Systematic review shows no improvement in quality of mindfulness research in 16 years

Should we still take claims about mental health benefits of mindfulness with a grain of  salt? A systematic review by one of mindfulness training’s key promoters suggests maybe so.

saltCritics have been identifying the same weaknesses in mindfulness research for almost two decades. This review suggests little improvement in 16 years the quality of randomized trials for mental health problems.

This study examined 171 articles reporting RCTs for:

(a) active control conditions, (b) larger sample sizes, (c) longer follow-up assessment, (d) treatment fidelity assessment, (e) reporting of instructor training, (f) reporting of ITT samples.

What was missed

Whether articles reporting RCTs had appropriate disclosure of financial or other conflicts of interest. COI pose significant risk of bias, especially when they are not reported.

This article discloses authors’ interests. One of the authors, Richard Davidson is a prominent promoter of mindfulness training.  A Web of Science search of Davidson RJ and mindfulness yielded 26 articles from 2002 to 2016. It would be interesting to check in see if these consistent weaknesses in mindfulness research are mentioned in these articles. To what extent do RCTs with Davidson as an author had these weaknesses, like being underpowered?

Critic: You say financial interests or other investments in a treatment are a risk of bias. Yet, this article is critical of mindfulness research. Wouldn’t you expect a more positive appraisal of the literature because of the authors having a confirmation bias?

Not necessarily. Conflicts of interest are a risk of bias, but don’t discredit an author, They only alert readers to be skeptical. Furthermore, the weaknesses in this literature are so pervasive, it would be difficult to put a positive spin on them.  Besides calling attention to specific weaknesses that need to be addressed in future research can become part of a pitch for more research.

The article

Goldberg SB, Tucker RP, Greene PA, Simpson TL, Kearney DJ, Davidson RJ. Is mindfulness research methodology improving over time? A systematic review. PLOS One. 2017 Oct 31;12(10):e0187298.

End of paper conclusion:

In conclusion, the 16 years of mindfulness research reviewed here provided modest evidence that the quality of research is improving over time. There may be various explanations for this (e.g., an increasing number of novel mindfulness-based interventions being first tested in less rigorous designs; the undue influence of early, high-quality studies). However, it is our hope that demonstrating this fact empirically will encourage future researchers to work towards the recommendations here and ultimately towards a clearer and scientifically-informed understanding of the potential and limitations of these treatments.

From the abstract


The current systematic review examined the extent to which mindfulness research demonstrated increased rigor over the past 16 years regarding six methodological features that have been highlighted as areas for improvement. These feature included using active control conditions, larger sample sizes, longer follow-up assessment, treatment fidelity assessment, and reporting of instructor training and intent-to-treat (ITT) analyses.

Data sources

We searched PubMed, PsychInfo, Scopus, and Web of Science in addition to a publically available repository of mindfulness studies.

Study eligibility criteria

Randomized clinical trials of mindfulness-based interventions for samples with a clinical disorder or elevated symptoms of a clinical disorder listed on the American Psychological Association’s list of disorders with recognized evidence-based treatment.

Study appraisal and synthesis methods

Independent raters screened 9,067 titles and abstracts, with 303 full text reviews. Of these, 171 were included, representing 142 non-overlapping samples.


Across the 142 studies published between 2000 and 2016, there was no evidence for increases in any study quality indicator, although changes were generally in the direction of improved quality. When restricting the sample to those conducted in Europe and North America (continents with the longest history of scientific research in this area), an increase in reporting of ITT analyses was found. When excluding an early, high-quality study, improvements were seen in sample size, treatment fidelity assessment, and reporting of ITT analyses.

Conclusions and implications of key findings

Taken together, the findings suggest modest adoption of the recommendations for methodological improvement voiced repeatedly in the literature. Possible explanations for this and implications for interpreting this body of research and conducting future studies are discussed.

Competing interests

RD is the founder, president, and serves on the board of directors for the non-profit organization, Healthy Minds Innovations, Inc. In addition, RD serves on the board of directors for the Mind and Life Institute. This does not alter our adherence to PLOS ONE policies on sharing data and materials

The variables examined in the systematic review

Six methodological features that have been recommended in criticisms of mindfulness research [10–12. 14]. These include: (a) active control conditions, (b) larger sample sizes, (c) longer follow-up assessment, (d) treatment fidelity assessment, (e) reporting of instructor training, (f) reporting of ITT samples.

…We graded the strength of the control condition on a five-tier system. We defined specific active control conditions as comparison groups that were intended to be therapeutic [17]. More rigorous control groups are important as they can provide a test of the unique or added benefit a mindfulness intervention may offer, beyond non-specific benefits associated with the placebo effect, researcher attention, or demand characteristics [11,14]. Larger sample sizes are important as they increase the reliability of reported effects and increase statistical power [11]. Longer follow-up is important for assessing the degree to which treatment effects are maintained beyond the completion of the intervention [10]. Treatment fidelity assessment allows an examination of the degree to which the given treatment was delivered as intended [12]. Treatment fidelity is commonly assessed through video or audio recordings of sessions that are coded and/or reviewed by treatment experts [18]. We coded all references to treatment fidelity assessment (e.g., sessions were recorded and reviewed, a checklist measuring adherence to specific treatment elements was completed). Relatedly, reporting of instructor training increases the likelihood that the treatment that was delivered by qualified individuals [12], which should, in theory, influence the quality of the treatment provided. Lastly, the reporting of ITT analyses involves including individuals who may have dropped out of the study and/or did not complete their assigned intervention [12]. Generally speaking, ITT analyses are viewed to be more conservative estimates of treatment effects [19,20], and are preferred for this reason.


Checking graphs in articles: Binge drinking in women dramatically increasing, while binge drinking in men decreasing.

From 2002 to 2013, binge drinking decreased by 2% in men while it increased by 13% in women.

Huge differences in alcohol consumption by most people versus the upper 10%.

I wanted to blog about a recent article in The New York Times about binge drinking, but with a different focus than that of the author. Gabrielle Glaser is the author of the recent book Her best-kept Secret: why women drink – how they can regain control. She’s more interested in getting into issues of treatment, which is the focus of the book. I want to focus on a provocative chart the article, that probably underscores her some of her points in the article more than she emphasized.

A reminder to check tables and graphs in articles. Don’t just gloss over the valuable information they may display.

But before I could write my blog, I discovered that my Facebook friend Mike Miller was already discussing it on his personal page. So I just borrowed from that with attribution. Then I found that he had previously touched on this topic and so I reproduced it as well. I recommend becoming Mike Miller’s friend on Facebook. I found it worth it to have his posts displayed at the top when I go to my news feed.

The article

The New York Times article is

The graph

who is drinking

What Mike Miller has to say about the graph:

The headline doesn’t say it, but the drawing suggests it — the “people consuming more alcohol” are women. From 2002 to 2013, binge drinking decreased by 2% in men while it increased by 13% in women. I’ve been noticing a few alcohol marketing and advertising schemes targeting women recently. You might also have noticed that the booze industry has broken it’s decades-old promise not to advertise hard liquor on television. They started doing it a few years ago and they’ve been ramping up since then. They’ve been using product placement and movies like “Bad Moms” and sneaky ads like the one shown in my first comment. The usual message is that parenting is very stressful and alcohol is great for stress and good clean fun, so let lose and have a drink. I also see this way of thinking promoted on Facebook.

Mike’s current Facebook page directs us to an earlier comment that he made about a graph in another article

Mike Miller September 26, 2014 ·

The article in the Washington Post

Think you drink a lot? This chart will tell you

The graph

drink alot chart

Mike’s comment

This is nuts! Friends of mine in Epidemiology who studied alcohol consumption told me about this years ago — that most consumption is by alcoholics and the alcohol industry is very aware of it. So the chart shows that half of American adults are drinking an average of about 1.7 drinks per *year* while the upper 10% is drinking 7 times that much per *day*. It looks like about 75% of consumption is by alcoholics.

