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Archive for October 5th, 2018

The fall of the US: The most cost-effective dismantling of a country yet

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Vladimir Putin can take a victory lap.

Any government depends heavily on accepted norms and procedures. When those fail, the government goes awry, and Putin managed the breaking of the US government at very low cost indeed.

Consider what happens when a motorcycle gang takes over a waltz party: the waltz party lacks the structures to resist brute force, having operated on norms and consensus, which the gang ignores. That is what President Trump and the GOP Congress are doing to the US government: ignoring norms, ignoring the delicate structure of traditions, and grinding things to ruin. Brett Kavanaugh is a disaster in waiting as a Supreme Court Justice (and the way his confirmation has been rammed through), but that’s the least of it. Do read The Fifth Risk, just to get a sense of how the US is fucked. (Here’s an extract from the beginning of the book.) In terms of competence, the US is like a large sailing ship now being commanded and run by a bunch of coal-miners who have never been in a boat before.

I think it’s game over, US. It’s depressing. But maybe civilization can never stand up to barbarians. Civilization is an intricate and yet delicate structure. Barbarians don’t give a shit. In fairness, they’re ignorant, but they represent Dunning-Kruger on steroids: totally ignorant, totally confident.

Update: For example, “E.P.A. to Eliminate Office That Advises Agency Chief on Science

Written by LeisureGuy

5 October 2018 at 3:42 pm

Chi-chi-chi recipe: Chicken chili with chickpeas

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This looks good, and I had the (unusual) foresight to use a large-enough pot: my large-diameter (to make sautéing easy) 6-qt pot.

2 Tbsp extra-virgin olive oil (6 WW points—everything else is 0 WW points)
1.5 large yellow onions, diced as described in an earlier video
good pinch of salt
about 1 Tbsp freshly ground black pepper

Sauté, stirring often, until onions are cooked through and transparent. Add:

8 cloves garlic, chopped small (I used hard-stem Red Russian garlic)
1/4 cup freshly grated ginger

Sauté for a minute or so, then add:

1 green bell pepper, chopped
2 Anaheim peppers chopped
2 Tbsp Mexican oregano
1.5-2 Tbsp ground cumin
1 Tbsp ground Ancho chili
1 Tbsp smoked paprika
1 Tbsp crushed dried rosemary
1 Tbsp dried thyme
1 Tbsp ground coriander

Sauté for a few minutes, then add

1 28-oz can diced tomatoes
2 14 oz cans chickpeas, drained and rinsed
2 Tbsp tomato paste (I use tomato paste in a tube, so I just squirt it in)
1 Tbsp tamari
1 Tbsp fish sauce
1 Tbsp liquid smoke

Stir and bring to simmer. Add:

2 chicken breasts, cut into chunks

Simmer 25-30 minutes.

I thought about adding the juice of a lemon or lime and may do it yet.

This is clearly going to be at least 8 one-cup servings, so at most 1 point per serving.

Written by LeisureGuy

5 October 2018 at 3:30 pm

Posted in Food, Low carb, Recipes

Doctors are surprisingly bad at reading lab results. It’s putting us all at risk.

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Daniel Morgan writes in the Washington Post:

The man was 66 when he came to the hospital with a serious skin infection. He had a fever and low blood pressure, as well as a headache. His doctors gave him a brain scan just to be safe. They found a very small bulge in one of his cranial arteries, which probably had nothing to do with his headache or the infection. Nevertheless, doctors ordered an angiogram to get images of brain blood vessels. This test, in which doctors insert a plastic tube into a patient’s arteries and inject dye, found no evidence of any blood vessel problems. But the dye injection caused multiple strokes, leading to permanent issues with the man’s speech and memory.

That case, recounted in JAMA Internal Medicine three years ago, is no surprise. As a doctor in a large urban hospital, I know how much modern medicine has come to rely on tests and scans. I review about 10 cases per day and order and interpret more than 150 tests for patients. Every year, doctors in this country order more than 4 billion tests in total. They’ve gotten more sophisticated and easier to execute as technology has advanced, and they’re essential to helping doctors understand what might be wrong with their patients.

