Slate Star Codex

http://slatestarcodex.com/2015/07/23/the-general-factor-of-correctness/

http://slatestarcodex.com/?p=3709

People on Tumblr are discussing Eliezer Yudkowsky’s old essay The Correct Contrarian Cluster, and my interpretation was different enough that I thought it might be worth spelling out. So here it is: is there a General Factor of Correctness?

Remember, IQ is supposed to come from a General Factor Of Intelligence. If you make people take a lot of different tests of a lot of different types, people who do well on one type will do well on other types more often than chance. You can do this with other things too, like make a General Factor Of Social Development. If you’re really cool, you can even correlate the General Factor of Intelligence and the General Factor of Social Development together.

A General Factor Of Correctness would mean that if you asked people’s opinions on a bunch of controversial questions, like “Would increasing the minimum wage to $15 worsen unemployment?” or “Which interpretation of quantum mechanics is correct?” or “are artificial sweeteners safe?” and then somehow discovered the answers to these questions, people who did well on one such question would do well on other types more often than chance.

This is a surprisingly deep and controversial issue, but one with potentially big payoffs. Suppose you want to know whose economic theories are right, but you don’t want to take the time to learn economics. Consider some position that was once considered fringe and bizarre, but now known to be likely true – for example, pre-Clovis settlement of the New World. Find the economists who believed in pre-Clovis settlement of the New World back when doing so was unpopular. Those economists have demonstrated a proven track record of being able to winnow out correct ideas amidst a sea of uncertainty. Invest in whatever company they tell you to invest in and make a killing.

I’m sort of joking, but also sort of serious – shouldn’t something like this work? If there’s such a thing as reasoning ability, people who are good at sifting through a mess of competing claims about pre-Columbian anthropology and turning up the truth should be able to apply that same skill to sifting through a mess of competing claims about economic data. Right?

If this is true, we can gain new insight into all of our conundra just by seeing who believes what about New World migration. That sounds useful. The problem is, to identify it we have to separate it out from a lot of closely related concepts.

The first problem: if you just mark who’s right and wrong about each controversial issue, the General Factor Of Correctness will end up looking a lot like a General Factor of Agreeing With Expert Consensus. The current best-known heuristic is “always agree with expert consensus on everything”; people who follow this heuristic all the time are most likely to do well, but we learn nothing whatsoever from their success. If I can get brilliant-economist-points for saying things like “black holes exist” or “9-11 was not a government conspiracy”, then that just makes a mockery of the whole system. Indeed, our whole point in this exercise is to see if we can improve on the “agree with experts” heuristic.

We could get more interesting results by analyzing only people’s deviations from expert consensus. If you agree with the consensus about everything, you don’t get to play. If you disagree with the consensus about some things, then you get positive points when you’re right and negative points when you’re wrong. If someone ends consistently ends up with a positive score beyond what we would expect by chance, then they’re the equivalent of the economist who was surprisingly prescient about pre-Clovis migration – a person who’s demonstrating a special ability that allows them to outperform experts. This is why Eliezer very reasonably talks about a correct contrarian cluster instead of a correct cluster in general. We already know who the correct cluster is, and all of you saying “I have no idea what Clovis is, but whatever leading anthropologists think, I think that too” are in it. So what? So nothing.

The second problem: are you just going to rediscover some factor we already know about, like IQ or general-well-educatedness? I’m not sure. WHen I brought this up on Tumblr, people were quick to point out examples of very intelligent, very well-educated people believing stupid things – for example, Newton’s obsession with alchemy and Biblical prophecy, or Linus Pauling’s belief that you could solve health just be making everyone take crazy amounts of Vitamin C. These points are well-taken, but I can’t help wondering if there’s selection bias in bringing them up. Yes, some smart people believe stupid things, but maybe even more stupid people do? By analogy, many people who are brilliant at math are terrible at language, and we can all think of salient examples, but psychometrics has shown again and again that in general math and language skills are correlated.

If we look for more general data, we get inconsistent results. Neither IQ nor educational attainment seems to affect whether you believe in climate change very much, though you can get slightly different results depending on how you ask and what you adjust for. There seems to be a stronger effect of intelligence increasing comfort with nuclear power. Other polls show IQ may increase atheism, non-racism, and a complicated cluster of political views possibly corresponding to libertarianism but also showing up as “liberalism” or “conservativism” depending on how you define your constructs and which aspects of politics you focus on. I am very suspicious about any of this reflecting real improved decision-making capacity as opposed to just attempts to signal intelligence in various ways.

The third problem: can we differentiate positive from negative selection? There are lots of people who believe in Bigfoot and ESP and astrology. I suspect these people will be worse at other things, including predicting economic trends, predicting world events, and being on the right side of difficult scientific controversies, probably in a way independent of IQ or education. I’m not sure of this. But I suspect it. If I’m right, then the data will show a General Factor of Correctness, but it won’t necessarily be a very interesting one. To give a reductio ad absurdum, if you have some mental disorder that causes you to live in a completely delusional fantasy world, you will have incorrect opinions about everything at once, which looks highly correlated, but this doesn’t necessarily prove that there are correlations among the people who are more correct than average.

The fourth problem: is there a difference between correctness and probability calibration? Suppose that Alice says that there’s a 90% chance the Greek economy will implode, and Bob has the same information but says there’s only an 80% chance. Here it might be tempting to say that one of either Alice or Bob is miscalibrated – either Alice is overconfident or Bob is underconfident. But suppose Alice says that there’s a 90% chance the Greek economy will implode, and Bob has the same information but says there’s only a 10% chance that it will. Now we’re more likely to interpret this in terms of them just disagreeing. But I don’t know enough about probability theory to put my finger on whether there’s a true qualitative difference.

This is important because we know calibration is a real thing and some people are good at it and other people aren’t but can improve with practice. If all we’re showing is that people who are good with probabilities are good with probabilities, then whatever.

But there are tantalizing signs that there might be something more here. I was involved in an unpublished study which I can’t upload because I don’t have the other authors’ permission, but which showed conclusively that people with poor calibration are more likely to believe in the paranormal (p < 0.001), even when belief in the paranormal was not assessed as a calibration question. So I went through the Less Wrong Survey data, made up a very ad hoc measure of total calibration skill, and checked to see what it did and didn't predict. Calibration was correlated with IQ (0.14, p = 0.01). But it was also correlated with higher belief in global warming (0.13, p = 0.01), with higher belief in near-term global catastrophic risk (-0.08, p - 0.01), increased support for immigration (0.06, p = 0.048) and with decreased support for the human biodiversity movement (0.1, p = 0.002). These were all independent of the IQ correlation. Notably, although warming and GCR were asked in the form of probabilities, immigration and HBD weren't, suggesting that calibration can be (weakly) correlated with opinions on a non-calibration task. Maybe the most intriguing evidence for a full-fledged General Factor of Correctness comes from Philip Tetlock and IARPA's Good Judgment Project, which got a few thousand average people and asked them to predict the probability of important international events like “North Korea launches a new kind of missile.” They found that the same small group of people consistently outperformed everyone else in a way incompatible with chance. These people were not necessarily very well-educated and didn’t have much domain-specific knowledge in international relations – the one profiled on NPR was a pharmacist who said she “didn’t know a lot about international affairs [and] hadn’t taken much math in school” – but they were reportedly able to outperform professional CIA analysts armed with extra classified information by as much as 30%.

These people aren’t succeeding because they parrot the experts, they’re not succeeding because they have more IQ or education, and they’re not succeeding in some kind of trivial way like rejecting things that will never happen. Although the article doesn’t specify, I think they’re doing something more than just being well-calibrated. They seem to be succeeding through some mysterious quality totally separate from all of these things.

But only on questions about international affairs. What I’d love to see next is what happens when you ask these same people to predict sports games, industry trends, the mean global temperature in 2030, or what the next space probe will find. If they can beat the experts in those fields, then I start really wondering what their position on the tax rate is and who they’re going to vote for for President.

Why am I going so into depth about an LW post from five years ago? I think in a sense this is the center of the entire rationalist project. If ability to evaluate evidence and come to accurate conclusions across a broad range of fields relies on some skill other than brute-forcing it with domain knowledge and IQ, some skill that looks like “rationality” broadly defined, then cultivating that skill starts to look like a pretty good idea.

Enrico Fermi said he was fascinated by the question of extraterrestrial life because whether it existed or it didn’t, either way was astounding. Maybe a paradox, but the same paradox seems true of the General Factor of Correctness.

Outside the Laboratory is a post about why the negative proposition – no such General Factor – should be astounding:

“Outside the laboratory, scientists are no wiser than anyone else.” Sometimes this proverb is spoken by scientists, humbly, sadly, to remind themselves of their own fallibility. Sometimes this proverb is said for rather less praiseworthy reasons, to devalue unwanted expert advice. Is the proverb true? Probably not in an absolute sense. It seems much too pessimistic to say that scientists are literally no wiser than average, that there is literally zero correlation.

