Friday, 6 June 2014

Meta-Matic: Meta-Analyses of CBT for Psychosis




Meta analyses are not a 'ready-to-eat' dish that necessarily satisfy our desire for 'knowledge' - they require as much inspection as any primary data paper and indeed, afford closer inspection...as we have access to all of the data. Since the turn of the year, 5 meta-analyses have examined Cognitive Behavioural Therapy (CBT) for schizophrenia and psychosis. The new year started with the publication of our meta analysis (Jauhar et al 2014) and it has received some comment on the BJP website, which I wholly encourage; however the 4 further meta-analyses in 4 last months have received little or no commentary...so, I will briefly offer my own.

Slow Motion (Ultravox)


1)      Turner, van der Gaag, Karyotaki & Cuijpers (2014) Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies

Turner et al assessed 48 Randomised Controlled Trials (RCTs) involving 6 psychological interventions for psychosis (e.g. befriending, supportive counselling, cognitive remediation); and found CBT was significantly more efficacious than other interventions (pooled together) in reducing positive symptoms and overall symptoms (g= 0.16 [95%CI 0.04 to 0.28 for both]), but not for negative symptoms (g= 0.04 [95%CI -.09 to 0.16]) of psychosis

The one small effect described by Turner et al as robust - for positive symptoms - however became nonsignificant when researcher allegiance was assessed. Turner et al rated each study for allegiance bias along several dimensions, and essentially CBT only reduced symptoms when researchers had a clear allegiance bias in favour of CBT - and this bias occurred in over 75% of CBT studies.

Comments:
One included study (Barretto et al) did not meet Turner et als own inclusion criteria of random assignment. Barretto et al state "The main limitations of this study are ...this trial was not truly randomized(p.867). Rather, patients were consecutively assigned to groups and differed on baseline background variables such as age of onset being 5 years earlier in controls than the CBT group (18 vs 23). Crucially, some effect sizes in the Barretto study were large (approx. 1.00 for PANNS total and for BPRS). Being non-random, it should be excluded and with 95% Confidence Intervals hovering so close to zero, this makes an big difference - I shall return to this Barretto study again below

Translucence (Harold Budd & John Foxx)


2)  Burns, Erickson & Brenner (2014) Cognitive Behavioural Therapy for medication-resistant psychosis: a meta analytic review

Burns et al examined CBT’s effectiveness in outpatients with medication-resistant psychosis, both at treatment completion and at follow-up. They located 16 published articles describing 12 RCTs. Significant effects of CBT were found at post-treatment for positive symptoms (Hedges’ g=.47 [95%CI 0.27 to 0.67]) and for general symptoms (Hedges’ g=.52 [95%CI 0.35 to 0.70]). These effects were maintained at follow-up for both positive and general symptoms (Hedges’ g=.41 [95%CI 0.20 to 0.61] and .40 [95%CI 0.20 to 0.60], respectively).

Comment
Wait a moment.... what effect size is being calculated here? Unlike all other CBT for psychosis meta analyses, these authors attempt to assess pre-postest change rather than the usual end-point differences between groups. Crucially - though not stated in the paper - the change effect size was calculated by subtracting the baseline and endpoint symptom means and then dividing by ...the pooled *endpoint* standard deviation (and not, as we might expect, the pooled 'change SD'). It is difficult to know what such a metric means, but the effect sizes reported by Burns et al clearly cannot be referenced to any other meta-analyses or the usual metrics of small, medium and large effects (pace Cohen).

This meta analysis also included the non-random Barretto et al trial, which again is contrary to the inclusion criteria for this meta analysis; and crucially, Barretto produced - by far - the largest effect size for general psychotic symptoms in this unusual analysis (See forest plot below).

Burns1

 
\

van der Gaag et al examined end-of-treatment effects of individually tailored case-formulation CBT on delusions and auditory hallucinations. They examined 18 studies with symptom specific outcome measures. Statistically significant effect-sizes were 0.36 for delusions and 0.44 for hallucinations. When compared to active treatment, CBT for delusions lost statistical significance (0.33), though CBT for hallucinations remained   significant(0.49). Blinded studies reduced the effect-size in delusions by almost a third (0.24) but unexpectedly had no impact on effect size for hallucinations (0.46).


Comment
van der Gaag et al state they excluded studies that "...were not CBTp but other interventions (Chadwick et al., 2009; Shawyer et al., 2012; van der Gaag et al., 2012). Shawyer et al is an interesting example as Shawyer and colleagues recognize it as CBT, stating “The purpose of this trial was to evaluate...CBT augmented with acceptance-based strategies" The study also met the criterion of being individual and formulation based.

More importantly, clear inconsistency emerges as Shawyer et al was counted as CBT in two other 2014 meta analysis where van der Gaag is one of the authors. One is the Turner et al meta analysis (described above) where they even classified it as having CBT allegiance bias - see below far right classification in Turner et al)

shawyerfig

And ....Shawyer et al is further included in a 3rd meta-analysis of CBT for negative symptoms by Velthorst et al (described below), where both van der Gaag & Smit are 2 of the 3 co-authors.