But my research has found that many physicians misunderstand test results or think tests are more accurate than they are. Doctors especially fail to grasp how false positives work, which means they make crucial medical decisions — sometimes life-or-death calls — based on incorrect assumptions that patients have ailments that they probably don’t. When we do this without understanding the science of risk and probability, we unacceptably increase the chances of making the wrong choice. In the worst cases, as with the man whose angiogram caused otherwise avoidable strokes, we increase the odds of unnecessarily putting patients in danger.

The first problem that doctors (and thus, patients) face is a basic misunderstanding of probability. Say that Disease X has a prevalence of 1 in 1,000 (meaning that 1 out of every 1,000 people will have it), and the test to detect it has a false-positive rate of 5 percent (meaning 5 of every 100 subjects test positive for the ailment even though they don’t really have it). If a patient’s test result comes back positive, what are the chances that she actually has the disease? In a 2014 study, researchers found that almost half of doctors surveyed said patients who tested positive had a 95 percent chance of having Disease X.

This is radically, catastrophically wrong. In fact, it’s not even close to right. Imagine 1,000 people, all with the same chance of having Disease X. We already know that just one of them has the disease. But a 5 percent false-positive rate means that 50 of the remaining 999 would test positive for it nonetheless. That means 51 people would have positive results, but only one of those would really have the illness. So if your test comes back positive, your true chance of having the disease is actually 1 out of 51, or 2 percent — a heck of a lot lower than 95 percent.

A 5 percent false-positive rate is typical of many common tests. The primary blood test to check for a heart attack, known as high-sensitivity troponin, has a 5 percent false-positive rate, for instance. U.S. emergency rooms often administer the test to people with a very low probability of a heart attack; as a result, 84 percent of positive results are false, according to a study published last year. These false-positive troponin tests often lead to stress tests, observation visits with expensive co-pays and sometimes invasive cardiac angiograms.

In one study, gynecologists estimated that a woman whose mammogram was positive had a higher than 80 percent chance of having breast cancer; the reality is that her chance is less than 10 percent. Of course, women who have a positive mammogram often undergo other tests, such as an MRI and a biopsy, which can offer more precision about the presence of cancer. But researchers have found that even after the battery of exams, about 5 of every 1,000 women will have a false-positive result and will be told they have breast cancer when they do not.

The confusion has serious consequences. These women are likely to receive unnecessary treatment — generally some combination of surgery, radiation or chemotherapy, all of which have serious side effects and are stressful and expensive. Switzerland and France, grasping this problem, are halting and reconsidering their mammogram programs. In Switzerland, they’re not screening ahead of time, preferring to manage cases of breast cancer as they’re diagnosed. In France, doctors are letting women decide for themselves whether to have the tests.

Studies have found that doctors make similar errors with other tests, including those for prostate and lung cancer, heart attack, asthma and Lyme disease. Of course, no test is perfect, and even very careful, statistically sophisticated doctors can sometimes make mistakes. That’s not the problem.

Too many of my colleagues do not understand that many of the tests they rely on are deeply fallible. In a study I published last year with several colleagues, we reviewed the treatment of 177 patients who were admitted to hospitals with a wide range of problems, from broken bones to severe intestinal pain, to see how necessary their tests were, as judged by the latest medical guidelines. We found that nearly 90 percent of the patients received at least one unnecessary test and that, overall, nearly one-third of all the tests were superfluous. Clearly, when patients receive tests that aren’t needed, there is a reasonable chance that doctors are using the results to make choices about treatment; by definition, these choices have a higher danger of being flawed.

In another paper, from 2016, my colleagues and I interviewed more than 100 doctors to gauge their understanding of the risks and benefits of 10 common medical tests or treatments. We found that nearly 80 percent of our subjects overestimated the benefits. Strangely, the doctors themselves acknowledged this, with two-thirds rating themselves as not confident in their understanding of tests and probability. Eight out of 10 said they rarely, if ever, talked to patients about the probability of test results being accurate.

I have to admit that I, too, sometimes fall prey to overvaluing test results regardless of their probability. Last year, I saw a patient who had problems breathing. His symptoms were typical of chronic obstructive pulmonary disease (COPD), but a test for a blood clot in the lung came back positive. This test has a relatively high false-positive rate, but we still started the patient on a blood thinner, which can treat clots but also has serious risks, such as internal bleeding. Within a few days, another test confirmed that he did not have a blood clot, so we discontinued the anticoagulant, which caused no permanent harm. But things could have gone much worse.

