I think that you mentioning Dozy is totally appropriate. In comparison to that Mitochondria startup shill article:
This wasn't the focus of an article, rather part of community feedback and follow-up to a topically related but unaffiliated article.
You didn't know the guy previously, rather than knowing the Mitochondria team before writing the article.
Compared to the previous investment opportunity of an early-stage biotech startup, I think that asking for advice and presumably much smaller funding for an app that is more likely to potentially turn a profit is much more appropriate.
I have to say I agree here. This felt topically appropriate, and importantly, it wasn't a bait and switch. There was no surprise about the advertisement when it came, because the topic and tone of the post until then fit it.
I agree also. Given the comment's context (which includes your previous post), I didn't even notice your mention might be deemed an advertisement until you asked if it was reasonable. I award a pass: this example was appropriate.
+1. I was one of the people concerned by the previous instance of advertising, but I think this is very different (and totally fine). It feels less central to why you wrote the post, you were in section clearly dedicated to highlighting commercial products (so we're already in quasi-endorsement mode), it felt much more organic and less like a bait and switch. The previous one seemed like a disguised advert, whereas this one seems like mentioning something relevant when it becomes relevant.
> (I know some of you don’t like when I advertise things on here; feel free to tell me in the comments whether or not you think this example was appropriate)
IMO, you should make it clear whether you have any personal stake in the things you're advertising. If you don't, IMO this is unambiguously fine; if you do, it's a bit more muddied (and the fact that you didn't make it clear leans against it).
I'm not really bothered by the existence of adverts or advertising. But a lot of people are, and seemingly for a bunch of different reasons. I think Scott should maybe figure out what reasons he finds valid and just stick to following rules that don't violate the valid reasons.
Some of the reasons I might imagine people dislike scott advertising:
1. Anti-commerce. Scott does have communist and socialist readers. I'm sure its not just marxbro. And these philosophies are against advertising and commerce in general, so the reminder of its existence, or the appearance of participation in the engine of commerce is an ugly bourgeoisie activity.
2. Money Motive Mistrust. Money is a motivator for most (nearly all?) people. Since it is such a powerful motivator, some people would rather have the money motivator removed or displaced from other activities. Pursuing money and truth might not mix well. They especially might not like the idea that some posts are motivated by truth and some are motivated by money. Just being able to honestly say that you have no financial stake in something is probably enough to appease this worry.
3. All Advertising is Evil. This viewpoint isn't often spelled out or explicitly taken. But some people just mistrust advertisements on a fundamental level. They see advertisements and their reaction is 'why do you need to advertise, if you are so great people will know about you'. Its like an extreme bayesian update after being fooled or lied to by too many advertisements. They've soured on the whole concept, and no one gets to be an exception.
Feel free to add more reasons, I'm not claiming this is an exhaustive list. Just some of the viewpoints I feel like I've encountered.
I think #3 is really just #2 in disguise. I don't think that there are many people that would object to a recommendation of something that they are willing to believe is truly disinterested.
here's one: i would rather say that i don't trust the charismatic friend at party -> scott link; i don't think he (or anyone really) can soberly judge things in that environment. maybe there is some paternalism here (*i* can see through the hype, of course, but other naive readers will be led astray...) but i think people in general should say what they think when they have reason to trust that what they think is more accurate than average, and i don't think scott achieves this wrt certain genres of startup type thing
Well, I think we have to allow people to have a social life 😀 But yeah, when filthy lucre is involved, the chance for immense drama to happen goes way up. Nothing causes more trouble in a family than when the will is read and "What do you mean Cousin Susie is getting the Spode teaset? Granny promised all these years that *I* would get that!"
Same way, "my friend told me about this great new start-up" and then someone puts money into it and it goes badly, and then they blame you for convincing them to invest in it. Especially if we weren't told at the start that this was a recommendation out of personal interest, then the comeback is "well you never said so I thought this was an impartial piece on reasoned grounds like when you wrote about varieties of pepper used in the 17th century, so I assumed it was okay to put my life savings, take out a second mortgage on my house, and sell my granny into indentured servitude as an investment opportunity that couldn't fail!"
Even if the piece in question *never* said "sell your granny and put the money into this", there is room for bitterness and blame because the human heart is a dark place and who has plumbed its depths?
Before he sees this and jumps in himself, I doubt this is an accurate depiction of what marxbro believes. Marxism isn't against commerce as far as I understand. It's just against the redirection of the fruits of value creation from labor to capital. As in, it's perfectly fine for apps to exist and be sold for revenue, but the revenue should accrue entirely to the engineers and doctors providing the service, not to investors.
I don't personally find the analysis super convincing, as it seems to ignore the needs of businesses that require great amounts of upfront capital when fixed cost structure is extremely front-loaded and you can't get in the black from operating revenue alone for a long time (say you're building airplanes and can't actually launch your first flight for two years or something). In cases like this, the simple provision of capital clearly creates value and the owners of the capital deserve compensation for that.
On the other hand, I do find the observation that the present state of the US economy tilts the split of profits between capital and labor far too much in the direction of capital pretty convincing.
Some versions of marxists are against almost all advertising. It is wasteful competitive spending in their eyes. Why not have a worker run council decide what should be produced, rather than letting businesses try to create demand for products that don't need to exist.
On #3, a lot of people have internalized "if I complain about X, then there will be less X." Even if they are simultaneously complaining about Y & Z, and X is much less worse than Y or Z. "They'll figure it out."
I think No. 2 would be the main area of concern for me. I don't mind if Scott invests sixty magic beans in the pegasus taxi service, but if he's going to write a piece about 'hey here's this cool new fly-in-the-clouds service starting up, I want to tell you how great it is!' then I prefer to know, rather than find out six months later that "Flying Unicorn Hackneys which went bust recently, leaving thousands of people out of pocket, was in fact a Ponzi scheme" and even if Scott was innocently involved, he was getting a return of five magic beans for his piece urging us all to break open the piggy-bank and put it all into Flying Unicorns.
As a corollary to the above, if Scott says "I think this is so cool and so great that I am putting my money where my mouth is and investing all my magic beans in it", that's fine. So long as we know upfront. There is a difference between "I heard about this thing and I want to tell you guys" and "A friend/a friend of a friend wants me to tell you guys about this thing", even if no money is involved.
However, this situation is quite different here: Wikipedia is a nonprofit and seeks to be objective, but people (not me!) are paying Scott + Substack lots of money to ensure that this blog continues to exist, and it's very clear that whatever Scott writes is going to be heavily flavored by his own thoughts and whatnot, so this calls for weaker standards. So IMO it's perfectly fine for Scott to advertise whatever he wants as long as he clarifies his relationship (although maybe the last half of the sentence is bad because writing "I have/don't have a stake in this!" with every ad seems mildly suspicious.)
I don't have any stake in this, but paradoxically it seems weird and kind of scammy to mention "I don't have any stake in this!" every time I advertise something.
That sounds potentially practical for longtime readers, but I think it's worth keeping in mind that he's probably going to accumulate new readers with time who won't have that context when they read new posts which advertise products.
It's also weird to say "I have a stake in this" every time you advertise something that is genuinely cool that you happen to have a stake in (and may have a stake in it because you genuinely think it is cool). As long as readers also think it is cool I don't really see an issue, but apparently plenty of other people do.
Declarations of conflict of interest are a thing; we all trust Scott, but it's probably no harm to have some kind of rule in place, even if that rule is "I'm going to mention this whether or not I am personally involved within six degrees of separation".
I think this particular mention is okay, since it's someone volunteering information on a topic already raised, and it's not "I wrote this BECAUSE a friend of a friend is looking for people to invest in a start-up and I get a commission if I send 100 potential investors their way". If Scott is investing himself or the likes, then a note about "Note: I am an investor/otherwise interested in the financial success or failure of this" is enough to let us know.