So, some of the same authors considered a study to be CBT in two meta-analyses, but not in a third. Interestingly, the exclusion of Shawyer et al is important because they showed that befriending significantly outperformed CBT in its impact on hallucinations. The effect sizes reported by Shawyer et al themselves at end of treatment for blind assessment (PSYRATS) gives advantages of befriending over CBT to the tune of 0.37 and 0.52; and also for distress for command hallucinations at 0.40



While the exclusion of Shawyer et al seems inexplicable, inclusion of Leff et al (2013) as an example of CBT is highly questionable. Leff et al refers to the recent 'Avatar therapy' study and at no place does it even mention CBT. Indeed, in referring to Avatar therapy, Leff himself states that he "jettisoned some strategies borrowed from Cognitive Behaviour Therapy, and developed some new ones"

And Finally...the endpoint CBT advantage of 0.47 for hallucinations in the recent unmedicated psychosis study by Morrison et al (2014) overlooks the fact that precisely this magnitude of CBT advantage existed at baseline i.e. before the trial began...and so, does not represent any CBT group improvement, but a pre-existing group difference in favour of CBT!

Removing the large effect size of .99 for Leff and the inclusion of Shawyer et al with a negative effect size of over .5 would clearly alter the picture, as would recognition that the patients receiving CBT in Morrison et al showed no change compared to controls. It would be surprising if the effect then remained significant...

Hiroshima Mon Amour (Ultravox)


4. Velthorst, Koeter, van der Gaag, Nieman, Fett, Smit, Starling Meijer C & de Haan (2014) Adapted cognitive–behavioural therapy required for targeting negative symptoms in schizophrenia: meta-analysis and meta-regression

Velthorst and colleagues located 35 publications covering 30 trials. Their results showed the effect of CBT to be nonsignificant  in alleviating negative symptoms as a secondary [Hedges’ g = 0.093, 95% confidence interval (CI) −0.028 to 0.214, p = 0.130] or primary outcomes (Hedges’ g = 0.157, 95% CI −0.10 to 0.409, p = 0.225). Meta-regression revealed that stronger treatment effects were associated with earlier year of publication, lower study quality.

Comment
Aside from the lack of significant effect, the main findings of this study were that the large effect size of early studies has massively shrunken and reflects the increasing quality of later studies e.g. more blind assessments.

Finally, as Velthorst et al note, the presence of adverse effects of CBT - this is most clearly visible if we look at the forest plot below - where 13 of last 21 studies (62%) show a greater reduction of negative symptoms in the Treatment as Usual group!

negedit





Friday, 21 February 2014

The Farcial Arts: Tales of Science, Boxing, & Decay




"Do you think a zebra is a white animal with black stripes, or a black animal with white stripes?"
 

Why do researchers squabble so much? Sarah Knowles recently posted this interesting question on her blog - it was entitled Find the Gap. The debate arose in the context of the new Lancet paper by Morrison et al looking at the efficacy of CBT in unmedicated psychosis. I would advise taking a look at the post, plus the comments raise additional provocative ideas (some of which I disagree with) about how criticism in science should be conducted.

So, why do researchers squabble so much? First I would replace the pejorative squabble with the less loaded argue. In my view, it is their job to argue...as much as it is the job of politicians to argue, husbands and wives, children, everyone- at least in a democracy! Our 'science of the mind', like politics gives few definitive answers and .... so, we see a lot of argument and few knock-out blows.

video
'I am Catweazle' by Luke Haines
 What you see before you is a version of something that may be true...
I am Catweazle, who are you?

But we might ask - why do scientists - and psychologists in particular - rarely land knock-out blows? To carry the boxing analogy forward...one reason is that opponents 'cover up', they naturally defend themselves; and to mix metaphors, some may even "park the bus in front of the goal".

And like boxing...science may sometimes seem to be about bravado. Some make claims outside of the peer-reviewed ring with such boldism that they are rarely questioned, while others make ad hominem attacks from the sidelines ...preferring to troll behind a mask of anonymity - more super-zero than super-hero.


A is for Angel Fish  

Some prefer shadow boxing - possibly like clinicians carrying on their practice paying little heed to the squabbles or possibly, even the science. For example, some clinicans claim that the evidence regarding whether CBT reduces the symptoms of psychosis is irrelevant since - in practice - they work on something they call distress (despite its being non-evidenced). Such shadow boxing helps keep you fit, but does not address your true strength - you can never know how strong your intervention is ...until its pitted against a worthy opponent, as opposed to your own shadow!

 

Despite this, the clashes do emerge between science and practice. Many fondly remember Muhammad Ali and his great fights against the likes of Joe Frazier (less attractive, didn't float like a butterfly). Fewer recall Ali's post-retirement battles including with the professional wrestler - Inoki - not a fair fight, not a nice spectacle and not decisive about anything at all - this is like the arguments between scientists and practitioners - they have different paradigms, aims and languages, with probably modest overlap - often a no-contest.

Race for the Prize by Flaming Lips
 .

Is 'Normal Science' all about fixed bouts?
We should acknowledge that some bouts are 'fixed', with some judges being biased toward one of the opponents. Again in science, this may happen in contests between an established intervention (e.g. CBT for psychosis, anti-psychotic medication etc) and those arguing that the intervention is not so convincing. Judges are quite likely to be advocates of the traditional therapy, or at least the status quo - this is a part of Kuhnian normal science - most people have trained and work within the paradigm, ignoring the problems until they escalate, finally leading to replacement (paradigm shift). These changes do not occur from knock-out blows but from a war of attrition, with researchers hunkered down in the trenches possibly advancing and retreating yards over years. What this means is that its hard to defeat an established opponent - unseating an aging champion requires much greater effort than simply protecting that champion


This is Hardcore - Pulp
I've seen the storyline played out so many times before.
Oh that goes in there.
Then that goes in there.
Then that goes in there.
Then that goes in there. & then it's over.