Basic misunderstandings about how tests work and how accurate they are contribute to a bigger problem. Although precise numbers are hard to come by, every year, many thousands of patients are diagnosed with diseases that they don’t have. They receive treatments they don’t need, treatments that may have harmful side effects. Perhaps just as important, they and those around them often experience enormous stress from these incorrect diagnoses. Treating nonexistent diseases is wasteful and often expensive, not only for patients but for hospitals, insurance companies and governments.

Doctors also tend to overuse some tests. In a paper last year, my colleagues and I highlighted some key examples: One was computed tomography (CT), a high-tech scanning technology that is increasingly used in patients with nonspecific respiratory symptoms. In cases with only mild respiratory problems, the test does not improve patient outcomes, and it can lead to false positives. Often the test shows small lung nodules that can lead doctors to follow up with a high-risk surgical biopsy for cancer — which is very unlikely to be the cause of the symptoms. The scan also exposes patients to radiation, which is a risk in itself; studies have found that between 1.5 and 2 percent of all cancers in the United States are caused by radiation from CT scans.

To be fair, it is not surprising that doctors tend to overestimate the precision and accuracy of medical tests. The companies that provide tests work hard to promote their products. Doctors often think that ordering more tests will protect from lawsuits. Moreover, medical schools offer limited instruction on how to understand test results, which means many doctors are not equipped to do this well. Even when medical students have short classroom instruction in test interpretation, it is rarely taught in a clinic with actual patients.

There is no simple solution. One key step is . . .

Continue reading.

Written by LeisureGuy

5 October 2018 at 2:11 pm

In Op-ed, Kavanaugh Assures Skeptics That He Will Say Whatever They Want to Hear

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Eric Levitz writes in New York:

At his first confirmation hearing before the Senate Judiciary Committee, Brett Kavanaugh said that “a good judge must be an umpire — a neutral and impartial arbiter who favors no litigant or policy.”

At his final one, he told the Democratic members of the panel that their behavior was “embarrassing”; suggested that they knew Christine Blasey Ford’s sexual-assault allegations against him were spurious, and were only feigning concern about her now because “you couldn’t take me out on the merits”; declared the entire investigation into his alleged sexual misconduct “a calculated and orchestrated political hit” fueled by “revenge on behalf of the Clintons and millions of dollars in money from outside left-wing opposition groups”; and warned his political rivals that, “What goes around comes around.”

Now, Kavanaugh wants you to know that he is “an independent, impartial judge” again. In an op-ed for The Wall Street Journal Thursday night, the Supreme Court nominee reiterated his belief in the vital importance of judicial neutrality — and (sort of) apologized for saying (unspecified) things that he shouldn’t have in his final appearance before the Senate:

I was very emotional last Thursday, more so than I have ever been. I might have been too emotional at times. I know that my tone was sharp, and I said a few things I should not have said. I hope everyone can understand that I was there as a son, husband and dad. I testified with five people foremost in my mind: my mom, my dad, my wife, and most of all my daughters.

Going forward, you can count on me to be the same kind of judge and person I have been for my entire 28-year legal career: hardworking, even-keeled, open-minded, independent and dedicated to the Constitution and the public good.

Here is a rough summary of what Brett Kavanaugh is, ostensibly, asking you to believe: Christine Blasey Ford is an exceptionally gifted (and exceptionally sociopathic) amateur actress — or else, a person suffering from a severe memory disorder — who wrongly accused him of a serious crime. This false allegation caused the Supreme Court nominee to lose control of his emotions, and, in a fit of frustrated anger, to write a (carefully proofread and copyedited) opening statement to the Senate that was full of wholly unsubstantiated claims about the vast, left-wing conspiracy against him. But this hyperpartisan tantrum was an aberration, one entirely out of step with his long, distinguished career (as a Republican operativeturned George W. Bush aide, turned far-right federal judge). When he isn’t being accused of a crime he did not commit, he will treat Democratic arguments with the utmost intellectual charity (heck, he might even be willing to entertain bizarre premises like “when a Democrat expresses concern about a sworn allegation of sexual assault against me, that is not dispositive evidence that George Soros has paid her to destroy my career by any means necessary”). He will be an independent, impartial judge — and definitely will not work to ensure that “what goes around comes around.”

