Transcranial Direct Current Stimulation

Epistemic status: rough-draft, I wouldn’t be surprised if my conclusions reversed

tDCS consists of a pair of sponge electrodes on the head, through which constant current is placed, at about 0.029-0.08 mA per square centimeter. Locations vary based on the intended effect of the treatment.  Extending treatment is usually done by prolonging duration rather than increasing intensity, as higher currents cause more cutaneous pain. When done correctly, the stimulation is painless, and therefore can be compared to sham stimulation as a control.[1]

Bottom lines: there are some serious methodological flaws in tCDS studies.  “Sham” stimulation isn’t a perfect control, so some significant proportion of the effect may be placebo. And there’s quite significant variation in how much a given application of current increases the evoked potential in the brain.  Also, almost all the studies are quite small.

Given that, though, the effect sizes on working memory are quite good — comparable or better to the best nootropics (caffeine, modafinil, and amphetamine.)

As a treatment for depression, tCDS looks less impressive; aggregating the best-quality studies gives no net effect compared to sham stimulation.

As a treatment for chronic pain, tCDS looks quite good, though there’s not very many studies.

Cognition

A study of 15 healthy females found a slight improvement on a working memory task from anodal stimulation to the DLPFC, but not from cathodal stimulation of the DLPFC, stimulation of M1, or sham stimulation.  Cohen’s d is 0.66. [2]

18 patients with Parkinson’s given 1-2 mA of tCDS to the DLPFC for 20 min found a 20% increase in correct answers on a 3-back task compared to sham stimulation for 2 mA.  Stimulation with 1 mA improved accuracy by only 5%. Stimulation of M1 had a significant improvement of reaction time but not accuracy. Cohen’s d is 3.5.[3]

32 patients given sham, anodal, or cathodal stimulation of the DLPFC or M1 found that accuracy on a word-memorization task was significantly better with anodal DLPFC stimulation than sham (88% correct vs. 80% correct), while cathodal stimulation was worse than sham.  Sham and M1 stimulation were similar.  Cohen’s d was 3.5. [7]

18 subjects given a verbal-associative task with anodal DLPFC tCDS vs sham or cathodal tCDS significantly improved mean scores (9 vs. 7 out of 12 correct). There was no effect on verbal fluency scores (a test of how many unique words one can produce in a short timespan).  Cohen’s d was 0.8.[8]

12 patients given a 2-back task with sham, anodal DLPFC tCDS, or transcranial random noise stimulation found a significant improvement in speed but not accuracy for 2-back anodal tCDS vs. sham.  Cohen’s d was 0 for accuracy, 0.36 for speed.[9]

10 Alzheimer’s patients treated with tCDS on the DLPFC and left temporal cortex found significantly more correct responses with tCDS vs sham on a memorization task (30 vs. 35 correct responses out of 55) but no improvement in Stroop or digit span tests.  Cohen’s d was 1.[12]

16 Parkinson’s patients given tCDS to the DLPFC significantly improved phonemic verbal fluency relative to sham and TPC stimulation (p < 0.002) but did not improve semantic verbal fluency.[17]

In a study of 12 healthy subjects given a naming task, reaction times were decreased with anodal tCDS to the DLPFC and increased with cathodal tCDS to the DLPFC.[18]

15 healthy subjects given a 3-back working memory task given anodal tCDS to the DLPFC significantly improved accuracy with tCDS vs sham (80% correct vs 69% correct).  Cohen’s d of 0.87.[18]

10 stroke patients given a 2-back working memory task, treated with anodal DLPFC tCDS or sham, found significant improvement in accuracy in anodal but not sham groups. Cohen’s d of 2.4.[19]

28 patients with major depression given a 2-back task given tCDS or sham on the DLPFC found a significant improvement in accuracy with the active version vs. sham: 58% vs 42% correct, p = 0.04, Cohen’s d about 4.[20]

58 healthy subjects given working memory training had an effect size of DLPFC tCDS vs. sham of 1.5 on digit span (p = 0.025) , 1.35 for Stroop accuracy, 1.3 on the CVLT, no effect on Raven’s.[21]

30 healthy older adults were given sham or real anodal tCDS to the left DLPFC and given a 3-back test; there was no significant effect of stimulation on working memory performance.[24]

37 patients with temporal lobe epilepsy had no improvement in working or episodic memory from anodal tCDS to the left DLPFC.[25]

Mean Cohen’s d for working memory accuracy, weighted by sample size: 1.5.

A meta-analysis of 16 studies of anodal DLPFC tCDS found a mean effect size of 0.14 for accuracy and 0.15 for reaction time.[22]

I’m not certain why I’m getting such different numbers, except that my “review” seems to have included different studies than the meta-analysis did.  If you averaged the results, you’d still get a mean effect size of 0.75, which corresponds to a strong effect.

Speech

10 aphasic stroke patients treated with anodal tCDS over Wernicke’s area vs. sham: significantly improved accuracy on a picture-naming task (40% vs 20% correct before training, and 70% vs 50% after training.)  Anodal tCDS also improved mean reaction time (1.8 sec vs 2.5 sec.)  The improvement persisted 3 weeks after treatment.[6]

In 10 healthy subjects, anodal tCDS over Broca’s area vs sham increased verbal fluency: mean number of words were 22 vs. 16, and mean number of syllables was 15 vs. 14.  There was no effect when the tCDS was switched to the right-hemisphere analogue of Broca’s area.[10]

Pain

A study of 17 patients with central pain due to traumatic spinal cord injury, given 2 mA of tCDS to the motor cortex M1 or sham tCDS found a significant improvement of pain scores — from a 7 (out of 9) to a 4.  The effects of consecutive sessions were cumulative.  There was no significant effect of treatment on anxiety or cognitive function.

32 female patients with fibromyalgia were treated with sham tCDS, tCDS of M1, or tCDS of the DLPFC.  M1 stimulation worked, sham and DLPFC did not. Out of a subjective improvement scale (where 2 is “much improvement”,  3 is “minimal improvement”, and 4 is “no change”, the group treated with M1 tCDS was at 2.5 and the sham group was at 3.5; the DLPFC group was at 3.  This was 2 mA, 20 min/day, for 5 days.[4]

41 female patients with fibromyalgia treated with tCDS on M1, DLPFC, or sham found that M1 stimulation significantly improved pain scores compared to DLPFC or sham: from about a 6 (which was baseline) to a 4.  No significant effect on depression scores.[11]

A meta-analysis of tCDS for chronic pain found a pooled effect size of 2.29 on pain symptoms.[23]

Depression

A meta-analysis of the use of tCDS in depression (directed to the DLPFC) found that the mean effect on depressive symptoms was significant: a Hedges’ g score of 0.743, significant at a p-value of 0.006. There’s a bit of a bias in the data: the Fregni and Boggio labs had significantly larger effect sizes than the other labs, and there was significant heterogeneity in results. Only a minority of patients (10-30%) were responders.  The average reduction in symptom severity was about 30%.[5]

Another meta-analysis of 6 RCTs of tCDS in depression found no significant effect of tCDS vs. sham on response rates or remission rates for depression.[13]

Blinding issues

There are more frequent reports of itching and burning with real than sham tCDS, suggesting that blinding may not be sufficient.[14]  Participants are able to guess more accurately than chance whether they are in the active or sham treatment.[15]

Other problems

The MEP (electrical activity change) due to tCDS is extremely variable both between individuals and within the same individual. The MEP effect of tCDS can be abolished by moving or thinking while the current is being administered.[16]

DIY

If you want to zap your brain, there are a variety of places that sell tCDS devices.

The Brain Stimulator is $59.95

The foc.us  stimulator is $249, plus headsets and cables.

The Apex is $139.99

The Fisher Wallace Stimulator is $699.

Soterix Medical makes the standard clinical-use device, for investigational use only.

And, of course, a lot of people make DIY versions.

Safety issue to keep in mind: high voltage to your brain is not good. Anything above 2 mA is outside the range of what’s been studied and probably a bad idea.  If it hurts your skin, it’s too strong. A TENS unit is too strong.  A 9-volt battery is too strong. Do not do the thing.

References

[1]Nitsche, Michael A., et al. “Transcranial direct current stimulation: state of the art 2008.” Brain stimulation 1.3 (2008): 206-223.

[2]Fregni, Felipe, et al. “Anodal transcranial direct current stimulation of prefrontal cortex enhances working memory.” Experimental brain research 166.1 (2005): 23-30.

[3]Boggio, Paulo S., et al. “Effects of transcranial direct current stimulation on working memory in patients with Parkinson’s disease.” Journal of the neurological sciences 249.1 (2006): 31-38.

[4]Fregni, Felipe, et al. “A randomized, sham‐controlled, proof of principle study of transcranial direct current stimulation for the treatment of pain in fibromyalgia.” Arthritis & Rheumatism 54.12 (2006): 3988-3998.

[5]Kalu, U. G., et al. “Transcranial direct current stimulation in the treatment of major depression: a meta-analysis.” Psychological medicine 42.09 (2012): 1791-1800.

