Wednesday, November 23, 2011

Irving Kirsch to debate Ian Anderson on antidepressants

And in other events-related-to-topics-I've-covered news, there will apparently be a debate this week at the 4th International Congress on Psychopharmacology of the Turkish Association for Psychopharmacology between Irving Kirsch and Ian Anderson on the proposition "Antidepressants are useful in the treatment of depression."

I agree with PZ about the usefulness of debates in deciding empirical matters, but I would love to see the video of this one!

(Duncan Double at Critical Psychiatry, where I first read about the debate, takes issue with a statement from Daniel Carlat, and I have a problem with it as well. Carlat says: "Unfortunately we know a good bit less about what we are doing than you might think...When I find myself using phrases like 'chemical imbalance' and 'serotonin deficiency', it is usually because I'm trying to convince a reluctant patient to take a medication. Using these words makes their illness seem more biological, taking some of the stigma away." Setting aside momentarily the ethics of claiming knowledge you don't possess and even suspect to be false in order to convince someone to take a drug, the question of removing an alleged stigma is an empirical one. Carlat is making an assumption here about medicalization and biologization that I don't believe holds up. I coincidentally came across a link recently to this 2009 article by Ben Goldacre - "A genetic cause for ADHD won't necessarily reduce the stigma attached." "[M]ore compelling than any individual study," Goldacre offers,
a review of the literature to date in 2006 found that overall, biogenetic causal theories, and labelling something as an "illness", are both positively related to perceptions of dangerousness and unpredictability, and to fear and desire for social distance. They identified 19 studies addressing the question. Eighteen found that belief in a genetic or biological cause was associated with more negative attitudes to people with mental health problems. Just one found the opposite, that belief in a genetic or biological cause was associated with more positive attitudes.
As a side note, excessive biologization and medicalization are problems in multiple regards, but a significant and insufficiently appreciated one is political. I have some significant criticisms of Bruce Levine's Surviving America's Depression Epidemic, but a compelling argument Levine (amongst many others over time) makes concerns the effects of treating psychological responses to a capitalist, consumerist, unequal society and its destructive hypercompetitive, alienating, standardizing culture as individual problems or medical pathologies rather than political issues. As Levine argues, this general tendency has been around from the beginning, when "Father of American Psychiatry" Benjamin Rush diagnosed an excessive desire for liberty as a "form of insanity": anarchia.)

Tunisian secularism film to be featured at US festival

In other film-I've-previously-mentioned news, Icarus Films reports that Neither Allah Nor Master, the film by Nadia al-Fani I mentioned in a recent post (but haven't yet had the opportunity to see), will be featured at the MESA (Middle East Studies Association) Film Festival in Washington, DC, which will run from December 1-4.

Reminder: It's Hard Being Loved by Jerks

Also during my unwilling hiatus, people were talking about the firebombing and response of French periodical Charlie Hebdo. I wasn't able to participate in the conversation at the time, but want to somewhat belatedly call attention once again to the documentary about Charlie Hebdo I recommended back in June - It's Hard Being Loved by Jerks. It's a great film and provides useful background for understanding current events.

Tuesday, November 22, 2011

Imogen Evans et al., Testing Treatments

Here’s another post I’d started prior to my externally imposed hiatus:

Ben Goldacre posted last week about the new edition of Testing Treatments by Evans et al. for which he’s written the preface. He links in his post to a site where you can download the entire PDF of the book for free (!!!), and it’s pretty good. It has much to offer, and I’ll discuss its strongest aspects first. Then I’ll make my criticisms.

The authors openly confront medical uncertainties, calling on medical professionals to acknowledge and address them rather than trying to project a false image of confident authority when that is unwarranted. They point out that much medical practice is based on limited knowledge concerning prescribed treatments, illustrating the point with the stories of several treatments used for years and even decades without being properly evaluated, and argue for a transformation of practice that integrates research with treatment in cases of uncertainty.

