Tuesday, 1 September 2009

Tedious psychological turf wars

Richard Bentall has a new book out so it was only a matter of time before he made his way into the British press. I don't have time for an indepth critique but here's a few selected highlights:
"Many studies have also reported an association between trauma in early life and psychosis. These effects are large: one recent study estimated that individuals who had been sexually abused in childhood were 12 times more likely than others to suffer from serious mental illness, and another calculated that the population-attributable risk of a diagnosis of schizophrenia associated with an inner-city childhood was 15% (that is, there would be 15% fewer cases if we all grew up in the countryside). The risk associated with having a parent with the diagnosis is 7% (ie, there would be 7% fewer cases if patients stopped having children)."(my emphasis)
Note that what this segment subtly doesn't point out is that the evidence suggests that schizophrenia in particular isn't actually associated with childhood abuse (unlike, say, depression).

The whole piece is a depressing blow in a pointless academic turf war where psychologists seek to undermine 'biological' psychiatric research (which, is to some extent justified) only to posit even weaker little barely-theories to replace it:
These effects are understandable in the light of psychological research. For example, early trauma seems to disrupt the process by which we distinguish between our own thoughts and our perceptions, leading to a specific risk of hallucinations. Disruption of early relationships with caregivers, coupled with victimisation, create a tendency to mistrust others and to anticipate threats, leading to paranoid delusions.(my emphasis)
I mean, seriously, what is the highlighted sentence even supposed to be telling us? That there is an association between trauma and hallucination? But he's just told us that, what does 'psychological research' tell us on top of that? What are the useful therapeutic insights that this research igives us?
To date, about 30 trials of cognitive therapy for psychosis have been completed; by comparison, in the period 2001-3, nearly 400 drug trials were published in the five leading American psychiatric journals. There is therefore an urgent need to develop a less drug-based, more person-centred approach to understanding and treating mental illness, which builds on the recent scientific findings and which takes the experiences of patients seriously.
CBT is similarly effective to antidepressants (but of little use in psychosis compared to anti-psychotics) but if psychologists think the recent success of psychological therapies supports their approach then they are going to have to look very hard at why their therapies are little better (and often worse) than the 'biological' therapies they seek to undermine.

The problem wth Bentall (and I've read Madness Explained) is that he makes valid but somewhat overstated arguments against things like psychiatric labels or the efficacy of psychoactive drugs but then thinks that he has somehow completely demolished existing medical understanding of mental illness and its treatment (rather than having slightly deflated its claims) and then goes on to make 'psychological' theories that are often much worse supported that the 'biological' theories he has just tried to undermine and also to present them as radically opposed to existing understanding rather than being complementary (which is what they are).

This is really just a slightly more sophisticated vesion of Oliver James - if mental illness doesn't have a genetic component then drugs don't work, if mental illness is associated with childhood abuse then we need psychological therapies. That mental illness is probably both partly genetic and partly associated with envronmental factors including childhood abuse (a) tells us nothing about whether drugs or therapy work, and (b) that the evidence tells us that both drugs and therapy work (depending on the diagnosis) is just too complex and nuanced for this pathetic dick-swinging Sunday supplement debate.