ODD Clinical Trial

This post is a sort of advertisement, except that no one's getting paid anything. A colleague of mine and his group just got a 2 year grant to conduct a trial of Regulation Focused Psychotherapy (RFP) for the treatment of Oppositional Defiant Disorder in children ages 5-12. This is the flyer:

That's the advertisement part. I think it's a great idea. But just to be clear, not only am I not being paid, I'm not involved in the study in any way except feeling pleased about it, and writing this post.

Why do I think it's a great idea? The American Academy of Child and Adolescent Psychiatry has a brochure about ODD. It describes treatment for ODD, which includes a combination of Parent-Management Training Programs and Family Therapy, Cognitive Problem-Solving Skills Training, Social-Skills Programs and School-Based Programs, plus or minus medication.

These are all useful tools, but none of them addresses the underlying affects, and difficulty in regulating these affects, that children with ODD experience. That's where RFP comes in.

The group conducting the study recently published the Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach.

In it, they describe the way, "RFP-C enables clinicians to help by addressing and detailing how the child’s externalizing behaviors have meaning which they can convey to the child," and more specifically, that RFP-C can:

• Achieve symptomatic improvement and developmental maturation as a result of gains in the ability to tolerate and metabolize painful emotions, by addressing the crucial underlying emotional component.
• Diminish the child’s use of aggression as the main coping device by allowing painful emotions to be mastered more effectively.
• Help to systematically address avoidance mechanisms, talking to the child about how their disruptive behavior helps them avoid painful emotions.
• Facilitate development of an awareness that painful emotions do not have to be so vigorously warded off, allowing the child to reach this implicit awareness within the relationship with the clinician, which can then be expanded to life situations at home and at school.

That's my pitch. So if you know anyone in the New York City area who could benefit from this trial, whether child, parent, educator or clinician, please get this information to them.

Thanks.

Outside In

In the context of my working on building my own practice website, I found a NY Times article, Inner Peace? The Dalai Lama Made a Website for That, compelling to read.

The website is, Atlas of Emotions, and it's not really about inner peace. It's more about the Dalai Lama's notion of emotions as reactive internal events that prevent inner peace, combined with information about the five emotions considered universal by the 149 experts surveyed for this purpose.

The emotions are:

Anger
Fear
Disgust
Sadness
Enjoyment

The site was conceived by the Dalai Lama as a "map of the mind", and developed by Dr. Paul Ekman (for $750,000), who conducted the survey, and has done pioneering work in nonverbal behaviors, especially facial expressions. He now has a company called the Paul Ekman Group, or PEG, which will teach you, for a fee, to read people's expressions and determine if, for example, they are lying. He was a major consultant for Inside Out, the Pixar movie that illustrates the emotional life of a girl named, Riley (I assume based on the expression, "Living the life of Riley," meaning the good life). He was also consultant and inspiration for the main character on the TV series, "Lie to Me", which I know nothing about.

The site is primarily visual, with the imagery designed by a company called, Stamen, that creates data visualizations. It's interesting that the colors used to depict the five emotions on the site:

match the colors of the corresponding characters in Inside Out:

I probably shouldn't be including either of these images without permission, but the Disney-fication was just so striking. Then again, we do associate colors with feelings, like red with anger, blue with sadness, and green with disgust, and red and green, at least, are related to changes in skin color that occur with their associated emotions. I don't know about purple with fear or yellow/orange with enjoyment.


The way the site works is you land on the home page, with those five circles of emotion, which are called, "continents". Remember, this is supposed to be a map. If you click on a continent, you get a brief description. For example, Sadness brings up, "We're saddened by loss."

You also get a menu to the right which lists, Continents, States, Actions, Triggers, Moods, and Calm. If you go to States, after you've clicked on Sadness, you get a graph of various states related to sadness, with overlaps, from least intense to most. The least intense for Sadness is Disappointment, "A feeling that expectations are not being met." The most intense is Anguish, "Intense agitated sadness."

There are left and right arrows to switch to other basic emotions, but also a down arrow, corresponding to the menu on the right, with more about the emotion you're looking at. The next one down is Actions, with another visual including a range of possible actions for each given state. For anguish, you can seek comfort, which is considered a constructive action. You can mourn, which is ambiguous. And you can withdraw, which is destructive.

This is a good illustration of one of the main limitations of the site-that it oversimplifies, but that probably makes it more widely accessible.

The next down is Triggers, which are either universal, like losing a loved one, or learned, like perceiving a loss of status.

And next down is Moods, the "longer lasting cousins" of emotions. For Sadness, the corresponding mood is Dysphoria.

That's as deep as the graphics go. The only thing left is calm, which you access from the right hand menu. It has nothing but a short description:

Experiencing Calm

A calm, balanced frame of mind is necessary to evaluate and understand our changing emotions. Calmness ideally is a baseline state, unlike emotions, which arise when triggered and then recede.