One of the more insightful aspects of the book is its elucidation of the ethical and regulatory “double standard” with regard to treatment and research:
In practice, what this means is that clinicians can give unproven treatments to patients, as long as patients consent, if therapies are given within the context of ‘routine’ clinical practice. By contrast, conducting any study of the same treatments to evaluate them properly would involve going through the protracted regulatory process. So clinicians are discouraged from assessing treatments fairly, and instead can continue to prescribe treatments without committing to addressing any uncertainty about them… (pp. 108-9).
Essentially, physicians are rather perversely prevented by this double standard from advancing knowledge in the course of their practice. Moreover, the authors argue, the current system of research is unfair to research subjects. The tests of treatments are often unnecessary - they discuss at length the problem that ethical reviews do not focus on the need for or contribution of the research in light of existing knowledge or the concrete usefulness of the information potentially obtained. They are also poorly designed and conducted, often twisted by those with an agenda, and the authors discuss (including linking to the eye-opening article discussed and available here) the numerous techniques used by drug and device makers to manipulate the research process to their ends.

They point to the fact that patients themselves rarely participate in the process of deciding research priorities. This quotation sums up the challenge:
‘Who has the power to see that research questions actually address the greatest needs of patients in all their misery and diversity? Why aren’t the most relevant questions being asked? Who is currently setting the questions? Who should be? Who shall direct this prioritisation? Patients are best able to identify the health topics most relevant to them and to inform their comfort, care, and quality of life, as well as its quantity. The patients are the David, who must load their slings against the Goliaths of the pharmaceutical companies who need evidence to market goods and make profits, and trialists who are driven by curiosity, the need to secure research money, professional acclaim, and career development. Profit, scientific inquiry, grant money, and research papers are acceptable only if the central motivation is the good of patients. Independent patients and organisations that advocate good quality research should ready their sling, carefully choose their stone, take aim, and conquer.’ - Refractor. Patients’ choice: David and Goliath. Lancet 2001; 358:768 (131)
Evans et al. make the case for eliminating the double standard and integrating research with practice so that information gained in the care of patients contributes to the growth of medical knowledge. Of course, in order for this to be productive, research needs to be designed and performed competently and fairly. The authors call for fair tests of treatments, and define well and in detail what they mean by this term. Their vision for fair tests encompasses the entirety of the research process - from the questions asked through the research design to the dissemination of results and systematic reviews and meta-analyses. They propose a system of research designed to be fair to and benefit the important participants, particularly patients. (I’m pleased that they appreciate and discuss the role for social scientists in advancing this program.)

So the book makes a solid case about what’s wrong with the current research system and some original and sound suggestions for changing it. Of course, I appreciate their objection to paternalism and emphasis on participation, openness, and the basic value that science should serve human needs and be consistent with democracy. I also like that they substantially recognize the negative and counterproductive influence of corporations in this context, although others have perhaps explained it better and more comprehensively. An aspect of the book I enjoyed particularly was the short discussions of the history of movements within science (e.g., of doctors and patients in relation to breast cancer and HIV/AIDS), and the authors’ acknowledgement of the complexities of these movements and the hidden role of corporations in some. And it shouldn’t need mentioning that I appreciate that they’ve made it available for free download.

However, I do have a few criticisms (which does seem ungrateful given the free download and all). The first deals with form rather than content. It takes great finesse to make text boxes blend seamlessly with the body text. Even when what they present is relevant and interesting, those bordered boxes tend to interfere with reading, especially when they carry over from one page to the next or appear mid-sentence. In most cases, including this one, the information they contain would be better integrated into the regular text. (The graphics are nothing spectacular, either.) Also, the lists of suggestions and proposals at the end are a bit excessive and become confusing.

The second set of criticisms relates to the authors’ proposals for overhauling the research system. While I agree that the current double standard should go and that research should be integrated with care, I can’t accept the basis for their call to weaken ethics regulations. The authors argue that
[t]he regulatory system for research, in its preoccupation with risk and protecting potential research participants, has become over-protective and overlooks the fact that patients and the public are increasingly involved as partners in the research process... (p. 109).
I certainly think that’s the ideal, and it may be more the case in the UK, but I’m not convinced at all that patients and the public are sufficiently involved as research partners in the US or many other countries that ethical standards could be relaxed while they remain protected. This is an odd claim given that, while they don’t go into the work of people like Harriet Washington and Sonia Shah, the authors clearly recognize the power that pharmaceutical companies hold over research. This isn't going to wither away if regulations are relaxed. They continue:
Requirements relating to provision of information and consent for studies are one of the ways in which the regulatory system acts to discourage rather than encourage research to address uncertainties about treatments. It is important – and ethical – to consider the interests of everyone currently receiving treatment, not just the few who participate in controlled trials. The standard for informed consent to treatment should therefore be the same whether people are being offered treatment within or outside the context of formal treatment assessments. To come to a decision that accords with their values and preferences, patients should have as much information as they want, and at a time that they want it (p. 110).
I agree with the general sentiment here, which goes to their point about double standards. Essentially, patients in care settings receiving treatments about which there’s uncertainty are not being provided with enough information or a say. They’re not even unwitting research subjects, since their use of “experimental” treatments isn’t contributing to scientific knowledge. I know the authors are arguing for a change in ethical standards and regulations that informs and empowers patients, which I support; but calling for the weakening of any ethical standards is dangerous in the existing context.

