clips are a powerful therapeutic agent:
Before every spot on the show, the guest-patients see themselves on a big screen in interviews, hidden camera from home, and some dramatic illustrations. They know they have a problem, they came to the show because of it, and they describe it in the clipped interviews, usually describing the distress, along with justifying causes. Still, when he asks them how it feels to see themselves like this, they suddenly own their problem, and are ready to talk about changing their behavior. I think what happens there is that people understand TV representations of life more than they can understand life. In life they are stressed and overwhelmed, and respond out of desperation without hope. Now they suddenly see this horrible person in the clip and they have a dramatic urge to reach a solution, like on TV. 


He adds healthy common sense education to yellow talkshow media:
He exposes talkshows audience to material that is not only very personally intusive to other people's lives, but also has a didactic position with some healthy directions like: don't drink too much, don't hit your kids, don't let your husband hit you - the basics... The don't is not something you see on Ricky Lake..


As part of this he also phrases his advice in a catchy way. Reruns and compilation shows help make it stick. My favorites are how he phrased neglect, when he tells a husband he can keep his over-consuming hobbies as long as he has quality time with his wife: "it's not what you're doing that's the problem, it's what you're not doing!" Or when he tells a drinking mom who does not see this as substance abuse: "of course you drink because you enjoy it, but it's your kids who pick up the tab!".

Dr Phil is also uncool, and the coolness points I gave him have limitations, the main one, is that as a showman he may be looking to pass a point, over being sensitive to how it may affect his guest-patients.


יום שישי, 11 בפברואר 2011

Could prolonged exposure therapy (PE) have saved Hemingway from suicide?

I explained to Ernest that the best way to get over his traumatic injury is to focus on it with full detail until the anxiety loses potency, and he gets used to the things he so far avoided. He first did not understand how this is different from his compulsion to write prose about his distress, but he was willing to try, as the seemingly brave approach seemed appropriate to him.

When first asked to rank his fears, he could not admit any fear. Later he was willing to write a list of "things he'd rather not have to face". On the bottom of the list he wrote things like sleeping with the lights off, in the middle of the list he wrote things like being trapped in a prison cell, and at the top he wrote he feared physical torture and severe injury. These things kept him anxious and awake at nights.

Explaining treatment rational took up most of the next two meetings and Ernest did not perform his homework for them. We discussed this as avoidance on his part, and agreed to move very slowly up his list of things he'd rather not face. We also agreed to start first in the therapy room, and only later at home when he was alone. 

Ernest sat in the dark without screaming after two very gradual training sessions. After three sessions I even left the room for a few minutes and found him dozing in the dark, as he was exhausted with lack of sleep. At home, he changed his working schedule from writing before dawn to writing in the late morning, and he began to catch some sleep in the dawn hours.

Therapy continued, and Ernest's most major in vivo was swimming in the deep sea, where he used to fear he would be torn to shreds by sharks. He said that being in the water cooled him even better than a Mojito. He could sleep, he was much less edgy, being more calm allowed him to function sexually and enjoy his wife's support and warmth. After 6 months follow-up he was bellow clinical level for PTSD, however, changing his working schedule to daytime made him more distracted and he did not publish additional prose.

Another disturbing image - Hemingway drinking while ready to shoot sharks:

Could cognitive processing therapy (CPT) have saved Hemingway from suicide?

Ernest is a 62 years old novel writer, suffering from PTSD (ante literam) and depression. He was wounded in his leg 40 years ago in WWI, during a bombardment of a medical evacuation point, and ever since he has suffered from many PTSD symptoms such as: insomnia and nightmares, obsessive preoccupations with death and suicide, vivid multi-sensory flashbacks, alcohol dependency, feelings of guilt and shame, and intimacy problems revolving around difficulty to trust his lovers. He came to my clinic depressed, saying that he was diagnosed with an acute liver disease caused by alcohol abuse, and that now being without alcohol, he could not escape the intensity of his war flashbacks. Although he did not believe in psychology, he felt he was unable to bare his intruding thoughts of death and suicide and came to ask for treatment.

Therapy strategy was mainly to get Ernest to talk and write about his emotions directly – stop emotional avoidance, and to move from third person fictional writing to personal writing – accept that the event occurred as it had occurred and that no alternative fictional scenarios can replace it. Ernest being a writer, he had very firm professional positions regarding these issues, and had difficulty to comply. His main subject of writing is his distress, but he only rarely writes about the traumatic event itself, and seldom writes about his emotions in intense situations. His position was that his writing should be clean of emotional import, and that laconic and concrete messages would better explain his experience than pathetic elaborations of what he felt.