[6]Fiori, Valentina, et al. “Transcranial direct current stimulation improves word retrieval in healthy and nonfluent aphasic subjects.” Journal of Cognitive Neuroscience 23.9 (2011): 2309-2323.

[7]Javadi, Amir Homayoun, and Vincent Walsh. “Transcranial direct current stimulation (tDCS) of the left dorsolateral prefrontal cortex modulates declarative memory.” Brain stimulation 5.3 (2012): 231-241.

[8]Cerruti, Carlo, and Gottfried Schlaug. “Anodal transcranial direct current stimulation of the prefrontal cortex enhances complex verbal associative thought.” Journal of Cognitive Neuroscience 21.10 (2009): 1980-1987.

[9]Mulquiney, Paul G., et al. “Improving working memory: exploring the effect of transcranial random noise stimulation and transcranial direct current stimulation on the dorsolateral prefrontal cortex.” Clinical Neurophysiology 122.12 (2011): 2384-2389.

[10]Cattaneo, Z., A. Pisoni, and C. Papagno. “Transcranial direct current stimulation over Broca’s region improves phonemic and semantic fluency in healthy individuals.” Neuroscience 183 (2011): 64-70.

[11]Valle, Angela, et al. “Efficacy of anodal transcranial direct current stimulation (tDCS) for the treatment of fibromyalgia: results of a randomized, sham-controlled longitudinal clinical trial.” Journal of pain management 2.3 (2009): 353.

[12]Boggio, Paulo S., et al. “Temporal cortex direct current stimulation enhances performance on a visual recognition memory task in Alzheimer disease.” Journal of Neurology, Neurosurgery & Psychiatry 80.4 (2009): 444-447.

[13]Berlim, Marcelo T., Frederique Van den Eynde, and Z. Jeff Daskalakis. “Clinical utility of transcranial direct current stimulation (tDCS) for treating major depression: a systematic review and meta-analysis of randomized, double-blind and sham-controlled trials.” Journal of psychiatric research 47.1 (2013): 1-7.

[14]Kessler, Sudha Kilaru, et al. “Differences in the experience of active and sham transcranial direct current stimulation.” Brain stimulation 5.2 (2012): 155-162.

[15]O’connell, Neil E., et al. “Rethinking clinical trials of transcranial direct current stimulation: participant and assessor blinding is inadequate at intensities of 2mA.” PloS one 7.10 (2012): e47514.

[16]Horvath, Jared Cooney, Olivia Carter, and Jason D. Forte. “Transcranial direct current stimulation: five important issues we aren’t discussing (but probably should be).” Frontiers in systems neuroscience 8 (2014): 2.

[17]Pereira, Joana B., et al. “Modulation of verbal fluency networks by transcranial direct current stimulation (tDCS) in Parkinson’s disease.” Brain stimulation 6.1 (2013): 16-24.

[18]Ohn, Suk Hoon, et al. “Time-dependent effect of transcranial direct current stimulation on the enhancement of working memory.” Neuroreport 19.1 (2008): 43-47.

[19]Jo, Jung Mi, et al. “Enhancing the working memory of stroke patients using tDCS.” American Journal of Physical Medicine & Rehabilitation 88.5 (2009): 404-409.

[20]Oliveira, Janaina F., et al. “Acute working memory improvement after tDCS in antidepressant-free patients with major depressive disorder.” Neuroscience letters 537 (2013): 60-64.

[21]Richmond, Lauren L., et al. “Transcranial direct current stimulation enhances verbal working memory training performance over time and near transfer outcomes.” Journal of Cognitive Neuroscience (2014).

[22]Hill, Aron T., Paul B. Fitzgerald, and Kate E. Hoy. “Effects of anodal transcranial direct current stimulation on working memory: a systematic review and meta-analysis of findings from healthy and neuropsychiatric populations.” Brain stimulation 9.2 (2016): 197-208.

[23]Luedtke, Kerstin, et al. “Transcranial direct current stimulation for the reduction of clinical and experimentally induced pain: a systematic review and meta-analysis.” The Clinical journal of pain 28.5 (2012): 452-461.

[24]Nilsson, Jonna, Alexander V. Lebedev, and Martin Lövdén. “No significant effect of prefrontal tDCS on working memory performance in older adults.” Frontiers in aging neuroscience 7 (2015).

[25]Liu, Anli, et al. “Exploring the efficacy of a 5-day course of transcranial direct current stimulation (TDCS) on depression and memory function in patients with well-controlled temporal lobe epilepsy.” Epilepsy & Behavior 55 (2016): 11-20.

The Gunas: A Model For Mental States

Epistemic Status: purely speculative play

Sometimes we learn the most from books we want to throw across the room.  The Bhagavad Gita was like that for me.

It’s a tiny section of the Mahabharata, itself embedded in a truly enormous tradition of Indian spiritual and philosophical thought that I have come to accept I will never make any appreciable headway on.  I have difficulty engaging with that tradition, because a lot of the shared presuppositions in the Eastern religions are so alien to my present values — basic things like “worldly daily life is inferior to ascetic spiritual life” or “the physical world isn’t real.”  It’s intensely frustrating, but in a way that sometimes seems productive, to bump up against a radically different worldview and try to extract value from it.

On the other hand, this means this post requires a warning. When I extract an idea that seems valuable to me from a tradition I’m this unfamiliar with, I’m almost certainly not representing that tradition faithfully.  You’re getting the asshole Western syncretic version.  I am nowhere near equipped to provide the Sanskrit-scholar version.

(If you have not been exposed to quite how big the Hindu tradition is, consider this guy, who, if Wikipedia is to be trusted, has achieved incredible fame and preeminence in philosophical traditions I’d never heard of and in art forms I’d never heard of.)

The Gunas

The Gita speaks of three “gunas”, translated variously as “qualities”, “virtues”, “properties”, of which everything and everyone consists, in different proportions. These are sattva (wisdom, harmony, purity), rajas (passion, activity, ambition), and tamas (ignorance, chaos, destruction).

The Gita says (Chapter 18, verses 23-25):

Action that is virtuous, deliberate, free from attachment, and without craving for results, is considered Sattvic. Action that is driven purely by craving for pleasure, selfishness, and with much effort is Rajasic. Action that is undertaken because of delusion, disregarding consequences, without considering loss or injury to others or self, is called Tamasic.

Likewise there are Sattvic, Rajasic, and Tamasic personality types (which are supposed to correspond to castes).

According to the Gita, “there is no agent but the gunas.” A person has multiple parts, multiple sub-agents, which each have their own agendas, and these sub-agents cycle around ceaselessly, doing their thing, unless one learns to master them through meditative practice.  By default, you are a Markov chain bopping around from state to state.

This seems to ring very true.  My own lived experience has been that I seem to experience multiple different states or moods, which come and go, have their own distinctive qualities, and have conflicting goals with one another.

This also matches a lot of concepts in psychology or cognitive science: Haidt’s elephant and rider metaphor, Minsky’s society of mind, and George Ainslie‘s thoughts about hyperbolic discounting as an expression of conflict between multiple selves.

Parallels and Differences in Western thought

These three gunas are echoed in George Dumezil’s trifunctional hypothesis, a theory of three archetypes that he were believed were common across all Indo-European mythologies:

• Sovereignty (judges and priests)
• Military (warriors and nobles)
• Productivity (herders, farmers, and artisans)

Sovereignty would be associated with the head, and the intellectual virtues (wisdom, justice, etc); military with the heart, and the warrior virtues (courage, honor, etc); and productivity with the belly or gonads, and qualities like fertility and luck.

Thus, Dumezil sees trios all over the place.  For instance, Odin (wise king of the gods ), Thor (brave warrior god), and Freyr (fertility and agricultural god).

The trifunctional hypothesis is a pretty close match for the parts of the soul in Plato’s Republic:

• Reason (associated with the guardians in his ideal city)
• Passions (associated with warriors)
• Appetites (associated with commoners)

Plato’s view is hierarchical: polities and persons function best when reason rules, passions execute on reason’s judgments, and appetites are subdued.  A lot of effort has to be put into educating people and organizing states in order to keep this organization in place.

This is not exactly the same model as is described in the Gita.  Tamas is mostly associated with lethargic or passive qualities: sloth, ignorance, apathy, confusion.  The appetites, in both Dumezil and Plato, are more associated with food and sex and active impulsiveness.

And the Gita is not exactly hierarchical in the way the Republic is; there’s some notion of getting beyond all three gunas, passing beyond the cycle of death and rebirth, going outside the frame through meditative insight.

There’s also a parallel with Freud’s id, ego, and superego, though that’s not quite exact either. The superego is a parental or societal inner voice, which is kind of a corrupted version of a voice of reason.  The ego is the locus of self-narrative, which isn’t quite the same as the locus of the emotions, though “egotistical” behavior is probably rajasic.  And the id is the seat of powerful, instinctual passions, which is a better fit with Plato’s appetites than with tamas.