It might feel scammy, but I don't think it is. Your platform is not quite l a social interaction between friends, but I see how it feels that way, and it would be weird to tell your friends "I don't have a stake in this" everytime you talked about a new 'thing'. But this isn't a social interaction between friends, and disclaimers are common in many publications (not that you're a traditional publication).
Besides, it's more honesty and care than we get from disguised ad-icles (feel like I've heard of a better term for ad articles but I can't remember) from many other publications.
Matt Levine solved a nearby problem by turning it into a bit. He mentions that he used to work at GS every time he writes them up -- which is pretty often -- but without even breaking his tone.
Ideally I would like for Scott to just have a categorical ban on advertising stuff he has a stake in (I like when he advertises stuff because he likes it, but having a stake in it introduces potential uncomfortable biases and reduces trust a bit, which I dislike). Although otoh... if he'd heard about this app and also the guy writing it was his roommate who couldn't currently afford rent, would I want him not to advertise it because of that? Having a hard time deciding.
Hm that's a good point. I think what I have issue with is misaligned incentives. With descriptive writing about Lorien Scott doesn't really have those - he started it based on ideas he likes. I would worry a bit more if he wrote a study about how Lorien has better results than rival psychiatric practices, I guess (or at least, it's something I'd be more careful than usual about accepting at face value).
As someone who did the Say Goodnight To Insomnia program many years ago and found it effective, I want to highlight something to those who are skeptical about the efficacy of "therapy": the CBT part of it may not have been doing most of the lifting. The program also includes a stringent sleep hygiene protocol.
In a nutshell:
* Give up caffeine and alcohol.
* Keep a sleep log to figure out how many hours of actual sleep you get each night.
* Add two hours to that number and then keep to a strict bed schedule. If you are getting three hours per night, say, then you get five hours in bed. In bed at 10pm, up at 3am, etc.
* As your sleep quality improves, expand the time bounds until you are getting a full night's sleep.
There's more, but that's the gist.
There is also a CBT component that involves self-talk to help with rumination and other impediments to sleep. And I'm in no way critical of that aspect of the program. But if you can actually gut out the sleep hygiene part, it's a pretty hard reset to the system.
Caveat: I have no idea whether things have changed since I did this over a decade ago.
The sleep hygiene part is essential; changing thinking won't help if that isn't done. But many people do tie themselves up in terrible sleep-knots by their worry about how much sleep they're getting, how wrecked they're going to be the next day etc. So the cognitive part is essential for a lot of people.
I actually do the bed schedule the opposite way around; if the person is getting 3 hs of sleep fairly regularly, and has to be up at 7 am, they only go to bed at 4, until they are consistently falling asleep within 15 minutes of going to bed. Then bed at 3:30 .... Works GREAT.
But the hardest of all for most people is the wake up time. I tell them they can go to bed anytime they want, but they can only vary their wake-up time by an hour, ever. So if you have to be up at 7 to go to work every weekday, but you were out having a great time or home watching old movies until super late on Friday night, you can only 'sleep in' until 8 Saturday morning. Ditto vacations, unless you're willing to take the chance of having to re-do the whole chain upon return.
"But if you can actually gut out the sleep hygiene part, it's a pretty hard reset to the system."
Yeah, I think the sleep restriction is the part that works: make yourself so dog-tired that your brain just shuts down and you fall asleep like a log. Deliberately keep yourself on five hours, then work up to six, then... until you get the full eight hours or whatever you are aiming towards.
Stopping the intrusive thoughts or racing mind by making your brain too foggy to even think is the kind of reset that works. And then you train yourself into the habit of "no talk, just sleep" as soon as your head hits the pillow (or hopefully you do)>
> But a part of me worries that "FDA-approved" has a certain cultural meaning, and if the FDA approves one category of thing with lower proof than usual, people are going to get confused and think it's on a firmer evidence base than it is.
With a software background and skimming that material, the impression I get from "FDA-approved, but with a lower burden for software certification" is "ordinary clinical trials have shown clinical efficacy of the app, but when it comes to making sure the app won't crash or tell the user to sleep for 4294967295 hours tonight or whatever, we aren't certifying that type of correct operation in the same way that we would for a pacemaker."
If I'm correct, it doesn't seem like they're sacrificing the "evidence base" in the clinical trial sense that the FDA culturally means to me. Software certification has nothing to do with evidence of clinical efficacy, but in general means evidence that you're following some specific formal software engineering process, and have the paperwork to prove it.
One particular issue that comes to mind for apps is that the phone itself lacks any FDA software certification (and we don't want a stupid situation where the app can only be prescribed for specific approved phone models), so certification of the app has inherent limits. If the phone crashes, the app crashes, etc.
Sorry I'm not super familiar with the American health care system beyond "it's ridiculess you think socialized healthcare is impossible". Does the FDA approval allow insurance providers to cover the cost of the app? Or could it be covered regardless of FDA approval. Even if the price were $20/month. That's $20 or $240 annually that many people either can't pay for, or would simply rather not.
I just started a new prescription that my insurance doesn't cover for some reason, and it's going to cost me $40/month. I'd rather switch to another drug if it's similarly effective, and costs me nothing.
I hope a bit of statistical nitpicking is in order:
"that in-person cognitive behavioral therapy for insomnia has an effect size of 0.98, and the same therapy delivered over the Internet has an effect size of 0.51 (both numbers significantly different from control, not significantly different from each other). Somryst itself has significantly outperformed placebo in several studies. A meta-analysis finds..."
These effect sizes (ES) don't have real units. 0.98 what? kg? m? The reason is that the difference between the groups is divided by the standard deviation, and both have the same unit, so we end up with a dimensionless number.
Some people might argue that ES have a unit, namely, the standard deviation---of what? Of the control group? Of the baseline measurement before randomization? The latter depends on the inclusion criteria, because strict inclusion criteria reduce the variance of the measurement.
Especially in sleep studies, it would be easy to report the effect of a therapy in hours, so using dimensionless "measures" of an effect does not seem necessary. Within a study, it does not cause too much harm (the 0.98 and 0.51 seem to describe the same dependent variable), but social scentists and psychologists and psychiatrist use these numbers to compare effects across studies or variables.
Example 1: A therapy increased sleep quality, as measured by a questionnaire, by 2 units (kg, say). Sleep duration was increased by 1 h. So, on which variable do we see a larger effect? Obviously, we cannot tell if 2 kg > 1 h. But psychologists can! Just convert both results to ES, say, 0.6 for quality versus 0.4 for duration, and then move on.
Example 2: Same as Example 1, but with two studies investigating two new therapies. For Therapy A, Study 1 finds improved sleep quality by 2 kg, ES = 0.6; for Therapy B, Study 2 finds increased duration of 1 h, ES = 0.4. Conclusion: Therapy A is better than B, because, well 2 kg are more than 1 h.
Example 3: Meta-Analysis. Same as Example 1, but with two studies both investigating the benefits of Therapy A. Study 1 uses sleep quality as the outcome variable and finds an improved qualty by 2 kg, ES = 0.6; Study 2 finds increased duration of 1 h, ES = 0.4. Meta-analyst says, the "average" effect is (0.6 + 0.4)/2 = 0.5, somehow averaging 2 kg and 1 h.
I concede it is a bit off-topic, but there are quite a few statistically literate people in this forum, and the use of ES is disturbingly high even in the statistically literate population.
Is kg a real unit of sleep quality? I would normally associate that with kilograms, which is clearly not a unit of sleep quality. I just tried to search through academic papers to see what sort of units are actually used and there seems to be no widespread consensus, with researchers either using fairly complicated aggregates of 40-50 different quantitative measures, or entirely subjective Likert scale ratings. Either one would either itself be unitless or at least extremely obfuscated units (0.05 * minutes/night + 0.02 * turns/hour * ... etc).
