Friday, 2 May 2014

FINDING A PLACE BETWEEN SCIENCE AND WOO

Edited Jan 14.








In February there was a debate at the Dana Centre:
Is a diagnosis of mental illness helpful? Can it ever be harmful? Do such diagnoses have any scientific credibility? And are the views of service users given enough weight?
Dr Alex Langford, one of the speakers, posted a link to his argument on Twitter:
The correct link is here:
http://psychiatrysho.wordpress.com/2014/02/12/categorically-ill-my-argument-in-favour-of-the-diagnosis-of-mental-illnesses/

And here is a thread of mostly positive comments: 


My comment:

I need to find my own footing in connection with the psychiatric concept of mental illness, in a place between science and woo, and your text was a great starting point. I have many questions in connection with what you have written, and I have gathered links to articles and books that I consider relevant to my search. 

RationalWiki defines woo like this:  


Woo is understood specifically as pseudoscience, uses a science-like formula, and attempts to place itself as scientifically, or at least reasonably, supported.
Woo is everywhere 
Woo generally contains most of the following characteristics:

Woo is usually not the description of an effect but of the explanation as to why the effect occurs. For example, homeopathy may occasionally give results, but as a placebo — the explanations for these occasional results, e.g. water memory, are woo.
Woo is used to blind or distract an audience from a real explanation or to discourage people from delving deeper into the subject to find a more realistic explanation. You can't make money if nobody buys your bullshit. (As such, "woo" that has zero paying customers is more like just ordinary batshit crazy.) 

You have not addressed the question of scientific credibility. But I found in a tweet that“75% said that diagnosis is not scientific.»

Quoting Carl Sagan: 
Science is more than a body of knowledge. It is a way of thinking; a way of sceptically interrogating the universe with a fine understanding of human fallibility. 
If we are not able to ask sceptical questions, to interrogate those who tell us that something is true, to be sceptical of those in authority, then we are up for grabs for the next charlatan (political or religious) who comes ambling along.
I don't consider psychiatrists to be charlatans. I see them as well-meaning professionals who work within a frame of knowledge where I have been unable to find room for sceptical interrogation. So I invite you to join me in a network of information:


 


Translation is my livelihood, and the concept of networks fits the way I find and evaluate information. 

There is a lot in the network that isn't evidence-based and hasn't been near a randomized double-blind study, but it does get checked for what James Lett calls FiLCHeRS in his “Field guide to critical thinking”

FALSIFIABILITY
LOGIC
COMPREHENSIVENESS
HONESTY
REPLICABILITY
SUFFICIENCY


In the network I  found an article you wrote in The Guardian: 
Why mental health bed cuts make me ashamed to work for the NHS

There is an undertone of immediacy and desperation in this article and in your argument that tugs at my heart. I respect your wish to help, your need to do the best you know for the people you are helping.

And the contents of your argument drip acid into old wounds of mine. Wounds of dehumanisation, othering, dealt by psychiatry and toxic psychology on top of similar childhood wounds. I know that professionals did not mean to harm me, they did what they knew was right, and it might have been easier to pick up the pieces if there had been intent to harm. Do you respect this as a part of my background?

I do not doubt your sincerity, your wish to make things better for the people you are helping, and that goes for all other psychiatrists, including the one who retraumatized me. I am just sceptical about the efficacy of the tools your profession is using to help people. 

What is your opinion on what Dr Michael Cornwall writes here?

"Will psychiatry's harmful treatment of our children bring about its eventual demise?"
For over 30 years, I’ve known and worked alongside many child psychiatrists. They are some of the most dedicated and caring people I have ever known.
When I would repeatedly protest to them about the dangers of prescribing antipsychotic meds and SSRI’s to children and teens, the psychiatrists, often with true anguish, would respond to me by saying, “But Michael, I have to do it! The latest brain imaging research says that psychosis damages the brain, and it has been shown that depression is caused by a lack of serotonin.”
The solid, peer-reviewed  research I would then offer, attempting to counter their biochemical, genetic-based, disease model beliefs, would unfortunately not be taken seriously enough to change my psychiatrist coworkers’ minds.
To no avail, I would urge them to consider that valuable scientific inquiry in the broader field of psychology doesn’t have to be limited to only studying genetics and the physical human brain. They shunned the evidence proving the efficacy of psychosocial alternatives to psychiatric medications. They seemed compelled to elevate applied neuroscience as a reified paradigm of understanding and treating human psychological distress.