The only other feature of the site is a link to the "Annex", where you can find the scientific basis for the work, some more complicated definitions, the signals of emotional display, and a page of "Psychopathology", which lists various DSM diagnoses related to each emotion.

I wasn't thrilled with this page. For one thing, I disagreed with some of the categorization. For example, as an anxiety disorder, OCD was listed under Fear. But etiologically, at least from an analytic standpoint, OCD is more about a way of dealing with aggression, so I would have listed it under Anger. It also lists Mania under enjoyment, with a qualification about it being pathological enjoyment. But I don't think this is what's actually meant by the term, Enjoyment.

And this page doesn't mention the DSM, even though it includes diagnoses like Disruptive Mood Dysregulation Disorder (DMDD).


Overall, I have mixed feelings about the Atlas of Emotions. On the one hand, it recognizes that we usually don't know why we feel what we feel, or do what we do, and that's useful to know. To quote the NY Times quoting the Dalai Lama:

“We have, by nature or biologically, this destructive emotion, also constructive emotion,” the Dalai Lama said. “This innerness, people should pay more attention to, from kindergarten level up to university level. This is not just for knowledge, but in order to create a happy human being. Happy family, happy community and, finally, happy humanity.”

On the other hand, the goal is a calm state:

“When we wanted to get to the New World, we needed a map. So make a map of emotions so we can get to a calm state.”

I think this calm state is supposed to be an absence of emotion, either good-feeling or bad-feeling, a Buddhist ideal, so emotion is viewed as the enemy:

“Ultimately, our emotion is the real troublemaker,” he said. “We have to know the nature of that enemy.”

When I read this, I was reminded of the talk I attended, that I wrote about in Laughing Rats, where Jaak Panksepp noted that, "Most learning takes place through affective shifts." So if we contain our emotions, do we prevent ourselves from learning new things?

And in that same talk, Jean Roiphe noted that, "Ego functioning often involves "taming" certain affects, especially through thought and language, but it also involves intensifying some affects, so that people can feel truly alive. A full human life can't be reduced to an all or nothing switch of feeling in response to external events."

Also, I'm not sure "calm" isn't an emotion.

Maybe I just have trouble with this because I'm so steeped in a culture of neurotically exaggerated emotions, so the ideal of inner peace isn't just unattainable, it's laughably unapproachable, which, for me, quickly turns into undesirable.

What's Your Take?

You've probably seen the tweets, etc. about the paper, Experimental evidence of massive-scale emotional contagion through social networks.  This was a study conducted by the:


Core Data Science Team, Facebook, Inc., Menlo Park, CA 94025;
Center for Tobacco Control Research and Education, University of California, San Francisco, CA 94143;
and Departments of Communication and Information Science, Cornell University, Ithaca, NY 14853

From January 11-18, 2012, Facebook adjusted its news feed algorithm so that 689,003 users received either less positive emotional content, or less negative emotional content, from friends. Then they looked at what people posted in response.

They found that less positive feed content yielded less positive posts, and less negative content yielded less negative posts. If that sounds confusing, they tried to make people either sadder or happier. The ones they tried to make sadder, by giving them less happy stuff to read, got sadder. And the ones they tried to make happier, by giving them less sad stuff to read, got happier.

They used linguistic software to determine the happiness or sadness of an individual post.

The paper was reviewed and edited by Susan T. Fiske, a professor of Psychology and Public Affairs at Princeton. It was published in the Proceedings of the National Academy of Sciences of the United States of America.

Facebook always has a news feed filtering system-they claim there would just be too much stuff to read in the feed, otherwise. In the case of the study, they simply adapted the filtering system to randomize users to happy or sad arms, and they claim that this is, "...consistent with Facebook's Data Use Policy, to which all users agree prior to creating an account on Facebook, constituting informed consent for this research."

Their goals seem to have included demonstrating that online interactions can have significant emotional impact, and debunking the theory that people get sad when they see how happy all their friends are on Facebook.

Well, I guess this is a powerful use of big data, but I just wish they had asked first. They claim they did, that informed consent was implicit in the Facebook user agreement. I think that's pushing it.

I happen to know a depressed adolescent (not my patient), a big user of Facebook, who was hospitalized a couple weeks after this experiment. Am I claiming this is why he was hospitalized? No. Could it have influenced his need for hospitalization? Maybe. Does an adolescent need a parent to sign informed consent? Could be.

It's a complicated issue. Every advertiser on the planet tries to manipulate people's emotions, so how is this different? Because Facebook wasn't trying to sell anything, it was just manipulating emotions to see what would happen? I don't know if that makes it better or worse.

An inquiry was made to Dr. Fiske about IRB approval. Her response:

Would it have adversely affected their data if they had done a mass posting?:


We interrupt this waste of time to bring you an important news bulletin! You may be randomized to participate in a study of your emotions. If you experience prolonged and unremitting sadness for more than 4 hours, please seek emergency medical assistance. If you wish to opt out of this experiment, click HERE.


I don't know. What do you think?