All posts by John pullyblank

M. Jackson Group Update – November 2018 – Can’t Stop Worrying

This month’s post is again from British Psychological Society Research Digest. 

The reasons why, once we start worrying, some of us just can’t stop

By Christian Jarrett

A certain amount of worrying is a normal part of life, especially these days with barely a moment passing without a disconcerting headline landing in your news feed. But for some people, their worrying reaches pathological levels. They just can’t stop wondering “What if …?”. It becomes distressing and feels out of control. In the formal jargon, they would likely be diagnosed with Generalised Anxiety Disorder, but excessive worrying is also a part of other conditions like panic disorder. There are many factors that contribute to anxiety problems in general, but a new review in Biological Psychology homes in on the cognitive and emotional factors that specifically contribute to prolonged bouts of worry. Its take-home points make an interesting read for anyone who considers themselves a worrier; and for therapists, the review highlights some approaches to help anxious clients get a hold of their excessive worrying.

The review authors, Graham Davey and Frances Meeten at the University of Sussex and the Institute of Psychiatry, Psychology and Neuroscience, explain that what gets many pathological worriers worrying in the first place is that they seem to be highly vigilant to any sources of threat and danger, and if there’s any ambiguity about whether a situation is threatening or not, they will tend to interpret it as being dangerous. If they haven’t yet heard from their daughter today, for instance, the problem worrier will not only notice this fact, they will also contemplate that it’s because she’s in trouble, rather than simply busy.

Studies have shown the causal role that these attentional biases seem to have by testing what happens when people are trained instead to pay more attention to positive aspects of situations, or to interpret ambiguous situations more positively. Asked to spend time after the training sitting quietly, focused on their breathing, worriers who’ve had the training report fewer intrusive worries compared with control participants.

Once a worry bout kicks in, one of the things that keeps it going in problem worriers is their deep held belief that worry is actually a good thing. This doesn’t make much sense at first. How can excessive worriers think worry is good when they find it so distressing? But while they find the worrying distressing and upsetting, and it feels out of control, research shows they also believe that it can help prevent bad things from happening, that it will help them be prepared for bad outcomes, and that it aids problem solving.

Related to this, problem worriers tend to have a kind of perfectionist approach to worrying. They think they can’t stop worrying until they’ve finished, in the sense of working through every eventuality and solving every problem. Less anxious people, in contrast, will tend to follow a principle of stopping worrying once they don’t feel like it anymore. Teaching pathological worriers to change their approach, to learn to stop worrying once they had enough of it, has been shown to prevent them from getting stuck in such long worry bouts.

Another key factor is low mood. Problem worriers tend to experience more negative moods, which are known to encourage a more analytical thinking style. In turn, this lays the ground for an overly zealous, perfectionist worry style that is in a sense impossible satisfy and leads to more distress and anxiety. Pathological worriers also tend to use their ongoing negative mood as a barometer for whether their worrying has been successful. The fact that they still feel down and anxious tells them that they’ve yet to anticipate or prepare for every disconcerting eventuality. Using “mood as information” in this way creates a kind of cognitive and emotional trap that propagates yet more worry.

You should seek professional help if you feel your worrying is becoming a problem, but the review offers some simple take-aways for breaking out of occasional uncontrolled worry bouts or preventing them happening in the first place. Because of the way that negative moods contribute to the perseveration of worry bouts, for instance, simply trying to combat a generally low mood is likely to help. This may be easier said that done, but if you can lift your mood (for example through going for regular walks), the evidence suggests a knock-on benefit will be less prolonged worrying.

It sounds ridiculously simple, but also thinking about the idea of stopping worrying when you’ve had enough of it, rather than when the worrying is somehow “finished” or “complete”, could be beneficial. In fact, earlier research has shown that merely learning about the cognitive and emotional factors that feed excessive worry can help some people.

From a therapeutic perspective, the review suggests that attentional training programmes (including “cognitive bias modification“) are likely to help prevent worry bouts from starting in the first place. Therapists could also consider engaging with anxious clients’ explicit beliefs about worrying, such as that it can prevent bad things happening or that they need to continue worrying until they’ve covered all the issues. Meanwhile, acceptance- or mindfulness-based approaches could help alleviate clients’ distress about worry, which in turn would help reduce the part that negative mood plays in prolonging a worry bout. As for where our deep-seated and sometime unhelpful beliefs about worry come from in the first place, Davey and Meeten said this is something awaiting further research.

The perseverative worry bout: A review of cognitive, affective and motivational factors that contribute to worry perseveration

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest

M. Jackson Group Update – October 2018 – Managing Chronic Pain

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
 
The Agency for Healthcare Research and Quality released an article: “Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review.”
 
The authors are  Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Winter C, Ferguson AJR.
 
Here are some excerpts:
 
[begin excerpts]
 
Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. 
 
Study quality was assessed, data extracted, and results summarized for function and pain.  Only trials reporting results for at least 1 month post-intervention were included. 
 
We focused on the persistence of effects at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).
 
<snip>
 
Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain.
 
Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect, SOE: low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: low). 
 
Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). 
 
<snip>
 
Chronic neck pain: At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low), but no improvement in pain was seen at any time (SOE: llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term….
 
<snip>
 
For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low). Evidence was sparse on interventions for hip and hand osteoarthritis. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: low). 
 
<snip>
 
Fibromyalgia: In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. At intermediate term for exercise (SOE: moderate), acupuncture, and CBT (SOE: low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all); massage (SOE: low) improved long-term pain slightly, but no clear impact on pain for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low) was seen. 
 
<snip>
 
Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE: low).
 
<snip>
 
Conclusions. Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. 
 
Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. 
[end excerpts]
 
The article is online at:
 
Ken Pope
 
POPE: THE AMERICAN PSYCHOLOGICAL ASSOCIATION OUTSOURCES ADJUDICATION OF ETHICS COMPLAINTS—5 FAR-REACHING CONSEQUENCES
POPE: APA’S CONTINUING HUMAN RIGHTS & ETHICS CRISIS—ACCEPTING RESPONSIBILITY, UNDERSTANDING CAUSES, IMPLEMENTING SOLUTIONS—European Psychologist—In Press—Updated & Revised July 2018
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
 
“The greatest weakness of most humans is their hesitancy to tell others how much they love them while they’re still alive.”  
—O.A. Battista (1917-1995)

M. Jackson Group Update – September 2018 – 5 Things to do When You Feel Overwhelmed

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
 
Harvard Business Review includes an article: “5 Things to Do When You Feel Overwhelmed” by Alice Boyes.
 