Perhaps this account strikes you as a plausible. But there is an alternative theory: Brett Kavanaugh is an opportunistic, partisan judge who will say whatever he needs to in order to win confirmation to the Supreme Court — and once there, will reason however he needs to in order to arrive at the conclusions the conservative movement prefers.

In this view, Kavanaugh’s public presentation has not been erratic — decorous and detached one day, unhinged and partisan the next — so much as consistently, ruthlessly calibrated to the political needs of the given moment.

So, when Donald Trump introduced Kavanaugh as his Supreme Court nominee in July, the judge immediately told a blatant falsehood to further ingratiate himself with this president and his followers, declaring that “no president has ever consulted more widely or talked to more people from more backgrounds to seek input for a Supreme Court nomination.” (Every judge the president considered had a background in the Federalist Society, a staunchly conservative legal network that advises Trump on all his judicial appointments.)

Then, when he first appeared before the Senate — and the primary obstacle to his confirmation was the unusually partisan nature of his résumé — he sang paeons to judicial impartiality, and recited innocuous nonsense phrases like, “I am a pro-law judge.”

When Ford’s allegation came to light, he denied in it in categorical terms (even though, deep down, he couldn’t be certain that her story wasn’t true, given his drinking habits at the time in question). Recognizing that demonizing a self-avowed sexual-assault survivor came with political hazards, he suggested to aides and advisers that Ford might have simply misidentified her true assailant. Once that theory flopped, and Ford actually showed up for her hearing, the primary threat to his nomination became the other equally conservative (but now, far less tainted) federal judges waiting in the wings. Thus, Kavanaugh decided he needed to give the Republican base a reason to insist on his nomination, and not merely that of a far-right judge like him. So, he campaigned for the position on Fox News, and then announced that anyone who opposed his nomination was complicit in a Clintonian conspiracy before the Senate. And when Democratic senators proceeded to ask him questions whose true answers were politically disadvantageous, he simply lied; when he wished to make Ford’s allegation look ridiculous, he declared that “all four witnesses have said it didn’t happen,” even though they had not said that, at all.

Now, with the GOP faithful firmly in his corner — and a couple squishy Republican senators voicing concerns about his partisanship — he has told them what they want to believe in the pages of The Wall Street Journal.

And while Kavanaugh insists in said pages that his recent actions aren’t characteristic of his jurisprudence, his record suggests otherwise. Specifically, in many of his rulings, the judge has demonstrated a similar affinity for using any available expedient to arrive at his preferred outcome. As Vox’s Matt Yglesias has noted:

If you read Kavanaugh’s decisions on cases regarding EPA regulations, you see a judge who poses as a defender of congressional prerogatives over an executive run amok. But if you glance instead at his ruling on a case relating to the Consumer Financial Protection Bureau, you see the opposite.

When creating this agency, Congress decided that the best way to create effective consumer protection would be to grant the agency a good measure of independence from the president — giving the agency a single director (rather than a five-person commission like the SEC or FCC) and giving the director a fixed-term. This, according to Kavanaugh, is unconstitutional because it violates the unitary nature of the executive branch.

So we cannot allow executive agencies to regulate aggressively because that would step on the prerogatives of Congress, but we cannot allow Congress to set up an aggressive regulatory agency because that would step on the prerogatives of the president.

Perhaps most tellingly of all, in an aside on a ruling related to the Affordable Care Act, Kavanaugh suggests that a president could simply choose not to enforce the law’s provisions. The absence of regulation, in other words, is always a permissible form of discretion and deference, whereas its presence is always suspect — with the question of who is supposed to defer to whom tossing like a hot potato according to the nature of the case. . .

Continue reading.

It strike me that putting Brett Kavanaugh on the Supreme Court reinforces the idea I get in reading The Fifth Risk (by Michael Lewis), that Russia truly has weakened and is destroying the United States. If you don’t believe me, read on the wrecking crew are demolishing the government on which the US depends.