Furthermore, the book doesn’t really address a major problem: that many doctors simply lack the knowledge of science and research methods necessary to integrate research and care properly. I think it’s important to get doctors engaged with this as part of an effort to increase their scientific understanding and competence, but it’s going to require a good deal of education and practice.

Finally, although Evans et al. discuss the what they consider an overemphasis on lab and animal research – suggesting that this is ethically problematic in that such research is far less likely to respond to the immediate needs of sick people – they don’t have anything to say about the ethical issues this research raises in terms of our moral relationship to nonhuman animals. The same criticisms the authors make about the ethical problems with bad research involving human subjects apply to animal research as well, perhaps more so because they can’t consent.

Overall, a good book that I’d recommend, maybe together with Goldacre’s Bad Science and a few others.

Monday, November 21, 2011

Dead Funny: Humor in Hitler's Germany - on laughter and oppression

I started writing this shortly after I read Rudolph Herzog's Dead Funny: Humor in Hitler's Germany

several weeks ago and was prevented by circumstances beyond my control from finishing or posting it at the time. Some recent events and claims about humor and its harmlessness and subversiveness have led me to return to it:

There was long a popular belief in the social sciences, if humor and other forms of “micro-resistance” were considered at all, that these worked to soften passions or divert energy and passion from serious, organized, effective rebellion against repressive conditions. People like James Scott

and Robin Kelley

took on this belief, using examples to make a convincing case that everyday forms of resistance, including jokes and pranks, can be both meaningful forms of resistance in themselves and form the foundation for wider rebellion.

Unfortunately, this latter insight has now itself become something of a default assumption, including in cases in which it hasn’t empirically been shown to apply. That is, humor, and especially political humor, is often assumed to be inherently subversive and daring. This is the view underlying the presentation of humor in Nazi Germany, both by those trying to minimize German enthusiasm for the regime in the postwar years and, oddly enough, amongst several of those responding to Rudolph Herzog’s recent book on the subject, Dead Funny. Herzog doesn’t attempt to make a general theoretical argument in engagement with academic literatures about the uses and political effects of humor, but instead addresses this particular era in response to concrete historical arguments that have been made about it.

He counters interpretations of the collections of “whispered jokes” published just after Germany’s defeat in the war:
People who laughed at Hitler within their own four walls, the authors of such compilations tried to suggest, disapproved of the Nazis and were perhaps even part of a tacit resistance. Recent research, however, has revealed that this notion, though a comforting idea, is little more than wishful thinking and historical legend–making (KL 52-55).
He states very clearly his thesis that in this context “Political jokes were not a form of resistance” (KL 55-58). They served as a release valve in a way that generally worked in the interests of the Nazis. “‘Whispered jokes’,” he argues, were “a surrogate for, and not a manifestation of, social conscience and personal courage” (KL 63-64) under the regime. But what amused people does provide us with evidence of how people thought (and didn’t think); they’re valuable, as he suggests, for “the insight they give into what preoccupied and moved Hitler’s ‘racial community’” (KL 41-42). “What makes them important today,” he argues, “is the way they reflect, as all old jokes do, what truly occupied, amused, and annoyed the people of their time. They open a window on the Third Reich, giving us an inside view more authentic in its way than can be found in official historical documents" (KL 111-113).

Herzog argues that political humor under the Nazi regime was not hard-hitting or resistant. In many cases it was the contemptuous humor of people who felt themselves victors. As the regime initially consolidated its power, “[w]hat moved people in Germany, what made them split their sides laughing, was the musty old Weimar Republic and its democracy” (KL 431-432). They laughed at the dismantling of the constitution, and they laughed at the League of Nations.