Here are some excerpts:
 
[begin excerpts]
 
Do your to-do lists stretch on and on — and on? Do you dread checking email on Friday afternoons, worried about seeing messages piling up when you’re just trying to get out the door? 
 
<snip>
 
You might feel anxious that you’re not working during times that are incompatible with working, like when you’re buckling your child into their car seat or you’re stuck in traffic. You may even feel anxious about the project you’re not working on when you’re busy plugging away on something else.
 
If you have moments of feeling overwhelmed by your workload, here are some suggestions to try.  Not all of these will be right for everyone, so pick what you think will help you. 
 
But always, always start with taking slow breaths (it’s better to focus on slow rather than deep breathing). Slow breathing helps you stop panicking and take a more long-term focus as it activates the brain’s prepare-and-plan mindset. If you focus on breathing out like you’re blowing up a balloon slowly, your breath in with naturally regulate itself.
 
Practice your acceptance skills with healthy self-talk
 
The best self-talk helps you feel calmer and in control. It combines self-compassion and appropriate responsibility-taking (not too much, not too little). Feeling excessively responsible is associated with a vulnerability to worry. Experiment with different types of self-talk and see what works best for you. 
 
As a kickoff, you might try:
“Even though I have many things to do, I can only focus on the one thing I’m doing right now. I’ll feel better if I do that.” 
 
“I would prefer to be able to get more done in a day, but I’m going to accept what I’m realistically able to do.” (This phrase utilizes a common cognitive-behavioral therapy technique where it’s recommended people swap out their “shoulds” for “prefer” or “could” in order to relieve anxiety and feel more empowered). 
 
I like the mantra “What’s the best action to take right now?” to remind me that ruminating about the past or worrying about the future interferes with optimal focusing and prioritizing. 
 
<snip>
 
Track your time to give yourself an accurate baseline
 
There’s some evidence from research comparing time tracking data to self-reports that people who say they work very long hours are generally overestimating. Large-scale research indicates that the proportion of people working over 60 hours per week is quite small, at around 6%. If you’re saying to yourself “I work 70 hours a week” your brain will react as if that were true, even if it’s an exaggeration.
 
How does this thinking error arise? Sometimes our brains jump to conclusions based on our emotions. When you feel anxious about work, your brain will overestimate how much you’re working, which in turn makes you feel more anxious and sets up a self-perpetuating cycle. When your perception of your workload is dramatically overblown, the situation feels hopeless, which will likely leave you feeling depressed as well as anxious and you’ll become avoidant.  You won’t take the practical steps you could to address your situation. If you’re making this estimation error, don’t take it too personally. This is a pervasive general pattern and not a personal flaw.
 
Try tracking your time for a single week. There are online tools for this, but you can also use a spreadsheet or just a notebook. Track your time without actively attempting to change your behavior. Your behavior will naturally shift in positive directions due to monitoring, so there’s no need to force it, at least initially.
 
<snip>
 
Limit brief work-related activities during non-work time, like checking your phone or firing off a quick email. 
 
Objectively these activities may only take a few minutes, but this pattern can feel like it consumes more time than it actually does, so curb these behaviors.
 
The flip side is that small bursts of meaningful non-work activities can help your life feel more balanced. For example, if I crouch down and look my two-year old in the eye when we’re having a moment together, those seconds give me a sense I’m doing more quality parenting, even though it’s a few minutes here and there. Five minutes of uninterrupted conversation feels more meaningful than 10 minutes of scattered attention.
 
Check your assumptions about other people’s expectations
 
We often self-generate rules we expect ourselves to follow. For example, “I need to reply to Sandra more quickly than she generally replies to me.” Or, “I need to reply to any email within the day.” Consider that when people take a while to respond, it sends the signal that they’re busy and prioritizing, and may lead to other people respecting their time to a greater extent.
 
One of my pet peeves is receiving “to do” emails on Friday afternoons — my fear is that if I don’t complete whatever is needed over the weekend, the early part of the following week will fill up and the person who emailed me will be left waiting for me to finish whatever it is I need to do. However, it’s worth considering that whoever contacted you as they were running out the door from work might not want a response during the weekend. Replying immediately to after-hours emails contributes to the always-on cycle for everyone.
 
Practice not responding to messages outside of business hours. Most people will get the message, and may appreciate you helping them with their own boundaries. When you limit your replies to business hours you’re more likely to consider where replying fits into your overall priorities than if your pattern is to jump to attention at any hour of the day upon receiving emails. Clarify expectations with others. Instead of assuming that your boss needs something done immediately, why not ask her when she needs it by? Let people know when you’ll get back to them. If something will realistically take you two weeks to get to, just say so. 
 
Examine your assumptions about what success requires
 
On a similar theme, you might also be self-generating faulty thoughts about what it takes to be successful in your field.  Perfectionistic assumptions like, “To succeed I need to work harder than everyone else” become especially problematic when you’re rising through the ranks in a competitive industry and you’re in a group of other overachievers. 
 
Here’s the tricky part about identifying your problem thoughts: our assumptions and self-generated rules are often implicit. When you’re feeling miserable or blocked, that’s a great time to hunt down any hidden assumptions that are contributing to that.
 
[end excerpts]
 
The article is online at:
 
Ken Pope
 
POPE: THE AMERICAN PSYCHOLOGICAL ASSOCIATION OUTSOURCES ADJUDICATION OF ETHICS COMPLAINTS—5 FAR-REACHING CONSEQUENCES
POPE: APA’S CONTINUING HUMAN RIGHTS & ETHICS CRISIS—ACCEPTING RESPONSIBILITY, UNDERSTANDING CAUSES, IMPLEMENTING SOLUTIONS—European Psychologist—In Press—Updated & Revised 
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
“I believe you are your work.  Don’t trade the stuff of your life—time—for nothing more than dollars.  That’s a rotten bargain.”
—Rita Mae Brown

M. Jackson Group Update – August 2018 – Intelligence Overconfidence

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:

PLoS ONE includes an article: “65% of Americans believe they are above average in intelligence: Results of two nationally representative surveys.”