Written by LeisureGuy

5 October 2018 at 1:31 pm

Posted in Books, Law

The Ultra-Ecological House

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Mea McNeil writes in Craftsmanship Quarterly:

One warm night last October, Ed Doody awoke abruptly to see trees, just yards away from his window, burning like paper. The blaze was one of a dozen historic fires last year in Northern California; this one had quickly swept north into Doody’s neighborhood in Mendocino’s Redwood Valley. A fierce wind whipped the flames directly toward Doody’s house, which was constructed with straw bales. Doody and his dog sought refuge in a charred clearing where they were pelted by hale-like embers. By the time this fire was out, it had burned 36,523 acres, destroyed nearly 500 homes, and taken eight lives, four on Doody’s ridge. But Doody’s strawbale house was left standing.

By this October, a new, thousand-fold larger conflagration, the largest in California history, had already burned over the summer just a few miles away, and experts promise more to come.

Meanwhile, in Joshua Tree, a giant, cactus-studded park 650 miles south, in the California desert, lies another strawbale house with a magnificent vaulted ceiling. Built 16 years ago for the late composer Lou Harrison, the home sits near six earthquake faults that have produced two major earthquakes in the past decade. Smaller quakes shake this area about 600 times a year, yet Harrison’s house, and its vaulted ceiling, have held just fine.

What’s going on here? Here’s a building material that’s not only tough, it’s also plentiful, easily renewable, and non-toxic from start to finish. As we will soon see, it can help stop climate change, by gathering a lot of the airborne carbon dioxide that contributes to the greenhouse effect (a process called sequestration). Strawbale walls also hold up well against gale-force winds, like those that recently devastated the Carolinas. As environmental challenges of this nature accumulate, why aren’t we making greater use of this stuff? Shouldn’t straw be housing the world?

STRAW HOMES, REINVENTED

The Harrison house is frameless—called “Nebraska style” after the turn-of-the-20th– century houses built on homesteads in the state’s Sandhills prairie. With no trees for structure and sandy earth that would not hold sod, the settlers stacked baled straw out of desperation. The houses proved comfortable in extreme heat and cold, and, by one account, quiet enough for a card game in a tornado. An exodus from the Sandhills during the Depression left behind a building method that was cheap, functional but seen as déclassé.

If anything, a strawbale home might be one of the most timeless designs. When masters deliberate the meaning of craftsmanship, they often talk about durability—the idea that, in order to have integrity, the items you make must stand the test of time, both functionally and aesthetically. A strawbale home might be a pretty good example of this principle.

No one is sure who started the modern straw bale building revival. Some point to the publication, in 1973, of Shelter, a book of yurts, domes, and divine proportions; the book had one page devoted to old baled “hay” structures. Another story is that when a Sandhills church wall was repaired in 1976, a window was added to show visitors its strawbale makings. Whatever the case, these “truth windows” (called “honesty windows” in the U.K.), became part of a new tradition that spread spontaneously. Within a couple of years, Matts Myhrman and the late Judy Knox, a pair of Arizona strawbale advocates who are called the grandparents of the revival, started teaching the technique.

Baleheads, as strawbale builders are sometimes called, have long had no codified philosophy, just a set of shared, passionate values. David Eisenberg, a former contractor who got in early on the strawbale revival, traces that to Knox. After a workshop, when Knox would gather the dozen or so participants to meet inside the structure that they’d built that day, “Every time I was astounded,” he said. “People would be brought to tears. I’d walk away thinking, ‘What is this? This is [just] a wall system.’”

Perhaps Knox had tapped into a zeitgeist—an increasingly unmet need. Here was a chance at handwork for anyone who felt like they were losing touch with their surroundings—people who were using electronics they didn’t understand, and driving cars they could no longer fix.

Unfortunately, when these new converts set out to construct their own strawbale homes, they found that local building departments were so unfamiliar with the method that permits in regulated areas were difficult to obtain. “I felt we were seducing people into something they couldn’t do,” Eisenberg says.

Even when permits were issued, the straw was reduced to function solely as insulation—infill for a frame made of wood. On one level, this worked fine. Straw is a hollow tube, the fibrous stalk that remains after the grain head is harvested; when compressed into bales, which are typically 16-24 inches thick, straw insulates magnificently by trapping air, much like bird feathers or animal fur. Meanwhile, other benefits of baled straw have gone ignored.