There are more unitless effect sizes, e.g. odds ratios. The trouble starts if one use unitless measures for comparing things or averaging them. I'd say, an ES of 0.4 is just as "better" than an ES of 0.2 as 10 kg is "better" than 8 m.
My main point is: They're not needed. And it seems to me that their only use is to, well, compare things or average things, so they cause more harm than good.
Headspace is mostly a meditation/mindfulness app but includes a sleep section. No idea how it compares to the cbt-I apps. You can get it for a small monthly subscription fee, and I know some companies have been buying bulk memberships for staff, don't know if doctors are prescribing it
Insomnia Coach, by the US Deptartment of Veteran Affairs, is a free CBT-i app. They also have one called CBT-i Coach; I'm not sure the difference between the two. I've only used the former, and the latter looks less polished from screenshots. They also have several other free mental health/therapy/coaching apps.
It’s wildly untrue to say it’s hard to charge more than $5 or $10 for an app!
Just in sleeping and wellness, Calm is $70/year, Headspace is £49.99/year, Sleep Cycle is £25/year, Pillow is £40/year – I could go on!
It is fair to say that pricing has gone from up-front to “free trial then hefty annual subscription”, but people are clearly paying – Calm generated $100 million+ in revenue last year!
This is an important point and missed in the original comments. It's very hard to sell the app itself, as in gating the ability to download and install it, for more than a few dollars. It is not at all hard to sell a subscription to a service that is accessed from an app for a lot more than that.
For what it's worth, I came across sleep.io, which I have no idea if it also qualifies - I never got into it except to take their onboarding quiz, after which it turned out they really are just an app (I don't have a smartphone) and there's no website equivalent. But they talk a lot about CBT in their science section, which suggests they might be in the same niche, too.
Note that uptodate isn't always uptodate, of course. I suppose they too suffer from the tragedy of legible expertise.
COMISA (comorbid insomnia and sleep apnea) is one of the most common forms of chronic insomnia. It can be treated with just CBT-i, but there is reason why you wouldn't want to do that! Sleep apnea leads to a host of other issues in the short and long term and should be treated along with the insomnia.
All should now, especially if they have insomnia, that sleep apnea is much more common than people usually presume, even in the young, thin crowd. If you have any sleep issues and some of the common comorbidities that come with sleep apnea (ADHD, GERD, bruxism, for example) then you really ought to get a sleep study done, and especially if you are younger, thinner, or more fit, you'll need a test done that will pick up on arousal based sleep disturbances along with the oxygen desaturation based disturbances that are more commonly done.
Also, I saw nothing wrong with the Mitochondria startup post. If it's not a sneaky ad, which that wasn't, and if it's interesting, then I'll keep reading. Microdosing DNP or discovering some better mitochondrial uncoupler for medicine is really interesting and if you personally know a team working on that and think that people here are interested, then it only makes sense to let people here know.
As someone who therapizes people, often with CBT/ACT strategies involved, I just want to say, the effectiveness of any of this type of strategy depends primarily on whether our frigging patients DO the frigging work! This is something that drives every therapist I know BONKERS. I do know that some therapists are better at this, since they have a kind of gentle persistence that I struggle to carry out, but even those ones have just a somewhat higher rate of compliance, it still ain't high.
Behaviour change is MUCH MUCH harder than most people realize, even for pretty small and simple stuff (5 frigging minutes of frigging slow deep breathing once a day, for frigs sake! FIVE MINUTES!).
Therapists dream and fantasize about all sorts of things that might work to increase the uptake on the strategies; follow our pts around nagging them, electric shock collars, charge them outrageous fees that only go down if they can show they DID THE STRATEGIES .....
I recently had a super interesting experience around this, because I DO have leverage over some people (unfortunately not my pts); my STUDENTS. In a Psych Disorders class, I offered people a range of strategies to try out, focussing on wellness and coping with the stress of COVID isolation and all-online learning. I told them to choose a strategy that was relevant to them. They then planned how to apply it 5 days a week for three weeks, and did so, with accountability. They knew it was WORTH GRADES. And they were curious to see what this was like, and super stressed, many of them. (And it's not hard to tell who faked their work on this assignment!)
Most struggled during the first week, forgetting to do the strategies, feeling they were doing them clumsily, that this was ridiculous etc. They only continued because it was a class assignment. It got easier in the 2nd week. By the third, applying the strategies was going quite smoothly, and many started experiencing good effects. SO FAST! They were astonished especially because I had framed this JUST as an experiential exercise around behaviour change, and told them it probably wouldn't actually start making a difference for them in that short time frame. I wanted to reduce placebo effects and disappointment, 'cause 3 weeks really is a short time. And many were astonished that it worked even though they didn't believe it would.
So I got to explain how, if something is effective, it WILL help most people who use it, even when they don't believe it will help. That if you have to believe in it for it to work, then that's not treatment, it's magic. AKA, the placebo effect. Excellent learning experience all around!
So yeah, if you want to try an app or a book or a therapist, the big secret is to DO IT.
Now if I could just figure out how to apply some leverage to my patients .....
"5 frigging minutes of frigging slow deep breathing once a day, for frigs sake! FIVE MINUTES!"
Does deep breathing do anything, though? It's the kind of general advice that gets given, and I've been given it, and I've tried it, and it works in a small way while I'm occupied with "make sure you are breathing slowly at a certain rate" but once I stop, the problems come back again.
Or I get so anxious about "am I breathing properly? too fast? not deep enough?" that ironically I literally forget how to breathe and have to stop the exercise because I'm smothering.
Hah! You have 'relaxation induced anxiety'! Yes, that's a thing and people research it and write academic papers about it! I laughed out loud the first time I came across one of those.
It ABSOLUTELY does something, however a lot of people don't get enough info/explanation about what it does, how, and when.
The benefits of Relaxed Breathing (RB) are both long-term and short-term. Over the long term, all sorts of good physiological and psychological things occur (because our mind is also part of our bodies) that come from giving the para-sympathetic nervous system more opportunities to do it's 'rest and repair' job. This starts to take effect over weeks and months of regular practice.
The short-term benefits, which is what people are often looking for, however, don't kick in (for most people) UNTIL you've been doing it long enough and consistently enough to start getting long-term benefits. You have to get really GOOD at this physical SKILL, in order for it to be effective in the moment. Even more so when you're doing it when already particularly tense or stressed.
I tell people; your goal is NOT to do this 'well' or to do it 'effectively so it reduces my tension/anxiety right away'. Your goal is to PRACTICE. Practice sometimes goes great, sometimes TERRIBLE. It's very hard to do well or do at all in the beginning, and gets somewhat easier and more consistently well-done over time. Even when we are an expert, sometimes practice goes terrible.
So, do this in a setting and moment where you feel safe.
Set a timer and put it where you'll hear it but not see it (looking to see how much time has passed is highly counter-productive, and the sound it makes when finished should not be an obnoxious one). Lie or sit comfortably, eyes open or closed as you prefer. ANY technique works (box breathing, just slow with mental counting ....) as long as
- your belly is going out/up as you breath in, and down/in as you exhale (that's what pulls down, then releases, the diaphragm at the bottom of your lungs)
- it's slow
How slow? I encourage starting with a slow count to 5 in 5 out, or box of 3-3-3-3. That'll be slow enough for anybody. Then go slower as you get better at it.
In one nostril and out the other? Calculate the rate of breathing according to your heart rate? Exhale longer or inhale longer? Use biofeedback or neurofeedback to guide? All bullshit. You can do those if you like, they're not harmful, but the research is clear; deep and slow is all you need. You can puff the air in or out, or do a slow stream. 5 minutes twice a day is enough to provide significant benefit.