Confirmation bias in JAMA Psychiatry article concerning neighborhood-level variation in risk of psychosis

quick takesThis is one in a series of Quick Takes intended to show you when you can reasonably dismiss an article from further consideration based on inspecting its abstract alone. Once again we are dealing with hype and exaggeration in a JAMA Network Journal.

The abstract reports but ignores that most incidence rate ratios (IRRs) confidence intervals included 1.0, and overall results are weak.


A more suitable conclusion would be that “only weak and inconsistent evidence was fouind  for neighborhood-level variation in risk of developing psychosis in rural populations.” That finding is somewhat surprising and inconsistent with some past research, but should not be suppressed.

This article represents a good teaching example of confirmation bias, whereby weak findings are interpreted as consistent with the dominant view in the literature.

Take away messages

Don’t assume that because a finding is reported in the prestigious JAMA journals, it is credible.

Pay attention to the numbers in abstracts, particularly the confidence intervals and whether they exclude 1.0.

Ponder the question of whether this kind of confirmation bias was required for such weak findings to get published in a prestigious medical journal.

The article

Association of Environment With the Risk of Developing Psychotic Disorders in Rural Populations: Findings from the Social Epidemiology of Psychoses in East Anglia Study Lucy Richardson, MSc1; Yasir Hameed, MRCPsych2; Jesus Perez, PhD, MRCPsych3; et al

Excerpt from the abstract

Results  The study included 631 participants who met criteria for FEP and whose median age at first contact was 23.8 years (interquartile range, 19.6-27.6 years); 416 of 631 (65.9%) were male. Crude incidence of FEP was calculated as 31.2 per 100 000 person-years (95% CI, 28.9-33.7). Incidence varied significantly between neighborhoods after adjustment for age, sex, race/ethnicity, and socioeconomic status. For nonaffective psychoses, incidence was higher in neighborhoods that were more economically deprived (IRR, 1.13; 95% CI, 1.06-1.20) and socially isolated (IRR, 1.11; 95% CI, 1.04-1.19). It was lower in more racially/ethnically diverse neighborhoods (IRR, 0.94; 95% CI, 0.87-1.00). Higher intragroup racial/ethnic density (IRR, 0.97; 95% CI, 0.94-1.00) and lower intragroup racial/ethnic fragmentation (IRR, 0.98; 95% CI, 0.96-1.00) were associated with a reduced risk of affective psychosis.

These are trivial differences of which only two of five reach conventional significance, when one actually inspects the confidence intervals. Maybe the authors and editors are assuming that readers pay attention to such information or maybe they are hoping that readers accept the earlier statement: Incidence varied significantly between neighborhoods after adjustment for age, sex, race/ethnicity, and socioeconomic status.

The article ends with an attempt to explain the “finding”:

We found evidence of variation in the incidence of FEP across the rural-urban continuum, associated with deprivation, social isolation, and racial/ethnic composition. Social adversities, or failure to assuage the negative consequences of such adversities,40 may increase risk,39 but carefully designed longitudinal studies are required to determine causality.

What is an incidence rate ratio?

“Incidence rate ratio (IRR) – Incidence rate ratio is the ratio of two incidence rates. The incidence rate is defined as number of events divided by the person-time at risk. To calculate the IRR, the incidence rate among the exposed portion of the population, divided by the incidence rate in the unexposed portion of the population, gives a relative measure (IRR) of the effect of a given exposure and approximates the relative risk or the odds ratio if the occurrences are rare.”

No, seats on the US Institute of Medicine advisory committees are not for sale, despite what the Dutch Parliament was told

How the Executive Director of the Health and Medicine Division of the IoM responded to Professor Pim van Gool, the President of the Dutch Health Council disparaging the reputation of the IoM in testimony to the Dutch Parliament.

A likely reason for this unprofessional behavior is that van Gool was motivated to discredit the IoM’s stance on myalgic encephalomyelitis/chronic fatigue syndrome (MEcfs) because a recent document fron the IoM undermines the status quo concerning the illness in the Netherlands..

The incident speaks to the trustworthiness and commitment of the Dutch Health Council to best evidence in evaluating policies concerning MEcfs. Patients and their carers and advocates would do well to be vigilant for the next move from the Dutch Health Council.

The excerpt below is a translation of a transcript from a June 15, 2016 hearing before the Dutch Parliament. The President and Vice President of the Health Council of the Netherlands were appearing before Parliament to inform members about the installation of advisory committees concerning MEcfs.

Special thanks to Lou Corsius who provided the videotape, complete with English subtitles,  as well as the official response from the Institute of Medicine, which was a direct response to an inquiry from Lou.

The misrepresentation of the Institute of Medicine that occurred has immediate current relevance because of the likelihood that  Parliamentiary meetings will soon be held to reevaluate the official Dutch position on this illness.

Who’s who in the excerpt from the transcript

Pim van Gool: President of the Dutch Health Council

Henk Van Gerven: MP, Chairman of this meeting

Hans Severens: Vice President of the Dutch Health Council

Transcript [downloaded and edited from the subtitles provided by Lou Coursius

Starting at 6 minutes 54 seconds

Van Gool:  We received the request to advise in April 2015. At that time we had already been starting up because we knew this request would be submitted. We took explicitly notice of the IOM [Institute of Medicine] report in the US, dated February 2015.

Van Gerven: Can you explain IOM? Not everybody knows what that is.

Van Gool: Institute of Medicine. That is… we want to say that is a bit like the American Health Council. It is not exactly comparable. They  show a bit less scrutiny towards the interests of participants there. Amongst other things one can buy a chair to participate in the advisory process. That is an interesting business model but that is not the model we apply (Van Gool and Severens chuckle). Immediately in May & June one of our most experienced and respected scientific secretaries, dr De Neeling, has contacted 9 scientific associations, the general practitioners, the specialists in internal medicine, in physical rehabilitation, the neurologists, the association for behavioural therapy, the paediatricians, physicians in occupational medicine, etcetera, to actually ….as a hall stand (as a frame) we took that American report, more than 300 pages, very broad exploration, with also a very interesting new position that has been taken,  including a proposition to use another terminology for these issues (he does not use the word illness). We asked them to reflect on this IOM report as a start, actually.

Why did Pim van Gool misrepresent the Institute of Medicine?

 He and his fellow health council members were quite unhinged by the shift in the official American position concerning MEcfs in a report released by the IoM in February 2015. van Gool alludes to the report in the transcript excerpt suggests there is a mobilization of effort to undermine it.

Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness

The full IoM report  is freely available here

A 4-page official briefing on the IoM report is available here.

The primary message of the committee’s report is that ME/CFS is a serious, chronic, complex, systemic disease that often can profoundly affect the lives of can profoundly affect the lives of patients.

IOM diagnostic.PNGImportantly, the IOM report provided new diagnostic criteria that made post-exertional malaise (PEM) a requirement for a diagnosis. It is a defining symptom:  no PEM means no diagnosis of MEcfs is warranted.


Dutch treatment studies employed looser criteria that did not require PEM. The IOM diagnostic criteria have subsequently been used by the US Agency for Healthcare Quality Research (AHQR) to reject the relevance of any research, notably Dutch research, that did not include PEM in the entry criteria. Furthermore, patients who are characterized by PEM are likely to be harmed by cognitive behavioral therapy and graded exercise therapy, which are considered frontline treatment in current Dutch guidelines. The US Center for Disease Control would subsequently removed CBT and GET from the list of recommended treatments.

To preserve their status quo, the Dutch Health Council must discredit the IOM report.