Monster-Barring: Protective Ad Hoc Championship Belts
Returning to CBT for psychosis, nobody should expect advocates to throw in the towel - that is not how science progresses. Rather, as the philosopher of science Imre Lakatos argues, we would expect them to start barricading against attacks with their protective belt - adding new layers of ad hoc defence to the core ideas. Adjustments that simply maintain the 'hard core', however, will highlight the research programme as degenerative.
 
 
Not a leg to stand on

Of course, the nature of a paradigm in crisis is that ad hoc defences emerge inluding examples of what Lakatos calls 'monster barring'. To take an example, CBT for psychosis advocates have seen it as applicable to all people with a schizophrenia diagnosis and when this is found wanting, the new position becomes: schizophrenia is heterogeneous and we need to determine for whom it works- monster barring protects the hypothesis against counter-examples by making exceptions (not tested and evidenced of course). This could go on indefinitely of course: CBT must be delivered by an expert with x years training; CBT works when used in the clinic; CBT works for those individuals rated suitable for CBT ...ad infinitum...What happens ultimately is that people lose faith, break ranks, become quiet deserters, join new ascending faiths - nobody wants to stay on a losing team.


Although sometimes, like Sylvester Stallone, scientific ideas make a come-back...spirits raise and everyone gets hopeful again, but secretly we all know that comebacks follow a law of diminishing returns and with the prospect that holding on for too long comes increased potential for... harm. A degenerative research program may be harmful because it is a waste of time and resources, because it offers false hope, and because it diverts intelligent minds and funds away from the development of alternatives with greater potential.

"If even in science there is no a way of judging a theory but by assessing the number, faith and vocal energy of its supporters, then this must be even more so in the social sciences: truth lies in power." Imre Lakatos

Queensbury rules
All core beliefs have some acceptable protection, the equivalent of gum shields and a 'box' I suppose, but some want to enter the ring wearing a suit of armour - here I will briefly mention Richard Bentall's idea of rotten cherry picking which emereged in the comments of the Find the Gap blog. Professor Bentall argues that as researchers can cherry pick analyses (if they dont register those analyses), critics can rotten cherry pick their criticisms, focusing on things that he declares... suit their negative agenda. In essence, he seems to suggest that we ought to define what is acceptable criticism on the basis of what the authors declare as admissible! I have already commented on this idea in the Find the Gap post. Needless to say, in science as in boxing, you cannot be both a participant and the referee!


Spectator sport
Some love nothing more than the Twitter/blog spectacle of two individuals intellectually thumping each other. But for others, just like boxing, science can seem unedifying (a point not lost on some service users ). Not everybody likes boxing, and not everybody likes the way that science operates, but both are competitive and unlike Alice in Wonderland, not everyone is a 'winner', but then even the apparent losers often never disappear....thus is the farcial arts.

Thursday, 6 February 2014

My Bloody Valentine: CBT for unmedicated psychosis

 
When I critiqued Morrison et als exploratory CBT trial with people who stop taking anti-psychotic medication, I promised to write a post on the final study
 
Well it appeared in the Lancet today and a free copy is here. I am not going to describe the study in detail as it is excellently covered in the Mental Elf blog today. Contrary to the fanfare of glowing comments by highly respected schizophrenia/psychosis researchers, I think the paper has so many issues that I may need to write a second post. But I'm keeping it simple here to concentrate on the primary outcome data - symptom change scores on the PANSS.

'Soon' by My Bloody Valentine (Andy Weatherall mix)


The study examines schizophrenia patients who have decided not to take anti-psychotic medications; 37 were randomly assigned to 9 months CBT and 37 assigned to - what the authors call TAU (but is obviously quite unusual...in an important manner that will become clear below)

What do the primary outcome PANSS scores (total, positive and negative symptoms) reveal?

Table 1. PANSS scores during the intervention (up to 9 months) and follow ups to 18 months

 
The key questions are:
Do the CBT and TAU groups differ in PANSS scores at the end of the intervention (9 months) and at the end of the study (18 months)? One simple way to address both questions is to calculate the Effect Sizes at 9 months and at 18 months.

9 months
PANSS total       =  -0.37   (95 CI -0.96 to 0.22)
PANSS positive  =  -0.18  (95 CI -0.77 to 0.40)
PANSS negative =  -0.45  (95 CI -1.04 to 0.14)
 
Examination of effect sizes at the end of the intervention (9 months) reveals that CBT and TAU groups do not differ significantly on any of the three primary outcome measures at the end of intervention (i.e. all CIs cross zero)

18 months
PANSS positive is nonsignificant, while PANSS total and PANSS  negative effect sizes are moderately sized, the lower end CIs are very close to zero (at -0.05 and -0.08) suggesting marginal significance
 
18 months
PANSS total = -0.75 (95 CI -1.44 to -0.05)
PANSS positive = -0.61 (95 CI -1.27 to 0.05)
PANSS negative = -0.45 (95 CI -1.47 to -0.08)

A closer inspection of the means shows that the significant differences at 18 months almost certainly reflects an increase in symptom scores for the TAU group rather than a decrease for the CBT group (compare CBT at 9 and 18 months and TAU at 9 and 18 months)


My final and crucial point concerns within group symptom reduction
Table 2 shows the baseline PANSS scores on primary outcome measures and its informative to compare change from baseline within each group (CBT and control)
 
Table 2. PANSS scores at baseline
 

If we compare baseline and the end of the intervention 9 months:

PANSS total
CBT group show a reduction from 70.24 to 57.95 =12.29 
TAU group show a reduction from 73.27 to 63.26 =10.01

PANSS positive
CBT group show a reduction from 20.30 to 16.0 =4.30
TAU group show a reduction from 21.65 to 17.0 = 4.65

PANSS negative
CBT group show a reduction from 13.54 to 12.50 = 1.04
TAU group show a reduction from 15.49 to 14.26 = 1.23

So, after 9 months of intensive CBT intervention, controls - who don't even receive a placebo - show a greater reduction in positive and negative symptoms !

