Reconstructing through altered states

Yesterday, I had the pleasure of doing a post-screening Q&A with the film-makers of an amazing documentary called My Beautiful Broken Brain.

One of the many remarkable things about the documentary is that one of the film-makers is also the subject, as she began making the film a few days after her life-threatening brain injury.

The documentary follows Lotje Sodderland who experienced a major brain haemorrhage at the age of 34.

She started filming herself a few days afterwards on her iPhone, initially to make sense of her suddenly fragmented life, but soon contacted film-maker Sophie Robinson to get an external perspective.

It’s interesting both as a record of an emotional journey through recovery, but also because Lotje spent a lot of time working with a special effects designer to capture her altered experience of the world and make it available to the audience.

I also really recommend a long-form article Lotje wrote about her experience of brain injury for The Guardian.

It’s notable because it’s written so beautifully. But Lotje told me she while she had regained the ability to write and type after her injury, she has been left unable to read. So the whole article was written through a process of typing text and getting Siri on her iPhone to read it back to her.

The documentary is available on Netflix.

Link to My Beautiful Broken Brain on Wikipedia.
Link to full documentary on Netflix.
Link to long-form article in The Guardian.

Is there a child mental health crisis?

CC Licensed Image from Wikimedia Commons. Click for source.It is now common for media reports to mention a ‘child mental health crisis’ with claims that anxiety and depression in children are rising to catastrophic levels. The evidence behind these claims can be a little hard to track down and when you do find it there seems little evidence for a ‘crisis’ but there are still reasons for us to be concerned.

The commonest claim is something to the effect that ‘current children show a 70% increase in rates of mental illness’ and this is usually sourced to the website of the UK child mental health charity Young Minds which states that “Among teenagers, rates of depression and anxiety have increased by 70% in the past 25 years, particularly since the mid 1980’s”

This is referenced to a pdf report by the Mental Health Foundation which references a “paper presented by Dr Lynne Friedli”, which probably means this pdf report which finally references this 2004 study by epidemiologist Stephan Collishaw.

Does this study show convincing evidence for a 70% increase in teenage mental health problems in the last 25 years? In short, no, for two important reasons.

The first is that the data is quite mixed – with both flatlines and increases at different times and in different groups – and the few statistically significant results may well be false positives because the study doesn’t control for running lots of analyses.

The second reason is because it looked at a 25-year period but only up to 1999 – so it is now 17 years out-of-date.

Lots of studies have been published since then, which we’ll look at in a minute, but these findings prompted the Nuffield Foundation to collect another phase of data in 2008 in exactly the same way as this original study, and they found that “the overall level of teenage mental health problems is no longer on the increase and may even be in decline.”

Putting both these studies together, this is typical of the sort of mixed picture that is common in these studies, making it hard to say whether there genuinely is an increase in child mental health problems or not.

This is reflected in data reported by three recent review papers on the area. Two articles focused on data from rating scales – questionnaires given to parents, teachers and occasionally children, and one paper focused on population studies that use diagnosis.

The first thing to say, is that there is no stand-out clear finding that child mental health problems are increasing in general, because the results are so mixed. It’s also worth saying that even where there is evidence of an increase, the effects are small to moderate. And because there is not a lot of data, the conclusions are quite provisional.

So is there evidence for a ‘child mental health crisis’? Probably not. Are there things to be concerned about – yes, there are.

Here’s perhaps what we can make out in terms of rough trends from the data.

It doesn’t seem there is an increase in child mental health problems for young children, that is, those below about 12. If anything, their mental health has been improving over the since the early 2000s. Here, however, the data is most scarce.

Globally, and lumping all children together, there is no convincing evidence for an increase in child mental health problems. One review of rating scale data suggests there is an increase, the other paper using the more rigorous systematic review approach suggests not – in line with the data from the review of diagnostic studies.