 
The authors are Patrick R. Heck, Daniel J. Simons, & Christopher F. Chabris.
 
Here’s how it opens:
 
[begin excerpt]
 
The statement that a majority of people claim to be more intelligent than average is literally a textbook example of overconfidence and self-enhancement [1–6]. Here we ask whether such “intelligence overconfidence” is reliably found in large samples weighted to be nationally representative, differs by method of data collection (telephone or online), and varies according to demographic factors including sex, age, and race/ethnicity. The answers to these questions will help solidify the evidence base for popular claims in psychology and contribute to research on self-perceptions, overconfidence, and intelligence.
 
Most demonstrations of the “smarter than average” effect are conducted using convenience samples, a method that raises concerns about generalizability [7,8]. Some studies have improved upon convenience sampling by collecting nationally representative survey data from college [9] and high school [10] students to measure change in self-positivity and narcissism over time. However, student populations suffer the limitations of failing to represent older and less-educated people, differing from the general population in income, race/ethnicity, and sex, and potentially having difficulty imagining the “average person” outside of a university environment.
 
Sampling from a more representative source of participants can overcome these limitations. Applying probability weighting to the sample can then account for over- and under-sampling of demographic groups. Some representative surveys of people’s beliefs about their own intelligence have been reported in the media [11,12]. However, these reports do not include important methodological details like sample sizes, weighting schemes, and inferential statistics. The only published study of a nationally representative sample of Americans reporting overconfident beliefs about relative intelligence was conducted over 50 years ago [13]. For these reasons, we decided to examine the pattern of intelligence overconfidence in the present U.S. population. From two large samples weighted to be nationally representative, drawn using distinct polling methods (telephone and online), with the second constituting a replication of the first, we report the proportions of Americans who agreed with the statement, “I am more intelligent than the average person”.
 
Although self-enhancement and overconfidence have been demonstrated across a broad range of traits [14,15], we chose to focus on the specific trait of intelligence because of its practical and theoretical importance.
 
[end excerpt]
 
Here’s how the Discussion section opens: “Two surveys, weighted to be nationally representative (total N = 2,821), found that nearly two-thirds of Americans believe that they are more intelligent than average. The survey methods (telephone, online) yielded similar overall agreement rates after weighting responses to match the U.S. population in sex, age, and race/ethnicity. In both surveys, men were more likely to express confidence in their intelligence than were women, and younger people were somewhat more likely to agree with the claim than older people.”
 
Here’s how it ends: “ We conclude that Americans’ self-flattering beliefs about intelligence are alive and well several decades after their discovery was first reported. Our results update the textbook phenomenon of intelligence overconfidence by (1) replicating the effect using large, representative, contemporary samples and two distinct survey methods, (2) demonstrating a degree of calibration across levels of education, and (3) showing moderation based on sex and age. The endurance of the smarter-than-average effect is consistent with the possibility that a tendency to overrate one’s own abilities is a stable feature of human psychology.”
The article is online at:
 
Ken Pope
 
POPE: THE AMERICAN PSYCHOLOGICAL ASSOCIATION OUTSOURCES ADJUDICATION OF ETHICS COMPLAINTS—5 FAR-REACHING CONSEQUENCES
POPE: APA’S CONTINUING HUMAN RIGHTS & ETHICS CRISIS—ACCEPTING RESPONSIBILITY, UNDERSTANDING CAUSES, IMPLEMENTING SOLUTIONS—European Psychologist—In Press—Updated & Revised July 2018
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
“It is of interest to note that while some dolphins are reported to have learned English — up to fifty words used in correct context — no human being has been reported to have learned dolphinese.” 
—Carl Sagan 

M. Jackson Group Update – July 2018 – Review of Antidepressant Medications

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
 
Lancet includes an article: “Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis.”
 
The authors are Andrea Cipriani, Prof Toshi A Furukawa, MD†, Georgia Salanti, PhD†, Anna Chaimani, PhD, Lauren Z Atkinson, MSc, Yusuke Ogawa, MD, Prof Stefan Leucht, MD, Henricus G Ruhe, PhD, Erick H Turner, MD, Prof Julian P T Higgins, PhD, Prof Matthias Egger, PhD, Nozomi Takeshima, MD, Yu Hayasaka, MD, Hissei Imai, MD, Kiyomi Shinohara, MD, Aran Tajika, MD, Prof John P A Ioannidis, MD, Prof John R Geddes, MD.
 
AS USUAL, FOR THOSE WHO WOULD LIKE ACCESS TO THIS ARTICLE, I’LL INCLUDE *BOTH*THE AUTHOR’S EMAIL ADDRESS (FOR REQUESTING ELECTRONIC REPRINTS) *AND* A LINK TO THE COMPLETE ARTICLE AT THE END BELOW.
 
Here’s how it opens:
 
[begin excerpt]
 
Psychiatric disorders account for 22·8% of the global burden of diseases.1 The leading cause of this disability is depression, which has substantially increased since 1990, largely driven by population growth and ageing.2 With an estimated 350 million people affected globally, the economic burden of depressive disorders in the USA alone has been estimated to be more than US$210 billion, with approximately 45% attributable to direct costs, 5% to suicide-related costs, and 50% to workplace costs.3 This trend poses a substantial challenge for health systems in both developed and developing countries, with the need to treat patients, optimise resources, and improve overall health care in mental health.
 
Grouped into various classes of drugs with slightly different mechanisms of action, antidepressants are widely used treatments for major depressive disorder, which are available worldwide. However, there is a long-lasting debate and concern about their efficacy and effectiveness, because short-term benefits are, on average, modest; and because long-term balance of benefits and harms is often understudied.4 Therefore, innovation in psychopharmacology is of crucial importance, but the identification of new molecular targets is difficult, primarily because of the paucity of knowledge about how antidepressants work.5 In routine practice, clinicians have a wide choice of individual drugs and they need good evidence to make the best choice for each individual patient. Network meta-analyses of existing datasets make it possible to estimate comparative efficacy, summarise and interpret the wider picture of the evidence base, and to understand the relative merits of the multiple interventions.6 Therefore, in this study, we aimed to do a systematic review and network meta-analysis to inform clinical practice by comparing different antidepressants for the acute treatment of adults with unipolar major depressive disorder.
 
