Month: September 2008

An article in The Guardian by psychoanalyst Darian Leader argues that new psychological therapies are driven by a capitalist approach to mental well-being and that they commoditise the soul.

This article is the latest salvo aimed at bashing cognitive-behavioural therapy (CBT), an evidence-based psychological treatment which has inspired the ire of psychoanalysts for recently being heavily funded by the UK government.

CBT is a psychological therapy that typically looks at the link between thoughts, feelings and behaviour and is usually time-limited to 12 or 16 sessions. It is evidence-based with meta-analyses and randomized controlled trials showing it to be effective for various conditions and it is subject to improvement and testing by cognitive science.

Not only that, but the research has been almost entirely funded independent of industry or special interest groups, meaning some of the major conflicts of that pervade mental health are absent (although some remain relevant).

Leader’s article repeats several common accusations which, when not plain wrong, are just a bit bizarre.

Chief among these are the fact that CBT does not go ‘deep enough’ and doesn’t address the root problem, and this is apparently related to a ‘quick fix’ capitalist view of human nature (a criticism often made by UK psychologist Oliver James).

There are two parts to the ‘doesn’t go deep enough’ criticism. The first is that psychoanalysis says that symptoms are not the problem, they’re just the expression of an underlying conflict, so if you treat the symptom another will appear in its place unless you’ve dealt with the unconscious turmoil. Virtually the only verifiable aspect of this is the idea of ‘symptom substitution’ which is both testable and entirely without evidence, as we discussed previously.

Leader refers to the fact that something could be empirically testable as the ‘new rhetoric of “science”‘ (yes, those are really scare quotes around the word science), but that aside, psychoanalysis certainly does go ‘deeper’ than CBT. This is because it continues for years on end.

Owing to the fact that public health organisations are reluctant to fund poorly validated treatments, there are few psychoanalysts who work in the health public system, so a typical session from the many hundreds of you will need can set you back about £60-100 pounds a hour in the UK.

I only mention this because it strikes me that a psychoanalyst is the last person who should be accusing anyone of mental capitalism, let alone focusing his criticism on a therapy that’s widely available on the public health system.

The rest of the article is full of curious straw men, saying that CBT aims to ‘correct’ people’s thinking (it doesn’t, it trains people to test themselves for how useful their assumptions and beliefs are), that it is unconcerned with early experiences (it isn’t and considers that many of our assumptions come from earlier life and childhood), and that symptoms are just seen as meaningless aberrations of the mind (if this was the case, why would CBT even try to tackle them?).

A further irony is that when actually tested with “science” – sorry, science – psychoanalytically-inspired therapies of the briefer kind actually do quite well for the limited evidence that exists. This seems to be particularly the case for people diagnosed with ‘personality disorder’ – a vague and controversial category but one which suggests the person has pervasive problems with sustaining relationships.

Interestingly, transference is one of the genuinely important, testable and innovative ideas to come out psychoanalysis, and it specifically describes how experiences of past relationships affect how we interpret social interactions.

Unfortunately, psychoanalysis has always had something a little homeopathic about it, suggesting that it treats people ‘holistically’ and so empirical studies and “science” are irrelevant. Oddly, Freud was quite convinced of the opposite – that he was doing science, despite virtually avoiding anything scientific during the development of his now famous therapy.

It comes down to the fact that if you want any particular therapy funded by the government or your health insurance company you need to do studies to show it’s effective.

Now let me give my statement of ‘full disclosure’ – I’m trained in CBT and have used it regularly. I don’t think it’s perfect or a cure all, but it is a very useful and effective way of working with distressed people, despite its drawbacks.

I think a lot of psychoanalysis is bunk but I also think other parts, like transference, are wonderful and innovative. Psychoanalytically-inspired therapies seem also to be powerful and effective on the basis of the little rigorous evidence that exists.