And if you realize you've forgotten to breath from your diaphragm? You've lost count and are again thinking about what you should have said when they said that? No matter. Just go back to the breathing. Repeat as many times as necessary until the timer goes off.
If you're particularly anxious/stressed when you begin, you may have trouble breathing slowly. So start with three breaths to a count of 3 in 3 out, then three breaths at 4 in 4 out, then settle in at 5 in 5 out.
The 'feeling like you're smothering' usually means you've gotten over-oxygenated. That can also create dizziness or tingling in face or hands. This can come from breathing in a way that creates more pressure on the exhale, such as pursing your lips and pushing the air, as if breathing through a straw or filling a balloon, or just from the depth of breathing and not going slow enough. Give yourself a break, then try again more slowly. Some people benefit from starting practicing just 2 minutes, then work their way up to 5.
As for many things that become general advice, there's a reason; this WORKS. But it's often poorly explained, poorly applied, just thrown out there. Short and simple doesn't mean EASY! At all!
Thank you, this is already *way* more explanation that I have ever got about it. The usual advice is "do this deep breathing thing" and then you're more or less left to sink or swim. Whatever about patients, I do wonder if doctors also expect it to start working more or less right from the start? Then when a patient comes back in three weeks time with "it's not doing anything for me", there's disillusionment on both sides; the patient thinks "this doctor is no good, recommending me this bullshit technique that didn't work" and the doctor is "well this patient is just not trying or willing to be compliant with a technique that SCIENCE SAYS! works". Whereas if both parties understood "it is going to take time before anything happens", it'd be a lot less stressful.
What you have said is actually encouraging, because you're telling me "No, it's not going to magically work right away, you have to keep trying, and this is the length of time and the rhythm you should aim for, and give it a few weeks to a couple of months before you see positive effects". Thank you!
You might want to take into consideration that many people may have insomnia (or other disorders) for reasons that also make it difficult to do the work or that make it so the work is less effective. Your students may have less of these issues. Insomnia is a great example as it is highly comorbid with sleep apnea (which is in turn highly comorbid with ADHD!).
Yeah, except that I make people check out whether they have sleep apnea or any other medical condition getting in the way of their sleep (thyroid etc) before we even try any of this. These strategies can also be very helpful for people with ADHD to at least improve their sleep (although they almost always also need lots of physical exercise, preferably outdoors, and some people need to avoid that being within 3 hs of their intended sleep time). And sleeping a bit better can make the ADHD more manageable as well.
The issue really is whether people first get good info on how to do this stuff, then if they EVEN TRY to apply the strategies. This doesn't only apply to people with ADD/ADHD, btw, see my other rant (I'm pretty ranty today). And then if it's not going well (can't apply, not working ....), bring that info back to do some problem-solving around that, etc.
True, but the most frustrating is that most of these patients want to try this stuff out. I'm trying to put my little bit of influence on that side of the balance, see if we can make it tip ...
I'm an unreasonable type of person. Reading the Sleepedy thing annoyed me because of George and Susan. Perfect Susan, who gets perfect sleep every night because she follows the perfect routine of not thinking, just get into bed and fall asleep.
I wanted to punch her in her perfect face. Meanwhile poor George gets blamed for being anxious and causing his own problems. So it looked like your employer was going to go bust and you'd be laid off and you were anxious about this and that caused lack of sleep? Silly George, nothing bad happened! But now you *made* yourself unable to sleep!
How about if George really did get laid off and is now struggling to find a new job and in the meantime he can't pay his rent and now he's facing the prospect of eviction - would they be less finger-wagging smug then about his insomnia?
It just reinforces for me that CBT works for certain people, when the underlying problem doesn't actually exist, it's just baseless worry. I get that changing your thoughts and cognition works for that. But if you have real worries, plus insomnia, I don't see how this will help much - the advice as part of it that "stay out of bed until you are falling down with tiredness and then you'll sleep" will work (in the short term) and then you allow yourself extra time in bed until you build up gradually to eight hours a night by which time you allegedly will have learned to fall asleep without thinking and thus keeping yourself awake, but do you need an app to tell you that?
The comp.risks take on this (or: what the Black Hat character from XKCD would do) is to create an interactive therapy app which seems helpful and gets approved, then turns dark and creepy on you when you use it long enough - longer than the FDA eval period. Imagine what a malicious therapy app which you had come to trust could do to your head.
That seems like a convoluted evil business plan? If it's FDA approved, it seems simpler to extract money from insurance companies without anyone noticing anything wrong.
RE: (I know some of you don’t like when I advertise things on here; feel free to tell me in the comments whether or not you think this example was appropriate)
This one feel fine to me. Now that I have a "YES" example and an "Ehhhhhh" example, the difference!
One is just a dude who is 80% probability: a cool dude! While the other is a business doin business things. It's probably fine to mention a buisness's buiness things in the context of "this is what they are doing and I think it is cool", but anything beyond that leaves endorsment and enters advocacy, is the feeling I guess.
Re: advertising, I have had no problem up until (and including) this point.
I think the key is moderation. If he was advertising it every post, or every other post, it would become distracting, and I'd start fixating on it/being annoyed myself. If it's one post a week or two weeks, then only the (small) tail of the distribution will care.
I’m an MFT and came across a very simple method of going to sleep or returning sleep when sleep is interrupted. It is likely that there’s some science out there on why this method works, though I can’t say I’ve looked into it...well, because on some intuitive level, it made sense to me (having once been a baby rocked inside a womb and once outside the womb, rocked as well), I tried it and it has worked for me, I have told others about it and it’s worked for them. So there’s about zero scientific engagement from my end and only a little qualitative date. So what is it? It’s rocking, it’s that simple. I’m a side sleeper so if I’m having trouble going to sleep, I lay on my side, my natural position, and I rock 15 to 30 times side to side. I don’t have to rock completely, just a gentle rock and boom, I’m asleep and can’t remember falling asleep or back asleep if I’ve woken during the night. When I first did it, my mind said to myself, “this won’t work” and it still worked. I don’t think there’s any potential harm in trying, it costs nothing and takes a minute, actually less than one minute. If you are so inclined, then try it.
Something I would like to see mentioned in the quizzes is "are you a parent of a newborn/toddler?". I technically have insomnia according to the criteria, but I have a newborn and I think that should be an exception. I also suspect that the techniques described in these apps won't help and aren't tailored for new parents.
This just looks like spam.
I think that you mentioning Dozy is totally appropriate. In comparison to that Mitochondria startup shill article:
This wasn't the focus of an article, rather part of community feedback and follow-up to a topically related but unaffiliated article.
You didn't know the guy previously, rather than knowing the Mitochondria team before writing the article.
Compared to the previous investment opportunity of an early-stage biotech startup, I think that asking for advice and presumably much smaller funding for an app that is more likely to potentially turn a profit is much more appropriate.
I have to say I agree here. This felt topically appropriate, and importantly, it wasn't a bait and switch. There was no surprise about the advertisement when it came, because the topic and tone of the post until then fit it.
I agree also. Given the comment's context (which includes your previous post), I didn't even notice your mention might be deemed an advertisement until you asked if it was reasonable. I award a pass: this example was appropriate.
Also agreed. The Mitochondria post was sketchy, this is totally appropriate.
+1. I was one of the people concerned by the previous instance of advertising, but I think this is very different (and totally fine). It feels less central to why you wrote the post, you were in section clearly dedicated to highlighting commercial products (so we're already in quasi-endorsement mode), it felt much more organic and less like a bait and switch. The previous one seemed like a disguised advert, whereas this one seems like mentioning something relevant when it becomes relevant.
+1
+1
Agreed.