But the proverb does appear true to some degree, and I propose that we should be very disturbed by this fact. We should not sigh, and shake our heads sadly. Rather we should sit bolt upright in alarm. Why? Well, suppose that an apprentice shepherd is laboriously trained to count sheep, as they pass in and out of a fold. Thus the shepherd knows when all the sheep have left, and when all the sheep have returned. Then you give the shepherd a few apples, and say: “How many apples?” But the shepherd stares at you blankly, because they weren’t trained to count apples – just sheep. You would probably suspect that the shepherd didn’t understand counting very well.

If, outside of their specialist field, some particular scientist is just as susceptible as anyone else to wacky ideas, then they probably never did understand why the scientific rules work. Maybe they can parrot back a bit of Popperian falsificationism; but they don’t understand on a deep level, the algebraic level of probability theory, the causal level of cognition-as-machinery. They’ve been trained to behave a certain way in the laboratory, but they don’t like to be constrained by evidence; when they go home, they take off the lab coat and relax with some comfortable nonsense. And yes, that does make me wonder if I can trust that scientist’s opinions even in their own field – especially when it comes to any controversial issue, any open question, anything that isn’t already nailed down by massive evidence and social convention.

Maybe we can beat the proverb – be rational in our personal lives, not just our professional lives.

And Correct Contrarian Cluster is about why the positive proposition should be equally astounding. If it’s true, you can gain a small but nonzero amount of information about the best economic theories by seeing what their originators predicted about migration patterns in pre-Columbian America. And you can try grinding your Correctness stat to improve your ability to make decisions in every domain of knowledge simultaneously.

I find research into intelligence more interesting than research into other things because improvements in intelligence can be leveraged to produce improvements in everything else. Research into correctness is one of the rare other fields that shares this quality, and I’m glad there are people like Tetlock working on it.

Discussion questions (adapted from Tumblr):

1. Five Thirty Eight is down the night before an election, so you search for some other good sites that interpret the polls. You find two. Both seem to be by amateurs, but both are well-designed and professional-looking and talk intelligently about things like sampling bias and such. The first site says the Blue Party will win by 5%; the second site says the Green Party will win by 5%. You look up the authors of the two sites, and find that the guy who wrote the first is a Young Earth Creationist. Do you have any opinion on who is going to win the election?

2. On the bus one day, you sit next to a strange man who mumbles about how Bigfoot caused 9-11 and the Ark of the Covenant is buried underneath EPCOT Center. You dismiss him and never see him again. A year later, you see on TV that new evidence confirms Bigfoot caused 9-11. Should you head to Florida and start digging?

3. Schmoeism and Anti-Schmoeism are two complicated and mutually exclusive economic theories that you don’t understand at all, but you know the economics profession is split about 50-50 between them. In 2005, a survey finds that 66% of Schmoeist economists and 33% of anti-Schmoeist economists believe in pre-Clovis settlement of the New World (p = 0.01). In 2015, new archaeological finds convincingly establish that such settlement existed. How strongly (if at all) do you now favor one theory over the other?

4. As with 3, but instead of merely being the pre-Clovis settlement of America, the survey asked about ten controversial questions in archaeology, anthropology, and historical scholarship, and the Schmoeists did significantly better than the anti-Schmoeists on 9 of them.

http://slatestarcodex.com/2015/07/22/freedom-on-the-centralized-web/

http://slatestarcodex.com/?p=3705

I.

A lot of libertarians and anarcho-capitalists envision a future of small corporate states competing for migrants and capital by trying to have the best policies.

But the Internet is about as close to that vision as we’re likely to find outside the pages of a political philosophy textbook. And I am far from convinced.

Let’s back up. Internet communities – ranging from a personal blog like this one all the way up to Facebook and Reddit – share many features with real communities. They work out rules for punishing defectors – your trolls, your harassers – and appoint a hierarchy of trusted individuals to carry out those rules. They try to balance competing concerns like free expression and public decency. They host cliques, power grabs, flame wars, even religious strife. They try to raise revenue, they establish a class system of Power Users and Premium Users, they deal with resentment from people who aren’t getting their way. They develop a culture.

The job of a community leader, be they a blogger or the CEO of Facebook, is a lot like the job of the Mayor of New York City: create a pleasant community where talented people will want to live and work, where wrongdoing is met with swift punishment, and where you can collect revenue without annoying your constitutents too much. But it’s even more like a hypothetical corporate state CEO in a Patchwork or Archipelago – wield absolute power, tempered by the knowledge that your citizens can leave at any time – and if they don’t, skim a little off the top of their productive activity.

In theory, this is supposed to lead to amazing communities as corporate states optimize themselves to get more customer-citizens and new polities arise to take advantage of deficiencies in the old.

In practice, we tried this with the Internet for a couple of years, and then moved to the current system, where individual sites like blogs and little storefronts are in decline and conversation and commerce have moved to a couple of giant corporations: Facebook, Twitter, Reddit, Amazon, Paypal.

These companies aren’t exactly monopolies. To some degree, if you’re unsatisfied with Facebook you can move to Twitter. But they’re not exactly competitors either – there are a lot of things Facebook is good for that Twitter fails completely, and vice versa. It’s like Coca-Cola vs. milk: in theory you’ve always got the choice to drink either in place of the other; in practice you usually know which one you need at any given time. In that sense, there’s no real Facebook competitor except eg Orkut or Diaspora, which no one uses.

Which suggests one reason why these sites are so dominant: their main selling point is their size. Facebook is the best because all of your friends are on it; if I made a much better Facebook clone tomorrow no one would go unless everyone else was already there (Google found this out the hard way). Amazon is the best because you can buy pretty much everything you want there; Paypal is the best because most sites take PayPal. So not only do they have no competitors, but it’s really hard to imagine one ever arising. In order to compete with Facebook, you not only need a better product, you need a product that’s so much better that everybody decides to switch en masse at the same time. The only example I can think of where this ever worked was the Great Digg Exodus, where Digg screwed up their product so thoroughly that everyone simultaneously said “@#!$ this” and moved to Reddit.

So instead of “let a thousand nations bloom”, it ended up more like “let five or six big nations bloom that we can never get rid of”.

II.

It’s a truism that the First Amendment only protects citizens from the government, not from other citizens. Nothing stops a private college from expelling any student who criticizes the administration, and nothing stops a private business from firing any employee who doesn’t support the boss’ preferred candidate. We apparently place our trust in the multiplicity of the market to maintain some semblance of freedom; out of thousands of competing companies, not all will ban the same political positions; if too many did so, other companies would start offering freedom of speech as a benefit and poach the more repressive companies’ employees and customers.

It’s a little concerning that we accept this argument about freedom of speech when we don’t accept it for anything else. We don’t trust the free market to necessarily preserve racial equality – that’s what anti-discrimination laws are for. We don’t trust the free market to necessarily preserve worker safety – that’s what OSHA and related regulations are for. We don’t even trust the free market to necessarily preserve fire safety – that’s why federal inspectors have to come in every so often to make sure you’re not secretly plotting to let your employees fry. Whenever we think something is important, we regulate the hell out of it, rights-of-private-companies to-set-their-own-policies be damned. But free speech? If you don’t trust the free market to sort it out, the only possible explanation is that you just don’t understand the literal text of the First Amendment.

The argument for non-discrimination laws is that discrimination isn’t just random noise. If a couple of companies here and there decided to discriminate, then they might be easily overtaken by nimbler companies willing to take any employees and customers who came to them; and even if they didn’t, a couple of companies here and there discriminating wouldn’t be the end of the world. The argument for non-discrimination laws is that discrimination can take the form of global social pressure in favor of discrimination, enforced by punishing defectors, to the point where certain races can find themselves locked out of the economy altogether.

Concerns about freedom of speech come from much the same place. Back when homosexuality was really taboo, you’d have a very tough time finding any reference to it, let alone a positive reference to it, in any newspaper or TV channel in the country. All the big companies knew that talking about it (or letting their editorial staff talk about it) was the sort of thing that could get them in trouble, and they had no particular incentive to do so – so they didn’t. Yes, eventually they reversed that policy, but I’m not exactly going to be able to cite an example that didn’t later become okay and still have everyone believe it’s a good example of something it was wrong to have banned!

But even when homosexuality was banned from formal discussion on the news, there was still the opportunity to discuss it with your friends in private. I don’t know much about the history of the gay rights movement, but I understand it was a few small groups of like-minded people who managed to coordinate such discussions among themselves using non-mass-media that started some of the activism that eventually led to it become accepted more generally.

Nowadays that’s a little more complicated. If every company in the world decided that their profit margin required them to appear Tough On Homosexuality, it wouldn’t just mean no mass media editorials. Insofar as a lot of the public square has been annexed by Facebook and Twitter and Reddit, the discussion can be kept out of the public square in a way it couldn’t have been previously. Insofar as the economy relies on PayPal and Amazon as a currency system and marketplace respectively, companies can just decide that currency cannot be used to support gay rights, in much the same way that for a while currency could not be used to support WikiLeaks. The nuclear option is that Google decides not to show gay-related sites in its search results, so that you could make as many persuasive arguments for legalizing homosexuality as you want and no one would ever find them unless you knock on their door and hand them the URL directly.