People mocked the personal foibles of Nazi leaders, often recycling old jokes about previous politicians in Germany and elsewhere, and with “no detectable hatred for party bigwigs” (KL 274-275):
They belong to that genre of political humor in which the shell of an ancient jest is simply refilled with content appropriate to its time. Some patterns of human behavior are so obvious, they can survive any change of system or regime. At heart, such jokes are apolitical, even when they are aimed at a well-known political figure (KL 277-279).

...In general, jokes from the early years of the Third Reich amounted to little more than harmless teasing of the regime and could be told in public without fear of reprisals (KL 491-492).
Ordinary Germans joked about Party social climbers and the boorish behavior of some officials. Such jokes were “largely harmless and silly” (KL 130-134). But popular humor also had a very dark, ugly side. Not only were popular jokes not subversive dark humor that thinly concealed a distaste for brutal Nazi methods, some reveled in violence. The popular responses in humor to the Night of the Long Knives are nauseatingly revealing. The public followed the Nazis’ lead and “came up with a number of extremely macabre jokes about Röhm’s bitter end” (KL 1086-1087). Röhm himself “quickly became the butt of a number of jokes. Significantly, most of the witticisms revolved around Röhm’s relatively open homosexuality rather than the violent excesses of his brownshirts” (KL 1056-1057); and “a number of stock ‘gay jokes’ were adapted to feature Röhm personally” (KL 1062).

There were jokes about pointless Nazi rituals, the growing web of Nazi organizations, and how participation in Nazi activities affected the daily life of families. These day-to-day inconveniences, Herzog notes, “stirred Germans far more than any concern for their Jewish fellow citizens or for members of the political opposition, even though the Nazis left no doubt that the future would be most unpleasant for both groups” (KL 448-450). And jokes about concentration camps (consolidated as jokes about Dachau) “seem to have been aimed more at accustoming Germans to this new phenomenon than articulating any real criticism of it” (KL 885-888). Furthermore, as Herzog suggests, as with other jokes about Nazi crimes, the many jokes about Dachau clearly suggest that the populace was well aware of what was happening there.

As they had mocked the League of Nations earlier, with military successes came jokes about the countries they’d defeated and even their southern European allies. More generally,
[t]he humor of the Third Reich was that of the victor and reflected the arrogance that comes from the belief that one has been proven right. The feelings of inferiority that had accrued during the Weimar period disappeared in the intoxication of Nazi military triumph. Humility was off the agenda, as more and more Germans began putting on superhuman airs and looking down with contempt at their supposed inferiors. Popular jokes celebrated the leaders of an empire that was supposed to last a thousand years and heaped scorn upon the vanquished (KL 1453-1457).
And of course throughout there were jokes about Jews. These revolved around crude stereotypes - Jewish greed, lasciviousness, and Communism were standard tropes.* “There were even,” he attests,
jokes that laughed at anti-Jewish violence, and these were told not just by hardcore Nazi party supporters, but also by hordes of willing opportunists and March violets (KL 1420-1421).