Moreover, the 'natural' reduction shown at 9 months by TAU is as large as the reduction shown by the CBT group at the very end of the trial (18 months: PANSS total =13.77; PANSS pos 5.67 and PANSS neg 1.01) - no significant difference exists between TAU reduction at 9 months and CBT reduction at 9 or 18 months

What then have Morrison et al shown?
I would argue that their data show, for the first time, how patients who choose to be unmedicated display fluctuations in symptomatology (as we might expect given they are unmedicated) ...but crucially, these fluctuations are as large as the changes seen in the CBT group. Hence, it is reasonable to ask...have Morrison et al simply documented 'normal fluctuation' in the symptomatology of unmedicated patients ...and nothing to do with CBT

Wednesday, 29 January 2014

Blinded by Science




"The New Year starts with a test of an established tenet of treatment in schizophrenia."

Its not often that we hear such phrases, but thus opens the 'highlights' section of the latest edition of the British Journal of Psychiatry, referring to our new meta-analysis examining Cognitive Behaviour Therapy (CBT) for the symptoms of Schizophrenia. This is the most comprehensive analysis ever undertaken, covering 50 Randomised Controlled Trials (RCTs) of this 'talk therapy' published over the past 20 years. The paper received press coverage and is, of course available for subscribers at the British Journal of Psychiatry, but I would like to give an overview for the interested lay reader, service-users or anyone who cannot access the journal.


Forbidden Colours (Sakamoto & Sylvian)
I’ll go walking in circles
While doubting the very ground beneath me
Trying to show unquestioning faith in everything

 

Looking at all trials regardless of quality, the paper reveals a small effect in terms of CBT reducing the symptoms of schizophrenia: effect sizes being 0.25 for positive and 0.13 for negative symptoms. To put these effect sizes into everyday language - the vast majority of patients in the CBT and control groups fail to differ at the end of the intervention: 82% and 90% of the CBT and control groups overlapped on positive and negative symptoms respectively.

But this is not the end of the story...

Study Quality
Studies vary in their quality (eg. studies with fewer methodological controls are more prone to bias). In this context, we draw attention to 'blinding' or 'masking' i.e. whether the person assessing symptoms at outcome knows if patients did or didn't receive CBT. We found that effect sizes were up to 7 times larger in nonblind than blind studies. And if you assess effect size in blind studies, the small effects totally disappear (see Table 1). In other words, when researchers know if the patients had received CBT, it massively inflates the positivity of the researchers ratings of patient benefit at outcome! In plain language, at the end of trials 94% and 97% of the CBT and control groups overlap on positive and negative symptoms respectively


Table 1. Comparison of effect sizes for blind (high risk) vs nonblind (low risk) studies


Soft by Lemon Jelly (with added "If you leave me now" by Chicago)

 
Whats happening in individual studies: Forest Plots
Forest plots show the effect size in each trial (the filled rectangle). The size of the rectangle represents the size of the sample tested in a study. The horizontal lines represent the 95% confidence intervals for each effect - these essentially tell us about the reliability of the estimated effect; shorter lines indicate that the estimate is more reliable; longer lines, less reliable. You will notice that larger CI lines emerge in studies with smaller samples and vice versa. The key thing to ask is ... Do the 95% CIs in any study cross zero? If they do, then the trial revealed a nonsignificant effect of CBT on symptoms.

Looking at Figure 1, we can see 25 of 33 studies document a non-significant impact of CBT on positive symptoms. Nonetheless, the overall effect across all 33 studies is significant i.e. ES= -.25 (95%CI -.37 to -.13). This reveals several things - that even when 75% of studies are nonsignificant, meta-analysis can produce an overall significant effect.

Figure 1. Forest plot of 33 studies examining the impact of CBT on positive symptoms


The picture for hallucinations is bleaker...with only 4 significant studies ever published

Figure 2 CBT for Hallucinations

And if it could be worse...it is for negative symptoms ...with no significant study since 2003



A few key take-home observations from the forest plots:
Positive symptoms - 25 of 33 (76%) studies are nonsignficant
Negative symptoms - 30 of 34 (88%) studies are nonsignificant
Hallucinations - 11 of 15 (73%) studies are nonsignificant

If anyone is interested in exploring the data and forest plots further, they may do so via a downloadable and interactive database on our website: http://www.cbtinschizophrenia.com/

You Cut Her Hair by Tom McRae

Symptoms or Distress?
One response to me about our paper, from some UK clinical psychologists, has been to say that ...they use CBT not to reduce the symptoms of psychosis, but to reduce the 'distress'. In the context of the clinical guidance provided to UK clinicians by the National Institute of Clinical Excellence (NICE), this response raises interesting questions about the relationship between science and practice.