Agreed
> (I know some of you don’t like when I advertise things on here; feel free to tell me in the comments whether or not you think this example was appropriate)
IMO, you should make it clear whether you have any personal stake in the things you're advertising. If you don't, IMO this is unambiguously fine; if you do, it's a bit more muddied (and the fact that you didn't make it clear leans against it).
I'm not really bothered by the existence of adverts or advertising. But a lot of people are, and seemingly for a bunch of different reasons. I think Scott should maybe figure out what reasons he finds valid and just stick to following rules that don't violate the valid reasons.
Some of the reasons I might imagine people dislike scott advertising:
1. Anti-commerce. Scott does have communist and socialist readers. I'm sure its not just marxbro. And these philosophies are against advertising and commerce in general, so the reminder of its existence, or the appearance of participation in the engine of commerce is an ugly bourgeoisie activity.
2. Money Motive Mistrust. Money is a motivator for most (nearly all?) people. Since it is such a powerful motivator, some people would rather have the money motivator removed or displaced from other activities. Pursuing money and truth might not mix well. They especially might not like the idea that some posts are motivated by truth and some are motivated by money. Just being able to honestly say that you have no financial stake in something is probably enough to appease this worry.
3. All Advertising is Evil. This viewpoint isn't often spelled out or explicitly taken. But some people just mistrust advertisements on a fundamental level. They see advertisements and their reaction is 'why do you need to advertise, if you are so great people will know about you'. Its like an extreme bayesian update after being fooled or lied to by too many advertisements. They've soured on the whole concept, and no one gets to be an exception.
Feel free to add more reasons, I'm not claiming this is an exhaustive list. Just some of the viewpoints I feel like I've encountered.
I think #3 is really just #2 in disguise. I don't think that there are many people that would object to a recommendation of something that they are willing to believe is truly disinterested.
here's one: i would rather say that i don't trust the charismatic friend at party -> scott link; i don't think he (or anyone really) can soberly judge things in that environment. maybe there is some paternalism here (*i* can see through the hype, of course, but other naive readers will be led astray...) but i think people in general should say what they think when they have reason to trust that what they think is more accurate than average, and i don't think scott achieves this wrt certain genres of startup type thing
Well, I think we have to allow people to have a social life 😀 But yeah, when filthy lucre is involved, the chance for immense drama to happen goes way up. Nothing causes more trouble in a family than when the will is read and "What do you mean Cousin Susie is getting the Spode teaset? Granny promised all these years that *I* would get that!"
Same way, "my friend told me about this great new start-up" and then someone puts money into it and it goes badly, and then they blame you for convincing them to invest in it. Especially if we weren't told at the start that this was a recommendation out of personal interest, then the comeback is "well you never said so I thought this was an impartial piece on reasoned grounds like when you wrote about varieties of pepper used in the 17th century, so I assumed it was okay to put my life savings, take out a second mortgage on my house, and sell my granny into indentured servitude as an investment opportunity that couldn't fail!"
Even if the piece in question *never* said "sell your granny and put the money into this", there is room for bitterness and blame because the human heart is a dark place and who has plumbed its depths?
Before he sees this and jumps in himself, I doubt this is an accurate depiction of what marxbro believes. Marxism isn't against commerce as far as I understand. It's just against the redirection of the fruits of value creation from labor to capital. As in, it's perfectly fine for apps to exist and be sold for revenue, but the revenue should accrue entirely to the engineers and doctors providing the service, not to investors.
I don't personally find the analysis super convincing, as it seems to ignore the needs of businesses that require great amounts of upfront capital when fixed cost structure is extremely front-loaded and you can't get in the black from operating revenue alone for a long time (say you're building airplanes and can't actually launch your first flight for two years or something). In cases like this, the simple provision of capital clearly creates value and the owners of the capital deserve compensation for that.
On the other hand, I do find the observation that the present state of the US economy tilts the split of profits between capital and labor far too much in the direction of capital pretty convincing.
Some versions of marxists are against almost all advertising. It is wasteful competitive spending in their eyes. Why not have a worker run council decide what should be produced, rather than letting businesses try to create demand for products that don't need to exist.
On #3, a lot of people have internalized "if I complain about X, then there will be less X." Even if they are simultaneously complaining about Y & Z, and X is much less worse than Y or Z. "They'll figure it out."
I think No. 2 would be the main area of concern for me. I don't mind if Scott invests sixty magic beans in the pegasus taxi service, but if he's going to write a piece about 'hey here's this cool new fly-in-the-clouds service starting up, I want to tell you how great it is!' then I prefer to know, rather than find out six months later that "Flying Unicorn Hackneys which went bust recently, leaving thousands of people out of pocket, was in fact a Ponzi scheme" and even if Scott was innocently involved, he was getting a return of five magic beans for his piece urging us all to break open the piggy-bank and put it all into Flying Unicorns.
As a corollary to the above, if Scott says "I think this is so cool and so great that I am putting my money where my mouth is and investing all my magic beans in it", that's fine. So long as we know upfront. There is a difference between "I heard about this thing and I want to tell you guys" and "A friend/a friend of a friend wants me to tell you guys about this thing", even if no money is involved.
#2 is also basically why Wikipedia et al heavily distrust ads/promotional language/etc of any kind (c.f. WP:COI, https://en.wikipedia.org/wiki/Wikipedia:Conflict_of_interest).
However, this situation is quite different here: Wikipedia is a nonprofit and seeks to be objective, but people (not me!) are paying Scott + Substack lots of money to ensure that this blog continues to exist, and it's very clear that whatever Scott writes is going to be heavily flavored by his own thoughts and whatnot, so this calls for weaker standards. So IMO it's perfectly fine for Scott to advertise whatever he wants as long as he clarifies his relationship (although maybe the last half of the sentence is bad because writing "I have/don't have a stake in this!" with every ad seems mildly suspicious.)
n=1 but I am a frequent reader, a socialist and not unilaterally opposed to advertising
I don't have any stake in this, but paradoxically it seems weird and kind of scammy to mention "I don't have any stake in this!" every time I advertise something.
Maybe you can post a PSA saying something like "unless otherwise stated, no stake in any promotions from this point on".
That sounds potentially practical for longtime readers, but I think it's worth keeping in mind that he's probably going to accumulate new readers with time who won't have that context when they read new posts which advertise products.
It's also weird to say "I have a stake in this" every time you advertise something that is genuinely cool that you happen to have a stake in (and may have a stake in it because you genuinely think it is cool). As long as readers also think it is cool I don't really see an issue, but apparently plenty of other people do.
Declarations of conflict of interest are a thing; we all trust Scott, but it's probably no harm to have some kind of rule in place, even if that rule is "I'm going to mention this whether or not I am personally involved within six degrees of separation".
I think this particular mention is okay, since it's someone volunteering information on a topic already raised, and it's not "I wrote this BECAUSE a friend of a friend is looking for people to invest in a start-up and I get a commission if I send 100 potential investors their way". If Scott is investing himself or the likes, then a note about "Note: I am an investor/otherwise interested in the financial success or failure of this" is enough to let us know.
It might feel scammy, but I don't think it is. Your platform is not quite l a social interaction between friends, but I see how it feels that way, and it would be weird to tell your friends "I don't have a stake in this" everytime you talked about a new 'thing'. But this isn't a social interaction between friends, and disclaimers are common in many publications (not that you're a traditional publication).
Besides, it's more honesty and care than we get from disguised ad-icles (feel like I've heard of a better term for ad articles but I can't remember) from many other publications.
Matt Levine solved a nearby problem by turning it into a bit. He mentions that he used to work at GS every time he writes them up -- which is pretty often -- but without even breaking his tone.