On our first session I had to convince him that even though he has been writing about the subject on and on for 40 years, he has not yet processed his experience fully. What grabbed him was the explanation about synthesized emotions compared to natural emotions. He felt he had been synthesizing emotions, and that the natural ability to feel has left him, he was either numb or distressed. He wanted to continue therapy and investigate this issue.

In his first homework he wrote about the effects of his trauma. Everything he was, was described as a result from his trauma – his problematic relationships, his risk taking behaviors, his sexual difficulties. Reviewing his essay, he did not allow me to perform a therapeutic split between his healthy side and injured side.

To his second session he came after reading about blockage points, and said he acknowledges something about this. He feels that his injury wasn’t a real battle injury, that he was awarded a fake medal, he was making coffee in a shed, a kilometer behind the front when a stray shell landed near – he was no hero, so he was not really injured. He cried, and said he was pathetic. I felt this was too intense, too soon for him, so after he calmed down, I asked him only if this direction is good for him, he agreed, and we continued.

We worked on recognizing emotions. He could not mention a situation that brought up an emotion in him. We went over the cognitive model of emotions being based on interpretations of the world. He said the world was basically very hostile, and that emotions are pains he tries to burry deep inside. After elaboration, he accepted that burying deep inside, is fear.
Therapy continued, and Ernest also rephrased his intimacy issues as trust issues, and his trust issues as fear of abandonment, based on his feelings that he was "not man enough". After 12 sessions, Ernest could recognize the blocking effect of the trauma on his cognitions, and the way they jammed his emotions in a state of fear. He recognized that feeling like a fake hero lead him to feel pathetic, unmanly and undeserving of emotions, that his third person characters were made up to deserve more than he did. He got a chance to cry during therapy, and noted how this was much better than drinking, really. His PTSD symptoms inventory was bellow clinical level after 5 months follow-up, but his laconic realism was badly damaged and he could not write prose again.

יום רביעי, 9 בפברואר 2011

The obsessive compulsive style (Shapiro, 1965)

In his chapter "obsessive compulsive style," David Shapiro (1965) describes the characteristics of obsessive compulsive (OC) people, beginning with the rigidity of thought which is clinically observed with compulsive characters. Shapiro depicts this characteristic as limited, very focused attention; an unwillingness to divert from an interest or a position or listen to other parties in conversation.

            Shapiro then depicts a second major characteristic as a mode of action. He refers to OC people as work prone, work invested, workaholics – not necessarily over-productive, but treating every life situation as a productive process that requires effort on their side – even enjoyment. Effort is described as mental effort of preoccupation about an issue, not necessarily making evident pragmatic efforts towards it. Shapiro connects this to a damaged sense of autonomy, attuned to a sense of should over a sense of will, with demanding impulses that threaten the cores of intent and control; then awareness becomes their struggle, and all human behavior becomes an issue to preoccupy with – an effort. Their struggle is to keep from madness.

            If a keyhole attention and a troubled soul aren’t enough, Shapiro adds a loss of the sense of reality to the mental dynamics of the obsessive compulsive people. The authentic position is replaced with a logical perspective. The logical perspective is maintained by the narrowing attention, and its maintenance is an effort. Spontaneous right and wrong are missing from their judgment and they mediate their experience with rational criticism instead.

            In view of DSM-IV-TR's criteria list for OCD and OCPD, I believe Shapiro is describing the dynamics of an obsessive compulsive personality disorder. His emphasis is on obsessions, and less on the very evident compulsions and rituals expected in an OCD by the manual. Furthermore, Shapiro's everyday register and empathic description of psyche dynamics may tell us that this phenomenon is on the clinical doorstep, not yet inside the madhouse.

It is said that Cameron Diaz suffers from OCD!
Jessica Alba too.

Classic CBT VS ACT

Classic CBT (cognitive behavioral therapy) aims to modify maladaptive cognitions by supplying more adaptive alternatives, while ACT (acceptance and commitment therapy) assumes the mind to be a meaningless chatterbox that should be habituated, not focused on, or manipulated.