NICE do state state that CBT be used to reduce distress (see above); however, this is intriguing on multiple levels. First, NICE base their recommendations on the meta-analysis conducted for them by the National Collaborating Centre for Mental Health (NCCMH), in which all of the data examined relates to RCTs aimed at symptom reduction....and not distress

This is perhaps exemplified by the following paragraph from the NICE guide


The NICE guide states that distress is the target, but that outcomes in trials is not distress. Second, some UK clinicians are clearly taking NICE guidance at face value saying they use CBT to 'reduce distress' - this is effectively unevidenced or off-label use of CBT. Third, and crucially, the evidence does not suggest that CBT reduces distress. For example, they refer to Trower et al 2004 as an example - actually, the study shows no benefit of CBT for distress after one year.

Additionally, I would question the reference to CBT improving 'function'  - the meta analysis in 2008 by Wykes et al showed that CBT has no significant impact on functioning in studies meeting their own minimally acceptable study quality. Fifth, they reference Garety et al regarding relapse prevention - our re-analysis of that study actually shows an increase in relapse for the CBT group. And finally, by the time of this NICE document in 2009, NICE had removed insight in psychosis as a target for CBT (following their 2002 recommendations), even though they had no evidence for it in the first place

Hærra by Ásgeir Trausti


These findings create a challenge for the guidance provided by Government organisations (in the UK, this is NICE) who advocate that "CBT be offered to all people with for schizophrenia".

CBT does not reduce positive symptoms, negative symptoms, or hallucinations; it does not prevent relapse, it does not reduce distress, it does not improve functioning, and it does not improve insight. In the paper we therefore call on NICE to reexamine their recommendation- especially as new guidance is due in 2014...in a matter of weeks!

Tuesday, 17 December 2013

Are Friends Electric - A Whig History of the Human Mind?


Asylums with doors open wide,
Where people had paid to see inside,
For entertainment they watch his body twist
Behind his eyes he says, ’I still exist.’

Atrocity Exhibition (Joy Division)
 
“Science is the ultimate pornography, analytic activity whose main aim is to isolate objects or events from their contexts in time and space. This obsession with the specific activity of quantified functions is what science shares with pornography.” 
―    The Atrocity Exhibition J.G. Ballard

   
I was invited by the BBC Radio 3 culture & arts programme NightWaves to review a new exhibition of 'Psychology' hosted at the Science Museum - entitled "Mind Maps: Stories from Psychology"

Here I discuss the exhibition on Radio 3 NightWaves with presenter Philip Dodd and various guests

The exhibition was far more stimulating than I anticipated - the first I can think of in my lifetime as a psychologist and the fact that it is hosted in the Science Museum of London and sponsored by the British Psychological Society are not trivial contextual features.



Mind Maps sets out its stall in this description at the entrance
"[it] traces five significant moments in the history of the nerves and mind, from 1780 to the present. Each is explored through scientific and technical advances and the controversies that they generated. These are not only stories about scientists and doctors, but also about their patients and the general public."
Arguably Psychology as a discipline did not arrive until 100 years later with the advent of Wilhelm Wundt's lab in Leipzig. What we classify as Psychology in this exhibition and generally is an interesting question

Dead Can Dance (the Arrival & the Reunion)
 

The introduction frames the exhibition within a context of creating narratives ....of scientists, doctors 'but also patients and the general public'. While it does create narratives about the scientists, the patients are absent. This is not a criticism by any means ...since the Science of Psychology is arguably...not principally in the business of creating narratives about people, unwell or otherwise.

The exhibition is less about developing views of the mind than developing technologies that themselves shape our view of the mind and ultimately, are used to treat 'broken minds'. The technology is sometimes beautiful, sometimes atrocious, and most intriguing when both. Parts of Mind Maps reminded me of visiting Gunther von Hagens' Body Works exhibition in London over 10 years previously  - where corpses were displayed or splayed ...so dehumanised that I viewed them as grotesque man-made artefacts.

Entering Mind Maps, we are confronted with a slice of human history - a human nervous system extracted from a 17th Century Italian criminal and varnished onto a table


Padua Man
The advanced societies of the future will not be governed by reason. They will be driven by irrationality, by competing systems of psychopathology J G Ballard

We might imagine or hope that such an entrance would then safely take us on a journey of increasingly benevolent ways of examining the mind and mental suffering - a Whig History of the Mind. The exhibition informs us "Our understanding of the way our nerves relate to our thoughts, behaviour and mental health has changed dramatically over the last 250 years" But ...has our understanding changed dramatically? I'm not sure that the exhibition does (or can) convey an impression of development in our models of the human mind and its 'treatments' - not because the exhibition fails in that regard, but because that elusive aim cannot be readily pinned and varnished.

Once we leave the varnished nerve-man, we enter Medical Electricity, the home of Reverend John Wesley, Luigi Galvani...and the obvious cultural links to Mary Shelley's Frankenstein. Electricity is a trope throughout the exhibition

18th Century Electric Therapy   
 
In the 'Medical Electricity' section we see this painting above. As shown, medical electricity was administered in a therapeutic context - the therapist (electrician?) stimulates the woman's head, in her home, where she is surrounded by family members - therapy as a drama!
 
Tubeway Army - Are Friends Electric, I hate to ask, but mine has broke down
 
While this wonderful painting is of its time, this start of the exhibition echoes its denouement, which features Transcranial Magnetic Stimulation (tMS). It is comforting to assume that the technology has improved and somehow must have a corollary in an improved understanding of the mind, its disorders and treatments...but does it and has it been dramatic?
 
