tag:blogger.com,1999:blog-70828780154214752442024-01-19T13:58:03.549-08:00LawsDystopiaBlogProfessor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.comBlogger39125tag:blogger.com,1999:blog-7082878015421475244.post-7180738550673256972017-11-26T12:14:00.002-08:002017-11-26T14:33:53.642-08:00Avatar Therapy...Cold Lazarus or Karaoke?<div class="separator" style="clear: both; text-align: center;">
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<i style="background-color: white; color: #545454; text-align: left;"><span style="font-family: inherit;">"The trouble with words is that you never know whose mouths they have been in" </span></i></div>
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<span style="background-color: white; color: #545454; font-family: inherit; text-align: left;">Dennis Potter</span></div>
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A new paper by Craig et al (2017) published in <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(17)30427-3/fulltext?elsca1=tlpr" target="_blank">Lancet Psychiatry</a> looks <span style="font-family: inherit;">at whether so-called Avatar Therapy reduces auditory hallucinations in people with psychosis. Avatar Therapy <span style="background-color: white; color: #333333;">is described by the authors as "...a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy."</span><span style="background-color: white; color: #333333;"> </span></span></div>
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In an earlier <a href="http://bjp.rcpsych.org/content/early/2013/02/11/bjp.bp.112.124883" target="_blank">proof of concept trial</a>, the same research group produced some interesting if limited findings. I commented briefly on the original trial methodology stating that "...it is <em>one </em>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."</div>
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Despite the obvious methodological limitations, the initial trial of Avatar Therapy was heralded by some as a "...<span style="font-family: inherit;"><span style="background-color: white;"><a href="http://bjp.rcpsych.org/content/203/3/233.2?sid=06cb22bd-3d9d-4618-ab18-9345edd7f76c" target="_blank"><i>therapeutic approach for voice hearers of potentially Copernican significance!</i>"</a></span></span></div>
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<span style="background-color: white; font-family: inherit;">Such hyperbole </span><span style="background-color: white;">for a new and emerging </span>intervention <span style="background-color: white; font-family: inherit;">is never a good sign in science ...though sadly all too common</span></div>
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The latest trial addresses many of the issues that previously I had raised - it has an active control condition (Supportive Counselling), they tested for blinding success (and unmasking occurred for 1-in-5 participants) and they use an intention to treat analysis. It involved 75 active voice hearers being randomly assigned to receive 6 weeks of Avatar Therapy and 75 assigned to receive 6 weeks of Supportive Counselling. So, it is a well-controlled and hence reliable trial.</div>
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The Horrors - Machine</div>
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<i>Your smile is nothing to live for</i></div>
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<i>But read out your lines</i></div>
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<i>And bring the fantasy to life</i></div>
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<i>You taste like a ghost</i></div>
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<i>A cold simulation</i></div>
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Although methodologically a much better trial, the findings raise other questions. This starts with how the abstract presents the results - it is highly selective and somewhat worrying that the abstract passed unremarked by editors and reviewers at a journal such as <i>Lancet Psychiatry ...so, </i>what does it say?</div>
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<i>"You cannot make a pair of croak-voiced Daleks appear benevolent even if you dress one of them in an Armani suit and call the other Marmaduke"</i> Dennis Potter</blockquote>
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So, what is the omission? The abstract highlight the PSYRATS-AH total score change at 12 weeks, but no mention of the re-assessment findings at follow-up 12 weeks later. Of course, it is important to know if a new intervention continues to show a benefit over the control comparison - especially when the intervention phase has finished</div>
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Back in 2013, after publication of the initial preliminary trial, I posed a question that was critical then and remains akey question 4 years later with the latest better-controlled trial...</div>
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Avatar Therapy - so I would imagine follow up is key - what happens when the person is not in front of a computer?</div>
— Keith R Laws (@Keith_Laws) <a href="https://twitter.com/Keith_Laws/status/414086750399524865?ref_src=twsrc%5Etfw">December 20, 2013</a></blockquote>
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In this context, it is worth checking the original objectives and hypotheses of the trial (<a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0888-6" target="_blank">published protocol</a> at <i>BMC Trials) </i><br />
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If we turn to the hypotheses...were they supported or not?</div>
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a) Avatar therapy reduced frequency and severity of hallucinations ...at 12 weeks</div>
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b) Avatar therapy reduced omnipotence but not malevolence ...at 12 weeks </div>
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c) not a single outcome measure advantage for avatar therapy was maintained ...at 24 weeks (including those described just above)</div>
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Indeed, Table 2 in the paper outlines <i>26 </i>outcomes measured at 24 weeks and not one revealed a significant advantage for Avatar Therapy over Supportive Counselling...even by chance, we might expect one!</div>
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d) The proposed analysis of cost-efficacy is absent from the paper</div>
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e) The proposed mediator analyses are absent from the paper</div>
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29 #Strafford APTS by Bon Ive<span style="font-family: inherit;">r</span></div>
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<span style="font-family: inherit;"><i><span style="background-color: white; color: #222222; text-align: left;">Sure as any living dream</span><br style="background-color: white; color: #222222; text-align: left;" /><span style="background-color: white; color: #222222; text-align: left;">It's not all then what it seems</span><br style="background-color: white; color: #222222; text-align: left;" /><span style="background-color: white; color: #222222; text-align: left;">And the whole thing's hauled away</span></i></span></div>
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The interpretation offered by the authors in their discussion is revealing. It begins with the assertion that "AVATAR therapy was feasible to deliver, <i>acceptable </i>to participants, and did not result in any adverse events that could be attributed to the therapy." It is unclear what is meant by 'acceptable' here since - as in the previous trial- Avatar Therapy produced a high drop out rate of almost 1-in-3 during the 6 weekly 50-minute sessions.</div>
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<span style="text-align: center;">Regarding the lack of difference at follow-up the authors suggest that </span></div>
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"...<i>the absence of a treatment-as-usual control condition complicates interpretation </i>of the absence of a significant difference between the two groups at 24 weeks. Although, as hypothesised, the large effect of AVATAR is maintained after therapy up to 24 weeks, participants who received supportive counselling show a small improvement after therapy, <i>reducing the between group difference</i>." (my italics)</blockquote>
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This is curious as the authors when discussing limitations of their previous Avatar Therapy trial concluded the opposite (quite correctly): </div>
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"By comparing Avatar Therapy with TAU we did not control for the
time and attention paid by the therapist to patients receiving the
therapy. In the proposed replication study we will include an
active control of supportive counselling" (Leff et al 2013, p.5)</blockquote>
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Second, to argue that "<i style="text-align: center;">participants who received supportive counselling show a small improvement after therapy, reducing the between group difference" </i><span style="text-align: center;">is somewhat bizarre - leaving aside the obvious therapeutic allegiance issue, when is a '<i>small' </i>improvement for Supportive Counselling, a '<i>large</i>' effect for Avatar Therapy?</span></div>
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<span style="text-align: center;">The bottom line is that Supportive Counselling had a therapeutic effect that was much larger than anticipated and at follow-up was comparable to that of Avatar Therapy. The main difference is that the benefit attributable to Supportive Counselling persisted throughout the whole trial and was on an upward trend, while the benefit of Avatar Therapy was restricted to the initial testing phase...and then plateaued.</span></div>
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<span style="text-align: center;">So, at the end of the trial, Supportive Counselling and Avatar therapy did not differ in efficacy on any of 26 measures...and on many key indicators, supportive counselling was still reducing the key outcome measures while Avatar therapy had plateaued ...we might even wonder what would emerge if the two groups had been tested another 12 weeks later.</span></div>
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<script async="" charset="utf-8" src="https://platform.twitter.com/widgets.js"></script>Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-62319865917803556882016-01-16T03:33:00.000-08:002016-01-18T01:03:48.979-08:00Science is 'Other-Correcting'<span style="font-family: inherit;"></span><br />
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<span style="font-family: inherit;"><strong>Les Autres (by Keith Laws)</strong></span></div>
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<strong><span style="font-family: inherit;"> “Are you all sitty comftybold two-square on your botty? Then I'll begin.”</span></strong></div>
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<span style="font-family: inherit;">Some scientists seem to think that 'publication' represents the final chapter of their <em>story</em>...but it is not ...and has never been. Science is a <em>process, not a thing</em> - it's nature is to evolve and some <em>stories </em>require postscripts. I have never been convinced by the ubiquitous phrase '<em>Science is self-correcting'</em>. Much evidence points to science being conservative and looking less self-correcting and more <em>ego-protecting. </em>It is also not clear why 'self' is the correct description - most change occurs because of the 'other' - <em>Science is other correcting</em>. What is different from the past however, is that corrections or postscripts - often in the form of <em>post publication peer review - </em>now have far greater <em>immediacy, accessibility, exposure and impact </em>than previously. </span><br />
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<span style="font-family: inherit;">This post details a <em>saga </em>that transpired when some colleagues and I highlighted data errors in a recent paper by Turkington and colleagues (2014) examining the efficacy of Cognitive Behavioural Therapy (CBT) for psychosis. It is a tale in 6 parts - the original paper and 5 letters published by the <em>Journal of Nervous and Mental Disease</em> ...the latest being published this month. </span><br />
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<span style="font-family: inherit;"><span style="font-family: inherit;"><span style="font-family: inherit;"><strong>Montague Terrace in Blue (Scott Walker)</strong></span></span></span></div>
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<span style="font-family: inherit;"><span style="font-family: inherit;"><em><span style="font-family: inherit;">Your eyes ignite like cold blue fire<br /> The scent of secrets everywhere<br /> A fist filled with illusions<br /> Clutches all our cares</span></em></span></span></div>
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<strong><span style="font-family: inherit;">1. </span></strong><strong><a href="https://www.dropbox.com/s/866o1m53rgycvj4/turkington2014.pdf?dl=0" target="_blank"><span style="font-family: inherit;">Turkington, D., Munetz, M., Pelton, J., Montesano, V., Sivec, H., Nausheen, B., & Kingdon, D. (2014). High-yield cognitive behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms: An exploratory trial. <i>The Journal of Nervous and Mental Disease</i>, <i>202</i>(1), 30-34.</span></a></strong></div>
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<span style="font-family: inherit;"><span dir="ltr" tabindex="-1">My curiosity about this paper was piqued by the </span><span dir="ltr" tabindex="-1"><em>impossibility</em> of data reported in Table 2 of the paper</span> (see my Tweet below). A quick glance at the <em>QPR intrapersonal </em>values displays a mean and lower end CIs both of which are -.45 ...something was clearly amiss as <strong>the mean effect size cannot have the same value as the lower end 95% confidence interval</strong>. </span></div>
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<span style="font-family: inherit;">This led to a brief Twitter discussion between myself and three other psychologists (Tim Smits, Daniel Lakens, Stuart Ritchie) and further oddities in the paper quickly emerged. The authors assert that multiple outcome measures revealed a significant benefit of CBT</span><br />
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<span style="font-family: inherit;">"<em>Parametric and nonparametric tests showed significant results between baseline and follow-up for all primary and secondary outcomes except for social functioning, self-rated recovery, and delusions" </em>Turkington et al 2014</span></blockquote>
<span style="font-family: inherit;">Curiously however<strong>, the paper contains no inferential statistics to support the claims - </strong>readers are expected to accept such assertions at face value. </span><span style="font-family: inherit;">Moreover, their claims about significant statistical tests are themselves <em>contradicted by the confidence intervals </em>that they present in their Table 2 - the 95% Confidence Intervals cross zero for every variable and so, would all be non-significant. </span><span style="font-family: inherit;">Add to this some very poorly presented Figures (see Figure 5 below), lacking axis labels and claiming to display <em>standard error </em>bars, which are in fact <em>standard deviation </em>bars</span><br />
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<span style="font-family: inherit;">...clearly a paper with basic errors, which escaped the seven authors, the reviewers and the editor! </span></div>
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" 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<span style="font-family: inherit;">These initial concerns were documented in blog posts by Daniel Lakens </span><a href="https://sites.google.com/site/lakens2/blog/howatwitterhibarendsupasapublishedlettertotheeditor" target="_blank"><span dir="ltr" id="sites-page-title" style="font-family: inherit;" tabindex="-1">How a Twitter HIBAR ends up as a published letter to the editor</span></a><span style="font-family: inherit;"> and Tim Smits "</span><a href="http://persuasivemark.blogspot.co.uk/2014/02/dont-get-all-psychotic-on-this-paper.html" target="_blank"><span style="font-family: inherit;">Don't get all psychotic on this paper"</span></a></div>
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<span style="font-family: inherit;">2. </span><a href="https://www.researchgate.net/publication/263516748_Statistical_Errors_and_Omissions_in_a_Trial_of_Cognitive_Behavior_Techniques_for_Psychosis_Commentary_on_Turkington_et_al" target="_blank"><span style="font-family: inherit;">Smits, T., Lakens, D., Ritchie, S. J., & Laws, K. R. (2014). Statistical errors and omissions in a trial of cognitive behavior techniques for psychosis: commentary on Turkington et al. <i>The Journal of Nervous and Mental Disease</i>, <i>202</i>(7), 566.</span></a><br />
<span style="font-family: inherit;"> </span><br />
<span style="font-family: inherit;">Our Twitter discussion coalesced into the above letter, which was published by the <em>Journal of Nervous and Mental Disease </em>...where we suggested that our concerns </span></div>
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<em><span style="font-family: inherit;">"...mandate either an extensive correction, or perhaps a retraction, of the article by Turkington et al.(2014). At the very least, the authors should reanalyze their data and report the findings in a transparent and accurate manner" </span></em></blockquote>
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<span style="font-family: inherit;">We assumed that the authors might be pleased to correct such errors, especially since the findings might have implications for the psychological interventions offered to people diagnosed with schizophrenia </span><span style="font-family: inherit;"> </span></div>
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<span style="font-family: inherit;">3. </span><a href="https://www.dropbox.com/s/y0cwx8ji3kj09el/Turkingtonresponse2014.pdf?dl=0" target="_blank"><strong><span style="font-family: inherit;">Turkington, D. (2014). The reporting of confidence intervals in exploratory clinical trials and professional insecurity: a response to Ritchie et al. <i>The Journal of Nervous and Mental Disease</i>, <i>202</i>(7), 567.</span></strong></a><br />
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<span style="font-family: inherit;">We were somewhat surprised when Professor Turkington <em>alone </em>replied<em>. </em>He incorrectly cites our letter (it was not <em>Ritchie et al </em>but to <em>Smits et al</em>), suggesting perhaps that he may not have taken our points quite that <em>seriously</em>...a view underscored perhaps by both the title and the content of his letter. Without apparently reanalysing or checking the data, he asserts:</span></div>
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<span style="font-family: inherit;"><em>" I can confirm that the findings have been accurately reported in our published article... In Table 2, the confidence intervals are calculated around Cohen’s d as indicated...The labeling of the axes on Figure 5 is self-eviden</em>t" Turkington 2014</span></blockquote>
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At this point, Professor Turkington also decided to e-mail the first author Tim Smits with an invite: </div>
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<span style="font-family: inherit;">“<em>I wonder if you would attend a face to face debate at Newcastle University to debate the issues. Your colleagues McKenna and Laws have already been slaughtered in London.”</em></span></blockquote>
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<span style="font-family: inherit;">Professor Turkington refers here to the </span><a href="http://www.kcl.ac.uk/ioppn/news/special-events/maudsley-debates/debate-archive-31-50.aspx" target="_blank"><span style="font-family: inherit;">50th Maudsley Debate (CBT for Psychosis has been oversold) </span></a><span style="font-family: inherit;">- where you can view the video of our apparent 'slaughter'. Tim Smits politely declined, emphasising the importance of Turkington and colleagues actually addressing the errors we had highlighted in their paper. </span></div>
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<em><strong><span style="font-family: inherit;">William Basinski DIP 4 from Disintegration Loops </span></strong></em></div>
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4<strong>. </strong>As a result, we made a request to the authors and the Journal for access to Turkington et als' data, which was kindly provided. Re-analysing their data confirmed all of our suspicions about the errors. We sent our re-analyses to Professor Turkington and his colleagues </div>
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We then sent a second letter to JNMD conveying our re-analyses of their data:<br />
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<a href="https://www.dropbox.com/s/czg5zjsbwws8rmw/seriously.pdf?dl=0&preview=seriously.pdf" target="_blank"><span style="font-family: inherit;">Smits, T., Lakens, D., Ritchie, S. J., & Laws, K. R. (2015). Correcting Errors in Turkington et al.(2014): Taking Criticism Seriously. <i>The Journal of Nervous and Mental Disease</i>, <i>203</i>(4), 302-303.</span></a></div>
<div class="gs_citr" tabindex="0">
<span lang="EN-US" style="font-family: "times new roman" , serif; font-size: 12pt;"></span><span style="font-family: inherit;"> </span></div>
<div class="gs_citr" tabindex="0">
<span style="font-family: inherit;">We recalculated the effects sizes, which were quite different from those reported by the authors- in some cases, strikingly so (if you compare <em>our</em> Table 2 below with the one in my Tweet above from Turkington et al). Our re-analysis confirmed that the confidence inetrvals were incorrect and every effect size was inflated ...by an average of 65%</span><br />
<span style="font-family: inherit;"> </span></div>
<div class="gs_citr" style="text-align: center;" tabindex="0">
<span style="font-family: inherit;"><img src="http://blogs.plos.org/mindthebrain/files/2015/04/new-table1.png" height="221" width="400" /></span></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;"></span><br /></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">At this point we received an email from the JNMD editor-in-Chief ...it was clearly not intended for us</span></div>
<blockquote class="tr_bq" style="text-align: left;" tabindex="0">
<em><span style="font-family: inherit;">"Shall we just publish a correction saying it doesn't alter the conclusions"</span></em></blockquote>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">Another email from the editor rapidly followed ...asking us to ignore the previous email, which we duly did ...along with some <em><a href="http://www.apa.org/monitor/2011/10/unwanted-thoughts.aspx" target="_blank">White Bears </a></em></span></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;"></span><br /></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">For comparison purposes of course, we included Turkington et al s original Table 2 and in an ironic twist, the <em>Journal of Nervous and Mental Disease </em>invoiced us (106.29 Euros) for reproducing a Table presenting incorrect data in JNMD...it was of course eventually waived following our protest.</span></div>
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<strong>Living my Life by Deerhunter</strong></div>
<div style="text-align: center;">
<em><span style="font-family: inherit;">Will you tell me when you find out how to conquer all this fear<br /> I've been spending too much time out on the fading frontier<br /> Will you tell me when you find out how to recover the lost years<br /> I’ve spent all of my time chasing a Fading Frontier</span></em></div>
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<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">5. At this point, </span><span style="font-family: inherit;">JNMD decided to ask their own biostatistician - rather than the authors - to respond to our letter: </span></div>
<div class="gs_citr" id="gs_cit1" tabindex="0">
<strong><a href="https://www.dropbox.com/s/iyxeemef83i6qpu/Biostat.pdf?dl=0" target="_blank"><span style="font-family: inherit;">Cicchetti, D. V. (2015). Cognitive Behavioral Techniques for Psychosis: A Biostatistician’s Perspective. <i>The Journal of Nervous and Mental Disease</i>, <i>203</i>(4), 304-305</span></a><span style="font-family: inherit;">.</span></strong></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;"> </span></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">In his letter, Dr Cicchetti attempted to rebuff our critique in the following manner</span></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<blockquote class="tr_bq">
<em><span style="font-family: inherit;">To be perfectly candid, the reader needs to be informed that the journal that published the Lakens (2013) article, Frontiers in Psychology, is one of an increasing number of journals that charge exorbitant publication fees in exchange for free open access to published articles. Some of the author costs are used to pay reviewers, causing one to question whether the process is always unbiased, as is the desideratum. For further information, the reader is referred to the following Web site: </span></em><a class="fulltext-HT" href="http://www.frontiersin.org/Psychology/fees" target="_blank"><em><span style="font-family: inherit;">http://www.frontiersin.org/Psychology/fees</span></em></a></blockquote>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">Cicchetti is here focussing on a paper about effect sizes cited in our letter and written by one of our co-authors - Daniel Lakens. Cicchetti makes the false claim that <em>Frontiers </em>pays it's reviewers. This blatant <em>poison-the-well </em>fallacy is an unfortunate attempt to tarnish the paper by Daniel and by implication, our critique, the journal <em>Frontiers </em>and quite possibly much of <em>Open Access</em></span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">Unfortunately, Dr Cicchetti failed to respond to any correspondence from us about his letter and his false claim remains in print ...</span><br />
<span style="font-family: inherit;"> </span></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">Beyond this, Dr Cicchetti added little or nothing to the debate, saying that everything rests on </span></div>
<blockquote class="tr_bq">
<span style="font-family: inherit;">"...the assumption that the revised data analyses are indeed accurate because I [Cicchetti] was not privy to the original data. This seemed inappropriate, given the circumstances."</span></blockquote>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">As remarked here by Tim Smits in his post entitled "</span><a href="http://persuasivemark.blogspot.nl/2015/04/how-credibility-spoiled-this-mini.html" target="_blank"><span style="font-family: inherit;">How credibility spoiled this mini-lecture on statistics", </span></a><span style="font-family: inherit;"> this is a little disingenuous. Cicchetti did have access to the data and so, why not comment upon the accuracy of what we said?</span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">Cicchetti's response was further covered by Neuroskeptic in his blog '</span><a href="http://blogs.discovermagazine.com/neuroskeptic/2015/04/04/journals-in-glass-houses/" target="_blank"><span style="font-family: inherit;">Academic Journals in Glass Houses'</span></a> and by Jim Coyne in his <a href="http://blogs.plos.org/mindthebrain/2015/04/14/sordid-tale-of-a-study-of-cognitive-behavioral-therapy-for-schizophrenia-gone-bad/" target="_blank">Sordid Tale </a>post<br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;"> </span></div>
<div class="gs_citr" style="text-align: left;" tabindex="0">
<span style="font-family: inherit;">6 </span><span style="font-family: inherit;">Finally<em> </em>just this week, JNND published another letter </span></div>
<div class="gs_citr" id="gs_cit1" tabindex="0">
<a href="https://www.dropbox.com/s/xzlz33e20s9a0lr/HewitEtAl2015%20JNervMentDis%20%28002%29.pdf?dl=0" target="_blank"><strong><span style="font-family: inherit;">Sivec, H. J., Hewit, M., Jia, Z., Montesano, V., Munetz, M. R., & Kingdon, D. (2015). Reanalyses of Turkington et al.(2014): Correcting Errors and Clarifying Findings. <i>The Journal of Nervous and Mental Disease</i>, <i>203</i>(12), 975-976.</span></strong></a><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">Finally, this month, the original authors - with the notable absence of Turkington - but with 2 added statistical advisors...seem to accept the validity of the points that we made .... up to a point!</span></div>
<div class="gs_citr" tabindex="0">
<blockquote class="tr_bq">
<span style="font-family: inherit;">"<em>In short, the original presentation of the effect size results were incomplete and inaccurate, and the original published data would not be appropriate for future power calculations or meta-analyses as noted by Smits et al. (2015). However, at the descriptive level the reported conclusions were, in the main, relatively unchanged (i.e., while being cautious to generalize, there were modest positive effects).</em> " Sivec et al 2015</span></blockquote>
Are the conclusions "relatively unchanged"? I guess it depends whether you think - for example - a doubling of the effect size from .78 to 1.6 for CPRS total symptoms makes much difference? Whether an overall average effect size inflation of 65% by Turkington et al is important or not? Whether future power estimates should incorrectly suggest an average sample size of n=45 or more accurately n=120. The latter point is crucial given the endemic low levels of power in CBT for psychosis studies<br />
</div>
<div class="gs_citr" tabindex="0">
<span style="font-family: inherit;">Regarding incorrect error bars, Sivec et al, now say:</span><br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"><em>"Consistent with the Smits et al. (2014) original critique, our statistical consultants also found that, for figures reported as histograms with standard error bars, the bars represented standard deviations and not standard errors. Because the figures are used for visual effect and because the bars are intended to communicate variation within the scores, figures were not reproduced with standard errors"</em> Sivec et al 2015</span></blockquote>
<span style="font-family: inherit;">and finally</span><br />
<blockquote class="tr_bq">
<span style="font-family: inherit;"><em>"In the original article, we reported "Parametric and nonparametric tests showed significant results between baseline and follow-up for all primary and secondary outcomes except for social functioning (PSP), self-rated recovery (QPR), and delusions” (p. 33).</em> <em>This statement is true only for the parametric tests...To be clear, most of the nonparametric tests were nonsignificant. This was not a critical part of the analyses" </em>Sivec et al 2015</span></blockquote>
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<span style="font-family: inherit;"></span> </div>
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So, after 5 letters, the authors - or most of them - acknowledge all of the errors - or most of them. Sivec et al obviously want to add a caveat to each 'admission'</span><span style="font-family: inherit;">, but the central fact is that the paper remains exactly as it did before we queried it. This means that only somebody who is motivated to plough through the subsequent 5 letters would discover the acknowledged errors and omissions and the implications</span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">Sensitivities regarding post-publication peer review are quite understandable, and perhaps as with the 'replication' initiative, psychologists <em>and </em>journals need to evolve more acceptable protocols for handling these issues. Is post-publication peer review worth the effort - "Yes!" The alternative is a psychology that echoes a progressively distorting noise while the true signal is a fading frontier. </span><br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com3tag:blogger.com,1999:blog-7082878015421475244.post-35497632101098558682015-11-06T13:14:00.000-08:002015-11-07T02:47:26.099-08:00Song for the Siren<br />
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<em>There is another future waiting there for you</em></div>
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<em>I saw it different, I must admit</em></div>
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<em>I caught a glimpse, I'm going after it</em></div>
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<em>They say people never change, but that's bullshit, they do</em></div>
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<em>Yes I'm changing, can't stop it now</em></div>
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<em>And even if I wanted I wouldn't know how</em></div>
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<em>Another version of myself I think I found, at last</em><br />
<strong>Yes I'm Changing by Tame Impala</strong></div>
