Thursday, 20 April 2017

A Little Note on Placebo and Meaning


What are placebo effects?


Some people think that "placebo effect" is the label given to cases of people believing they've recovered or perceiving their symptoms to have decreased or gone, when those people have received no medically active intervention: so, they've received a sugar pill perhaps, or a sham surgical intervention of some kind and in response perceive their symptoms to have improved or believe themselves to have recovered. However, this is not what we mean by "placebo effect", it's actually far more mind-blowing than that! 

It is not simply that people believe or perceive themselves to have recovered or believe that the condition has gone into remission, it is that they HAVE, as a matter of clinically verifiable fact, recovered as if having received a pharmaceutically active or surgical intervention. Daniel E. Moerman’s book Meaning, Medicine and the "Placebo Effect" is replete with examples, as are many other papers and books on placebos. This much about placebos is uncontroversial, even though it is, as noted above, pretty mind-blowing.

When Randomised Controlled Trials of drugs or surgical interventions are carried-out, there are two phenomena that have to be controlled for, in addition to existing treatments, so that we might ascertain whether the intervention under scrutiny has genuine medical efficacy: these are "placebo effects" and regression to the mean.

Regression to the mean is basically the statistically significant fact that some people just get better over time anyway, so we need to control for these people and not confuse measurement of this phenomenon in our trial data with a response to the intervention on trial.

What is referred to as the "placebo effect" is something else: people respond as if they have been treated with a medically active treatment when we know they have not received such (they’ve been given a sugar pill or sham surgery, for example). As I noted above, this isn’t merely about them believing themselves to be better, nor is it about them perceiving their symptoms to have gone; it is that they have recovered in ways physiologically comparable to those who have recovered in response to receiving treatment, and they have done so in ways that cannot be accounted for by regression to the mean.

So, an RCT will have a control group which receives no treatment at all (the regression to the mean control group) and one or more control groups who are administered sham treatments (the placebo control(s)), in addition to the groups who receive the intervention being trialled and groups receiving the competing intervention(s), such as, perhaps, the current market leading drug for that condition.

Explaining Placebo


So, what is the explanation for the placebo response? What is the explanation, for example, for why the person (the body) actually produces dopamine when administered a sham treatment, what is called endogenous dopamine release, and which mimics the dopamine that would have been introduced had that person received the medically active intervention? For, putting this another way: the person's biochemistry endogenously mimics the introduction of clinically administered exogenous dopamine. Indeed, there are many many more examples of such biochemical and physiological changes which come about through the administering of what have been called "placebos", which have been shown to mimic or replicate the changes that the active medical interventions are designed to introduce or cause. Such interventions can take the form of surgical or pharmaceutical interventions.

Well, the standard folk explanation for this has perhaps been to assume this is a n example of a conditioned response: i.e. to assume that there is something akin to classic Pavlovian conditioning taking place.

However, there are a number of reasons not to accept this: first, there are a wealth of arguments which show that actually there is no such thing as Pavlovian conditioning, as traditionally conceived and as it takes hold in the folk imagination; rather, there is the learning of associations.  Second, even if there were such a thing as the 'conditioning of popular psychological mythology', the necessary conditions for such conditioning in many cases of placebo responses just are not present. And third, such conditioning cannot account for the cultural indexicality/variance widely observed in studies of placebo responses, because cultural differences often generate different responses in people who might otherwise be depicted as having had the same conditioning or learning.

So, in the 1980s Irving Kirsch (the guy who is probably better known to those outside placebo studies for his critique of antidepressants: I.e. he demonstrated that FDA approved and widely prescribed antidepressants were no more effective than placebos) proposed the response-expectancy explanation for placebo responses. This explains placebo responses as responses to expectations: for example, you expect to find it difficult to sleep having had a double espresso late at night, and your expectation is based on your beliefs that caffeine is a stimulant and that a double espresso gives you a strong shot of caffeine. In response to this expectation you do indeed suffer disrupted sleep. However, unbeknownst to you, your host last night had run out of your favoured Java blend and, so as to avoid the shame which would inevitably follow from such a social faux pas, had elected to give you a Swiss water decaffeinated double espresso, without informing you. So, your poor sleep was a placebo response, based on our expectation, which in turn was based on your (false) belief that the coffee was caffeinated.

The response-expectancy explanation is the dominant explanation to date. In fact, when I attended the big placebo conference in Leiden earlier this month (April 2017 - the inaugural conference of the Society for Interdisciplinary Placebo Studies - SIPS) the vast majority of those speaking at the conference proceeded as if this was the explanation: placebos are expectancy responses. I was one of only two dissenting voices (of which I was aware) among the speakers, the other being  the cognitive psychologist, Jan De Houwer (...I found common intellectual ground with a cognitive psychologist.)