[end excerpt]
 
Here’s an excerpt from the Discussion section:
 
[begin excerpt]
 
We found that all antidepressants included in the meta-analysis were more efficacious than placebo in adults with major depressive disorder and the summary effect sizes were mostly modest. 
 
Some antidepressants, such as escitalopram, mirtazapine, paroxetine, agomelatine, and sertraline had a relatively higher response and lower dropout rate than the other antidepressants. 
 
By contrast, reboxetine, trazodone, and fluvoxamine were associated with generally inferior efficacy and acceptability profiles compared with the other antidepressants, making them less favourable options. To make our results as relevant and robust as possible to inform clinical practice, we decided to focus on head-to-head studies and at the same time emphasise the certainty of the retrieved evidence. Our assessment overall found few differences between antidepressants when all data were considered, while there was more diversity in the range of efficacy and dropout patterns seen across the head-to-head comparisons than the meta-analysis of antidepressants versus placebo.
 
The present findings in adults contrast with the efficacy of antidepressants in children and adolescents, for which fluoxetine is probably the only antidepressant that might reduce depressive symptoms.21 
 
This differential efficacy across age groups might reflect heterogeneous mechanisms and causes of depression,22 smaller number of studies in young people, or different methodological issues affecting adult and paediatric trials.23 
 
The effect sizes were also smaller in more recent and larger placebo-controlled trials than in older and smaller ones, which might be an indicator of bias.
 
[end excerpt]
 
Here’s how the article ends: “The findings from this network meta-analysis represent the most comprehensive currently available evidence base to guide the initial choice about pharmacological treatment for acute major depressive disorder in adults. All statements comparing the merits of one antidepressant with another must be tempered by the potential limitations of the methodology,32the complexity of specific patient populations, and the uncertainties that might result from choice of dose or treatment setting. We hope that these results will assist in shared decision making between patients, carers, and their clinicians.”
REPRINT REQUESTS & OTHER CORRESPONDENCE: mailto:andrea.cipriani@psych.ox.ac.uk
 
The article is online at:
 
Ken Pope
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
 
POPE: FIVE STEPS TO STRENGTHEN ETHICS IN ORGANIZATIONS AND INDIVIDUALS: 
EFFECTIVE STRATEGIES INFORMED BY RESEARCH AND HISTORY—Routledge (imprint of Taylor & Francis)
Hardbound—Kindle—Nook—eBook—Google Book
 
POPE: “AWARD ADDRESS: THE CODE NOT TAKEN: THE PATH FROM GUILD ETHICS TO TORTURE AND OUR CONTINUING CHOICES”—
Canadian Psychology/psychologie Canadienne article free online at:
 
“Every sentence that I utter should be regarded by you not as an assertion but as a question.” 
—Niels Bohr, Nobel Prize in Physics (1885-1962) 

M. Jackson Group Update – June 2018 – Pseudoscience

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
 
Scott Lilienfeld has written an excellent forward (“Navigating a Post-Truth World: Ten Enduring Lessons from the Study of Pseudoscience”) to an excellent book: Pseudoscience: The Conspiracy Against Scienceedited by Allison B. Kaufman & James C. Kaufman, published by MIT Press (2018).
 
Here’s how the forward opens: “We find ourselves living increasingly in a ‘post-truth’ world, one in which emotions and opinions count for more than well-established findings when it comes to evaluating assertions.  In much of contemporary Western culture, such catchphrases as ‘Don’t confuse me with the facts,’ ‘Everyone is entitled to my opinion,’ and ‘Trust your gut’ capture a troubling reality, namely, that many citizens do not—and in some cases, apparently cannot—adequately distinguish what is true from what they wish to be true.  This overreliance on the ‘affect heuristic,’ the tendency to gauge the truth value of a proposition based on our emotional reactions to it (Slovic, Finucane, Peters, and MacGregor, 2007), frequently leads us to accept dubious assertions that warm the cockles of our hearts, and to reject well-supported assertions that rub us the wrong way.  We are all prone to this error, but one hallmark of an educated person is the capacity to recognize and compensate for it, at least to some degree.”
 
Here are some excerpts from the 10 enduring lessons:
 
[begin excerpt]
 
(1) We are all biased. Yes, that includes you and me.
 
<snip>
 
(2) We are largely unaware of our biases. Research on bias blind spot (Pronin, Lin, and Ross, 2002) demonstrates that most of us can readily identify cognitive biases in just about everyone except for one person—ourselves. As a consequence of this metabias, we often believe ourselves largely immune to serious errors in thinking that afflict others.
 
<snip>
 
(3) Science is a systematic set of safeguards against biases. Despite what most of us learned in high school, there is probably no single “scientific method”—that is, a unitary recipe for conducting science that cuts across all research domains (McComas, 1996). Instead, what we term “science” is almost certainly an exceedingly diverse, but systematic and finely honed, set of tools that humans have developed over the centuries to compensate for our species’ biases (Lilienfeld, 2010). Perhaps foremost among these biases is confirmation bias, the propensity to selectively seek out, selectively interpret, and recall evidence that supports our hypotheses, and to deny, dismiss, and distort evidence that does not (Nickerson, 1998). As social psychologists Carol Tavris and Elliott Aronson (2007) have observed, science is a method of arrogance control; it helps to keep us honest. 
 
(4) Scientific thinking does not come naturally to the human species. As many authors have noted, scientific thinking is unnatural (McCauley, 2011). It needs to be acquired and practiced assiduously.
 
<snip>
 
(5) Scientific thinking is exasperatingly domain-specific. Findings in educational psychology suggest that scientific thinking skills generalize slowly, if at all, across different domains. This point probably helps to explain why it is so difficult to teach scientific thinking as a broad skill that can be applied to most or all fields (Willingham, 2007). This sobering truth probably also helps to explain why even many Nobel Prize winners and otherwise brilliant thinkers can easily fall prey to the seductive sway of pseudoscience.
 
<snip>
 
(6) Pseudoscience and science lie on a spectrum. As I noted earlier, there is almost surely no bright line distinguishing pseudoscience from science. Like many pairs of interrelated concepts, such as hill versus mountain and pond versus lake, pseudoscience and science bleed into each other imperceptibly.
 