For example, when a patient is afraid of flying, the classic CBT approach would be to teach him more realistic risk evaluation, which is minimal in this case, a manageable way to interpret his physical over-arousal, as expectation of danger – not actual danger, and behavioral exposure as means to learn that there is no real danger.

The ACT approach would not argue with the patient's risk assessment in flying and in his panic, claiming that these serve avoidance, and that the patient should just listen passively to the arguments in his mind like they were an open channel radio with other people talking, until the volume fades, and he can just go through the motions, just do what he should do, disregarding his anxious thoughts and feelings.

If we put aside the contradictory theoretical frameworks, we can find that a pragmatic similarity would be the behavioral "just do it," and the difference is whether to tackle specific maladaptive cognitions or circumvent them. A combined practice could be to direct the patient to exposure, tackling the grossly maladaptive cognitions that lead to avoidance, and circumventing debates where cognitive debating is a cause for avoidance. Alternatively we could use CBT when we can offer a more adaptive cognition and ACT when the cognition is sensible but nevertheless distressful. Another distinction can be to tackle the ego-ayntonic cognitions, which the patient tries to justify with arguments, while circumventing the ego-dystonic cognitions, which admits have no sense behind them.

In my view, psychotherapy's curative effect is replacing dogmatic responses with a soft dissonance that allows variability of response – not providing a more adaptive response but facilitating adaptivity itself. Classic CBT should not provide a right answer - "you know flying is 10X less dangerous than driving" - but provide the patient a grain of salt to his preconceptions - "did you ever question your conception that flying is dangerous?" - show him that another way is possible. In that way, ACT should not ask the patient to give up the meaning of his thoughts ("what were the numbers? You see? Meaningless, and you're stuck with them!") as much as it should alleviate intensity of the patient's internal debate regardless of the arguments - "where does all this thinking lead you?" – show that it can be harmful by itself. If the mutual goal of mental agility can be established, the therapist can vary his practices, being attuned to the patient's field of preoccupations, and estimating the patient's capacity to loosen up a variety of dogmatic mental structures. The combined practice can be focusing on specific cognitions as a start, and then generalizing the same principle to the entire internal discourse, giving the patient room for air. Unifying these practices under one goal could also allow us to measure their effects comparatively, and use them more appropriately.

יום שישי, 28 בינואר 2011

Assimilation and accomodation in lay language:

I'm still reading this CPT book, and I have to translate the words assimilation and accommodation to lay language when I read. I wish I had a Dr Phil expression for them, so I will try to make them up. So imagine a Texan accent when I say this:

Over-accommodation: "If you fall off your horse, it don't matter if you get back on it, but don't take it out on your pickup truck..."

Assimilation: "With better boots you'd still be in this bullshit."

Accommodation: "You wasn't planning on the wind when you put your hat on this morning, but what else could you do?"

As country music hall-of-famer, Garth Brooks says, "if you want them to listen, you better take it down to three chords and the truth".

יום חמישי, 27 בינואר 2011


I'm reading this book by Dr. Derbi and Prof. Resick about treating PTSD with Cognitive Processing Therapy (CPT). As a side note, the writers say that taking anti-depressants during therapy is ok, but with a notice that it may prevent success from being attributed correctly to the efforts of the patient. 

In my view, isolating variables is a sceintific practice, and not the way to happiness. If you're depressed and you do 10 things to treat yourself: prozac, psychotherapy, chocolate, yoga, walks in the park etc., and then you're not depressed anymore, you did a good job.

It is inefficient to do 10 things without isolating the one that works, but if we go there, psychotherapy probably won't come out as efficiency queen either. 

In the search for well-being, I think a blitzkrieg model more fitting. Do 20 things that you think will make you feel better, 50% of them will work, and you have no reason to ask which. Well-being based on one practice is very fragile. 

I could write more but a picture of Dumbo seems more to the point, meaning that placebos and coincidental pseudo-factors of well-being are welcomed.

My New Blog

This is my new blog. I hope to write here stuff that will be interesting to me and to others. Still unclear about what. Not about my personal life. Not totally professional. An attempt to filter something that's not all bullshit and still very open to new thinking. I will try to write simply, I will try to write shortly, I will try to put illustrations and media in it.

The subjects that come to mind, for a blog like this, have to do with psychtherapy, life coaching, organizational approaches, and human experience in a the stage between personal experience and abstract form.