For my part, I just don't think the response-expectancy explanation works. Here are the problems, as I see them.

To expect something one has to represent, in the form of a belief, the putative state of affairs one is expecting and the problem is that in many documented cases of placebo responses there is simply no evidence that those responding to the sham treatment have such a belief (unlike in the coffee example). However, and this is the more telling point, there are many cases of placebo responses where those responding to sham treatments in placebo-type ways do not have the epistemic resources, or even access to them, such that they might form the required belief. So, it is not merely that there are cases of "placebo responses" where those who respond do not appear to have the beliefs that would be required in order to form the expectation, it is that they don't have access to the data that would be required to serve as the 'building blocks' for such an expectation.  

So, what of expectation now? If, as the response-expectancy crowd want to do, we hold on to expectancy as an explanation for "placebo responses", then we need to provide warrant for our having extended the grammar of “to expect”, such that in this use it is not internally related to, it does not invoke, a propositionally structured belief, a representation of a state of affairs. This, in turn entails having access to the epistemic resources, which, recall, we have seen are simply unavailable in many cases of placebo responses.

We can put the argument of the last paragraph less abstractly: if you want to stick with expectancy, you owe us an explanation as to how someone can expect something while not being in a position to know what it is they are expecting, i.e. how can one expect something without being able to specify or represent the something they are expecting?

Alternatively, we can leave the grammar of 'to expect' as it is, stop trying to square this particular circle, and instead drop the overly restrictive reliance on response-expectancy as a global explanation for "placebo responses". Then, instead, we might talk more broadly about meaning responses (as Dan Moerman does), and set about, via ethnographic investigations of people responding in medically significant ways to pharmaceutically and surgically inert interventions, gaining better understanding of medically significant meaning responses.

Here we are talking about the world having meaning in a way that does not demand that we first have the resources to form beliefs about (possible) states of affairs in the world, for we don't need to expect something to cure us for us to be cured when we have received a sham treatment. Rather, we move beyond such a representationalist picture of cognition, to more enactive or even ethnomethodologically-informed accounts.

That’s the issue, and that is why I’m so preoccupied with this right now.


Tuesday, 18 April 2017

General Election - Second Referendum

Identify the anti-Brexit candidate in your constituency and vote for them. (If there is more than one anti-Brexit candidate, identify the one with the best chance of winning and influencing their party policy)

Persuade all anti-Brexit friends to do the same. Hold your nose if you have to, and do it.

Treat this general election as a second referendum.

If you are motivated by anti-establishment sentiment, then whatever you believed that amounted to last summer, you have a second stab at it now. Clue: Johnson, Gove, Fox, May etc. _are_ the establishment (and those of them who campaigned for Brexit lied about NHS funding and much, much more)

May is being opportunistic in calling the election now, after repeatedly stating she would not do so. Moreover, recall the Fixed Term Parliament Act, designed to stop opportunistically-called snap elections..? Is this someone to trust? (Ans. NO)

May has called this election for no other reason than the lead in the opinion polls indicates to her that she is guaranteed another five years and an increased majority. HOWEVER, if we reframe this election successfully as a SECOND REFERENDUM and as a vote on whether we want a small minded racist Britain with rising inequality and a dismantled health service (now servicing the pockets of Tory cronies) or an open, progressive and increasingly egalitarian Britain with good health provision for all (serving the health of the nation) she might well turn out to have been mistaken.

Let's reframe this election to be a second referendum and not about what we feel about Corbyn, or what the media tell us about Corbyn. If we do so, then those opinion poll figures will be rendered irrelevant.

Tuesday, 22 November 2016

Lessons

About 16 years ago, as part of the work I was doing for my Ph.D. thesis, I visited the Fortunoff video archive for Holocaust testimonies at Yale university. I was interested in the phenomenon of survivor shame.

After 10 days of watching video recordings of interviews with Holocaust survivors a number of things stuck with me and remain prominent in my thoughts to this day. I'll list two here.

1. Many of those interviewed who were survivors had lived silent for three decades or more. Many of them were speaking now either because they had been persuaded it was important for them to do so or because they had been moved to break their silence because of the emergence of the denialist movement. In short, testifying to what happened then was a deeply distressing experience and often had psychological consequences. They did it because they felt it was important that the truth be known and not doubted.

2. I watched a number of interviews with those who had managed to escape Germany, Poland and so on in the 1930s, and made it to the US. What came up several times was the following: they would receive letters from friends and family back in Europe which would make light of the changed circumstances, which would play down the horrors of forced removal to ghettos and so forth. While there are a number of possible explanations for this, what seemed to emerge from the interviews was that those writing the letters simply couldn't comprehend the magnitude of what was happening or that the psychological burden of comprehension was simply too much, particularly if you had a family to hold together. So people downplayed the hardship and the horror as a way of seeking to convince themselves things would be alright, that it wasn't as bad as it seemed (and would become).