(The thermonuclear option is that browsers just include some code to refuse to render any site relating to homosexuality, and now you’re done. But that is ridiculous – who would ever believe that browser companies would take it upon themselves to be the arbiter of people’s personal beliefs about homosexuality?)

This is not entirely theoretical. You want some really weird porn? You probably won’t find it on Amazon, according to the delightfully-named article Amazon’s War On Bigfoot Erotica. After they got bad press for hosting some kind of out-there stuff, they decided that anything which offended too many people’s sensibilities was a liability. This echoes a much more serious decision from a few years earlier: Paypal threatened to suspend the accounts of any companies selling sufficiently gross erotic books. Booksellers, many of whom made only a tiny percent of their profit from erotica, claimed that their hands were tied; if you can’t use PayPal, selling on the Internet suddenly becomes a much more dubious proposition. This story has a happy ending; Paypal eventually amended their policy to limit it to much more specific cases. But for a while, it was touch-and-go enough that a few people started wondering: “Hey, maybe we shouldn’t have entrusted our entire commercial infrastructure to a private company with no accountability.”

Advocates of net neutrality like to worry about a “two-tiered” Internet, where the companies that can make sweetheart deals with the ISPs are easy for everyone to access, and everybody else can only be accessed with a bit more money and a bit more trouble. Well, I worry about a two-tiered marketplace of ideas. Write decent erotica, socially approved erotica where everyone has heterosexual sex and then goes to church afterwards, and you can sell it on Amazon, collect profits using PayPal, talk to your friends about it on Facebook, and advertise on Reddit. Write weird erotica, the kind that other people might find offensive, and you might have to start your own website, take payment via some inconvenient method like Bitcoin, have trouble advertising it by word of mouth, and not be able to talk about it on literary discussion forums. It’s not that you’ve been banned from writing your erotica. You can write it. It’s just that practically nobody else will ever hear about it or buy it, except maybe the tiny fraction of people who are already extremely clued-in to the weird erotica scene and know exactly where to look for it.

This isn’t so much different from the old days when nobody would talk about homosexuality. Indeed, one could argue that the modern world is friendlier to people with unpopular ideas – there are more opportunities to self-publish, to bypass traditional bookstores, and to get covered in weird niche news outlets.

But at the same time, the amount of the information ecology controlled by private companies has increased drastically, and if private companies don’t like you, now you have entirely new problems.

III.

I used to think that there was enough demand for a free marketplace of ideas that if a company become too restrictive, another one would spring up to replace it. Then I suffered through the conflict between Reddit and Voat.

Reddit recently alienated (no pun intended) some of its users, who decided to move en masse to an alternative Reddit-like platform called Voat, whose owner promised not to restrict content unless it was illegal (in his home country of Switzerland, which permits a lot). I don’t want to get into the details too much (though I did explain my perspective on it on Tumblr), but suffice it to say that (one) (small) part of the problem was that people thought Reddit was failing its free speech principles by cracking down on various unsavory groups.

HL Mencken once said that “the trouble with fighting for human freedom is that one spends most of one’s time defending scoundrels. For it is against scoundrels that oppressive laws are first aimed, and oppression must be stopped at the beginning if it is to be stopped at all.”

There’s an unfortunate corollary to this, which is that if you try to create a libertarian paradise, you will attract three deeply virtuous people with a strong committment to the principle of universal freedom, plus millions of scoundrels. Declare that you’re going to stop holding witch hunts, and your coalition is certain to include more than its share of witches.

So while some small percent of Reddit’s average users moved over, a very large percent of its witches did. Sometimes the witchcraft was nothing worse than questioning Reddit’s political consensus. Other times, it was harassment, hate groups, and creepy porn.

(I don’t want to get into the eternal “you’re hosting child porn!” versus “photos of clothed fifteen year olds aren’t child porn, they’re perfectly fine!” debate, except to say that when the universe finally runs down, and we all succumb to entropy, the second-to-last post on the ultra-cyber-quantum-internet will be “posting holograms of neotenous transhumans is totally in conformity with the First Law Of Robotics as long as they are older than thirteen million years and created the hologram themselves”, and the last post will be “lol u r a perv”)

I feel obligated to say that, in spite of CONSTANT MEDIA SMEARS, Reddit’s community is amazing, puts in astounding effort to help its members and fight for good causes all over the world, and that the representation of weirdoes and neotenous-transhuman-hologram people is no higher than any other part of the population. But that’s not zero. And a disproportionate number of those people became interested in the new site.

Already, we see why the typical answer “If you don’t like your community, just leave and start a new one” is an oversimplification. A community run on Voat’s rules with Reddit userbase would probably be a pretty nice place. A community run on Voat’s rules with the subsection of Reddit’s userbase who will leave Reddit when you create it is…a very different community. Remember that whole post on Moloch? Even if everyone on Reddit agrees in preferring Voat to Reddit, it might be impossible to implement the move, because unless everybody can coordinate it’s always going to be the witches who move over first, and nobody wants to move to a community that’s mostly-witch.

But the problem isn’t just natural self-sorting. The problem is natural self-sorting, plus enemy action. Remember, the big corporations do what they do because it’s what everyone in society is demanding. To break from that mold is to pretty much set yourself up as everyone’s enemy and invite retaliation. The media and Reddit’s SJ community quickly denounced Voat as Public Enemy No 1; as a result, in its first week it got DDoS attacked, deleted by its hosting company with no explanation except “the content on your server includes politically incorrect parts”, and had its PayPal account frozen. As a result, the Great Reddit Exodus was placed on hold while they tried to get their site back up, and by the time they did Reddit had switched CEOs and the momentum was gone.

Advocates of free-market governance and “let a thousand nations bloom” like to talk as if overly restrictive laws in one polity will immediately result in the rise of other competing policies that throw off their shackles and outcompete the first. But even on the relatively lawless Internet, where startup costs are so low that a random student from Switzerland can decide on a whim to take on one of the largest websites in the world, it’s way more complicated than that.

IV.

Actually, the whole Reddit thing left a bad taste in my mouth.

It would be paranoid to say that there are people for whom fighting against free speech is a terminal value, but let me make a slightly weaker claim. There are people who consider themselves the protectors of decency, who notice that their opponents are usually using the value “free speech” to oppose their demands, and so “free speech” to these people becomes the equivalent of “small government” or “tolerance and equality” or “family values” – a value which most people agree is good, but which has gotten claimed by one side of a political argument so hard that for the other side it becomes an outgroup signal and sign of cringeworthy bad arguments which must be shot down. These people don’t quite have fighting free speech as a terminal value, but you might as well model them as if they do. These are the people who say “freeze peach” in the same way other people say “but mah jawbs!”

And these people have a winning strategy. I’ve seen it with Reddit and any other website that gets on their bad side. The strategy is weaponized stereotype campaigns. If a site tolerates witches, describe it as a witch site about witchcraft populated entirely by witches. It’s super easy. By happy coincidence, Slate even has an article calling people out on it this very week.

Think about it like this. No matter how many brilliant artists, scientists, and humanitarians Islam produces, in the mind of a good chunk of Westerners it will always be associated first and foremost with terrorism. Redditors, Diggians, Tumblrites, 4chanistas, Instagramastanis, Slashdotmen, Metafilterniks – all are groups that the average person knows a whole lot less about than they do Muslims. A concerted campaign to irrevocably identify an entire online community with a few atrocious actions by its worst members will succeed pretty much instantly. There are 36 million Redditors, so unless they advertise solely in the saint demographic, we expect the worst members to be pretty bad. Therefore, Reddit is at the mercy of anyone with the resources to start such a campaign. Reddit Inc’s main asset is its brand, so it has every incentive to cave – even a principled leadership would rather make a few administrative changes than sacrifice the whole to save some Holocaust deniers or whatever.

After that, the site’s userbase has two options – either suck it up, or go off somewhere else. Go off somewhere else, and they’ll get DDoSed, taken down by their host, and slowly starved of money like Voat, at the same time as the same media forces accuse the new site of being a hot spot for witchcraft – this time with good reason. The new site might not die out completely, but it will be sufficiently established in the hearts of everyone as a Bad Place that it will be stuck in the same equilibrium as central Detroit – only people with no other options will go there, because it is inhabited mostly by the sort of people with no other options.

The worst possible end-game for this is the two-tier marketplace of ideas mentioned above, with an unfortunate twist – everyone knows that the second tier is inhabited entirely by witches, and therefore being on the second tier is sufficient to convict you. Unpopular ideas are gradually forced out of the first tier by media smear campaigns, and from then on everyone believes the effort was justified, because it’s one of those second-tier ideas that you only find in the same sites as the racists and trolls and child pornographers. You’re not a second tier kind of person, are you? No, we didn’t think so.

I have no particular solution to this. Certainly the well-intentioned solutions other people are working on, like a decentralized crypto-Reddit that can’t be moderated even in principle, are unlikely to help (hint: what is the most striking difference between Bitcoin marketplaces and normal marketplaces?) My primary hope is that it’s just not a real problem. Certainly there has been very little in the way of speech restriction so far, and what little there has been has been against things which, on the object level, I’m happy to see gone. It’s entirely possible that we’ll escape with only a few things banned that probably deserve it. I certainly hope this is the case.