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Some 'follow-up' observations to my earlier <a href="http://keithsneuroblog.blogspot.co.uk/2015/11/pace-thoughts-about-holes.html" target="_blank">'Thoughts about Holes' </a>post on the PACE follow-up study of Chronic fatigue Syndrome/ME by Sharpe et al 2015. <br />
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To recap, after completing their final outcome assessment, <em>some </em>trial participants were offered an additional PACE therapy..."If they were still unwell, they wanted more treatment, and their PACE trial doctor agreed this was appropriate. The choice of treatment offered (APT, CBT, or GET) was made by the patient’s doctor, taking into account both the patient’s preference and their own opinion of which would be most beneficial.” <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60096-2.pdf" target="_blank"><span style="color: #29aae1;">White et al 2011</span></a><br />
I have already commented on some of the issues about how these decisions were made, but here I focus on the <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00317-X/supplemental" target="_blank">Supplementary Material </a>for the paper (see particularly <em>Table C </em>at the bottom of this post) and - what I believe to be some unsupported ...or unsupportable inferences made about the PACE findings recently.<br />
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<strong>Song to the Siren by Tim Buckely</strong></div>
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<strong>(from the Monkees TV show)</strong></div>
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<em>Did I dream you dreamed about me?<br />Were you here when I was flotsom?<br />Now my foolish boat is leaning <br />Broken lovelorn on your rocks</em></div>
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I will start with three recent quotes making key claims about the success of the PACE follow-up findings and discuss the evidence for each claim. <br />
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1) First, in a <a href="http://www.nationalelfservice.net/other-health-conditions/chronic-fatigue-syndrome/the-pace-trial-for-chronic-fatigue-syndrome-choppy-seas-but-a-prosperous-voyage/" target="_blank">Mental Elf</a> blog this week, (Sir) Professor Simon Wessely rightly details and praises the benefits of randomised controlled trials (RCT), concluding that PACE matches-up quite well. But to extend Prof Wessely's nautical motif, I'm more interested in how 'HMS PACE' was seduced by the song of the Sirens, forced to abandon methodological rigor on the shallow rocky shores of bias and confound. <br />
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Prof Wessely states<br />
<blockquote class="tr_bq">
"<em>There was no deterioration from the one year gains in patients originally allocated to CBT and GET</em>. <em>Meanwhile those originally allocated to SMC and APT improved </em>so that their outcomes were now similar. What isn’t clear is why. It may be because many had CBT and GET after the trial, but it may not. Whatever the explanation for the convergence , <em>it does seem that CBT and GET accelerate improvement, </em>as the accompanying commentary pointed out (Moylan, 2015)."</blockquote>
It seems to me that specific claims for "no deterioration from the one year gains in patients originally allocated to CBT and GET" might be balanced by the equally valid statement that we also saw "<strong>no deterioration from the one year gains in patients originally allocated to SMC and APT</strong>". Almost one-third of the CBT and GET groups did, however, receive additional treatments as did the SMC and APT groups. As I mentioned in my <a href="https://keithsneuroblog.blogspot.com/b/post-preview?token=6fJB3lABAAA.86YEFhJXQF5H9zwlDlZi3L4WJMZ7fsmWjhhH4eA87yI2NHyOlJnnfWrVaEgDT3HS9QbV6_0ULG71ZNtDpdLhvw.saPb21O4DWla1nkLqZDH_w&postId=3549763210109855868&type=POST" target="_blank">previous post</a>, the mean group scores at follow-up are now a smorgasbord of PACE interventions, meaning that the group means lack... meaning! <br />
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At best, the PACE follow-up data might show that deterioration did not occur in the GET and CBT groups <em>to any greater or lesser extent than it did in the SMC and APT groups</em>. The original groupings effectively no longer exist at follow-up and we should certainly not flit between explanations sometimes based on initial randomised groupings and sometimes based on additional nonrandomised therapies. <br />
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In terms of deterioration, we know only one thing - one group were close to showing a significantly greater number of patients reporting 'negative change' during follow-up and contrary to the claim, this was the CBT group (see Table D in supplementary materials)<br />
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<strong>Yes I'm Changing by Tame Impala</strong></div>
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2) Second, in the abstract of the PACE paper by Sharpe et al draw conclusions about long-term benefits of the original therapy groups:<br />
<blockquote class="tr_bq">
"<em>The beneficial effects of CBT and GET seen at 1 year were maintained at long-term follow-up a median of 2·5 years after randomisation</em>. Outcomes with SMC alone or APT improved from the 1 year outcome and were similar to CBT and GET at long-term follow-up, <em>but these data should be interpreted in the context of additional therapies </em>having being given according to physician choice and patient preference after the 1 year trial final assessment." (my italics)</blockquote>
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<span style="font-family: ScalaLancetPro-Bold; font-size: xx-small;"></span></span><br />
Again for the reasons just outlined, we cannot infer that CBT and GET maintained any benefits at follow-up anymore than we could argue that APT or even the control condition (SMC) maintained their own benefits. The smorgasbord data dish prevent any meaningful inference<br />
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3) Finally, in a <a href="http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00475-7/abstract" target="_blank">Commentary</a> <span id="goog_732697530"></span>that appeared in <em>Lancet Psychiatry </em>alongside the paper (mentioned by Prof Wessely above), Moylon and colleagues suggest hypotheses about the benefits of CBT and GET remain 'unproven' but that CBT and GET may <em>accelerate </em>improvement: </div>
<blockquote class="tr_bq">
"The authors hypothesise that the improvement in the APT and SMC only groups might be attributed to the effects of post-trial CBT or GET, because more people from these groups accessed these therapies during follow-up. <em>However, improvement was observed in these groups irrespective of whether these treatments were received, and thus this hypothesis remains unproven.</em> ....<em>Overall, our interpretation of these results is that structured CBT and GET seems to accelerate improvement of self-rated symptoms of chronic fatigue syndrome compared with SMC or SMC augmented with APT</em>..."</blockquote>
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<strong>Round and Round by Ariel Pink's Haunted Graffiti </strong></div>
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<em>It's always the same, as always<br /> Sad and tongue tied<br /> It's got a memory and refrain<br /> I'm afraid, you're afraid<br /> And we die and we live and we're born again<br /> Turn me inside out<br /> What can I say...<br /> Merry go 'round<br /> We go up and around we go</em></div>
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Moylon et al rightly point out that improvement occurred "<em>irrespective of whether these treatments were received, and thus this hypothesis remains unproven" . </em>Although not apparent from the main paper, the supplementary material throws light on this issue, however, Moylon et al are only half right!<br />
<br />
We can see in Table C of the supplementary material (see below) that those in the CBT group, APT and SMC showed significant improvements even when no additional therapies were provided - so, Moylon are correct on that score. By contrast, the same cannot be said of the GET group. At follow-up, GET shows no significant benefit on measures of fatigue (CFQ) or of physical function (SF-36PF) ...whether they received additional adequate therapy, partial therapy or indeed, no further therapy! <br />
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This is even more interesting when we consider that Table C reveals data for 20 GET patients (16%) who had subsequently received 'adequate CBT' - and it clearly produced no significant benefits on their fatigue or their physical function scores. So, what are we to conclude? That CBT is ineffective? CBT is ineffective following GET? That these patients are 'therapy resistant'? Therapy resistant because they received GET?<br />
<br />
Whatever the explanation, GET is the only group to show no improvement during follow-up. Even with no additional therapy, both the SMC controls and the APT group improved, as indeed did CBT. The failure of GET patients to respond to adequate additional CBT therapy is curious, not consistent with the claims made and does not look 'promising' for either GET or CBT. <br />
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The inferences described above do appear to be holed below the water line. <br />
<br />
1) CBT does not appear to accelerate improvement ...at least in people who have previously received GET<br />
2) People who received GET show no continuing improvement post-therapy<br />
and 3) CBT may heighten the incidence of 'negative change' .<br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com9tag:blogger.com,1999:blog-7082878015421475244.post-37760012289720722912015-11-01T11:47:00.003-08:002015-11-01T11:47:36.087-08:00PACE - Thoughts about Holes <div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfyiD_mwIebpQbZYVvBcZLyi6qAhVWOMHpU4PHcNK9Ic2XHeD7xCXgBNAzGCZdMdezuTrXj_yJsmUfkxqTS63Km4GqEQgVtHOHkQesnCv7Xi4FB6A_kgeox9NGNapxkJ9BHDRNwHRZvps/s1600/IMG_1058.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfyiD_mwIebpQbZYVvBcZLyi6qAhVWOMHpU4PHcNK9Ic2XHeD7xCXgBNAzGCZdMdezuTrXj_yJsmUfkxqTS63Km4GqEQgVtHOHkQesnCv7Xi4FB6A_kgeox9NGNapxkJ9BHDRNwHRZvps/s400/IMG_1058.JPG" width="298" /></a></div>
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This week <em>Lancet Psychiatry </em>published a <a href="http://www.thelancet.com/pdfs/journals/lanpsy/PIIS2215-0366%2815%2900317-X.pdf">long term follow-up study</a> of the PACE trial assessing psychological interventions for Chronic Fatigue Syndrome/ME - it is available at the website following free registration<br />
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On reading it, I was struck by more questions than answers. It is clear that these follow-up data show that the interventions of Cognitive behavioural Therapy (CBT), Graded Exercise Therapy (GET) and Adaptive Pacing Therapy (APT) fare no better than Standard Medical Care (SMC). While the lack of difference in key outcomes across conditions seem unquestionable, I am more interested in certain questions thrown up by the study concerning decisions that were made and how data were presented.<br />
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A few questions that I find hard to answer from the paper...<br />
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<strong>1) How is 'unwell' defined? </strong><br />
The authors state that “After completing their final trial outcome assessment, trial participants were offered an additional PACE therapy. <strong>if they were still unwell</strong>, <strong>they wanted more treatment, and their PACE trial doctor agreed this was appropriate. The choice of treatment offered (APT, CBT, or GET) was made by the patient’s doctor, taking into account both the patient’s preference and their own opinion of which would be most beneficial.” </strong><a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)60096-2.pdf" target="_blank"><strong>White et al 2011</strong></a><br />
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But how was ‘unwell' defined in practice? Did the PACE doctors listen to patient descriptions about 'feeling unwell' at face-value or did they perhaps refer back to criteria from the previous PACE paper to define 'normal' as patient scores being “within normal ranges for both primary outcomes at 52 weeks” (CFS 18 or less and PF 60+) . Did the PACE Doctors exclude those who said they were still unwell but scored 'normally' or those who said they were well but scored poorly? None of this seems any clearer from the <a href="http://www.biomedcentral.com/content/pdf/1471-2377-7-6.pdf" target="_blank">published protocol </a>for the PACE trial.<br />
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<strong>Holes by Mercury Rev</strong></div>
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<em>Holes, dug by little moles, angry jealous<br /> Spies, got telephones for eyes, come to you as<br /> Friends, all those endless ends, that can't be<br /> Tied, oh they make me laugh, an' always make me<br /> ....Cry</em></div>
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<strong>2) How was additional treatment decided and was it biased?</strong><br />
With regard to the follow-up phase, the authors also state that “The <strong>choice of treatment offered (APT, CBT, or GET) was made by the patient’s doctor</strong>, taking into account both the patient’s preference and <strong>their own opinion of which would be most beneficial</strong>”. <br />
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But what precisely informed the PACE doctors’ choice and consideration of “what would be most beneficial”?<br />
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They say “These choices were made <strong>with knowledge of the individual patient’s treatment allocation and outcome</strong>, <strong>but before the overall trial findings were known</strong>” This is intriguing …The doctors know the starting scores of their patients and the finishing scores at 52 weeks. In other words, the decision-making of PACE Doctors was non-blind, and thus informed by the consequences of the trial and how they view their patients have been progressing in each of the four conditions.<br />
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3) The authors say” Participants originally allocated to SMC in the trial were the most likely to receive additional treatment followed by those who had APT; those originally allocated to the rehabilitative therapies (CBT and GET) were less likely to receive additional treatment. <strong>In so far as the need to seek additional treatment is a marker of continuing illness, these findings support the superiority of CBT and GET as treatments for chronic fatigue syndrome</strong>.”<br />
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Because more participants were assigned further treatments following some conditions (SMC APT)rather than others (CBT GET), doesn't necessarily imply "support for superiority of CBT and GET" at all. It all depends upon the decision making process underpinning the choice made by PACE clinicians. The trial has not been clear on whether <em><strong>only </strong></em>those who met criteria for being 'unwell' were offered additional treatment...and what were the criteria? This is especially pertinent since we already know that <a href="http://www.meassociation.org.uk/2015/10/trial-by-error-the-troubling-case-of-the-pace-chronic-fatigue-syndrome-study-investigation-by-david-tuller-21-october-2015/" target="_blank">13% of patients were entered into the original PACE trial who met criteria for being 'normal'</a><br />
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<strong>Opus 40 by Mercury Rev </strong></div>
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<em>"Im alive she cried, but I don't know what that means"</em></div>
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We know that the decision making of PACE doctors was not blind to previous treatment and outcome.<br />
It also seems quite possible that participants who had initially been randomly assigned to SMC wanted further treatment because they were so evidently dissatisfied with being assigned to SMC rather than an intervention arm of the trial - before treatment, half of the SMC participants thought that SMC was 'not a logical treatment' for them and only 41% were confident about being helped by receiving SMC. <br />
Such dissatisfaction would presumably be compounded by receiving a mid-trial Newsletter saying how great CBT and GET participants were faring! It appears that mid-trial, the PACE team published a newsletter for participants, which included selected patient testimonials stating how much they had benefited from “therapy” and “treatment”. The newsletter also included an article telling participants that the two interventions pioneered by the investigators and being trialled in PACE (CBT and GET) had been recommended as treatments by a U.K. government committee “based on the best available evidence.” (see <a href="http://www.meassociation.org.uk/2015/10/trial-by-error-the-troubling-case-of-the-pace-chronic-fatigue-syndrome-study-investigation-by-david-tuller-21-october-2015/">http://www.meassociation.org.uk/2015/10/trial-by-error-the-troubling-case-of-the-pace-chronic-fatigue-syndrome-study-investigation-by-david-tuller-21-october-2015/</a>) <br />
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So, we also cannot rule out the possibility that the SMC participants were also having to suffer the kind of frustration that regularly makes wait-list controls do worse than they would otherwise have done. They were presumably informed and 'consented' at the start of the trial vis-a-vis the possibility of further (different or same) therapy at the end of the trial if needed? This effectively makes SMC a wait-list control and the negative impact of such waiting in psychotherapy and CBT trials is well-documented (for a recent example <a href="http://www.nationalelfservice.net/treatment/cbt/its-all-in-the-control-group-wait-list-control-may-exaggerate-apparent-efficacy-of-cbt-for-depression/">http://www.nationalelfservice.net/treatment/cbt/its-all-in-the-control-group-wait-list-control-may-exaggerate-apparent-efficacy-of-cbt-for-depression/</a>)<br />
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Let us return to the issue of how 'need' (to seek additional treatment)<strong> </strong>was defined. undoubtedly the lack of PACE Doctor blinding and the mid-trial newsletters promoting CBT ad GET, along with possible PACE Doctor research allegiance would all accord with greater numbers of CBT (and GET) referrals ...and indeed, CBT being the only therapy that was further offered to some participants - presumably after not being successful the first time!). The decisions appear to have little to do with patients showing a ‘need to seek additional treatment” and nothing at all to do with establishing "<strong>superiority of CBT and GET as treatments for chronic fatigue syndrome</strong>.”<br />
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4) perhaps I have missed something, but group outcome scores at follow-up seem quite strange. To illustrate with an example, does the follow-up SMC mean CFQ =20.2 (n=115) also include data from 6 participants who switched to APT, 23 to CBT and 14 to GET? If so, how is this any longer labelled as an SMC condition? The same goes for every other condition – they confound follow-up of intervention with change of intervention. What do such scores mean…? And how can we now draw any meaningful conclusions about any outcomes ...under the heading of the initial group to which they were assigned? <br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com19tag:blogger.com,1999:blog-7082878015421475244.post-47303780326946270512015-05-28T13:54:00.000-07:002015-09-14T02:09:26.030-07:00Science & Politics of CBT for Psychosis<div style="text-align: center;">
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"<em><strong>Let me tell you about scientific management</strong></em><br />
<em><strong>...</strong></em><em><strong>And the theft of its concealment" </strong></em><br />
The Fall - Birmingham School of Business </div>
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Recently the <strong>British Psychological Society </strong>invited me to give a public talk entitled <em><strong><a href="http://www.bps.org.uk/events/networking-event-science-and-politics-behind-cognitive-behavioural-therapy-psychosis" target="_blank">CBT: The Science & Politics behind CBT for Psychosis</a></strong></em>. In this talk, which was filmed (see link at the bottom), I highlight the unquestionable bias shown by the <strong>National Institute of Clinical Excellence (NICE) </strong>committee <a href="https://www.nice.org.uk/guidance/cg178" target="_blank">(CG178) </a>in their advocacy of CBT for psychosis. </div>
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The bias is not concealed, but unashamedly served-up by NICE as a dish that is high in 'evidence-substitute', uses data that are past their sell-by-date and is topped-off with some nicely picked cherries. I raise the question of whether committees - with such obvious vested interests - should be advocating on mental health interventions. </div>
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<strong>Tim Hecker - Live Room + Live Room Out</strong></div>
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I present findings from our own recent meta-analysis (<a href="http://bjp.rcpsych.org/content/204/1/20.short" target="_blank">Jauhar et al 2014</a>) showing that three-quarters of all RCTs have failed to find any reduction in the symptoms of psychosis following CBT. I also outline how trials which have used non-blind assessment of outcomes have inflated effect sizes by up to 600%. Finally, I give examples where CBT may have adverse consequences - both for the negative symptoms of psychosis and for relapse rates</div>
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<strong>Clicking on the image below takes you to the video</strong> </div>
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The video is 1 hour in length & is linked to accompanying slides </div>
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<strong> </strong><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZjTdR24gJKWAdwIvY3JgnVOsQ2caL2oJIhHLVqA0xIbGywtJG_h5uJjwjUOBJU44WnDV3LbzNX1y6SLeipIYrua_Nsr1tU8Nyap-Wc172p8B7g29VzTYVHtl8HPsTIxl_EDjL8XDFwjs/s1600/BPS2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZjTdR24gJKWAdwIvY3JgnVOsQ2caL2oJIhHLVqA0xIbGywtJG_h5uJjwjUOBJU44WnDV3LbzNX1y6SLeipIYrua_Nsr1tU8Nyap-Wc172p8B7g29VzTYVHtl8HPsTIxl_EDjL8XDFwjs/s320/BPS2.jpg" width="220" /></a></div>
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-67216176867524556102014-06-06T14:25:00.002-07:002014-06-06T14:25:46.329-07:00Meta-Matic: Meta-Analyses of CBT for Psychosis<div style="text-align: center;">
<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=hK-11PKxWsOYCM&tbnid=WSRedjw4Zv5clM:&ved=0CAUQjRw&url=http%3A%2F%2Fhopedog.wordpress.com%2F2010%2F12%2F&ei=08ORU_aPE8HE7Aag64D4Ag&bvm=bv.68445247,d.ZGU&psig=AFQjCNHwEE4GB4P5bZ_cOBW9-1YE8GXRFQ&ust=1402147735514330" id="irc_mil" style="border-image: none; border: 0px currentColor;"><img src="http://hopedog.files.wordpress.com/2010/12/john_foxx-metamatic_deluxe.jpg" height="320" id="irc_mi" style="margin-top: 0px;" width="319" /></a><a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&docid=hK-11PKxWsOYCM&tbnid=WSRedjw4Zv5clM:&ved=0CAUQjRw&url=http%3A%2F%2Fthep5.blogspot.com%2F2009%2F01%2Fjohn-foxx-metamatic.html&ei=KcKRU6PgLYOd7Qb-8ICoBQ&bvm=bv.68445247,d.ZGU&psig=AFQjCNHwEE4GB4P5bZ_cOBW9-1YE8GXRFQ&ust=1402147735514330" id="irc_mil" style="border-image: none; border: 0px currentColor;"></a></div>
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Meta analyses are not a 'ready-to-eat' dish that necessarily <em>satisfy</em> 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 (<a href="http://bjp.rcpsych.org/content/204/1/20.short" target="_blank">Jauhar et al 2014</a>) and it has received some <a href="http://bjp.rcpsych.org/content/204/1/20.short#responses" target="_blank">comment on the BJP website</a>, 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.<br />
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Slow Motion (Ultravox)</div>
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<strong>1) <a href="http://journals.psychiatryonline.org/article.aspx?volume=171&page=523" target="_blank">Turner, van der Gaag, Karyotaki & Cuijpers (2014) Psychological Interventions for Psychosis: A Meta-Analysis of Comparative Outcome Studies</a></strong><br />
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Turner et al assessed 48 Randomised Controlled Trials (RCTs) involving 6 psychological interventions for psychosis (e.g. befriending, supportive counselling, cognitive remediation); and found <strong>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</strong><br />
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The one small effect described by Turner et al as <em>robust</em> - for positive symptoms <strong>- however became nonsignificant when </strong><strong><em>researcher allegiance </em>was assessed</strong>. 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. <br />
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<strong>Comments</strong>:<br />
<strong>One included study (Barretto et al) did not meet Turner et als own inclusion criteria of random assignment. </strong>Barretto et al state <strong>"The main limitations of this study are ...this <em>trial was not truly randomized</em>" </strong>(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<br />
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Translucence (Harold Budd & John Foxx)</div>
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<strong>2) <a href="http://journals.psychiatryonline.org/Article.aspx?ArticleID=1857288" target="_blank">Burns, Erickson & Brenner (2014) Cognitive Behavioural Therapy for medication-resistant psychosis: a meta analytic review</a></strong><br />
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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. <strong>Significant effects of CBT were found at post-treatment for positive symptoms (Hedges’ g=.47 [95%CI 0.27 to 0.67])</strong> and<strong> </strong>for <strong>general symptoms (Hedges’ g=.52 [95%CI 0.35 to 0.70]).</strong> These effects were<strong> 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).</strong><br />
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<strong>Comment</strong><br />
Wait a moment.... what effect size is being calculated here? Unlike all other CBT for psychosis meta analyses, these authors attempt to assess <strong>pre-postest <em>change</em> </strong>rather than the usual end-point differences between groups. <strong>Crucially - though not stated in the paper - the <em>change</em> <em>effect size</em> 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'). </strong>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).<br />
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This meta analysis <strong>also included the non-random Barretto et al trial</strong>, which again is contrary to the inclusion criteria for this meta analysis; and crucially, <strong>Barretto produced - by far - the largest effect size for general psychotic symptoms in this unusual analysis (See forest plot below). </strong><br />
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<a data-mce-href="http://keithrlaws.files.wordpress.com/2014/04/burns1.jpg" href="http://keithrlaws.files.wordpress.com/2014/04/burns1.jpg"><img alt="Burns1" class="aligncenter wp-image-500 size-large" data-mce-src="http://keithrlaws.files.wordpress.com/2014/04/burns1.jpg?w=640" src="http://keithrlaws.files.wordpress.com/2014/04/burns1.jpg?w=640" height="294" width="400" /></a><br />
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<a href="http://www.sciencedirect.com/science/article/pii/S0920996414001340" target="_blank"><strong>3) van der Gaag, Valmaggia & Smit (2014) </strong><strong>The effects of individually tailored formulation-based cognitive behavioural therapy in auditory hallucinations and delusions: A meta-analysis</strong></a></div>
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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 <strong>effect-sizes were 0.36 for delusions and 0.44 for hallucinations</strong>. When compared to <strong>active treatment, CBT for delusions lost statistical significance (0.33), though CBT for hallucinations remained significant(0.49).</strong> <strong>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).</strong> <br />
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<strong>Comment</strong><br />
van der Gaag et al state they <strong>excluded studies </strong>that <strong>"...were not CBTp but other interventions</strong> (Chadwick et al., 2009; <strong>Shawyer et al., 2012</strong>; van der Gaag et al., 2012). <strong>Shawyer</strong> <strong>et al</strong> is an interesting example as Shawyer and colleagues recognize it as CBT, stating “The purpose of this trial was to evaluate...<strong><em>CBT augmented with acceptance-based strategies" </em></strong>The study also met the criterion of being individual and formulation based.<br />
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More importantly, clear inconsistency emerges as <strong>Shawyer et al was counted as CBT <em>in two other 2014 meta analysis where van der Gaag is one of the authors. </em></strong>One is<em> </em>the<em> </em>Turner et al meta analysis (described above) where they even classified it as having <strong>CBT allegiance bias </strong>- see below far right classification in Turner et al)<br />
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<a data-mce-href="http://keithrlaws.files.wordpress.com/2014/04/shawyerfig.jpg" href="http://keithrlaws.files.wordpress.com/2014/04/shawyerfig.jpg"><img alt="shawyerfig" class="aligncenter wp-image-503 size-full" data-mce-src="http://keithrlaws.files.wordpress.com/2014/04/shawyerfig.jpg" src="http://keithrlaws.files.wordpress.com/2014/04/shawyerfig.jpg" height="55" width="602" /></a><br />
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And ....<strong>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. </strong><br />
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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 <strong>Shawyer et al is important because they showed that befriending <em>significantly</em> outperformed CBT in its impact on hallucinations. </strong>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<br />
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While the exclusion of Shawyer et al seems inexplicable, <strong>inclusion of Leff et al (2013) as an example of CBT is highly questionable</strong>. Leff et al refers to the recent <strong>'Avatar therapy'</strong> study <strong>and at no place does it even mention CBT</strong>. Indeed, in referring to Avatar therapy, Leff himself states that he "<a data-mce-href="http://www.mindincambs.org.uk/Docs/AvatarTherapy.pdf" href="http://www.mindincambs.org.uk/Docs/AvatarTherapy.pdf"><strong>jettisoned some strategies borrowed from Cognitive Behaviour Therapy, and developed some new ones</strong></a>"<br />
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And Finally...the endpoint CBT advantage of 0.47 for hallucinations in the recent unmedicated psychosis study by <strong>Morrison et al (2014)</strong> 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!<br />
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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...<br />
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Hiroshima Mon Amour (Ultravox)</div>
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<strong><a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9270443&fileId=S0033291714001147" target="_blank">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</a></strong><br />
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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.<br />
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<strong>Comment </strong><br />
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. <br />
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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!<br />
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<a data-mce-href="https://keithrlaws.files.wordpress.com/2014/06/negedit.jpg" href="https://keithrlaws.files.wordpress.com/2014/06/negedit.jpg"><img alt="negedit" class="aligncenter wp-image-527 size-large" data-mce-src="https://keithrlaws.files.wordpress.com/2014/06/negedit.jpg?w=640" height="381" src="https://keithrlaws.files.wordpress.com/2014/06/negedit.jpg?w=640" width="640" /></a><br />
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<br />Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-21429834690768722972014-02-21T11:57:00.002-08:002015-11-25T13:21:52.530-08:00The Farcial Arts: Tales of Science, Boxing, & Decay <div style="text-align: center;">
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<strong><em>"Do you think a zebra is a white animal with black stripes, or a black animal with white stripes?"</em></strong></div>