However, there does seem to be a trend for an increase in anxiety and depression in teenage girls. And data from the UK particularly does seem to show a mild-moderate upward trend for mental health problems in adolescents in general, in comparison to other countries where the data is much more mixed. Again, though, the data isn’t as solid as it needs to be.

This leaves open some important questions though. If we’re talking about a crisis – maybe the levels were already too high so even a drop means we’re still at ‘crisis level’. So one of the most important questions is – what would be an acceptable level of mental health problems in children?

The first answer that comes to mind is ‘zero’ and not unreasonably – but considering that some mental health problems arise from largely unavoidable life stresses, bereavements, natural disasters and accidents, it would be unrealistic to expect that no child suffered periods of disabling anxiety or depression.

This also raises the question of where we decide to make the cut-off for ’emotional problems’ or ’emotional disorders’ in comparison to ‘healthy emotions’. We need anxiety, sadness and anger but they can also become disabling. Deciding where we draw the line is key in answering questions about child mental health.

So there is no way of answering the question about ‘acceptable levels of mental health problems’ without raising the question of the appropriateness of how we define problems.

Similarly, a very common finding is huge variation between countries and cultures. Concepts, reporting, and the experience of emotions can vary greatly between different cultural groups, making it difficult to make direct comparisons across the globe.

For example, the broadly Western understanding of anxiety as a distinct psychological and emotional experience which can be understood separately from its bodily effects is not one shared by many cultures.

It’s worth saying that cultural changes occur not only between peoples but also over times. Are children more likely to report emotional distress in 2016 compared to 1974 even if they feel the same? Really, we don’t know.

All of which brings us to the question- why is there so much talk about a ‘mental health crisis’ in young people if there is no strong data that there is one?

Partly this is because the mental health of children is often a way of expressing concerns about societal changes. It’s “won’t someone think of the children” given a clinical sheen. But it is also important to realise that consultations and treatment for child mental health problems have genuinely rocketed, probably because of greater awareness and better treatment.

In the UK at least, it’s also clear that talk of a ‘child mental health crisis’ can refer to two things: concerns about rising levels of mental problems, but also concerns about the ragged state of child mental health services in Britain. There is a crisis in that more children are being referred for treatment and the underfunded services are barely keeping their head above water.

So talk of a ‘crisis in rising levels of child mental health problems’ is, on balance, an exaggeration, but we shouldn’t dismiss the trends that the data do suggest.

One of the strongest is the rise in anxiety and depression in teenage girls. We clearly have a long way to go, but the world has never been safer, more equal and more full of opportunities for our soon-to-be-women. Yet there seems to be a growing minority of girls affected by anxiety and depression.

At the very least, it should make us think about whether the society we are building is appropriately supporting the future 50% of the adult population.

An echo of your former self

CC Licensed Image by Flickr user Karen Axelrad. Click for source.The journal Neurology has a brief case study reporting an intriguing form of auditory hallucination – hearing someone speaking in the voice of the last person you spoke to.

The phenomenon is called palinacousis and it usually takes the form of hallucinating an echo or repetition of the voice you’re listening to and it’s particularly associated with problems with the temporal lobes.

This case is a little different, however.

A 70-year-old right-handed white man was brought by his wife to the emergency room due to odd behavior for 2 days… According to the patient, he could not explain why people talking to him sounded strange, speaking in different voices which he heard before. For example, he would talk to a man and would hear him as talking with the voice of the woman he previously talked to. He thought it was funny and he could not concentrate on what the other person was saying because he would be laughing…

On occasion, he complained of hearing a very low-pitched intonation in people’s voices, including his own. At other times, he would hear a cyclical pattern of sounds that transitioned from noisy to silent. His most disturbing auditory symptoms persisted for several days and presented in 2 distinct forms. At first, he described hearing his deceased mother’s voice speaking to him through other people’s speech. Later on, he mentioned that after talking to one person, he would hear a second person speaking to him in the first person’s voice. He would also sometimes hear his voice as if it was the voice of the person he just spoke to. During physical therapy, the patient reported that therapist voices would suddenly change to those of people he had heard on television, which provoked uncontrollable fits of laughter.