I’m just annoyed that we’ve gotten ourselves in a corner where we have to depend on hope.

http://slatestarcodex.com/2015/07/19/ot24-hopen-change/

http://slatestarcodex.com/?p=3703

This is the semimonthly open thread. Post about anything you want, ask random questions, whatever. Also:

1. Obvious change is obvious. There are still some bugs to be ironed out, and ironed they will be. Thanks to Michael Keenan and Trike (especially Catherine Truscott) for some help. All positive changes are theirs; all remaining flaws are due to my pickiness alone. My obsessiveness finally overcame my laziness and I standardized the ads too; if you’re an advertiser and you don’t like it, send me an email and we’ll talk.

2. I’ve also added a bunch of new links to the blogroll. The categorization system isn’t very serious (some of you may recognize it?) and I’m still thinking about how I want to do it on a longer-term basis.

3. I’m grateful for all the interesting comments I received about cognitive-behavioral therapy, which helped me understand it a lot better. The impression I’m getting is that its ‘insights’ seem obvious/patronizing to everybody, but the real agent of change is forcing you to do the worksheets and exercises on a regular basis until they’ve really sunk in. Comment of the week is Mirzhan Irkegulov describing his experiences with it.

4. After the successes of other people in the community like Alicorn and Miri and Gwern, and multiple strong recommendations, I am opening a Patreon account so you can give me money. I DO NOT NEED MONEY (though, like many people, I like it). I have a job and am fairly comfortable. This blog is provided free and there is in no sense an implied agreement that if you like it you are under pressure to donate. I also don’t want to funge against anyone giving to charity or anybody who needs money more than I do. But if you feel a burning, burning desire to give me money, and it’s not going to prevent it from going to anything more important, well, now you can. My Patreon account is here. I am a little proud of the subtitle.

http://slatestarcodex.com/2015/07/18/reverse-psychology/

http://slatestarcodex.com/?p=3702

[Content warning: suicide]

I.

It all started when I made that phone call.

I was really bad. All the tenure-track positions I’d applied to had politely declined, and I saw my future in academia gradually slipping away from me. Then the night before, my boyfriend had said he thought maybe we should start seeing other people. I didn’t even know if we were broken up or not, and at that point I couldn’t bring myself to care. I sat on my bed, thinking about things for a while, and finally I called the suicide hotline.

“Hello?” a woman’s voice answered on the other side. Somehow, just hearing someone else made me feel about five times better.

“Hello,” I said, a little more confidently. “I’ve been thinking of committing suicide. I need help.”

“Okay,” she said. “Is there a gun in your house?”

“No.”

“All right. The first thing you need to do is get one. Overdosing on pills is common, but it almost never works. You can get a firearm at almost any large sporting goods store, but if there aren’t any near you, we can start talking about maybe jumping from a high…”

“What the HELL?” I interrupted, suddenly way more angry than depressed. “You’re supposed to @#!$ing tell me not to do it!”

“This is the suicide hotline,” the woman said, now sounding confused. Then, “Are you sure you weren’t thinking of the suicide prevention hotline?”

“Give me a break! I took a psychology class in undergrad, I know what a suicide hotline is!”

“I’m sorry you seem to be upset. But this is the suicide hotline. It’s like how there’s the Walk For Breast Cancer, but also the Walk Against Breast Cancer.”

“There’s the what? But…I was in the Walk For Breast Cancer! I thought…”

“It sounds like you have some issues,” said the woman, politely.

“Ugh,” I said. “Yeah.”

“Do you feel like you need professional help?”

“Yeah.”

“I do have a free clinic with an opening available tomorrow at three PM, would you like me to slot you in for an appointment?”

So you’re probably wondering why in the world I would take an appointment arranged by the suicide hotline that wasn’t a suicide prevention hotline. The answer is – were you even listening? A free clinic? With an appointment available the next day? Normally I was lucky if I found a place with an opening in less than two months and a co-pay that wasn’t completely ruinious. You bet I was taking that appointment before someone else snatched it up.

Dr. Trauer’s office looked gratifyingly normal. There was a houseplant, a diagram of the cranial nerves, some Abilify® merchandise, and on the wall one of those Magic Eye stereographic images that resolved into a 3D picture of the human brain. Dr. Trauer himself looked like your average doctor – a little past middle age, a little overweight, a short greying beard. He motioned me to sit down and took the paperwork I’d been filling out.

“Hmmmm,” he said, reading it over. “29 years old, postdoc in biochem, recent relationship trouble…mmmm…you did the right thing.”

“In coming here?”

“No, in considering suicide. After getting rejected from a tenure-track position, your life is pretty much over.”

“WHAT?”

“I mean, here you are, hundreds of thousands of dollars in debt, with only one area of expertise, and now you’ve been rejected from it. I can totally see why you might think it’s worth ending it all.”

“But…there are lots of other things I can do! I can get a job in industry! I can work in something else! Even if I can’t find a job right away, I have parents who can help support me.”

“Industry!” Dr. Trauer was having none of it. “A bunch of bloodsuckers. Do you realize how bad work in the private sector is these days? They’ll abuse you and then spit you out, and once you’ve been out of university too long nobody else will want you.”

“Lots of people want biochemists! If I work for a company for a few years, I’ll have more experience and maybe that will make me more attractive to employers! What…what kind of a psychiatrist are you, anyway?”

“Cindy didn’t tell you?”

“Cindy?”

“The woman on the phone.”

“She didn’t really tell me anything!”

“Well,” said Dr. Trauer. “To answer your question, we’re dark side psychiatrists. This is the state’s only dark side psychiatry clinic.”

“Dark side psychiatry? Really?”

“We’re a…well, some people say sect, but I like to think of it as more of a guild…dedicated to improving negative mental health. Think of it this way. When you’re a hijacked murder-monkey hurtling toward your inevitable death, sanity is a completely ridiculous thing to have. And when the universe is fifteen billion light-years across and almost entirely freezing void, the idea that people should have ‘coping skills’ boggles the imagination. An emotionally healthy person is a person who isn’t paying attention, and our job is to cure them.”

“There’s more than one of you?”

“Oh, yes. There’s a thriving dark side psychiatric community. There are dark side psychopharmacologists – you’d be amazed what a few doses of datura can do to a person. There are dark side psychotherapists who analyze and break down people’s positive cognitions. There are dark side child psychiatrists who catch people when they’re young, before sanity has had a chance to take root and worsen. And there are dark side geriatric psychiatrists, who go from nursing home to nursing home, making sure that the elderly are not warehoused and neglected at exactly the time it is most important to ensure that stroke or dementia does not protect them from acute awareness of the nearness of death.”

“That’s awful!” I said.

“Is it? Look where sanity’s gotten you. You want to kill yourself, but you don’t have the courage. Work with me for ten sessions, and I promise you we can help you get that courage.”

“You’re a @#!$ing quack,” I said. “And if you think killing yourself is so great, how come you haven’t done it yourself yet?”

“Who says I haven’t?” asked Dr. Trauer.

His hand went to his face, and he plucked out his right eye, revealing an empty void surrounded by the bleached whiteness of bone. I screamed and ran out of the clinic and didn’t stop running until I was in my house and had locked the door beside me.

II.

“…and that’s pretty much the whole story, doctor,” she told me. “And then I looked to see if there were any real psychiatrists in the area and someone referred me to you.”

“Well,” I said, my face unreadable. “I can certainly see why you’re complaining of, how did you put it, ‘depression and acute stress disorder’.”

“Not so acute anymore. It took me two months to get an appointment at your clinic.”

“Oh,” I said. Then, “Sorry, we’re sort of backed up.” Then, “Okay. We’ve got a lot we have to work on here. Let me tell you how we’re going to do it. We’re going to use a form of therapy that challenges your negative cognitions. We’re going to take the things that are bothering you, examine the evidence for them, and see if there are alternative explanations.”

“What do you mean?” she asked.

“Well,” I said. “It seems to be this Dr. Trauer incident that’s traumatized you a lot. I can see why you would be stressed out. The way you tell it, it sounds absolutely terrifying.”

“You don’t believe me,” she said, not accusatory, just stating a fact.

“I think it would be helpful to examine alternate explanations,” I said. “I’m willing to assume it happened exactly as you tell it. I can see why you would think Dr. Trauer wanted you to commit suicide. But are there any alternative explanations for the same event?”

“I don’t see how there can be,” she said. “He outright said that he thought I should kill myself.”

“Right. But from what you know of psychiatrists and therapy – and you did say you took some classes in undergrad – are there any other reasons he might have said something like that?”

She thought for a second. “Wait,” she told me. “There’s a technique in therapy called paradoxical intention. Where you take a patient’s irrational thought, and then defend and amplify it. And then when the patient hears it from someone else, she realizes how silly it sounds and starts arguing against it, and then it’s really hard to keep believing it after you’ve shot it down yourself.”