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<strong>Why do researchers squabble so much? </strong>Sarah Knowles recently posted this interesting question on her blog - it was entitled <a href="http://saraheknowles.wordpress.com/2014/02/14/find-the-gap/" target="_blank">Find the Gap</a>. The debate arose in the context of the new Lancet paper by Morrison et al looking at the efficacy of <a href="http://keithsneuroblog.blogspot.co.uk/2014/02/my-bloody-valentine-cbt-for-unmedicated.html" target="_blank">CBT in unmedicated psychosis</a>. 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 <em>should </em>be conducted. <br />
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So, why do researchers squabble so much? First I would replace the pejorative <em>squabble </em>with the less loaded <em>argue. </em>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.<br />
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<strong>'I am Catweazle' by Luke Haines</strong></div>
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<strong> </strong><strong><em>What you see before you is a version of something that may be true...</em></strong></div>
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<em><strong>I am Catweazle,</strong> <strong>who are you?</strong></em></div>
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But we might ask - why do scientists - and <em>psychologists </em>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". <br />
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And like boxing...science may sometimes seem to be about <em>bravado</em>. Some make claims outside of the peer-reviewed ring with such <em>boldism </em>that they are rarely questioned, while others make <em>ad hominem </em>attacks from the sidelines ...preferring to troll behind a mask of anonymity - more super-zero than super-hero. <br />
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<strong>A is for Angel Fish </strong> </div>
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Some prefer shadow boxing - possibly like clinicians carrying on their <em>practice</em> paying little heed to the <em>squabbles </em>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 <em>distress </em>(despite its being non-evidenced)<em>.</em> Such shadow boxing helps keep you fit, but does not address your <em>true strength</em> - you can never know how strong your intervention is ...until its pitted against a worthy opponent, as opposed to your own shadow!<br />
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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 - <a href="http://www.theguardian.com/sport/blog/2009/nov/11/the-forgotten-story-of-ali-inoki" target="_blank">Inoki </a>- 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.<br />
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<strong>Race for the Prize by Flaming Lips</strong></div>
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<em><strong>Is 'Normal Science' all about fixed bouts?</strong></em><br />
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 <em>status quo</em> - this is a part of Kuhnian <em>normal science </em>- 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<br />
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<strong>This is Hardcore - Pulp</strong></div>
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<em>I've seen the storyline played out so many times before. <br />Oh that goes in there. <br />Then that goes in there. <br />Then that goes in there. <br />Then that goes in there. & then it's over. </em></div>
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<strong><em>Monster-Barring: Protective Ad Hoc Championship Belts</em></strong><br />
Returning to CBT for psychosis, nobody should expect advocates to <em>throw in the towel </em>- that is not how science progresses. Rather, as the philosopher of science <em>Imre Lakatos </em>argues, we would expect them to start barricading against attacks with their protective <em>belt - </em>adding new layers of <em>ad hoc </em>defence to the <em>core </em>ideas<em>. </em>Adjustments that simply maintain the 'hard core', however, will highlight the research programme as <em>degenerative</em>.<br />
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<em> <a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=WshTYpZ0X3XBqM&tbnid=W_39rKSHXWVesM:&ved=0CAUQjRw&url=http%3A%2F%2Fbenswithen.blogspot.com%2F&ei=tvQFU4DtB-GZ0AXe-4CgDw&bvm=bv.61725948,d.ZGU&psig=AFQjCNHq7Cww7R01cMyt7tpayaR5ZU6VDg&ust=1392985609754723" id="irc_mil" style="border: 0px currentColor;"><img class="irc_mut" height="223" id="irc_mi" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnGXxvp6Jxj68VCEJyfvhGYvxL9m3-HAlw_YxR0qXflUY6DdscWidAfi9-kirfpFdrNJe7dcWXUjZ2_FPOD3H_n65ttho1oawWyUGdaeVJQKT_L3mQf5jYVmnHsVDDyF2ZIXg4X1Woq5M/s400/1985jc.jpg" style="margin-top: 0px;" width="400" /></a></em></div>
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<strong>Not a leg to stand on</strong></div>
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Of course, the nature of a paradigm in crisis is that ad hoc defences emerge inluding examples of what Lakatos calls <strong>'monster barring'. </strong>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 <em>wanting, </em>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. <br />
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<a data-ved="0CAcQjRxqFQoTCJqrrpC9jMYCFQoy2wodDpoAjw" href="https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRxqFQoTCJqrrpC9jMYCFQoy2wodDpoAjw&url=https%3A%2F%2Fplus.google.com%2F%2BCollegexpress&ei=EAh8VZrjFYrk7AaOtIL4CA&bvm=bv.95515949,d.ZGU&psig=AFQjCNEhQe5nYPXPiqrVyYx55Cgmm9Hytg&ust=1434278275473692" id="irc_mil" jsaction="mousedown:irc.rl;keydown:irc.rlk;irc.il;" style="border-image: none; border: 0px currentColor; clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img height="127" id="irc_mi" src="https://lh3.googleusercontent.com/-SJiEDt0o2dE/VTe3ITz_A1I/AAAAAAAAFxw/0N0WDCupcYA/w500-h200/tumblr_msbe5jvObZ1rf3wd1o1_500.gif" style="margin-top: 101px;" unselectable="on" width="320" /></a><br />
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 <em>potential</em>.<br />
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<strong><em>"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." </em>Imre Lakatos</strong></blockquote>
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<strong><em>Queensbury rules</em></strong><br />
All core beliefs have some acceptable <em>protection</em>, 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 <em><strong>rotten cherry picking</strong> </em>which emereged in the comments of the <em>Find the Gap </em>blog. Professor Bentall argues that as researchers can <em>cherry pick </em>analyses (if they dont register those analyses), critics can <em>rotten cherry pick </em>their criticisms, focusing on things that he declares... <em>suit their negative agenda</em>. 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 <a href="http://saraheknowles.wordpress.com/2014/02/14/find-the-gap/#comment-100" target="_blank">commented</a> on this idea in the <em>Find the Gap</em> post. <strong>Needless to say, in science as in boxing, you cannot be both a participant and the referee!</strong><br />
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=KkJ4FXcxzcvprM&tbnid=Lo-09uYGyV-0IM:&ved=0CAUQjRw&url=http%3A%2F%2Fiamreadyforafall.blogspot.com%2F&ei=f3UHU86DPOGR1AWQt4GIDA&bvm=bv.61725948,d.ZGU&psig=AFQjCNE6V-jnfCkqaBOrj1-oeZ1jQFelZA&ust=1393083932364108" id="irc_mil" style="border: 0px currentColor;"><img class="irc_mut" src="http://image.toutlecine.com/photos/z/o/o/zoo-1985-03-g.jpg" height="237" id="irc_mi" style="margin-top: 0px;" width="400" /></a></div>
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<strong><em>Spectator sport </em></strong><br />
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 <em>Alice in Wonderland</em>, not everyone is a 'winner', but then even the apparent <em>losers </em>often never disappear....thus is the farcial arts.<br />
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<span style="font-family: inherit;">When I critiqued Morrison et als <a href="http://keithsneuroblog.blogspot.co.uk/2012/11/cbt-shes-lost-controls-again.html" target="_blank">exploratory CBT trial with people who stop taking anti-psychotic medication</a>, I promised to write a post on the final study </span><br />
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<span style="font-family: inherit;">Well it appeared in the </span><span style="font-family: inherit;">Lancet</span><span style="font-family: inherit;"> today and a free copy is <a href="http://download.thelancet.com/flatcontentassets/pdfs/S0140673613622461.pdf" target="_blank">here</a>. I am not going to describe the study in detail as it is excellently covered in the </span><a href="http://www.thementalelf.net/treatment-and-prevention/medicines/antipsychotics/pilot-study-suggests-that-cbt-may-be-a-viable-alternative-to-antipsychotics-for-people-with-schizophrenia-or-does-it/" target="_blank"><span style="font-family: inherit;">Mental Elf blog </span></a><span style="font-family: inherit;">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 </span><span style="font-family: inherit;">here to concentrate on the primary outcome data - symptom change scores on the PANSS.</span><br />
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<strong>'Soon' by My Bloody Valentine (Andy Weatherall mix)</strong></div>
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<span style="font-family: inherit;">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 <strong>unusual...</strong>in an important manner that will become clear below)</span><br />
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<span style="font-family: inherit;">What do the primary outcome PANSS scores (total, positive and negative symptoms) reveal?</span><br />
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<strong><span style="font-family: inherit;">Table 1. PANSS scores during the intervention (up to 9 months) and follow ups to 18 months</span></strong><span style="font-family: inherit;"> </span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-7F1YzYtReB3wwp7UBZORyUV7pc-LcFP4rYGOhrKd0QlJ-kH8hWifsCuNUNeIHuc_-qsUxQqUpx0Ysdgk8QstFnUELEc4OU9mDhZBTmjUYJzc3rKxHTAJVT-tXAncRZ0TnIPvYHWUCEA/s1600/PANSStrial.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-7F1YzYtReB3wwp7UBZORyUV7pc-LcFP4rYGOhrKd0QlJ-kH8hWifsCuNUNeIHuc_-qsUxQqUpx0Ysdgk8QstFnUELEc4OU9mDhZBTmjUYJzc3rKxHTAJVT-tXAncRZ0TnIPvYHWUCEA/s1600/PANSStrial.jpg" height="140" width="640" /></span></a></div>
<span style="font-family: inherit;"> </span><br />
<span style="font-family: inherit;"><span style="font-family: inherit;">The key questions are: </span><br />
<span style="font-family: inherit;">Do the CBT and TAU groups differ in PANSS scores at the end of the intervention (9 months) and </span><span style="font-family: inherit;">at the end of the study (18 months)? </span><span style="font-family: inherit;">One simple way to address both questions is to calculate the Effect Sizes at 9 months and at 18 months. </span><br />
</span><br />
<strong><span style="font-family: inherit;">9 months</span></strong><br />
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<strong><span style="font-family: inherit;">PANSS total = -0.37 (95 CI -0.96 to 0.22)</span></strong></div>
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<strong><span style="font-family: inherit;">PANSS positive = -0.18 (95 CI -0.77 to 0.40)</span></strong></div>
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<strong><span style="font-family: inherit;">PANSS negative = -0.45 (95 CI -1.04 to 0.14)</span></strong></div>
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<span style="font-family: inherit;"> </span></div>
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Examination of effect sizes at the end of the intervention (9 months) reveals that <strong>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)</strong></div>
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<span style="font-family: inherit;"> </span></div>
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<strong><span style="font-family: inherit;">18 months</span></strong><br />
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<span style="font-family: inherit;">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</span></div>
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<strong><span style="font-family: inherit;"></span></strong> </div>
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<strong><span style="font-family: inherit;">18 months</span></strong></div>
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<strong><span style="font-family: inherit;">PANSS total = -0.75 (95 CI -1.44 to -0.05)</span></strong></div>
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<strong><span style="font-family: inherit;">PANSS positive = -0.61 (95 CI -1.27 to 0.05)</span></strong></div>
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<strong><span style="font-family: inherit;">PANSS negative = -0.45 (95 CI -1.47 to -0.08)</span></strong></div>
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">A closer inspection of the means shows that the significant differences at 18 months almost certainly reflects an <strong>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)</strong></span><br />
<strong><span style="font-family: inherit;"></span></strong><br />
<strong><span style="font-family: inherit;"></span></strong><br />
<span style="font-family: inherit;"><strong>My final and crucial point concerns within group symptom reduction</strong></span><br />
<span style="font-family: inherit;">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)</span><br />
<span style="font-family: inherit;"> </span><br />
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<strong><span style="font-family: inherit;">Table 2. PANSS scores at baseline</span></strong></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSzhKH9IJZXgOcBW1CQVQW8NNhSb46S4F1Mt8gGK5huBHofNnfUer9o_0hKL252PWhQsI83KAf_41ZKCFn33C-iFeRsGPB8JI-RG1Tu2kNPPmpd0MNHAIqV_j8_uS9gsiyuf4QHcQQDZo/s1600/Panssbaseline.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSzhKH9IJZXgOcBW1CQVQW8NNhSb46S4F1Mt8gGK5huBHofNnfUer9o_0hKL252PWhQsI83KAf_41ZKCFn33C-iFeRsGPB8JI-RG1Tu2kNPPmpd0MNHAIqV_j8_uS9gsiyuf4QHcQQDZo/s1600/Panssbaseline.png" height="217" width="400" /></span></a></div>
<span style="font-family: inherit;"> </span><br />
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If we compare baseline and the end of the intervention 9 months:<br />
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<strong>PANSS total</strong><br />
CBT group show a reduction from 70.24 to 57.95 =<strong>12.29 </strong><br />
TAU group show a reduction from 73.27 to 63.26 =<strong>10.01</strong><br />
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<strong>PANSS positive</strong><br />
CBT group show a reduction from 20.30 to 16.0 =<strong>4.30 </strong><br />
TAU group show a reduction from 21.65 to 17.0 = <strong>4.65</strong><br />
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<strong>PANSS negative</strong><br />
CBT group show a reduction from 13.54 to 12.50 = <strong>1.04 </strong><br />
TAU group show a reduction from 15.49 to 14.26 = <strong>1.23</strong><br />
<span style="font-family: inherit;"></span><br />
<strong><span style="font-family: inherit;">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 !</span></strong><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;"><strong>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) - </strong>no significant difference exists between TAU reduction at 9 months and CBT reduction at 9 or 18 months</span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;"><strong>What then have Morrison et al shown? </strong></span><br />
<span style="font-family: inherit;">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 <strong>as large as the changes seen in the CBT group</strong>. Hence, it is reasonable to ask...<strong>have Morrison et al simply documented 'normal fluctuation' in the symptomatology of unmedicated patients ...and nothing to do with CBT</strong></span>Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com3tag:blogger.com,1999:blog-7082878015421475244.post-75204922488828911192014-01-29T07:21:00.001-08:002014-01-29T07:21:07.406-08:00Blinded by Science<br />
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<em>"The New Year starts with a test of an established tenet of treatment in schizophrenia." </em></div>
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<a href="http://bjp.rcpsych.org/content/204/1/A3.full" target="_blank">British Journal of Psychiatry 'Highlights' January 2014</a></div>
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Its not often that we hear such phrases, but thus opens the 'highlights' section of the latest edition of the <em>British Journal of Psychiatry</em>, referring to our new meta-analysis examining <a href="http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy" target="_blank">Cognitive Behaviour Therapy</a> (CBT) for the symptoms of Schizophrenia. This is the most comprehensive analysis ever undertaken, covering 50 <a href="http://en.wikipedia.org/wiki/Randomized_controlled_trial" target="_blank">Randomised Controlled Trials</a> (RCTs) of this 'talk therapy' published over the past 20 years. The paper received <a href="http://www.bbc.co.uk/news/health-25574773" target="_blank">press coverage </a>and is, of course available for subscribers at the <a href="http://bjp.rcpsych.org/content/204/1/20" target="_blank">British Journal of Psychiatry</a>, but I would like to give an overview for the interested lay reader, service-users or anyone who cannot access the journal.<br />
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<strong><em>Forbidden Colours</em> (Sakamoto & Sylvian)</strong><br />
<em>I’ll go walking in circles<br />While doubting the very ground beneath me<br />Trying to show unquestioning faith in everything</em><br />
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Looking at all trials regardless of quality, the paper reveals a <a href="http://www.tea.state.tx.us/Best_Practice_Standards/How_To_Interpret_Effect_Sizes.aspx" target="_blank">small effect </a>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: <strong>82% and 90% of the CBT and control groups overlapped on positive and negative symptoms respectively. </strong><br />
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<strong>But this is not the end of the story...</strong><br />
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<strong><em>Study Quality</em></strong><br />
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 <strong>7 times larger in nonblind than blind studies</strong>. And if <strong>you assess effect size in <em>blind</em> studies, the small effects totally disappear (see Table 1)</strong>. 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, <strong>at the end of trials 94% and 97% of the CBT and control groups overlap on positive and negative symptoms respectively</strong><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBOVqln_QxPj7-sgfpGtZ_2ax6Za6tgSMefwb1Q7_Vn7zC6IZMmLpTJ-iLTM5eacIXfcbcZxKHN41xiHU5t3MoyMcXbwMQY5q63GmgzjpmjfAGl1Qkg65aqnJRx8_g_Y-GZ1dxJqk7baY/s1600/blindBJP.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBOVqln_QxPj7-sgfpGtZ_2ax6Za6tgSMefwb1Q7_Vn7zC6IZMmLpTJ-iLTM5eacIXfcbcZxKHN41xiHU5t3MoyMcXbwMQY5q63GmgzjpmjfAGl1Qkg65aqnJRx8_g_Y-GZ1dxJqk7baY/s1600/blindBJP.jpg" height="137" width="640" /></a></div>
<strong>Table 1. Comparison of effect sizes for blind (high risk) vs nonblind (low risk) studies</strong><br />
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<strong><em>Soft</em> by Lemon Jelly (with added "<em>If you leave me now</em>" by Chicago)</strong></div>
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<strong><em>Whats happening in individual studies: Forest Plots</em></strong><br />
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% <a href="http://www.measuringusability.com/blog/ci-10things.php" target="_blank">confidence intervals </a>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 ... <strong>Do the 95% CIs in any study cross zero? </strong>If they do, then the trial revealed a nonsignificant effect of CBT on symptoms. <br />
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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.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmfOd36H7xpTN-_ZWby-a1-Ccy1E8Dun9fkMfs6yyjJqkPv6MzmUscD1BLFLM5vlKBF8m34auWjyLy3dFWsciF2n6_PISehF3ooaa1aBFtumU4qONna_TyPGRM_y5uiAiskosFZXPHHvQ/s1600/positivesympts.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmfOd36H7xpTN-_ZWby-a1-Ccy1E8Dun9fkMfs6yyjJqkPv6MzmUscD1BLFLM5vlKBF8m34auWjyLy3dFWsciF2n6_PISehF3ooaa1aBFtumU4qONna_TyPGRM_y5uiAiskosFZXPHHvQ/s1600/positivesympts.jpg" height="452" width="640" /></a></div>
<strong>Figure 1. Forest plot of 33 studies examining the impact of CBT on positive symptoms </strong><br />
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The picture for <strong>hallucinations </strong>is bleaker...<em>with only 4 significant studies ever published </em><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3qEjdnMGN7JK7bBoh4DLEHioRhYRO_GOIxqxJAh-i53KOsz6ocfbHa0GnqU-AKmkqhX1_XperhTi_H68W5I9PCeek3bM1DjWtBBoCU7aF6EzqIsrZMWmOSdXRwYYpe_GRVvIjdij80Mc/s1600/Hallucinations.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj3qEjdnMGN7JK7bBoh4DLEHioRhYRO_GOIxqxJAh-i53KOsz6ocfbHa0GnqU-AKmkqhX1_XperhTi_H68W5I9PCeek3bM1DjWtBBoCU7aF6EzqIsrZMWmOSdXRwYYpe_GRVvIjdij80Mc/s1600/Hallucinations.jpg" height="387" width="640" /></a></div>
<strong>Figure 2 CBT for Hallucinations</strong><br />
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And if it could be worse...it is for negative symptoms ...with no significant study since 2003<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizmgcC-gXU9nm7wzBYoQE1H3vGkbk6if8WG1ySXhP-OLqde1xjVUCvQpO1BgTN01MwYrsS2N-xh_5UgM7aBSJ13ZmsyRFyNU8NinL3Z6csmZ7rRi7sRR6sbgxaLW72O0HGs0-n5cKY3tk/s1600/negativesymps.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizmgcC-gXU9nm7wzBYoQE1H3vGkbk6if8WG1ySXhP-OLqde1xjVUCvQpO1BgTN01MwYrsS2N-xh_5UgM7aBSJ13ZmsyRFyNU8NinL3Z6csmZ7rRi7sRR6sbgxaLW72O0HGs0-n5cKY3tk/s1600/negativesymps.jpg" height="502" width="640" /></a></div>
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A few key take-home observations from the forest plots:<br />
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Positive symptoms - 25 of 33 (76%) studies are nonsignficant </div>
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Negative symptoms - 30 of 34 (88%) studies are nonsignificant </div>
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Hallucinations - 11 of 15 (73%) studies are nonsignificant </div>
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<strong>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: </strong><a href="http://www.cbtinschizophrenia.com/"><strong>http://www.cbtinschizophrenia.com/</strong></a><br />
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<strong><em>You Cut Her Hair</em> by Tom McRae </strong></div>
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<strong>Symptoms or Distress?</strong> <br />
One response to me about our paper, from some UK clinical psychologists, has been to say that ...they use CBT <strong>not to reduce the symptoms of psychosis, but to reduce the 'distress'</strong>. In the context of the clinical guidance provided to UK clinicians by the National Institute of Clinical Excellence (<a href="http://guidance.nice.org.uk/CG82/QuickRefGuide/pdf/English" target="_blank">NICE), </a>this response raises interesting questions about the relationship between <strong>science and practice</strong>.<br />
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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 <a href="http://www.nice.org.uk/nicemedia/live/11786/43607/43607.pdf" target="_blank">National Collaborating Centre for Mental Health (NCCMH)</a>, in which all of the data examined relates to RCTs aimed at <strong>symptom reduction....and not distress</strong><br />
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This is perhaps exemplified by the following paragraph from the NICE guide <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdiSSyRJMZK2szi13aRzKHbKAUyD1QWH2A385w-quKThARWtebHvZ925fuKad94MWtTRE2EeboJusm9r2nDoivWozJBbCLkG_jOBAiFeoLnhWd_RiLZd2_CJtTwUIIA81TPRXJUm_bUps/s1600/dsitress2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdiSSyRJMZK2szi13aRzKHbKAUyD1QWH2A385w-quKThARWtebHvZ925fuKad94MWtTRE2EeboJusm9r2nDoivWozJBbCLkG_jOBAiFeoLnhWd_RiLZd2_CJtTwUIIA81TPRXJUm_bUps/s1600/dsitress2.jpg" height="292" width="640" /></a></div>
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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 <strong>unevidenced or off-label use of CBT</strong>. Third, and crucially, the evidence does <strong>not </strong>suggest that CBT reduces distress. For example, they refer to Trower et al 2004 as an example - actually, <strong>the study shows no benefit of CBT for distress </strong>after one year. <br />
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Additionally, I would question the reference to CBT improving 'function' - the meta analysis in 2008 by <a href="http://schizophreniabulletin.oxfordjournals.org/content/34/3/523.full" target="_blank">Wykes et al</a> 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 <a href="http://bjp.rcpsych.org/content/193/4/344.3" target="_blank">re-analysis </a>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<br />
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<strong><em>Hærra </em>by Ásgeir Trausti </strong></div>
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These findings create a challenge for the guidance provided by Government organisations (in the UK, this is <a href="http://www.nice.org.uk/newsroom/news/PatientsWithPsychosisShouldBeOfferedTherapy.jsp" target="_blank">NICE</a>) who advocate that "<strong>CBT be offered to all people with for schizophrenia</strong>". <br />
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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!Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-6418081976842164282013-12-17T13:39:00.001-08:002013-12-17T13:39:35.079-08:00Are Friends Electric - A Whig History of the Human Mind?<br />
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<em>Asylums with doors open wide,<br />Where people had paid to see inside,<br />For entertainment they watch his body twist<br />Behind his eyes he says, ’I still exist.’</em><br />
<strong>Atrocity Exhibition (Joy Division)</strong></div>
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<em>“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.”</em><em> </em></div>
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― <strong>The Atrocity Exhibition </strong><strong>J.G. Ballard</strong><br />
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I was invited by the BBC Radio 3 culture & arts programme <em>NightWaves </em>to review a new exhibition of 'Psychology' hosted at the <em>Science Museum </em>- entitled "<a href="http://www.sciencemuseum.org.uk/visitmuseum/Plan_your_visit/exhibitions/mind_maps/object_highlights.aspx" target="_blank"><em>Mind Maps: Stories from Psychology</em>"</a><br />
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Here I discuss the exhibition on <a href="http://www.bbc.co.uk/iplayer/episode/b03kpb68/Night_Waves_Mind_Maps_Freud_Psychotherapy_Partition/" target="_blank">Radio 3 NightWaves </a>with presenter Philip Dodd and various guests<br />
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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 <em>Science</em> <em>Museum</em> of London and sponsored by the <em>British Psychological Society </em>are not trivial contextual features.<br />
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<em>Mind Maps </em>sets out its stall in this description at the entrance<br />
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"[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."</blockquote>
Arguably <em>Psychology </em>as a discipline did not arrive until 100 years later with the advent of Wilhelm Wundt's lab in Leipzig. What we classify as <em>Psychology </em>in this exhibition and generally is an interesting question<br />
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<strong>Dead Can Dance (the Arrival & the Reunion)</strong></div>
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The introduction frames the exhibition within a context of creating narratives ....of scientists, doctors '<em>but also patients and the general public'. </em>While it does create narratives about the scientists, the patients are absent. This is not a criticism by any means ...since the S<em>cience </em>of Psychology is arguably...<em>not </em>principally in the business of <em>creating narratives </em>about people, unwell or otherwise.<br />
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The exhibition is less about developing views of the mind than developing <em>technologies </em>that themselves shape our view of the mind and ultimately, are used to <em>treat</em> 'broken minds'. The technology is sometimes beautiful, sometimes atrocious, and most intriguing when both<em>. </em>Parts of <em>Mind Maps </em>reminded me of visiting <em>Gunther von Hagens' </em><a href="http://www.theguardian.com/education/2002/mar/19/arts.highereducation" target="_blank">Body Works </a>exhibition in London over 10 years previously - where corpses were displayed or splayed ...so dehumanised that I viewed them as grotesque man-made artefacts.<br />
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Entering <em>Mind Maps</em>, we are confronted with a <em>slice </em>of human history - a human nervous system <em>extracted</em> from a 17th Century Italian criminal and varnished onto a table <br />
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<em><strong>Padua Man </strong></em></div>
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<em>The advanced societies of the future will not be governed by reason. They will be driven by irrationality, by competing systems of psychopathology </em><strong>J G Ballard</strong></div>
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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 <a href="http://en.wikipedia.org/wiki/Whig_history" target="_blank"><em>Whig History of the Mind</em></a>. The exhibition informs us "Our understanding of the way our nerves relate to our thoughts, behaviour and mental health <em>has changed dramatically over the last 250 years</em>" But ...has our <em>understanding </em>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. </div>
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Once we leave the varnished nerve-man, we enter <em>Medical Electricity, </em>the home of <a href="http://en.wikipedia.org/wiki/John_Wesley" target="_blank">Reverend John Wesley</a>, <a href="http://en.wikipedia.org/wiki/Luigi_Galvani" target="_blank">Luigi Galvani</a>...and the obvious cultural links to Mary Shelley's Frankenstein. <em>Electricity </em>is a trope throughout the exhibition<em>. </em> <br />
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<strong>18th Century Electric Therapy </strong> </div>
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In the <em>'Medical Electricity' </em>section<em> </em>we see this painting above. As shown, medical electricity was administered in a <em>therapeutic context - t</em>he <em>therapist (electrician?) </em>stimulates the woman's head, in her home, where she is surrounded by family members - therapy as a <em>drama</em>! </div>
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<strong>Tubeway Army - Are Friends Electric, I hate to ask, but mine has broke down</strong></div>
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While this wonderful painting is of its time, this start of the exhibition echoes its denouement, which features <a href="http://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation" target="_blank">Transcranial Magnetic Stimulation (tMS)</a>. It is comforting to assume that the <em>technology </em>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? </div>
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Undoubtedly these early forms of electric therapy -if beneficial - derived their <em>benefit </em>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).</div>
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<strong>D'Arsonval Cage </strong></div>
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The electrical current continues through the work of Galvani, animating the dead legs of frogs, <a href="http://collectmedicalantiques.com/gallery/alternating-current" target="_blank">D'Arsonval cages</a> 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 <a href="http://en.wikipedia.org/wiki/William_Grey_Walter" target="_blank">William Walter Grey </a>(whose stroboscope stimulation work influenced the artist Brion Gysin to develop his <em><a href="http://keithsneuroblog.blogspot.co.uk/2013/04/the-dream-machine-cut-ups-cut-ins-cut.html" target="_blank">Dream Machine</a></em>, which I spoke about in a previous post)</div>
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<strong>The Electrotherapy Couch (note the metal handles) </strong></div>
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<strong>-if only Freud had one</strong></div>
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Despite some psychological angles, we might question whether (m)any of these 'interventions' occurred <em>under the watch </em>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 - <em>breathing life into the dead and death into the living</em>. Although the exhibition doesn't mention other new methods like deep brain stimulation, it could be argued that the <em>general approach </em>has not changed that dramatically in 250 years<br />