In this case, the gentleman didn’t have damage to his temporal lobes, but a bleed that affected his right parietal lobe, which may have led to the atypical form of this hallucination.

In a recent paper, Sam Wilkinson and I noted that palinacousis is one example of an auditory hallucination that typically isn’t experienced as if you’re being communicated to by an external, illusory agent – which are perhaps the least common as most people hear hallucinated voices that appear as if they have some social characteristics.

However, it seems as if there’s even a social version of palinacousis where the echo is of someone’s voice form transposed on to the current speaker.

Link to PubMed entry for case study.

Critical mental health has a brain problem

A common critical refrain in mental health is that explaining mental health problems in terms of a ‘brain disorder’ strips meaning from the experience, humanity from the individual, and is potentially demeaning.

But this only holds true if you actually believe that having a brain disorder is somehow dehumanising and this constant attempt to distance people with ‘mental health problems’ from those with ‘brain disorders’ reveals an implicit and disquieting prejudice.

It’s perhaps worth noting that there are soft and hard versions of this argument.

The soft version just highlights a correlation and says that neurobiological explanations of mental health problems are associated with seeing people in less humane ways. In fact, there is good evidence for this in that biomedical explanations of mental health problems have been reliably associated with slightly to moderately more stigmatising attitudes.

This doesn’t imply that neurobiological explanations are necessarily wrong, nor suggests that they should be avoided, because fighting stigma, regardless of the source, is central to mental health. This just means we have work to do.

This work is necessary because all experience, thought and behaviour must involve the biology of the body and brain, and mental health problems are no different. Contrary to how it is sometimes portrayed, this approach doesn’t exclude social, interpersonal, life history or behavioural explanations. In fact, we can think of every type of explanation as a tool for understanding ourselves, rather than a mutually exclusive explanation of which only one must be true.

On the other hand, the strong version of this critical argument says that there is ‘no evidence’ that mental health problems are biological and that saying that someone has ‘something wrong with their brain’ is demeaning or dehumanising in some way.

For example:

“such approaches, by introducing the language of ‘disorder’, undermine a humane response by implying that these experiences indicate an underlying defect.”

“The idea of schizophrenia as a brain disorder might offer further comfort by distancing ‘normal’ from disturbing people. It may do this by placing disturbing people in a separate category and by suggesting uncommon process to account for their behaviour…”

“The fifth category… consists people suffering from conditions of definitely physical origin… where psychiatric symptoms turn out to be indications of an underlying organic disease… medical science has very little to offer most victims of head injury or dementia, since there is no known cure…”

“To be sure, these brain diseases significantly affect mental status, causing depression, psychosis, and dementia, particularly in the latter stages of the illness. But Andreasen asks us to believe that these neurological disorders are “mental illnesses” in the same way that anxiety, depression, bipolar disorder, and schizophrenia­ are mental illnesses. This kind of thinking starts us sliding down a slippery slope, blurring distinctions that must be maintained if we are to learn more about why people are anxious, depressed, have severe mood swings, and lose contact with reality.”

There are many more examples but they almost all involve, as above, making a sharp distinction between mental health difficulties and ‘biological’ disorders, presumably based on the belief that being associated with the latter would be dehumanising in some way. But who is doing the dehumanising here?

These critical approaches suggest that common mental health problems are best understood in terms of life history and meaning but those that occur alongside neurological disorders are irrelevant to these concerns.

Ironically, this line of reasoning implies that people without clearly diagnosable neurological problems can’t be reduced to their biology, but people with these difficulties clearly can be, to the point where they are excluded from any arguments about the nature of mental health.

Another common critical claim is that there is ‘no evidence’ for the causal role of biology in mental health problems but this relies on a conceptual sleight of hand.