<snip>
 
Still, as I have pointed out, the fact that there is no categorical distinction between pseudoscience and science does not mean that we cannot differentiate clear-cut exemplars of each concept.
 
(7) Pseudoscience is characterized by a set of fallible, but useful, warning signs.
 
<snip>
 
Such warning signs differ somewhat across authors, but often comprise an absence of self-correction, overuse of ad hoc maneuvers to immunize claims from refutation, use of scientific-sounding but vacuous language, extraordinary claims in the absence of compelling evidence, overreliance on anecdotal and testimonial assertions, avoidance of peer review, and the like (Lilienfeld, Lynn, and Lohr, 2014).  Despite their superficial differences, these warning signs all reflect a failure to compensate for confirmation bias, an overarching characteristic that sets them apart from mature sciences.
 
(8) Pseudoscientific claims differ from erroneous claims.  Intuitively, we all understand that there is a fundamental difference between fake new and false news. The latter is merely incorrect, and typically results from the media getting things wrong.  In contrast, the former is deceptive, often intentionally so. Similarly, many and arguably most assertions in science are surely erroneous, but that does not render them pseudoscientific.
 
<snip>
 
(9) Scientific and pseudoscientific thinking are cut from the same basic psychological cloth. In many respects, this is one of the most profound insights imparted by contemporary psychology.  Heuristics—mental shortcuts or rules of thumb—are immensely valuable in everyday life; without them, we would be psychologically paralyzed.  Furthermore, in most cases, heuristics lead us to approximately correct answers. 
 
<snip>
 
Still, when misapplied, heuristics can lead to mistaken conclusions.  For example, many unsubstantiated complementary and alternative medical remedies draw on the representativeness heuristic as a rationale for their effectiveness (Nisbett, 2015).  Many companies market raw brain concentrate in pill form to enhance memory and mood (Gilovich, 1991).  The reasoning, apparently, is that because psychological difficulties stem from an inadequately functioning brain, “more brain matter” will somehow help the brain to work better.
 
(10) Skepticism differs from cynicism. Skepticism has gotten a bad rap in many quarters, largely because it is commonly confused with cynicism. The term “skeptic” derives from the Greek word “skeptikos,” meaning “to consider carefully” (Shermer, 2002). Skepticism requires us to keep an open mind to new claims but to insist on compelling evidence before granting them provisional acceptance. In this respect, skepticism differs from cynicism, which implies a knee-jerk dismissal of implausible claims before we have had the opportunity to investigate them carefully (Beyerstein, 1995). In fairness, some individuals in the “skeptical movement” have at times blurred this crucial distinction by rejecting assertions out of hand. Skeptics need to be on guard against their propensities toward disconfirmation bias, a variant of confirmation bias in which we reflexively reject assertions that challenge our preconceptions (Edwards and Smith, 1996).
 
[end excerpts]
 
Here’s the publisher’s page for the book:
 
Here’s the Amazon page for the book:
Here’s the Barnes & Noble page for the book:
Ken Pope
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
 
POPE: FIVE STEPS TO STRENGTHEN ETHICS IN ORGANIZATIONS AND INDIVIDUALS: 
EFFECTIVE STRATEGIES INFORMED BY RESEARCH AND HISTORY—Routledge (imprint of Taylor & Francis)
Hardbound—Kindle—Nook—eBook—Google Book
 
POPE: “AWARD ADDRESS: THE CODE NOT TAKEN: THE PATH FROM GUILD ETHICS TO TORTURE AND OUR CONTINUING CHOICES”—
Canadian Psychology/psychologie Canadienne article free online at:
 
“Science is more than a body of knowledge; it is a way of thinking.  I have a foreboding of an America in my children’s or grandchildren’s time–when the United States is a service and information economy; when nearly all the key manufacturing industries have slipped away to other countries; when awesome technological powers are in the hands of a very few, and no one representing the public interest can even grasp the issues; when the people have lost the ability to set their own agendas or knowledgeably question those in authority; when, clutching our crystals and nervously consulting our horoscopes, our critical faculties in decline, unable to distinguish between what feels good and what’s true, we slide, almost without noticing, back into superstition and darkness.”
—Carl Sagan, The Demon-Haunted World: Science as a Candle in the Dark (Random House, 1996, p. 25)

M. Jackson Group Update – May 2018 – Post-Truth

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  His post is as follows:
 
I just finished a fascinating new book in the MIT Press Essential Knowledge series: Post-Truth by Lee McIntyre.
 
It provides a carefully documented account of the how more and more people are moving away from respecting and learning from science and evidence, and are moving toward trusting feelings, dogma, and in-groups.  It explores the move toward a world of “alternative facts” and the implications of that move for different aspects of our individual, social, cultural, and political lives.
Here’s an excerpt: 
 
[begin excerpt]
 
In his work on the psychology of emotion and moral judgment, David DeSteno, a psychologist at Northeastern University, has studied the effect of such “team affiliation” on moral reasoning. In one experiment, subjects who had just met were randomly divided into teams by giving them colored wristbands. Then they were separated. The first group was told that they would be given the option of performing either a fun ten-minute task or a difficult forty-five-minute one. Each subject was then placed alone in a room and told that he or she should choose which to do—or decide by a coin flip—but that in either case the person who entered the room afterward would be left with the remaining task. What subjects didn’t know is that they were being videotaped. Upon exiting the room 90 percent said that they had been fair, even though most had chosen the easier task for themselves and never bothered to flip the coin. But what is absolutely fascinating is what happened next. When the other half of the subjects were asked to watch a videotape of the liars and cheaters, they condemned them—unless they were wearing the same color wristband.7 If we are willing to excuse immoral behavior based on something as trivial as a wristband, imagine how our reasoning might be affected if we were really emotionally committed. 
 
Motivated reasoning has also been studied by neuroscientists, who have found that when our reasoning is colored by affective content a different part of our brain is engaged. When thirty committed political partisans were given a reasoning task that threatened their own candidate—or hurt the opposing candidate—a different part of their brain lit up (as measured by a functional-MRI scan) than when they were asked to reason about neutral content. It is perhaps unsurprising that our cognitive biases would be instantiated at the neural level, but this study provided the first experimental evidence of such differential function for motivated reasoning.8 With this as background we are now ready to consider two of the most fascinating cognitive biases that have been used to explain how our post-truth political beliefs can affect our willingness to accept facts and evidence.
 