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<strong>Harmonia (1976..with Brian Eno) - Almost</strong></div>
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The finale of <em>Mind Maps </em>is more evidently <em>psychological</em> in the form of <em>Cognitive Behavioural Therapy</em>, alongside <em>Avatar Therapy </em>and the so-called <em>Communicube and Communiwell</em>. 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? <br />
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<strong>Julian Leff's <em>Avatar Therapy </em>for those who 'hear voices'</strong></div>
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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) <a href="http://commonsenseatheism.com/wp-content/uploads/2011/01/Lilienfeld-Psychological-Treatments-That-Cause-Harm.pdf" target="_blank">Psychological Treatments that Cause Harm</a>; Linden's (2012) <a href="http://onlinelibrary.wiley.com/doi/10.1002/cpp.1765/abstract" target="_blank">How to Define, Find and Classify Side Effects in Psychotherapy: From Unwanted Events to Adverse Treatment Reactions</a>; David Nutt's (2008) <a href="http://ts-si.org/files/UncriticalPositiveRegard.pdf" target="_blank">Uncritical Positive Regard: Issues in the Efficacy and Safety of Psychotherapy</a>; and dating back to Bergin (1963) <a href="http://psycnet.apa.org/journals/cou/10/3/244.pdf" target="_blank">The effects of Psychotherapy: Negative Results Revisited</a>. - What would we expect from a therapy that 'invades the mind'?<em> </em><br />
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<strong>The Communicube</strong></div>
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Aside form CBT, the <a href="http://www.communicube.co.uk/" target="_blank">Communicube</a> 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 <em>one </em>trial in the <a href="http://bjp.rcpsych.org/content/early/2013/02/11/bjp.bp.112.124883.abstract" target="_blank">British Journal of Psychiatry.</a> The study, which shows that creating and interacting with avatars may reduce auditory hallucinations, received significant press attention. Nonetheless, it is <em>one </em>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<br />
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<em>“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.” </em></div>
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<strong>H P Lovecraft</strong></div>
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<span style="font-size: x-small;">The various instagram pictures were taken at the Exhibition preview - thanks to my lovely wife for parting temporarily with her I-Phone for science!</span><br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-38151323846563678862013-09-04T12:18:00.000-07:002016-02-20T10:24:03.367-08:00No Journey's End <div class="separator" style="clear: both; margin-left: 1em; margin-right: 1em; text-align: center;">
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<span class="bqQuoteLink"><em>At any street corner the feeling of absurdity can strike any man in the face</em></span><br />
<strong>Albert Camus</strong></div>
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<em>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.</em></div>
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<strong>Albert Camus</strong><br />
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<a href="http://i191.photobucket.com/albums/z43/sevenarts/cinema/punchandjudy.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" border="0" closure_uid_690493550="11" src="http://i191.photobucket.com/albums/z43/sevenarts/cinema/punchandjudy.jpg" height="150" style="display: block; margin-top: 0px; text-align: center;" width="200" /></a>Street entertainment at Covent Garden, London was noted as far back as May 1662 in <a href="http://en.wikipedia.org/wiki/Samuel_Pepys" title="Samuel Pepys">Samuel Pepys</a>'s diary, when he recorded the first mention of a <a href="http://en.wikipedia.org/wiki/Punch_and_Judy" title="Punch and Judy">Punch and Judy</a> 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.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-4gMUtmno4TFuGvNiPR_ezP6w3Z4krfo5Z4kJVeiIevLP6owSNkXhFLiceEeZZ-izEjHrlId_irqAR2aCIFUyKk0RRPgRIGkY4f3TfLbV8nYBqMTcG1xEIePvQ1DfTcvC1yqCsZCj5Ao/s1600/cgarden.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-4gMUtmno4TFuGvNiPR_ezP6w3Z4krfo5Z4kJVeiIevLP6owSNkXhFLiceEeZZ-izEjHrlId_irqAR2aCIFUyKk0RRPgRIGkY4f3TfLbV8nYBqMTcG1xEIePvQ1DfTcvC1yqCsZCj5Ao/s320/cgarden.jpg" width="320" /></a><br />
<strong><em>Covent Garden - looking toward the defunct market</em></strong></div>
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In the late 70s, Covent Garden was home to the original <em>Punks </em>and shortly after, to the <em>New Romantics </em>inside the unassuming 'shop fronts' of the <em>Roxy</em> and <em>Blitz clubs </em>respectively. Less well-know perhaps, but with much more personal resonance for me (which I may return to in a later blog), the <em>Rock Garden </em>played home to many great <em>indie </em>bands in the late 70s/early 80s; while the <em>Africa Centre </em>also hosted some great music in its ironic colonial-style hall. <br />
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<strong><em>Covent Garden Doorways into a Twilight Zone?</em></strong></div>
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Before the London Underground and Local Governments <em>franchised </em>busking, before you needed a licence, insurance or to pass an audition before being allowed to <em>entertain </em>in Covent Garden ...anyone could <em>perform </em>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 <em>The Covent Garden Seal Of Quality</em>. I'm sorry, you have failed."<br />
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One who possibly redefined the <em>Covent Garden Seal of Quality</em>, but who has been unforgivably <em>lost in time...</em>was <em>Michael O’Shea</em>. I remember exiting the darkness of Covent Garden Underground and being drawn to the 'other-worldly' sounds<em> </em>emanating from this individual. O'Shea was improvising on - and hunched over - what I learned was his home-made musical instrument - the <em>Mo Cara </em>(Gaelic for <em>'My friend</em>'). 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 <br />
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<strong><em>Voices by Michael O'Shea</em></strong></div>
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On the sleeve of his eponymous and only recorded output, Michael O'Shea describes the <em>Mo Cara </em>inspired by:<br />
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"..Algerian musician <em>Kris Hosylan Harpo</em>, who accompanied me on his <em>'zelochord' </em>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. <em>The first Mo Cara was born, taken from the middle of a door, which was rescued from a skip in Munchen" </em></div>
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Returning to the UK in 1979, the Mo Cara Mark II was born when </div>
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"...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"</div>
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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. </div>
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<span itemprop="author"><a href="http://www.angiemuldowney.co.uk/wp-content/uploads/2012/10/clive-boursnell-covent-garden-3.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="clive boursnell - covent garden 3" border="0" class="alignnone size-full wp-image-7416" src="http://www.angiemuldowney.co.uk/wp-content/uploads/2012/10/clive-boursnell-covent-garden-3.jpg" height="200" title="clive boursnell - covent garden 3" width="200" /></a><a href="http://www.angiemuldowney.co.uk/wp-content/uploads/2012/10/clive-boursnell-covent-garden-1.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="clive boursnell - covent garden 1" border="0" class="alignnone size-full wp-image-7414" src="http://www.angiemuldowney.co.uk/wp-content/uploads/2012/10/clive-boursnell-covent-garden-1.jpg" height="200" title="clive boursnell - covent garden 1" width="197" /></a><em>Old Souls of Covent Garden</em></span></div>
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<span itemprop="author">Photos by Clive Boursnell</span><br />
<span itemprop="author"><span id="btAsinTitle"><a href="http://www.amazon.co.uk/Covent-Garden-Vegetable-Flower-Markets/dp/0711228604/ref=sr_1_1?s=books&ie=UTF8&qid=1377626325&sr=1-1" target="_blank">Covent Garden: The Fruit, Vegetable and Flower Markets: Images from Fruit, Vegetable and Flower Markets </a></span></span><br />
<span itemprop="author">by Peter Ackroyd & Clive Boursnell </span><br />
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I have garnered a few biographic details from his album cover and other sources. Michael Oliver O'Shea was born in Newry, Northern Ireland in 1947, but grew up just across the border in Carlingford, Co. Louth in the Irish Republic. he left school to join the British Army aged 17 - a short-lived relationship that ended when he went AWOL for two years, was court-martialed and subsequently jailed. Further biographic details are taken here from <em>Wilson Neate </em>at <em>AllMusic</em>:</div>
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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 <a href="http://www.allmusic.com/artist/ronnie-scott-mn0000332807">Ronnie Scott</a>, who was fascinated by the Mo Cara's mix of East Asian, South Asian, and Irish sounds. <a href="http://www.allmusic.com/artist/scott-mn0000332807">Scott</a> offered the Irishman a residency in his club's prestigious Downstairs Room and became his agent. This led to his opening for <a href="http://www.allmusic.com/artist/ravi-shankar-mn0000404463">Ravi Shankar</a> at the Royal Festival Hall and he even played on a <a href="http://www.allmusic.com/artist/rick-wakeman-mn0000300245">Rick Wakeman</a> project, although his contribution was subsequently discarded. Despite encouraging signs, O'Shea's career did not take off and he returned to busking."</blockquote>
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While playing in Covent Garden, a friend of mine <a href="http://www.cartoons.ac.uk/artists/tomjohnston/biography" target="_blank">Tom Johnston </a>(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 - <a href="https://en.wikipedia.org/wiki/Bruce_Gilbert" target="_blank">Bruce Gilbert</a> and <a href="https://en.wikipedia.org/wiki/Graham_Lewis" target="_blank">Graham Lewis</a> of the group <a href="https://en.wikipedia.org/wiki/Wire_(band)" target="_blank">Wire</a>. Enraptured by his unique sound, they asked O'Shea to record for their newly formed <em>Dome </em>record label. Following the dissolution of Wire, Lewis and Gilbert started <em>Dome, </em>with the explicit goal of exploring “<em>...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)</em></div>
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=w0S1MyK0_ySq5M&tbnid=wxJs0N2LnMjvgM:&ved=0CAUQjRw&url=http%3A%2F%2Frevrock.blogspot.com%2F2010%2F02%2Foutdoor-minersthe-story-of-wireshow-286.html&ei=tncXUuHDDcH40gXknYG4BA&bvm=bv.51156542,d.d2k&psig=AFQjCNH8N-jT1W_J6kljdJqfysjjv7EWBw&ust=1377356035227678" id="irc_mil" style="border: 0px currentColor;"></a> </div>
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<strong><em>Wire: Graham Lewis</em>, Colin Newman, <em>Bruce Gilbert </em>& Robert Gotobed</strong></div>
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O'Shea was quite ambivalent about further forays into the music business<em> - </em>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 <em><a href="http://keithsneuroblog.blogspot.co.uk/2013/03/burning-blue-soul-history-repeats-itself.html" target="_blank">Burning Blue Soul </a></em>- which I previously blogged about) <br />
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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 <em>untitled </em>as <em>Dome 2</em>. </div>
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A little later 1982, O'Shea worked with Tom Johnston and Matt Johnson (<em>The The</em>) on a projected album, but sadly nothing came of it. </div>
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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<br />
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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, <a href="http://www.youtube.com/watch?v=YD1HHFT4_AE"><strong>No Journey's End </strong></a>- it is said that those present at the recording were <em>'reduced to tears by its unearthly beauty'</em></div>
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=w0S1MyK0_ySq5M&tbnid=wxJs0N2LnMjvgM:&ved=0CAUQjRw&url=http%3A%2F%2Frevrock.blogspot.com%2F2010%2F02%2Foutdoor-minersthe-story-of-wireshow-286.html&ei=tncXUuHDDcH40gXknYG4BA&bvm=bv.51156542,d.d2k&psig=AFQjCNH8N-jT1W_J6kljdJqfysjjv7EWBw&ust=1377356035227678" id="irc_mil" style="border: 0px currentColor;"></a><br />
<a href="https://www.youtube.com/watch?v=YD1HHFT4_AE" target="_blank"><img src="http://uzine.files.wordpress.com/2010/06/fac9e-media_http1bpblogspot_vmhbe-scaled500.jpg?w=320&h=320" height="200" width="200" /></a><br />
<em><strong>No Journeys End</strong></em><br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com4tag:blogger.com,1999:blog-7082878015421475244.post-42220224568511417262013-08-10T10:42:00.001-07:002015-10-05T04:26:37.420-07:00No Thyself (or Another Green World)<span style="font-family: inherit;"></span><br />
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<strong><a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=H_DCYsJoBBQa7M&tbnid=pziCw9YTJE_WpM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.tomgold.co.uk%2Fblog%2F&ei=AnK8Uf34F-fL0AXmjIGQCw&bvm=bv.47883778,d.d2k&psig=AFQjCNEo9A3_7tcG17yo9WHu1V3AW7Adfw&ust=1371390646553413" id="irc_mil" style="border: 0px currentColor;"><span style="font-family: inherit;"></span></a></strong><br />
<strong><a href="http://en.wikipedia.org/wiki/Stanley_Green" target="_blank">Stanley Green</a></strong><br />
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<span style="font-family: inherit;"><em>I don't know whether I ever knew you<br />but I know you<br />I know you never knew me<br />I don't know<br />Do you want to? Do you want to? Do you want to...</em></span><br />
<strong>You Never Knew Me (by Magazine)</strong><br />
<span style="font-family: inherit;"><em></em><br /></span><a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=Yd0hbs65Q4DMiM&tbnid=vB5toE4nhmIY-M:&ved=0CAUQjRw&url=http%3A%2F%2Fgifsoup.com%2Fview%2F2304989%2Fneurons.html&ei=4njVUeKHDsed0QXlsoDwAQ&bvm=bv.48705608,d.d2k&psig=AFQjCNEoTRobz6lUM5x4LGmmqrMryv83sQ&ust=1373030986178768" id="irc_mil" style="border: 0px currentColor;"></a><span style="font-family: inherit;"> </span></div>
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Real Life</span></h4>
<em><strong>"I could've been Raskolnikov, but Mother Nature ripped me off"</strong></em><br />
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<span style="font-family: inherit;"><span style="font-family: inherit;">With his typical <em>boldism</em>, Professor Richard Bentall recently remarked on my blog:</span></span></div>
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</span><a href="http://keithsneuroblog.blogspot.co.uk/2013/04/the-dream-machine-cut-ups-cut-ins-cut.html" target="_blank"><span style="font-family: inherit;">"Whether or not you think that CBT is helpful to patients. I'm inclined to believe the patients on this issue"</span></a><span style="font-family: inherit;"> </span><br />
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<span style="font-family: inherit;">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.<em> </em>How could - or should - the user-voice (or 'lived experience') inform the <em>science</em> of clinical research and clinical interventions... or are those voices and experiences <em>in </em>but not <em>of</em> science ? </span></div>
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<em><span style="font-family: inherit;"><strong>My mind...It ain't so open<br />That anything...Could crawl right in</strong></span></em><br />
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<span style="font-family: inherit;">An over-riding <em>faith </em>in and <em>prioritising of </em>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)? </span><span style="font-family: inherit;">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 <a href="http://uhra.herts.ac.uk/xmlui/bitstream/handle/2299/5741/903449.pdf?sequence=3" target="_blank">evidence</a> states </span></div>
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<strong><span style="font-family: inherit;">Parade by Magazine </span></strong></div>
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<em><span style="font-family: inherit;">They will show me what I want to see<br />We will watch without grief<br />We stay one step ahead of relief</span></em><em><br /><span style="font-family: inherit;">....What on Earth... is the size of my life ?</span></em></div>
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Secondhand Daylight</h4>
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<span style="font-family: inherit;"><strong><em>I've got this bird's eye view and it's in my brain<br />Clarity has reared its ugly head again...so this is Real Life</em></strong></span><br />
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<span style="font-family: inherit;">The prioritising of service users also appears in the recent soi-disant </span><a href="http://dcp.bps.org.uk/document-download-area/document-download$.cfm?file_uuid=8ACC19EA-A3A4-638B-10F6-DE654D84EEC1&ext=pdf" target="_blank"><span style="font-family: inherit;">paradigm shift document</span></a><span style="font-family: inherit;"> from the British Psychological Society Division of Clinical Psychology: </span></div>
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<span style="font-family: inherit;"><em>"The needs of services users should be central to any system of classification</em>. 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" </span></blockquote>
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<span style="font-family: inherit;"><span style="font-family: inherit;">Again, of course, we are not told how any <em>system of classification </em>could be based on the diverse views of service-users. </span>This is a <em>should-based </em>position statement rather than an <em>evidence-based </em>science statement - in which service-users seemingly view descriptors of their problems as part of the '<em>cure' </em>or as the <em>problem.</em> Or more correctly, how some influential clinical psychologists view such labels as being part of the problem for service-users<em>....</em>everyone's view is 'entertained', but some are preferred.</span><br />
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The Correct Use of Soap</h4>
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<span style="font-family: inherit;"><strong><span style="font-family: inherit;">"<em><strong>I am angry I am ill and I'm as ugly as sin, my irritability keeps me alive and kicking"</strong></em></span></strong></span><br />
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</span><span style="font-family: inherit;">A related and interesting trend in some areas of clinical psychology is the increasing reliance on patient self-report as a complementary or even <em>only </em>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 </span><a href="https://en.wikipedia.org/wiki/Wilhelm_Wundt" target="_blank"><span style="font-family: inherit;">Wilhelm Wundt </span></a><br />
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<strong>Willhelm Wundt was here</strong></div>
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<em> "I am myself inclined to hold that man really thinks very little and very seldom" Wundt 1892</em></div>
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<span style="font-family: inherit;">When investigating clinical interventions, some researchers depend heavily on patient self-rating scales. </span><span style="font-family: inherit;">It wouldn't be overly surprising if <em>self </em>and <em>clinician </em>measures were discrepant or for researchers to (de)emphasise either measure according to their hypothesis. </span><br />
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<span style="font-family: inherit;">Indeed, I have previously alluded to the <em>clinician-self discrepancy</em>. For example, in my post (</span><a href="http://keithsneuroblog.blogspot.co.uk/2012/11/cbt-shes-lost-controls-again.html" target="_blank"><span style="font-family: inherit;">CBT: Shes Lost Controls Again</span></a><span style="font-family: inherit;">) 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 <strong>no recovery following CBT</strong>. 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.</span></div>
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<strong>You Never Knew Me (by Magazine)</strong></div>
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<em>....Do you want the truth </em></div>
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<em>or do you want your sanity?</em></div>
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<em>You were hell and everything else </em></div>
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<em>...was just a mess</em><br />
<em>I found I'd stepped into </em></div>
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<em>the deepest unhappiness</em><br />
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<em>...Hope doesn't serve me now</em><br />
<em>I don't move fast at all these days</em><br />
<em>You think you've understood</em><br />
<em>You're ignorant that way</em></div>
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<em>I'm sorry, I'm sorry, I'm sorry, I'm sorry</em><br />
<em>I can't be cancelled out like this</em></div>
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Magic, Murder & the Weather</h4>
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<strong><em>"Who are these madmen! what do they want from me!<br />with all of their straight-talk from their misery"</em></strong><br />
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<span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"></span></span></span></span> <span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">Largely unexamined, we studiously avoid asking questions like...who or what best captures 'depression'? The person rating their own experiences (on something like the <a href="http://en.wikipedia.org/wiki/Beck_Depression_Inventory" target="_blank">Beck Depression Inventory: BDI</a>) or a clinician assessing them from the outside with other scales? </span></span></span></span><br />
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<span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><strong>Definitive Gaze (by Magazine)</strong></span></span></span></div>
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<span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><em>I like watching you<br />but I don't watch what I'm doing<br />got better things to do<br />so this is Real Life....you're telling me</em></span></span></span></div>
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</span><span style="font-family: inherit;">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? </span><span style="font-family: inherit;"><a href="http://www.sciencedirect.com/science/article/pii/S0272735810000954" target="_blank"><span style="font-family: inherit;">Cuijpers et al 2010</span></a><span style="font-family: inherit;"> 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 "<em>clinician-rated instruments resulted in a <strong>significantly </strong>higher effect size than self-report instruments from the same studies</em>" </span></span><br />
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<span style="font-family: inherit;">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 <em>well!"</em>. </span><br />
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<span style="font-family: inherit;"><strong>Feed the Enemy by Magazine</strong></span></div>
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<span style="font-family: inherit;"><em> But they always seem to know<br />exactly what they're talking about<br />now they've got you in a corner<br />you've got no room to move<br />you've got no room for doubt<br />that's exactly what they're talking about</em></span></div>
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<span style="font-family: inherit;">Turning this around, what is the evidence that people with severe psychiatric problems can reliably assess their own experience?<strong> </strong>What happens if a core component of severe psychiatric disorders is that <em>insight</em> is compromised? I am not denying <em>insight </em>to those with severe psychiatric disorders ...rather, this is a question for <em>all of us </em>- who amongst us can accurately assess their mental states -nevermind a troubled mind? </span><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><a href="http://schizophreniabulletin.oxfordjournals.org/content/33/6/1324.full.pdf" target="_blank"><span style="font-family: inherit;">Studies indicate </span></a><span style="font-family: inherit;">that between 50 & 80% of those diagnosed with schizophrenia show <em><strong>partial</strong> </em>or even <strong><em>total</em> <em>lack of insight </em></strong>into the presence of their mental disorder per se (Insight being defined here as the awareness of having a mental disorder and its symptoms).</span></span></span></span></span><br />
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<span style="font-family: inherit;">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? </span><span style="font-family: inherit;">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?<br />
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No thyself</h4>
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<span style="font-family: inherit;"><strong><em>"Your furniture is made to injure me"</em></strong></span><br />
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<span style="font-family: inherit;">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 '<em>I feel better/cured/recovered' </em>... whatever these mean to the sufferer. This could be independent of ascertaining the veracity of this claim </span></div>
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<span style="font-family: inherit;">But should we refer to this as <em>science</em> or <em>evidence-based? </em>Perhaps this is where some clinical psychologists are destined - outside, beyond normal science - maybe we should call it <em>outre science</em> </span><br />
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<span style="font-family: inherit;">Do you <em>no thyself?</em></span></div>
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<span style="font-size: x-small;"><strong>Postscript: </strong>Stanley Green was a wonderfully eccentric character (the <em>Protein man</em>) from my early teenage working life around Soho in the late 70s. In my book, anyone with such <em>dedication </em>deserves to be remembered...I have of course stuck to his dietry advice ever since!</span></div>
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<br />Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com5tag:blogger.com,1999:blog-7082878015421475244.post-61803768859141965852013-06-10T12:49:00.002-07:002013-06-10T13:02:12.920-07:00Fear of Science<div align="center">
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<em>Drugs won't change you<br />Religion won't change you</em><br />
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<em>Science won't change you<br />Looks like I can't change you<br />I try to talk to you, to make things clear<br />but you're not even listening to me...</em><br />
<strong>Mind (Talking Heads)</strong></div>
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This is a supplement to my <a href="http://keithsneuroblog.blogspot.co.uk/2013/05/clinical-psychology-anti-or-ante-science.html" target="_blank">'Clinical Psychology is Anti- or Ante- Science?</a>' post and addresses comments made by Dr Lucy Johnstone regarding the <em>British Psychological Society (BPS) Division of Clinical Psychologists (DCP) </em>'<a href="http://dcp.bps.org.uk/dcp/the_dcp/news/dcp-position-statement-on-classification.cfm" target="_blank">Paradigm Shift' </a>document. Johnstone was the chief architect of the document and the main spokesperson on that document in the media.</div>
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<strong>There's no <em>'f'</em> in <em>paradigm shift</em></strong></div>
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<strong>1) Is the plan to replace diagnosis (with formulation)?</strong><br />
Re the position of the DCP in the '<a href="http://dcp.bps.org.uk/dcp/the_dcp/news/dcp-position-statement-on-classification.cfm" target="_blank">Paradigm Shift' </a>document and whether it represents is <em>a call for <strong>replacing </strong>diagnosis or not? </em><br />
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It would seem crucial to determine what the <em>British Psychological Society DCP </em>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 - <strong>any confusion or lack of clarity on such an issue would seem not only unacceptable, but potentially harmful</strong><br />
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<strong>Memories cant wait (Talking Heads)</strong></div>
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In trying to clarify the idea of whether formulation is designed as a 'replacement for diagnosis, what follows is part of a <em>Twitter </em>conversation between LJ and myself on this issue:<br />
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6.31 June 7th - LJ says the DCP position document is <strong>not advocating replacement of diagnosis with formulation</strong><br />
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7.05 June 7th - I post two Twitter statements from <strong>LJ, where she clearly advocates replacement (or abandonment) of diagnosis with formulation </strong>- actual links below<br />
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2.27 Hune 7th - @nuAmbiguous asks a reasonable question - <strong>seems odd not to want to replace it if you see it as dehumanising</strong><br />
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2.49 June 7th - Then <strong>LJ says she 'definitely does" want to replace it</strong><br />
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2.53 June 7th - Finally, @nuAmbiguous asks a question that remained unanswered<br />
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<strong>The Twitter discussion starts at the bottom and works upwards</strong></div>
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Here are Tweets from Lucy Johnstone saying <a href="https://twitter.com/ClinpsychLucy/status/291645196167413760" target="_blank">"Read my blog on how formulation can replace diagnosis"</a> and here saying "<a href="https://twitter.com/ClinpsychLucy/status/333615518412050433" target="_blank">UK Clinical Psychologists Call for the Abandonment of Psychiatric Diagnosis...</a>" And finally, Lucy Johnstone's blog clearly headed with <a href="http://www.madinamerica.com/2013/05/uk-clinical-psychologists-call-for-the-abandonment-of-psychiatric-diagnosis-and-the-disease-model/" target="_blank">abandonment</a> in which she says <br />
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"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 <a href="http://www.madinamerica.com/wp-content/uploads/2013/05/DCP-Position-Statement-on-Classification.pdf" target="_blank">Position Statement today</a> <strong>calling for the end of the unevidenced biomedical model implied by psychiatric diagnosis</strong>."</blockquote>
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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. <br />
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Service users and all providers need to know <em>precisely </em>what is being proposed by the professional body representing UK (clinical) psychologists and its representatives. <br />
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<strong>2) </strong>LJ says<strong> </strong>"The DCP statement <strong>calls for a joint effort </strong>to develop a multifactorial and contextual approach...<strong>as an alternative to diagnosis (Rec 3)"</strong><br />
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First, you again clearly state 'alternative to diagnosis'. Second, you call for <em>joint effort </em>but with whom?<em> </em>The implication may be ...with psychiatrists and other service providers - but actually <strong>Recommendation 3 (shown below) refers only to working with service users - part of the Recommendation you edited from your response on my post</strong><br />
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You go onto say <strong>Recommendation 5 (below) </strong>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 <strong>replace diagnosis with formulation</strong>? or the <a href="http://www.blogger.com/%22http://dcp.bps.org.uk/dcp/the_dcp/news/dcp-position-statement-on-classification.cfm" target="_blank">DCP webpage </a>saying "...<strong>the DCP continues to advocate the use of psychological
formulation</strong>"<br />
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3) You refer to scientist-practitioner models - As you (oddly) refer to yourself as being "<strong>glad not to be a scientist", </strong>that you see yourself essentially as a <em>practitioner </em>only. This would seem to resonate with the title of my post - 'Clinical Psychology - anti- or ante- science?'</div>