Lou Corsius alerted the IOM to Pim van Gool and obtained this response:

The official response from the Institute of Medicine

Director IOM: Official statements President Dutch Health Council incorrect

Van: Behney, Clyde <>

Verzonden: zondag 19 juni 2016 22:40

Aan: Lou Corsius

CC: Frakes, Chelsea

Onderwerp: RE: Questions about scrutiny IOM, claims posed by president of Health Council of the Netherlands

Dear Mr. Corsius,

Thank you for bringing this matter to our attention.  The National Academies of Sciences, Engineering, and Medicine (the Academies) stand behind the Institute of Medicine (IOM) report, which was prepared by experts in the subject matter and was subjected to our rigorous peer review process before it was released, as we do for each of our studies.

I can assure you that the only way one can become a member of the National Academy of Medicine (NAM, formerly IOM) is by being elected by the members of the National Academy of Medicine based on distinguished professional achievement in a field related to medicine and health. One must first be nominated by two members of the NAM who are required to document how a nominee meets the criteria for membership and then be subsequently elected by the full membership of the NAM.

One cannot buy a membership in the NAM, nor can one buy a role as a member of one of the committees that conduct studies and produce our reports. Additionally, all members, including the chairs, of our study committees undergo a very strict review for conflicts of interest prior to their appointment, and we also notify the public about the proposed members for each of our committees twenty days before the first committee meeting so that the public can identify any potential conflicts of interest before the committee begins its work.

Thank you again for making us aware of the statements.

Very best regards,


Clyde J. Behney

Executive Director

Health and Medicine Division

National Academies of Sciences,

Engineering, and Medicine



Probing the claim a black, working-class man would have to call 80 psychotherapists to get an appointment.

Study of returned calls from psychotherapists for requests for first appointments got lots of attention in social media but were claims accurate?

hands from da VinciA recent paper  reporting results of calls to psychotherapists for a first appointment got lots of attention in social media after a story in The Atlantic  made provocative statements about  its results.

Some of the claims in the Atlantic article resonated with readers assumptions about how difficult it is to get an appointment

Even for those with insurance, getting mental healthcare means fighting and through phone tag, payment confusion, and even outright discrimination

A lot of the attention to the Atlantic article was due to prominent display of the claim:

black man would

Sure, it is plausible that a black working-class man would have a harder time getting an appointment, but it really take 80 to get a first appointment?

The Atlantic article zeroed in the interaction between gender, class, and race that was presented as more complex in the actual report of the study

Among working-class callers, the study showed equal rates of appointment offers between white and black callers; if perceived race were causing class misidentification by therapists, then one would instead expect to see lower appointment offers for black working-class callers. If anything, the true race differences within the middle class may be slightly smaller than observed, and the class differences among blacks may be slightly larger than observed. Ultimately, the sizeable and statistically significant effects support the conclusion that there is a true disadvantage to black middle-class help seekers and all working-class help seekers, relative to middle-class whites.

So maybe class mattered more than race.

The apparent strength of findings might reflect methodological weaknesses of the study and the author’s stereotypes as much as the prejudices of the therapists who were called. The Atlantic article noted:

Heather Kugelmass, a doctoral student in sociology at Princeton University, selected 320 therapists from the directory of Empire Blue Cross Blue Shield’s HMO plan in New York City. She then had voice actors call them and leave voicemail messages saying they were depressed and anxious. They asked for a weekday evening appointment. She distinguished between different income groups by altering the vocabulary and grammar in the scripts, and she used studies on African-American vernacular and Black-accented English to craft the African-American callers’ scripts. The lower-income white callers spoke in a heavy, New York City accent. All of the callers mentioned they  had the insurance that the therapists purportedly accepted.

The Atlantic article acknowledged:

And it’s hard to purposefully make a person sound poor or black. In the working-class white script, for example, the actor said “hiya doc,” instead of “hello,” and mentioned “on the website I seen your name.” The working-class black script included flourishes that bordered on cartoonish, like “a’ight?” and “my numba.”

The Atlantic article drew some strong reactions, like from a psychologist from Australia, where there are different expectations of psychotherapists:

facebook shocked.

But a Minnesota psychiatrist offered a more sympathetic view of the therapists, noting that insurance companies and managed care share some of the responsibility for the difficulties those in need have in getting a first psychotherapy appointment.

only ways to keep doors open

Finally, the Atlantic article provided some relevant statistics

Between 30 and 50 percent of psychologists run their own practices, which allows them to largely control their own schedules, client rosters, and insurance networks. About 30 percent appear to accept no insurance at all, according to the American Psychological Association, a trade group for psychologists.


More than half of all counties in the U.S. have no practicing psychiatrists, psychologists, or social workers. In any given year, about one in five Americans has a mental illness, according to the National Alliance on Mental Illness, but nearly 60 percent of those people don’t get services.

And some good quotes, like:

“If it’s a market where you pretty much have to pay for yourself, the rich are always going to win,” Stanford University psychiatry professor Keith Humphreys told KQED recently

The original study reintroduced the concept of the YAVIS patient desired by therapists, something  I have discussed with respect to psychosocial care of cancer patients. The article said

Research suggests that psychotherapists (hereafter also called “therapists”) favor help seekers with the “YAVIS” attributes: young, attractive, verbal, intelligent, and successful (Tryon 1986). Consistent with the YAVIS hypothesis, Teasdale and Hill (2006) found that therapists prefer “psychologically minded” clients and those who share similar values and attitudes. These effects were independent of the demographic characteristics (including race) of the help seekers, but the results were survey based, so social desirability pressures may have influenced the results. In another study, black patients were rated by psychiatrists as “less psychologically minded” as well as “less articulate, competent, [and] introspective” than otherwise equivalent white patients (Geller 1988:124).

The Atlantic article

Not White, Not Rich, and Seeking Therapy

The original study

Kugelmass H. “Sorry, I’m Not Accepting New Patients” An Audit Study of Access to Mental Health Care. Journal of Health and Social Behavior. 2016 Jun;57(2):168-83.


Through a phone-based field experiment, I investigated the effect of mental help seekers’ race, class, and gender on the accessibility of psychotherapists. Three hundred and twenty psychotherapists each received voicemail messages from one black middle-class and one white middle-class help seeker, or from one black working-class and one white working-class help seeker, requesting an appointment. The results revealed an otherwise invisible form of discrimination. Middle-class help seekers had appointment offer rates almost three times higher than their working-class counterparts. Race differences emerged only among middle-class help-seekers, with blacks considerably less likely than whites to be offered an appointment. Average appointment offer rates were equivalent across gender, but women were favored over men for appointment offers in their preferred time range.

eBook_Mindfulness_345x550Preorders are being accepted for e-books providing skeptical looks at mindfulness and positive psychology, and arming citizen scientists with critical thinking skills. 

I will also be offering scientific writing courses on the web as I have been doing face-to-face for almost a decade. I want to give researchers the tools to get into the journals where their work will get the attention it deserves.

Sign up at my website to get advance notice of the forthcoming e-books and web courses, as well as upcoming blog posts at this and other blog sites. Get advance notice of forthcoming e-books and web courses. Lots to see at


At least 3 reasons you don’t have to read Understanding Psychosis and Schizophrenia 2

Has the British Psychological Society lost its audience for misrepresentatingn of serious mental disorder?

understanding psychosisThe excellent post by Sameer Jauhar and Paul Morrison about the second edition of Understanding Psychosis and Schizophrenia is getting few comments. Perhaps this is because much of the second edition repeats the heavily criticized first edition, while further eliminating citation of research that would prove embarrassing to what is said.



An earlier post by Keith Laws, Alex Langsford, and Samei Huda about first edition was probably among the most accessed Mental Elf blog post ever.

Understanding Psychosis and Schizophrenia (2014) National Elf Service

I took the first edition seriously enough to respond with some heavily accessed posts my own, including one with a slideshow.

