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!
 

 
 

 



Monday, 10 June 2013

Fear of Science

 
Drugs won't change you
Religion won't change you

...
Science won't change you
Looks like I can't change you
I try to talk to you, to make things clear
but you're not even listening to me...

Mind (Talking Heads)

This is a supplement to my 'Clinical Psychology is Anti- or Ante- Science?' post and addresses comments made by Dr Lucy Johnstone regarding the British Psychological Society (BPS) Division of Clinical Psychologists (DCP) 'Paradigm Shift' document. Johnstone was the chief architect of the document and the main spokesperson on that document in the media.
 
There's no 'f' in paradigm shift


1) Is the plan to replace diagnosis (with formulation)?
Re the position of the DCP in the 'Paradigm Shift' document and whether it represents is a call for replacing diagnosis or not?

It would seem crucial to determine what the British Psychological Society DCP are saying on this issue - both formally through the document itself and informally through their representative i.e. Lucy Johnstone. The document received much fanfare publicity, with its apparent ramifications for service users and providers of every persuasion - any confusion or lack of clarity on such an issue would seem not only unacceptable, but potentially harmful


Memories cant wait (Talking Heads)

In trying to clarify the idea of whether formulation is designed as a 'replacement for diagnosis, what follows is part of a Twitter conversation between LJ and myself on this issue:
 

6.31 June 7th - LJ says the DCP position document is not advocating replacement of diagnosis with formulation

7.05 June 7th - I post two Twitter statements from LJ, where she clearly advocates replacement (or abandonment) of diagnosis with formulation - actual links below

2.27 Hune 7th - @nuAmbiguous asks a reasonable question - seems odd not to want to replace it if you see it as dehumanising

2.49 June 7th - Then LJ says she 'definitely does" want to replace it

2.53 June 7th - Finally, @nuAmbiguous asks a question that remained unanswered

The Twitter discussion starts at the bottom and works upwards

Here are Tweets from Lucy Johnstone saying "Read my blog on how formulation can replace diagnosis" and here saying "UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis..." And finally, Lucy Johnstone's blog clearly headed with abandonment in which she says
"In a bold and unprecedented move for any professional body, the UK Division of Clinical Psychology, a sub-division of the British Psychological Society, issued a Position Statement today calling for the end of the unevidenced biomedical model implied by psychiatric diagnosis."

So, we have replacement or no replacement? Does it depend upon the time and audience being addressed? This is an unacceptable way to operate and should make the BPS and DCP feel rightly embarrassed.

Service users and all providers need to know precisely what is being proposed by the professional body representing UK (clinical) psychologists and its representatives.


2) LJ says "The DCP statement calls for a joint effort to develop a multifactorial and contextual approach...as an alternative to diagnosis (Rec 3)"

First, you again clearly state 'alternative to diagnosis'. Second, you call for joint effort but with whom? The implication may be ...with psychiatrists and other service providers - but actually Recommendation 3 (shown below) refers only to working with service users - part of the Recommendation you edited from your response on my post
 
You go onto say Recommendation 5 (below) refers to formulation being promoted as 'ONE' response. This is fine, but what others are you also promoting? and how does this sit with your clear statements above calling to replace diagnosis with formulation? or the DCP webpage saying "...the DCP continues to advocate the use of psychological formulation"

 
3) You refer to scientist-practitioner models - As you (oddly) refer to yourself as being "glad not to be a scientist", that you see yourself essentially as a practitioner only. This would seem to resonate with the title of my post - 'Clinical Psychology - anti- or ante- science?'
 
 

 
 
4) You go onto say that
"It is primarily about working with HUMAN EMOTIONAL DISTRESS and HUMAN RELATIONSHIPS. This is why the charge of lack of reliability and validity (in the sense applied to medical diagnoses) is not fatal or even relevant to formulation. (your caps...you seem to like caps)
 
And that those researchers who have examined reliability and validity in formulation - and found it sadly lacking - are 'deeply misguided'. Might these individuals be the science end of science-practitioner who are deeply misguided?