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4) You go onto say that </div>
<blockquote class="tr_bq">
"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. (<em>your caps...you seem to like caps</em>)<br />
</blockquote>
And that those researchers who have examined reliability and validity in formulation - and found it sadly lacking - are <strong>'deeply misguided'. </strong>Might these individuals be <strong>the <em>science </em>end of science-practitioner who are <em>deeply misguided</em>?</strong><br />
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I also note that these are quite bizarre claims <em>...</em>Are you denying that psychiatrists a) also work with <em>human emotional distress and human relationships</em>? If, so why is your <strong>chief criticism of diagnosis based on issues of reliability and validity? </strong>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 <em>'deeply misguided' </em>colleagues would argue<br />
<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=rG2-3StuM5wLQM&tbnid=xMJr12G0GB_XvM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.aronsonsecurity.com%2Fblog%2F&ei=zva1UcujBKeu0QX004CACw&psig=AFQjCNF-OHeTdZW8JCGhibpKps7gUETtVQ&ust=1370965970425827" id="irc_mil" style="border: 0px currentColor;"></a><br />
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<strong> Modern anti-psychiatry is more <em>nots</em> than <em>knots</em></strong></div>
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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 <strong>avoid answering the question and instead divert to reliability in diagnosis</strong><br />
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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<br />
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6) I am glad to see that you have taken such an interest in my academic <em>and personal life </em>- feeling it necessary to refer to my wife (whom you don't even know)<br />
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You also refer to my never using 'formulation' ....as if it is based in some <em>expertise</em><br />
How does this fit with your saying:<br />
<blockquote class="tr_bq">
<br />
"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)"</blockquote>
or as you say here in in your typical self-contradictory fashion<br />
<blockquote class="tr_bq">
<em>"Formulation is both simple and complex, common sense and controversial, depending on how it is defined and used" </em></blockquote>
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! <br />
...it just leaves us in <em>Knots with lots of nots</em><br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-44610430716121013492013-05-31T13:01:00.000-07:002013-06-16T04:27:48.097-07:00Clinical Psychology- Anti or Ante-Science?<br />
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<em>Watch out, you might get what you're after<br />Cool babies, strange but not a stranger<br />I'm an ordinary guy<br />Burning down the house<br />Hold tight, wait 'till the party's over<br />Hold tight, we're in for nasty weather</em></div>
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<strong>Burning Down the House (Talking Heads)</strong></div>
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Have some clinical psychologists developed a bad case of ...<em>anti-science?</em><br />
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<h4>
Burning down the House, Pull up the Roots and I Get Wild</h4>
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 <em>formulation </em>(recently also accompanied by <em><a href="http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health" target="_blank">paradigma shiftitis </a></em>) - other symptoms will follow in later posts<br />
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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 <em>any </em>diagnosis -psychiatric or <em>otherwise</em>. Often these questions about diagnosis are framed in a low evidence, high hyperbole manner - for example saying they are <a href="http://www.guardian.co.uk/commentisfree/2009/aug/31/psychiatry-psychosis-schizophrenia-drug-treatments">"...hardly more meaningful than star signs"</a>. 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. <br />
<br />
<h4>
Making Flippy Floppy and Slippery People</h4>
Given the recent 'position statement' by the <em>British Psychological Society's (BPS) Division of Clinical Psychology (DCP) - </em><a href="http://dcp.bps.org.uk/dcp/the_dcp/news/dcp-position-statement-on-classification.cfm" target="_blank"><strong>Time for a Paradigm Shift in Psychiatric Diagnosis</strong></a><strong> </strong>(link to full document at foot of that page) <em><a href="http://dcp.bps.org.uk/dcp/the_dcp/news/dcp-position-statement-on-classification.cfm" target="_blank"> </a>- </em>it is worth taking a closer look at the alternative to diagnosis proposed by the DCP -so-called <strong><em>Formulation</em></strong><br />
<strong><em></em></strong><br />
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<strong>Pere Ubu (Non-Alignment Pact: 1977) </strong></div>
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In their <a href="http://www.canterbury.ac.uk/social-applied-sciences/ASPD/documents/DCPGuidelinesforformulation2011.pdf">Good Practice Guidelines on the use of Psychological Formulation</a>, the DCP states "<a href="http://www.canterbury.ac.uk/social-applied-sciences/ASPD/documents/DCPGuidelinesforformulation2011.pdf">there is no universally agreed definition of formulation</a>", but do rather nebulously state that:<br />
<blockquote class="tr_bq">
<br />
"Psychological formulation is <strong>the summation and integration of the knowledge </strong>that is acquired by this assessment process that may involve psychological, biological and systemic factors and procedures" </blockquote>
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In the same document, they reference Clinical psychologist <strong>Gillian Butler (1998) </strong>who says<br />
<blockquote class="tr_bq">
<br />
"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 <strong>hypotheses to be tested</strong>.”<br />
</blockquote>
and later <strong>Kuyken (2006</strong>) is quoted as saying<span style="color: #231f20; font-family: NewBaskervilleStd-Roman;"><span style="color: #231f20; font-family: NewBaskervilleStd-Roman;"></span></span><br />
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<br />
'...formulation is ‘a balanced <strong>synthesis of the intuitive and rational cognitive systems’ </strong><span style="color: #231f20; font-family: NewBaskervilleStd-Roman;"><span style="color: #231f20; font-family: NewBaskervilleStd-Roman;"><strong>
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So, Formulation is a hypothesis that links (any specific?)theory and (any specific?) practice that balances intuitive and rational cognitive systems?<br />
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<br />
and then later still, what <strong><em>formulation is not</em>? </strong><br />
<blockquote class="tr_bq">
"<strong>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)"</strong></blockquote>
Plausible to whom? How do we assess <em>usefulness</em> as opposed to <em>truth</em>? It seems from the way that some clinical psychologists speak that formulation is viewed as <em>orthogonal to veracity </em><span style="background-color: white;">- indeed, it is implicit that multiple formulations of the same case are not only possible but possibly desirable(?)</span><br />
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<strong>This Heat: 24 Track loop (1978)</strong></div>
<h4>
Girlfriend is Better</h4>
In this context, it is worth unpacking this very recent post - <a href="http://dxsummit.org/archives/197" target="_blank">So... What happens next? </a>by the clinical psychologist Peter Kinderman in the light of the DCP paradigm shift document: <br />
<blockquote class="tr_bq">
Of course, <strong>traditional psychiatrists, and many members of the public, say that they find a diagnosis helpful and even comforting</strong>. But <strong>the truth </strong>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’, <strong>any comfort from a diagnosis is likely to be illusory.</strong></blockquote>
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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 <em>(Science and anti-science)</em>. 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 <em>illusory comfort </em>from <em>real comfort </em>in his patients - that would take some expertise!<br />
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<h4>
Moon Rocks </h4>
<strong>What about the evidence on formulation? </strong><br />
Bieling & Kuyken (2003) state in their paper <a href="http://rom.exeter.ac.uk/documents/Psyc/wkuyken/03%20Case%20Formulation-%20CP-Sci%26Pract.pdf">Is Cognitive Case Formulation Science or Science Fiction?</a> <br />
<blockquote class="tr_bq">
In terms of the scientific status of the cognitive case formulation process, current <strong>evidence for the reliability of the cognitive case formulation method is modest, at best</strong>. There is <strong>a striking paucity of research examining the validity of cognitive case formulations or the impact of cognitive case formulation on therapy outcome.</strong><br />
<strong></strong> </blockquote>
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 <br />
<blockquote class="tr_bq">
"Clinicians may make these errors <strong>so habitually </strong>that in cognitive case formulations of identical cases using identical formulation methods it is not possible to accurately establish consensus."</blockquote>
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Of course, some clinical psychologist essentially argue for <em>a science of the individual. </em>In their review of case formulation in mental health, <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpm.12069/pdf">Rainforth & Laurenson 2013</a> state<br />
<blockquote class="tr_bq">
… there are difficulties in promoting commonality due to the individual nature of the formulation, based on <strong>the service user presentation, traits, personality experiences and needs</strong>, and <strong>issues relating to practitioner skills and experience</strong>...The complex nature of formulation-based approaches to treatment planning contains vulnerability due <strong>to judgemental and inferential bias</strong>. Benefits for standardizing treatments were noted; however, this also <strong>highlights a dilemma in whether to use standardized or individualized approaches to CF</strong>.</blockquote>
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In other words, it sounds awfully like <em>no two formulations would be the same</em><br />
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<strong>Who benefits from formulation?</strong><br />
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.<br />
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Some evidence suggests that <strong>formulation benefits staff </strong>rather than the patients or the outcomes for patients<br />
<blockquote class="tr_bq">
"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" <a href="http://pb.rcpsych.org/content/30/9/341.full">Summers 2006</a>.<br />
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</div>
</blockquote>
Kuyken et al (2005) in their paper <a href="http://www.sciencedirect.com/science/article/pii/S0005796704002244" target="_blank">'The reliability and quality of cognitive case formulation'</a> say:<br />
<blockquote class="tr_bq">
<br />
Our review suggests that, <strong>contrary to the claimed benefits of cognitive case formulation, it is not a panacea, and its evidence base is weak at best. </strong>Our review suggests instead that it is a <strong>promising but currently limited approach to describing and understanding patients’ presenting problems</strong></blockquote>
<br />
They suggest "the quality of formulations ranged from very poor to good, with only 44% rated as being at least <em><strong>good enough</strong></em>." 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, <strong>only a minority of formulations are rated as "good enough"</strong><br />
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<h4>
Swamp</h4>
<strong>Perhaps reliability and validity are irrelevant to the anti-science of formulation?</strong><br />
<blockquote class="tr_bq">
<br />
"<strong>Formulations may be reliable and valid but have no impact on treatment outcome</strong>. In contrast, <strong>they may be unreliable and invalid but lead </strong>through some alternative mechanism (e.g., increasing therapist self-confidence or enhanced alliance) <strong>to improved outcome</strong>." Bieling & Kuyken (2003) - see also p34 <a href="http://www.canterbury.ac.uk/social-applied-sciences/ASPD/documents/DCPGuidelinesforformulation2011.pdf" target="_blank">Good Practice Document</a> Johnstone et al 2011</blockquote>
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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 <em>improve outcome. - </em>Actually, <strong>no empirical scientific evidence exists to show that formulation improves outcome</strong>. Moreover no evidence at all exists to support the bold claim that formulation is in fact orthogonal to reliability and validity. <br />
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<br />
Finally, clinical psychologists may see <strong>formulation as an art rather than a science</strong>. Indeed, the <a href="http://www.canterbury.ac.uk/social-applied-sciences/ASPD/documents/DCPGuidelinesforformulation2011.pdf">BPS Good Practice Guidelines on Psychological Formulation</a> states<br />
<blockquote class="tr_bq">
"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 <strong>a kind of artistry that also involves intuition, flexibility and critical evaluation of one’s experience</strong>. In other words, <strong>formulation is ‘a balanced synthesis of the intuitive and rational cognitive systems’ </strong>(Kuyken, 2006, p.30)."</blockquote>
Again, it seems little interest in the science rather than the <em>artistry of formulation</em><br />
<br />
<strong>Formulation is a treatment in itself?</strong><br />
Interestingly the BPS document on psychological formulation states <strong>"It should also be noted that developing a formulation can be a powerful intervention in itself" </strong>- 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<br />
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<h4>
This Must be the Place (naive melody)</h4>
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....<br />
<br />
An ironic conclusion, that the touted Kuhnian <strong>paradigm shift </strong>appears to be one going backwards into <strong>pre-science</strong> or perhaps....formulation its better described as <strong>ante-science</strong>Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com57tag:blogger.com,1999:blog-7082878015421475244.post-37069786649778904602013-05-12T13:16:00.001-07:002014-12-28T15:40:14.336-08:00Psychology - Seductive, but is it Science? <div style="text-align: center;">
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<em><strong>Harvey</strong>: Tell me. We're alone here. No witnesses.<br /><strong>Art</strong>: Tell you?<br /><strong>Harvey</strong>: A sort of confirmation.<br /><strong>Art</strong>: Tell you what?<br /> <strong>Harvey</strong>: About ravishment</em></div>
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I am an <em>unintentional psychologist</em>. As teenager, I was persuaded to add Psychology as my final 'A'-level "...probably useful to have a <em>science</em>" 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. <br />
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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. <br />
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Can we really refer to this capacious church of psychology as <em>science?</em><br />
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<strong>'La Ritournelle' by Sébastien Tellier</strong></div>
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<strong>(</strong><strong>"its awesome" according to my 5 yr old son Vivek)</strong></div>
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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 <em>psychology </em>as if it were a unitary discipline - rather we have <em>psychologies</em>. 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...<em>anti-science </em>(something I will return to in a later post). <br />
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Possibly because of a (righteous) historical fear of <em>introspection</em>, 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 <a href="http://en.wikipedia.org/wiki/Null_hypothesis" target="_blank">null findings</a>, questionable research practices such as selective reporting, hyperbole, evidence denial and even outright fraud, all combined with the shallow pursuit of <em>the curious</em>.<br />
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"..<em>.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</em>." <strong>Nicolas Roeg</strong></blockquote>
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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 <em>currently practices</em><br />
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<a href="http://www.guardian.co.uk/science/blog/2013/feb/27/psychologists-bmc-psychology" target="_blank">It's time for psychologists to put their house in order</a> - My original article in the <em>Guardian </em>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 <a href="http://www.biomedcentral.com/bmcpsychol/" target="_blank">BMC Psychology</a><strong>,</strong> which is addressing some of the issues regarding null findings and replications<br />
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<a href="http://www.biomedcentral.com/2050-7283/1/2" target="_blank">Negativland - a home for all findings in psychology</a> - The <em>Open Access </em>paper that I published in <em>BMC Psychology </em>(which<em> </em>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). <br />
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<a href="http://www.bbc.co.uk/programmes/p016bhzx" target="_blank">BBC Radio3 NightWaves </a>audio recording of debate - <strong><em>Is Psychology a Science? </em></strong>- between myself and the philosopher <a href="http://en.wikipedia.org/wiki/Rupert_Read" target="_blank">Rupert Read </a>on BBC Radio 3 <em>Night Waves </em>programme (it was linked to my Guardian article). One point argued by Read, is that it is in fact <em>impossible to replicate </em>experiments in psychology - because of the historical nature of <span style="background-color: white;">human beings. I am pretty sure <em>no </em>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)</span><br />
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<a href="http://blog.talkingphilosophy.com/?p=6884" target="_blank">Why Psychology ain't Science</a> - piece written by Rupert Read following our debate, where he expands on why he thinks psychology is not (and <em>cannot</em> be) a science. This largely <em>seems </em>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"<br />
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<em>"Established Psychology is one of those juggernauts that Wittgenstein didn’t like, and rightly so." </em>Rupert Read<br />
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<strong>Keith Jarrett - The Koln Concert</strong></div>
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<a href="http://storify.com/NeuroWhoa/psychology-as-science" target="_blank">Storify</a> - 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 <em>random timeless Twitter space</em><br />
<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=VKPy-9Dh3qCpGM&tbnid=oTBOdi6Jdz238M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.tumblr.com%2Ftagged%2Fyear%3A%25201980&ei=yTuBUeyNEqOb0AXE54GADg&bvm=bv.45921128,d.d2k&psig=AFQjCNFZIe20jPZaprniE_Tz-9aaAezehA&ust=1367510282457478" id="irc_mil" style="border: 0px currentColor;"></a><br />
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<span dir="auto"><strong>E=MC<span style="font-size: small;"><sup>2 </sup>by Big Audio Dynamite </span></strong></span></div>
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a paean to Nic Roeg</div>
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Even <em>if </em>we psychologists do eventually show the determination to get our house in order - many will still view psychology as a pseudoscience - <strong>what is important....is how we psychologists view what we do and how we practice what we do</strong></div>
Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com2tag:blogger.com,1999:blog-7082878015421475244.post-77596576511525334372013-04-29T06:16:00.001-07:002015-07-02T06:04:36.595-07:00The Dream Machine - Cut ups, cut ins, cut outs<div style="text-align: center;">
<img src="http://photos1.blogger.com/blogger/6133/418/1600/brion.0.jpg" /></div>
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<em>Our new soap that's peachy keen saves your soul and keeps you clean<br />It's recommended, used by the Queen<br />Gonna improve your IQ, help in everything you do<br />It's economic, don't cost too much.</em></div>
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<em> </em><strong>Know Your Product (The Saints) </strong></div>
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Hutton P and Taylor PJ. Cognitive behavioural therapy for psychosis prevention: a systematic review and meta-analysis. <em>Psychological Medicine </em>(2013): 1-20</h3>
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In January I blogged on a meta-analysis by Stafford, Jackson, Mayo-Wilson , Morrison & Kendall published in the BMJ - My post - <a href="http://keithsneuroblog.blogspot.co.uk/2013/01/its-just-story-transition-to-psychosis.html" target="_blank">Its Just a Story: Transition to Psychosis & CBT</a> - concerns whether CBT may prevent transition to psychosis.</div>
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<strong><em>Cut ups</em></strong></div>
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Three months on and we have another meta-analysis on the same topic from one author (Hutton) who coincidentally works in the lab of one author (Morrison) on the earlier paper </div>
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<strong>It's a mash-up (Pistols meet Madonna)</strong></div>
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As noted, I have already covered some problems with the original BMJ paper and much of what I said there applies here. Nonetheless, the current meta-analysis makes greater claims for CBT preventing <em>transition to psychosis</em> e.g. over longer periods of time.</div>
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<em>At every time point, the relative risk of transition was reduced by more than 50% for those receiving CBT. </em>(Hutton & Taylor 2013)</blockquote>
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<strong>The Saints (1978, Know your Product)</strong></div>
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<strong>A fine Australian export</strong></div>
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<em>"Where's the Professor...we need him now"</em></div>
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Why do Hutton & Taylor come to somewhat grander conclusions in favour of CBT? One reason is because they included a study not included by Stafford et al. The study is by <strong>Bechdolf et al</strong>. (2012) <a href="http://bjp.rcpsych.org/content/200/1/22.full" target="_blank">"Preventing progression to first-episode psychosis in early initial prodromal states." </a>As Figure 2 (below) from Hutton & Taylor shows, this Bechdolf paper is the most favourable towards CBT preventing transition (with largest risk ratio here at 6 months, but also in their 12 month (0 and 9 transitions for Experimental and controls respectively) and 18-24 month analyses (1 and 10 transitions) - so is worth looking at in more detail</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEcHCxjNnkI_NVwi8EKW4X92I4ieC8I55Vw5Mh_5CCqWEv0mnbHL56VuYEqkkIEuXCSZFIAztGoygZeJ7P0PJo1gJtFna_9uwHvw9iB21L_gIa1bZR73dwD-052a47Ni2Lxe4ZlC2FB-0/s1600/6months.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEcHCxjNnkI_NVwi8EKW4X92I4ieC8I55Vw5Mh_5CCqWEv0mnbHL56VuYEqkkIEuXCSZFIAztGoygZeJ7P0PJo1gJtFna_9uwHvw9iB21L_gIa1bZR73dwD-052a47Ni2Lxe4ZlC2FB-0/s1600/6months.jpg" /></a></div>
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Its not that Stafford et al were unaware of the Bechdolf paper, so why did they not include it...?</div>
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Crucially, Bechdolf et al used <em><strong>Integrated Psychological Intervention (IPI), </strong></em>which does include individual CBT, <strong>but also group skills training, cognitive remediation and multifamily psychoeducation</strong>. So, even if changes in transition rates emerge - they are no more attributable to CBT than any other component of the IPI intervention. Unsurprisingly then, in their meta analysis, Stafford et al examined IPI studies including the Bechdolf study separately from their CBT analyses.</div>
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<strong>Jim Morrison (& the Doors) duets with Amy Whinehouse</strong></div>
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Some mash-ups are made in heaven</div>
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Its also worth noting that Bechdolf et al also differs from the all other studies as their participants were <em>prodromal</em>, i.e. had self-reported symptoms which they describe as preceding the <em>subthreshold psychotic symptoms </em>typically used as entry conditions in the other studies. Finally, Stafford et al rated study quality using the <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC428525/pdf/bmj32801490.pdf" target="_blank">GRADE </a>system (for risk of bias, inconsistency, indirectness, imprecision, and publication bias) and classed the Bechdolf et al study as <em>'very low' </em>quality evidence - indeed, the lowest possible in that framework<em>.</em></div>
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=muexDWT7SjAEIM&tbnid=MjtJDdV-OqqV4M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.tumblr.com%2Ftagged%2Ffm%2520einheit&ei=MQ14UY-1BMmm0AWk7YCwBQ&psig=AFQjCNGmq04rP00KprOtBlYNZeH5O2TxWw&ust=1366907407435057" id="irc_mil" style="border: 0px currentColor;"><img src="http://24.media.tumblr.com/tumblr_lq8ts5o78Q1qedb29o1_500.gif" height="150" id="irc_mi" style="margin-top: 25px;" width="200" /></a></div>
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<em>You can't fake quality any more than you can fake a good meal</em></div>
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<strong>William Burroughs </strong></div>
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A second difference concerns the inclusion of <strong>McGorry et al </strong>(2012) by Hutton & Taylor. Again its worth examining this study in more detail</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhppEefRJ3VOJo0C4hD6emKyaHzOoMLIqvrXeJzvikbIIzl3c06IoZIpd1BkyLO8DQxyMpdlun7dN7_pGYVKhwf9LObLsncclXss71TRmp5gsB-h7TRN8DRgjxlDFngwfjgIRZ-3SzkWsQ/s1600/Convert18-24.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhppEefRJ3VOJo0C4hD6emKyaHzOoMLIqvrXeJzvikbIIzl3c06IoZIpd1BkyLO8DQxyMpdlun7dN7_pGYVKhwf9LObLsncclXss71TRmp5gsB-h7TRN8DRgjxlDFngwfjgIRZ-3SzkWsQ/s1600/Convert18-24.jpg" /></a></div>
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<span style="font-family: inherit;">First, what is the design of the McGorry et al study? Well...participants were randomly assigned to the following groups: </span></div>
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<span style="font-family: inherit;"> <strong>Cognitive Therapy + Risperidone</strong></span></div>
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<strong><span style="font-family: inherit;"> Cognitive Therapy + Placebo</span></strong></div>
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<strong><span style="font-family: inherit;"> or Supportive Therapy + Placebo. </span></strong></div>
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<span style="font-family: inherit;"> Plus </span></div>
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<span style="font-family: inherit;">a <strong>'Monitoring' </strong>group - or those people who refused random assignment - so are <span lang="EN-US"><o:p>not -in fact - part of a randomised trial (but self-selecting controls!)</o:p></span></span></div>
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<span lang="EN-US"><o:p></o:p></span><span style="font-family: inherit;"> </span></div>
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<span lang="EN-US"><o:p><span style="font-family: inherit;">McGorry et al then have no CBT group (as such) and no randomised control group (as such)...</span></o:p></span></div>
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<span lang="EN-US"><o:p></o:p></span><span style="font-family: inherit;"> </span></div>
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<span lang="EN-US"><o:p><strong><span style="font-family: inherit;">So, its difficult to see how the studies by Bechdolf et al and McGorry et al could be described as assessing the impact of CBT <em>per se</em></span></strong></o:p></span></div>
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<strong><span style="font-family: inherit;"><span lang="EN-US"><o:p>and when they are r</o:p></span><span lang="EN-US"><o:p>emoved them from the equation ...the effect is non-existent</o:p></span></span></strong></div>
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<span lang="EN-US"><o:p></o:p></span> </div>
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<span lang="EN-US"><o:p>As mentioned, I have covered the Stafford et al meta analysis and some of the studies and issues in my other post. Nevertheless, I would conclude by reiterating: </o:p></span></div>
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<span lang="EN-US"><o:p>a) the extremely low transition rates (<10%) of <strong>Ultra High Risk </strong>individuals </o:p></span></div>
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<span lang="EN-US"><o:p>b) CBT shows no evidence of preventing transition - indeed, no single study shows a significant and reliable effect; <span lang="EN-US"><o:p>and finally, </o:p></span></o:p></span></div>
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<span lang="EN-US"><o:p>c) even if CBT did prevent transition to psychosis ...How would it actually be <em>preventing psychosis?</em> The whole approach is bereft of any theoretical ideas on this notion - one thing is sure - it is NOT via the reduction of symptoms - as both meta analyses definitely show that symptoms do not change from before to after CBT</o:p></span></div>
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<span lang="EN-US"><o:p></o:p></span> </div>
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~</div>
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When Brion Gysin spoke about his '<a href="http://en.wikipedia.org/wiki/Dreamachine" target="_blank">Dream Machine'</a>, he said it was "<em>The worlds only artwork that you look at with eyes tightly closed" - </em>I wonder if the same might be said of CBT for psychosis.</div>
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=1QjBJq4yeSXCOM&tbnid=TdoxAprcezycOM:&ved=0CAUQjRw&url=http%3A%2F%2Fschonmagazine.com%2Ftag%2Fdavid-bowie%2F&ei=1LF3Uc3VEPK00QXU34HQCw&bvm=bv.45580626,d.d2k&psig=AFQjCNEoHNr6QuRvf8AuCouZM6bM1T-L7A&ust=1366885182191784" id="irc_mil" style="border: 0px currentColor;"></a> </div>
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<a href="http://upload.wikimedia.org/wikipedia/commons/c/cc/Waiting_for_Godot_set_Theatre_Royal_Haymarket_2009.jpg"></a></div>
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com12tag:blogger.com,1999:blog-7082878015421475244.post-70395317043527810872013-03-11T13:36:00.001-07:002014-06-12T07:17:36.237-07:00Burning Blue Soul - History Repeats Itself<div style="text-align: center;">
<a href="http://upload.wikimedia.org/wikipedia/en/2/24/The_The_-_Burning_Blue_Soul_original_cover.jpg"><img alt="File:The The - Burning Blue Soul original cover.jpg" src="http://upload.wikimedia.org/wikipedia/en/2/24/The_The_-_Burning_Blue_Soul_original_cover.jpg" height="283" width="300" /></a></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">...then supposin' your legs just
withered away</span></i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><br />
<i>& you had to somehow slide around on your</i><br />
<i>backside - for the rest of your days.</i><br />
<i>"Imagine"... that you're happy now.</i><br />
<i>"It's easy if you try" - because we're all caught</i><br />
<i>up in a mortifying loop - LIFE</i><br />
<b>Song Without An Ending</b><o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">A brief Twitter conversation led me recently to reminisce about <i>Burning
Blue Soul. </i>Although attributed to <i>The the</i>, it was in fact the first
album released on September 7th 1981 under Matt Johnson's own name on the
then fledgling <a href="http://en.wikipedia.org/wiki/4AD" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">4AD</span></a>
label.<o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Why mention it some 32 years later? Well... I know a little about the
making of this album...'back in the day' Matt Johnson and I were close friends.