There is indeed no evidence for consistent causal factors – conceptualised in either social, psychological or biological terms – that would explain all mental health problems of a certain type, or more narrowly, all cases of people diagnosed with say, schizophrenia or bipolar disorder.

But this does not mean that if you take any particular change conceptualised at the neurobiological level that it won’t reliably lead to mental health problems, and this is true whether you have faith in the psychiatric diagnostic categories or not.

For example, Huntingdon’s disease, dementia, 22q11.2 deletion syndrome, Parkinson’s disease, brain injury, high and chronic doses of certain drugs, certain types of epilepsy, thyroid problems, stroke and many others will all either reliably lead to mental health problems or massively raise the risk of developing them.

Critical mental health advocates typically deal with these examples by excluding them from what they consider under their umbrella of relevant concerns.

The British Psychological Society’s report Understanding Psychosis simply doesn’t discuss anyone who might have psychosis associated with brain injury, epilepsy, dementia or any other alteration to the brain as if they don’t exist – despite the fact we know these neurological changes can be a clear causal factor in developing psychotic experiences. In fact, dementia is likely to be the single biggest cause of psychosis.

In a recent critical mental health manifesto, the first statement is “Mental health problems are fundamentally social and psychological issues”.

This must ring hollow to someone who has developed, for example, psychosis in the context of 22q11.2 deletion syndrome (25% of people affected) or depression after brain injury (40% of people affected).

It’s important to note that these problems are also clearly social and psychological, but to say mental health problems are ‘fundamentally’ social and psychological, immediately excludes people who either clearly have changes to the brain that even critical mental health advocates would accept as causal, or who feel that neurobiology is also a useful way of understanding their difficulties.

All mental health problems are important. Why segregate people on the basis of their brain state?

The ‘not interested in mental health problems associated with brain changes’ approach tells us who critical mental health advocates exclude from their zone of concern: people with acquired neurological problems, people with intellectual disabilities, older adults with dementia, children with neurodevelopmental problems, and people with genetic disorders, among many others.

I’ve spent a lot of time working with people with brain injury, epilepsy, degenerative brain disorders, and related conditions.

Humanity is not defined by a normal brain scan or EEG.

Mental health problems in people with neurological diagnoses are just as personally meaningful.

Social and psychological approaches can be just as valuable.

If your approach to ‘destigmatising’ mental health problems involves an attempt to distance one set of people from another, I want no part of it.

What a more inclusive approach shows, is that there are many causal pathways to mental health problems. In some people, the causal pathway may be more weighted to problems understood in social and emotional terms – trauma, disadvantage, unhelpful coping – in others, the best understanding may more strongly involve neurobiological changes – brain pathology, drug use, rare genetic changes. For many, both are important and intertwine.

Unfortunately, much of this debate has been sidetracked by years of pharmaceutical-funded attempts to convince people with mental health difficulties that they have a ‘brain disease’ – which often feels like adding insult to injury to people who may have suffered years of abuse and exclusion.

But what’s under-appreciated is the over-simplified ‘brain disease’ framework also rarely helps people with recognisable brain changes. Their mental health difficulties reflect and incorporate their life history, hopes and emotional response to the world – as it would with any of us.

So let’s work for a more inclusive approach to mental health that accepts and supports everyone regardless of their measurable brain state, and that aims for a scientific understanding that recognises there are many pathways to mental health difficulties, and many pathways to a better future.

Psychotherapies and the space between us

Public domain image from pixabay. Click for source.There’s an in-depth article at The Guardian revisiting an old debate about cognitive behavioural therapy (CBT) versus psychoanalysis that falls into the trap of asking some rather clichéd questions.

For those not familiar with the world of psychotherapy, CBT is a time-limited treatment based on understanding how interpretations, behaviour and emotions become unhelpfully connected to maintain psychological problems while psychoanalysis is a Freudian psychotherapy based on the exploration and interpretation of unhelpful processes in the unconscious mind that remain from unresolved conflicts in earlier life.