I also note that these are quite bizarre claims ...Are you denying that psychiatrists a) also work with human emotional distress and human relationships? If, so why is your chief criticism of diagnosis based on issues of reliability and validity? and b) no connection exists at all between your first and second sentence - why is the lack of reliability and validity not relevant to formulation? Just saying they are not does not make it so...as your 'deeply misguided' colleagues would argue

 Modern anti-psychiatry is more nots than knots
 
5) I asked "...couldn't different clinical psychologists give different formulations of the same client" - this is obviously the case from what you and others say. Nonetheless, it is notable that you avoid answering the question and instead divert to reliability in diagnosis

In response I would say a) service users in particular need to know if the formulation you are offering is an unreliable assessment? Would it vary from one psychologists to another?  and b) your non-answer referring me to diagnosis is a simply an attempt to avoid answering, but diagnosis clearly has a lot better evidence than formulation in terms of reliability and validity and the all-important relationship to outcomes (while formulation meets none of these even adequately as noted in my previous post


6) I am glad to see that you have taken such an interest in my academic and personal life - feeling it necessary to refer to my wife (whom you don't even know)

You also refer to my never using 'formulation' ....as if it is based in some expertise
How does this fit with your saying:

"A formulation is not an expert pronouncement, like a medical diagnosis, but a ‘plausible account’ (Butler, 1998, p.1), and as such best assessed in terms of usefulness than ‘truth’ (Johnstone, 2006)"
or as you say here in in your typical self-contradictory fashion
"Formulation is both simple and complex, common sense and controversial, depending on how it is defined and used"
I am sure we could all make plausible accounts that have no reference to truth, which are simple or complex, common sense or controversial....depending on how we choose to define and use it!
...it just leaves us in Knots with lots of nots


 

Friday, 31 May 2013

Clinical Psychology- Anti or Ante-Science?


Watch out, you might get what you're after
Cool babies, strange but not a stranger
I'm an ordinary guy
Burning down the house
Hold tight, wait 'till the party's over
Hold tight, we're in for nasty weather
Burning Down the House (Talking Heads)


Have some clinical psychologists developed a bad case of ...anti-science?

Burning down the House, Pull up the Roots and I Get Wild

Although scientists thought this disabling disorder had been eradicated in the previous century, we are seeing increasing numbers of clinical psychologists presenting with a variety of anti-science symptoms. I start here with the symptom of formulation (recently also accompanied by paradigma shiftitis ) - other symptoms will follow in later posts

I understand the reservations that psychologists have routinely and historically expressed about psychiatric diagnoses. Indeed, questions can be always be raised about the reliability and validity of any diagnosis -psychiatric or otherwise. Often these questions about diagnosis are framed in a low evidence, high hyperbole manner - for example saying they are "...hardly more meaningful than star signs". One thing is sure, much research has attempted to assess the reliability and validity of diagnoses like schizophrenia - whether people decide the evidence is sufficiently impressive is then at least a matter of empirical - rather than simply ideological - debate.

Making Flippy Floppy and Slippery People

Given the recent 'position statement' by the British Psychological Society's (BPS) Division of Clinical Psychology (DCP) - Time for a Paradigm Shift in Psychiatric Diagnosis (link to full document at foot of that page) - it is worth taking a closer look at the alternative to diagnosis proposed by the DCP -so-called Formulation

Pere Ubu (Non-Alignment Pact: 1977)

In their Good Practice Guidelines on the use of Psychological Formulation, the DCP states "there is no universally agreed definition of formulation", but do rather nebulously state that:

"Psychological formulation is the summation and integration of the knowledge that is acquired by this assessment process that may involve psychological, biological and systemic factors and procedures"

In the same document, they reference Clinical psychologist Gillian Butler (1998) who says