What’s odd is that rather than being pleased that a psychological therapy is being widely promoted and throwing their ideas into the mix, some psychoanalysts seem to have gone on the attack and retreated into the the “we’re above science” position, while this actually seems a perfect opportunity to take the chance to test the evidence for psychoanalytic treatments while the funders are listening.

I’m constantly struck by the irony that for a practice that focuses on resolving conflicts, psychoanalysis has a long tradition of infighting. This latest episode seems to be the most recent manifestation of this recurrent pattern. Troubled infancy perhaps?

UPDATE: With uncanny timing, today’s New England Journal of Medicine has published a meta-analysis on the effectiveness of long-term (1 year+) psychodynamic psychotherapy in complex mental disorders, finding it a useful and effective treatment. It’s not a huge sample of studies (11 RCTs and 12 observational studies) but clearly suggests the benefit of this type of psychological treatment (thanks Ben!).

Link to oddly acerbic ‘A quick fix for the soul’ article.

The latest edition of The New Yorker has the tragic story of a US Marine who became famous after writing about his struggle with PTSD for the Marine Corps Gazette, met the President as a result, but who later killed himself owing to the intensity of his experiences.

The New Yorker Article weaves the story of decorated Staff Sergeant Travis Twiggs with commentary on the effects of PTSD and the current support for US veterans who have been traumatised by their experiences.

Compared with other American wars, the conflicts in Iraq and Afghanistan seem to be producing victims at a high rate. A recent RAND Corporation study estimated that three hundred thousand veterans of America’s post-9/11 wars—nearly twenty per cent of those who have served—are suffering from P.T.S.D. or major depression, and many more cases are expected to surface in the years ahead. This elevated rate is generally attributed to the rigors of a long war being fought without conscription: multiple deployments and heavy use of National Guard and reserve units. And on the ground, at unit level, the discouragement of anyone with stress symptoms from asking for help is intense. The same RAND study found that, mainly because of the stigma still attached to P.T.S.D., only half of those afflicted have sought treatment.

Twiggs was apparently a highly experienced, highly decorated and trusted marine and the article demonstrates one of the key findings of military psychiatry: every man has his limit.

The holy grail of military psychiatry has been to develop a way of predicting who will suffer psychiatric illness before deployment but this has never been realised because the biggest predictor is not the character or attributes of the soldier, but the intensity of the fighting to which they’re exposed.

Saying that, there are other factors which do contribute, and unfortunately the US military seem to have a policy of extended and lengthy tours which may explain why rates of PTSD are higher in the deployed US military than in the soldiers of other forces in the same conflict.

The New Yorker article is vivid and tragic in equal measure, but helps to illustrate the personal experiences behind the statistics.

Link to New Yorker article ‘The Last Tour’ (via Furious Seasons).
Link to Travis Twiggs’ article for the Marine Corps Gazette.

ABC Radio National’s All in the Mind had a two part series on the implications of neuroplasticity – particularly the discovery that the brain can physically ‘rewire’ itself through adulthood, albeit in a more limited way in comparison to the process that occurs during childhood.

I found the second part a little more satisfying than the first as it’s a bit more focused, but it’s also interesting as it mostly discusses the relationship between neuroplasticity and psychotherapy.

The interviewee is psychiatrist Norman Doidge who is obviously quite a committed Freudian and argues than many of Freud’s ideas can be now understood in terms of neuroplasticity.

Some of his comments are provocative, some innovative and others a little too much like dogma re-interpreting modern neuroscience, but it’s a fascinating conversation none-the-less.

One of the difficulties with the term ‘neuroplasticity’ is that it’s actually fairly vague. It is often applied to normal neuronal changes (during memory formation, for example) to the growth of new neurons (neurogenesis) to the changes in activation after brain injury seen on neuroimaging studies and to improvements in abilities after brain injury even when no direct measurement of the brain has taken place.

This means it can be all things to everyone and easily fits into any other explanation of change without necessarily adding anything.

We know that neuroplasticity happens. Saying how it happens is key, and a measure of a good explanation is where this knowledge helps us understand the cognitive and behavioural changes better.