I thought I would share a few increasingly fragmentary memories of the making of - what I
believe is a - seminal album - not to everyone's taste, <strong>but then it wouldn't
be seminal if it were to everyone's taste.</strong> This unique record has been over-shadowed
by the later - more accessible work that reached an international audience.</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Music is an <em>experience</em> and so<em>,</em> I usually flounder when asked to describe it and this is no exception. My inclination is always to say - <em>listen </em>to it - that's the reason it was made...and to this end, I have put a few pieces from <em>Burning Blue Soul </em>in this post! Despite my reservations, I <em>know </em>that the roots of </span><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><em>Burning Blue Soul, </em>its<em> </em></span><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">wonderful mélange of... English pastoral
psychedelia and Krautrock invention (Krautedelia?) filtered through the
hypochondria and religious and cultural allusions of someone whose 19th birthday passed in the summer
1981. Matt was a Magpie.</span></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">I'm wasting away with worry<br />
& my heart just skipped a beat<br />
But then again...<br />
I felt much calmer<br />
I opened up a can of 'Instant Karma'<br />
a yoga posture for self awareness<br />
& the devil rides out of<br />
YOUR LIFE!!!<br style="mso-special-character: line-break;" />
</span></i><b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">(Like a) Sun Rising
Through My Garden</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Nobody could doubt the invention and courage of Burning Blue Soul - of an 18/19 year old opening his psyche not indulgently to an established adoring audience, but to any other person experiencing life as <em>ununderstandable</em>.</span></span><br />
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"></span></span><br />
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">The album is a <em>trip </em>from the meandering quasi-orchestral Can and Faust-like tribal rhythmic loops of '<i>Red Cinders in the Sand',</i> to the chirping grasshopper percussion and sound of the Pungi (as played by snake charmers [<strong>*correction </strong>my Indian wife assures me it is <a href="http://en.wikipedia.org/wiki/Shehnai" target="_blank">Shennai</a> - music played at Indian weddings - & may be for the groom leaving!]) in <i>'(Like a) Sun Rising through my Garden'</i>, the layered forward and backward guitars of '<em>Icing up' </em>and several visits from the ghost of John Lennon - especially on '<em>Bugle Boy' </em>(and various lyrical nods to 'Imagine', 'Instant Karma' and "Ive got a million Beatles under my skin" on other songs)<em>, </em>add the lyrical whimsy of Syd Barrett, and occasional vocal nods to Tim Buckley ....until the closing echoic oriental lament of '<em>Another Boy Drowning' ...."</em>we all know we edging our way toward the end" - so odd for someone so young (unless you knew Matt) </span></span><br />
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">..with the final words of <em>Burning Blue Soul </em>being:</span></span><br />
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<em>Movin' on, opening new doors...Life just doesn't seem that simple anymore. </em></div>
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<em>In case I don't see you again...I hope you'll feel glad that you know me while I was here</em></div>
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Summer Nights 1981</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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Its worth thinking about what was happening in the summer of '81? We had
entered the first of Margaret Thatcher's terms of office, unemployment had
risen to nearly 3 million, the warm nights were lit up by the so-called 'Race
riots' in Brixton, Toxteth, Chapeltown and Hansworth. I recall many smaller
disturbances happening all around me in London at the time. Charles and Diana
married, MTV launched, the Maze 'hunger strikes' came to their inevitable conclusion. The first recognized cases of AIDS appeared and Pope
John Paul II was shot. Most of these events were chronicled in the snapshot of
1981 that is Burning Blue Soul.</div>
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Almost every lyric can be traced to specific autobiographical events - for example</div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">I like you... I
think that you're pretty good<br />
But I think that you think, that I...<br />
Well... that I'm a bit undercooked...</span></i></div>
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<b><i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">...</span></i></b><i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">100,000 people today were burned.</span></i></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">I felt a pang of concern,</span></i></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">- what are we waitin' for - a message of hope.</span></i></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">- from the... POPE!</span></i></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">I think he got shot... as well!</span></i></div>
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Song Without An Ending</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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The "I like you...I think you're pretty good" was I believe derived from a voice recording that Matt had made of his youngest brother Gerard (probably no more than 3 at the time). Gerard has grown from cute small boy to the writer and director of the acclaimed movie <a href="http://en.wikipedia.org/wiki/Tony_(2009_film)" target="_blank"><em>Tony</em></a>. <span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">As always, being a magpie, Matt incorporated news events into his lyrical content - Pope John Paul II had indeed been shot while the album was being recorded</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">It was a paean to the past - albeit one that had become part of our past
in the future - nothing is new, nothing is old. The influences are
psychedelic, although psychedelia had long gone to be replaced by the creative darkness of the late 70s and early 80. </span><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">- all added to a high degree of existential anxiety,
hypochondria and the fearless experimentation of someone with nothing much
to lose (no job, no major record contract) - it is a proverbial <b>musical
DSM <a href="http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">(<i>Diagnostic and Statistical Manual of Mental Disorders)</i></span></a>,
but carries within each song... the cure for a disorder</b></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><i>I
have no future, for I've had no past<br />
I'm just sittin' here<br />
Pullin' arrows<br />
Out of my heart<br />
History repeats itself<br />
Within the realms of my inexperience</i></span></div>
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Icing Up</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Now <i>I have had a past</i>, memories do come to mind - Matt had not
long passed his driving test and we spent long summer days in 1981 listening to
early and final version of the songs on a cassette player in his car (I vaguely
recall it wasn't even built into the dashboard, but a portable - so the quality
was impeccable). We would drive around the sunny Essex countryside, in the days
when seatbelts were unrequired, smoking cigarettes (almost always mine...as recorded in a later lyric for <em>Waiting for the Upturn</em>). <br />
<br />
The album was recorded in fits and starts in different studios, with different
producers and engineers over the best part of that year - and some of this
explains the eclectic feel and broad sweep ...of the album and how it coalesces
or not into a single coherent piece. As an aside 10 years later, I remember
similar journeys in the early 90s listening to early drafts of songs from <i>Dusk
</i>in Matt's car (e.g. without the vocals), travelling out to his parents
lovely countryside home. I think the car was a place for Matt to reflect on and
hone his songs.<br style="mso-special-character: line-break;" />
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Red Cinders in the
Sand</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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The album opens with <i>Red Cinders in the Sand - </i>if this isn't an English
version of Faust's Krautrock, then what is? The piece starts quietly with Matt
whispering '<i>an hallucination' . </i>It is a set of rhythms, the like of
which would later become de rigeur for many <i>tribal </i>bands - all mostly
through the use of tape loops (Matt worked at De Wolfe studios in Wardour
Street - so was constantly putting tapes together), overlaid with sitars,
'broken' guitar sounds and what can only be described as the kinds of brass
sounds you hear in epic Roman movies plus the simple sound of stuff crashing
(for want of a better description)<br />
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Bugle Boy</span></b></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">The country is
riddled with social ills & aches,<br />
But my heart is calmed by her embrace,<br />
I'm trying to tell something to the world,<br />
- But my words are slurred & slow,<br />
Have you ever been caught up in a dream,<br />
where your legs were froze.<br />
I was left alone, with my thoughts and my guitar.<br />
But it felt hopeless,<br />
Like the desire of the moth - for a star.<br />
Sometimes... nothing seems unreal,<br />
this strange little boy said<br />
"Mister, play us your guitar" & I said -<br />
"No... I can't"<br />
& put my guitar in the car-<br />
Listening to the music of heaven & earth,<br />
Have you ever thought you were the<br />
- Most important thing in the universe.<br />
I didn't know whether to strengthen my<br />
Weaknesses - or play to my strengths.<br />
Yeah...<br />
I was trapped in the triviality of- everydayness.<br />
I said.<br />
"There's magic in my head, girl.<br />
but I only use it when I'm depressed"<br />
I don't suppose she heard me.<br />
She was too busy admiring her dress.</span></i></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">She said I was
pretentious<br />
I said - just young - & - well intentioned,<br />
Who can save us now<br />
- the world rots...<br />
I did know the secret of the universe<br />
... only I forgot!!</span></i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">The album is often described as a refrain from bedsit land - only partly
true as Matt still lived in his parents' pub in Loughton (The Crown). Aside
form the car, the cellar of the Crown was a prominent site for listening to,
playing music and just trying out stuff - bear in mind that the music which populates
BBS is not the product of someone going into the studio with an album of songs
in mind and simply recording them Rather it was the evolution of many months
(or years of teenage gestation) - indeed, parts of songs frequently migrated
from one track to another.</span></div>
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=5BaOF1IDptef1M&tbnid=El2ZOXfR9FsJ7M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.flickr.com%2Fphotos%2Fphil1956clarke%2F5277945677%2F&ei=B5o9UcmbOrHs0gWpkYFY&bvm=bv.43287494,d.ZGU&psig=AFQjCNG-jTtJh_1lqAlZIUbbSTjyOExj_w&ust=1363078020164218" id="irc_mil" style="border: 0px currentColor;"><img src="http://farm6.staticflickr.com/5244/5277945677_7c8a4f727a_z.jpg" height="307" id="irc_mi" style="margin-top: 43px;" width="457" /></a></div>
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<b>The Crown (Loughton, Essex) - </b><br />
<i>Below ground level, amongst the beer barrels, Burning Blue Soul was
conceived and born</i><o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Its important to bear in mind that Matt was not a 'musician' in the
traditional sense - he was reasonably comfortable on keyboards having had some
lessons, but most of the time he stuck to the guitar ....in an open-E tuning.
He was not confident about the songs on BBS, and I recall conversations with
him about various pieces - which all sounded great to me and over three decades
later....you know what....they still sound fresh and relevant to me - from the
prescient musical styles through to the remarkable personal, social and
political lyrical voice for someone so young.</span></div>
<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p> </o:p></span><br />
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><i>Whispering
sadness, like a mild form of madness,<br />
or a line from a meaningful song,<br />
Turn your eyes to the lord,<br />
but the churches are empty,<br />
they're is now no escape from your longing.<br />
Things are gonna start getting good,<br />
...you hear them call,<br />
You captured the unspoken feelings of my heart,<br />
... which gave me a start.<br />
I know I'm nowhere near perfection<br />
...I'm pointing in the wrong direction</i> </span></div>
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Delirious</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"> </span><br />
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<a href="http://25.media.tumblr.com/tumblr_mb4gxuPG871rc22qso1_1280.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://25.media.tumblr.com/tumblr_mb4gxuPG871rc22qso1_1280.jpg" height="199" width="200" /></a></div>
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<span style="clear: left; color: #333333; float: left; font-family: "Arial","sans-serif"; font-size: 10pt; margin-bottom: 1em; margin-right: 1em; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Where did the <i>Burning
Blue Soul</i> cover idea come from? I might claim some influence: the name '<i>Burning
Blue Soul' </i>and the cover design came from me and was heavily and obviously
influenced by <i>The Psychedelic Sounds of the 13th Floor Elevators. </i>I also
believe I suggested the half laminate cover to give a 60s feel and finally, the
original cover photography for the sleeve and insert was done by my brother.<o:p></o:p></span><span style="color: #29aae1; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB; mso-no-proof: yes; text-decoration: none; text-underline: none;"><v:shape alt="http://25.media.tumblr.com/tumblr_mb4gxuPG871rc22qso1_1280.jpg" href="http://25.media.tumblr.com/tumblr_mb4gxuPG871rc22qso1_1280.jpg" id="Picture_x0020_18" o:button="t" o:spid="_x0000_i1033" style="height: 148.5pt; mso-wrap-style: square; visibility: visible; width: 150pt;" type="#_x0000_t75">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpslHwBBiT7dqbFNh8Dfg-Bs8uYBzn99TTat_o6FUfN35DEAFAfOrTdPUn7BRQNDxdJLda2BzCJJ6GWW4rK3YKGWzq07hP-3JjR3fQ3X7dZWKIxo1OuQe8PRhZfOeonCYcVPej8aAeTQ4/s1600/ThanksBBS.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpslHwBBiT7dqbFNh8Dfg-Bs8uYBzn99TTat_o6FUfN35DEAFAfOrTdPUn7BRQNDxdJLda2BzCJJ6GWW4rK3YKGWzq07hP-3JjR3fQ3X7dZWKIxo1OuQe8PRhZfOeonCYcVPej8aAeTQ4/s320/ThanksBBS.jpg" height="240" width="320" /></a></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">The internal sleeve notes indicate the various influences around at the time. A major one was <i><a href="http://en.wikipedia.org/wiki/Wire_(band)" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">Wire - </span></a></i>present physically in the guise of Bruce Gilbert and Graham Lewis - and spiritually through the massive affection for their album <i><a href="http://en.wikipedia.org/wiki/154_(album)" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">154</span></a></i> released at that time. Credits also appear for other close friends- <a href="http://www.cartoons.ac.uk/artists/tomjohnston/biography" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">Tom Johnston,</span></a>renowned cartoonist for the Sun newspaper; <a href="http://www.ashworth-photos.com/music/musicArchive.html" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">Peter Ashworth</span></a>, whose name you may not recognise, but almost certainly your record collection contains covers that he photographed (check out his link); <a href="http://en.wikipedia.org/wiki/Stevo_Pearce" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">Stevo</span></a> (Steve Pearce) the creator of Some Bizzare records and manager of Soft Cell amongst others; <a href="http://en.wikipedia.org/wiki/Andy_Dog_Johnson" target="_blank"><span style="color: #29aae1; text-decoration: none; text-underline: none;">Andrew Johnson</span></a>, Matt's brother and responsible for the later distinctive artwork for <em>The the </em>as well as a painting of Matt on the reverse cover<em>; </em>and finally Pete Maben, who was a recording engineer who dealt with some of the sessions (and ran a little recording studio in Forest Gate East London)</span><br />
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Another Boy
Drowning</span></b></div>
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<i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">There are no voices
- as the time approaches,<br />
I wanted to be like Bob Dylan<br />
Until I discovered Moses<br />
Saturday night & I was lying in my bed<br />
The window was open & raindrops<br />
Were bouncing off my head<br />
When it HIT me like a Thunderbolt!!!<br />
"I don't know nothing- & I'm scared<br />
that I never will"</span></i><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEJxbnNM0pVEQbzOX41wj3r2cxZJpD34rkxJmXExz6noJay4eHM04BrBrpsslrgfO-KVUaCLHmvZ4vZKsE14QDo-RbiMJV83c2vj_naP3IvhRjE7yEPc5lgilHCVT8efRoWqfuQwTOXeA/s1600/Me1980.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhEJxbnNM0pVEQbzOX41wj3r2cxZJpD34rkxJmXExz6noJay4eHM04BrBrpsslrgfO-KVUaCLHmvZ4vZKsE14QDo-RbiMJV83c2vj_naP3IvhRjE7yEPc5lgilHCVT8efRoWqfuQwTOXeA/s400/Me1980.jpg" height="287" width="400" /></a></div>
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While writing this blog, I found this image on the web - it dates from 1980/81 and shows the youthful Matt Johnson on the left, peeking over someones shoulder; Charlie Blackburn holding the first <em>the The </em>single on 4AD (CB and MJ were in a band called the <em>Marble Index </em>prior to <em>the The</em>). Sadly I cant recollect the other two people.... but my good self is on far right wearing my distinctive pyjamas and leather jacket combo - </div>
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I have no recollection of where it was taken or what we were doing - I'm innocent!</div>
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<b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">Burning Blue Soul</span></b><span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><o:p></o:p></span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Red Cinders in the Sand"</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Song Without an Ending"</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Time (Again) for the Golden
Sunset" </span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Icing Up" </span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"(Like a) Sun Rising Through My
Garden"</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Out of Control"</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Bugle Boy"</span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Delirious" </span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"The River Flows East in
Spring" </span></div>
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<span style="color: #333333; font-family: "Arial","sans-serif"; font-size: 10pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;">"Another Boy Drowning" </span></div>
Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com7tag:blogger.com,1999:blog-7082878015421475244.post-12325941827091507102013-02-28T14:31:00.001-08:002013-03-12T22:19:37.534-07:00Scientists are Artists: From Brian Eno to the Amygdala<div style="text-align: center;">
<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=y5XW775hNzKVKM&tbnid=CZxWQFdNhWiM-M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.ektoplazm.com%2Ffree-music%2Famygdala-modus-operandi&ei=0l8sUbD3D4Oh0QXjqYHICg&bvm=bv.42965579,d.d2k&psig=AFQjCNGTMC2879S5jVNK8hl-rOEJ2YSA-A&ust=1361948876532013" id="irc_mil" style="border: 0px currentColor;"><img height="320" id="irc_mi" src="http://www.ektoplazm.com/img/amygdala-modus-operandi-300x300.jpg" style="margin-top: 47px;" width="320" /></a><br />
<span style="font-family: inherit;"><em>Dipping swords in metaphors yeah but what does he know?<br />We're always one step behind him he's Brian Eno<br />Brian Eno!<br />He promised pretty worlds and all the silence<br />I could dream of </em></span><br />
<span style="font-family: inherit;"><em>Brian Peter George St John Le Baptiste De La Salle Eno</em></span><br />
<span style="font-family: inherit;"><strong>Brian Eno by MGMT </strong></span><span style="font-family: inherit;"> </span><span style="font-family: inherit;"> </span><br />
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<span style="font-family: inherit;">Scientists are geeks and artists and musicians are cool ....aren't they? </span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">Science and <em>scientists </em>are viewed as somewhat controlled, controlling, rule-bound, formulaic (the Scientific <em>Method</em>) and emotionally bereft Mr Spocks. By contrast, <em>artists </em>are seen as inspired, more random, often troubled and free souls who free us and our imaginations </span><br />
<br />
<span style="font-family: inherit;">These stereotypes are a view of the seemingly quiescent <em>surface </em>of science. Scrape beneath the tranquil surface though ...and you often find a festering, turbulent and creative underbelly. </span><br />
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<span style="font-family: inherit;">It is important to acknowledge and embrace the <strong><em>art of science</em></strong>, embrace the random....but being scientists and perhaps self-defeating...<strong>we might like some rules to help us control this random (ha!) creative process!</strong></span><br />
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<span style="font-family: inherit;">In this context, let me introduce <em>Brian Peter George St John Le Baptiste De La Salle Eno </em>or as he is more commonly known - <em>Brian Eno</em>. Eno is, of course, best know for producing many famous bands (U2, Bowie, Talking Heads) and was a founder member of Roxy Music. His influence on electronica has featured in my <a href="http://keithsneuroblog.blogspot.co.uk/2012/06/revox-xerox-redux-thomas-leer-robert.html" target="_blank">blog </a>previously.</span><br />
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;">Here I mention his </span><span style="font-family: inherit;"><strong>Oblique Strategies</strong> (<i><b>Over One Hundred Worthwhile Dilemmas</b></i>) - a deck of simple printed cards created by </span><a href="http://en.wikipedia.org/wiki/Brian_Eno" title="Brian Eno"><span style="font-family: inherit;">Brian Eno</span></a><span style="font-family: inherit;"> and artist </span><a href="http://en.wikipedia.org/wiki/Peter_Schmidt_(artist)" title="Peter Schmidt (artist)"><span style="font-family: inherit;">Peter Schmidt</span></a><span style="font-family: inherit;"> and first published in 1975.<sup> </sup>Each card contains an aphorism intended to help artists break creative blocks. </span></div>
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<strong>"By This River" (Eno, Roedelius, Moebius) from <em>Before & After Science</em></strong></div>
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<strong><em></em></strong> </div>
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<span style="font-family: inherit;"><span style="font-family: inherit;"><span style="font-family: inherit;">The idea of Oblique Strategies is to select cards at random - <strong>here is a program that does this for you</strong></span></span><br />
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<a href="http://oblicard.com/"><span style="font-family: inherit;"><strong>http://oblicard.com/</strong></span></a><strong> </strong></div>
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The cards contain a phrase or cryptic remark that may be used to overcome a creative impasse or dilemma. Some are specific to music composition and Eno has used them throughout his own recordings and his production of others - the cards were a key part of the production of David Bowie's seminal Berlin trilogy of <em>Low</em>, <em>Heroes </em>and <em>Lodger</em>.</div>
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<blockquote class="tr_bq">
"We used oblique strategies a lot. <em>Sense of Doubt was done almost entirely
using the cards</em>, and we did talk about work methods. But no, I don't think we
[Eno & Bowie] have that much in common. But that's fine, so long as there's give and take"</blockquote>
<div class="firstindentsp">
Working on <i>Sense Of Doubt</i>, Bowie and Eno each
pulled out an Oblique Strategy card and kept it a secret from the other. As Eno
described it:</div>
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<blockquote class="tr_bq" style="text-align: left;">
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It was like a game. We took turns working on it; he'd do one overdub and I'd do the next. The idea was that each was to observe his Oblique Strategy as closely as he could. And as it turned out they were entirely opposed to one another. Effectively mine said, <em>'Try to make everything as similar as possible.' … and his said, 'Emphasize differences.</em></div>
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<strong> "Sense of Doubt" by David Bowie - incipient alien hand syndrome</strong></div>
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<span style="font-family: inherit;"><strong>Many of the cards are however more general and useful in many situations </strong>- I have often found them to act as catalysts for creative ideas both in a previous more artistic career and now as a scientist. </span><br />
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Science and art are not mutually exclusive and most, if not all, of us engage with both ...the struggle between <em>structure </em>and <em>serendipity</em> and not a reduction of one to the other </div>
</span>As Eno says<br />
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<em>Of course, the chances of you getting a great piece of music are quite remote....But the chances of you getting a seed for something are quite strong. </em></blockquote>
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<span style="font-family: inherit;">Oblique Strategies will not give you a high H-Index or guarantee a successful scientific career, but may provide that lacking <em>creative </em>spark at the many overly-analytical stages of the scientific process</span><br />
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<a class="image" href="http://en.wikipedia.org/wiki/File:Rorschach_blot_03.jpg" style="margin-left: 1em; margin-right: 1em;"><img alt="" class="thumbimage" height="219" src="http://upload.wikimedia.org/wikipedia/commons/thumb/8/82/Rorschach_blot_03.jpg/220px-Rorschach_blot_03.jpg" srcset="//upload.wikimedia.org/wikipedia/commons/thumb/8/82/Rorschach_blot_03.jpg/330px-Rorschach_blot_03.jpg 1.5x, //upload.wikimedia.org/wikipedia/commons/thumb/8/82/Rorschach_blot_03.jpg/440px-Rorschach_blot_03.jpg 2x" width="320" /></a></div>
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In this context, it is worth noting that the Oblique Strategy cards are a simple stimulus open to massive interpretation - not unlike inkblot cards from the <a href="http://en.wikipedia.org/wiki/Rorschach_test" title="Rorschach test">Rorschach test</a>. Research shows that the number of unique responses to random figures (like the one above) is linked to having larger amygdalae. <a href="http://amygdalar%20enlargement%20associated%20with%20unique%20perception/" target="_blank">Asari et al (2010) </a>asked healthy participants to report what the figure looked like the number of responses correlated positively with amygdala size. <br />
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=yFj-vDs52vTWKM&tbnid=lqLETxEaWMUaMM:&ved=0CAUQjRw&url=http%3A%2F%2Fpolemie.com%2Fgustav%2F%3Fattachment_id%3D159&ei=xy4tUafgGuvL0AXe-oC4Dw&psig=AFQjCNHzV5h42V_BCz0LspRW_XJ5lhDxnA&ust=1362001832531728" id="irc_mil" style="border: 0px currentColor; margin-left: 1em; margin-right: 1em;"><img height="208" id="irc_mi" src="http://polemie.com/gustav/wp-content/uploads/2011/11/amygdala-hippocampus.jpg" style="margin-top: 47px;" width="320" /></a></div>
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<span style="font-family: inherit;">The authors suggest of course that amygdalar enlargement in the normal population might be related to creative mental activity. </span>Indeed, unique Rorschach responses are observed at higher frequency in the artistic population (e.g. Ramachandra, 1994; Rorschach, 1921) as well as more frequently in those with psychosis (e.g. Exner, 2003)....<strong>So, perhaps Oblique Strategies will enlarge your amygdalae</strong></div>
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<strong>"Through Hollow Lands" For </strong><a href="http://en.wikipedia.org/wiki/Harold_Budd"><strong>Harold Budd</strong></a><strong> (arr. </strong><a href="http://en.wikipedia.org/wiki/Fred_Frith"><strong>Fred Frith</strong></a><strong>, Eno) </strong></div>
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<strong>from <em>Before & After </em>S<span style="font-family: inherit;"><span style="font-family: inherit;"><em>cience</em></span></span></strong></div>
