Wednesday, 29 May 2013

Rise of the Headclutchers

It was recently brought to my attention by Twitter user @sectioned_ that there is an alarming new breed of mental health sufferer called the Headclutcher. So prevalent are these people that the media have started to use them to illustrate nearly every story they run about mental health. As a way of documenting emerging cases I have started to upload them to this blog. Please get in touch (in the comments section) with any new examples and I will add them here. The disorder seems almost exclusively to effect women, so any cases recorded in men will be especially helpful. 

Is this lady distressed because of an undisclosed mental health problem or because she has been chosen to illustrate such a laughably dichotomous and poorly put together debate piece about mental health diagnosis?

This photo almost certainly does not actually depict the suicidal lady in this report who was told to have a cup of tea when she phoned an NHS helpline, unless perhaps she is holding the phone extremely close in order to hear the operator.

Like something out of The Ring, the pyjama'd child, who was used to illustrate this story on Mental Elf, is perhaps lamenting the fact that she is so small she can fit in the palm of an enormous hand.

The Mail reported that women experience 40% more mental health problems than men, and used this picture showing two women playing hide and seek to try and cheer themselves up.

The Guardian reported on the same study and used this photo of a 1960s Californian folk musician trying to compose a song about the issue.

This lady is trying to hide her identity so that we don't associate her with this sloppy comment piece in The Mail arguing for the societal exclusion of mental health patients, under the false premise of "breaking the taboo".

The BBC was lucky to find this lady who was willing to pose for a photo and was just as dismayed about the publication of DSM-5 as Peter Kinderman in his piece on their website.

This lady's headclutching began, if The Guardian is to be believed, when the DSM-5 was published. The disorder has not yet advanced to clutching with the second hand, so there is still hope for her.

Twitter user @suzyg001 alerted me to the fact that, what with this example from The Guardian and the lady at the top of my post: "Deep ribbing on the sleeves of one's jumper appears to be associated with this condition"

This example from a therapy website would seem to offer confirmation of the link.

Yet more evidence of the ribbed-jumper-headclutching link, courtesy of @chasingdata, who found this article on The Daily Mail. Of course this looks like headclutching, but given this lady's attire it may well be a dance or yoga position. She may also be dismayed that The Mail has only now cottoned on to the over-30 year old change from "Manic Depression" to "Bipolar Disorder".

Rare Male Headclutchers:

Thanks to @Sectioned_ we have documentary evidence of a male headclutcher! However, this poor chap only seems to have been used by the BBC because he illustrates the fact that men were more likely than women to kill themselves in 2011:

Stories about students are often an excuse for a picture of a female undergraduate, so hats off to The Guardian for using this guy to illustrate a story about mental health in universities. He is sad because his headclutching renders him unable to pick up any of the books surrounding him:

Is this gentleman clutching his head because his cup of tea has gone cold, or because he's perversely dismayed that a law has been passed to tackle mental health discrimination?

And Finally:

There is new hope for the treatment of Headclutchers, documented in this photo used by The Guardian, which appears to show a sufferer with her hands successfully restrained just behind her head. Presumably they were tied there by the blurry young man now gazing so intently at her:


I have a letter in this month's Psychologist magazine, which you can read here. The letter is my response to the overly dichotomous debate in the Observer triggered a few weeks ago when the DCP issued their statement rejecting DSM.

Thursday, 23 May 2013

What Does the Narrative Fallacy Mean for Psychological Formulation

As part of my training to be a clinical psychologist, I am learning to construct formulations. These are short causal stories about a person's life which help us to understand why they are experiencing the things that have pushed them to seek help. It is premised on the idea that our experiences make us who we are, and that exploring a person's history explains why they are suffering. In the words of one phrase doing the rounds at the moment we should ask "not what's wrong with you, but what's happened to you?" Formulation is a self-evidently important part of all psychotherapy (which after all, generally deals in how people's experience has taught them to be who they are), and it has a particularly political role at the moment, as it has recently been proposed as an alternative to diagnosis by the British Psychological Society's Division of Clinical Psychology.

However, formulation has a thorny epistemological problem to contend with. In his book on the importance of rare events, "The Black Swan" Nassim Nicholas Taleb discusses the "Narrative Fallacy". This is Taleb's name for the phenomenon whereby humans, myth-making creatures that we are, make erroneous stories up to explain the facts that we encounter in our lives. This is particularly important in the realm of investment, where a causal understanding of the fluctuations of markets can allow traders to reap gains and avoid losses. Indeed, it is on an investment news blog that I found this fantastic example.