…The violent fantasies of most Nazis were shared by many ‘nonpolitical’ Germans. The constant stream of anti-Semitic propaganda likely contributed to this, but ordinary Germans seemed to have come up with the majority of anti-Jewish jokes on their own—a troubling indication of a fundamental animosity toward Jews and Jewishness (KL 1423-1426).
Existing anti-Semitism was consciously prodded by the regime, especially in comedic films. Herzog reports that “Ninety percent of all films made during the Third Reich were insignificant, superficial comedies intended to distract Germans from state terrorism and, later, the hardships of war” (KL 1513-1514). These popular films were calculated to subtly convey their political, racist messages:
The distorted image of Jewishness at the center of Robert and Bertram’s comic plot was not just a reflection of crude beer-tent anti-Semitism. It was part of a coolly planned, larger strategy. A seemingly harmless comedy was a far more effective means of infusing poisonous propaganda than the weekly newsreels. Audiences laughed and did not expect any political message. But the humor in question made them receptive to the campaigns that led to the persecution, ostracism, and extermination of Jews (KL 1584-1588; my italics).
One of the most important points Herzog makes is about the importance of context:
Jokes of this sort were in constant circulation and reinforced and confirmed popular anti-Jewish stereotypes. And though the readership of the Stürmer may have collected and passed them on, anti-Jewish jokes were also told by apolitical Germans. They were a symptom of the latent anti-Semitism that had survived beneath the surface of German society and long before the Nazis took power had laid the groundwork for the persecution of Jews in the Third Reich. The line between harmless kidding and defamatory jokes full of resentment was blurry, and not every joke-teller may have been aware of when he crossed the border from mere bad taste to injuriousness. Nonetheless, even naively repeated clichés helped ostracize the once completely integrated Jewish minority. Once Jews were seen by the public as outsiders or intruders, the authorities could do with them what they wanted. In this sense, no anti-Jewish joke, however mild, was harmless. Moreover, making light of Jews against the backdrop of their persecution, disappropriation, and forced exile was heartless and cyclical, and it gave a gloss of legitimacy to those acts of injustice. The difference between Nazi-era jokes about money-mad Jews and the jokes about tightwad Scotsmen that were popular after the war (many of the latter were adaptations of the former), was that the Scots were not a persecuted minority in Germany, nor was there widespread resentment against them (KL 1400-1410; my italics).
It’s easy today to read about this toothless and even fawning and celebratory humor in the Nazi era and attribute at least some significant portion of it to overwhelming repression and fear. But Herzog counters this notion with a discussion of the actual consequences for critical humor, drawing on his own interviews and a quantitative study by Meike Wöhlert. Again, the idea pushed by postwar apologists and believed by many to this day is that even mildly critical humor in the Nazi regime was subversive and perilous. As Herzog says, “The compilations of jokes that circulated in Germany after the war bore titles like Deadly Laughter and When Laughter Was Dangerous, but there is not much evidence that the jokes they contained were inevitably risky for the teller” (KL 969-972). Insults to the government and leadership increased as the war turned, and laws tightened. But as Herzog points out, especially in the early years but really throughout the Nazi era,
the system never functioned as comprehensively as the Nazis would have liked. It wasn’t possible to keep all German citizens under surveillance or to watch over what happened in every house and on every street corner. And Germans going about their daily lives no doubt knew that the state was not omnipotent (KL 949-953).
The majority of Herzog’s interviewees “said that they were indeed able to tell political jokes freely, openly, and without fear of punishment” (KL 960-961). Quantitative research Herzog refers to (but doesn’t discuss in as much detail as I’d wish) finds that the majority of critical joke-tellers, when they were arrested at all, were released with a warning or relatively light punishment:
The historian Meike Wöhlert has analyzed and compared the judgments rendered by courts responsible for malicious acts of treason in five cities. Although her research only deals with registered cases and not unofficial ones, the results suggest that the telling of political jokes was a mass phenomenon beyond state control. In 61 percent of official cases, joke-tellers were let off with a warning, alcohol consumption often being cited as an extenuating circumstance. (People who had had one too many in bars were considered only partially responsible for their actions, and because most of the popular jokes that made it to court had been told in bars, the verdicts were accordingly lenient.) Fines were rarely handed down, and in only 22 percent of cases were those found guilty sentenced to any time in jail. Strangely, the harshest sentences for “maliciousness” were rendered in prewar Nazi Germany, but even then the term of incarceration seldom exceeded five months (KL 962-968).
In the last years of the war, there were some death sentences for joke-tellers (some of them turned in by one of “a small army of eager informers who delivered hundreds of fellow citizens critical of the regime to the gallows,” KL 2123-2125), but Herzog suggests that these were “extreme exceptions to the rule” (KL 969-972) and calls attention to the double standards by which people were judged and sentenced. Telling critical or even defeatist jokes on its own was, even in these later years, not likely to get people in real trouble; the harsh sentences were imposed upon those whom the government had deemed enemies of the regime, and jokes were rather a pretext or further evidence of the person’s hostility:
The draconian punishments handed down by the People’s Court were aimed at making examples of certain individuals and could hardly have failed to have at least part of their desired effect. As the number of death sentences increased, so did people’s feeling of being under threat when they told jokes critical of the regime. Yet this does not mean, as has been so often suggested, that laughter in the Third Reich was deadly. Merely telling a political joke did not put the joke teller’s life at risk. The real risk arose when the Nazis were looking for an excuse to remove an unwanted member of the community. What mattered was not the “misdemeanor” itself, but the overall picture the authorities made of a defendant’s attitude toward National Socialism (KL 2240-2246).
Jewish comedians and cabaret performers of course had a high priority as targets of repression. Herzog discusses the vibrant cabaret worlds of Berlin and Austria in the Weimar era, calling these cities the “capitals of Jewish humor” in the “golden age of Jewish comedy” that would be destroyed by the Nazis. He tells the terrible stories of a few Jewish and non-Jewish performers, including some in exile and further exile (how difficult it must have been for people to translate comedy into foreign cultures and languages is hard to imagine), and briefly – too briefly! – mentions the public trial of the comedian Werner Finck and colleagues, which itself would make for great theater. He also describes the gallows humor to which people resorted in the face of marginalization, persecution, and even mass killings and death camps. The author argues that
the fundamental difference between German and German-Jewish jokes was less a matter of tone or edge than of function. Whereas “whispered jokes” among Germans served primarily as a release valve for pent-up popular frustration, jokes told by their Jewish countrymen can be interpreted as an attempt to muster courage—or, as the great compiler of Jewish-German jokes Salcia Landmann put it, as an expression of Jews’ will to survive against all odds. These jokes make fun of the terrors Jews experienced every day. As such, the blackest Jewish humor expresses defiance: I laugh, therefore I am. My back is to the wall, and I’m still laughing (KL 95-100).
So there were people for whom telling political jokes made life more dangerous, and for whom humor could be a daring act of defiance or basic sanity and survival. But, as Herzog shows, this was not the case for the majority of the German population. Indeed, he notes that Hitler himself enjoyed humor that reflected Nazi ideology:
Hitler and his cohorts liked the idea of using cabaret routines to threaten dissidents. The pompous dictator who loved to pose publicly as an emperor also had his lighter side: he enjoyed popular entertainment and crude jokes…. The Nazi leadership who ruthlessly turned their goons on Jewish comedians and opposition cabaret performers were not at all immune to humor, as long as it toed the party line (KL 1469-1473).
Some humor, as the book shows, was quite compatible with and even functional for violent oppression.