[end excerpt]
 
Another excerpt: “The ‘backfire effect’ is based on experimental work by Brendan Nyhan and Jason Reifler, in which they found that when partisans were presented with evidence that one of their politically expedient beliefs was wrong, they would reject the evidence and ‘double down’ on their mistaken belief.  Worse, in some cases the presentation of refutatory evidence caused some subjects to increase the strength of their mistaken beliefs.”
 
Another excerpt:
 
[begi excerpt]
 
Post-truth was foreshadowed by what has happened to science over the last several decades. Once respected for the authority of its method, scientific results are now openly questioned by legions of nonexperts who happen to disagree with them. It is important to point out that scientific results are routinely scrutinized by scientists themselves, but that is not what we are talking about here. When a scientist puts forth a theory, it is expected that it will be put through the paces of peer review, attempts at replication, and the highest order of empirical fact checking that can be performed by one’s scientific peers. The rules for this are fairly transparent, since they are in service of the scientific value that empirical evidence is paramount in evaluating the worth of a scientific theory. But mistakes can occur even with the most scrupulous safeguards in place. The process can be quite brutal, but it is necessary to make sure that, insofar as is possible, only good work gets through. Thus, failures to disclose any potential sources of bias—conflicts of interest, the source of one’s funding—are taken especially seriously. 
 
Given this high level of scientific self-scrutiny, why would nonscientists feel it necessary to question the results of science? Do they really think that scientists are lax? In most cases, no; yet this is exactly the sort of claim that is routinely spread by those who find their ideological beliefs in conflict with the conclusions of science.1 In some instances laypersons feel it is in their interest to question both the motives and the competence of scientists. And this is where “science denialism” is born.
 
[end excerpt]
 
Here’s a shortened version of the About the Author section: “Lee McIntyre is a Research Fellow at the Center for Philosophy and History of Science at Boston University and an Instructor in Ethics at Harvard Extension School. He is the author of Dark Ages: The Case for a Science of Human Behavior (MIT Press).”
 
The Amazon webpage for the paperback & Kindle versions is at:
The Basrnes & Noble page for the book is at:
Ken Pope
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
 
POPE: FIVE STEPS TO STRENGTHEN ETHICS IN ORGANIZATIONS AND INDIVIDUALS: 
EFFECTIVE STRATEGIES INFORMED BY RESEARCH AND HISTORY—Routledge (imprint of Taylor & Francis)
Hardbound—Kindle—Nook—eBook—Google Book
 
POPE: “AWARD ADDRESS: THE CODE NOT TAKEN: THE PATH FROM GUILD ETHICS TO TORTURE AND OUR CONTINUING CHOICES”—
Canadian Psychology/psychologie Canadienne article free online at:
 
In times of universal deceit, telling the truth will be a revolutionary act. 
—George Orwell

M. Jackson Group Update – April 2018 – Counter-Intuitive Findings

10 of The Most Counter-Intuitive Psychology Findings Ever Published

By Christian Jarrett

One of the most annoying things you can say to a psychologist is: “Isn’t it all just common sense?”. No it’s not, as the list below demonstrates. But anyway, such a criticism of the field misses the point. Many findings in psychology can seem obvious after the fact, but we can’t know in advance which aspects of folk wisdom will stand up to scientific scrutiny. Striving for the objective truth through empirical testing – that’s what science is for, whether applied to molecules or minds.

That said, it’s always fun to share those findings that clash with received wisdom. So for your reading pleasure (and for the next time someone asks you the “common sense” question), here are 10 particularly counter-intuitive findings from the psychology archives. Please use comments to share your own favourites that we’ve missed.

1. Self-help Mantras Can Do More Harm Than Good
If you’ve got low self-esteem, you might want to avoid uttering positive mantras such as “I’m a lovable person”. A 2009 study found that people lacking in self-belief who spoke this phrase to themselves didn’t feel any better afterwards. In fact they felt worse, possibly because the repeated utterance led them to generate contradictory thoughts automatically. On a related note, there’s evidence that positive fantasies can also backfire. It’s thought that visualising your aims can cultivate a relaxed mindset that leads you to overlook the hurdles between you and your goals.

2. People Do Not Learn Better When Taught Via Their Preferred “Learning Style”
An incredibly popular idea, including among teachers, is that pupils learn better when they are taught information via their preferred modality, such as auditory, visual or by doing. In fact research has shown that people do not perform better when they are taught information via the modality that they say they prefer. A 2008 review of the learning styles concept put it like this: “there is no adequate evidence base to justify incorporating learning-styles assessments into general educational practice.” Want more? – here’s all you need to know about the learning styles myth in 2 minutes.

3. Criminals Show Cooperation and Prosocial Behaviour in Economic Games
It’s easy to demonise people who have broken the law. However, recent studies using economic games that test fairness and cooperation show that this is short-sighted. Last year, researchers observed prisoners’ performance on a famous game known as the “prisoner’s dilemma” – the convicted criminals actually displayed more cooperation during the game than undergrad students. Similarly, another study published this year found that people with a criminal record displayed just as much “prosocial motivation” (i.e. they distributed money fairly) in the “dictator game” as those without such a record.

4. Bottling Up Your Anger May Actually Be Good For You
Folk wisdom states that it’s better to relieve your anger by letting it out. In fact a tendency to lose one’s temper tends to go hand in hand with poorer health. Another study found that hitting a punch-bag while thinking about the person who made you angry actually just makes you angrier. It’s a complicated area, and expressing anger constructively may sometimes be a good thing to do, but the old rule that’s it always better to let it all it out is definitely flawed.

5. We Make Many Decisions Mindlessly
Unless we’re exhausted or intoxicated, we usually feel as though we are very much in control of our own choices and that we make them consciously and deliberately. This intuitive view is challenged by research on what’s known as “choice blindness”. In one study from 2005, participants picked out the face they found more attractive from successive pairs of photos. When researchers used sleight of hand to switch the chosen photo for the rejected photo, participants proceeded to justify their choice all the same, apparently ignorant of the switch. It was a similar story in 2010 when participants chose between different jams.