And what do you think of psychiatrist Sandra Steingard's conclusion in Do We Need to See Inside the box?
Frankly, I surprise myself with the conclusion that it is not essential to understand the brain in order to be of help to people experiencing emotional distress even in its most severe forms. It counters assumptions that seemed fundamental to me for so long. Yet, I am no longer sure we need to see inside the box, although I understand why we want to look. The brain is such a remarkable organ. But as Dr. Insel points out, funding is not unlimited and priorities need to be made. Psychiatry is nowhere near to being the clinical neuroscience that he envisions it to be, and prematurely acting that way is not without hazards.

I found this in your blog: Committed: Is it time we stopped ‘sectioning’ people? And I respect and appreciate your willingness to question established procedures:
A patient’s ability to make a decision about treatment for themselves is not taken into account. If two doctors and a social worker agree that detaining a patient is the best thing for their health or safety, or for the protection of other people, they can detain the patient. That’s all there is to it.
(...)
By using the Mental Health Act, psychiatrists are led to focus on the wrong question when they see a patient. Instead of thinking about what this patient wants and if I can help them get it, they’re thinking is this patient sectionable? This damages potentially therapeutic relationships.
(...) 
If we ever want to be seen as truly equal with other branches of medicine, we should start valuing and empowering the choices of our patients as highly as they do.
In the last sentence I have quoted, you describe the main problem I have with psychiatry. And not only does psychiatry not value and empower the choices of patients, it has the power to treat dissent, sceptical interrogation and autonomy as symptoms of mental illness. 

I am not anti-psychiatry, I am pro-choice. And there will only be actual choice when we have an Advance Medical Directive that makes it possible to specify in a legally binding manner which types of mental help we wish to strictly exclude and which ones we wish to allow.

An advance directive would have been very helpful to me a long time ago, and it might also have helped some of the patients that Jake, a former patient advocate, is telling us about here: 

 
JAKE at 1900: One client was told she had a psychotic illness and needed anti-psychotic medication. She felt that what she was experiencing was more of a psychological issue and wanted support from a psychologist. She got a psychologist to come and visit and really enjoyed it and felt that she was getting somewhere. I saw her being told by a psychiatrist on the ward that because she believed that psychology could help her, this was evidence that she was ill and needed to be sectioned. I'm not making that up, I witnessed that being told. As soon as you question their very narrow and fixed way of looking at things, they won't hesitate to force you.
We have freedom of religion in our part of the world, and we are not assured freedom of therapy ... at least not once psychiatry gets involved. 



My network contains much information about helpful psychosocial alternatives to psychiatric treatment. Do you reject all such alternatives? 

I ask because of this: 



Is "psychiatry" synonymous with "science" in your cognitive frame? 

Could you please give some examples of what you consider to be totally stupid ideas? 

I have never thought of science as narrow-minded, but I have often wondered why psychiatry filters out so much relevant information of the kind that Dr Michael Cornwall mentions. 

Do you and your colleagues see yourselves as sole defenders of scientific rationality in a wilderness of misguided mental health superstitions? 

Is dissenting mental help just as irrational as voodoo, ESP and cryptozoology?

And what is your opinion on the information in the following links?



Filters Against Folly: How to Survive despite Economists, Ecologists and the Merely Eloquent by Garrett Hardin.  In his review of this book, Carl Bajama writes: 
We need lay defenses to protect ourselves against the assumptions (conscious and unconscious), the biases, the prejudices and ignorance of experts so that we can evaluate the claims of experts as we citizens try to identify the most appropriate course of action. Hardin contends that the greatest folly citizens can commit when confronted with expert testimony is to accept expert statements uncritically. The statement that “The authority of a scholar is measured by how long he/she can delay progress in his/her field” applies equally to experts in engineering and government as well as in science and theology.