Undoubtedly these early forms of electric therapy -if beneficial - derived their benefit from placebo, the impact of family support and so on - this is one main difference from current methods - where we attempt to control and assess placebo (whether successfully for example, in tMS or other treatments ...is another issue).
 
 
D'Arsonval Cage

The electrical current continues through the work of Galvani, animating the dead legs of frogs, D'Arsonval cages and even the notion of the electrotherapy couch. After this section, we lightly gloss over Galton, Freud and Pavlov ...until electricity returns again with ECT and leucotomies rendered through electrical charge to burn brain-holes. We also see a positive side of electricity in EEG and the pioneering work of William Walter Grey (whose stroboscope stimulation work influenced the artist Brion Gysin to develop his Dream Machine, which I spoke about in a previous post)

The Electrotherapy Couch (note the metal handles)
-if only Freud had one

Despite some psychological angles, we might question whether (m)any of these 'interventions' occurred under the watch of psychologists. Of course the brain is an electro-chemical system (and there is an extremely small display on medication), but it doesn't immediately follow that electricity will be the key to aid our understanding - breathing life into the dead and death into the living. Although the exhibition doesn't mention other new methods like deep brain stimulation, it could be argued that the general approach has not changed that dramatically in 250 years

Harmonia (1976..with Brian Eno) - Almost


The finale of Mind Maps is more evidently psychological in the form of Cognitive Behavioural Therapy, alongside Avatar Therapy and the so-called Communicube and Communiwell. Do these represent a closing case for a Whig history or a new-age Stoicism?  Might we at least argue that our techniques have become more benign, less invasive?


Julian Leff's Avatar Therapy for those who 'hear voices'


First we know remarkably little about possible adverse consequences of CBT or psychotherapy per se - and absence of evidence is definitely not evidence of absence in this case. But where adverse consequences have been examined, we have reason to be concerned: see Lilienfeld's (2007) Psychological Treatments that Cause Harm; Linden's (2012) How to Define, Find and Classify Side Effects in Psychotherapy: From Unwanted Events to Adverse Treatment Reactions; David Nutt's (2008) Uncritical Positive Regard: Issues in the Efficacy and Safety of Psychotherapy; and dating back to Bergin (1963) The effects of Psychotherapy: Negative Results Revisited. - What would we expect from a therapy that 'invades the mind'?


The Communicube


Aside form CBT, the Communicube and Avatar Therapy were somewhat odd and weak choices to end an otherwise interesting and thought-provoking exhibition. I am unaware of any published trial data on the Communicube (or Communiwell) - rather it seems the BPS have - inexplicably - offered a significant marketing opportunity for what looks like an untrialled commercial therapy. Concerning Avatar Therapy, Julian Leff and colleagues have recently published data from one trial in the British Journal of Psychiatry. The study, which shows that creating and interacting with avatars may reduce auditory hallucinations, received significant press attention. Nonetheless, it is one study with no active control condition, no testing of whether blinding was successful, and crucially...a drop-out rate of 35% and no intention to treat analysis. So, if one marketing idea and one potentially flawed study represent the future of psychological intervention, then we maybe I entered the exhibition through the exit door

“The most merciful thing in the world, I think, is the inability of the human mind to correlate all its contents... some day the piecing together of dissociated knowledge will open up such terrifying vistas of reality, and of our frightful position therein, that we shall either go mad from the revelation or flee from the light into the peace and safety of a new Dark Age.”
H P Lovecraft
 

The various instagram pictures were taken at the Exhibition preview - thanks to my lovely wife for parting temporarily with her I-Phone for science!





 
 
 
 

Wednesday, 4 September 2013

No Journey's End

  
At any street corner the feeling of absurdity can strike any man in the face
Albert Camus
All great deeds and all great thoughts have a ridiculous beginning. Great works are often born on a street corner or in a restaurant's revolving door.
Albert Camus
 

Street entertainment at Covent Garden, London was noted as far back as May 1662 in Samuel Pepys's diary, when he recorded the first mention of a Punch and Judy show in Britain. In my late teens (1978-1980), I had occasion to spend quite a lot of time in Covent Garden. Although now a mandatory (soul-less) stop for tourists, it was then very different. What was a lively fruit and vegetable market had closed a few years earlier in 1974, leaving an ethereal contour around the empty market...that was a hub for many who would later become well-known artists and musicians.



Covent Garden - looking toward the defunct market

 
In the late 70s, Covent Garden was home to the original Punks and shortly after, to the New Romantics inside the unassuming 'shop fronts' of the Roxy and Blitz clubs respectively. Less well-know perhaps, but with much more personal resonance for me (which I may return to in a later blog), the Rock Garden played home to many great indie bands in the late 70s/early 80s; while the Africa Centre also hosted some great music in its ironic colonial-style hall.


Covent Garden Doorways into a Twilight Zone?
 
Before the London Underground and Local Governments franchised busking, before you needed a licence, insurance or to pass an audition before being allowed to entertain in Covent Garden ...anyone could perform on the street. Quality was not homogenised nor sanitised - a good thing as far as I am concerned! As someone said to Shane MacGowan (the Pogues) when busking in Covent Garden in early 80s "Very few people have come here and failed what we like to call The Covent Garden Seal Of Quality. I'm sorry, you have failed."