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<span style="font-family: inherit;">To finish with a random, creative amygdala-Brain Eno connection - here is 'Through Hollow Lands' from Eno's <em>Before and After Science </em>album. </span><span style="font-family: inherit;">The psychology link? This piece was co-arranged by and features <strong>Fred Frith </strong>- one of the founding members of the illustrious and wonderfully monickered <a href="http://en.wikipedia.org/wiki/Henry_Cow" target="_blank">Henry Cow</a> - an art group that came out of Cambridge University in the late 1960s/early 1970s. Fred Frith is, of course, the brother of the psychologist <a href="http://en.wikipedia.org/wiki/Chris_Frith" target="_blank">Chris Frith</a>... </span>who has written extensively on <a href="http://rstb.royalsocietypublishing.org/content/362/1480/671.full" target="_blank">the Social Brain?</a> (mentioning the amygdala a lot) and here is Henry Cow with their track <em>Amygdala</em></div>
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I wonder if scientists have large amygdalae?</div>
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<strong>'Amygdala' by Henry Cow </strong><br />
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<em>Intellect catching up with intuition</em></div>
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com1tag:blogger.com,1999:blog-7082878015421475244.post-89584128200232177442013-02-09T08:30:00.000-08:002013-02-09T08:56:21.210-08:00Satellites of Love: uninterpretable results<div style="text-align: center;">
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=T5hY8-vhC1v20M&tbnid=WJmgG8QpMpIPOM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.funkidslive.com%2Ffeatures%2Famys-aviation%2Famys-aviation-auto-pilot%2F&ei=ylcWUamGI8yz0QWH_oGgBw&bvm=bv.42080656,d.d2k&psig=AFQjCNGGxkaU9aKjxEWvUjFHH2bcQ_r6DA&ust=1360505116033832" id="irc_mil" style="border: 0px currentColor;"><img height="260" id="irc_mi" src="http://www.funkidslive.com/wp-content/uploads/2012/12/Autopilot.jpg" style="margin-top: 0px;" width="181" /></a><em><br />In llama land there's a one-man band<br />And he'll toot his flute for you<br />Come on fly with me, let's take off in the blue</em></div>
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Frank Sinatra (Come Fly with Me)<br />
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Cognitive Behavioral Therapy for negative symptoms in psychotic disorders: a pilot study</h3>
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Staring, Hurne & van der Gaag (2013 in press)</h3>
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Another month and another CBT for psychosis study that is <strong>uninterpretable</strong>. In previous months, I have commented here and on Twitter about CBT for psychosis studies often failing to use a control group and/or blinding of outcome assessments. As an example, I recently blogged on: <a href="http://keithsneuroblog.blogspot.co.uk/2012/11/cbt-shes-lost-controls-again.html" target="_blank"><strong>Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial</strong></a><strong> </strong>by Morrison et al<br />
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Here we have another, in press at <em>Journal of Behavior Therapy and Experimental Psychiatry. </em>While Morrison et al referred to theirs as <strong>'exploratory'</strong>, Staring et al provide us with the ubiquitous .... <strong>'pilot'</strong><br />
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<strong>Satellite of Love by Lou Reed</strong></div>
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<strong>What did Staring et al do?</strong></div>
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In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative symptoms received an average of 17,5 sessions of CBT-n (CBT for negative symptoms). At baseline and end-of-treatment, they assessed negative symptoms. They claim that "Intention-to-treat analyses showed a within group effect size of 1.26 on negative symptoms"</div>
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<strong>An effect size of 1.26 is, of course, massive - if only it meant something. </strong>As noted previously nonblind (open) studies are prone to large bias and without a control group, who knows why they changed. To be fair to the authors, they do have a limitations section - and it is quite large! Here is part of it:<br />
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"This was an <strong>uncontrolled </strong>study. Therefore the efficacy findings are <strong>biased</strong>. Patients may have improved over the course of the study by <strong>self-initiated change </strong>or <strong>because other treatments were helpful</strong>. The lack of a control group means that this effect was not controlled for."<br />
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"Second, also as a consequence of the uncontrolled design, measurements were not blind. We mostly used <strong>self-report measurements, and patients were fully aware that they had received an active treatment </strong>for their negative symptoms. This may have caused efficacy to be overestimated"<br />
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=NBwGNaD6LXe-pM&tbnid=6wsewoHC7XGYeM:&ved=0CAUQjRw&url=http%3A%2F%2Fllamalandfunland.tumblr.com%2Fpost%2F13259195534&ei=iWsWUdaTJ4Sa1AXo2YDwAw&bvm=bv.42080656,d.d2k&psig=AFQjCNEoxjP1J1i6yjzNskp7WWOdZb20RA&ust=1360510163296154" id="irc_mil" style="border: 0px currentColor;"></a> <a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=NBwGNaD6LXe-pM&tbnid=6wsewoHC7XGYeM:&ved=0CAUQjRw&url=http%3A%2F%2Fllamalandfunland.tumblr.com%2Fpost%2F13259195534&ei=iWsWUdaTJ4Sa1AXo2YDwAw&bvm=bv.42080656,d.d2k&psig=AFQjCNEoxjP1J1i6yjzNskp7WWOdZb20RA&ust=1360510163296154" id="irc_mil" style="border: 0px currentColor;"><img height="260" id="irc_mi" src="http://25.media.tumblr.com/tumblr_lv6ek8C9mp1r6lybao1_500.jpg" style="margin-top: 0px;" width="226" /></a></div>
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One thing we may be sure of is that the effect is overestimated...why? Because studies meeting <em>acceptable </em>quality i.e. RCTs that are blind and with controls suggest an effect size of <strong>at most .20 and nonsignificant (Wykes et al 2008) - </strong>Seems an <strong>overestimation is likely - by about 6 fold</strong>!<br />
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Anyway, my point here is that we need to have some monitoring of studies that are essentially <strong>uninterpretable. </strong>To borrow a phrase from Lou Reed, I see them as "<strong>Satellites of Love</strong>" - autopilot research - probably done out of love - but ultimately clutter-up the science atmosphere. <br />
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The authors finish with:<br />
"Randomized controlled trials with sufficient statistical power will need to be performed in order to confirm or refute our results"<br />
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This is somewhat odd because, as noted, many RCTs have already shown CBT to be ineffective for negative symptoms - as such... the study was refuted at conception<br />
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...All such satellites should engage auto-pilot and return to 'Llama land'<br />
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p.s. ask youself - would the study have been published if the results were negative?<br />
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<a data-ved="0CAUQjRw" href="http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=NBwGNaD6LXe-pM&tbnid=6wsewoHC7XGYeM:&ved=0CAUQjRw&url=http%3A%2F%2Fllamalandfunland.tumblr.com%2Fpost%2F13259195534&ei=iWsWUdaTJ4Sa1AXo2YDwAw&bvm=bv.42080656,d.d2k&psig=AFQjCNEoxjP1J1i6yjzNskp7WWOdZb20RA&ust=1360510163296154" id="irc_mil" style="border: 0px currentColor;"></a><br /></div>
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-86395153965505269132013-01-29T12:56:00.002-08:002013-01-29T12:56:54.922-08:00Its Just a Story: Transition to Psychosis & CBT<div id="gs_cit1">
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<em>I've been living through changes...And I could swing for you<br />I can see the veins in my hands...Are showing through</em></div>
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<em>But if you disguise what...These things are doing to me<br />If you criticize them...I'll know that you can see...<br />Until you realise<br />It's just a story</em></div>
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<strong>The Teardrop Explodes (Treason) </strong></div>
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Stafford MR, Jackson H, Mayo-Wilson E, Morrison AP, & Kendall T. (2013). Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ, 346, f185</h3>
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Oh the irony ....just as many (often in the UK) were clamouring for the DSM-5 to dispense with so-called <strong>Attenuated Psychosis Syndrome </strong>(which they did <a href="http://www.nature.com/news/psychosis-risk-syndrome-excluded-from-dsm-5-1.10610" target="_blank">reject</a>), the Brits sneaked it in through the back door as <strong>(Ultra) High Risk for Psychosis </strong>in the new NICE guidelines for <a href="http://www.nice.org.uk/nicemedia/live/14021/62392/62392.pdf" target="_blank">Psychosis and Schizophrenia in Children and Young People</a>. In their 485 page guide, NICE advise on 'treatment' for those aged between under 18 (estimates suggest a 0.4% prevalence of psychotic disorders in children aged between 5 and 18 years)<br />
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The cliche states that <strong>'An ounce of prevention is worth a pound of cure</strong>' and a recent meta-analysis (<a href="http://www.bmj.com/highwire/filestream/625774/field_highwire_article_pdf/0/bmj.f185" target="_blank">Open Access in BMJ</a>) examines whether various interventions might prevent or delay transition to psychotic disorders for people at 'High Risk'. The paper was written by some members of the NICE committee who prepared the guideline for children and young people; and underpins some of their decision making process...so, is worthy of closer inspection<br />
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I want to focus on their recommendation - CBT - as their conclusion implies CBT is the best course of 'action' for preventing transition to psychosis<br />
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Stafford et al declare that "<strong>Among people at “ultra high risk” of psychosis, about 22% to 40% transition within 12 months </strong>[and that]<strong> </strong>Interventions that delay or prevent transition to psychosis from this prodromal syndrome could be clinically and economically important." Unquestionably, if up to 40% of those who would go on to develop psychosis (schizophrenia) could receive an intervention to <em>delay </em>or even <em>prevent </em>such a transition, this might be viewed as a worthy ambition. <br />
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<strong>What is (Ultra) High Risk and what did Stafford et al do?</strong><br />
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Stafford et al meta-analysed 5 studies examining people "judged to be at risk of developing psychosis on the basis on a <strong>clinical assessment identifying prodromal features</strong>."</div>
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<strong>and they conclude that</strong> Cognitive Behavioural Therapy has the effect of "reducing transition to psychosis at 12 months (risk ratio 0.54 (95% confidence interval 0.34 to 0.86); risk difference −0.07 (−0.14 to −0.01)."<br />
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<strong>Teardrop Explodes (Treason 1980) - Julian Cope as popstar and unfortunate dancing </strong></div>
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<strong>A few of my observations:</strong><br />
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1) The authors report that the Risk Difference is -0.07. This means that CBT produces a <strong>7% reduced risk for transition to psychosis compared to control</strong>. To translate this into another common metric, the <a href="http://en.wikipedia.org/wiki/Number_needed_to_treat" target="_blank">Number Needed to Treat (NNT),</a> an average of 14 people need to be treated with CBT to prevent one person developing psychosis - this NNT is somewhat larger than typically claimed by individual studies!<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijfZgvW2aRtgBtjlU1Cvmd3ekpt1vIIeEwjFTzttcYd52Xt96vTVTK_OxtKQNsqaUaINGGD1TdqDYZuzKYTGDNED6t3UITrbaTwP2Gkba9WUowH6eS_m105bJiqD-s_IYXPfavWrLB3Us/s1600/Trans.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="176" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijfZgvW2aRtgBtjlU1Cvmd3ekpt1vIIeEwjFTzttcYd52Xt96vTVTK_OxtKQNsqaUaINGGD1TdqDYZuzKYTGDNED6t3UITrbaTwP2Gkba9WUowH6eS_m105bJiqD-s_IYXPfavWrLB3Us/s400/Trans.jpg" width="400" /></a></div>
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<strong>Figure 1. </strong>Risk Ratios for Number of transitions to psychosis in CBT vs supportive counselling</div>
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2) As can be seen in Fig 1, the small significant effect reflects the pooling of 5 studies; however, <strong>none of the five studies were themselves significant! </strong>The wonderful world of meta analysis (I have referred to this phenomenon previously in my blogs on using <a href="http://keithsneuroblog.blogspot.co.uk/2012/03/whats-your-poison-lsd-vs-alcohol.html" target="_blank">LSD to treat alcholism</a> and <a href="http://keithsneuroblog.blogspot.co.uk/2012/07/negativland-what-to-do-about-negative.html" target="_blank">how to deal with negative findings</a><br />
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Figure 1 also shows that the transition rate is extremely small in these studies - nowhere near the heights of 40% but closer to 10% on average. In other words, <strong>90% of the identified High Risk individuals do not develop psychosis at all! </strong>In this context, we need to seriously consider the risks of labelling 9/10 people as High Risk when they are not! The stigma of being labelled High Risk was one major complaint about adding Attenuated Psychosis Syndrome to the DSM-5. As McGorry et al (2003) rightly state "<em>most cases of first episode psychosis still come from the low-risk and undetected groups</em>" (p.784) - not from the ironically entitled 'Ultra High Risk'!<br />
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3) Although the NNT and Risk Difference figures are not overly impressive, they do appear to record a significant effect. Nonetheless, the difference between CBT and control in conversion rates disappears beyond 12 months i.e. the point at which this meta-analysis terminates. As the authors state:<br />
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"At 18 months, there was low quality evidence that CBT is associated with fewer transitions (0.63 (0.40 to 0.99)), and <strong>the effect did not remain significant in sensitivity analysis </strong>(0.55 (0.25 to 1.19))."<br />
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If a small effect of CBT disappears beyond 12 month comparisons - how useful is it? And why stop at 12 months?<br />
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4) Analysis of the effects of CBT on symptoms of psychosis is also worth considering in transition studies and the authors did examine this. <br />
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"<strong>Combined effects for positive symptoms of psychosis, depression, and quality of life were not significant at any time point</strong>."</blockquote>
To reiterate, CBT did not impact symptoms at all!<br />
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5) Finally, the authors claim that all of the 5 included studies were high quality (having excluded others for example, for lack of blinding for raters at outcome). Their Figure 2 (see below) indicates that the 5 CBT studies (Addington 2011; Morrison 2004; Morrison 2011; Phillips 2009 and van der Gaag 2011), were all blind at outcome assessment (see blinding of outcome assessment column)<br />
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However, the Morrison et al (2004) study was not blinded at outcome - as they say in that 2004 paper <br />
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"Assessors were <strong>intended to be masked</strong> to the condition to which the patient was allocated; however, this proved difficult in practice because the participants often divulged information about their therapist, or used language that suggested they were receiving cognitive therapy...<strong>It proved impossible fully to maintain masking to treatment allocation for assessment of the primary outcome</strong>" Morrison et al (2004)</blockquote>
It seems somewhat odd to make such a mistake- as Morrison one of the authors of this current meta-analysis! <strong>Removing Morrison et al (2004) from the analysis reduces the Risk Ratio (RR=.60 [.37 to 0.99) which now becomes marginally significant (p=.044) and suggests that the NNT with CBT would be 22 to stop one psychosis transition. </strong><br />
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To conclude, it seems that Ultra High Risk for Psychosis, which has been sneaked into NICE guidelines for children and the young, has a limited application - probably less than 1 in 10 individuals actually convert. Moreover, the claim that CBT provides the best form of 'treatment' also seems unsubstantiated. As usual, I am sure we will hear claims for further, better, larger trials - to justify the conclusion already made!<br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com8tag:blogger.com,1999:blog-7082878015421475244.post-82582907873896528642012-12-22T10:57:00.004-08:002012-12-22T12:07:25.147-08:00Santa Dog<table __gwtcellbasedwidgetimpldispatchingblur="true" __gwtcellbasedwidgetimpldispatchingfocus="true" cellspacing="0" class="GLVTYVNL0">
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<em>Santa Dog's a Jesus Fetus<br />Santa Dog's a Jesus Fetus<br />Santa Dog's a Jesus Fetus<br />Has no presents,<br />Has no presence<br />In the future...<br />...In the future</em></div>
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I started blogging mid March 2012 and until now, made 18 posts. As we approach Christmas and the end of the year, here are my Top 5 in terms of views</div>
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<strong>Santa Dog by the Residents (my favourite xmas song)</strong></div>
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Number 5: <a href="http://keithsneuroblog.blogspot.com/2012/03/whats-your-poison-lsd-vs-alcohol.html" target="_blank">Whats Your Poison - LSD vs Alcohol</a><strong></strong></h3>
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At number 5 was my very first post on the meta-analysis by Krebs & Johansen suggesting using LSD as a treatment for alcoholism. The study attrated a lot of media attention and the following striking comment from Prof David Nutt that: <em>"Overall there is a big effect, show me another treatment with results as good; we've missed a trick here…This is probably as good as anything we've got [for treating alcoholism]." </em>Needless to say, I was not as convinced and my blog drew some ire from one of the authors, who e-mailed me asking me to refrain from any more public comments and then posted their own response on the <a href="http://www.nature.com/news/lsd-helps-to-treat-alcoholism-1.10200" target="_blank">Nature </a>wesbite (strangely through an intermediary!)</div>
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Number 4: <a href="http://keithsneuroblog.blogspot.com/2012/09/strange-fruit-is-racism-mental-illness.html" target="_blank">Strange Fruit: Is Racism a Mental Illness?</a> </h3>
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At Number 4 was my blog on whether racism could be a form of mental illness. Originally spurred by a newspaper article about a man who tried to use his schizophrenia diagnosis to mitigate his violent racist behaviour in court...and failed; and a subsequent Twitter interaction with @JonesNev, who argued that schizophrenia "often does lead otherwise liberal, kind, non-racist people to become glaringly,
bluntly racist, sexist, phobic, nymphomanic, hostile". Anyway, it led me to investigate past claims from psychiatrists that racism is an abnormal belief that could qualify as a delusion.</div>
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Number 3: <a href="http://keithsneuroblog.blogspot.com/2012/11/cbt-shes-lost-controls-again.html" target="_blank">CBT: She's Lost Control(s) Again</a></h3>
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Number 3 was one of my several blogs about CBT. In this case, the first study to examine using CBT to alleviate symptoms in cases of psychosis where the individuals have chosen to be unmedicated. Of course, the study attracted wide media attention and for me, premature attention for their unfinished trial of CBT in unmedicated psychosis (e.g on BBC Radio 4 <em>All in the Mind </em>link in the blog). The study contains major methodological flaws, nobody should view it as other than fatally flawed and I await the results of their properly controlled trial for some interpretable data.</div>
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Number 2: <a href="http://keithsneuroblog.blogspot.com/2012/04/cbt-you-spin-me-round.html" target="_blank">CBT: You Spin me Round</a></h3>
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At number 2, another CBT study and with the same main author as the unmedicated trial at number 3. This time it was using CBT to prevent transition to psychosis. The main upshot here is that it failed to show any effect - yet the authors went to extraordinary lengths to spin the results positively. We should not blame journalists when results are unreasonably/falsely represented in the media - however in this case: authors, media and even the journal (British Medical Journal) were at fault for spinning unanimously negative results</div>
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Number 1: <a href="http://keithsneuroblog.blogspot.com/2012/07/negativland-what-to-do-about-negative.html" target="_blank">Negativland: What to do about negative findings?</a></h3>
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By a clear margin, my Negativland blog received the most hits. This post concerned the issue of how we deal with negative findings in science (psychology). Since this post, a great deal of much-needed discussion has occurred around this issue and about how psychology in particular might get its house in order. I have subsequently much expanded the ideas in this blog and hopefully, an article will appear in the Open Access journal <a href="http://www.biomedcentral.com/bmcpsychology" target="_blank">BMC_Psychology</a> in the New Year.</div>
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I have enjoyed my 10-month foray into blogging and much appreciate all of the feedback and interactions that have stemmed from this - thanks for your interest <br />
Merry Xmas and a Happy New Year</div>
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-91732330836820589972012-12-11T05:56:00.000-08:002012-12-18T08:40:16.203-08:00Significantly nonsignificant<div class="separator" style="clear: both; text-align: center;">
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<span style="font-size: small;"><em>In the morning I'd awake and I couldn't remember<br />What is love and what is hate? - the calculations error</em></span></div>
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<strong>Flaming Lips (Morning of the Magicians)</strong></div>
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<span style="font-size: large;"><strong>Cognitive behaviour therapy for psychosis can be adapted for minority ethnic groups: A randomised controlled trial</strong></span></div>
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<span style="font-size: large;">Shanaya Rathod, Peter Phiri, Scott Harris, Charlotte Underwood, Mahesh Thagadur, Uma Padmanabi & David Kingdon</span></div>
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<strong><em><span style="font-family: AdvTT5235d5a9;"><span style="font-family: AdvTT5235d5a9;"></span></span></em></strong> </div>
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Recently I have commented on what I see as methodologically poor, biased and spun studies of CBT for psychosis - every time I want to blog on someting else, out comes another questionable study - this time 'in press' at <a href="http://www.sciencedirect.com/science/article/pii/S0920996412006214" target="_blank">Schizophrenia Research</a>, which I think requires comment - in particular, the gap between the reality and presentation of findings <br />
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This is an RCT looking at the use of CBT in UK minority groups with a diagnosis of schizophrenia <br />
A total, n = 33 participants, who were randomly allocated to CBT for psychosis (CBTp n = 16) and treatment as usual (TAU n = 17). Although a relatively small study, the authors did a power analysis based on previous pilot studies and suggest that a minimum of 12 per arm of the trial would be sufficiently powered - obviously they exceed this expectation.<br />
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Did the CBT group show any benefit (i.e. reduction of symptoms) over the TAU group?<br />
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Well, the authors say yes in the abstract:<br />
<blockquote class="tr_bq">
<em>Results</em>: Post-treatment, the intervention group showed statistically significant reductions in symptomatology on overall CPRS scores, CaCBTp Mean (SD) = 16.23 (10.77), TAU = 18.60 (14.84); p = 0.047,with a difference in change of 11.31 (95% CI:0. 14 to 22.49); Schizophrenia change: CaCBTp = 3.46 (3.37); TAU = 4.78 (5.33) diff 4.62 (95% CI: 0.68 to 9.17); p = 0.047 and positive symptoms (delusions; p = 0.035, and hallucinations; p = 0.056). At 6 months follow-up, MADRAS change = 5.6 (95% CI: 2.92 to 7.60); p < 0.001. <strong>Adjustment was made for age, gender and antipsychotic medication. </strong> </blockquote>
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<em>Conclusion</em>: <strong>Participants in the CaCBTp group achieved statistically significant results post-treatment compared to those in the TAU group with some gains maintained at follow-up. </strong>High levels of satisfaction with the CaCBTp were reported</blockquote>
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The key aspect here though is the bolded statement, added casually at the end of the results about <em><strong>'adjustment'</strong></em>. Table 1 from the paper presented below indicates (as the authors rightly admit) that the TAU group were older, had longer duration of illness and greater medication and they duly adjusted analyses for these variables<br />
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However, <strong>the abstract results all refer to unadjusted scores - </strong>see the Table 2 below - all are taken from the non-adjusted column. If you glance to the final column (Adjusted reduction from baseline) - not a single comparison is significant!<br />
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<strong>Table 2 Results</strong><br />
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<span style="font-family: AdvTT5235d5a9; font-size: small;"><span style="font-family: AdvTT5235d5a9; font-size: small;">Maybe someone can explain to me, what is happening here? Is it blatant author spinning to get further funding (as they mention this in the discussion). Is it collusion from reviewers, who let this through? Failure to spot the obvious by reviewers? <br />
Perhaps I am overly critical - letters on a postcard (in the comments section please)</span></span>Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com8tag:blogger.com,1999:blog-7082878015421475244.post-74240568597774534582012-12-03T02:31:00.000-08:002015-08-13T04:19:46.592-07:00Who Watches the Watchmen? Bias in Studying Bias<div class="separator" style="clear: both; text-align: center;">
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<em>The coins are often very old by the time they reach the jeweller <br />With his
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<strong>The Jeweller (by Pearls Before Swine)</strong></div>
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<span style="font-size: large;"><strong>Publication bias in meta-analyses of the efficacy of psychotherapeutic interventions for schizophrenia. </strong><br /> Niemeyer & Musch & Pietrowsky (2012)</span></div>
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<strong>Dan Dreiberg</strong>: I'm not the one still hiding behind a mask; <b>Rorschach</b>: No. You're hiding in plain sight. Interaction from <em>The Watchmen</em> </div>
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<em>Hiding things in plain sight </em>is often the best place to hide them!<em> </em>In my last blog, I referred to <a href="http://keithsneuroblog.blogspot.co.uk/" target="_blank"><em>Daylight Robbery Syndrome</em></a><em> </em>where researchers say things so boldly that readers may be convinced of their validity even when they are not consistent with the data. Here I would like to refer to how researchers may intentionally or unintentionally hide something in front of the reader.<em> </em>In particular, how the application of methods used for detecting bias in meta-analyses may themselves be prone to their own biases. </div>