ANSWERS HIDDEN IN PLAIN SIGHT

“From the beginning, it was not an easy sell,” Eisenberg recalls. “I began to question why it was so much harder to get building permits for sustainable buildings than for the most toxic, wasteful building systems.” After studying the problem, he says, “I realized that the codes are exclusively designed around industrialized building. And no one was responsible for the large and serious consequences.”

Just for starters, consider the stunning difference, regarding  . . .

Continue reading.

Photos at the link.

Written by LeisureGuy

5 October 2018 at 10:29 am

Here’s a Name to Remember: All County Building Supply & Maintenance

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Kevin Drum points out a bit from the NY Times piece on Trump’s tax fraud:

I’ve written a couple of times about the blockbuster New York Times story that documented the routine tax fraud which helped build the Trump empire from its earliest days—and which Donald Trump eventually inherited. But maybe you’d like an example to make this more concrete. So here’s a name for you from the depths of Trump lore: All County Building Supply & Maintenance.

The year is 1992 and Donald is deep into bankruptcy proceedings, living on a small allowance doled out to him monthly by his banks. Naturally his father was there to help bail him out. He started by incorporating a new company, All County Building Supply & Maintenance, and putting a favorite nephew in charge. Its purpose was to act as a central purchasing agent for all of the Trump properties.

That doesn’t sound so bad, does it? Efficient, even. Needless to say, there’s much more:

All County’s main purpose, The Times found, was to enable Fred Trump to make large cash gifts to his children and disguise them as legitimate business transactions, thus evading the 55 percent tax.

The way it worked was remarkably simple. Each year Fred Trump spent millions of dollars maintaining and improving his properties. Some of the vendors who supplied his building superintendents and maintenance crews had been cashing Fred Trump’s checks for decades. Starting in August 1992, though, a different name began to appear on their checks — All County Building Supply & Maintenance.

….[All County] billed Fred Trump’s empire for those same services and supplies, with one difference: All County’s invoices were padded,marked up by 20 percent, or 50 percent, or even more, records show. The Trump siblings split the markup.

For example, if a new boiler cost $300, All County would pay the vendor the invoiced price but bill the Trump Organization $400. The extra $100 would be split up among the Trump kids—and needless to say, no gift taxes were paid on that money.

So far, this sounds illegal as hell, but nothing more. Trump being Trump, though, he found to way expand this grift so he wasn’t just cheating the government, but plundering his working-class tenants as well. Fred’s nephew, John Walter, did the dirty work:

As an owner of rent-stabilized buildings in New York, Fred Trump needed state approval to raise rents beyond the annual increases set by a government board. One way to justify a rent increase was to make a major capital improvement….Fred Trump, according to Mr. Walter, saw All County as a way to have his cake and eat it, too. If he used his “expert negotiating ability” to buy a $350 refrigerator for $200, he could raise the rent based only on that $200, not on the $350 sticker price “a normal person” would pay, Mr. Walter explained….As Robert Trump acknowledged in his deposition, “The higher the markup would be, the higher the rent that might be charged.”

State records show that after All County’s creation, the Trumps got approval to raise rents on thousands of apartments by claiming more than $30 million in major capital improvements. Tenants repeatedly protested the increases, almost always to no avail, the records show.

In a nutshell, then:

  • All County purchased appliances and fixtures for Trump properties at low negotiated prices.
  • It inflated the prices it charged to the Trump Organization.
  • It then doled out the difference to the Trump kids without paying any taxes on it.
  • And the Trump Organization used the inflated prices as a way of raising rents more than it was allowed to.

I doubt there’s any proof that Donald Trump had any knowledge of this. But it’s inconceivable that he didn’t. By 1992 he was running the Trump Organization almost completely even if he didn’t own it. He knew exactly what was going on, and his bankruptcy gave him a huge motivation to set up schemes like this:

“All of this smells like a crime,” said Adam S. Kaufmann, a former chief of investigations for the Manhattan district attorney’s office….Mr. Kaufmann said the Trumps’ use of All County would have warranted investigation for defrauding tenants, tax fraud and filing false documents.

Ladies and gentlemen, this is your president of the United States. Makes you proud, doesn’t it?

POSTSCRIPT: Are you curious about how the Times found out about this scam? It was only because his sister referenced All County on a disclosure form when she became a federal judge. That was it. If not for that, nobody would ever have known about any of this.