I nodded. “That’s definitely a therapeutic method, and sometimes a very effective one. Do you have any evidence that this is what Dr. Trauer was doing?”

“Yes! As soon as he said I should commit suicide, I started arguing against him. He told me that if I couldn’t get a tenure track position there would be no other jobs available, and I told him there would be! Then he told me that the jobs would be terrible and I’d never be able to make a happy life for myself with them, and I argued that I would! That must have been what he was going for!”

She suddenly looked really excited. Then, just as suddenly, the worry returned to her face.

“But then what happened with his eye? I swear I saw him take it right out of the socket.”

I nodded. “Can you think of any alternate explanations for that?”

Thinking about it that way, it only took her like five seconds. She slapped her head like she’d been an idiot. “A glass eye. He probably had some kind of injury, had to put in a glass eye, and could take it out any time he wanted. He must have thought it would be a funny gag and didn’t realize how traumatized I’d be. Or he wanted to scare me into realizing how much I wanted to live. Or something.”

I nodded. “That does sound like a reasonable explanation.”

“But…don’t people with glass eyes usually have like scar tissue and normal skin behind them? This guy, I swear it was just the bone and this empty socket, like you were seeing straight to his skull.”

“You’re asking the right questions,” I said. “Now think a little more.”

“Hmmmm,” she said. “I guess I was really, really stressed out at the time. And I only saw it for, like, a fraction of a second. Maybe my brain was playing tricks on me.”

“That can definitely happen,” I agreed.

She looked a lot better now. “I owe you a lot of thanks,” she said. “I’ve only been here for, like, fifteen minutes, and already I think a lot of my stress has gone away. All of this really makes sense. That paradoxical intention thing is actually kind of brilliant. And I can’t deny that it worked – I haven’t been suicidal since I talked to the guy. In fact…okay, this is going to sound really strange, but…maybe I should go back to Dr. Trauer.”

I wrinkled my forehead.

“It’s not that I don’t like you,” she said. “But he had this amazing free clinic, and what he did for me that day…now that I realize what was going on, that was actually pretty incredible.”

“Hold on a second,” I said.

I left the room, marched up to the front desk, took the directory of medical providers in the area off the shelf, marched back to the room. I started flipping through the pages. It was in alphabetical order…Tang…Thompson…Tophet…there we go. Trauer. My gaze lingered there maybe just a second too long, and she asked if I was okay.

“Um, yeah,” I said. “It’s just that he doesn’t – he doesn’t take your insurance. That’s the problem.”

“It’s okay,” she told me. “He said it was a free clinic. So that shouldn’t a problem.”

“Well, uh…the thing is…when you see out-of-network providers, your insurance actually charges, charges an extra fee. Even if the visit itself is free.”

She looked skeptical. “I’ve never heard of that.”

“It’s new. With Obamacare.”

“Really? How high a fee is it?”

“It’s…um…ten thousand dollars. Yeah, I know, right? Thanks, Obama.”

“Wow,” she said. “I definitely can’t afford that. I guess I’ll keep coming here. Not that there’s anything wrong with that. You’ve been very nice. It’s just that…with Dr. Trauer…well…sorry, I’ll stop talking now. Thanks a lot, doctor.” She stood up and shook my hand before heading for the door. “Seriously, I can’t believe how much you’ve helped me.”

No, I thought, as she departed you can’t. I told her she was asking the right questions, and she was, but not all of them.

For example, why would a man with only one working eye have a stereographic Magic Eye image in his office?

I picked up my provider directory again, stared a second time at the entry for Dr. Trauer. There was a neat line through it in red pen, and above, in my secretary’s careful handwriting, “DECEASED”.

Before returning the directory to the front desk, I took my own pen and added “DO NOT REFER” in big letters underneath.

http://slatestarcodex.com/2015/07/16/cbt-in-the-water-supply/

http://slatestarcodex.com/?p=3698

[Epistemic status: Very speculative, <50% confidence, thinking out loud. Don't let this turn you off therapy.]

Here’s a vignette from cognitive-behavioral therapy book When Panic Attacks, heavily edited for length:

A chronically anxious medical school professor named Nate suffered from low-self-esteem and feelings of inadequacy. One day, Nate brought me a copy of his CV. I was blown away. He’d listed over sixty pages of research publications, prestigious awards, and keynote addresses he’d given at major conferences around the world. I asked Nate how he reconciled his low self-esteem with all of his accomplishments. He said that every time he looked at his CV, he felt discouraged and told himself that his colleagues’ research studies were far more rigorous and important than his own. He said his paper seemed “soft” and consisted primarily of theoretical work, rather than hard-core laboratory research with real tissue. He said “Dr. Burns, no matter how much I accomplish, it never seems good enough.”

Perfectionism was clearly one of Nate’s self-defeating beliefs. I suggested that Nate use the Pleasure/Perfection Balance Worksheet to test this belief. I told him to write “If I can’t do something perfectly, it’s not worth doing at all” on the top of the sheet, and asked him to list several activities in the left-hand column. I told him to predict how satisfying and rewarding each activity would be, to record how satisfying and rewarding it was afterwards, and to rate how perfectly he did each activity. That way he could find out of it was true that he only enjoyed the things he did perfectly.

The next week, Nate had some interesting results to share with me. One of his activities was giving the welcoming lecture ot the incoming class of medical students. Nate gave this lecture every year because he was considered to be the most charismatic speaker at the medical school. Nate predicted this lecture would be 70% satisfying, but his actual satisfaction as only 20%. This was surprising, since he’d received a thirty-second standing obation, and he’d rated his perfection level for the talk at 90%.

I asked Nate why his satisfaction rating was so low. He explained that he always got standing ovations, so he routinely timed them. The previous year, the medical students had stood and cheered for more than a minute at the end of his talk. This year, the only stood and cheered for half a minute. Nate felt disappointed and started worrying that he was over the hill.

The second entry on Nate’s Pleasure/Perfection Balance Worksheet was that [he fixed a broken pipe in his bathroom]. He had to make several trips to the hardware story to buy tools and parts and to get tips on how to do it, so he didn’t get the pipe fixed until 10 PM. How explained that any plumber could have fixed the pipe in five minutes, so he rated his perfection as 5%. But his satisfaction level for this activity was 100%. In fact, he felt exhilarated. Nate said it was the most satisfying thing he’d done in years.

The result of Nate’s experiment was not consistent with his belief that things weren’t worth doing unless he did them perfectly. It dawned on him that there were many sources of satisfaction in his life that he’d overlooked, such as taking a walk through the woods with his wife, even though neither of them were world-class hikers, playing squash with his son, even though neither of them were champions, or just going out with his family for ice cream cones on a warm summer evening.

This experiment had a significant impact on Nate’s feelings of self-esteem and on his career. He told me that his feelings of anxiety and inferiority decreased, and his productivity actually increased because he was no longer so worried about having to do everything so perfectly.

At first I assumed this story was made up, but the book claims these are based on real patients, and even mentions how the writer showed videos of some of these therapy sessions to his classes. Interesting. How about another?

Several years ago, I did a three-day intensive workshop for a small group of psychotherapists in Florida. A marriage and family therapist named Walter explained that he’d been struggling with anxiety and depression for several months because Paul, the man he’d lived with for eight years, had found a new lover and left him. He put his hand on his chest and said: “It feels real heavy, right here. There’s just a sense of loneliness and emptiness about the whole experience. It feels so universal and final. I feel like this pain is going to go on forever, until the end of time.”

I asked Walter how he was thinking and feeling about the breakup with Paul. What was he telling himself? He saidL “I feel incredibly guilty and ashamed, and it seems like it must have been my fault. Maybe I wasn’t skillful enough, attractive enough, or dynamic enough. Maybe I wasn’t there for him emotionally. I feel like I must have screwed up. Sometimes I feel like a total fraud. Here I am, a marriage and family therapist, and my own relationship didn’t even work out. I feel like a loser. A really, really big loser.”

Walter recorded these five negative thoughts on his daily mood log:

1. I’ll never be in a loving relationship again
2. I must be impossible to live with and impossible to be in a relationship with
3. There must be something wrong with me
4. I totally screwed up and flushed my life down the toilet
5. I’ll end up as an old, fat, gray-haired, lonely gay man

He believed all of these thoughts very strongly.

You can see that most of Walter’s suffering results from the illogical way he’s thinking about the rejection. You could even say that Walter is treating himself far more harshly than Paul did. I thought the Double Standard Technique might help because Walter seemed to be a warm and compassionate individual. I asked wehat he’d say to a dear friend who’d been rejected by someone he’d been living with for eight years. I said “Would you tell him that there’s something wrong with him, that he screwed up his life and flushed it down the toilet for good?”

Walter looked shocked and said he’d never say something like that to a friend. I suggested we try a role-playing exercise so that he could tell me what he would say to a friend who was in the same predicament […]

Therapist (role-playing patient’s friend): Walter, there’s another angle I haven’t told you about. What you don’t understand is that I’m impossible to live with and be in a relationship with. That’s the real reason I feel so bad, and that’s why I’ll be alone for the rest of my life.