If Plato envisions a monarchy of the soul, Freud envisions the possibility of revolution — if you suppress the id too brutally, there’s a chance it’ll rise up and cause chaos.

Parallels with Biology

The gunas seem to roughly match to different neuroendocrine processes, according to Stephen Porges’ polyvagal theory.

According to this theory, the dorsal vagal nerve and its branches, which are evolutionarily ancient (found in reptiles and amphibians) and unmyelinated, governs autonomic processes like digestion and breathing, and the “freeze response” to danger.  The sympathetic nervous system and the hypothalamic/pituitary/adrenal axis govern the “fight-or-flight” response.  And the ventral vagal complex, which is evolutionarily recent and myelinated, governs social and exploratory behavior — sucking, looking around, sniffing, listening, speaking, etc.

Porges describes

three distinct subsystems, which are phylogenetically ordered and behaviorally linked to communication (e.g. facial expression, vocalization, listening), mobilization (e.g. fight-flight behaviors), and immobilization (e.g. feigning death, behavioral ‘shutdown’, and syncope).

“Vagal tone”, or the ability to calm down physiological arousal and also make it more flexibly appropriate to the occasion, has experimentally derived associations with  emotional intelligence and secure attachment.

The systems in the polyvagal theory seem to correspond to three kinds of mental states: frozen passivity, anger/fear/excitement, and calmness/curiosity/affection/communication.  These seem to correspond well with the three gunas.

Perhaps there literally are, in some biological sense, different parts of the mind — that is, processes that are only active one at a time, and correspond to different global patterns of behavior and affect, so that it makes sense to ask “is this person in mode A, B, or C right now?”  An uncontroversial example would be “awake vs. asleep” — you can tell, both behaviorally and with an EEG, whether a person is awake or asleep, and while we don’t know fully what sleep is for, nobody questions that “sleep” is a well-formed concept.  Maybe there’s something analogous for the gunas that has to do with mood and parasympathetic activity.

Gita	Plato	Freud	Plain English	Element	Body Part	Polyvagal Theory
Sattva	Reason	Superego	Thinking	Air	Head	Ventral Vagal
Rajas	Passion	Ego	Doing	Fire	Heart	Sympathetic
Tamas	Appetite	Id	Being	Earth	Belly, Gonads	Dorsal Vagal

Sattva from the inside

Sattva wants to understand everything and optimize everything. Sattva wants to feel clear, calm, insightful.  When you’re in a sattvic state, you’re always asking “How could this be better?”  How could this idea be made more precise, how could my behavior be more correct, where do I find quality and excellence?  Sattva’s traditional color is white, and its mood is bright, rarefied, elevated.

Sattva virtues:

• wisdom
• awareness
• reflectiveness
• insight
• justice

Sattva failure modes:

• pedantry
• paralysis through abstraction
• control-oriented forms of malice (criminal masterminds, totalitarian governments, gaslighting and isolation as tools of abuse)

Sattvic activities:

• introspection
• writing
• planning
• learning
• reorganizing or improving systems

Rajas from the inside

Rajas wants to do stuff and do it hard.  Rajas wants to feel active and exhilarated and victorious. Rajas wants to win, to beat the other guy, to be special and important, to push through obstacles.  When you’re in a rajasic state, you’re trying really hard to do the thing; there’s a quality of fierce intensity, of “gotta gotta gotta gotta do it!”  Rajas’s traditional color is red, for obvious reasons — it’s about blood, both in the sense of “violence” and the sense of “getting enough oxygen for intense activity.”

Rajas virtues:

• courage
• passion
• energy
• ambition
• determination

Rajas failure modes:

• violent aggression
• drama-seeking, picking fights, ego-trips
• annoyingness
• dogmatism, obsession
• dominance-oriented forms of malice (e.g. bullying someone until they cry)

Rajasic activities:

• fighting
• dancing
• competing
• passionate romance
• hard work
• taking initiative

Tamas from the inside

Tamas is the hardest of the gunas to pin down. It seems to want a state of rest: no obligations, nothing to attend to, no active consciousness, just a comfortable, womblike cave.  It’s a sense that the world is intrusive in its demands, and one wants to retreat from it, or find palliatives from it, or hide from it.  When you’re in a tamasic state, you’re trying to get relief or hide from painful things or be at peace, or maybe just to sleep.  Tamas‘s traditional color is black, which makes sense if you think of it as the nighttime state, the hide-under-the-covers state.

Tamas virtues:

• endurance
• patience
• survival in traumatic conditions

Tamas failure modes:

• depression
• procrastination
• addiction
• neediness
• self-sabotage
• apathy, lethargy, sullenness
• brain fog
• willful ignorance, evasion
• patheticness

Tamasic activities

• sleeping
• eating rich foods
• drinking alcohol
• being entertained
• cuddling
• vegging out

Take-Aways

If you have this model of the gunas, you can simply ask yourself: which am I in at the moment? How do my gunas change over the course of a day or a week?

You can consciously change from one guna to another (I’ve managed to switch from tamas to sattva a few times).

You can also consciously try to offer nice things to the much-maligned lower gunas: take up martial arts to satisfy rajas, or have a fondue-and-wine night to satisfy tamas.  I have the rough “pagan common sense” intuition that you should be nice to entities if you want them to be nice to you, and this includes parts of yourself.

I’m not yet aware from first-hand experience about the “going meta” thing that meditation supposedly offers, but I’d expect that there’s probably something to it.

Sane Thinking About Mental Problems

Epistemic status: exhortatory and personal, but pretty confidently my true belief

CW: suicide mention

When I was a teenager, I was depressed.  And the way I thought mental illness worked, the way I had learned from novels and from some of the adults around me, was as follows.

You are in pain. You try as hard as you can to hide this from others, keep up with all your responsibilities, be a “good girl.” But you are in pain, and eventually something’s gotta give. At some point, you “hit rock bottom” — you express your emotional pain through some act of self-destruction that is impossible to hide. At that point, people around you will be horrified, and will send you off to an inpatient clinic, where you will rest, recuperate, and be healed by wise and sympathetic doctors and therapists.

This is really not how it works, and it is a destructive myth that I think is actively wrong to teach children.

The reality is that mental health care is hard to get. For various economic reasons, there is a shortage of therapists, a shortage of beds in hospitals, and so on. A lot of people really struggle to get mental health care.

And mental health professionals are not magic. There is no guarantee that going to therapy, or taking medications, will solve your problems. It’s still often worth doing, but it’s not a “happily ever after,” and in some cases will be useless or harmful.

Moreover, there is a lot of discrimination against the mentally ill today. The stigma of mental illness can impair your ability to get an education, or keep a job.

All of which means that people with mental health issues are constantly in the position of making practical tradeoffs, sometimes quite painful ones, sometimes ordinary uneventful ones, between taking time to focus on getting well and just keeping the business of daily life running. The myth that, as soon as you acknowledge that you have a problem, that your life will be swept away into a therapeutic cocoon, is laughably unrealistic for pretty much everybody.  Life goes on, even when you’re crazy.  You go on.

And everybody, from people who just struggle with the odd neurosis to people who are severely disabled, has to more or less muddle through with the good humor, determination, and common sense they already have, and without any absolute answers from on high.  Even if you wind up needing help — and needing help is normal — you’re still driving your life.  You can’t pass the steering wheel to anybody else, and even if you could, that would be incredibly dangerous and you really don’t want to do that.

This is nothing new to people who have already been around the block.  But it would have been news to a younger version of me, and I’m writing this for her, and for anyone like her who might be reading.

Letter to a Young Depressive

You’re wondering if this is real.

It seems like life shouldn’t be like this. Surely not everyone spends long nights at the lab wondering whether acrylamide or ethanol or the strong bases are the best way to go.

But you’re fine, your grades are still good, god knows you’re managing, you don’t want to wreck your chance at college by going to the school counselor, and anyhow it’s not clear whether your problems are real or fake, so for now, you do your best to keep your head above water.

It has not occurred to you that one could try to stop wanting to die.

So: yes, it’s real.

If you looked up the DSM definition of depression, you would very definitely meet criteria. But that’s not the point.

The point is that you are unhappy, and that in itself matters. It turns out you are allowed (actually, required, but that’s a long story) to care about your own life and achieve your own happiness.  It also turns out that’s possible even for people who have made bad choices. It turns out you always have the right to live.  It turns out you are good.

That’s a lot of impossible concepts, I know, and it’ll take you a long time to work them out, and that’s also fine.

The accessible part is this: you can start trying to be happier, now.  You don’t have to take big risky steps like therapy or meds if you’re not ready for that. You can write in your diary, you can read the odd self-help or psychology or philosophy book, you can talk to a friend.  You can do more things that make you happy and fewer things that make you unhappy.  The incremental, DIY, trial-and-error forms of self-care that you work out on your own are not futile.  In fact, there’s a chance they’ll be the only things that work.  And even if you do get professional help eventually, you’ll be doing the “homebrew” stuff anyway.  That part never goes away.  Recovery just means getting good at it.