"A formulation is the tool used by clinicians to relate theory to practice… It is the lynchpin that holds theory and practice together… Formulations can best be understood as hypotheses to be tested.”
 
and later Kuyken (2006) is quoted as saying

'...formulation is ‘a balanced synthesis of the intuitive and rational cognitive systems’

So, Formulation is a hypothesis that links (any specific?)theory and (any specific?) practice that balances intuitive and rational cognitive systems?


and then later still, what formulation is not?
"A formulation is not an expert pronouncement, like a medical diagnosis, but a ‘plausible account’ (Butler, 1998, p.1), and as such best assessed in terms of usefulness than ‘truth’  (Johnstone, 2006)"
Plausible to whom? How do we assess usefulness as opposed to truth? It seems from the way that some clinical psychologists speak that formulation is viewed as orthogonal to veracity - indeed, it is implicit that multiple formulations of the same case are not only possible but possibly desirable(?)

This Heat: 24 Track loop (1978)

Girlfriend is Better

In this context, it is worth unpacking this very recent post - So... What happens next? by the clinical psychologist Peter Kinderman in the light of the DCP paradigm shift document:
Of course, traditional psychiatrists, and many members of the public, say that they find a diagnosis helpful and even comforting. But the truth is that this comfort comes from knowing that your problems are recognised (in both senses of the word), understood, validated, explained (and explicable) and that the person you’re speaking to has a decent plan to help you. A problems list and a formulation can do that. Paradoxically, better than a diagnosis – since, for example, two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ might have absolutely nothing in common, not even the same ‘symptoms’, any comfort from a diagnosis is likely to be illusory.

Doesn't Peter Kinderman seem to speak about diagnosis as meeting just those criteria set out by Lucy Johnstone for assessing formulation? As Kinderman says, psychiatrists and patients often view diagnosis as a ‘plausible account’ and presumably diagnosis may also be assessed in terms of usefulness rather than ‘truth’?  It does sometimes seem as though clinical psychologists want to use different criteria for assessing diagnoses and formulations (Science and anti-science).  Further, don't these claims sound somewhat modest and mundane for a paradigm shift? On the basis of saying that no two people with a schizophrenia diagnosis have anything in common, he leaps to the conclusion that "any comfort from a diagnosis is likely to be illusory" - presumably we do return to 'truth' as opposed to ill-usion. Indeed, it would be interesting to hear how Professor Kinderman delineates illusory comfort from real comfort in his patients - that would take some expertise!

Moon Rocks

What about the evidence on formulation?
Bieling & Kuyken (2003) state in their paper Is Cognitive Case Formulation Science or Science Fiction?
In terms of the scientific status of the cognitive case formulation process, current evidence for the reliability of the cognitive case formulation method is modest, at best. There is a striking paucity of research examining the validity of cognitive case formulations or the impact of cognitive case formulation on therapy outcome.
 
One problem, of course, is that all humans are prone to biases and influence of short-cut heuristics that include halo effects, illusory correlations, framing biases, recency effects, confirmatory biases, and failure to consider normative standards. Bieling states that
"Clinicians may make these errors so habitually that in cognitive case formulations of identical cases using identical formulation methods it is not possible to accurately establish consensus."

Of course, some clinical psychologist essentially argue for a science of the individual. In their review of case formulation in mental health, Rainforth & Laurenson 2013 state
… there are difficulties in promoting commonality due to the individual nature of the formulation, based on the service user presentation, traits, personality experiences and needs, and issues relating to practitioner skills and experience...The complex nature of formulation-based approaches to treatment planning contains vulnerability due to judgemental and inferential bias. Benefits for standardizing treatments were noted; however, this also highlights a dilemma in whether to use standardized or individualized approaches to CF.

In other words, it sounds awfully like no two formulations would be the same

Who benefits from formulation?
As noted by Kinderman above, those who use formulation do, of course value it believing it benefits their patients ….but this remains unsubstantiated by any acceptable notions of empirical scientific evidence.