Herzog’s study is historically illuminating and also contributes to a body of work from which we can draw several broader insights. The most general is that humor – even bad or "innocent" humor - should be taken, well, seriously in understanding relations of inequality, oppression, and resistance. It's wrong to dismiss the potential social and political effects of jokes or stories told for a laugh. But at the same time we should be wary of generalizing unduly from some examples to the claim that all humor, or all humor that offends or pushes a line, is necessarily brave, subversive, or challenging. The people telling and targeted by the jokes or stories, their content, and the sociopolitical context – particularly the relations of power and privilege – in which humor exists are all crucial to understanding its (potential) social meaning.

*In one case, Herzog discusses a specific popular joke which conveyed the greedy stereotype:
Pinkus and a Gentile are attacked in the forest, and as the highwaymen are about to frisk them, Pinkus takes out his wallet and says to his fellow victim: “Ah, I just remembered. I owe you 500 schillings” (KL 1397-1399).
Coincidentally, I’d just read the same joke in David Graeber’s Debt (p. 7). He calls it “an old vaudeville gag” and offers a telling by Steven Wright:
I was walking down the street with a friend the other day and a guy with a gun jumps out of an alley and says “stick ’em up.”

As I pull out my wallet, I figure, “shouldn’t be a total loss.” So I pull out some money, turn to my friend and say, “Hey, Fred, here’s that fifty bucks I owe you.” The robber was so offended he took out a thousand dollars of his own money, forced Fred to lend it to me at gunpoint, and then took it back again.
I don’t know where the joke got its start, and it’s probably very old, but the characters featured and of course circumstances in which it’s told clearly shift its meanings.


Loro Parque. I'd like to read English translations of these decisions providing the full justifications.

This all makes a mockery of the idea of rescue and rehabilitation of wild animals. It makes these efforts look like thinly veiled and cynical means of obtaining captive performers and breeders for corporations, or at the least too easily coopted for this purpose. People and governments who support rescue efforts should be assured that their work and money will not support captures, and the public should be made aware of this situation.

Anxiously awaiting Morgan decision

The judge's decision should be announced within hours.