It is a bad idea, if you can avoid it, to “hit rock bottom”, but if you do crash spectacularly, the reality is that it’s just more life, with some added inconveniences.  Actually going to a mental hospital is not very much like it’s depicted in YA novels.  It is a liminal space that gives you time to recuperate, but it’s often mundane, sometimes shitty, and quite short-term, and afterwards you still have to go on with life.  If you’ve damaged yourself physically, or damaged your relationships, or whatever, now you have to go on with life while damaged, which is why it’s generally a bad idea.  Regardless of your degree of involvement with mental health professionals or the psych system, you’re going to be making tradeoffs and practical choices.  That part also never goes away.

The Big Lie

The mantra taught to young people today is “If you’re having trouble, get professional help.”  And also, “If you see someone in trouble, don’t try to help them yourself, get them professional help.”

In college, I had a barrage of orientation sessions where we were told that if a classmate or friend was struggling with an emotional or psychological problem, that we should not attempt to handle the situation on our own, but should refer them to the school’s mental health facilities.

Think, for a moment, about how wrong this is.

They are teaching kids not to be kind to sad friends, but to report them to the authorities instead.

So I watched my roommate, who had life-threatening mental health problems, as she was  abandoned by all her friends at the first sign of weakness. I saw our little quad talking around the problem, trying to “get her help” that never actually came, passive-aggressively blaming her for being ill.  I watched the laughable incompetence of the mental health people as they did precisely the wrong things for her. I was too socially awkward to do much more than clumsily ask her to stop hurting herself.  She became an evangelical Christian because those were the only people on campus who were actually nice to her.

Even at the time, I knew something was wrong with the culture — it drove me into a despair of my own — but I wasn’t sure it wasn’t just me who was out of step.  It wasn’t until later, until I read Allen Ginsberg, that I got external confirmation that it was normal to suffer along with a mentally ill friend, that it was normal to give a damn.

ah, Carl, while you are not safe I am not safe, and now you’re really in the total animal soup of Time —

The irony was that I was taking a course that semester called “The Politics of Friendship.”  We read De Amicitia and the Nicomachean Ethics and The Four Loves.  And meanwhile, in the real life I saw around me, there was nothing like that, nothing at all, only callousness and falseness and denial.

Ivy League schools in particular deceive students into believing that they can treat mental illness, when in fact they do not have the resources to do so. Colleges tend to encourage mentally ill students to go on leave — and not come back.  A few years ago, an anonymous op-ed from a schizophrenic Harvard student made the news:

Harvard should abolish the present oft-coerced leave of absence imposed on students who admit themselves to the infirmary. Students who decide to go on leave are often unaware that in order to return, they must prove that they have held a job or internship and that they have been seeking treatment. The burden of this policy falls brutally on students from poor backgrounds, students lacking robust health insurance, and students with unstable family situations. Ironically, these are the very students who are more likely to have experienced trauma.

Another Yale undergrad who struggled with mental illness writes of being expelled after going to “Mental Hygiene.”  Another Yalie reports that her psychiatrist said, “Well, the truth is, we don’t necessarily think you’ll be safer at home. But we just can’t have you here.”  As with most colleges, Yale’s mental health services vastly undershoot the demand, and Yale is not entirely candid about this fact, not telling students about the (limited) number of therapy slots available, the long wait times, and the risk of being asked to “voluntarily” withdraw — which still requires paying tuition for the classes you don’t take.  Recently a Princeton student sued the university for violating his medical confidentiality by requiring him to “voluntarily” withdraw after a suicide attempt.  The issue seems to be pervasive.

My closest friend in college was threatened with expulsion, unless he went to therapy, because he wrote a short story for a creative-writing class that involved violence.  Specifically, it was a science-fiction short story about a slave rebellion.  He said that other short stories in the class contained violence too, sometimes much more gruesome; the problem was that he depicted justified, good-guys-fighting-bad-guys, violence.

Not only does this mean that a student’s education can be suspended on highly subjective criteria, but in practice those criteria are profoundly opposed to justice.

The problem isn’t necessarily that schools aren’t equipped to serve the needs of mentally ill students. No school can be all things to all people, health care is scarce and expensive, and a school’s main mission is education, not treatment.  The problem is that schools promise that students will be taken care of.  The message is “don’t worry about solving your problems on your own — we have lots of wonderful professionals to solve them for you!” Which is absolutely the opposite of the truth.

There’s a human cost to not being honest about the limits of mental health care at colleges.

I remember scrolling through Facebook once, while hanging out with a friend who was a student at Yale Law, when suddenly my face fell and she asked “What’s wrong?”  Well, another friend of mine had lost his job, and I was worried about him.

My Yale friend was very impressed and made a big deal about how compassionate I was.

And that struck me as weird. Surely anyone would be sad about a friend who lost his job. A good friend would try to help him get back on his feet, or do some other concrete act of service.

But there are actually a lot of Ivy League types for whom common sympathy is unusual, to whom it doesn’t occur to pause for a moment and be sad for someone else.  We’re taught not to. We’re taught that other people’s troubles are not our problem, unless we can get public credit for some kind of conspicuous charitable work.  The right thing to do is to keep reaching for the brass ring and to resist the temptations of sympathy.

Sad friend? There are professionals to handle that.

A ragged urchin, aimless and alone,
  Loitered about that vacancy; a bird
Flew up to safety from his well-aimed stone:
  That girls are raped, that two boys knife a third,
  Were axioms to him, who’d never heard
Of any world where promises were kept,
Or one could weep because another wept.

Auden’s world is real today, except that it’s not among ragged urchins, but among privileged and intelligent young people, that integrity and compassion are out of the ordinary.

Frames and Fluidity

There are multiple ways of looking at problems with the mind.  I don’t think that there’s a best one, but that it’s practical to switch between them pragmatically and to be mindful of the local advantages and disadvantages of each frame.

The medical model speaks of mental illness as a type of disease, which can be treated medically.  The mentally ill are sick, and they can get well.  They are patients.

The advantage of the medical paradigm is that it’s largely the only one that engages with the awesome power of psychopharmacology. It’s not an exact science, but there is no doubt that brain drugs affect the brain and can be studied experimentally, which is more than you can say for a lot of other approaches to the mind.  Some medications work spectacularly, some less so, but either way, there’s a tangible concreteness to thinking of mental illness as a physical problem, an engineering problem.  You can get some purchase that way.

One downside of the medical paradigm is that it’s demoralizing to view your situation as a catastrophic aberration, as something that should not be, especially if it’s not going to be swiftly fixed.  This problem also affects the physically disabled and chronically ill.  If you’re living with an issue indefinitely, it has to become ordinary to you, it has to become your new normal. And it usually will, by default. People get used to using wheelchairs and hearing aids. But if you’re constantly rehearsing the thought that you’re broken, or spiraling out of control, and in need of someone to “fix” you — then you’re going to be more miserable than your condition strictly requires, and more passively accepting of medical authority than is safe or useful.

The social model of disability frames mental issues as disabilities, in the sense that they are socially discriminated against by a “one-size-fits-all” society.  It emphasizes the right to access, to be treated decently, to have a normal life, even if you’re not neurotypical.

A major advantage of the social model and the disability community is frank talk between disabled people.  The questions become “how do I make my life work while disabled?” and “how do I keep from being jerked around by an unfriendly system?”  And, from the people thinking in this vein, you can get bonding, advice, practical problem-solving, camaraderie, validation, and courage.

A major disadvantage, though, is that the disability paradigm takes permanence for granted, and frequently mental illness involves the possibility of getting well.  If your identity and community are based around disability, then healing can subconsciously seem disloyal.

What I’d call the “skill model” is a family of viewpoints which say that problems of the mind are fundamentally about being weak at a skill, and recovery is about gaining that skill.

Some forms of therapy are straightforwardly skill-based. Cognitive remediation therapy is just memory and concentration practice.  Dialectical Behavioral Therapy is largely about teaching the skill of managing emotions.  Behavioral activation is a concept from cognitive-behavioral therapy that says “if you practice doing stuff, you’ll be able to do more stuff.”   Exposure therapy is literally just practice doing the thing you’re scared of.

Some types of self-help outside the world of formally trained psychology are also skill-based. Some people approach meditation this way, or Stoicism, or a regular exercise practice, as a way of training yourself to be saner. Unfuck Your Habitat is about gaining the skill of keeping your house clean.  Ureshiku Naritai is a very nice, straightforward essay that epitomizes a skill-based way of overcoming depression: the author trained herself to notice which things improved and worsened her mood, and did more of the former and less of the latter.

The advantage of the skill-based approach is that it incorporates the human capacities of learning and trying.  Once you have the lightbulb moment of “wow, I can try to get better on purpose?”, once you start working directly on things rather than waiting for someone to “treat” you, your progress can accelerate quite suddenly. The skill model takes you, meaning your “wise mind” or the part of you that wants to be sane, seriously as an agent, and enlists your effort and intelligence.