From this I take these lessons (among others): 

re 1. Testifying to crimes, calling out and documenting injustice, is not whining, it's not a personality flaw, it's not something people want to do or do because they think it makes them look good. It is something that is very difficult to do, that takes courage. People lived for 30 years and more without telling a soul what they'd witnessed and experienced. There is little pride in identifying oneself as a victim, particularly if the crimes perpetrated against you involved all-out attack on your dignity. 
The right wing attacks on people calling out injustice which depict those people as whiners, and as weak, are the reverse of the truth. Fascists are the weak who bully in an attempt to hide from themselves their own weakness. Those who stand for justice when it would be easier to stay silent are the drivers of all that is good in humanity.

re 2.when catastrophic political change is happening history shows us that it invariably creeps up on us, it happens not with a dramatic bang, not with the sudden horrific entrance of obviously evil people, but incrementally, so we just don't see it for what it is until later, much later. We don't see it for what it is for numerous psychological reasons and because bad people rarely do bad things in the name of badness. Be aware of this tendency and try to find the courage to see things for what they are, don't seek to explain away the alt-right as jesters because that helps frame them as less of a threat. It is important to see these people for who they are.

Thursday, 10 November 2016

Failure of a Research Programme

Liberal political philosophy has failed. It has failed not because of its politics, but because of its epistemology. Its politics of toleration and justice is still as important as it ever was, all progressive political projects must aspire to defending and promoting these virtues. I am not here dismissing the liberal virtues. But liberal political philosophy as a research programme is in a terminally degenerative state because it never saw these things as virtues in need of nurturing, but saw them as principles to be applied.

Liberal political philosophers often simply dismissed the communitarian critique, advanced by philosophers such as Charles Taylor and Alasdair MacIntyre, as conservative critiques and thereby missed the more important philosophical point of those critiques: that social change does not come from jurisprudence.

Bush to Trump or How to Respond to Disappointment and Failure

Since G.W. Bush came to power in 2001 things happened from which the left, reasonably, assumed they'd benefit. 

The disasters of the illegal wars, Abu Ghraib, etc. 
(with associated anti-war movement); 

the financial crisis 
(with associated Occupy movement)

the increasing disillusionment with career politicians 
(remember the expenses scandal here in the UK, and the duck house?) 

and

the continuing unfolding global catastrophe that is human created climate change
(policies of economic growth based on carbon economies are clearly, and unequivocally, unsustainable)


The left naturally expected to benefit from a decade of political crises and failures, but if anything these have translated, as of now, into failings for the left while the populist right have benefited. 

I guess in the face of this one has a choice to either reckon with one's failings, regroup, learn and transform with a view to building an effective left alternative or one enters into some kind of denialism, which allows you to convince yourself, at great cost to your integrity and potentially to humanity, that the failings can be decoded as successes.

Apportioning Blame

Let's say you got two TV shows. One of those shows, made and broadcast by Network A, incites racial hatred and is watched by 60% of the viewing public. The other, made and broadcast by Network B, is watched by 30% and was kinda dull, middle of the road, conservative television. (the other 10% of those with TVs were reading books, playing video games or writing shit on Facebook, I guess).

Do we really blame the writers and broadcasters of the dull show on Network B for the crimes which result from people having watched the show that incited racial hatred on Network A?


Sure, it would be better had network B put something on against Network A's show, which was both more attractive to viewers and had a more radically progressive message for those viewers. But really, you cannot blame Network B for the crimes perpetrated by Network A.

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DNC shouldn't have selected HRC, but if we're ranking responsibility for the racist and sexist violence that will emerge from Trump's victory then it doesn't fall at the door of the DNC. While they take their place in the list of those bearing responsibility, they're well down that list below Trump himself, the GOP, those who voted for Trump, the people who actually go out an perpetrate the violence, a racist US media, a me first selfish culture, and so on.

Parable (after Stoker)


So, you're a progressive character and you notice that a range of servants, employees and one or two townsfolk are enabling the local blood-sucking undead count, from up at Castle Dracula, by shifting his coffin around during daylight hours, keeping his castle in order and directing unsuspecting travellers his way.

Do you decode this as progressive expression of class interests, a rejection of the bourgeois order, and something you need to attach yourself to: a kind of people's vampirism?

or

Do you focus on the fundamental immorality of vampirism, where some are treated, in a very literal and corporeal sense, as means to the ends of others' health and well being, and therefore seek to unconditionally reject, and fight, vampirism and those who enable it to flourish?

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