Patient (role-playing as if therapist is his friend who just had a bad breakup): Gosh, I’m surprised to hear you say that, because I’ve known you for a long time and never felt that way about you. In fact, you’ve always been warm and open, and a loyal friend. How in the world did you come to the conclusion that you were impossible to be in a relationship with?

Therapist (continuing role-play): Well, my relationship with [my boyfriend] fell apart. Doesn’t that prove I’m impossible to be in a relationship with?

Patient (continuing role-play): In all honesty, what your’e saying doesn’t make a lot of sense. In the first place, your boyfriend was also involved in the relationship. It takes two to tango. And in the second place, you were involved in a reasonably successful relationship with him for eight years. So how can you claim that you’re impossible to live with?

Therapist (continuing role-play:) Let me make sure I’ve got this right. You’re saying that I was in a reasonably successful relationship for eight years, so it doesn’t make much sense to say that I’m impossible to live with or impossible to be in a relationship with?

Patient (continuing-role-play:) You’ve got it. Crystal clear.

At that point, Walter’s face lit up, as if a lightbulb had suddenly turned on in his brain, and we both started laughing. His negative thoughts suddenly seemed absurd to him, and there was an immediate shift in his mood…after Walter put the lie to his negative thoughts, I asked him to rate how he was feeling again. His feeling of sadness fell all the way fromj 80% to 20%. His felings of guilt, shame, and anxiety fell all the way to 10%, and his feelings of hopelessness dropped to 5%. The feelings of loneliness, embarassment, frustration, and anger disappeared completely.

The book is quite long, and it’s full of stories like this. The author, who’s one of the top cognitive-behavioral psychiatrists in the world, describes his experience with the therapy as:

[When I first learned about this therapy, I thought] depression and anxiety seemed far too serious and severe for such a simplistic approach. But when I tried these methods with some of my more difficult patients, my perceptions changed. Patients who’d felt hopeless, worthless, and desperate began to recover. At first, it was hard to believe that the techniques were working, but I could not deny the fact that when my patients learned to put the lie to their negative thoughts, they began to improve. Sometimes they recovered right before my eyes during sessions. Patients who’d felt demoralized and hopeless for years suddenly turned the corner on their problems. I can still recall an elderly French woman who’d been bitterly depressed for more than fifty years, with three nearly-successful suicide attempts, who started shouting “Joie de vivre! Joie de vivre!” (“joy of living”) one day in my office. These experiences made such a strong impact on me that I decided my calling was in clinical work rather than brain research. After considerable soul-searching, I decided to give up my research career and become a full-time clinician. Over the years, I’ve had more than 35,000 psychotherapy sessions with depressed and anxious patients, and I’m every bit as enthusiastic about CBT as when I first began learning about it.

Okay. I am not one of the top cognitive-behavioral therapists in the world. I’ve been studying formal cognitive-behavioral therapy for about a week now, and been doing untrained ad hoc therapy on inpatients for a couple years. But I’ve also gotten to observe a lot of other people doing therapy, and talked to people who have had therapy, and treated patients who were simultaneously undergoing therapy, and the impression I got was very different.

Dr. Burns asks patients to question whether their anxiety and their negative thoughts are rational, and their faces light up and all of their psychiatric problems suddenly melt away.

The therapists I’ve seen ask patients to question whether their anxiety and their negative thoughts are rational, ever so tactfully, and the patients say “No shit, Sherlock, of course they aren’t, but just knowing that doesn’t help or make them go away, and I’ve been through this same spiel with like thirty people already. Now shut up and give me my Xanax.”

In my last post, someone asked what to do if they found cognitive-behavioral therapy hokey and patronizing. I said, only half joking, that “if you don’t like hokey patronizing things, CBT may not be for you.” I know it’s mean, and pessimistic, but everyone I’ve talked to has had pretty much the same experience. I used to attribute this to my friends being pretty smart, and maybe CBT was aimed as less intelligent people, but Nate The Genius Medical School Professor seems pretty smart. So does Walter The Therapist. Burns’ book includes a bunch of other vignettes about high-powered lawyers, graduate students, et cetera. They all find his suggestions of “Well, have you considered that your irrational negative thoughts might not be rational?” super life-changing.

You might have read the study this graph comes from: The Effects of Cognitive-Behavioral Therapy As An Anti-Depressive Treatment Is Falling: A Meta-Analysis. As you can see, the Hedges’ g declined from about 2.5 in 1980 to around 1 today. The latest embarrassing set of results now show CBT doing no better than its old nemesis psychoanalysis. Why?

There are a lot of possible explanations. The smart money is always on “it never worked very well, but we’re finally doing studies that aren’t hopelessly biased”, but the analysis doesn’t find a clear difference in study quality. Other suggestions are that therapists have gotten less committed over time, or that the patient populations has changed. All of these sound reasonable. But let me mention one more possibility.

Every so often, psychiatrists joke about how so many people are depressed we might as well put Prozac in the water supply. Sometimes we say the same thing about lithium, although in that case we’re not joking.

Nobody’s ever talked about putting cognitive-behavioral therapy in the water supply, but insofar as that’s meaningful at all I would say we’ve kind of done it. Cognitive-behavioral ideas, like perfectionism, excessive self-blame, conditional versus unconditional self-respect, deep breathing, goal-setting, et cetera have become basic parts of popular culture. The whole self-esteem movement isn’t exactly cognitive-behavioral, but it’s certainly allied, and it certainly represents a shift to a style of thinking about the self and about psychology in a way that’s much more fertile for cognitive-behavioral ideas. Inside Out was kind of “Cognitive Behavioral Therapy: The Movie”.

Although the particular book I’m reading is from 2006, Burns himself was one of Aaron Beck’s original students and one of the first cognitive-behavioral therapists ever. I wonder how many of these patients who seem absolutely shocked to realize that maybe their anxiety isn’t rational come from that very early period.

It’s very hard to track changes in people’s basic beliefs about psychology. I was flabbergasted to learn that until Dr. Benjamin Spock’s landmark 1940s book on child care, parents were told not to hug, kiss, or show affection to babies, because that would coddle them and make them weak, pampered adults. Before that, parents interacted with their kids much less, and it was assumed that siblings and nannies and friends would raise them, or they would raise themselves. It’s easy to read books about ancient Greece and not notice that they have a completely different view of the role of the self/individual than we do. So it wouldn’t surprise me if a lot of the psychology we consider “obvious” is CBT that has seeped out into the water supply over the past thirty years.

If that were true, it would explain why CBT is no longer as effective – it’s just telling people things they already know.

It could be fairly asked: then why isn’t everybody already better? Depression seems to be increasing, though there’s a lot of argument about exactly how much; that doesn’t sound like what would happen if everyone were automatically getting a background level of therapy.

Here’s a theory, though it’s on even shakier ground than the other one. The meta-analysis proposes that CBT may have lost some placebo effect over time because patients no longer think of it as The Exciting New Thing. I’m not sure I can go along with that – my own analysis of psychotropic medications suggests patients very much prefer the old ones for some reason. But a big part of psychotherapy is placebo effect, so they might be on to something.

What part of psychotherapy provides the placebo? Is it going to the clinic? Talking to the therapist? Hearing fancy words like “self-estimation”? Doing worksheets?

One thing a lot of therapies have in common is that they provide the feeling of insights. For example, psychoanalysts are very good at coming up with surprising-but-plausible ways that your current problems are linked to things that happened to you as a child; the usual result is a patient feeling enlightened, like “You’re right, the leg pain that’s been bothering me is in the same part of my leg that accidentally brushed up against my mother’s breast one time when I was seven, that’s pretty interesting.”

Suppose that in the old days, CBT was an insight a minute and you were constantly hearing surprising things you’d never thought about before. And nowadays, you’re kind of absorbing a lot of those things by osmosis without it seeming too insightful, and then the therapy itself is anticlimactic. Could that lessen the placebo effect enough to account for the data?

I don’t know. Maybe after I’ve been training in formal CBT for more than a week, I’ll have more data and can report back to you.

[EDIT: Sarah writes: “In a way, seeing CBT stuff in pop culture inoculates people, I think. People will get as far as noticing “this negative thought is an anxiety symptom”, but not as far as *actually reversing it*. When people hadn’t heard of CBT, they first got the “this negative thought is irrational” message in a context when they were actively working on their problems, so they followed through with the ‘hard’ step of actually reversing the thought. Now, people run into the revelation that the ‘inner critic’ is wrong just by browsing facebook, when they’re *not* actively trying to fight their anxiety problems, so the revelation loses its force.”]

[EDIT 2: Paul Crowley points out a very similar theory in The Guardian]

http://slatestarcodex.com/2015/07/13/things-that-sometimes-work-if-you-have-anxiety/

http://slatestarcodex.com/?p=3696

Anxiety disorders are the most common class of psychiatric disorders. Their US prevalence is about 20%. They’re also among the least recognized and least treated. We have sort of finally beaten into people’s thick skulls that depression isn’t just being sad, and you can’t just turn your frown upside down or something – but the most common response to anxiety disorders is still “Anxiety? So what, everyone gets that sometimes.”