Some evidence suggests that formulation benefits staff rather than the patients or the outcomes for patients
"care planning, staff-patient relationships, staff satisfaction and teamworking, through increasing understanding of patients, bringing together staff with different views and encouraging more creative thinking" Summers 2006.
 
Kuyken et al (2005) in their paper 'The reliability and quality of cognitive case formulation' say:

Our review suggests that, contrary to the claimed benefits of cognitive case formulation, it is not a panacea, and its evidence base is weak at best. Our review suggests instead that it is a promising but currently limited approach to describing and understanding patients’ presenting problems

They suggest "the quality of formulations ranged from very poor to good, with only 44% rated as being at least good enough." and among mental health practitioners in training this fell to 24.1%. Formulations were distributed across the range from very poor to good (‘‘very poor’’ 22.1%; ‘‘poor’’ 33.6%; ‘‘good enough’’ 34.5%; ‘‘good’’ 9.7%). In other words, only a minority of formulations are rated as "good enough"


Swamp

Perhaps reliability and validity are irrelevant to the anti-science of formulation?

"Formulations may be reliable and valid but have no impact on treatment outcome. In contrast, they may be unreliable and invalid but lead through some alternative mechanism (e.g., increasing therapist self-confidence or enhanced alliance) to improved outcome." Bieling & Kuyken (2003) - see also p34 Good Practice Document Johnstone et al 2011

What this highlights most is the view that, while evidence for reliability and validity for formulation is lacking, it just doesn’t matter! The implication is that the lack of evidence for formulation is irrelevant, as it may still improve outcome. - Actually, no empirical scientific evidence exists to show that formulation improves outcome. Moreover no evidence at all exists to support the bold claim that formulation is in fact orthogonal to reliability and validity.


Finally, clinical psychologists may see formulation as an art rather than a science. Indeed, the BPS Good Practice Guidelines on Psychological Formulation states
"the subject matter of our discipline [clinical psychology], human beings and human distress, is not best served by the narrow ‘technical-rational’ application of research to practice. Rather, it requires a kind of artistry that also involves intuition, flexibility and critical evaluation of one’s experience. In other words, formulation is ‘a balanced synthesis of the intuitive and rational cognitive systems’ (Kuyken, 2006, p.30)."
Again, it seems little interest in the science rather than the artistry of formulation

Formulation is a treatment in itself?
Interestingly the BPS document on psychological formulation states "It should also be noted that developing a formulation can be a powerful intervention in itself" - this is an interesting notion insofar as it has no typical 'science' oriented evidence-base whatsoever - and if it is an intervention in itself then it ought to be evidence-based

This Must be the Place (naive melody)

So, formulation cannot be defined, it is a hypothesis, a theory-practice link. It has no basis in truth, it is based in usefulness (though possibly not usefulness to the patient it seems) . It may be an intervention in itself, and also not imply an intervention. It is unreliable and lacks validity. It has no evidential link to outcome. It is artistry linked to intuition...in short, it is anti-science....

An ironic conclusion, that the touted Kuhnian paradigm shift appears to be one going backwards into pre-science or perhaps....formulation its better described as ante-science

Sunday, 12 May 2013

Psychology - Seductive, but is it Science?

 
Harvey: Tell me. We're alone here. No witnesses.
Art: Tell you?
Harvey: A sort of confirmation.
Art: Tell you what?
 Harvey: About ravishment

I am an unintentional psychologist. As teenager, I was persuaded to add Psychology as my final 'A'-level  "...probably useful to have a science" I mused. Within days, psychology had consumed me with its easy charm - taking me to places that were simultaneously familiar and exotic - and we duly began a relationship that has persisted for 30 years.

Psychology is the perfect partner - being whatever we want it to be. As a psychology undergraduate, one day I was dissecting brains or measuring social behaviour in cockroaches, the next I was mesmerised by William James' poetic words on emotion or a lecturer telling me that I wanted to have sex with my mother.