The downside of the skill-based approach is that some mental illnesses don’t respond well to it, and if you don’t find a way to engage the gears that bring you to “wow, I can do this!”, it can sound quite condescending. The negative stereotype of the skill model is “I fixed my depression with yoga and you can too!” which gets a bitter chuckle from old pros at the badbrains game.

What I’d call the “spiritual model” is a final family of viewpoints, which are related in that they take the denotational content of mental problems seriously, especially mood problems.

In this model, if you are having a crisis of faith, then your depression is fundamentally about religion, and you’re going to need to figure out your answers to religious questions.  If your problems take the form of extreme guilt, then you’re going to have to engage with ethical philosophy and figure out a form of ethics that is compatible with life.  If you’re experiencing nihilistic despair, then you’re going to have to find a source of meaning.  If you’re having delusions, you might need to build up a stable epistemology.

The spiritual model takes unhappiness as a normal or even universal part of the human condition, not something exclusive to “abnormal psychology.” People get profoundly unhappy; people have to find a way to overcome despair; the way to overcome your despair is to figure out where you have a misunderstanding and gain the insight that will resolve it.

The advantage of this approach is that it is much more individual and fine-grained than the other approaches.  It deals with your mind, not the generic mind that has similar problems to yours. And it engages with your mind, including your mental illness, as a peer — not as something to fix or to accept, but as someone to talk to and listen to. It allows for the possibility that your strange thoughts while depressed or manic or whatever might in fact be true, at least in some facets.  There’s a sense in which resolving inner conflicts is “getting to the root of the problem”, actually untangling the knots in your mind, rather than “merely” palliating symptoms.  The work of life, from the spiritual point of view, is building a valid and life-sustaining personal philosophy, and almost incidentally, this will resolve many “psychological problems.”

The downside of this approach is that sometimes your problems aren’t really about anything discernible, and it’s counterproductive to try to seek meaning in them, rather than just trying to manage or treat or accommodate them.  Sometimes trying a spiritual approach just means getting trapped in ruminating or becoming an “insight junkie”, with no productive effect on your actual problems.

It’s very rare to see discussions of mental illness that treat multiple possible frames as valid and usable.  I’ve seen personal narratives where people shifted from one frame to another and present it as “seeing the light,” but I think that’s not the whole story. I suspect that successfully living with, or recovering from, mental problems involves being somewhat eclectic about frames.

I switch between frames a lot myself. To wit:

My tendency towards anxiety is probably best framed medically — my whole family is tight-wound, I have genetic mutations that mean my adrenaline level is going to be higher than normal, and my anxiety responds really well to medication.

I view a lot of things, like Uber and text-based communication and to-do lists and calendars, as basically assistive tech for my poor spatial awareness and executive function, which is a very social-model perspective.  I use a bunch of hacks like weighted blankets to make myself physically comfortable when it’s practical, without viewing my unusual needs as shameful “symptoms”, which is also a very social-model way of looking at things.

I think about building resilience and fortitude to emotional shocks from a skill-based perspective.  There’s a lot of value in practicing toughness or patience or self-restraint.  Like Ben Franklin, I think you can sometimes reinforcement-learn your way to virtue.

I largely deal with my guilt and shame issues through the spiritual approach. Learning that the things that torment me are illusory and based on bad philosophy has been extraordinarily helpful. Reading and friendship — and I’ve had truly wonderful and wise friends — have allowed me to work towards a perspective on life that promotes my survival and flourishing.

“Shit Happens”: The Value of Normalizing

The one frame I don’t find helpful for thinking about mental problems is the frame of horror.  “How could this happen? This shouldn’t happen!  This is the worst and everything is falling apart!” is unproductive and often cruel.

Here’s the issue:

I’ve had the cops called on me for crying in public.

A friend of mine, who has dyspraxia, has had the cops called on her for walking funny.

We’re mild-mannered white women, so we got off easy. If we weren’t, those encounters could have been deadly.  When somebody has a panicked overreaction to seeing someone behaving weirdly, the consequences can be quite serious.

The reality is that about one-fifth of Americans experience mental illness in a given year.  This is a medical-paradigm statistic so obviously there are reasons to be skeptical of it; but the point remains that having problems with your mind is common. It is so common that it does not make sense to freak out about it.  It has to be acknowledged as part of the landscape of life.

When a person with mental problems freaks out about them, it’s usually self-destructive.  Self-pity or internalized ableism or a victim mentality are not conducive to getting better.  Feeling like “OMG this is terrible!” is understandable, but it’s not an aid to recovery.

When people freak out about others’ mental problems, they can range from callous (abandoning friends because they’re “crazy”) to frankly evil (violating people’s rights and committing violence against them because they’re “crazy”).

The antidote to freaking out is the acknowledgement that “shit happens.”

You have to expect that misfortune is pretty common, you have to account for the fact that most people you meet will experience misfortune at some point in their lives, and you have to learn a sort of reasonable tolerance about that.  Otherwise you’ll be in denial about reality, and that’s inevitably going to hurt someone.

Denial-followed-by-freakout is how we got into the mess that is campus mental health policy, and probably a lot of other systemic problems as well.

If we take a pragmatic, balanced, trial-and-error, “shit happens”, kind of perspective on the problems of the mind — if we accept that they’re very common and we have to make the best of them, both individually and communally — we’ll be a lot more prepared to deal with life as it is.

Ain’t Gonna Study War No More

Epistemic Status: Personal

People are often confused when I say I’m an anarchist, and it takes a while to explain what I mean, so I think it may be worth posting about.

The thing is, I believe in peace.

Yep, this is the old-fashioned non-aggression principle.  Consent. Voluntariness. Mutual benefit. Live and let live. All that jazz.

Nation shall not lift up sword against nation, neither shall they learn war any more. 

For me, it’s not an abstract formalism set up to justify why taxes should be lower or something.  Peace is a state that you can be at, or not, with others. Peace is what happens when two cats take a nap next to each other in a square of sunlight, and they don’t bother each other, but are okay in each other’s company. Peace is a state of deep, secure, calm nonintrusion.  Peace is what my husband and I try to practice in our marriage, for instance.

Peace means that nobody is giving orders, implicitly or explicitly. It means when you speak to a person you’re saying “I think you would value hearing this”, not “I’m going to try to alter you.”  It’s a kind of politeness and respect for privacy.  To get it exactly right takes a lot of work, and everyone makes mistakes at it.  But it’s a beautiful thing when it can be achieved.

Peace is the precondition for individual perception or creation. You have to be left alone for long enough to have a mind of your own. A child who gets enough time to play and dream will start making things. Poking and prodding interrupts that process.

Adults also have to be left alone to make things, if we are ever going to have nice things.  If you don’t let people make factories or houses or drugs, we won’t have any.

And cruelty hurts. Harshness hurts. Normal sympathy tells us that.  All things being equal, being mean is bad. I don’t care that it sounds childish, that’s what I actually believe.

Ok, but non-peace is everywhere. The world contains wars and governments, and pushy assholes, and probably always will as long as there are people. And there may be necessary evils, situations where aggression is unavoidable. Isn’t it naive of me to just stand here saying “peace is good”?

This is the point when I have to make clear that I’m talking about a stance rather than a system.  The question is always “what do I do?”, “where do I place the Sarah in the world?”  I don’t have a God’s-eye view; my understanding literally comes out of my own brain, which is embedded in one person, who exists in the world.  So there’s no real principled separation between believing and doing.

What defines you, as an agent with bounded computation, is what you focus on and what simplifying heuristics you use. Defining the “typical case” vs “outliers” is a form of frame control that is inevitable, an ineluctable form of choice, so you may as well do it intentionally.

My stance is that my attention belongs on the win-win, peaceful, productive parts of the world. My stance is to place myself on the side of aspiring to higher standards and aiming for joyful wins.  I think that outlook is both well suited to me and significantly undervalued in the public.  We may need people in this world who are all about making harsh tradeoffs, protecting against tail risks, guarding the worst off, being leaders or guardians or sheepdogs — but that’s a completely different frame, a different stance, and I don’t think it’s really possible to see the world through both simultaneously.

In the frame I find healthiest, the “typical case” is that people are individual persons who fare best when their consent is respected, that by default “doing well” and “doing good” correlate, that “do your own thing, seek growth and happiness, don’t aggress upon others” is usually the best bet, and that cases where that’s not possible are the exceptions and aberrations, to be worked around as best as possible.  Peace is the main course, force is a bitter condiment that we must occasionally taste.

This is the lens through which Leopold Bloom sees the world:

But it’s no use, says he. Force, hatred, history, all that. That’s not life for men and women, insult and hatred. And everybody knows that it’s the very opposite of that that is really life.

— What? says Alf.

— Love, says Bloom. I mean the opposite of hatred.

I’ve often noticed a hope deficit — people are very quick to try to decide which necessary evil they have to accept, and it doesn’t occur to them to ask “what would it look like if things were just straightforwardly good?”  There’s a creative power in optimism that people don’t seem to appreciate enough.