But it’s hard to describe how disabling anxiety can be. A lot of people with nominally much worse conditions – depression, bipolar, even psychosis – will insist that they want their anxiety treated before anything else, because they can live with the rest. On the other hand, while a lot of people with psychosis have enough other problems that treating the psychosis barely puts a dent in their issues, a lot of people with anxiety would be happy and productive if they could just do something about it.

Since I’ve gotten some positive comments on my discussion of depression treatments I thought I’d go through some of the things I’ve seen used to treat anxiety. I’ll include the same disclaimer:

This will be inferior to reading official suggestions, but you will probably not read official suggestions, and you may read this. All opinions here are my own, they are not endorsed by the hospital I work at, they do not constitute medical advice, I have a known habit of being too intrigued by extremely weird experimental ideas for my own good, and you read this at your own risk. I am still a resident (new doctor) and my knowledge is still very slim compared to more experienced professionals. Overall this is more of a starting point for your own research rather than something I would expect people to have good results following exactly as written.

I’ll mostly be talking about what’s called generalized anxiety disorder, with some applicability to panic disorder. Social anxiety, specific phobias, et cetera are their own thing, as is anxiety secondary to other illnesses – but some of the advice may cross over. I’m not going to get too into diagnosis, because generalized anxiety disorder is pretty much exactly what you think it is and a lot (though not all) of this will be applicable for subclinical anxiety as well.

I. Diet And Lifestyle

You didn’t think you were going to get out of this part, did you?

Pretty much every study – epidemiological or experimental, short-term or long-term, has shown that exercise decreases anxiety. The effect seems limited to aerobic exercise like walking, running or swimming, preferably for longer than twenty minutes. Various mechanisms have been postulated including norepinephrine, endogenous opioids, and decreased inflammation.

There’s less agreement on diet. The people who hate fat says high-fat diets cause anxiety. The people who hate carbs say high-carb diets cause anxiety. The people who hate processed food say processed foods cause anxiety. The people who recommend fish oil for everything say insufficient fish oil causes anxiety. None of it seems super credible, but Mayo Clinic has some suitably bland advice.

The one very important connection – if you drink too much coffee, or any other source of caffeine, that will make you anxious. I once had a patient come to me with severe recurrent anxiety. I asked her how much coffee she drank, and she said about twenty cups per day. Suffice it to say this was not a Dr. House-caliber medical mystery.

Also needless to say: get enough sleep. Seriously. Get enough sleep.

Many people find that various breathing exercises or other sorts of mindfulness activities can be helpful in the short term and sometimes build skills useful for the long term. My hospital gives people these handouts on breathing techniques and progressive muscle relaxation. I’ve made fun of HeartMath in the past, but I only learned about them because many people find some success, probably placebo-ish, with their quick coherence technique. If you’re an overachiever and want to get really into this sort of stuff, people always say good things about yoga and especially pranayama breathing. Studies seem to back this up (1, 2, 3) though you’ve got to be careful to weed out the studies by very religious Hindus trying to prove they’ve been right all along.

Meditation has similarly positive results. Here’s a study showing that an intervention to teach patients meditation resulted in decreased anxiety with p < 0.001 even three years later. Here's a meta-analysis of 39 studies finding an effect size of about 0.6 (medium) in the general population, and an effect size of about 1.0 (large) in people with anxiety disorders. But here’s an equal and opposite review that found only “equivocal” results. As far as I can tell, most people investigating meditation think it works pretty well. The meditation techniques that seem to work best are mindfulness meditation and transcendental meditation. You can learn a little about mindfulness meditation here. In order to learn about Transcendental Meditation, send a check made out for $5000 to Maharishi Mahesh Yogi, PO Box….

II. Therapy

Cognitive-behavioral therapy works okay for anxiety just like it works okay for everything else. The Big Graph O’ Effect Sizes says that psychotherapy on average has an effect size of 0.51 in generalized anxiety, compared to medication’s 0.31. This shouldn’t be taken too seriously – the confidence intervals overlap and there’s a wide range of efficacy for different medications – but you won’t be doing any worse by going for the therapy first. Even the Cochrane Review, famous for never drawing any conclusion other than “more research is needed”, is tentatively willing to say that psychotherapy works for anxiety disorders. Their study trends towards finding that cognitive behavioral therapy works better than supportive therapy, but is unable to prove significance – apparently more research is needed.

Exposure therapy can also be useful for panic attacks or specific phobias. This is where they expose you to the thing you’re scared of (or deliberately initiate a panic attack) and keep doing it until you stop being scared and start being bored. According to a bunch of studies it works neither better nor worse than cognitive-behvioral therapy for most things, but my unsupported impression has always been that it’s better at least for panic disorder. Cognitive-behavioral therapy seems clearly superior for social phobia.

You can get psychotherapy from any qualified psychotherapist, a category including counselors, social workers, psychologists, and sometimes psychiatrists. Ones who use “a school” (for example, describe themselves as practicing cognitive behavioral therapy) are usually considered better than those who don’t (“Oh, I do a little of everything with every patient”). If you can’t find (or don’t want to find) a good therapist, there is preliminary evidence that a good self-help therapy workbook (“bibliotherapy”) is about as good as real therapy – including for anxiety (study, other study, yet another study).

I have no special insight into which self-help workbooks are any good, but The Cognitive Behavioral Workbook for Anxiety: A Step-By-Step Program seems to get pretty good ratings.

III. Medications

To be tried after diet and lifestyle interventions when possible.

Medication can work either instead of or in addition to therapy. There are at least seven categories of commonly used conventional anxiety medications: SSRIs, SNRIs, antihistamines, antipsychotics, anticonvulsants, benzodiazepines, and azapirones. These can be divided into mostly-acute (antihistamines and benzos) and mostly-long-term (SSRIs, SNRIs, anticonvulsants, azathioprines), with antipsychotics kind of being a tossup. Depending on whether you just need to get through the occasional panic attack or whether you’re in a chronic unremitting anxiety state, you might want one, the other, or both.

You probably know antihistamines (example: Benadryl) from the many common over-the-counter members of this class. They have some mild short-term anti-anxiety effects. Benadryl will work in a pinch if you need something without a prescription, but the most commonly used anxiolytic antihistamine is hydroxyzine (“Vistaril”, “Atarax”), which is a bit more powerful and less likely to make you fall asleep. As far as anxiolytics go it’s pretty safe as long as it doesn’t make you too sleepy. If you just need something to take the edge off the occasional anxiety attack, this works fine.

Benzodiazepines (examples: Xanax, Ativan, Valium, Klonopin) are very effective in the short-term but also very controversial. In some people they are very habit-forming and can produce a picture very similar to addiction to alcohol (which they chemically resemble). Keep in mind how bad an idea it might be to become extremely addicted to prescription pills that you may suddenly lose access to depending on how your doctor is feeling (you might expect doctors would take the difficulty of coming off these drugs into account, but you might expect a lot of things from doctors that don’t always happen). Studies suggest benzodiazepines can sometimes build tolerance, and that after a month or two of frequent use, they lose their positive effect and you need them just to feel normal. That having been said, a subset of patients – and I can’t tell at this point if it’s a majority or a minority – go on benzodiazepines, do very well, stay on them for long periods without getting dependent, and never have anxiety again. It’s kind of a crapshoot. The most generally recognized “safe” use of benzos is the occasional Xanax to deal with rare but very stressful situations (for example, flying on an airplane if you’re scared of heights). Other people say Klonopin is safer than some of the others and that it’s worth a shot as long as you realize that “Klonopin dose gradually creeping upwards” is a sign that you’re getting into a bad place and need to react immediately. Most people recommend trying other things first before you come here, but once you’ve exhausted other options these can be a powerful last resort.

SSRIs (examples: Prozac, Celexa, Lexapro, Zoloft) are the mainstay of chronic anxiety treatment just like they’re the mainstay of chronic everything-else treatment. As usual, they have real but modest effects after about a month or so, more in some people and less in others. As usual, if one SSRI doesn’t work for you, you might want to try another. These are pretty safe aside from the sexual side effects. Some people get mild withdrawals if they go off these too quickly, so don’t do that. A lot of people use both an SSRI for chronic treatment, plus either an antihistamine or benzo for “break-through” anxiety.

SNRIs (examples: Effexor, Cymbalta) are like SSRIs, but for two neurotransmitters instead of one. This is supposed to make them a little bit more effective. Maybe they are, maybe they aren’t. Fewer sexual problems than SSRIs, but worse discontinuation syndrome. They’re a good second-line chronic medication if SSRIs don’t work. Effexor is probably the best.

Azapirones (example: BuSpar) is, unusually, a rare drug which is specifically targeted at anxiety, rather than a being a repurposed antidepressant or something. BuSpar is very safe, not at all addictive, and rarely works. Every so often somebody comes out with a very cheerful study saying something like “Buspar just as effective as benzodiazepines if given correctly!” and everybody laughs hysterically and goes back to never thinking about it.