“Understanding Psychosis and Schizophrenia” and mental health service users 

Barney Carroll on domesticating psychosis [with slide show providing a detailed, evidence-based critique]

But I’m not to be lured  into a discussion again that goes nowhere with BPS authors who react like vampires to garlic whenever evidence is brought up that contradicts their cherished fixed beliefs.

Thankfully, Sameer Jauhar and Paul Morrison zero in on some key points that show the aversion to debating evidence persists. Here are three, but you can find more in their post.

Unwarranted claims that cognitive behavior therapy has effects equivalent to medication for psychosis.

The [BPS] authors state: Experiencing multiple childhood traumas appears to give approximately the same risk of developing psychosis as smoking does for developing lung cancer.

They cite a study where items on a screening questionnaire correlated with recall of adverse events, with an odds ratio of 11 (Bentall et al., 2012).

They state half of people who experience psychosis will experience problems only once, and recover completely, quoting a review which cites 9 studies.

On average, people gain around as much benefit from CBT as they do from taking psychiatric medication.

The authors cite various meta-analyses, but the effect sizes given are not comparable to those for psychotropic medication, especially when considering effects of blinding, even taking into account criticisms regarding included studies (Jauhar et al., 2014), see below.

The discussion thread on the earlier edition of UPS by Keith Laws and colleague drew heavily on Jauhar et al’ excellent meta analysis to demolish claims about the effectiveness  of CBT. That the authors don’t now cite it at all is telling. I don’t believe in the repression of traumatic memories, but I do believe in authors selectively citing only evidence that fits with their biases.

 Exaggerated claims that trauma is strongly linked to psychosis

The [BPS] authors state:

Experiencing multiple childhood traumas appears to give approximately the same risk of developing psychosis as smoking does for developing lung cancer.

They cite a study where items on a screening questionnaire correlated with recall of adverse events, with an odds ratio of 11 (Bentall et al., 2012).

They state half of people who experience psychosis will experience problems only once, and recover completely, quoting a review which cites 9 studies.


It is mathematically impossible to explain how the factors they give could contribute to the prevalence they mention; the odds ratio for childhood trauma is between 2-4 in most meta-analyses (Morgan and Gayer‐Anderson, 2016) (with methodological limitations). The odds ratio for smoking and lung cancer varies depending on smoking status and cell type, anywhere up to around 100 (Pesch et al., 2012) and evidence they put for a similar association is based on items from a screening questionnaire that measures phenomena that are not related to what people conventionally call psychosis. Even then, the odds ratio of 11 does not sit well with odds given for current smokers and lung cancer.

Put simply, not everyone who experiences psychosis (however defined) has these risk factors, and not everyone who has these risk factors develops psychosis.

Exaggerated recovery rates for schizophrenia and other psychosis

The review stating 50% of people have recovery at follow-up is not a systematic review. A more recent systematic review suggested that only 13% of people with a diagnosis of schizophrenia met the criteria for recovery (Jääskeläinen et al., 2013). Long-term follow-up of people presenting with first episode psychosis show significant heterogeneity in symptomatic and functional outcome: a multi-centre UK first-episode study showing, in geographically defined populations, that 50% were in symptomatic remission at 10 years (a number of whom were taking antipsychotics), though only 15% fulfilled criteria for functional recovery (Revier et al., 2015).

Preorders are being accepted for e-books providing skeptical lookseBook_PositivePsychology_345x550 at mindfulness and positive psychology, and arming citizen scientists with critical thinking skills. Right now there is a special offer for free access to a Mindfulness Master Class. But hurry, it won’t last.

I will also be offering scientific writing courses on the web as I have been doing face-to-face for almost a decade. I want to give researchers the tools to get into the journals where their work will get the attention it deserves.

Beware of the pinkwashing of suicide prevention

Cause marketing of cosmetics to prevent suicide could mark the return of exploitation of a good cause for profit.

Just as with we learned with Breast Cancer Pink Ribbon campaigns, we need to ask questions about what is being accomplished, where the profits are going and whether we should object.

Two companies announced special deals on cosmetics to reduce suicide.

Brandt Skincare ‘s $38 limited-edition #sayiloveyou skin-care kit

brandt kit with tattooBrandt skin care announced it was launching a special deal in #sayiloveyou skin-care kit for suicide awareness month


After renowned celebrity dermatologist Dr. Fredric Brandt died by suicide in 2015, his friends and colleagues (given that he was known for being unfailingly warm and outgoing, the two often overlapped) started the Dr. Brandt Foundation in his honor to raise awareness by encouraging meaningful, empathetic conversations around mental illness and provide a support system for those whose lives have been affected by its devastating effects.

This Sunday, to coincide with Suicide Prevention Awareness Month, the Foundation is set to launch a new social media campaign to help raise money, promote understanding, and encourage fans and followers to join the fight against suicide and depression. Getting involved is easy: For every image of a heart posted to Instagram with the hashtag #sayiloveyou, the Foundation will donate $1 to its suicide prevention project up to $100,000.

Dr. Brandt Skincare will also offer a $38 limited-edition #sayiloveyou skin-care kit, available September 10, that includes a collection of the brand’s best-selling products, a signature tote bag, and a temporary heart tattoo (yes, for the ‘gram), with a percentage of the proceeds going to the Dr. Brandt Foundation. (Of course, you can always donate directly to the cause, too.)

Not to be outdone, NYX announced #LuvOutLoud

way to go

NYX’s #LuvOutLoud donates $6,000 to The Trevor Project, a non-profit that helps provide support and suicide prevention for LGTBQ youth.

Whether it’s black lipstick, bold brows, or something as simple as faux freckles, makeup can send a meaningful message about who you are, what you stand for, and the way you want to be seen. But the process of turning your personal beauty choices into part of your identity can start even before it makes its way to your face, like when you buy a tube of Luv Out Loud, a new collection of liquid lipsticks from NYX Professional Makeup,.


The lipsticks don’t just represent the NYX mantra of “inclusivity, acceptance, and artistry for all” in name alone: The brand teamed up with makeup artist and social-media influencer Angel Merino, aka @mac_daddyy, to donate $6,000 to The Trevor Project, a non-profit that helps provide support and suicide prevention for LGTBQ youth.

NYX’s new lipstick line supports the LGBTQ+ community 

Makeup for the win!

NYX has new matte lipsticks coming out — and they benefit a beautiful cause. It’s always great when our makeup addictions serve a higher purpose, right?

The brand has partnered with celebrity makeup artist Angel Merino to raise money for the LGBTQ+ community with its Luv Out Loud collection.

NYX and Angel will donate $6000 to The Trevor Project — an organization that fights to keep suicide rates down among LGBTQ+ youth.

The brand is also hosting a contest that allows people to enter to win $10,000 that will be donated to the charity of their choice.

All you have to do is post a video of yourself talking about how a part of your life represents one of the empowering shade names in the new collection.

“It’s déjà vu all over again.” – Yogi Berra 


Pinkwashing was first applied to:

The practice of a company using support of breast cancer-related charities to promote itself and its products or services.

But then became:

(LGBT) The practice of a state or company presenting itself as gay-friendly and progressive, in order to downplay their negative behavior.

Pink Ribbon Blues

folgersBreast Cancer, Concept Brand with Pink Ribbon Logo Breast Cancer, Concept Brand with Pink Ribbon Logo

Gayle Sulik, author of Pink Ribbon Blues: How Breast Cancer Culture explained:

A brand must inspire people to spread the word about your “product.” One of most powerful ways to do this is through an emotional connection that encourages consumers to identify with the brand message.

Nike’s “Just Do It” slogan with accompanying “swoosh” logo dared consumers to take action and challenge themselves. Igniting a purpose beyond the mere purchase of athletic gear, the company tapped into an American belief about the importance of hard work and getting ahead. Many brands are designed to influence how people think of themselves. Am I classic, trendy, healthy, conscientious, rugged, interesting? In the context of Nike’s product line, “doing it” also meant engaging in physical activity that likely required Nike gear. But it was the message not the product that led to sales.