I think I’m not going to do that much more digging into social-science topics, because they aren’t as amenable to finding peaceful wins.  The framing puts me in the position of asking “do I support inflicting this harm or that harm on millions of people?”  And this is ridiculous; I, personally, will never do such a thing, and don’t want to.  If I ever make a valuable contribution to the world it will almost certainly be through making, not ruling. So anything that sets things up as the question of “what would I do, if I were a ruler” is corrosive.  The world is a mixture of peace and war, but I want my part in it to be peaceful.

Police Shootings: How Bad Are Things?

Epistemic Status: rough, back-of-envelope

How many people are killed by police in the US? How does this compare to death rates from other causes?

In 2015, the Washington Post counted 990 Americans shot by police, the Guardian counted 1146 killed, and Fatal Encounters reported 1357, while the FBI and BJS’s 7-year average number of police killings per year were 418 and 380, respectively.

In 2012, an estimated 55,400 people were killed or hospitalized by police; 1 in 291 stops or arrests resulted in hospital-treated injury or death.  1063 suffered fatal injuries. Beatings were by far the most common cause of injury, while shooting was the most common cause of death.

I’m inclined to believe the reporters’ numbers over the FBI and BJS’s numbers, and estimate something like 1000-1500 police killings a year, and tens of thousands of police-caused hospitalizations a year.

Comparison to Total Homicides

According to the CDC, there were 15,809 homicides in America in 2014, and 2.1 million emergency room visits for assault in 2011.

This means that 5-10% of all homicides are committed by police.  3% of all severe assaults are committed by police.

There are about 765,000 police in the US. There are about 152 million men, who commit about 90% of homicides; there were 9972 male homicide perpetrators in 2010.  Thus, roughly, a policeman is 30x as likely to kill you as a randomly chosen man is.

Breakdown by Race

According to the Washington Post, 48% of people killed by police are white, while 25% were black. (The remainder were of a different or unknown race.)  This represents an overrepresentation of black people and underrepresentation of white people, since the US is 62% white and 13% black.  Black people are 2.5x as likely as white people to be killed by police.

There’s some research showing that there is no racial disparity in the rate of police killing per encounter, but researching “per encounter” rates of violence hides a lot under the rug.  If police are biased against black people, they are more likely to “encounter” them, looking for a reason to arrest them, and thus are more likely to escalate to violence. On the other hand, black people commit more crimes (per population) than white people.  Teasing out what constitutes police bias and what constitutes justifiable increased policing intensity is a tough subject.  What’s not in doubt is that the burden of police killings falls disproportionately on black people.

Comparison to Lynching

While this may seem an inflammatory comparison, a lynching, like a police killing, is an extrajudicial killing of a suspected or alleged criminal.

According to the Tuskegee Institute, the year with the highest number of lynchings, 1892, saw 61 whites lynched and 161 blacks lynched.

Given that the US population in 1892 was only about 20% of its current size, this means that, adjusted for population, about as many people are killed by police today as were lynched in the 1890s.

Looking at black people specifically, who were 12% of the US population in 1890, just as they are today, the risk of being lynched for a black person was about twice as high in the 1890s than the risk of being shot by a cop for a black person is today. Lynchings were notably more skewed towards black people than police shootings are.

Comparison to Police States

There is absolutely no comparison in magnitude between anything happening in the US criminal justice system and Stalin’s Great Purge, which killed between 600,000 and 1.2 million people, out of a population of roughly 100 million.

As we noticed with hate crimes, looking at serious problems of violence in the US can put into perspective how terrifyingly, unimaginably bad Hitler and Stalin were. Our problems are not trivial, but totalitarian regimes are…a fundamentally different kind of thing.

Augusto Pinochet had an estimated 40,018 people killed, tortured, or forcibly disappeared between 1973 and 1990, or an estimated 2354 per year, out of a population of 10-13 million.  His regime was at least 50x as deadly as US police are.

South Africa under apartheid tried and executed about 134 political prisoners between 1961 and 1989, which is not quite comparable to police killings, but is a lower rate than exists in the US.  However, South African “deaths in police custody” in 1997-2004, immediately after apartheid, averaged 434 deaths a year, while 763 people were killed by the apartheid government’s police in 1985, an unusually violent year.  Police killings in apartheid South Africa were roughly 5x as common per population as they are in the present-day US, while police killings in 1990’s South Africa were roughly 2.5x as common as they are in the present-day US.

According to a recent human rights agency’s report, 323 people have died in Egyptian prison facilities since 2013 after the recent coup, as well as 624 protesters killed.   This is comparable to the number of police killings in the US.

245 people were killed by Venezuelan security and police forces in 2015; per population, this is about twice as many as police killings in America.

Thailand’s war on drugs, which involved 2800 extrajudicial killings in the first three months after it began in 2003, is at least 10x as deadly as police in America are.

200 people died in police custody last year in Russia, about half the rate of police shootings in America per population.

The US is generally, but not always, less deadly to its citizens than typical authoritarian regimes.  The US has similar rates of death due to police as present-day South Africa, Russia, Venezuela, and Egypt.

Comparisons to other causes of death

Like all kinds of homicide, the number of police homicides pales in comparison to the number of deaths due to disease. Cancer kills more than hundreds of times as many people per year than police do. Suicide kills 30-40x as many.  Infant mortality kills more than 15 times as many.  HIV kills six times as many people.   Doctors and medical researchers are still on the front lines against death.

And prison itself probably causes quite a bit more humanitarian damage than police killings do.

However, justice matters too. An innocent person killed by police is wronged, in a way that a person who succumbs to a disease is not. Police killings count towards the vaguely defined but important category of “evidence that we don’t live in a free and just society”, in the same way that torture, detention without trial, mass surveillance, and other civil liberties violations do.

 

If Prison Were a Disease, How Bad Would It Be?

 

Epistemic status: highly uncertain

As of 2013, 2,220,300 adults were incarcerated in US state and federal prisons and county jails.

The majority of these people –about 60% — are incarcerated for nonviolent offenses such as theft, drugs, or public order violations.

How bad is this, in terms of years of life lost?  How much damage is due to being imprisoned?  (ETA: of course, in this context, I am only looking at the harms of prisons, not the benefits due to the deterrent effect of prisons, or the harms of crime. This should not be read as a claim that prison has zero deterrent effect!)

One article attempts to quantify:

African American males can expect to spend 3.09 years lifetime in prison, on average, and Hispanic and Caucasian males will spend on average 1.06 and 0.50 years, respectively.

Comparing life expectancies of people who have and have not gone to prison, as if “prison” were a disability, they compute that white males lose 19,665 person-years of life to prison per 100,000, black males lose 139,507 person-years, and Hispanic males lose 45,766 person-years.

For comparison purposes, here is a table of person-years of life lost to the most common diseases in the US.  Cancer, the top killer, only appears to cost 2882 person-years of life per 100,000.  All causes together only cost 38,211 person-years of life per 100,000.

These numbers are really weird.  They would place prison as being responsible for nearly half of all person-years of life lost.  That would be an utterly shocking result. I’m skeptical.

(ETA: it turns out that the authors of this study were looking at a stock, not a flow, of person-years lost to prison, as Ben notes below. Do not use this study’s numbers to estimate the harms of prison, they don’t make a lot of sense.)

Epidemiologist Ernest Drucker, in his book A Plague of Prisons, tried to quantify the years of life lost to imprisonment for drug offenses in New York State.   He estimated a total of 360,000 years of life in prison between 1973 and 2008. This isn’t a fair comparison to diseases, though, because a year living in prison is not as bad as being dead, and prison has harms outside the time actually spent in prison.  If we were to count years in prison as “years of life lost”, however, then, given that there are roughly 19 million people in New York, drug offenses alone cost 55 person-years of life per 100,000, which is a more modest number.  

A study of the dose-response effect of years of prison on mortality found that each additional year in prison (compared to being released on parole) produced a 2-year decline in life expectancy.  For comparison purposes, smokers lose on average 11-12 years of life expectancy compared to nonsmokers.  Getting a diagnosis of colon cancer means losing about 10 years of life expectancy, while getting a diagnosis of testicular cancer means losing 1.3 years of life expectancy.

If we combine these numbers, assume each year in prison is roughly equivalent to two years of life lost, then New York State’s drug incarceration is responsible for about 110 person-years of life per 100,000, which is about half the death rate due to HIV.  This is a more believable number, though it would still make the list of the top 15 causes of death by years of life lost. But it’s only for drug incarceration, which is responsible for only about 1/5 of all incarceration.

If we look at the total number of people incarcerated in New York State, or 77,227, we get an estimated 810 person-years of life lost to prison in New York per 100,000 population, which is more than the national YLL of homicide.  And if we extrapolate to the full 2,220,300 Americans incarcerated, assume 2 years of life lost per year in prison, we get a rate of person-years of life lost due to prison per 100,000 population of 1396, which would make “prison”, if it counted as a cause of death, the sixth worst public health problem in terms of person-years of life lost.