Can we really refer to this capacious church of psychology as science?

'La Ritournelle' by S├ębastien Tellier
("its awesome" according to my 5 yr old son Vivek)

For most of my academic life as a psychologist, I have endured a dissonance - never doubting that psychology was a science, but believing it is impossible to define a science. Thirty years on, defining science still seems like counting angels on the head of a pin, though now...I believe it's a mistake to refer to psychology as if it were a unitary discipline - rather we have psychologies. And more recently, reservations about the scientific status of some psychologies have begun to feed my obsessive dissonance. Indeed, I would venture that some of these psychologies are...frankly...anti-science (something I will return to in a later post).

Possibly because of a (righteous) historical fear of introspection, psychologists tend to look outwards rather than inwards...which brings me to my point about how psychology currently operates. Psychologists engage in a version of science that is systemically corrupted and blinkered. The evidence on this issue seems unquestionable to me - as indicated by the lack of published replications and null findings, questionable research practices such as selective reporting, hyperbole, evidence denial and even outright fraud, all combined with the shallow pursuit of the curious.

"...you cannot intellectualise your genes, which make aspects of your life inevitable. You cannot intellectualise yourself out of obsession. You cannot cure yourself of it." Nicolas Roeg

In this context, I am posting a collection of recent pieces where I have discussed problems in the practice of psychology - and the extent to which these issues undermine the scientific status of psychology as it currently practices

It's time for psychologists to put their house in order - My original article in the Guardian where I outline some of the systemic problems inherent in the way that psychology currently operates - especially with regard to publishing and my section editorship at the new journal BMC Psychology, which is addressing some of the issues regarding null findings and replications
 
Negativland - a home for all findings in psychology - The Open Access paper that I published in BMC Psychology (which I'm delighted to see has over 10,000 downloads in 2 months). This paper reviews many problems and distortions that beset psychology and how these are longstanding - raising questions about the resistance to change amongst psychologists. One upshot of this unwillingness is how it plays out in the minds of the public - whether we believe psychology is a science or not in any technical intellectual sense becomes redundant if the wider perception of psychology is that it has little credibility and masquerades as a perverse charade of science (see Rupert Read's points below).


 

BBC Radio3 NightWaves audio recording of debate - Is Psychology a Science? - between myself and the philosopher Rupert Read on BBC Radio 3 Night Waves programme (it was linked to my Guardian article). One point argued by Read, is that it is in fact  impossible to replicate experiments in psychology - because of the historical nature of human beings. I am pretty sure no psychologist would agree with this philosophical point - and I explain that we use naive participants. Indeed, Read's argument strikes me as essentially incoherent - at what point does the historical nature of humans kick-in? Presumably, even after one individual has been tested in any experiment - in which case, no experimentation is possible in psychology (nevermind replication)


Why Psychology ain't Science - piece written by Rupert Read following our debate, where he expands on why he thinks psychology is not (and cannot be) a science. This largely seems to consist in his straw-man positioning me as a simplistic Popperian as opposed to his seemingly Kuhnian view of science. "...real science is: roughly, Kuhnian puzzle-solving within a research tradition, in a field that is not one that we construct and inhabit just by virtue (following here Schutz and Garfinkel and Wittgenstein) of being competent social actors"

"Established Psychology is one of those juggernauts that Wittgenstein didn’t like, and rightly so." Rupert Read


Keith Jarrett - The Koln Concert


Storify - this is a collation of the many Tweet discussions that followed our debate on whether Psychology is a Science (compiled by @neurowhoa) - they have been nicely ordered along the line of themes as they emerged in random timeless Twitter space


E=MC2 by Big Audio Dynamite
a paean to Nic Roeg
 
 
Even if we psychologists do eventually show the determination to get our house in order - many will still view psychology as a pseudoscience - what is important....is how we psychologists view what we do and how we practice what we do