One who possibly redefined the Covent Garden Seal of Quality, but who has been unforgivably lost in time...was Michael O’Shea. I remember exiting the darkness of Covent Garden Underground and being drawn to the 'other-worldly' sounds emanating from this individual. O'Shea was improvising on - and hunched over - what I learned was his home-made musical instrument - the Mo Cara (Gaelic for 'My friend'). Stories about the eccentricity of his 'performances' are part true and part myth - he did sometimes play in high heels, stockings, a pleated skirt with a matching turban...and with ping pong balls in his cheeks or a dead Salmon under his arm...I will leave the myths

Voices by Michael O'Shea

On the sleeve of his eponymous and only recorded output, Michael O'Shea describes the Mo Cara inspired by:
 
"..Algerian musician Kris Hosylan Harpo, who accompanied me on his 'zelochord' when I was playing Indian sitar in France during the summer of 1978. Having sold my sitar in Germany and being desperate for money to travel to Turkey, I conceived of the idea of combining both sitar and zelochord. The first Mo Cara was born, taken from the middle of a door, which was rescued from a skip in Munchen"

Returning to the UK in 1979, the Mo Cara Mark II was born when
"...keeping the original zelochord/sitar sound, I added the sound from another instrument I had invented...the Black Hold Space Echo Box and to finish the new Mo Cara I added amplification and electronics"

Essentially, the Mo Cara was a mix of a hammered dulcimer, zelochord and sitar. It was constructed from an old wooden box over which O'Shea had stretched 17 strings (with I believe a further 6 strings underneath the main ones) and played with chop-sticks. 




In the mid-'70s, he went to Bangladesh as a volunteer, returning with dysentery, hepatitis, and a sitar. While convalescing he learned to play the sitar and then busked around Europe and the Middle East. Back in London, O'Shea busked with the Mo Cara, the bizarre sight and sound of the instrument instantly attracting crowds. In early 1980, he was spotted by a talent scout for Ronnie Scott, who was fascinated by the Mo Cara's mix of East Asian, South Asian, and Irish sounds. Scott offered the Irishman a residency in his club's prestigious Downstairs Room and became his agent. This led to his opening for Ravi Shankar at the Royal Festival Hall and he even played on a Rick Wakeman project, although his contribution was subsequently discarded. Despite encouraging signs, O'Shea's career did not take off and he returned to busking."
 
While playing in Covent Garden, a friend of mine Tom Johnston (who was a well-known cartoonist for the Evening Standard and the Sun newspapers amongst others), introduced O'Shea to two other friends of ours at that time - Bruce Gilbert and Graham Lewis of the group Wire. Enraptured by his unique sound, they asked O'Shea to record for their newly formed Dome record label. Following the dissolution of Wire, Lewis and Gilbert started Dome, with the explicit goal of exploring “...how far one could go with improvisation and studio technology and have it still be described as music. Pretty straightforward stuff really: make things, no rules, but be quick.” (Gilbert)
Wire: Graham Lewis, Colin Newman, Bruce Gilbert & Robert Gotobed
 
O'Shea was quite ambivalent about further forays into the music business - preferring his improvised street performances. Nonetheless, Lewis and Gilbert invited O'Shea to Blackwing Recording Studio, where they worked a great deal themselves and with others (e.g. they produced some of Matt Johnson's Burning Blue Soul - which I previously blogged about)    

One year after the invitation O'Shea appeared unannounced at the studio ...saying his horoscope augured well and duly recorded his album on 7th July 1981 (produced by Wire’s B.C. Gilbert & G. Lewis, engineered by Eric Radcliffe & John Fryer) and this emerged untitled as Dome 2.

A little later 1982, O'Shea worked with Tom Johnston and Matt Johnson (The The) on a projected album, but sadly nothing came of it.
 
In December 1991, Michael O'Shea was struck by a Post Office van as he stepped off a London bus... and died two days later

Sadly, O'Shea's work is no longer commercially available and I have uploaded just two pieces from the album. The final track here is the album's 15-minute masterpiece, No Journey's End - it is said that those present at the recording were 'reduced to tears by its unearthly beauty'


No Journeys End
  

Saturday, 10 August 2013

No Thyself (or Another Green World)



Stanley Green

I don't know whether I ever knew you
but I know you
I know you never knew me
I don't know
Do you want to? Do you want to? Do you want to...

You Never Knew Me (by Magazine)

 

Real Life

"I could've been Raskolnikov, but Mother Nature ripped me off"
 

With his typical boldism, Professor Richard Bentall recently remarked on my blog:
"Whether or not you think that CBT is helpful to patients. I'm inclined to believe the patients on this issue" 
Although nobody would deny the right of those with mental health problems (or indeed, anyone) - to have their voice heard, Richard Bentall's comment hints at a dilemma for some clinical psychologists. How could - or should - the user-voice (or 'lived experience') inform the science of clinical research and clinical interventions... or are those voices and experiences in but not of science ?

 
 
My mind...It ain't so open
That anything...Could crawl right in

 

An over-riding faith in and prioritising of patient experience is a laudable ambition, but one that creates significant problems for clinical psychology. Would Professor Bentall be consistent and retain the same enthusiasm for his criterion to assess the efficacy of pharmacological interventions (or even self-medication)? When we enter the realm of lived-experience, all experiences must be equally entertained - it is not a world of science, priority is not determined by evidence - there is no priority beyond those advocated by the loudest and most polemic voices. Professor Bentall clearly does prefer the opinions of some patients - those who espouse preferences that accord with his own - CBT for psychosis - whatever the evidence states
 
 
Parade by Magazine
They will show me what I want to see
We will watch without grief
We stay one step ahead of relief

....What on Earth... is the size of my life ?
 