Ideally I would like for Scott to just have a categorical ban on advertising stuff he has a stake in (I like when he advertises stuff because he likes it, but having a stake in it introduces potential uncomfortable biases and reduces trust a bit, which I dislike). Although otoh... if he'd heard about this app and also the guy writing it was his roommate who couldn't currently afford rent, would I want him not to advertise it because of that? Having a hard time deciding.
I am 100% fine with Scott writing about their medical practice (Lorien).
> their
Scott's male, AFAICT, so I think you should use he/him/his pronouns to refer to him.
(Also just in case anyone else is confused about my gender: I'm also male.)
Hm that's a good point. I think what I have issue with is misaligned incentives. With descriptive writing about Lorien Scott doesn't really have those - he started it based on ideas he likes. I would worry a bit more if he wrote a study about how Lorien has better results than rival psychiatric practices, I guess (or at least, it's something I'd be more careful than usual about accepting at face value).
As someone who did the Say Goodnight To Insomnia program many years ago and found it effective, I want to highlight something to those who are skeptical about the efficacy of "therapy": the CBT part of it may not have been doing most of the lifting. The program also includes a stringent sleep hygiene protocol.
In a nutshell:
* Give up caffeine and alcohol.
* Keep a sleep log to figure out how many hours of actual sleep you get each night.
* Add two hours to that number and then keep to a strict bed schedule. If you are getting three hours per night, say, then you get five hours in bed. In bed at 10pm, up at 3am, etc.
* As your sleep quality improves, expand the time bounds until you are getting a full night's sleep.
There's more, but that's the gist.
There is also a CBT component that involves self-talk to help with rumination and other impediments to sleep. And I'm in no way critical of that aspect of the program. But if you can actually gut out the sleep hygiene part, it's a pretty hard reset to the system.
Caveat: I have no idea whether things have changed since I did this over a decade ago.
The sleep hygiene part is essential; changing thinking won't help if that isn't done. But many people do tie themselves up in terrible sleep-knots by their worry about how much sleep they're getting, how wrecked they're going to be the next day etc. So the cognitive part is essential for a lot of people.
I actually do the bed schedule the opposite way around; if the person is getting 3 hs of sleep fairly regularly, and has to be up at 7 am, they only go to bed at 4, until they are consistently falling asleep within 15 minutes of going to bed. Then bed at 3:30 .... Works GREAT.
But the hardest of all for most people is the wake up time. I tell them they can go to bed anytime they want, but they can only vary their wake-up time by an hour, ever. So if you have to be up at 7 to go to work every weekday, but you were out having a great time or home watching old movies until super late on Friday night, you can only 'sleep in' until 8 Saturday morning. Ditto vacations, unless you're willing to take the chance of having to re-do the whole chain upon return.
"But if you can actually gut out the sleep hygiene part, it's a pretty hard reset to the system."
Yeah, I think the sleep restriction is the part that works: make yourself so dog-tired that your brain just shuts down and you fall asleep like a log. Deliberately keep yourself on five hours, then work up to six, then... until you get the full eight hours or whatever you are aiming towards.
Stopping the intrusive thoughts or racing mind by making your brain too foggy to even think is the kind of reset that works. And then you train yourself into the habit of "no talk, just sleep" as soon as your head hits the pillow (or hopefully you do)>
I wonder if the CBT part feeds into the sleep hygiene, as in negative self-talk saps your ability to stick to a schedule and maintain discipline.
Have there been any studies of hygiene only without therapy vs hygiene with CBT?
> But a part of me worries that "FDA-approved" has a certain cultural meaning, and if the FDA approves one category of thing with lower proof than usual, people are going to get confused and think it's on a firmer evidence base than it is.
With a software background and skimming that material, the impression I get from "FDA-approved, but with a lower burden for software certification" is "ordinary clinical trials have shown clinical efficacy of the app, but when it comes to making sure the app won't crash or tell the user to sleep for 4294967295 hours tonight or whatever, we aren't certifying that type of correct operation in the same way that we would for a pacemaker."
If I'm correct, it doesn't seem like they're sacrificing the "evidence base" in the clinical trial sense that the FDA culturally means to me. Software certification has nothing to do with evidence of clinical efficacy, but in general means evidence that you're following some specific formal software engineering process, and have the paperwork to prove it.
One particular issue that comes to mind for apps is that the phone itself lacks any FDA software certification (and we don't want a stupid situation where the app can only be prescribed for specific approved phone models), so certification of the app has inherent limits. If the phone crashes, the app crashes, etc.
So I don't really see any problem here.
Sorry I'm not super familiar with the American health care system beyond "it's ridiculess you think socialized healthcare is impossible". Does the FDA approval allow insurance providers to cover the cost of the app? Or could it be covered regardless of FDA approval. Even if the price were $20/month. That's $20 or $240 annually that many people either can't pay for, or would simply rather not.
I just started a new prescription that my insurance doesn't cover for some reason, and it's going to cost me $40/month. I'd rather switch to another drug if it's similarly effective, and costs me nothing.
"I agree that apps are inherently low-risk"
The risk to any given individual may be lower than ingesting a physical substance, but apps *scale*.
arguably, physical substances that can be manufactured in quantity also scale.
I hope a bit of statistical nitpicking is in order:
"that in-person cognitive behavioral therapy for insomnia has an effect size of 0.98, and the same therapy delivered over the Internet has an effect size of 0.51 (both numbers significantly different from control, not significantly different from each other). Somryst itself has significantly outperformed placebo in several studies. A meta-analysis finds..."
These effect sizes (ES) don't have real units. 0.98 what? kg? m? The reason is that the difference between the groups is divided by the standard deviation, and both have the same unit, so we end up with a dimensionless number.
Some people might argue that ES have a unit, namely, the standard deviation---of what? Of the control group? Of the baseline measurement before randomization? The latter depends on the inclusion criteria, because strict inclusion criteria reduce the variance of the measurement.
Especially in sleep studies, it would be easy to report the effect of a therapy in hours, so using dimensionless "measures" of an effect does not seem necessary. Within a study, it does not cause too much harm (the 0.98 and 0.51 seem to describe the same dependent variable), but social scentists and psychologists and psychiatrist use these numbers to compare effects across studies or variables.
Example 1: A therapy increased sleep quality, as measured by a questionnaire, by 2 units (kg, say). Sleep duration was increased by 1 h. So, on which variable do we see a larger effect? Obviously, we cannot tell if 2 kg > 1 h. But psychologists can! Just convert both results to ES, say, 0.6 for quality versus 0.4 for duration, and then move on.
Example 2: Same as Example 1, but with two studies investigating two new therapies. For Therapy A, Study 1 finds improved sleep quality by 2 kg, ES = 0.6; for Therapy B, Study 2 finds increased duration of 1 h, ES = 0.4. Conclusion: Therapy A is better than B, because, well 2 kg are more than 1 h.
Example 3: Meta-Analysis. Same as Example 1, but with two studies both investigating the benefits of Therapy A. Study 1 uses sleep quality as the outcome variable and finds an improved qualty by 2 kg, ES = 0.6; Study 2 finds increased duration of 1 h, ES = 0.4. Meta-analyst says, the "average" effect is (0.6 + 0.4)/2 = 0.5, somehow averaging 2 kg and 1 h.
I concede it is a bit off-topic, but there are quite a few statistically literate people in this forum, and the use of ES is disturbingly high even in the statistically literate population.
Is kg a real unit of sleep quality? I would normally associate that with kilograms, which is clearly not a unit of sleep quality. I just tried to search through academic papers to see what sort of units are actually used and there seems to be no widespread consensus, with researchers either using fairly complicated aggregates of 40-50 different quantitative measures, or entirely subjective Likert scale ratings. Either one would either itself be unitless or at least extremely obfuscated units (0.05 * minutes/night + 0.02 * turns/hour * ... etc).