Anticonvulsants (examples: Depakote, Neurontin, Tegretol, Lyrica) are seizure medications that sometimes sort of work for anxiety. Most of them have strong side effects and limited utility. The exception is Lyrica (pregabalin), which is pretty new but has shown excellent safety and efficacy in studies. It doesn’t have an FDA indication for anxiety and it’s pretty expensive, so you might have a hard time getting it, but it is at least a well-kept secret.

Atypical antipsychotics (examples: Seroquel, Zyprexa, Abilify, Geodon) are, as always, overused. Most of them either make you gain lots of weight, put you at increased risk for heart rhythm problems, make you feel terrible, put you at risk of permanent movement disorders, or all of the above. They do often treat anxiety, sometimes very well, and psychiatrists like them because they’re good all-purpose no-nonsense drugs with big advertising budgets, but unless you’re also psychotic consider trying some other things first before you try these.

An article in Journal of Psychopharmacology tries to compare the efficacy of all of these classes of drugs and gets the following effect sizes (bigger number = bigger effect):

Pregabalin: 0.5
Antihistamine: 0.45
SNRI: 0.42
Benzo: 0.38
SSRI: 0.36
Azapirone: 0.17
Alternative medicine: -0.31

(remember, other studies suggest psychotherapy is around 0.5)

I heavily challenge the claim that antihistamines are more effect than (or anywhere near as effective as) benzos. I don’t know the confidence intervals on these numbers, so I would suggest reading it as “Everything is about equally effective, except azapirones which aren’t as good”. Their “alternative medicine” category was mostly kava and homeopathy, and I have no idea why it came out negative (kava’s pretty good, and homeopathy shouldn’t separate from 0).

There are also some less commonly used drugs that might help people who don’t respond to any of these.

As usual, MAOIs are very effective, moderately dangerous, and super hard to get. They seem to work especially well for panic disorder and social anxiety.

Clonidine is a medication usually used to control blood pressure. It’s somewhat effective against anxiety and some people think it should be used more. But it can cause you to become too sedated (abnormally low heart rate) and in some people it makes anxiety worse for some reason.

Beta-blockers (example: propranalol) are another blood pressure medication. It is especially effective against somatic symptoms of anxiety – racing heartbeat, shaking, et cetera – and sometimes getting rid of those can make the anxiety go away entirely. It’s most famous for its use against performance anxiety: about a third of musicians use them in concerts, and I’ve heard similar rumors about public speakers, actors, et cetera. I used to think this was a little-known piece of trivia, but whenever I bring it up to doctors (“Hey, did you know some people use beta-blockers for performance anxiety”) the usual response is “Oh, yeah, I prescribe myself some of that when I have to give a presentation at grand rounds.” They don’t seem quite as good for longer-term anxiety disorders, though some people have had good results with them.

I once saw an excellent psychiatrist whom I deeply respect try everything on a patient with severe treatment-resistant anxiety with no results whatsoever until finally he came to Thorazine. This treated the patient’s anxiety pretty well, at the cost of provoking quite a bit of anxiety in the doctor.

Without meaning to give medical advice, and with the caveat that you should ask your doctor for their opinion – one good pharmacological treatment algorithm for anxiety disorders is:

If you just have occasional outbursts that bother you, take occasional doses of hydroxyzine.

If you have a longer-term problem, start with an SSRI. If that doesn’t work, either try more SSRIs and SNRIs, or go to Lyrica. You might as well be on BuSpar somewhere in the process too. If none of that works, choose your poison (or have it chosen for you) among MAOIs, benzos, clonidine, or antipsychotics.

IV. Alternative Treatments

To be used out of curiosity or desperation only – you have other options and these are not guaranteed safe or effective.

Massage therapy, acupuncture, aromatherapy, and everything else in the category of “unnecessarily medicalized relaxing thing” all perform very well as long as you don’t look too hard for a suitable control group. Yes, these are probably placebo, but they’re very effective placebos and if they both work I would rather take a placebo than an antipsychotic.

Inositol and l-theanine are both found in small quantities in the diet (inositol in some vegetables, theanine in tea) and supplementing them has been inconsistently found to help with anxiety. Inositol had some preliminary evidence for effectiveness in panic disorder, but a more recent meta-analysis was unimpressive. I can only say that I have some anecdotal evidence of extremely positive reactions to inositol, but we all know what they say about anecdotal evidence. Keep in mind that the dose used in studies is way larger than the dose anyone will give you – usually corresponding to about 20 of those 500 mg inositol pills a day. This makes it expensive and inconvenient, and most people just compromise by taking so little inositol it shouldn’t possibly be able to have any effect. L-theanine also has a lot of small studies in support, although there’s some question on whether it works on its own or whether it just has useful synergistic effects with caffeine. Sun-theanine is generally considered the most effective form, and recommended dose is about 100 – 400 mg. Both these supplements are afaik very safe and a good option for people who want to test things that might or might not work but have minimal risk. Magnesium should also be in here somewhere.

GABA is the main inhibitory neurotransmitter in the nervous system, and a lot of these other interventions are attempts to convince the brain to release more GABA or potentiate the GABA that’s already released. Can we just cut out the middleman and ingest GABA pills directly? The supplement industry would like you to think so, and you can certainly buy them anywhere supplements are sold, but it’s generally believed that orally ingested GABA can’t cross the blood-brain barrier. The Russians have developed a modified version of GABA that doesn’t have this problem; called picamilon, it seems to be a pretty popular anxiety treatment on the other side of the Pharmacological Iron Curtain. It’s pretty easy to get as a non-prescription supplement here in the West. There are very few studies on it, the ones that exist are in Russian, and I have nothing to go on but a couple of anecdotal reports, most of which are positive (though I personally noticed no effects). But the mechanism of action is plausible, and the long history of successful Russian use at least suggests it probably won’t kill you immediately. Most common dosage seems to be about 100 – 300 mg.

The nootropics/supplement/nutraceutical community also suggest ashwagandha and bacopa for anxiety; various low-quality studies support the use of both (ashwagandha meta-analysis, bacopa study 1, bacopa study 2, bacopa study 3). Bacopa may take several months of frequent use before it starts working; I tried it briefly and had to stop because of gastrointestinal side effects, which are pretty common. There’s also some worry around heavy metal contamination. Swanson’s and Nootropic Depot’s are two that have third-party testing showing they’re uncontaminated.

Kava is a traditional drink from various Pacific islands with anxiolytic properties. Multiple meta-analyses including a Cochrane review find it to be an effective anxiety treatment, but its safety is in question after reports of several cases of liver failure caused by the plant. This may be yet another case of people exaggerating freakishly rare side effects; the risk has been estimated at less than one in a million doses (though remember that if you take it daily for ten years, that number bcomes 1/300). Others suggest a rate as low as one in a hundred million but this assumes zero underreporting; others challenge this assumption. Possibly it is only poorly prepared kava causes liver problems; for traditionally prepared kava, look for preparations that specify they are made from root/rhizome material only. The American Academy of Family Physicians recommends that:

Physicians who supervise patients taking kava for the treatment of GAD should take care to avoid the following: (1) high dosages (more than 300 mg per day); (2) combining kava with hepatoactive agents; (3) using non-root preparations; and (4) exposure for longer than 24 weeks. Use of WS1490 standardized kava extract is also recommended. If these safety precautions are followed, kava can be appropriate therapy for selected patients diagnosed with GAD

Don’t take kava if you have any liver problems, if you’re on any medications that might interact with it, or if you plan on drinking alcohol at the same time. Consider talking about it with your doctor first and getting plans to check liver enzymes regularly.

Selank is an experimental Russian anti-anxiety medication going through their version of clinical trials. It’s a bit high-maintenance – you have to keep it refrigerated or else it decays, and the only two functional means of administration are injection or nasal spray – but anecdotal evidence is extraordinarily positive. No side effects have been found thus far, but needless to say by the time you get to “injecting experimental Russian medications into yourself” we have left the point where we can entirely guarantee this is a good idea. Ceretropic sells a nasal spray version, which is probably more convenient than having to inject it.

Phenibut is another Russian anti-anxiety medication, but it’s very addictive and dangerous. Even the fearless people of r/nootropics stay away from this one. Highly un-recommended.

Overall, the best evidence seems to be for l-theanine (especially if you drink coffee) and bacopa (especially if you’re willing to wait months for any effect), with picamilon also worth your time to try and Selank as an option for the very adventurous.

V. Conclusions

No treatment stands out as extremely effective, and the best route to dealing with anxiety probably depends on many factors like your amount of free time, your motivation, your access to medical care, and your willingness to put up with side effects. After you’ve fixed lifestyle issues, I think any of “self-help workbook”, “start SSRIs”, or “try l-theanine” are good first options. On the other hand, benzodiazepines, antipsychotics, and kava are all options I would hold off on until you’ve tried a couple of other things.

Like with the depression post, the most important conclusion you can take from this is that you have lots of options. Please don’t let people give you an SSRI and then give up. Work with your doctor. Anxiety actually has a pretty good prognosis if people work on it, but it can be a difficult and frustrating process. Just remember: there are lots of options.

PS: Relevant Onion