Indeed, Doidge does a good job of discussing how various forms of neuroplasticity might reflect different types of behavioural changes, which makes the programme time well spent.

Link to part one of ‘The power of plasticity’
Link to part two.

An unintentionally funny headline from The Telegraph: “Home Office considers downgrading ecstasy”, presumably to just a general feeling of contentment.

The serious story behind the headline is the annual ritual in the UK where the government asks a panel of scientific advisors about the link between the legal classification of drugs and the scientific evidence for their harm, and then ignores them.

This recent review is being headed up by psychopharmacologist David Nutt who was also involved in the government commissioned report that used the scientific evidence to rank recreational drugs, both legal and illegal, by their dangerousness. As is traditional, the list bore no relation to the legal classification and was ignored.

Not that it matters, as a recent World Health Organisation study that found that drug laws in any particular country were not related to the extent of drug use by the population.

There’s nothing like an evidence-based drugs policy.

Link to Telegraph story (thanks Tenyen!).
Link to World Health organisation study in PLoS Medicine.

Apologies if Mind Hacks posts are a little irregular over the next week or so. I’m currently in the process of leaving London and moving to the beautiful city of Medellín, Colombia, where I’ll be working with some fantastic neuropsychiatrists at the Universidad de Antioquia and the Hospital Universitario San Vicente de Paúl.

I leave a week today and I shall be continuing with Mind Hacks although I might be a bit scrambled by the move and the jet lag for a while.

It looks like I shall be discovering a great deal about Latin American cognitive science over the next few months, so I’ll try to pass on some of the highlights here.

Other than that, normal service should continue!

If you’re interested in neuropsychiatry in Colombia, the open-access national psychiatry journal Revista Colombiana de Psiquiatría published a special issue last year that gave an impressive review of the area and it includes summaries in English.

Link to full-text of special issue.

The Clinical Psych Blog has caught Eli Lilly publishing identical data on its new antidepressant drug in two separate scientific papers. This is a dubious practice often carried out to make a drug seem to have more supporting evidence than than has actually been collected.

The study, originally published in the Jan 2008 edition of the Journal of Clinical Psychiatry tested the new antidepressant duloxetine (trade name ‘Cymbalta’) and looked at symptoms of both depression and physical pain.

Eli Lilly have been trying to promote duloxetine as a drug that helps with physical pain for a while, despite the fact that a meta-analysis published earlier this year found that there was no evidence for its pain killing properties.

This new study looks at whether the drug helps physical pain when patients are switched from traditional SSRI medication. It finds that it does help physical pain, but doesn’t include a control group, so really doesn’t tell us anything specific about the drug. Maybe people were just getting better anyway. We can’t tell.

However, a study about to appear in the Journal of Psychiatry Research uses exactly the same data set. In fact, the only thing that’s different is there’s a couple of minor additional subscale results.

Publishing different articles on the same data is not necessarily foul play, but protocol says you do two things. The first is to say it’s the same data that’s been published before so everyone knows where they stand, and the second is you report a new and scientifically interesting analysis.

This new article does neither, contrary to the rules of the scientific journal Eli Lilly have published in, but also contrary to the general spirit of honesty and fair play that allows doctors to reasonably assess the evidence upon which they base their treatment decisions.

Clinical Psych Blog notes a few more suspicious things about the articles (new authors mysteriously appear, for example) and looks at the study in more depth if you want the full scientific details.

Also good if just want to see a major pharmaceutical company get caught with their pants down.

Link to Clinical Psych Blog on dodgy duplicate publication.

The October issue of The Psychologist has just hit the wires and two of articles, freely available online, have a fascinating take on the Victorian mind. The first looks at the 19th century understanding of insomnia, and the second on what master detective Sherlock Holmes can teach modern cognitive psychology. The game is afoot!

The article on the Victorian’s view on insomnia is fascinating as it illustrates how far our thinking has come in terms of the relationship between body and mind.