Written by LeisureGuy

5 October 2018 at 9:48 am

Psychotherapy is not harmless: on the side effects of CBT

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Christian Jarrett, a cognitive neuroscientist turned science writer, writes in Aeon:

The structured nature of cognitive behavioural therapy (CBT) and its clearly defined principles (based on the links between thoughts, feelings and behaviours) make it relatively easy to train practitioners, ensure standardised delivery and measure outcomes. Consequently, CBT has revolutionised mental-health care, allowing psychologists to alchemise therapy from an art into a science. For many mental-health conditions, there is now considerable evidence that CBT is as, or more, effective than drug treatments. Yet, just like any form of psychotherapy, CBT is not without the risk of unwanted adverse effects.

A recent paper in Cognitive Therapy and Research outlines the nature and prevalence of these unwanted effects, based on structured interviews with 100 CBT-trained psychotherapists. ‘This is what therapists should know about when informing their patients about the upcoming merits and risks of treatment,’ write Marie-Luise Schermuly-Haupt of the Charité University of Medicine in Berlin and her colleagues.

The researchers asked each CBT therapist (78 per cent of whom were female, average age 32, with an average of five years’ experience) to recall their most recent client who had taken part in at least 10 sessions of CBT. The chosen clients mostly had diagnoses of depression, anxiety or personality disorder, in the mild to moderate range.

The interviewer – an experienced clinical psychologist trained in CBT – followed the checklist of unwanted events and adverse treatment outcomes, asking each therapist whether the client had experienced any of 17 possible unwanted effects from therapy, such as deterioration, new symptoms, distress, strains in family relations or stigma.

The therapists reported an average of 3.7 unwanted events per client. Based on the therapists’ descriptions, the interviewer then rated the likelihood of each unwanted event being directly attributable to the therapeutic process – making it a true side effect (only those rated as ‘definitely related to treatment’ were categorised as such).

Following this process, the researchers estimated that 43 per cent of clients had experienced at least one unwanted side effect from CBT, equating to an average of 0.57 per client (one client had four, the maximum allowed by the research methodology): most often distress, deterioration and strains in family relations. More than 40 per cent of side effects were rated as severe or very severe, and more than a quarter lasted weeks or months, though the majority were mild or moderate and transient. ‘Psychotherapy is not harmless,’ the researchers said. There was no evidence that any of the side effects were due to unethical practice.

Examples of severe side effects included: ‘suicidality, breakups, negative feedback from family members, withdrawal from relatives, feelings of shame and guilt, or intensive crying and emotional disturbance during sessions’.

Such effects are not so surprising when you consider that CBT can involve exposure therapy (ie, gradual exposure to situations that provoke anxiety); discussing and focusing on one’s problems; reflecting on the sources of one’s stress, such as difficult relationships; frustration at lack of progress; and feelings of growing dependency on a therapist’s support.

The longer that a client had been in therapy, the more likely she was to have experienced one or more side effects. Also, and against expectations, clients with milder symptoms were more likely to experience side effects, perhaps because more serious symptoms mask such effects.

Interestingly, before the structured interviews, the therapists were asked to say, off the top of their heads, whether they felt that their client had had any unwanted effects – in this case, 74 per cent said they had not. Often it was only when prompted to think through the different examples of potential side effects that therapists became aware of their prevalence. This chimes with earlier research that’s documented the biases which can lead therapists to believe that therapy has been successful when it hasn’t.

Schermuly-Haupt and her colleagues said a conundrum raised by their findings was whether unpleasant reactions that might be an unavoidable aspect of the therapeutic process should be considered side effects. ‘We argue that they are side effects although they may be unavoidable, justified, or even needed and intended,’ they said. ‘If there were an equally effective treatment that did not promote anxiety in the patient, the present form of exposure treatment would become unethical as it is a burden to the patient.’

There are reasons to treat the new findings with caution: the results depended on the therapists’ recall (an in-the-moment or diary-based methodology could overcome this problem), and about half the clients were also on psychoactive medication, so it’s possible that some adverse effects could be attributable to the drugs rather than the therapy (even though this was not the interviewer’s judgment). At the same time, though, remember that . . .

Continue reading.

Written by LeisureGuy

5 October 2018 at 9:22 am

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