 

Secondhand Daylight

I've got this bird's eye view and it's in my brain
Clarity has reared its ugly head again...so this is Real Life


The prioritising of service users also appears in the recent soi-disant paradigm shift document from the British Psychological Society Division of Clinical Psychology:
"The needs of services users should be central to any system of classification. Service users express a wide range of views on psychiatric diagnosis, and the DCP recognises the importance of being respectful of their perspectives. Some service users report that diagnosis is useful in putting a name to their distress and assisting them in the understanding and management of their difficulties, whereas for others the experience is of negativity and harm"
Again, of course, we are not told how any system of classification could be based on the diverse views of service-users. This is a should-based position statement rather than an evidence-based science statement - in which service-users seemingly view descriptors of their problems as part of the 'cure' or as the problem. Or more correctly, how some influential clinical psychologists view such labels as being part of the problem for service-users....everyone's view is 'entertained', but some are preferred.

 

The Correct Use of Soap


"I am angry I am ill and I'm as ugly as sin, my irritability keeps me alive and kicking"
 
A related and interesting trend in some areas of clinical psychology is the increasing reliance on patient self-report as a complementary or even only source of data. Introspection as a primary source of data has its place in psychology ...although some might argue that place resides not in the last century, but the one before that - in the 50,000+ pages written by Wilhelm Wundt
 
 

Willhelm Wundt was here
 "I am myself inclined to hold that man really thinks very little and very seldom" Wundt 1892
 

When investigating clinical interventions, some researchers depend heavily on patient self-rating scales. It wouldn't be overly surprising if self and clinician measures were discrepant or for researchers to (de)emphasise either measure according to their hypothesis.

Indeed, I have previously alluded to the clinician-self discrepancy. For example, in my post (CBT: Shes Lost Controls Again) on Morrison et als recent study claiming that CBT reduced symptomatology in unmedicated individuals with schizophrenia. One feature of this methodologically poor study is that the patients rated themselves as... experiencing no recovery following CBT. If we are to prefer to believe patients, then we must conclude that CBT is ineffective in cases of unmedicated psychosis - not, of course the conclusion that Morrison et al promoted in the media - based on their own nonblind assessment of their patients.

 
You Never Knew Me (by Magazine)

....Do you want the truth
or do you want your sanity?
You were hell and everything else
...was just a mess
I found I'd stepped into
the deepest unhappiness
...Hope doesn't serve me now
I don't move fast at all these days
You think you've understood
You're ignorant that way
I'm sorry, I'm sorry, I'm sorry, I'm sorry
I can't be cancelled out like this
 

Magic, Murder & the Weather

"Who are these madmen! what do they want from me!
with all of their straight-talk from their misery"

 
 Largely unexamined, we studiously avoid asking questions like...who or what best captures 'depression'? The person rating their own experiences (on something like the Beck Depression Inventory: BDI) or a clinician assessing them from the outside with other scales?



Definitive Gaze (by Magazine)
I like watching you
but I don't watch what I'm doing
got better things to do
so this is Real Life....you're telling me

It's tempting, of course, to assume perhaps that some combination of both (self and clinician) is required. But as we saw above, does a combination help or create confusion and importantly, does it offer greater opportunities for researchers to cherry-pick or fudge results? Cuijpers et al 2010 conducted a meta-analysis of 48 psychotherapy (largely CBT) intervention RCTs comparing outcomes on self vs clinician ratings for the same patients and found that "clinician-rated instruments resulted in a significantly higher effect size than self-report instruments from the same studies"

Like the Morrison et al study of psychosis outlined above, such findings could impact outcomes for some patients - its easy to imagine a clinician declaring (contrary to the beliefs of the patient): "I know what you are saying, but believe me...as far as I am concerned you are well!".


Feed the Enemy by Magazine
But they always seem to know
exactly what they're talking about
now they've got you in a corner
you've got no room to move
you've got no room for doubt
that's exactly what they're talking about
 

Turning this around, what is the evidence that people with severe psychiatric problems can reliably assess their own experience? What happens if a core component of severe psychiatric disorders is that insight is compromised? I am not denying insight to those with severe psychiatric disorders ...rather, this is a question for all of us - who amongst us can accurately assess their mental states -nevermind a troubled mind?  Studies indicate that between 50 & 80% of those diagnosed with schizophrenia show partial or even total lack of insight into the presence of their mental disorder per se (Insight being defined here as the awareness of having a mental disorder and its symptoms).

It is notable that the culture of self-assessment is more prevalent for some disorders than others. Why do we liberally use self-rating scales (BDI) to assess depression and its interventions, but very rarely use self-ratings to assess schizophrenia and its interventions? Is it really to do with the fabled lack of insight in schizophrenia? What is the evidence that they are any less accurate than those with severe depression? What about people with bipolar disorder....would it be OK to have self-assessment for their depression, but rely on clinicians to assess their mania?

 

No thyself

"Your furniture is made to injure me"

Finally we arrive at the more pervasive and crucial question - what is the purpose of psychological intervention? One obvious aim might be to enable the patient to eventually say  'I feel better/cured/recovered' ... whatever these mean to the sufferer. This could be independent of  ascertaining the veracity of this claim

But should we refer to this as science or evidence-based? Perhaps this is where some clinical psychologists are destined - outside, beyond normal science - maybe we should call it outre science 

Do you no thyself?


Postscript: Stanley Green was a wonderfully eccentric character (the Protein man) from my early teenage working life around Soho in the late 70s. In my book, anyone with such dedication deserves to be remembered...I have of course stuck to his dietry advice ever since!