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This current paper, published recently in <em><a href="http://www.sciencedirect.com/science/article/pii/S0920996412001764" target="_blank">Schizophrenia Research</a>, </em>examines publication bias in studies of "psychotherapeutic interventions for schizophrenia"<em>. </em></div>
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<strong><em> Opening Scene from the Watchmen (Unforgettable by Nat King Cole)</em></strong></div>
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<span class="highlight">As the authors Niemeyer et al rightly state: </span><br />
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"Meta-analyses are prone to publication bias, the problem of selective publication of studies with positive results. It is unclear whether the efficacy of psychotherapeutic interventions for schizophrenia is overestimated due to this problem. This study aims at enhancing the validity of the results of meta-analyses by investigating the degree and impact of publication bias."</blockquote>
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This is certainly true for trials of psychological interventions, where the decision to submit a paper for publication is related to the outcome of the trial. For example, <a href="http://psycnet.apa.org/journals/pro/17/2/136/" target="_blank">Coursol and Wagner</a> (1986) found that when therapeutic studies had positive outcomes (i.e. clients improved) 82% submitted their paper, but with negative outcomes (client did not improve) only 43% submitted their articles (for similar conclusions from a recent meta analysis, see Hopewell et al 2009). </div>
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Returning to the current paper, Niemeyer et al used current standard meta-analytic methods to estimate bias, including: Begg and Mazumdar's adjusted rank correlation test, Egger's regression analysis and the trim and fill procedure. They applied these techniques to data sets derived from systematic reviews up to September 2010. I have remarked on these bias methods briefly in my previous post <a href="http://keithsneuroblog.blogspot.co.uk/2012/07/negativland-what-to-do-about-negative.html" target="_blank">'Negativland'</a>.</div>
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Following their analyses Niemeyer et al concluded:</div>
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"Overall, we found only moderate evidence for the presence of publication bias. With one notable exception, the pattern of efficacy of psychotherapy for schizophrenia was not changed in the data sets in which publication bias was found. Several efficacious therapies exist, and their efficacy does not seem to be the result of publication bias."<br />
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This <em>apparent</em> lack of bias in this paper might be contrasted with the large bias documented by <a href="http://www.ncbi.nlm.nih.gov/pubmed/20194536" target="_blank">Cuipjers et al (2010) </a>in studies examining CBT for depression. Cuipjers and colleagues found an effect size of .67 in 175 comparisons comparing CBT to a control condition; however adjustment for publication bias according to Duval & Tweedie’s trim and fill procedure reduced the mean effect size to 0.42 with 51 studies assumed to be missing i.e residing in file drawers because they were negative. </div>
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I intend to concentrate briefly on the 10 data sets from meta-analyses for studies of CBT for schizophrenia (2 data sets from Lynch et al 2010; 1 from Lincoln et al 2008; 1 from Wykes et al 2008; 5 from Zimmerman et al 2005; and 1 from Jones et al 2010: see Table 1)</div>
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<strong>Table 1. Bias analysis of CBT for schizophrenia meta analyses (from Niemeyer & Musch 2012)</strong></div>
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<strong>A few notable features about Table 1 and the analysis of bias</strong><br />
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1) Our meta analysis (<strong>Lynch, Laws & McKenna 2010</strong>) criticised for being overly selective by some (because we analysed high quality studies using an active control group!) produced a data set with the fewest imputed (i.e. missing studies)<br />
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2) The <strong>Wykes</strong> <strong>et al (2008) </strong>analysis is curious. First the authors state that the effect size was <em>Cohen's d </em>- when in fact <em>Glass' delta </em>was used (a quite different effect size). This could of course be a simple error. The choice of outcome variable, however, is not an error - the authors chose to analyse <em>Low Quality </em>studies from the Wykes paper. Why would a study of bias select only low quality studies and not the high quality or at least both? <br />
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<strong>Table 2 </strong>shows where these (positive symptom) effect sizes were derived from the Wykes et al paper. What is clear is that the low quality studies are not significantly heterogeneous, while the high quality studies show significant heterogeneity - indeed this is partly borne out by the far broader spread of scores for the 95% confidence intervals in high quality studies (even though they constitute almost half the number of low quality studies)<br />
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<strong>Table 2 Effect sizes from Wykes et al (2008)</strong><br />
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By selecting low quality studies, it would seem that the probability of finding bias may be diminished and at the very least, the estimate of bias is unreliable<br />
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3) From the <strong>Lincoln et al</strong> (2008) meta-analysis, the authors selected data for 9 studies comparing CBT vs TAU. Omitted, however, was an additional comparison of 10 studies of CBT vs active control (see Table 3 below)<br />
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<strong>Table 3. Data from Lincoln et al (2008) Meta-analysis</strong><br />
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The notable thing again is that the authors chose to exclude one analysis that has: a) a larger sample b) a non-significant effect and c) far greater 95% Confidence Intervals i.e. variance. Again, these factors could obviously conspire against finding bias and leave us uncertain about bias in this meta-analysis.<br />
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4) From the <strong>Zimmerman et al</strong> meta analysis, the authors included 5 analyses and all bar the last had proportionally large numbers of imputed studies. The one comparison that produced no imputed studies was the comparison with an 'active' control (like Lynch et al - which also produced no imputed studies)<br />
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5) Finally Niemeyer & Musch selected one comparison from the <strong>Jones et al</strong> (2010) Cochrane meta-analysis - a somewhat odd choice to be included - measuring 'relative risk for leaving a study early'. <br />
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These decisions are made somewhat odder and less reliable by the fact that Niemeyer & Musch failed to include any data from meta-analyses by the same Cochrane group examining symptoms (<a href="http://www.ncbi.nlm.nih.gov/pubmed/15495000" target="_blank">Jones et al 2004</a>) or indeed other meta-analyses such as that by <a href="http://journals.lww.com/jonmd/Abstract/2001/05000/Cognitive_Behavioral_Therapy_for_Schizophrenia__An.2.aspx" target="_blank">Rector and Beck (2002) </a>or the <a href="http://www.nice.org.uk/nicemedia/live/11786/43639/43639.pdf" target="_blank">UK NICE Committee (2009)</a><br />
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Anyway, to conclude, the bias analysis of CBT for Psychosis by Niemeyer et al is itself biased by unexplained choices made by the reviewers themselves. Not being psychic, I have no idea why they made these choices or what differences it would make to include different measures and additional meta-analyses. One thing I do know, however, is that any claim that bias does not exist in studies examining CBT for psychosis...is a biased and unreliable! Researchers are familiar with the idea of <em><strong>GIGO (Garbage In Garbage Out)</strong>, </em>which has often been levied at meta-analysis - perhaps we now need to consider <em><strong>METAGIGO</strong></em>! <br />
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Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com1tag:blogger.com,1999:blog-7082878015421475244.post-7937244577160914412012-11-27T12:56:00.000-08:002013-03-09T02:37:49.686-08:00In a Manner of Speaking<div class="separator" style="clear: both; text-align: center;">
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<em>In a Manner of speaking<br />I just want to say<br />That I could never forget the way<br />You told me everything<br />By saying nothing</em></div>
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<strong>In a Manner of Speaking (by Tuxedo Moon)</strong></div>
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I was recently asked to write an article on some of the problems associated with psychological research (e.g. publication bias, authors 'spinning' their results and so on). We often hear complaints from scientists that journalists put a false spin on their findings; however, I am interested in how authors present or spin their own findings. <br />
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Sometimes this spinning in a paper seems to starkly contrast with results of the paper. I can only conclude that some reviewers or editors suffer from what I would call the <strong><em>'Daylight Robbery Syndrome' </em></strong>- from the adage that some burlgars are unlikey to be caught because they rob you so blatantly. Here are my current top five quotes from papers on CBT for psychosis published in high impact journals ...For me, the quotes are the academic equivalent of someone kicking down your front door in broad daylight and then carrying off your 42 inch plasma TV screen under their arm past all of your friends and neighbours... </div>
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Therapeutic work is rife with vague statements, bias and misrepresentations; however, I am sure comparable examples exist in other areas and that readers may readily be able quote examples from their own research areas.</div>
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<strong>In a Manner of Speaking (covered by Nouvelle Vague) </strong></div>
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<strong>1. " Interestingly, psychosocial treatments—such as cognitive behavioural therapy (CBT) and, more recently, arts therapies (music therapy, art therapy, and body movement or dance therapy)—have shown more promise than drug treatments in reducing negative symptoms and their impact, and the National Institute for Health and Clinical Excellence (NICE) has recently recommended these treatments."</strong><br />
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The editorial goes on to discuss the largest, best and most recent study of art therapy for addressing the symptoms of people with schizophrenia (the so-called <a href="http://www.bmj.com/content/344/bmj.e846" target="_blank">Matisse trial by Crawford et al 2012</a>)<br />
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<strong>"The findings of the Matisse trial unfortunately suggest that art therapy, as currently practised in the UK, is unlikely to be of clinical benefit for people with negative or other symptoms of schizophrenia—a conclusion that the profession of art therapy will no doubt find unsettling. However, arts therapies, because they rely on creative expression rather than verbal communication, and some cognitive behavioural approaches, still have the greatest potential for success in the treatment of negative symptoms."</strong></blockquote>
<em>Kendall, T. (2012). Treating negative symptoms of schizophrenia. BMJ-British Medical Journal, 344(7847), 8.</em><br />
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<span style="font-family: AdvPS497E2; font-size: xx-small;"><span style="font-family: AdvPS497E2; font-size: small;">In additon to the elephantine self-contradiction of the latter paragraph - two other things are wrong here. </span></span><span style="font-family: AdvPS497E2; font-size: xx-small;"><span style="font-family: AdvPS497E2; font-size: small;">First, CBT does not significantly reduce negative symptoms - <span style="font-family: AdvPS497E2; font-size: xx-small;"><span style="font-family: AdvPS497E2; font-size: small;">Wykes et al (2008) meta-analysis shows that studies with "acceptable" levels of quality find no significant impact of CBT on negative symptoms. S</span></span></span></span><span style="font-family: AdvPS497E2; font-size: xx-small;"><span style="font-family: AdvPS497E2; font-size: small;">econd arts therapy does not appear to reduce psychotic symptoms nor does it outperform medication in reducing negative symptoms.</span></span> The fact is that no study has compared medication versus any of these therapies ...and so, no data even exist on the issue. </div>
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Perhaps Editorials - <em>unlike this one in the BMJ </em>- really ought to be peer-reviewed!</div>
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<strong>2. Although we failed to show a statistically significant effect of the intervention we cannot rule out a beneficial effect of the cognitive therapy on transition rate (although it could be argued that the sample size required to show such an effect, and the small effect sizes reported here, would make such an endeavour unfeasible in practical terms and unwarranted in clinical terms).</strong></blockquote>
<em>Morrison AP, Stewart SL, French P, Bentall RP, Birchwood M, Byrne R, Davies LM,
Fowler D, Gumley AI, Jones PB, Lewis SW, Murray GK, Patterson P, Dunn G. Early
detection and intervention evaluation for people at risk of psychosis: multisite
randomised controlled trial. British Medical Journal, 344 </em><br />
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The failure to find a significant effect does not eliminate possibility of an effect! I have to ask, what could then eliminate the possibility of an effect...especially with a very small effect size and a huge sample required? Extremely torturous admission of CBT failure...or is it?</div>
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<strong>3. Patients receiving either CBT or supportive counselling in combination with usual treatment demonstrated better symptomatic recovery but no significant reduction in relapse compared with those receiving usual treatment alone... We suggest that the optimum psychosocial management of early schizophrenia would include a combination of CBT and family intervention. </strong></blockquote>
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<em>Tarrier, N., Lewis, S., Haddock, G., Bentall, R., Drake, R., Kinderman, P., ... & Dunn, G. (2004). Cognitive-behavioural therapy in first-episode and early schizophrenia 18-month follow-up of a randomised controlled trial. The British Journal of Psychiatry, 184(3), 231-239.</em></div>
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How to ignore one whole strand of the main findings and also to make a nonsignificant result sound as if it were significant! CBT was no better than Supportive Counselling and yet the authors advocate CBT alongside family intervention - and the latter was not examined at all in this study...a strange conclusion-cocktail! </div>
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<strong>4. We did not find significant between-group differences on symptom reduction, indicating no significant benefit of CBT over PE.” [psycho-education]...The use of an active rather than passive control intervention created a more stringent comparison for CBT, which may have further reduced power to detect the hypothesized changes” </strong></blockquote>
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<em>Cather, C., Penn, D., Otto, M. W., Yovel, I., Mueser, K. T., & Goff, D. C. (2005). A pilot study of functional cognitive behavioral therapy (fCBT) for schizophrenia. Schizophrenia Research, 74(2), 201-209.</em></div>
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The finding of no significant benefit of CBT is <em>blamed </em>on a pesky control group - those cheeky controls reducing power! If only we hadn't used controls, our results, we would have had a significant result .. hey diddle diddle... <br />
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<strong>5. In the linear regression, faster resolution of symptoms in the groups allocated to either psychological treatment condition was seen, compared with routine care alone, but not at statistically significant levels...In summary, for auditory hallucinations, CBT is an improvement on routine care (but the effect is not statistically significant at the α =0.05 level) </strong></blockquote>
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<em>Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon, D., ... & Dunn, G. (2002). Randomised controlled trial of cognitive—behavioural therapy in early schizophrenia: acute-phase outcomes. The British Journal of Psychiatry, 181(43), s91-s97.</em></div>
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It doesn't mater how many times one says 'faster', 'better', improvement' - 'No'significant effect' means <strong>no significant effect</strong>!<br />
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<span class="grand"><em>Blind commitment to a theory is not an intellectual virtue: </em></span><span class="grand"><em>it is an intellectual crime</em>.</span></div>
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Imre Lakatos (1970) </div>
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<span style="color: black;"></span><span style="font-family: inherit;"> </span>Professor Keith R Lawshttp://www.blogger.com/profile/11760248140027990471noreply@blogger.com0tag:blogger.com,1999:blog-7082878015421475244.post-27730468335272010572012-11-11T07:27:00.001-08:002014-04-05T09:37:49.087-07:00CBT: She's Lost Control(s) Again<div class="separator" style="clear: both; text-align: center;">
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<em><strong>And of a voice that told her when and where to act,<br /> She said I've lost<br /> control again</strong></em></div>
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<strong>Joy Division (Shes Lost Control Again)</strong></div>
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Cognitive therapy for people with a schizophrenia spectrum diagnosis not taking antipsychotic medication: an exploratory trial</h3>
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Morrison, Hutton, Spencer, Barratt, Brabban, Callcott, Christodoulides, Dudley, French, Lunley, Tai & Turkington</div>
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This <a href="http://www.mentalhealthexcellence.org/wp-content/uploads/2013/09/Morrisonetal2011CTwithnomeds.pdf" target="_blank">study</a>, published recently in<em> Psychological Medicine</em> marks a departure from previous CBT for psychosis studies as it involves administering CBT to individuals who are unmedicated - and alongside the media attention (<a href="http://www.bbc.co.uk/iplayer/episode/b01nq1cl/All_in_the_Mind_CBT_for_psychosis_US_elections_and_mental_health/" target="_blank">All in the Mind</a>), it is important to look more closely at the study itself.</div>
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Morrison and 11 colleagues examined a small sample of 20 participants with schizophrenia spectrum disorders (actually 18 and one also didn't complete the therapy - so 17). All were <em>outpatients</em> - who had not been taking antipsychotic medication for at least 6 months. Morrison et al measured the impact of CBT on symptomatic outcome measures: Positive and Negative Syndromes Scale (PANSS), which was administered at baseline, 9 months (end of treatment) and 15 months (follow-up). Secondary outcomes were dimensions of hallucinations and delusions, self-rated recovery and social functioning. Rather than dismiss missing data, the authors chose to impute the missing data in the following analyses:</div>
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Their main findings were stated as:</div>
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"significant beneficial effects on all primary and secondary outcomes at end of treatment and follow-up, with the exception of self-rated recovery at end of treatment. Cohen’s d effect sizes were moderate to large [for PANSS total, d=0.85, 95% confidence interval (CI) 0.32–1.35 at end of treatment; d=1.26, 95% CI 0.66–1.84 at follow-up]."</div>
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The authors conclude that the</div>
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"study provides preliminary evidence that CT is an acceptable and<strong> effective treatment for people with psychosis who choose not to take antipsychotic medication</strong>. An adequately powered randomized controlled trial is warranted."<span data-mce-style="font-family: AdvpalSR; font-size: xx-small;" style="font-family: AdvpalSR; font-size: xx-small;"><span data-mce-style="font-family: AdvpalSR; font-size: xx-small;" style="font-family: AdvpalSR; font-size: xx-small;"><span data-mce-style="font-family: AdvpalSR; font-size: xx-small;" style="font-family: AdvpalSR; font-size: xx-small;"></span></span></span></div>
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Now, I do think this is important because some individuals may see this study and attendant media as a basis to decide not to take antipsychotic medication. I have no qualms about personal choice when based on evidence - so let us examine the evidence.</div>
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<strong>Joy Division: Shes Lost Control</strong></div>
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So, what does the study show? Well, the answer comes from the design of the study. It is a <strong>pretest - posttest design i.e. there is no control group</strong>. So, a within-group analysis with no control group. Without a control group of any description, we cannot know if any change is a generalised consequence of the added interaction (rather than anything about CBT itself). And without even a Treatment as Usual (TAU) control group, we cannot exclude the possibility that any change would have occurred regardless of therapy e.g. regression to the mean.</div>
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Second, the trial is an <strong>Open Trial i.e. the outcome measures are not made blind. </strong>All participants are evaluated by members of the team who were involved in the administering the trial. The lack of blinding is the biggest drawback to the evaluation of therapy and is well documented by all meta-analyses in this area (Lynch, Laws & McKenna 2010; Wykes et al 2008).</div>
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So, the study suffers from a host of <strong>threats to validity</strong>: a) <a data-mce-href="http://en.wikipedia.org/wiki/Regression_toward_the_mean" href="http://en.wikipedia.org/wiki/Regression_toward_the_mean" target="_blank">regression to the mean </a>i.e. extreme scores at start simply move toward the (lower) mean on second testing (with no control we cant estimate or eliminate this); b) <a data-mce-href="http://en.wikipedia.org/wiki/Hawthorne_effect" href="http://en.wikipedia.org/wiki/Hawthorne_effect" target="_blank">Hawthorne effect </a>i.e. any change is due to the special circumstances patients find themselves in (with no control, we cant eliminate this); c) lack of <a data-mce-href="http://en.wikipedia.org/wiki/Blind_experiment" href="http://en.wikipedia.org/wiki/Blind_experiment" target="_blank">blinding </a>i.e. those measuring outcome were involved in the study and aware that all patients had received CBT - the authors don't provide detail on this, but presumably some or all of the 8 different therapists administering the CBT to the participants and/or those who designed the study</div>
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<strong>Losing Control adds up!</strong></div>
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<strong>T</strong><strong>o summarise - no control group and no blinding of outcome measures. </strong></div>
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Can we see what happens in such designs with medicated patients? Well, below is a table from a meta-analysis by the CBT guru Aaron Beck looking at effect size for pretes-posttest analyses in medicated patients (Rector & Beck 2002; so 'good' the journal republished it in 2012). Now Morrison et al found <em>d=.85</em> for overall symptoms -Rector and Beck report a much larger mean effect size of <em>d=1.31</em> for pre-post comparison (CBT-RC). So, the effect with unmedicated is substantially less - consider the size in some studies here - Pinto is almost three times that reported by Morrison et al!</div>
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This doesn't alter the fact that Morrison et al do report a substantial effect in unmedicated patients of .8+. However, the second thing to note about the table above is the comparison of CBT with a so-called active control (ST-RC) i.e. a condition that controls for the generalised impact of just interacting with another, receiving attention etc - here the controls are supportive therapy, befriending and so on. This shows that an effect size of .63 emerges in pretest postest designs for something as simple as befriending - not that much smaller than Morrison et al claim to attribute to CBT.</div>
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The final and key point though concerns the lack of blind evaluation. As Morrison et al note in their discussion:</div>
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"CBT for psychosis trials that attempt masking were reported to be associated with a reduction of effect sizes of nearly 60% (Wykes et al 2008)"</div>
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Actually, what Wykes et al say is</div>
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"There is a tendency for the unmasked studies to be overoptimistic about the effects of CBTp, with effect sizes of 50%–100% higher than those found in masked studies."</div>
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60% may be an average, but the reduction could range from 50-100%!</div>
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<strong>Crucially, the patients may not feel better. </strong>At the end of the study, the patients rated themselves as experiencing <strong>no recovery (pre and post); although they did report a <em>minor</em> improvement at the follow-up. </strong>In other words, the non-blind researchers perceived a much greater change than the patients themselves - approximately double the effect size!</div>
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<strong>To conclude:</strong> the use of a pretest-posttest design with no blinding means the authors are unable to draw conclusions about the efficacy of CBT in the study. The effect size is much smaller than in pretest-postest comparisons with medicated patients; of the .85 reported, how much is attributable to generic effects of interaction (and nothing to do with CBT) - well it could be .63; and if we assume a minimum of 60% of this may reflect lack of blinding - then what are we left with? An effect size of possibly less than .1 <strong>- in other words - (next to) nothing! </strong><strong>And patients are not even convinced!</strong></div>
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So, their conclusions that the "study<strong> provides preliminary evidence that CT is an acceptable and effective treatment for people with psychosis who choose not to take antipsychotic medication" </strong>seems unwarranted<strong>.</strong> Some might say, well its called 'exploratory' - but that is no excuse for a design that leaves the data uninterpretable and may even lead to some people changing their behaviour (withdrawing from their medication). I also understand that an RCT with blind assessment is being conducted - indeed, much of the press around this study has been about the uncompleted study - a bit cart before the horse! But at the moment - no data published exist to show that CBT reduces psychotic symptoms in unmedicated individuals</div>
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<strong>References</strong></div>
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</span><span style="font-family: "Times New Roman","serif"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: EN-GB;"><span style="font-size: small;">Lynch, D., Laws, K. R., & McKenna, P. J.
(2010). Cognitive behavioural therapy for major psychiatric disorder: does it
really work? A meta-analytical review of well-controlled trials. <i>Psychological
medicine</i>, <i>40</i>(01), 9-24.<o:p></o:p></span></span></div>
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<span style="font-family: "Times New Roman","serif";"><span style="font-size: small;">Wykes,
T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior
therapy for schizophrenia: effect sizes, clinical models, and methodological
rigor. <i>Schizophrenia Bulletin</i>, <i>34</i>(3), 523-537.<o:p></o:p></span></span></div>
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