I won’t go into the comparisons the article makes about the evidence for CBT vs psychoanalysis except to say that in comparing the impact of treatments, both the amount and quality of evidence are key. Like when comparing teams using football matches, pointing to individual ‘wins’ will tell us little. In terms of randomised controlled trials or RCTs, psychoanalysis has simply played far fewer matches at the highest level of competition.

But the treatments are often compared due to them aiming to treat some of the same problems. However, the comparison is usually unhelpfully shallow.

Here’s how the cliché goes: CBT is evidence-based but superficial, the scientific method applied for a quick fix that promises happiness but brings only light relief. The flip-side of this cliché says that psychoanalysis is based on apprenticeship and practice, handed down through generations. It lacks a scientific seal of approval but examines the root of life’s struggles through a form of deep artisanal self-examination.

Pitching these two clichés against each other, and suggesting the ‘old style craftsmanship is now being recognised as superior’ is one of the great tropes in mental health – and, as it happens, 21st Century consumerism – and there is more than a touch of marketing about this debate.

Which do you think is portrayed as commercial, mass produced, and popular, and which is expensive, individually tailored, and only available to an exclusive clientèle? Even mental health has its luxury goods.

But more widely discussed (or perhaps, admitted to) are the differing models of the mind that each therapy is based on. But even here simple comparisons fall flat because many of the concepts don’t easily translate.

One of the central tropes is that psychoanalysis deals with the ‘root’ of the psychological problem while CBT only deals with its surface effects. The problem with this contrast is that psychoanalysis can only be seen to deal with the ‘root of the problem’ if you buy into to the psychoanalytic view of where problems are rooted.

Is your social anxiety caused by the projection of unacceptable feelings of hatred based in unresolved conflicts from your earliest childhood relationships – as psychoanalysis might claim? Or is your social anxiety caused by the continuation of a normal fear response to a difficult situation that has been maintained due to maladaptive coping – as CBT might posit?

These views of the internal world, are, in many ways, the non-overlapping magisteria of psychology.

Another common claim is that psychoanalysis assumes an unconscious whereas CBT does not. This assertion collapses on simple examination but the models of the unconscious are so radically different that it is hard to see how they easily translate.

Psychoanalysis suggests that the unconscious can be understood in terms of objects, drives, conflicts and defence mechanisms that, despite being masked in symbolism, can ultimately be understood at the level of personal meaning. In contrast, CBT draws on its endowment from cognitive psychology and claims that the unconscious can often only be understood at the sub-personal level because meaning as we would understand it consciously is unevenly distributed across actions, reactions and interpretations rather than being embedded within them.

But despite this, there are also some areas of shared common ground that most critics miss. CBT equally cites deep structures of meaning acquired through early experience that lie below the surface to influence conscious experience – but calls them core beliefs or schemas – rather than complexes.

Perhaps the most annoying aspect of the CBT vs psychoanalysis debate is it tends to ask ‘which is best’ in a general and over-vague manner rather than examining the strengths and weaknesses of each approach for specific problems.

For example, one of the central areas that psychoanalysis excels at is in conceptualising the therapeutic relationship as being a dynamic interplay between the perception and emotions of therapist and patient – something that can be a source of insight and change in itself.

Notably, this is the core aspect that’s maintained in its less purist and, quite frankly, more sensible version, psychodynamic psychotherapy.

CBT’s approach to the therapeutic relationship is essentially ‘be friendly and aim for cooperation’ – the civil service model of psychotherapy if you will – which works wonderfully except for people whose central problem is itself cooperation and the management of personal interactions.

It’s no accident that most extensions of CBT (schema therapy, DBT and so on) add value by paying additional attention to the therapeutic relationship as a tool for change for people with complex interpersonal difficulties.

Because each therapy assumes a slightly different model of the mind, it’s easy to think that they are somehow battling over the ‘what it means to be human’ and this is where the dramatic tension from most of these debates comes from.

