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.


Political Scientist said...

The book seems to be aimed at a lay audience - do you think this means that he's given up/been unsuccessful in convincing fellow professionals, and so has taken his case to non-experts?

pj said...

Well, to be honest, there has always been an anti-psychiatry movement that primarily communicates by books rather than the scientific literature.

Bentall is just about within the scientifically respectable end of this movement, although he's more from the psychological end which can get a bit loopy even within the academic tent - people like Joanna Moncrieff are more within the psychiatric camp.

But the problem with all these people is that they create a pseudo-radical chic - the truth is that nothing works well, although it seems to work a bit, our diagnoses are rubbish, but have some limited validity etc.

But you can't make money or a name for yourself by just offering up limited criticism - that puts you largely in the mainstream - so you need to hit the right note with the zeitgeist and currently that means talking about how great therapy is and how mental illness is all about abuse and not genetics. There is no ability to think in shades of grey here, it is all either/or.

To be fair Bentall's first book (Madness Explained) was more scientific and made some valid points - it is nust that he then drew wild conclusions about how drugs don't work and therapy is king from the valid points.

But that's how Sunday supplement science works - they don't do subtlety.

Zarathustra said...

Oh dear, and I used to be such a good little RD Laing acolyte too.

Anyone who thinks we can forget about using antipsychotics and just apply some CBT when treating people in the grip a deep psychosis really needs to spend some time on an acute psychiatric ward. I give their comfortable broadsheet assumptions approximately 5 minutes.

The sad thing is, if he'd said, say, personality disorder instead of psychosis, then he might have had a valid point. There's a lot of deeply damaged and abused people out there with PD diagnoses who would genuinely benefit from good-quality, long-term psychological support and aren't getting it. Now that would be a much more worthwhile issue for psychologists like Bentall to focus on rather than trying to conquer territory from the psychiatrists.

Neuroskeptic said...

I do have some sympathy for Bentall because although he clearly goes off the deep end quite often, he does ask the right questions and take them to their logical conclusion -

For example in Madness Explained he attacks the Kraepelian dichotomy of schizophrenia / bipolar disorder. He makes some good points, not that he is the first person to do so.

But he is one of the few people who takes these arguments seriously enough to stand up and say "We should stop using the terms schizophrenia and bipolar".

Now I know psychiatrists tend to say at this point "They're useful clinically / heuristically" but this is not, really, a very satisfying argument. I'm sure the term "lying bastard" is useful clinically as well (some patients are, right?) but it's not printed in textbooks and academic papers.

pj said...

That depends - some of his arguments against the dichotomy are pretty dodgy - and something that is useful clinically means it has some value - e.g. in guiding medications (rarely would you give lithium in schizophrenia).

It's a bit like saying that depression is likely a heterogeneous collection of conditions - true enough, but that doesn't mean antidepressants don't work.

Neuroskeptic said...

Right, but again, the heterogeneity of depression (and more broadly the weakness of DSM criteria) is one of those things that most psychiatrists will agree with but then they go away and use DSM criteria in all their research.

Or again take the Hamilton scale for depression. I was at a conference talk about DBS for depression recently. One slide showing that the antidepressant effects are gradual and take months to fully occur (in terms of decreasing HAMD scores). That's clinically extremely important if true.

But when I talked to the speaker afterwards, he said that in his experience the antidepressant effect of DBS is immediate, and the apparent delay is because the HAMD "sucks" (he's American).

Yet he used it, and we all use it. I use it myself and I criticize it every chance I get.

My point is that mainstream psychiatrists are generally their own best critics (certainly Bentall hasn't said much that's both true and new) but they don't act on their criticism. Whereas Bentall at least "walks the walk". Well, unless he secretly puts clozapine in his patient's tea...

pj said...

Ah, but that's precisely my point - psychiatrists are aware of the limitations of their methods - but they're the best they have so there is no alternative at the moment - people like Bentall take evidence of something being not 100% useful to mean that it is 0% useful (i.e. throwing the baby out with the bathwater) and they also then pull alternative approaches out of their arses which have even less utility than the ones they've just criticised.

Neuroskeptic said...
This comment has been removed by the author.
Neuroskeptic said...

Yeah, that's certainly true. I just wish we'd spend a bit more time improving our methods rather than applying them and then criticizing them.

pj said...

To be fair, it isn't like a lot of time and effort hasn't gone into trying to develop better methods. Unfortunately we don't have a huge amount to show for it.

dopamine said...

Bentall isn't 'against' drugs at all - something people who took the time to actually read what he says would acknowledge. Rather he states the position that there is no evidence that drugs specifically correct any underlying pathology when exerting their therapeutic effects; and that drugs should not be the main focus of psychiatric treatment. He also warns against psychological treatments being excessively relied upon.

Bentall actually quotes a case in his recent book where a patient of his who stopped taking antipsychotics had a very poor outcome.

pj said...