6. Opposites Don’t Attract
When it comes to human relationships, the aphorism that “opposites attract” turns out to be wide of the mark. There are of course exceptions, but mountains of evidence highlights how we are drawn to friends and romantic partners who are similar to ourselves, whether in terms of physical appearance, their personality, interests, or beliefs – known as “homophily”. To take just two examples, a study from 2010 found that people found faces more attractive when (unbeknown to them) they’d been morphed with their own; and a paper from 2011 found that people tend to choose to sit near others who look like themselves.

7. Wine Experts Don’t Know if They’re Smelling Red or White Wine
There is a vast literature on the limitations of expertise (for instance, political pundits are mostly useless at predicting electoral outcomes), but one of my favourite examples concerns people who study wine. A 2001 investigation showed that all it took to trick trainee oenologists into thinking a white wine smelt of red wine, was to dye it red. This research also challenges the intuitive belief that our senses are largely separate – in fact, perceptual experience derives from a blending of the senses, as shown for example via the McGurk Effect.

8. It Helps to Have Narcissists on Your Team
We usually think of narcissists – people with inflated views of their own skills and self-importance – as individuals to avoid. However, a study published in 2010 found that their presence can have a beneficial effect in the context of creative team work. When groups of four people were challenged to come up with new ways for a company to improve, it was the groups with two narcissists in their ranks who performed the best. The researchers think the presence of some narcissists helps generate healthy in-group competition.

9. Placebo Treatments Can Work Even When People Are Told It’s A Placebo
The amazing power of the placebo effect – the way that our beliefs about the action of an inert medicine can trigger substantial physiological effects – is itself, counter-intuitive. More surprising perhaps, is that the effect can still occur even when people know the medicine is inert. This was shown in a 2010 study involving people with IBS. “Our study suggests that openly described inert interventions when delivered with a plausible rationale can produce placebo responses,” the researchers said.

10. Sometimes a Pregnant Woman’s Depression is Advantageous For Her Baby
There is lots of evidence showing the adverse effects of a stressful pregnancy. But dig deeper into this field and you find some surprising results. For instance, a 2012 study uncovered an association between depression in pregnancy and superior functioning in the child at ages three and six months. This was found in the specific context in which the mother’s depression continued into the postnatal period. The finding is consistent with the “predictive-adaptive response model”, which says that adversity in-utero can have adaptive advantages if adversity is also encountered after birth.

Please do share your own favourite counter-intuitive findings via comments!
_________________________________

–Further reading–
The 10 most controversial psychology studies ever published.

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest

M. Jackson Group Update – March 2018 – Retirement and Memory

This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.  In posting this article to Facebook, I had an interesting discussion regarding the subgroup of retirees who actually engage in as many or more activities after “retirement” than in their former employment. In my opinion, it’s quite possible that they are protected from the cognitive changes discussed below. Overall, it turns out that we have to keep the cognitive, social, and physical motors running…  The article summary is as follows:
The European Journal of Epidemiology has scheduled a study for publication in a future issue: “Effect of retirement on cognitive function: the Whitehall II cohort study.”
 
The authors are Dorina Cadar, Maria Fleischmann, Stephen Stansfeld, Ewan Carr, Mika Kivimäki, Anne McMunn, & Jenny Head.
 
Here’s the abstract: “According to the ‘use it or lose it’ hypothesis, a lack of mentally challenging activities might exacerbate the loss of cognitive function. On this basis, retirement has been suggested to increase the risk of cognitive decline, but evidence from studies with long follow-up is lacking. We tested this hypothesis in a cohort of 3,433 civil servants who participated in the Whitehall II Study, including repeated measurements of cognitive functioning up to 14 years before and 14 years after retirement. Piecewise models, centred at the year of retirement, were used to compare trajectories of verbal memory, abstract reasoning, phonemic verbal fluency, and semantic verbal fluency before and after retirement. We found that all domains of cognition declined over time. Declines in verbal memory were 38% faster after retirement compared to before, after taking account of age-related decline. In analyses stratified by employment grade, higher employment grade was protective against verbal memory decline while people were still working, but this ‘protective effect’ was lost when individuals retired, resulting in a similar rate of decline post-retirement across employment grades. We did not find a significant impact of retirement on the other cognitive domains. In conclusion, these findings are consistent with the hypothesis that retirement accelerates the decline in verbal memory function. This study points to the benefits of cognitively stimulating activities associated with employment that could benefit older people’s memory.”
 
The article is online at:
 
Ken Pope
 
POPE: “AWARD ADDRESS: THE CODE NOT TAKEN: THE PATH FROM GUILD ETHICS TO TORTURE AND OUR CONTINUING CHOICES”—
Canadian Psychology/psychologie Canadienne article free online at:
 
POPE: FIVE STEPS TO STRENGTHEN ETHICS IN ORGANIZATIONS AND INDIVIDUALS: 
EFFECTIVE STRATEGIES INFORMED BY RESEARCH AND HISTORY—Routledge (imprint of Taylor & Francis)
Hardbound—Kindle—Nook—eBook—Google Book
 
POPE & VASQUEZ:  ETHICS IN PSYCHOTHERAPY AND COUNSELING: A PRACTICAL GUIDE (5th EDITION)—John Wiley & Sons
Print—Kindle—Nook—eBook—Apple iBook—Google Book
 
“He not busy being born
Is busy dying.”
—Bob Dylan

M. Jackson Group Update – February 2018 –Gender Dysphoria

This month’s post is from the British Psychological Society Research Digest from January 17, 2018 (https://digest.bps.org.uk/2018/01/17/most-children-and-teens-with-gender-dysphoria-also-have-multiple-other-psychological-issues/).

Most children and teens with gender dysphoria also have multiple other psychological issues

GettyImages-811322022.jpgBy Alex Fradera

New research on gender identity disorder (also known as gender dysphoria, in which a person does not identify with their biological sex) questions how best to handle the condition when it arises in children and adolescents. Should biological treatments be used as early as possible to help a young client transition, or is caution required, in case of complicating psychological issues?

Melanie Bechard of the University of Toronto and her colleagues examined the prevalence of “psychosocial and psychological vulnerabilities” in 50 child and teen cases of gender dysphoria, and writing in a recent issue of the Journal of Sex and Marital Therapy, they argue their findings show that physicians should be considering these factors more seriously when deciding on a treatment plan. Salting the situation, one of the paper’s co-authors is Kenneth Zucker, an expert on gender dysphoria who was last year considered too controversial for Canadian state television.