The 12 cognitive biases that prevent you from being rational by George Dvorsky
As a supplement to Dvorsky's negativity bias, I add Oliver Burkman's article on positivity bias: Happiness is a glass half empty


Sanda Kaufman, Michael Elliott and Deborah Shmueli 
Frames are cognitive shortcuts that people use to help make sense of complex information. Frames help us to interpret the world around us and represent that world to others. They help us organize complex phenomena into coherent, understandable categories. When we label a phenomenon, we give meaning to some aspects of what is observed, while discounting other aspects because they appear irrelevant or counter-intuitive.
As I see it, ignorance about frames is one cause of psychotherapeutic dehumanisation. Psychiatrists and other mental helpers can - with the best of intentions, of course - be so stuck in their professional frame that they discount crucial information about people they are helping. 

This sketch illustrates the framing problem from an engineering point of view:



Link in case you can't see the embed: http://youtu.be/BKorP55Aqvg

I am not an engineer, but therapists, both psychiatric and psychological, have expected responses from me that are as meaningless in the context of my life as "seven red lines, perpendicular, some drawn with green ink and some with transparent ink, one in the shape of a kitten".



Daniel Kahneman’s “Thinking, Fast and Slow”at least the information about System 1 and System 2, should be required reading for everyone who works in medicine and the mental help sector. We would all benefit from a reminder, once in a while, of what Stephen Jay Gould calls “a little homunculus in my head” that jumps to conclusions. 


From Two Brains Running By JIM HOLT:
System 2, in Kahneman’s scheme, is our slow, deliberate, analytical and consciously effortful mode of reasoning about the world. System 1, by contrast, is our fast, automatic, intuitive and largely unconscious mode. It is System 1 that detects hostility in a voice and effortlessly completes the phrase “bread and. . . . ” It is System 2 that swings into action when we have to fill out a tax form or park a car in a narrow space. (As Kahneman and others have found, there is an easy way to tell how engaged a person’s System 2 is during a task: just look into his or her eyes and note how dilated the pupils are.) 
 More generally, System 1 uses association and metaphor to produce a quick and dirty draft of reality, which System 2 draws on to arrive at explicit beliefs and reasoned choices. System 1 proposes, System 2 disposes. So System 2 would seem to be the boss, right? In principle, yes. But System 2, in addition to being more deliberate and rational, is also lazy. And it tires easily. (The vogue term for this is “ego depletion.”) Too often, instead of slowing things down and analyzing them, System 2 is content to accept the easy but unreliable story about the world that System 1 feeds to it. “Although System 2 believes itself to be where the action is,” Kahneman writes, “the automatic System 1 is the hero of this book.” System 2 is especially quiescent, it seems, when your mood is a happy one. 
 At this point, the skeptical reader might wonder how seriously to take all this talk of System 1 and System 2. Are they actually a pair of little agents in our head, each with its distinctive personality? Not really, says Kahneman. Rather, they are “useful fictions” — useful because they help explain the quirks of the human mind.


Jeffrey Saltzman explains  WYSIATI like this: 
Daniel Kahneman coined the acronym WYSIATI which is an abbreviation for “What you see is all there is”. It is one of the human biases that he explores when he describes how human decision-making is not entirely based on rational thought. Traditionally, economists believed in the human being as a rational thinker, that decisions and judgments would be carefully weighed before being taken. And much of traditional economic theory is based on that notion. Dr. Kahneman’s life’s work (along with his co-author Dr. Amos Tversky) explodes that notion and describes many of the short-comings of human decision-making. He found that many human decisions rely on automatic or knee-jerk reactions, rather than deliberative thought. And that these automatic reactions (he calls them System 1 thinking) are based on heuristics or rules of thumb that we develop or have hard-wired into our brains. 



Does psychiatry recognize the human world of perception and experience?