Mostly though, models of the mind are just maps that help us get places. All are necessarily stylised in some way to accentuate different aspects of human nature. As long as they sufficiently reflect the territory, this highlighting helps us focus on what we most need to change.

Alzheimer’s from the inside

There’s an excellent short-film, featuring journalist Greg O’Brien, who describes the experience of Alzheimer’s disease as it affects him.

It’s both moving and brilliantly made, skilfully combining the neuroscience of Alzheimer’s with the raw experience of experiencing dementia.

I found it in this Nautilus article, also by O’Brien, who has taken the rare step of writing a book about the experience of Alzheimer’s disease before it affected his ability to write.

Link to short film Inside Alzheimer’s on vimeo.
Link to Nautilus article.

The real history of the ‘safe space’

There’s much debate in the media about a culture of demanding ‘safe spaces’ at university campuses in the US, a culture which has been accused of restricting free speech by defining contrary opinions as harmful.

The history of safe spaces is an interesting one and a recent article in Fusion cited the concept as originating in the feminist and gay liberation movements of the 1960s.

But the concept of the ‘safe space’ didn’t start with these movements, it started in a much more unlikely place – corporate America – largely thanks to the work of psychologist Kurt Lewin.

Like so many great psychologists of the early 20th Century, Lewin was a Jewish academic who left Europe after the rise of Nazism and moved to the United States.

Although originally a behaviourist, he became deeply involved in social psychology at the level of small group interactions and eventually became director of the Center for Group Dynamics at MIT.

Lewin’s work was massively influential and lots of our everyday phrases come from his ideas. The fact we talk about ‘social dynamics’ at all, is due to him, and the fact we give ‘feedback’ to our colleagues is because Lewin took the term from engineering and applied it to social situations.

In the late 1940s, Lewin was asked to help develop leadership training for corporate bosses and out of this work came the foundation of the National Training Laboratories and the invention of sensitivity training which was a form of group discussion where members could give honest feedback to each other to allow people to become aware of their unhelpful assumptions, implicit biases, and behaviours that were holding them back as effective leaders.

Lewin drew on ideas from group psychotherapy that had been around for years but formalised them into a specific and brief focused group activity.

One of the ideas behind sensitivity training, was that honesty and change would only occur if people could be frank and challenge others in an environment of psychological safety. In other words, without judgement.

Practically, this means that there is an explicit rule that everyone agrees to at the start of the group. A ‘safe space’ is created, confidential and free of judgement but precisely to allow people to mention concerns without fear of being condemned for them, on the understanding that they’re hoping to change.

It could be anything related to being an effective leader, but if we’re thinking about race, participants might discuss how, even though they try to be non-racist, they tend to feel fearful when they see a group of black youths, or that they often think white people are stuck up, and other group members, perhaps those affected by these fears, could give alternative angles.

The use of sensitivity groups began to gain currency in corporate America and the idea was taken up by psychologists such as the humanistic therapist Carl Rogers who, by the 1960s, developed the idea into encounter groups which were more aimed at self-actualisation and social change, in line with the spirit of the times, but based on the same ‘safe space’ environment. As you can imagine, they were popular in California.

It’s worth saying that although the ideal was non-judgement, the reality could be a fairly rocky emotional experience, as described by a famous 1971 study on ‘encounter group casualties’.

From here, the idea of safe space was taken up by feminist and gay liberation groups, but with a slightly different slant, in that sexist or homophobic behaviour was banned by mutual agreement but individuals could be pulled up if it occurred, with the understanding that people would make an honest attempt to recognise it and change.

And finally we get to the recent campus movements, where the safe space has become a public political act. Rather than individuals opting in, it is championed or imposed (depending on which side you take) as something that should define acceptable public behaviour.

In other words, creating a safe space is considered to be a social responsibility and you can opt out, but only by leaving.