In the final chapter of Madness Explained Bentall poos poos the use of anti-psychotics and advocates CBT. Since the evidence very much favours anti-psychotics over CBT I think it is quite clear what Bentall, like many others on his side of this particular psychological vs. psychiatric turf war, thinks.

The more moderate, plausible and mainstream types like Bentall are forced to recognise that psychoactive drugs have some efficacy - to not do so would cast them out of the mainstream and undermine their credibility - but this does not stop them from trying to undermine their use at every opportunity while simultaneously overstating the evidence for the benefit of psychological therapies.

The sensible middle road is to admit that all therapies are a bit crap and that all psychiatric services are also a bit crap. But, as I said before, that doesn't play so well in the chattering classes opinion-from-a-newspaper-article world that people like Bentall and James inhabit.

The same is found on the other side, and something I've very much seen in the US, where the BigPharma 'psychiatric illness is a chemical imbalance' message is swallowed whole.

dopamine said...

OK. Bentall actually says openly in public forums that he is not hostile to the use of antipsychotics, precisely because there is strong evidence that they reduce symptomatic distress in acutely psychotic people.

His objection is not to their use but to their overuse, for too long, in too high doses.

Your characterisation of him as a 'stealth antipsychiatrist' is incorrect. His views on antipsychotics are not a sop to the mainstream majority, masking a hidden hostility. What he is hostile about is the financial vested interest rhetoric masquerading as science that characterises a lot of modern psychiatry, and this is totally appropriate.

Why do people insist on forcing extreme polarisation in this debate? Psychologists are all trained in neuroanatomy and neuropsychology, so it would be bizarre indeed to think that they are brainless in their approach. Hardly any clinical psychologists are against the use of antipsychotics - it's just untrue to suggest that they are, sorry.

In actual fact, it's this false polarisation and casting of psychologists as 'biologically nihilistic' that is the most tedious aspect of a debate that is actually pretty relevant to many people's experience of illness and treatment.

pj said...

If Bentall is only in favour of use of anti-psychotics in acute psychosis I think saying he is largely anti-medication is a pretty accurate portrayal in that case. The evidence that anti-psychotics reduce recurrence presumably being less useful to his argument.

I'm not characterising clinical psychologists in general as anti-psychiatry or anti-medication, but Bentall I am indeed calling the moderate end of a 'psychologising' spectrum.

You complain about the "financial vested interest rhetoric masquerading as science that characterises a lot of modern psychiatry"

I'm unconvinced this is an accurate portrayal of modern psychiatry, certainly in the UK. My impression is that this is a straw man used to try and discredit mainstream psychiatry.

You complain about false polarisation, but just who is Bentall casting himself in opposition to? A psychiatric establishment who just want to medicate? I call bullshit on that, psychiatrists have been bemoaning their problems accessing services such as clinical psychologists, social workers and similar for years.

Neuroskeptic said...

"His objection is not to their use but to their overuse, for too long, in too high doses."

I'm against their overuse too, because by definition, "over"use is wrong.

Who, specifically, does he think should be taken off antipsychotics, or given reduced doses? Because if we know that, we can ask how sensible it is. But saying he's against overuse is like saying he's against war - everyone's against war, in theory, but people interpret that differently.

I think antipsychotics are probably over-used in the treatment of non-psychotic disorders. e.g. the market is booming in atypicals for depression, in the USA such use tripled from 1997 to 2005 as I wrote on my blog recently.

And I have evidence to back that up - or rather the lack of any evidence that they're any better than several safer, established alternatives, for which there is excellent evidence, such as lithium. Plus the dubious preclinical rationale, the weakness of clinical trial methodologies, etc.

But if someone came along and said "I think antipsychotics are overused in depression because... well, you know, pharma and stuff" I would not be impressed... I'm not saying that's what Bentall does, I genuinely don't know (I read Madness Explained but years ago). But does he?

Neuroskeptic said...

...I don't mean about antipsychotics for depression, I mean about the dose and duration of use in psychosis.

Anonymous said...

In 'Madness Explained' RB is quite explicit in saying trials using CBT for so-called 'positive symptoms' were not as successful as he had hoped.

Haariet said...

The quote from RB also fails to recognise that correlation does not equal causation... he treats the associations with countryside etc as if they are causal contributors to psychosis ("there would be 15% fewer cases if we all grew up in countryside"), but I seriously doubt these comments are based on intervention studies (correct me if I'm wrong). Otherwise, this is a pretty basic error

Ron Unger said...

Regarding the idea Zarathustra had that it is impossible to apply a purely psychological approach to "deep psychosis" - you really should read up on the Soteria experiment, or Diabasis, or the Open Dialogue http://www.power2u.org/downloads/fiveyarocpsychotherapyresearch.pdf approach used in upper Scandanavia. Such approaches don't always work, but they often do - in a 5 year outcome study, the Open Dialogue people kept 2/3 of people first diagnosed with psychosis totally off antipsychotics, and had only a 14% rate of people on disability. We hear so little about such approaches because they aren't usually tried, not because they don't work. If we actually listened to the science, psychological approaches would be our first line of approach, with antipsychotics a distant backup.