A quick fix for the soul or slow milking of the cash cow

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.

Encephalon 55, emeralds, neurons and fine whiskey

The 55th edition of the Encephalon psychology and neuroscience writing carnival has just appear online, and as noted by the gracious host, Neuroscientifically Challenged, it’s reached its emerald anniversary.

A couple of my favourites include two genuinely exceptional posts: one on targets for deep brain stimulation and their effects, and another on computational neuroscience that was published in Edinburgh University’s science magazine.

Some years ago, I spent a compelling couple of weeks at a computational neuroscience summer school in Edinburgh University, who have always been keen on neural simulation and have been AI pioneers for many years.

They had a curious habit of plying all the attendees with fine single malt whiskey before bringing in a distinguished guest speaker for the last lecture of each day. It worked and I’ve been fascinated with the topic ever since.

The computational neuroscience article is from the excellent Neuronism blog, and if you want something that goes into all the wonderful detail, this month’s PLoS Biology has a fantastic review article that discusses all the main concepts in the field.

It turns out that after decades of research, delegates at a conference called the Brain Connectivity Workshop realised that different people used the same terms to mean different things (I suspect this may have also been whiskey related).

They decided to write a definitive article on the subject and this is what just appeared in PLoS Biology.

Link to Encephalon 55.
Link to PLoS Biology article.

The war within

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.

Neuroplastic fantastic

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.

Hemispheric fantasies

This is quite a remarkable study from a 1985 edition of the International Journal of Neuroscience that investigated whether the apparent greater use of mental imagery during masturbation by men than women was due to differences in hemispheric specialisation.

To test whether this might be to do with brain organisation, rather than gender itself, the researchers tested the idea by asking about imagery during masturbation in right-handed males, who typically show strong hemispheric specialisation, and left-handed men, who typically show less specialisation.

Unfortunately, I don’t have access to the full paper and have no idea whether the claim that women typically report less imagery and fantasy is still thought reliable, as these sorts of findings are notoriously influenced by how the question is asked.

However, the study seemed to find partial support for it’s own hypothesis at least.

Sex and handedness differences in the use of autoerotic fantasy and imagery: a proposed explanation.

Int J Neurosci. 1985 May;26(3-4):259-68.

Gottlieb JF.

Previous research has described a greater use of fantasy and imagery during masturbation by men, than women. This study suggests that this gender disparity results from the increased frequency of bilateral speech representation found in the female brain. Support for this theory was obtained by comparing the use of autoerotic fantasy and imagery in another group distinguished by their degree of cerebral lateralization: dextral vs. sinistral males. The prediction that masturbatory fantasy and imagery would be more common in the more lateralized dextral males was partially confirmed in this study.

I gave up looking for a suggestive yet tasteful image than combined the concepts of sex and hemispheric specialisation, so I’ve illustrated this post with picture of a flower instead.

As an aside, brain anatomy has a few rude jokes thrown in. For example, the mammillary bodies are two small round areas that are part of the limbic system. Their name comes from the fact that the look like breasts.

I was told by a neuroanatomy lecturer that one of the reasons given for why women shouldn’t study medicine in the 1900s was because they’d be offended by the blue humour.

However, the tradition has continued and there are many bawdy mnemonics that help modern students of the nervous system learn the names and functions of the cranial nerves.

Link to PubMed entry for hemispheric fantasy study.

Down on ecstasy

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.

Travels, posting frequency and Medellín

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.