I used kg just to illustrate that sleep quality, even if it is just a Likert rating, has some unit.
I would expect it to be unitless, just like how a p-value has no unit.
There are more unitless effect sizes, e.g. odds ratios. The trouble starts if one use unitless measures for comparing things or averaging them. I'd say, an ES of 0.4 is just as "better" than an ES of 0.2 as 10 kg is "better" than 8 m.
My main point is: They're not needed. And it seems to me that their only use is to, well, compare things or average things, so they cause more harm than good.
Headspace is mostly a meditation/mindfulness app but includes a sleep section. No idea how it compares to the cbt-I apps. You can get it for a small monthly subscription fee, and I know some companies have been buying bulk memberships for staff, don't know if doctors are prescribing it
Insomnia Coach, by the US Deptartment of Veteran Affairs, is a free CBT-i app. They also have one called CBT-i Coach; I'm not sure the difference between the two. I've only used the former, and the latter looks less polished from screenshots. They also have several other free mental health/therapy/coaching apps.
It’s wildly untrue to say it’s hard to charge more than $5 or $10 for an app!
Just in sleeping and wellness, Calm is $70/year, Headspace is £49.99/year, Sleep Cycle is £25/year, Pillow is £40/year – I could go on!
It is fair to say that pricing has gone from up-front to “free trial then hefty annual subscription”, but people are clearly paying – Calm generated $100 million+ in revenue last year!
It is not impossible, but it is really, really hard to sell them.
What worse, it is a complete lottery whether you success.
"Some companies managed" is not negating "it is really hard".
This is an important point and missed in the original comments. It's very hard to sell the app itself, as in gating the ability to download and install it, for more than a few dollars. It is not at all hard to sell a subscription to a service that is accessed from an app for a lot more than that.
I, for one, think this advertising is okay, since he's a fellow EA.
So was Jonah whose company I advertised the first time.
I thought you were very-much-more-than-okay the first time too. (But I'm like a David Friedman libertarian.)
For what it's worth, I came across sleep.io, which I have no idea if it also qualifies - I never got into it except to take their onboarding quiz, after which it turned out they really are just an app (I don't have a smartphone) and there's no website equivalent. But they talk a lot about CBT in their science section, which suggests they might be in the same niche, too.
Note that uptodate isn't always uptodate, of course. I suppose they too suffer from the tragedy of legible expertise.
COMISA (comorbid insomnia and sleep apnea) is one of the most common forms of chronic insomnia. It can be treated with just CBT-i, but there is reason why you wouldn't want to do that! Sleep apnea leads to a host of other issues in the short and long term and should be treated along with the insomnia.
All should now, especially if they have insomnia, that sleep apnea is much more common than people usually presume, even in the young, thin crowd. If you have any sleep issues and some of the common comorbidities that come with sleep apnea (ADHD, GERD, bruxism, for example) then you really ought to get a sleep study done, and especially if you are younger, thinner, or more fit, you'll need a test done that will pick up on arousal based sleep disturbances along with the oxygen desaturation based disturbances that are more commonly done.
Also, I saw nothing wrong with the Mitochondria startup post. If it's not a sneaky ad, which that wasn't, and if it's interesting, then I'll keep reading. Microdosing DNP or discovering some better mitochondrial uncoupler for medicine is really interesting and if you personally know a team working on that and think that people here are interested, then it only makes sense to let people here know.
As someone who therapizes people, often with CBT/ACT strategies involved, I just want to say, the effectiveness of any of this type of strategy depends primarily on whether our frigging patients DO the frigging work! This is something that drives every therapist I know BONKERS. I do know that some therapists are better at this, since they have a kind of gentle persistence that I struggle to carry out, but even those ones have just a somewhat higher rate of compliance, it still ain't high.
Behaviour change is MUCH MUCH harder than most people realize, even for pretty small and simple stuff (5 frigging minutes of frigging slow deep breathing once a day, for frigs sake! FIVE MINUTES!).
Therapists dream and fantasize about all sorts of things that might work to increase the uptake on the strategies; follow our pts around nagging them, electric shock collars, charge them outrageous fees that only go down if they can show they DID THE STRATEGIES .....
I recently had a super interesting experience around this, because I DO have leverage over some people (unfortunately not my pts); my STUDENTS. In a Psych Disorders class, I offered people a range of strategies to try out, focussing on wellness and coping with the stress of COVID isolation and all-online learning. I told them to choose a strategy that was relevant to them. They then planned how to apply it 5 days a week for three weeks, and did so, with accountability. They knew it was WORTH GRADES. And they were curious to see what this was like, and super stressed, many of them. (And it's not hard to tell who faked their work on this assignment!)
Most struggled during the first week, forgetting to do the strategies, feeling they were doing them clumsily, that this was ridiculous etc. They only continued because it was a class assignment. It got easier in the 2nd week. By the third, applying the strategies was going quite smoothly, and many started experiencing good effects. SO FAST! They were astonished especially because I had framed this JUST as an experiential exercise around behaviour change, and told them it probably wouldn't actually start making a difference for them in that short time frame. I wanted to reduce placebo effects and disappointment, 'cause 3 weeks really is a short time. And many were astonished that it worked even though they didn't believe it would.
So I got to explain how, if something is effective, it WILL help most people who use it, even when they don't believe it will help. That if you have to believe in it for it to work, then that's not treatment, it's magic. AKA, the placebo effect. Excellent learning experience all around!
So yeah, if you want to try an app or a book or a therapist, the big secret is to DO IT.
Now if I could just figure out how to apply some leverage to my patients .....
Now if I could just figure out how to apply some leverage to myself.....
"5 frigging minutes of frigging slow deep breathing once a day, for frigs sake! FIVE MINUTES!"
Does deep breathing do anything, though? It's the kind of general advice that gets given, and I've been given it, and I've tried it, and it works in a small way while I'm occupied with "make sure you are breathing slowly at a certain rate" but once I stop, the problems come back again.
Or I get so anxious about "am I breathing properly? too fast? not deep enough?" that ironically I literally forget how to breathe and have to stop the exercise because I'm smothering.
Hah! You have 'relaxation induced anxiety'! Yes, that's a thing and people research it and write academic papers about it! I laughed out loud the first time I came across one of those.
It ABSOLUTELY does something, however a lot of people don't get enough info/explanation about what it does, how, and when.
The benefits of Relaxed Breathing (RB) are both long-term and short-term. Over the long term, all sorts of good physiological and psychological things occur (because our mind is also part of our bodies) that come from giving the para-sympathetic nervous system more opportunities to do it's 'rest and repair' job. This starts to take effect over weeks and months of regular practice.
The short-term benefits, which is what people are often looking for, however, don't kick in (for most people) UNTIL you've been doing it long enough and consistently enough to start getting long-term benefits. You have to get really GOOD at this physical SKILL, in order for it to be effective in the moment. Even more so when you're doing it when already particularly tense or stressed.
I tell people; your goal is NOT to do this 'well' or to do it 'effectively so it reduces my tension/anxiety right away'. Your goal is to PRACTICE. Practice sometimes goes great, sometimes TERRIBLE. It's very hard to do well or do at all in the beginning, and gets somewhat easier and more consistently well-done over time. Even when we are an expert, sometimes practice goes terrible.
So, do this in a setting and moment where you feel safe.
Set a timer and put it where you'll hear it but not see it (looking to see how much time has passed is highly counter-productive, and the sound it makes when finished should not be an obnoxious one). Lie or sit comfortably, eyes open or closed as you prefer. ANY technique works (box breathing, just slow with mental counting ....) as long as
- your belly is going out/up as you breath in, and down/in as you exhale (that's what pulls down, then releases, the diaphragm at the bottom of your lungs)
- it's slow
How slow? I encourage starting with a slow count to 5 in 5 out, or box of 3-3-3-3. That'll be slow enough for anybody. Then go slower as you get better at it.