The pink ribbon works in a similar way. It functions as a logo for a “set of expectations, memories, stories and relationships that, taken together, account for a consumer’s decision to choose” the breast cancer brand.

The breast cancer brand draws from a collection of symbols, images, and meanings within pink ribbon culture to maintain the principal message that breast cancer is a vitally important cause, and that supporting it indicates good will toward women. The brand encourages people to buy and display pink in the name of increased awareness, improvement in women’s lives, faith in medical science, and hope for a future without breast cancer. The brand capitalizes on emotional responses related to fear of the disease, hope for a cure, and the goodness of the cause.

pinkwashed productsThe movie Pink Ribbon Blues, Inc slammed “pink-washing” in breast cancer marches and awareness campaigns

The film questioned

the priorities of the campaigns and the broad use of the pink-ribbon logo as a fight-breast-cancer addition to products as diverse as T-shirts, toilet tissue and handguns.



“For me, pink ribbons were something very innocent,” said Lea Pool, director of the made-in-Canada documentary, which emphasizes the corporate sponsors of many of the events.

“I think it’s still not a bad idea, but I was very afraid of all the corporations and how they hijacked the disease and how they made profits out of that, and how there is pink-washing in the process of doing fund-raising.”


“It’s not about raising money it’s asking the question about where that money is going,” said Pool. Coining a phrase from an activist web site, she added: “Think before you pink.”

Think Before You Pink

Breast Cancer Action launched an effective campaign to get people asking questions before they participated or donated to a breast cancer walk.

Each year, hundreds of thousands of people come together to participate in breast cancer walks and runs across the U.S. Since the first breast cancer walks began in the 1980s, they have become one of the most common ways for people to try to do something about breast cancer.

Some of these walks have become huge affairs that are hosted by multi-million dollar charities and sponsored by multi-billion dollar corporations that raise millions to “end breast cancer.” And yet each year, 250,000 women are diagnosed with breast cancer and 40,000 women die of this disease.

NFL cheerleaderThe NFL Pink October, A Perfect Catch was launched and  came under particular scrutiny

NFL’s A Perfect Catch

Overview of the NFL’s Fundraising Efforts for the American Cancer Society

The NFL does not profit from the sale or auction of breast cancer awareness-identified (“Pink”) merchandise. Since 2009, the first year of the NFL’s “A Crucial Catch” campaign, the NFL’s work has raised approximately $4.5 million for the American Cancer Society, with the majority of the contribution coming from the sale of Pink items at retail and via the NFL Auction website. Beginning with the 2011 “A Crucial Catch” Campaign, money raised via the campaign supports the American Cancer Society’s Community Health Advocates National Grants for Empowerment (CHANGE) program. This program promotes health equity and addresses cancer screening disparities through community based cancer prevention and early detection programs that increase access to breast cancer screenings. The program officially launched in 2012 within 17 communities across the country (each within 100 miles of an NFL city) where data showed that the population had lower breast cancer screening rates and higher mortality rates relative to other communities. The goal of the program is to add multiple locations in 2013 and beyond; and assist even more women in their efforts to prevent cancer and find cancer early.

buy pink nfl

Here’s why the NFL’s annual pink campaign does almost nothing to fight breast cancer

The NFL has its own perilous health issues that the league has attempted to cover up. And in fact, they toned down all the pink last year in what appeared to be an effort to avoid looking too hypocritical – after the league bungled several domestic violence cases involving players.

The issue with football’s self-congratulatory awareness month goes beyond pink pom-poms, pink penalty flags and pink cleats. Hardly any of the money raised during this month even reaches the American Cancer Society. But the criticism – many from breast cancer survivors – hasn’t phased the NFL or many of its partners.


Business Insider wrote in 2013 that just 8.01 percent of money from NFL Breast Cancer Awareness merchandise goes to research efforts. Even worse, VICE Sports reported last year that none of that money goes toward cancer research programs. A spokeswoman for the American Cancer Society told VICE the NFL donations go to awareness, education and screenings.

The NFL program promoted breast cancer screening without regard to the evidence questioning its effectiveness and risks versus benefits, especially among younger women.

“Screening doesn’t save lives and screening mammography … is different from diagnostic mammography,” Jagger says. “The NFL has no business providing medical advice to women that is outdated, unproven, and misguided.”

Jagger quotes well-regarded and independently conducted research that shows screening mammography has no overall impact on survival rates of women with the disease.

The NFL Won’t Turn Pink In 2017

After eight straight Octobers of painting fields, cleats, and helmets with pink ribbons, the NFL has decided to discontinue its “pink October” initiative, The MMBQ reports.

Since 2009, NFL games in the month of October have featured football players wearing pink in support of awareness and screening initiatives alongside the American Cancer Society. However, the league will now expand the campaign in an effort to raise awareness and screening for other forms of cancer as well.

The new campaign, which will keep the original name of “A Crucial Catch,” will allow individual teams to choose the cause that they’ll champion during a three-week window in October.

The move comes after years of criticism that the NFL’s “pinkwashing” actually does very little for breast cancer patients in terms of funding research for the cure. The new campaign will still focus on education and screenings, instead of raising funds for research.

I am offering e-books providing skeptical eBook_Mindfulness_345x550lookseBook_PositivePsychology_345x550at mindfulness and positive psychology, and arming citizen scientists with critical thinking skills so they dan decide for themselves. I am also offering scientific writing courses on the web as I have been doing face-to-face for almost a decade. I want to give researchers the tools to get into the journals where their work will get the attention it deserves.

Sign up at my website to get advance notice of the forthcoming e-books and web courses, as well as upcoming blog posts at this and other blog sites. Get advance notice of forthcoming e-books and web courses. Lots to see at

How advice gurus sell more products when corporations discover mindfulness training doesn’t work

competative advantage

Corporations purchasing expensive mindfulness training packages for corporate leadership and rank and file employees inevitably discover they do not obtain the benefits that are claimed for mindfulness. How can this become a strategic opportunity for advice gurus to sell more products?

value of happinessIn a recent article in Harvard Review of Business (HBR) article, Daniel Goleman and Matt Lippincott deftly explain that if corporations still believe in the promises of mindfulness, they should purchase their product, training in emotional intelligence. They claim the support of unpublished research, but, as we will see, the published research casts doubts on their product being backed by much evidence.

book cover_24582677-2ecc-4456-a2c1-c2eadfcb8d5b.jpgNo matter. We have a fascinating example of associations with Harvard, research, and University of Pennsylvania being used to brand an advice product as effective and backed by science.  It is a strategy that Amy Cuddy used to present herself as an advice guru before the launch of power posing. Elizabeth Dunn and Michael Norton use the HRB to launch their campaign for the science of smarter spending, how money can buy you happiness, if you follow their advice.

The click link “What really makes mindfulness works” suggests an article from Harvard Review of Business explainswhat really makes mindfulness training work. Actrually, the article actually pitches products for when corporations find mindfulness does not  live up to expectations.

Without Emotional Intelligence, Mindfulness Doesn’t Work

The first two paragraphs skillfully criticize mindfulness as a fad, but argue for a “complicated relationship” between mindfulness and improved executive performance, setting the reader up for a pitch for their product, which provides a more effective route.

Mindfulness has become the corporate fad du jour, a practice widely touted as a fast-track to better leadership. But we suspect that not all the benefits laid at its feet actually belong there. Our research and analysis has revealed a complicated relationship between mindfulness and executive performance—one that is important for leaders to understand as they seek to develop in their careers.