As recently as 2013, Zucker headed the American Psychiatric Association’s group deciding the diagnostic criteria for gender dysphoria, but he fell from grace in 2015 when he was fired from his clinic at the Toronto Centre for Addiction and Mental Health for failing to follow the now prominent “gender-affirmative” approach that places a clinical emphasis on smoothing the process of gender transition for children and adolescents who say they no longer identify with their biological sex.

Zucker’s approach, in contrast, was more hesitant and he questioned the ease with which young people can draw conclusions about their gender identity during a universally tumultuous stage of life. He also placed more emphasis on the costs that transition may bear upon an individual. To say that he considered transition a last resort would be as much of a caricature as saying the gender affirmative approach considers it a first resort, but they clearly represent different points on this spectrum.

To Zucker’s critics he was a transphobe, his approach analogous to gay conversion therapy (the now widely condemned use of psychological therapy to attempt to alter a client’s sexual orientation) – for example, he reportedly advised some parents to discourage their younger children from behaving in ways that contradicted their assigned gender.

Last year, hostility toward Zucker’s views was substantive enough to lead the Canadian broadcaster CBC to pull a BBC documentary that reported his perspective. For his part,  Zucker continues to maintain that his priority has always been the wellbeing of his clinical charges. The recent articlethat he co-authored with Bechard and others puts into the scientific record one of the concerns of his clinic, that gender dysphoric youth are a psychologically vulnerable population.

The paper examines the case files of 17 people assigned a male gender and 33 people assigned a female gender, at birth, based on their biological sex. Following their experience of gender dysphoria, the clients had been referred to a specialist gender identity service for young people, at which time they were aged 13 to 20. Sixty-four per cent of the clients were homosexual with respect to the gender they were assigned at birth.

The researchers looked for evidence of 15 factors that can signify or contribute to psychological issues, from self-harm to a previous outpatient therapy visit, and found that over half their sample had six or more of these factors. The majority had two or more prior diagnoses of a psychological disorder, the most common being a mood disorder such as depression. More than half had reported thinking about suicide, a third had dropped out of high school, a quarter had self harmed. A history of sexual abuse was rarer, observed in ”only” 10 per cent of cases.

All these measures are likely to be underestimates because they depended on the clients’ own descriptions during their initial interview at the gender identity clinic. Without a control group, it’s hard to say whether these rates of psychological distress are higher than for other client groups. Certainly though, the findings are consistent with the sense that these individuals were already in a state of psychological vulnerability when they were referred for gender dysphoria.

Bechard’s team present in-depth examples of two clients, both assigned as female at birth, that bring these psychological complexities to life, demonstrating the kinds of situations these cases often involve.

The first individual was very intelligent but struggling socially, especially around girls. They were fixated on emphasising their femininity in selfies, leading the parents to suspect body dysmorphic disorder (a troubling belief that there is something wrong with one’s body). This individual’s boyfriend then came out as gay. Sometime following this, the client disclosed that they identified as a boy. This change in identity happened “overnight” with no developmental history of cross-gender identification.

The second client’s history is more convoluted: at around age 14-15 this individual had disclosed that they were transgender (now identifying as male), and had felt this way for a while. This individual also had a history of anxiety, social problems interacting with girls, and extreme anxiety about sexuality. From the point of disclosing their gender dysphoria, they also reported that they were gay (oriented towards men) but had no interest in romantic/sexual relations.

In both these cases, after an initial assessment the individual was given testosterone treatment by a physician against the wishes of the parents – in the first case, the physician actually refused to meet the parents, and in the second, the physician recorded that the issues raised by the parents regarding anxiety, sexual and social problems weren’t relevant for the course of action. Sadly, in the case of the second individual, a few months after the start of the hormone treatment, they made a suicide attempt that required hospitalisation; the reasons for this were not reported.

Are the indicators of psychological vulnerability identified in these case histories the consequence, cause or simply coincident to gender identity disorder? If they are all solely a fall-out from the gender dysphoria, then the decisive approach of the physicians described above has a certain sense to it. But if some of the psychological complications pre-dated the gender dysphoria, or were separate from it, then at the very least this would suggest that the consulted physicians should have considered a broader treatment plan, and considered the psychological complications when judging their clients’ “readiness” to commence biomedical treatments.

The possibility that disclosure of gender dysphoria may in some cases be driven by earlier psychological vulnerabilities and social problems seems likely to be greater than zero. This is a controversial idea among many online trans activists, but actually it isn’t among health practitioners, even those who espouse the gender affirmation philosophy, who recognise that some young gender identity referrals may be transiently mixed-up individuals.

The issue of pre-existing or concurrent psychological vulnerabilities also speaks to the fact that a substantial proportion, perhaps even the majority, of children who experience some form of gender identity challenge, later come to endorse the gender they were raised as (further commentary and discussion); the new findings may also be relevant to the experience of detransitioning individuals, who reach similar conclusions, but often after a much greater investment in the process of transition – a phenomenon that is struggling to get scientific attention.

However, when a child with gender dysphoria is “insistent, persistent, and consistent” over an extended period, then (under the gender affirmative approach) this is typically treated as a good indicator that it is appropriate to begin facilitating the transition process. The trouble is, psychological vulnerabilities can also be persistent, and if a young person feels like they’ve found the solution, it’s understandable that they might not want to let go.

Life can sometimes feel as complicated as the Gordian knot, the legendary challenge that was seemingly impossible to disentangle. It’s understandable to weigh up a radical solution, like Alexander the Great cleaving the knot with a single sword-stroke: to abandon your external environment for a new home, to step outside of the confines of an identity that may be the source of the myriad issues plaguing you.

This research from Bechard, Zucker and company provides preliminary evidence about the psychological vulnerabilities of children and teens with gender dysphoria, extending previous workthat’s shown high rates of self-harm and suicidal ideation in this group, but more research is required to give us the full clinical picture. As such, this new paper represents just the latest sally in a difficult, complicated conversation that’s far from over: a conversation about how we can most compassionately treat those who feel out of step with where they find themselves in the social world.

Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A “Proof of Principle” Study