The deadliness of prison, depending on which numbers you use, seems to range from “truly implausibly bad” to “one of the most serious public health problems in America.”

The leading causes of death among former inmates are drug overdose, cardiovascular disease, homicide, and suicide; the highest elevated risks, at 10-12x the population expected rates, were drug overdose and homicide, especially at 0-2 weeks after release. Prison puts people in more danger than they were before.

Some suggested mechanisms for why prison is so dangerous include poor conditions such as overcrowding that expose prisoners to infectious disease; violence within prisons; poor medical care inside prisons; and increased risky behaviors, due to trauma or psychological harm or lack of material opportunities for ex-cons.

For US-centric and present-day-centric utilitarian calculations, prison looks really, really bad. Reducing the prison population seems potentially important on a level comparable to working on Big Problems like cancer, heart disease, diabetes, car accidents, etc.

If nobody were imprisoned for drug crimes, then (aside from any additional risks incurred from the resulting increased drug use) the drop in incarceration alone would save more American lives than eradicating HIV from the US today.

 

 

 

Hate Crimes: A Fact Post

CW: violence, rape, murder, racism.

Epistemic status: a few days’ worth of background reading, way outside my field. This is me “showing my work” in how I orient myself, not a substitute for social science.

Since the Trump election, I’ve been concerned about what, concretely, a resurgence in racism might mean, and how likely it is.  There are people I respect saying “anything could happen” and warning us to stay vigilant and prepared to resist acts of fascist tyranny. There are also people I respect telling everyone to calm down because it’s probably not that bad.

As a grandchild of a resistance fighter against the Nazis, I was raised to believe that it can happen here, and we have to be prepared.  Part of preparation, though, is realism.  What exactly are we facing, and what kind of preparation is appropriate?  The first step is trying to assess the situation accurately.

It may seem naive to start by reviewing hate crime statistics.  The numbers probably aren’t all that accurate; and recorded hate crimes are nowhere near all the harms due to racism.  I’ll be making some attempts to deal with the first issue later in this post.  As for the second, well, this is a very primitive attempt to come to my own conclusions. I would need to be an economist with far more resources and time, in order to, say, estimate the cumulative economic damage of redlining.  For the moment, I want to do the exercise of looking at some numbers and coming to my own conclusions — not because I expect to do that better than social scientists do, but to practice original seeing, which I think is important for getting outside the sway of others’ opinions.

Why hate crime? Because racial violence is one of the concrete “bad outcomes” that we implicitly fear, when we fear a “rise in racism”.  So it makes sense to ask things like how common it is now, and how common it was in the past, or how common it is in other countries, to get a sense of the range of where things can go.

Overview

There are two major data sources in the US for information on hate crimes. One is the Department of Justice’s National Crime Victimization Survey, which is taken from a sample of about 100,000 households, and asks them detailed questions about crimes they’ve been the victims of.  The other is the FBI’s Uniform Crime Reporting database, which collects recorded crimes from police departments across the country. These sources conflict quite a bit.

The US only began recognizing “hate crime” as a legal category in the 90’s, so older information on hate crime is mostly unavailable. For (very rough) comparison purposes, I’m also going to look at statistics on lynching and on race riots, to get a sense of past levels of racial violence. I’ll also briefly compare these to contemporary Russian hate crime statistics, for an example of a country which famously has a severe problem with racial violence.

UCR Data

In 2015, there were 5850 hate crime incidents reported to the FBI by police departments.  

Of these, 36% were motivated by anti-black bias, 13% by anti-gay (male) bias, 12% by anti-white bias, 12% by anti-Jewish bias, 5% by anti-Muslim bias, 4% by anti-LGBT bias excluding gay males, and 2% by anti-Hispanic bias.

(I was surprised to see so low a rate of hate crimes against Hispanics, and so high a rate against whites.)

There were 18 murders and 13 rapes. There were 4482 crimes against persons, of which 41.3% were intimidation, 37.8% assault, and 19.7% aggravated assault.  (That is, a total of 2577 assaults.) The majority of the 2338 hate crimes directed against property were acts of vandalism.

The states with the highest number of hate crimes per capita were:

• DC
• Massachusetts
• North Dakota
• Montana
• Kentucky

Southern states in general have lower per-capita rates of hate crime than northern states, according to the UCR; and Mississippi has a grand total of zero hate crimes reported, which is highly suspicious.  There is a serious underreporting problem with hate crimes — several major Southern cities never report hate crimes at all, such as Birmingham, Alabama; Jackson, Mississippi; and Baton Rouge, Louisiana.  So it’s quite likely that these numbers are underestimates.

The UCR has been keeping hate crime stats since 1995. Hate crime rates have been slowly declining in that period.  Anti-black hate crimes are about ⅔ their 90’s level, anti-Jewish hate crimes are about 60% of their 90’s level, anti-white hate crimes are about half, etc.

The number of anti-Muslim hate crimes spiked in 2001, from negligible to about 500, and then declined to a stable but higher-than-before level.

So, clearly, it is possible for current events to cause a spike in hate crimes.  This is a special type of a spike in hate crimes, though: Muslims may have been so small and new a population in the US that they just weren’t a habitual target of bigotry before September 11.  The September 11th hate crimes spike tells us that current events can rapidly create new targets of bigotry, even when they were largely left alone before.

NCVS Data

From 2004-2012, the rate of hate crime victimization in the population, according to the self-reports in the NCVS survey, remained steady at roughly 1 per 1000 persons 12 or older.

This would imply a much higher rate of hate crime than the UCR reports — roughly 260,000 a year — and even if we only count those crimes which survey respondents said they reported to police, that’s still 120,000.  However, according to the NCVS, only 14,380 hate crimes were confirmed by police investigators. Most reports of hate crimes do not result in the police concluding there was a hate crime.  And, of those, we might infer, only a fraction are reported to the UCR, given that the UCR’s hate crime numbers are less than half the number that the NCVS says were confirmed by police.

This low rate of police recording and police reporting is specific to hate crimes, not common across all crime.  The UCR and NCVS also include reporting on non-hate crimes like rape, robbery, aggravated assault, etc. In most of these cases, the number of crimes that the NCVS says were reported to police is comparable to the number of crimes that the UCR says were recorded by police.

Crime	# (NCVS 2012)	% reported to police (NCVS 2012)	# recorded by police (UCR 2012)	recording rate
Rape	431840	32.5	90185	0.64
Robbery	578580	60.9	327374	0.93
Aggravated assault	816760	58.4	764449	1.6
Simple assault	3179440	40	n/a	n/a
Burglary	2904570	60	1579527	0.91
Motor vehicle theft	564160	83.3	707758	1.5
Theft	11142310	29	5706346	1.76
All hate crime	293790	34	6718	0.067
Violent hate crime	263540	34	4810	0.053

The one exception is hate crime, where only about 5% of hate crimes reported to police are recorded in the UCR.

That this discrepancy exists specifically in hate crimes suggests that police preferentially take hate crimes less seriously than other crimes.  And, indeed, according to the NCVS, police were more likely to take reports and make arrests in non-hate crimes vs. hate crimes.

However, the fact that there are cases where the NCVS numbers significantly undershoot the UCR numbers — giving the nonsensical result that the police record more e.g. motor vehicle thefts than victims report to police — suggests that the NCVS may have some serious sampling bias.

In the NCVS 2012 data, 52% of hate crime victims were white, 13% were black, and 30% were Latino.  This throws some doubt on the much lower rate of anti-Hispanic hate crimes in the UCR data — maybe Latinos/Hispanics are less likely to report hate crimes to the police, or less likely to be taken seriously by the police.

According to the NCVS, 16% of hate crimes were “serious violent crimes” (robbery, aggravated assault, or rape), 44% were “simple assault”, and 22% were property crime.

So How Many Hate Crimes Are There?

The unfortunate fact is that we don’t know how many hate crimes there are, because both our major data sources seem to have serious flaws.

How big a deal is hate crime, in terms of damage to human life? What are the casualty rates?

According to the NCVS,  5% of hate crimes were aggravated assault causing injury, and 10.6% were simple assault causing injury, giving roughly 32,760 injuries a year due to hate crime.

The NCVS doesn’t report murders.  The UCR’s numbers of 18 hate-crime murders a year are probably an underestimate, but also probably not as much of an underestimate as the other types of crime, since I would expect that people are more likely to report murders to the police than other crimes. There were a total of 15,809 homicides in the US in 2011.  If 0.1% of all crimes are hate crimes, as the NCVS reports, and homicide is a representative crime, then this would predict 15 hate-crime homicides a year, which is comparable to the UCR’s numbers.

My tentative order-of-magnitude estimates are that there are 10-20 hate-crime murders a year, and tens of thousands of hate-crime injuries.

Lynchings

According to the Tuskeegee Institute archives, lynchings in 1882-1968 were at most one or two hundred killings a year.