 Mindfulness is a method of shifting your attention inward to observe your thoughts, feelings, and actions without interpretation or judgment. A mindfulness practice often begins simply by focusing on your breath, noticing when your mind wanders, and then bringing it back to your breath. As you strengthen your ability to concentrate, you can then shift to simply noting your inner experience without getting lost in it at any point in your day. The benefits attributed to this kind of practice range from stronger relationships with others to higher levels of leadership performance.

The next paragraph introduces Sean, “a senior leader at a Fortune 100 corporation” who will tell you that mindfulness played a critical role in transforming his career.

To allay readers’ suspicions that Sean may be a fiction contrived by the authors to make a point, they next claim he is one of  “42 senior leaders from organizations throughout the world who practice mindfulness and whom one of us (Matt Lippincott) studied at the University of Pennsylvania.”

This “research” is described in HBR as producing a promoter’s dream list of benefits to practicing mindfulness. Unfortunately, no link is provided to an actual report of methods and results.

I Googled Matt Lippincott. A link to ResearchGate came up

Lippincott has no published research listed, but there was a link to an unpublished dissertation.

This qualitative research study examined detailed reports by senior organizational leaders linking mindfulness to improved leadership effectiveness. Extensive research supports the existence of a relationship between mindfulness and cognitive, physiological, and psychological benefits that may also have a positive impact on leadership effectiveness. Currently, however, little is known about the processes potentially enabling mindfulness to directly influence leadership effectiveness, and as a result this study was designed to explore this gap in the literature. Data was collected through in-depth interviews with forty-two organizational leaders in North and South America and Europe, many with a history of leadership roles at multiple global organizations. Participants credited mindfulness for contributing to enduring improvements to leadership capabilities, and data analysis revealed new findings clarifying the perceived relationship between mindfulness and tangible results for organizational leaders. Specifically, the results indicate that mindfulness is perceived to contribute to the development of behaviors and changes to awareness associated with improved leadership effectiveness. A potential relationship between mindfulness and the development of emotional intelligence competencies linked to increased leadership performance was revealed as well. The contribution of this study to current literature is also discussed, as are recommendations for future research.

So a dissertation with a weak methodology that allows invoking “research” and “University of Pennsylvania” for credibility.

Back to the wrap up of the HBR article, we get the buy-our-product punch line:

We believe that by focusing on mindfulness-as-corporate-fad, leaders run the risk of missing other opportunities to develop their critical emotional skills. Instead, executives would be better served by deliberately assessing and improving their full range of emotional intelligence capabilities. Some of that work may well involve mindfulness training and practice, but it can also include formal EQ assessment and coaching. Other tools and approaches include role-playing, modeling other leaders you admire, and rehearsing in your mind how you might handle emotional situations differently. By understanding that the mechanism behind mindfulness is the improvement of broader emotional intelligence competencies, leaders can more intentionally work on all of the areas that will have the strongest impact on their leadership.

The two authors

Daniel Goleman is Co-Director of the Consortium for Research on Emotional Intelligence in Organizations at Rutgers University, co-author of Primal Leadership: Leading with Emotional Intelligence, and author of The Brain and Emotional Intelligence: New Insights, Leadership: Selected Writings, and A Force For Good: The Dalai Lama’s Vision for Our World. His latest book is Altered Traits: Science Reveals How Meditation Changes Your Mind, Brain, and Body.

Matthew Lippincott is a business owner, researcher, and author involved in the creation of new leadership development solutions. He holds a doctoral degree from the University of Pennsylvania, and has previously held leadership positions at two of the world’s largest software companies.

We get a sense of former Psychology Today editor Daniel Goleman trying to create a brand of advice that unites the Dalai Lama, the good, and corporate competitiveness. Lippincott has delivered a Penn Wharton dissertation uniting mindfulness and emotional intelligence. He got work on this basis.

Hmm, did the link emerge from the data, or is this dissertation simply an informercial aimed at getting a job marketing the combo of mindfulness and emotional intelligence?

The scientific status of emotional intelligence

According to Wikipedia:

Emotional intelligence (EI) is the capability of individuals to recognize their own and other people’s emotions, discern between different feelings and label them appropriately, use emotional information to guide thinking and behavior, and manage and/or adjust emotions to adapt to environments or achieve one’s goal(s).[1]

Although the term first appeared in a 1964 paper by Michael Beldoch, it gained popularity in the 1995 book by that title, written by the author, psychologist, and science journalist Daniel Goleman. Since this time, Goleman’s 1995 analysis of EI has been criticized within the scientific community,[2] despite prolific reports of its usefulness in the popular press.

The Wikipedia offers three stinging critiques backed by links to references.

Emotional intelligence cannot be recognized as form of intelligence

Goleman’s early work has been criticized for assuming from the beginning that EI is a type of intelligence or cognitive ability. Eysenck (2000)[57] writes that Goleman’s description of EI contains unsubstantiated assumptions about intelligence in general, and that it even runs contrary to what researchers have come to expect when studying types of intelligence:

“[Goleman] exemplifies more clearly than most the fundamental absurdity of the tendency to class almost any type of behavior as an ‘intelligence’… If these five ‘abilities’ define ’emotional intelligence’, we would expect some evidence that they are highly correlated; Goleman admits that they might be quite uncorrelated, and in any case if we cannot measure them, how do we know they are related? So the whole theory is built on quicksand: there is no sound scientific basis.”

Emotional Intelligence confuses skills with moral qualities.

Adam Grant warned of the common but mistaken perception of EI as a desirable moral quality rather than a skill, Grant asserting that a well-developed EI is not only an instrumental tool for accomplishing goals, but has a dark side as a weapon for manipulating others by robbing them of their capacity to reason.

Emotional Intelligence has little predictive value.           

Landy (2005)[61] claimed that the few incremental validity studies conducted on EI have shown that it adds little or nothing to the explanation or prediction of some common outcomes (most notably academic and work success).

Some further links I also discovered

Steve Topak’s Don’t Believe the Hype Around ‘Emotional Intelligence’ 

What if I said that emotional intelligence is the ability to recognize, understand and control emotions – not just our own but the emotions of others, as well? What if I said it can be used to manipulate behavior? That sounds a bit different, doesn’t it? Not such a no-brainer anymore, is it?


This is not some sort of rhetoric slight of hand nor is that definition controversial. It’s common doctrine. But if authors, consultants and executive coaches were to say that Adolf Hitler was as adept at emotional intelligence as Martin Luther King Jr. – as Adam Grant explains in The Atlantic – they would not sell many books or book a lot of gigs.

Excerpts from a nice comprehensive review

Kilduff M, Chiaburu DS, Menges JI. Strategic use of emotional intelligence in organizational settings: Exploring the dark side. Research in organizational behavior. 2010 Dec 31;30:129-52.

Just as the cognitively smart person may be able to understand options and draw conclusions quickly and competently, so the emotionally intelligent person may be able to assess and control emotions to facilitate the accomplishment of various goals, including the one of getting ahead. We suggest that high-EI people (relative to those low on EI) are likely to benefit from several strategic behaviors in organizations including: focusing emotion detection on important others, disguising and expressing emotions for personal gain, using misattribution to stir and shape emotions, and controlling the flow of emotion-laden communication.


We have shown that the strategic disguise of one’s own emotions and the manipulation of others’ emotions for strategic ends are behaviors evident not only on Shakespeare’s stage but also in the offices and corridors where power and influence are traded.

Take away messages.

Don’t expect top quality science from Harvard Business Review, but sliced and diced stuff to sell products a research-based.

Be skeptical of researchers who promote their studies in HBR. They are often publishing an infomercial that to be effective must make extravagant claims that require stronger and more unambiguous findings than research  can possibly produce.

eBook_Mindfulness_345x550I will soon be offering e-books providing skeptical lookseBook_PositivePsychology_345x550 at mindfulness and positive psychology, and arming citizen scientists with critical thinking skills so they dan decide for themselves. I also be offering scientific writing courses on the web as I have been doing face-to-face for almost a decade. I want to give researchers the tools to get into the journals where their work will get the attention it deserves.