I have translated some paragraphs from Dr Anna Luise Kirkengen's Norwegian review of The Decent Society by Avishai Margali"Om å bli truffet" (On being hit) 
Margalit demands that a society should be civilized, that is to say that the members of this society do not humiliate each other. In addition he demands that society should be just, in that the institutions of society do not treat its members unequally. And in addition to these two fundamental principles he demands this: A society should be decent. And that means that the institutions of the society do not humiliate its members.
And how can my profession of medicine be a humiliating social institution?
The answer is: By not recognizing the human world of perception and experience. In other words: Medicine humiliates people who have bodily afflictions that biomedicine ignores, refuses to acknowledge or rejects. To put it more precisely: The field of medicine can humiliate suffering and tormented people because of its scientific and objectivistic understanding of human bodies and human beings. 

Psychiatry has a history of humiliating the people it helps, and I can say the same about the varieties of psychological therapy that have led hurting people into interminable labyrinths of bullshit - assertions presented as truth:


Sigmund Freud and the Cover-Up of "The Aetiology of Hysteria" by Jonathan Eisen 
In 1896, the young psychiatrist Sigmund Freud presented the first major paper he had ever written to his colleagues at Vienna's Society for Psychiatry and Neurology. Freud considered that his paper, entitled "The Aetiology of Hysteria," was of the utmost importance, since it proposed what he believed to be an irrefutable cause for the neuroses suffered by many of his patients. Quite simply, when listening sympathetically to his women patients, Freud had heard that as children they had suffered sexual assaults, and he believed that it was these acts of violence which had led to the victims' mental illness later in life. 
The point of the paper was that sexually abused children, many of whom had come from "respectable" middle class homes, displayed significant "hysterias" later on in life—an observation that today would pass as obvious to the point of banality, but something that in 1896 provoked a backlash among Freud's older colleagues. 


Amazon link to The Therapy Industry: The Irresistible Rise of the Talking Cure, and Why It Doesn't Work  by Paul Moloney 
Paul Moloney has written a brilliant and erudite book that might help us see through the mystifying fog of ideas in our present culture that leads us to seek individual therapy and self-help as cures for our ills, rather than people focusing on changing the main causes of distress in the C21st and getting together to create a society that is less damaging to us all. (Dr Guy Holmes, Clinical Psychologist)
To date The Therapy Industry is the most comprehensive, accessible and best-documented critique available of the whole theory and practice of psychological therapy. Indispensable. (David Smail, author of 'Taking Care: An Alternative to Therapy')
This book combines intellectual acuity, a well-developed political sensitivity and a comprehensive grasp of the literature with an experienced clinician’s tacit knowledge, wisdom and insight. Reading it may change how you think about psychology, about therapy, and perhaps even about yourself. (Dr John Cromby, Senior Lecturer in Psychology, Loughborough University)
Which is why I would welcome a Council on evidence-based psychotherapy.

Trustworthy psychiatry? 
“Well, it’s kind of like the town’s water-works — they do a good job. When you turn on the faucet in your kitchen sink, you know that good, clean water comes out and you can drink it or cook with it. You trust that it will work, and that you won’t get sick from the water. It’s the same with psychiatry here — we trust them. When we have problems, we go to them. They are reliable, they care about us, and they do a good job. They help us. They make our lives better. It’s just normal. But really, we don’t think about it too much. Mostly, it’s really just like the water-works — we expect it to work, and it does.”
The speaker is a satisfied customer of the Open Dialogue model
Fundamental to the approach is the shift away from an immediate emphasis on trying to eradicate symptoms.   The conversation, or dialogue, is not “about” the person, but a way of “being with” them and living through the crisis together.  
According to a sarcastic psychiatrist on Twitter, this is “a miracle psychological cure from Northern Finland”. 

It will be interesting to see how this works out in the long run, and if it can be transferred into other cultures. I am sceptical about "living through the crisis together" if that involves violent family members, and I need to read more about this.  

But what a lovely description of helpful mental help: "When we have problems, we go to them. They are reliable, they care about us, and they do a good job. They help us. They make our lives better. It’s just normal."

I wish for a future where it is normal that mental help makes lives better.

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