Despite the fact that we now think of sleep as primarily to do with the mind and brain, early Victorian theories rarely considered these as important and instead suggested seemingly odd ‘treatments’ focused on the blood, for example.

Over time people started becoming more brain centric, seemingly due to the discovery of effective sleep-inducing medications, and more aware of the effects of stress, anxiety and thought on sleep.

The article on Holmes and cognitive psychology is by two authors who research the psychology of expertise. Case studies of experts are often used to illustrate the theories but in this case, however, they argue that Sherlock Holmes could serve equally as well.

To this day, research on expertise has devoted little attention to expert reasoning, and the few available studies on this theme mostly deal with inductive reasoning. However, experts use abductive reasoning in many situations. Abductive reasoning consists of starting from observed data and deriving from these data the most likely explanation or hypothesis. From this explanation, the data can be deduced by implication (e.g. Hanson, 1958). Holmes clearly explains the method of reasoning to Watson in A Study in Scarlet (1887):

‘In solving a problem of this sort, the grand thing is to be able to reason backward. That is a very useful accomplishment, and a very easy one, but people do not practise it much. In the everyday affairs of life it is more useful to reason forward, and so the other comes to be neglected. There are fifty who can reason synthetically for one who can reason analytically.’ ‘I confess’, said I, ‘that I do not quite follow you.’

‘I hardly expected that you would. Let me see if I can make it clearer. Most people, if you describe a train of events to them, will tell you what the result would be. They can put those events together in their minds, and argue from them that something will come to pass. There are few people, however, who, if you told them a result, would be able to evolve from their own inner consciousness what the steps were which led up to that result. This power is what I mean when I talk of reasoning backward, or analytically.’

In this example, Holmes describes in his words, but also with precision, the nature of abductive reasoning.

The only drawback is that the article finishes just as it gets going, but a great idea none-the-less.

Link to ‘Insomnia ‚Äì Victorian style’.
Link to ‘Can Sherlock Holmes help cognitive psychology?’.

Full disclosure: I’m an unpaid associate editor of The Psychologist.

Using documents obtained under the freedom of information act, the New England Journal of Medicine has just published an eye-opening article on the involvement of psychiatrists on ‘war on terror’ interrogations who participate despite their professional ban.

The piece is timely because American psychologists have just been banned from these interrogations after a drawn out internal battle. However, the main psychiatric body swiftly and unequivocally banned their members from doing the same in 2006.

As we speculated previously, these bans are unlikely to have much effect on the individual level owing to the secret nature of the work and the consequent difficulty in finding and disciplining members who disregard ethical regulations.

This new article demonstrates that the ethical rules are indeed being flouted by some psychiatrists, as military documents show several have been trained as members of the Behavioural Science Consultation or ‘biscuit teams‘ that work with interrogation techniques condemned as torture by the UN and Red Cross.

Yet documents recently provided to us by the U.S. Army in response to requests under the Freedom of Information Act (FOIA) make clear that the Department of Defense still wants doctors to be involved and continues to resist the positions taken by medicine’s professional associations… The memo appears to claim that psychiatrists should be able to provide advice regarding the interrogation of individual detainees if they are not providing medical care to detainees, their advice is not based on medical information they originally obtained for medical purposes, and their input is “warranted by compelling national security interests.” The advice envisaged by the memo includes “evaluat[ing] the psychological strengths and vulnerabilities of detainees” and “assist[ing] in integrating these factors into a successful interrogation.”…

Other documents obtained under FOIA indicate that between July 2006 and October 2007, five Army psychiatrists were put through the “behavioral science consultation” training course. The policy memo raises critical questions about that course, among them, Why are consultants receiving training in “learned helplessness” ‚Äî a term that invokes the work of psychologist Martin Seligman, who used electric shocks to induce passive behavior in dogs and destroy their will to escape?

The NEJM has also made the US Military’s ‘behavioural science consultantion policy’ it gained through the freedom of information act available online and it makes for interesting if not slightly disturbing reading.