Sign up at my website to get advance notice of the forthcoming e-books and web courses, as well as upcoming blog posts at this and other blog sites. Get advance notice of forthcoming e-books and web courses. Lots to see at

Acceptance and Commitment Therapy and Positive Psychology: Theoretical integration or product line expansion?

doritosDoes combining ACT and positive psychology yield something like a Nacho Cheese Doritos® Locos Tacos Supreme? A product line expansion for ACT?

As documented in a previous blog post, the founders of Acceptance and Commitment Therapy seem to be crafting themselves as workshop gurus. This is at the expense of attending to the pressing need to develop a base of evidence appropriate to the claims being made for the efficacy of ACT.

By the usual standards, the evidence is weak that ACT is an effective treatment for any of a range of clinical problems. There is no evidence that ACT is superior to the already disseminated psychotherapies its promoters would replace.

ACT joining forces with the huge  positive psychology movement could be a strategic next step, if expanding the market for ACT products is the goal. There are obvious theoretical differences between ACT and positive psychology, but signs are that these differences are sidestepped in joint marketing ventures. Press releases are on the web for a “historic “captains of both ships” Barbara ‘Positivity’ Fredrickson and Steven ‘ACT’ Hayes having a “historic meeting in Berlin.

Talks by Fredrickson and Hayes are also jointly being promoted here. 

A historic meeting of Positive Psychology and ACT

Zegers Hein interviews  Barbara Fredrickson & Steven Hayes

Some excerpts from the article and interview:

Positive Psychology and ACT (Acceptance and Commitment Therapy) are different movements within psychology. Yet they also have quite a lot in common. We witnessed the two captains of both ships meet for the very first time: Barbara ‘Positivity’ Fredrickson and Steven ‘ACT’ Hayes. Here is an exclusive report of this historic meeting in Berlin, Germany1. This meeting is indicative of Positive Psychology 2.0, the so-called ‘second wave positive psychology’ that embraces ‘negative’ emotions. Questions are raised that are highly relevant for this MOOC, such as: Would you prefer to feel all kinds of emotions or just to be happy? Can ‘negative’ emotions be positive?

Positive Psychology and Acceptance and Commitment therapy (‘ACT’ for short, pronounced as one word) both appeared at about the same time within the history of psychology. Since its inception, Positive Psychology has always held ‘The Meaningful Life’ as a central pillar. Similarly, within ACT, moving towards meaningful ‘Valued Living’ is a core process. What, then, are the differences between both movements?

Positive’ Psychology vs. ‘Dark’ ACT?

Fredrickson: ‘Positive Psychology, to me, is not a separate domain of psychology. It’s an emphasis, a leaning, a call within psychology to also focus on positive aspects.’ But isn’t this positive emphasis different from what ACT proclaims?

Hayes: ‘When ACT first got popular attention with a story in ‘Time’, this story was titled ‘Happiness is not normal’. Which is of course something we’d never said, but some reporter wrote down. Another headline of that time was ‘Hello Darkness’. And I get that (laughs). From the beginning, we’ve cared about meaning and purpose and values-based action. Constructing the sort of lives that make life worth living.’ Turning towards his neighbor: ‘And Barbara has, throughout her career, really focused on the relationship between positive emotions and behaviour. And that is of central importance, I think, to ACT.’

Sweet Sadness

ACT consciously tries to avoid labeling emotions ‘positive’ or ‘negative’. How would you define positive emotions for ACT? Hayes: ‘It seems to be so contextually bound, that you can flip it. Take for instance sadness, is that negative? Clearly not. If my mother died last spring, sadness is what I would want, right? Is that a negative emotion? No, it’s not a negative emotion. In fact, are there any negative emotions (that are not contextually bound)? If you live them fully, and put them into your life that leads you in a values-based direction?’

So what ‘negative’ are we talking about here? Fredrickson: ‘I think that, as a field, we’ve inherited some language in terms of calling classes of emotions ‘positive’ and ‘negative’, and there’s so much levels at which you could define that ‘positive’ and ‘negative’. I think that what’s meant by it, is this: ‘If all other things were equal, would this be a wanted state? Would you want the state to continue?’ Hayes nods in agreement when Fredrickson continues: ‘Negative emotions are useful if connected to context, but become negative if disconnected from context.’

When pressed for a further clarification of this distinction, Fredrickson continues: ‘I think of it as a can opener. Positive emotions, or hedonic well-being, is a way to open people up, in a way so they can see and appreciate more meaning. And experiencing meaning more is in itself an emotional uplift too’.

‘By the way, speaking of opening up’, Fredrickson smiles, ‘another illustration may be the licence plate I have chosen to put on the car I drive. The licence plate on my car reads: “Be Open”.’

Choose to feel

Hayes: ‘Exactly. Be Open. And for me, that includes openness to sadness. The point is that openness to sadness – including seeing the suffering of others, and being moved by it – is critical to compassion and happiness. Said in another way, the poets are right: it is our tears that scoop out a place for our laughter to reside.

But Barbara’s license plate on her car is right on: ‘Be Open’. Note, it is not “Be Happy.” It’s “Be Open”’, Hayes points out. ‘I have a similar sign on the wall of my office: “Choose to Feel.”

None of this is in any way theoretically clear, but maybe it is unfair to apply the standards of an entirely different form of discourse.  “Pepsi’s the One”  is advertising, not a theoretical propositon or an evidence-bassed statement. Probably the same for some of the sloganeering in this interview. But was does this do for the credibility of Hayes and Fredrickson when they want to speak more seriously?

I can’t wait for next year’s model, Positive Psychology 2.0, or did I miss it and  now have to wait for the fall release of Positive Psychology 3.0?

Personally, I am a great fan of traditional tacos and all their regional Latin Amercian variations. Some neuva ola and fusion tacos are tasty, too. But  I can’t bring myself even to go near a Nacho Cheese Doritos® Locos Taco Supreme. Just not authentic enough and the fake cheese is gross.

eBook_PositivePsychology_345x550I will soon be offering e-books providing skeptical looks at positive psychology and mindfulness, as well as scientific writing courses on the web as I have been doing face-to-face for almost a decade.

Sign up at my website to get advance notice of the forthcoming e-books and web courses, as well as upcoming blog posts at this and other blog sites. Get advance notice of forthcoming e-books and web courses. Lots to see at

Electroconvulsive therapy: a crude, controversial out-of-favor treatment?


quick takes

Recently there was a debate on Twitter about the safety and efficacy of an important treatment, electroconvulsive therapy (ECT). Maybe on Twitter everybody is entitled to their opinion, but I think it is our right and responsibility when medically important information is being discussed, that we challenge opinions been expressed without substantiation. We do it all the time with quack medical advice and self-help gurus, we should do it more often with advice offered to vulnerable persons facing difficult medical decisions.

my prioritizing parakeets

tenorThis is the first of a series of quick digests of the literature concerning electroconvulsive therapy. It’s intended to aid mental health professionals having discussions with seriously depressed persons and their families concerning treatment options.

In the Twitter discussion, we saw far too many clinicians and persons posing as clinicians offering unsubstantiated opinions. Some were simply well-meaning, but ill informed. Some were quacks. Others had an ideological commitment that they wanted to promote, but not expose to debate. We should call them out.

A lot of what I will be offering over coming post about ECT will be current and classic literature. However I will try to include more accessible sources as well. Where possible, I will link the two.

In this blog post I start with an excerpt from an article in The Conversation that is available for reposting and excerpting under its creative Commons license. The article’s author, George Kirov  is a Clinical Professor at Cardiff University who supervises the ECT delivery in Cardiff.