At the peak in 1892, the total number of lynchings in the US was 230, with 161 blacks and 61 whites killed.

Controlling for population growth, and comparing lynchings of black people directly to all hate-crime murders, (yes, obviously this is an imperfect comparison), this means that “hate-crime killings” were roughly 45x as common per population in the late 19th century as they are today.

The NAACP numbers claim there were 3436 people lynched between 1889 and 1922, or an average of 104 lynchings per year.

Lynchings began to decline in the 1920’s, potentially due to a variety of causes: the urbanization of the South, more active anti-lynching efforts by state police and the National Guard, the activism of the NAACP, and the attempt to pass the Dyer Anti-Lynching Bill in 1922. (It passed in the House but failed in the Senate.)

(Image from Harry Truman’s report on civil rights.)

It’s worth noting that this is what a climate of lawless terror looks like.

It wasn’t that black people had to use a separate drinking fountain or couldn’t sit at lunch counters, or had to sit in the back of the bus.

You really must disabuse yourself of this idea. Lunch counters and buses were crucial symbolic planes of struggle that the civil rights movement used to dramatize the issue, but the main suffering in the south did not come from our inability to drink from the same fountain, ride in the front of the bus or eat lunch at Woolworth’s.

It was that white people, mostly white men, occasionally went berserk, and grabbed random black people, usually men, and lynched them. You all know about lynching. But you may forget or not know that white people also randomly beat black people, and the black people could not fight back, for fear of even worse punishment.

This constant low level dread of atavistic violence is what kept the system running. It made life miserable, stressful and terrifying for black people.

White people also occasionally tried black people, especially black men, for crimes for which they could not conceivably be guilty. With the willing participation of white women, they often accused black men of “assault,” which could be anything from rape to not taking off one’s hat, to “reckless eyeballing.”

This is going to sound awful and perhaps a stain on my late father’s memory, but when I was little, before the civil rights movement, my father taught me many, many humiliating practices in order to prevent the random, terroristic, berserk behavior of white people. The one I remember most is that when walking down the street in New York City side by side, hand in hand with my hero-father, if a white woman approached on the same sidewalk, I was to take off my hat and walk behind my father, because he had been taught in the south that black males for some reason were supposed to walk single file in the presence of any white lady.

This was just one of many humiliating practices we were taught to prevent white people from going berserk.

I remember a huge family reunion one August with my aunts and uncles and cousins gathered around my grandparents’ vast breakfast table laden with food from the farm, and the state troopers drove up to the house with a car full of rifles and shotguns, and everyone went kind of weirdly blank. They put on the masks that black people used back then to not provoke white berserkness. My strong, valiant, self-educated, articulate uncles, whom I adored, became shuffling, Step-N-Fetchits to avoid provoking the white men. Fortunately the troopers were only looking for an escaped convict. Afterward, the women, my aunts, were furious at the humiliating performance of the men, and said so, something that even a child could understand.

This is the climate of fear that Dr. King ended.

To get that experience, you only need a few dozen actual recorded lynchings per year.  The indirect impact of living under threat of violence far exceeds the literal death count.

This is what it looks like, historically, to have 45x the rate of racial violence of today.

Race Riots

For most of US history before the 1960’s, a “race riot” was racial violence by white people against nonwhite people (usually black, sometimes immigrants such as Filipinos or Mexicans).  Whole towns might be attacked and burned. In the early 20th century, these were extremely bloody: in the Tulsa race riot of 1921, whites literally bombed a black neighborhood from private airplanes, killing about 300 and forcing thousands from their homes.

While lynchings were largely a rural Southern activity, race riots were urban and nationwide.

There is no central repository of race riot casualty statistics that I could find, so I have some quick-and-dirty Internet numbers here; this is not an exhaustive list.

• 1898 Wilmington, 18 black deaths
• 1906 Atlanta, 25-100 black deaths
• 1917 East St. Louis, 40-200 black deaths, plus arson; 6000 fled the city
• 1919 “Red Summer”: roughly 310 deaths
• 1920 Ocoee: 50-60 deaths
• 1921 Tulsa: 300 dead, more than 800 hospitalized
• 1923 Rosewood: 8-150 deaths
• 1930 Watsonville: 12 severe injuries, one death
• 1935 Harlem: 3 dead, hundreds wounded
• 1943 Detroit: 34 deaths, 344 wounded; Harlem 6 deaths; Zoot Suit Riots, no deaths but many injuries
• 1963 Birmingham: 50 wounded;
• 1964 Rochester: 4 dead, 350 injured; Harlem 1 dead, 118 injured; Philadelphia 344 injured
• 1965 Watts  34 dead
• 1966 Hough 4 deaths, 50 injuries
• 1967 Newark 26 deaths, hundreds of injuries, Plainfield one death, Detroit 43 dead, 1189 injured, Milwaukee 4 deaths, 100 injuries
• 1968 King assassination riots: 43+ deaths, 2500+ injuries
• 1969 York one death, 60+ injuries.

A return to the levels of racial violence of the 1910’s-1920’s would mean, relative to population, roughly a 50x increase in the number of “hate crime” murders compared to today. As with lynching, this is what a climate of terror looks like.

A return to the levels of racial violence of the 1960’s would constitute a roughly 5x jump, compared to the number of hate crime homicides of today. That’s what it looks like to live in what we now remember as a “turbulent” time.

Pre-1963, only 10% of race riots could be attributed to escalation by blacks. Afterwards, most race riots were still started by whites but the proportion became closer to 60/40.

Mass racial violence dissipated through the 70’s and never again reached its 60s peak, with a few exceptions such as the Rodney King riots of 1992, which killed 50 people and caused $1B in property damage.

Hate crimes in Russia

There are estimated tens of thousands of neo-Nazi skinheads in Russia. In 2008, Amnesty International estimated 85,000 neo-Nazis in Russia.  Over the past ten years, there are an average of 56 hate-crime-related deaths a year, and 378 injuries.    Source, from SOVA, a Russian think tank that studies racism and xenophobia in Russia.

Racism in Russia is most commonly directed against Africans, Central Asians, Jews, and Vietnamese. Only a few percent of the Russian population are peoples of the Caucasus, and there are only 186,000 Jews in Russia, so this is a much more intensive campaign of violence than it would be in the US; the US is about 23% nonwhite; so, conservatively, accounting for Russia’s lower total population and lower non-Russian population than the US, racial violence in Russia is maybe 31x as deadly, in terms of risk of being victimized, as it is in the US.  

Once again, this is what a climate of fear and widespread mob violence looks like. Dozens of hate-crime murders per year, more than an order of magnitude more common than hate-crime murder is in the US.

(Anti-LGBT violence is also a serious problem in Russia but we don’t seem to have good statistics on how common it is; one report says 300 attacks per year.)

Did hate crimes in the US increase post-election?

UCR and NCVS numbers come out yearly, so it’s clearly too soon to tell from those sources.

There’s allegedly a 30% jump in NYC hate crimes this year, and the NYPD has instituted a special police unit to fight the uptick.

The SPLC has set up an opportunity for people to report hate crime incidents around the election, but all those they cited were “intimidation” — verbal harassment and threats.  The most common type was anti-immigrant intimidation.  The most common locations were schools.  

Another tracking site for hate crimes reports 79 self-reported incidents of “violence”, but I noted several errors (duplicates, shootings that were apparently non-hate-related, non-violent crimes).

I think that it’s important to be watchful to see if a post-election rise in hate crimes holds up, but we don’t have enough evidence to be confident that there’s been one.

Scenario Planning

The “really bad” scenario for hate crime in the US is a rise of 30-50x in serious mob violence motivated by bigotry and tacitly condoned by the state. This, we know from historical and international evidence, feels from the inside like living in a dangerous, lawless, oppressive place.

I do not think mob violence alone will cause genocide on a much larger scale. The twenty million murders committed by the Nazis are a different, alien, unthinkable scale of operation.  I suspect you need governments for that. Governments that actively want to exterminate a population, not just keep it fearful and subordinate.  Mob violence is much more common than official campaigns of extermination, and is a more likely threat scenario.

One good thing is that it’s probably not possible to jump to 1890’s-1920’s levels of racial mob violence all at once. If that were to happen, we’d see a smaller uptick before it gets that bad.  If we’re watchful, we’ll have warning, and we may be able to counteract the problem.

The SPLC has advice on how to prevent hate crime. I’m not sure how well validated this is, but what they emphasize is community response. Churches and town councils can organize things like prayer meetings, candlelight vigils, public gatherings with marches and speeches, and other public, communal displays of support for the victims of hate crimes and refusal to tolerate hate in the community.  Forming “coalitions for tolerance” to protest hate crimes and support victims of hate can send a forceful message to hate groups that they are not welcome, and potentially prevent future crimes.

I don’t know much about this topic, but I’d probably want to read more on the psychology and dynamics of mob violence, and whether there are known techniques for defusing or preventing it. I’d very much appreciate if more knowledgeable people shared info about this.