It clearly states that ‘biscuit teams’ can comprise of psychologists, psychiatrists and physicians and notes that ‘behavioural science technicians’ must have at least 10 years experience in mental health.

The document constantly re-states the ethical obligations of the team members but is full of contradictions – for example, by stating that members must remain within “professional ethical boundaries established by their professional associations” despite the fact that the document is dated after psychiatrists were banned from taking part.

It also notes later that ethical codes do not supersede “US and international law, regulations and DoD [Department of Defense] policy” suggesting that they can be overruled where necessary.

It also contains some remarkably vague statements about the confidentiality of medical and mental health information and whether it can be used in an interrogation – apparently not when it could result in “inhumane treatment or would not be in accordance with applicable law”.

This is telling, considering that the NEJM reported in 2005 that at Guantanamo Bay “health information has been routinely available to behavioral science consultants and others who are responsible for crafting and carrying out interrogation strategies”.

Link to NEJM on psychiatrists in banned interrogations (via CC).
Link to US Military’s ‘behavioural science consultantion policy’.

Slate has an interesting article arguing that there is a pervasive liberal bias in the interpretation of studies on political beliefs that casts right-wing voters in a bad light.

You’ll have to forgive the spectacularly wrong-headed first paragraph (summary: this week the Obama campaign has been described as panicking, so why have neuroscience studies suggested liberal voters are less fearful?) but it does make an interesting and important point.

The piece riffs on a recent study published in Science that reported that conservatives show greater skin conductance and higher blink rates to threatening images than liberals, indicating higher levels of arousal.

This was widely interpreted as suggesting conservatives are more fearful than liberals. Although the study didn’t ask about fear directly, both blinking and sweating have been linked to elevated fear responses before.

The researchers themselves were very careful simply to discuss the results and didn’t make any value judgements on their claims, but the Slate article makes the point that it was widely discussed as if the study found a weakness in conservative voters.

These interpretations are interesting, because they immediately make a value judgement about whether the fear response is appropriate or not. As the Slate piece notes, another interpretation is that liberal participants were less emotionally responsive.

Most pointedly, the article also suggests a wider bias in the interpretation of studies on individual politics so differences linked to conservative views are cast in a negative light, and that this could be due to the overwhelming number of Democrats in science.

Unfortunately, the piece doesn’t do a good job of separating the scientific findings, the researchers’ interpretation and the subsequent commentaries (although no more so than other science articles) but the main thrust is relevant to the distinction between data and its meaning.

This is a pervasive problem in psychology and neuroscience and one researchers are very careful to avoid, at least in the scientific literature. That is, not to over-interpret the findings or the significance of a single study.

Individual studies cannot be interpreted without reference to other scientific work, not least because the methods are usually drawn from a base of other studies which have validated them. Individual studies also rarely provide evidence that any value-based interpretations are correct.

However, this also means that critiques that aim to counter the negative value judgements based on a dissection of the methods without reference to other studies are equally as invalid.

This was the case with a prior Slate article that had some valid points but was generally remarkably off key for this reason as it picked apart the details of the method without reference to the amount of evidence for their validity.

It’s a bit like saying “a neurologist says my friend has brain damage, but he used a Babinski sign test that involved stroking the bottom of his foot – but the foot is at the other end of the body!”.

Even seemingly implausible methods can be valid because science is full of counter-intuitive findings. The important thing is not how they seem on the surface, but what other scientific evidence supports them.

Political bias in the interpretation of studies on personal politics is widespread, so beware of any over-interpretation in either direction, and take anyone who uses a single study to make their point with a pinch of salt.

UPDATE: Wired Science has some good commentary on this post and notes I may have been too hasty (i.e. wrong!) in my judgement of the press coverage of the recent study, which was generally more careful than I had given it credit for.

Link to Slate article on bias in neuroscience interpretation.
Link to text of recent Science study.
Link to PubMed entry for same.