Electroconvulsive therapy does work – and it can be miraculous

The use of electroconvulsive therapy (ECT) to treat psychiatric disorders is on the rise in England, according to a new report in the Guardian. There was an 11% rise in the number of procedures performed on the NHS between 2012-13 and 2015-16.

ECT involves passing an electric current through the head of an anaesthetised patient. The aim is to produce an epileptic fit. It is used mostly to treat severe or treatment-resistant depression, but it can also have beneficial effects in some cases of mania and schizophrenia.

Its therapeutic effect was discovered in 1938. Today, it remains the most effective treatment for severe depression. Yet, for some reason, it is always presented in a negative light. Not least in The Guardian’s latest report where it is described as “a crude, controversial treatment, which fell sharply out of favour around the turn of the millennium”. Cue the inevitable debate about the treatment.

Although presented as “exclusive data” in the Guardian, the authors largely reiterate the data collected by the body that monitors ECT in the UK: the ECT Accreditation Service (ECTAS). The data is freely available on the Royal College of Psychiatrists website and counted 2,148 courses of ECT given during 2014-2015.

A quick glance through the ECTAS document can tell us a lot about the nature of the illnesses treated with ECT and the remarkable outcomes: 51.7% of people were rated as “severely ill” and another 18.7% as “among the most severely ill” prior to ECT. At the end of their treatment, however, 74.4% were “much improved/very much improved”, while only 1.7% had deteriorated. This is a treatment reserved for the most severely depressed patients, and it produces unrivalled improvements. Despite this, it is still a treatment that has its passionate opponents.

What does the evidence show?

Let us consider some of the arguments of the opponents. Speaking to The Guardian, Richard Bentall, a professor of clinical psychology at the University of Liverpool, said he “doesn’t believe that there are adequate clinical trials of ECT to establish its effectiveness” and that the design of trials had not been “up to scratch”. In other words, we are not sure that ECT works.

But there have been plenty of trials. A review in The Lancet listed the various ways ECT had been tested over the years. ECT has been compared with simulated ECT (six trials, all favouring real ECT). ECT has been compared with drugs in 13 trials (11 favoured ECT). Bilateral ECT was more effective than unilateral (that is, treatments given to the whole brain are more effective than those given to half of the brain). And, finally, six trials that compared higher electric charges with lower electric charges found that higher charges produced greater improvements.

Still, every few years the opponents of ECT demand more evidence. In response to such demands, a large study was conducted in the US (the CORE report on 253 patients) and the results were published in 2004. The study set the bar for improvement very high: it required depressed patients to have almost no symptoms on two consecutive measurements at the end of the treatment period. Three-quarters of patients reached those remission criteria. No other treatment in psychiatry has come even close to such effects

I suspect that the opponents of ECT will still reject the evidence from new trials – after all, one can find something “not up to scratch” with anything, if one has already formed a strong belief. Perhaps such people might be persuaded if they go to an ECT clinic and witness one of the miraculous changes that can occur there. I do this with medical students who come to observe one session of ECT, as part of their education.

Every few weeks, we have a patient who enters the treatment room mumbling incoherently, or telling us that they are a sinner deserving to be punished, or complaining that they have no intestines or some other vital body part or function. And, after a single bout of ECT, while still in the recovery room, some of these patients start talking coherently and change the topic away from their tormenting delusions. The students come back, after exchanging a few words with the patients, with their jaws dropped and a sense of disbelief in their eyes. This does not happen every day, and usually takes more than one session, but you only need to see it once to remember forever that ECT does work.

A now classic article cited in The Conversation

The UK. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet. 2003 Mar 8;361(9360):799-808.

A free summary of it in Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Results of the review

Seventy-three RCTS were included in the review. In addition, fourcohort studies and three observational studies were also identified.

The authors noted that a meta-analysis of the data on short-term efficacy from RCTs was possible. Real ECT was significantly more effective than simulated ECT in reducing depressive symptoms (6 RCTs, n=256); the standardised effect size (SES) was -0.91 (random-effects) (95% confidence interval, CI: -1.27, -0.54). At 6 months, no significant difference was noted. There was no significant difference between the ECT and simulated ECT for premature discontinuation (3 trials). No deaths were reported.

Treatment with ECT was significantly more effective than pharmacotherapy in reducing depressive symptoms (n=1,144; SES -0.80, 95% CI: -1.29, -0.29). Discontinuation was typical in both groups, but significantly lower in the ECT arm (risk difference 0.03, 95% CI: -0.09, -0.03). Four trials in this group had discontinuations in the pharmacotherapy arm only. One trial reported a death in each group.

Bilateral ECT was more effective than unipolar ECT (n=1,408; SES 0.32, 95% CI: -0.46, 0.19). Six trials reported that the times to orientation were longer for patients treated with bilateral ECT than for those treated with unilateral ETC. Four trials reported the results from testing retrograde memory within a week of the end of the course of ETC.

Observational studies: four non-randomised cohort studies were found, of which three reported lower overall mortality in patients treated with ECT and one showed no difference. Funnel plots did not reveal any publication bias.

Authors’ conclusions

ECT was shown to be an effective short-term treatment for depression and is probably more effective than drug therapy. Bilateral ECT is moderately more effective than unilateral ECT, while high-dose ECT is more effective than low-dose ETC.

The DARE summary includes evaluation of the quality of the evidence that is reviewed and the quality with which it is reviewed.

A classic article by Max Fink, whose international reputation is grounded in evidence-based appraisals of ECT research, including his own citation classics.

Fink M, Taylor MA. Electroconvulsive therapy: evidence and challenges. JAMA. 2007 Jul 18;298(3):330-2.

Remission Efficacy for Depressive Illness Many studies documenting the efficacy of ECT for depressive illness have been published,3 finding ECT superior to “sham” ECT and to medications in the treatment of patients with severe depressive illness. Two multisite collaborations—the Consortium for Research in ECT (CORE)4 and Columbia University Consortium (CUC)2—studies are illustrative. Both were designed to examine relapse prevention after successful ECT involving patients with major unipolar depression. The 2  patient groups were similar in mean age (55 and 59 years), sex ratio (70% female), and pretreatment severity (mean Hamilton Depression Scale scores, about 34).Index episode duration was 24 to 31weeks (CUC study) and 45 to 49 weeks (CORE study). At remission, themean Hamilton scores were 5 to 6(±3). Remission rates were 55% (159 of 290 patients completing the CUC study) and 86% (341 of 394 patients completing the CORE study). These results compare favorably to the initial 30% remission rate with citalopram and the remission rates of about 23% with bupropion, 21% with sertraline, and 25% with venlafaxine for patients who did not respond to citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial of outpatients with nonpsychotic major unipolar depression.5

A recent large scale study of inpatient mortality

Liang CS, Chung CH, Tsai CK, Chien WC. In-hospital mortality among electroconvulsive therapy recipients: A 17-year nationwide population-based retrospective study. European Psychiatry. 2017 May 31;42:29-35.

ECT recipients had lower odds of in-hospital mortality than did those who did not receive ECT.


Using data from the Taiwan National Health Insurance Research Database from 1997 to 2013, we identified 828,899 inpatients with psychiatric conditions, among whom 0.19% (n=1571) were treated with ECT.


We found that ECT recipients were more frequently women, were younger and physically healthier, lived in more urbanized areas, were treated in medical centers, and had longer hospital stays. ECT recipients had lower odds of in-hospital mortality than did those who did not receive ECT. Moreover, no factor was identified as being able to predict mortality in patients who underwent ECT. Among all patients, ECT was not associated with in-hospital mortality after controlling for potential confounders.


ECT was indicated to be safe and did not increase the odds of in-hospital mortality. However, ECT appeared to be administered only on physically healthy but psychiatrically compromised patients, a pattern that is in opposition with the scientific evidence supporting its safety. Moreover, our data suggest that ECT is still used as a treatment of last resort in the era of modern psychiatry.

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