In one nostril and out the other? Calculate the rate of breathing according to your heart rate? Exhale longer or inhale longer? Use biofeedback or neurofeedback to guide? All bullshit. You can do those if you like, they're not harmful, but the research is clear; deep and slow is all you need. You can puff the air in or out, or do a slow stream. 5 minutes twice a day is enough to provide significant benefit.
And if you realize you've forgotten to breath from your diaphragm? You've lost count and are again thinking about what you should have said when they said that? No matter. Just go back to the breathing. Repeat as many times as necessary until the timer goes off.
If you're particularly anxious/stressed when you begin, you may have trouble breathing slowly. So start with three breaths to a count of 3 in 3 out, then three breaths at 4 in 4 out, then settle in at 5 in 5 out.
The 'feeling like you're smothering' usually means you've gotten over-oxygenated. That can also create dizziness or tingling in face or hands. This can come from breathing in a way that creates more pressure on the exhale, such as pursing your lips and pushing the air, as if breathing through a straw or filling a balloon, or just from the depth of breathing and not going slow enough. Give yourself a break, then try again more slowly. Some people benefit from starting practicing just 2 minutes, then work their way up to 5.
As for many things that become general advice, there's a reason; this WORKS. But it's often poorly explained, poorly applied, just thrown out there. Short and simple doesn't mean EASY! At all!
Thank you, this is already *way* more explanation that I have ever got about it. The usual advice is "do this deep breathing thing" and then you're more or less left to sink or swim. Whatever about patients, I do wonder if doctors also expect it to start working more or less right from the start? Then when a patient comes back in three weeks time with "it's not doing anything for me", there's disillusionment on both sides; the patient thinks "this doctor is no good, recommending me this bullshit technique that didn't work" and the doctor is "well this patient is just not trying or willing to be compliant with a technique that SCIENCE SAYS! works". Whereas if both parties understood "it is going to take time before anything happens", it'd be a lot less stressful.
What you have said is actually encouraging, because you're telling me "No, it's not going to magically work right away, you have to keep trying, and this is the length of time and the rhythm you should aim for, and give it a few weeks to a couple of months before you see positive effects". Thank you!
You might want to take into consideration that many people may have insomnia (or other disorders) for reasons that also make it difficult to do the work or that make it so the work is less effective. Your students may have less of these issues. Insomnia is a great example as it is highly comorbid with sleep apnea (which is in turn highly comorbid with ADHD!).
Yeah, except that I make people check out whether they have sleep apnea or any other medical condition getting in the way of their sleep (thyroid etc) before we even try any of this. These strategies can also be very helpful for people with ADHD to at least improve their sleep (although they almost always also need lots of physical exercise, preferably outdoors, and some people need to avoid that being within 3 hs of their intended sleep time). And sleeping a bit better can make the ADHD more manageable as well.
The issue really is whether people first get good info on how to do this stuff, then if they EVEN TRY to apply the strategies. This doesn't only apply to people with ADD/ADHD, btw, see my other rant (I'm pretty ranty today). And then if it's not going well (can't apply, not working ....), bring that info back to do some problem-solving around that, etc.
This is a human-condition issue in my opinion. Our influence over others is inherently limited.
True, but the most frustrating is that most of these patients want to try this stuff out. I'm trying to put my little bit of influence on that side of the balance, see if we can make it tip ...
I'm an unreasonable type of person. Reading the Sleepedy thing annoyed me because of George and Susan. Perfect Susan, who gets perfect sleep every night because she follows the perfect routine of not thinking, just get into bed and fall asleep.
I wanted to punch her in her perfect face. Meanwhile poor George gets blamed for being anxious and causing his own problems. So it looked like your employer was going to go bust and you'd be laid off and you were anxious about this and that caused lack of sleep? Silly George, nothing bad happened! But now you *made* yourself unable to sleep!
How about if George really did get laid off and is now struggling to find a new job and in the meantime he can't pay his rent and now he's facing the prospect of eviction - would they be less finger-wagging smug then about his insomnia?
It just reinforces for me that CBT works for certain people, when the underlying problem doesn't actually exist, it's just baseless worry. I get that changing your thoughts and cognition works for that. But if you have real worries, plus insomnia, I don't see how this will help much - the advice as part of it that "stay out of bed until you are falling down with tiredness and then you'll sleep" will work (in the short term) and then you allow yourself extra time in bed until you build up gradually to eight hours a night by which time you allegedly will have learned to fall asleep without thinking and thus keeping yourself awake, but do you need an app to tell you that?
The book may be annoying, but that's not how GOOD therapists who do CBT do it. Fortunately! And ACT, the newer cousin of CBT even less so.
The comp.risks take on this (or: what the Black Hat character from XKCD would do) is to create an interactive therapy app which seems helpful and gets approved, then turns dark and creepy on you when you use it long enough - longer than the FDA eval period. Imagine what a malicious therapy app which you had come to trust could do to your head.
This comment reminded me of this old story of Scott's:
https://slatestarcodex.com/2015/07/18/reverse-psychology/
That seems like a convoluted evil business plan? If it's FDA approved, it seems simpler to extract money from insurance companies without anyone noticing anything wrong.
It reminds me of the XKCD comic about the evil tech company - https://xkcd.com/792/
RE: (I know some of you don’t like when I advertise things on here; feel free to tell me in the comments whether or not you think this example was appropriate)
This one feel fine to me. Now that I have a "YES" example and an "Ehhhhhh" example, the difference!
One is just a dude who is 80% probability: a cool dude! While the other is a business doin business things. It's probably fine to mention a buisness's buiness things in the context of "this is what they are doing and I think it is cool", but anything beyond that leaves endorsment and enters advocacy, is the feeling I guess.
Fuzzy as shit.
FWIW I thought your mention of the Dozy founder was extremely acceptable!
Maybe FDA approved needs to be replaced with some kind of efficacy rating system. People are used to the AAA all the way to "D"
ionamind.com is an excellent i-cbt app that simulates what a low intensity cbt therapist would do
I googled Night Owl and found it also in Google Play, what am I missing?
https://play.google.com/store/apps/details?id=mindware.nightowl
Re: advertising, I have had no problem up until (and including) this point.
I think the key is moderation. If he was advertising it every post, or every other post, it would become distracting, and I'd start fixating on it/being annoyed myself. If it's one post a week or two weeks, then only the (small) tail of the distribution will care.
I’m an MFT and came across a very simple method of going to sleep or returning sleep when sleep is interrupted. It is likely that there’s some science out there on why this method works, though I can’t say I’ve looked into it...well, because on some intuitive level, it made sense to me (having once been a baby rocked inside a womb and once outside the womb, rocked as well), I tried it and it has worked for me, I have told others about it and it’s worked for them. So there’s about zero scientific engagement from my end and only a little qualitative date. So what is it? It’s rocking, it’s that simple. I’m a side sleeper so if I’m having trouble going to sleep, I lay on my side, my natural position, and I rock 15 to 30 times side to side. I don’t have to rock completely, just a gentle rock and boom, I’m asleep and can’t remember falling asleep or back asleep if I’ve woken during the night. When I first did it, my mind said to myself, “this won’t work” and it still worked. I don’t think there’s any potential harm in trying, it costs nothing and takes a minute, actually less than one minute. If you are so inclined, then try it.
Something I would like to see mentioned in the quizzes is "are you a parent of a newborn/toddler?". I technically have insomnia according to the criteria, but I have a newborn and I think that should be an exception. I also suspect that the techniques described in these apps won't help and aren't tailored for new parents.