Information in a formulation is assumed to be in some way causally relevant, connected to an individual's current suffering in an explanatory way. But when do we decide that such information is causally relevant and when it isn't, especially when considering the nature/nurture mush that remains so difficult to parse? We can say that some events can be said theoretically to have a causal role, but we also know people are differentially susceptible to the adversity that they experience. A great deal rides on this. A clinician might decide, for the sake of an obvious example, that a person's voices arise from a dissociative response to a trauma, but they may also be due to an organic psychosis caused by an underlying pathology like a brain tumour. The consequences of such mis-specification could be devastating.

Psychiatric history is full of problematic causal stories; in the 1950s and 60s it was common to blame Autism on "refrigerator mothers", which came to be seen as essentially placing blame on mothers for a disorder we now think of as substantially genetic.

All theories are narratives, and formulation as described by the BPS has some good theoretical safeguards, being described as "hypotheses to be tested" in the BPS practice guidelines. This quote also comes from those guidelines:
"It should be acknowledged that all human beings are meaning-makers who create narratives about their lives and difficulties. Formulations differ from this kind of explanation by being strongly rooted in psychological theory and evidence." (p.7)
However, formulation, as a touted alternative to diagnosis, is subject to the same potential for epistemic misuse as the alternative. It has often been said that diagnosis is "just a hypothesis", but the case against it rides, in part, on the fact that it is too often taken as "gospel" truth (the DSM is "psychiatry's bible" after all right?)

The promotion of formulation is a testament (another bible reference!) to the idea that a sequence of events at the psychological/social level should be given an important role in constructing an explanation. This factors in important information that has historically been overlooked by psychiatry. However, taken without the necessary skepticism, it runs the risk of disregarding the possible irrelevance of psychosocial factors relative to biological factors in any given case. If formulation is to work responsibly we should remain open to the possibility that some of the problems people have are caused by the elements less visible to the narrating eye.

Wednesday, 15 May 2013

The Good, The Bad and The Ugly: Thoughts on the Bentall/Laws Showdown

Richard Bentall changed the direction of my career. His magnum opus Madness Explained came out when I was a final year undergraduate, and without it I doubt I would have opted to pursue training in clinical psychology. The book is by turns a history of psychiatry, a philosophically literate critique of the notion of psychopathology and an erudite account of the (then) state of the art in psychological research into psychosis. It was and remains a thrilling and considered read.

So I was disappointed to see Bentall brought low by a feud with another psychosis researcher; in the comments section of a blog of all places. Keith Laws is professor of cognitive neuropsychology at Hertfordshire University and was also, delightfully, a founder member of arch misery-rockers The The. Over at his "Neuro-blog" Laws maintains a sardonic and colourful critique of bad science in psychology.

The dispute in question (in the comments section of this post) concerns one of Laws' main targets, research into CBT for psychosis (CBTp). Laws has authored at least one meta-analysis that shows CBTp is no better than a control at improving people's symptoms. In addition to this, he is an avid chronicler of all the rhetorical tricks and methodological sleights of hand that have allowed pro CBTp researchers to promote the intervention, which is listed by NICE in their recommendations for treating people diagnosed with Schizophrenia. Bentall appears to have had enough.

The Good:

Schizophrenia research is almost intractably mired in its own dodgy metaphors. A clear view of the target is constantly obscured by the not-so-subtle implications of the DSM; that it is a genetic brain disease, and one which inevitably leads to cognitive decline and can only be treated by drugs. This metaphor gets us into all sorts of trouble, the worst of which is that people designated Schizophrenic end up receiving only this "medical" (though equating the medical with the pharmacological is itself a mischaracterisation) sort of treatment and have limits placed on their opportunity to receive support pertaining to the social and psychological aspects of their life. In this context, research into CBTp seemed to offer the promise of an alternative; a way of crow-barring the psychological into the medical field by validating it not only as humane, but as evidence-based. Only thus, it would seem, can more person-focused treatments find room in the resource scarce arena of mental health.

The Bad:

However, CBTp needs to play by the same rules as its competitors. Even if it feels like a kind thing to deliver, and even if service users want it, it's not OK to mislead. CBTp is only one way of offering help to people instead of patients, and unless it is better than the others, it does not deserve privilege in a resource-strapped environment. Now you could argue that the findings that speak against CBT are bogus because the evidence in question is not based on the outcomes that are important to patients. I think this idea has some traction, but it is a problem with Evidence Based Medicine as a whole, and to raise it only in relation to a specific case smacks of moving the goalposts. If you suspect the actually existing data of limiting our vision in some way, you need to show why, and provide evidence that backs up your case.

The Ugly:

What could be uglier than an over-aggrieved self-defence in the face of the evidence? Bentall seems to think that Laws is personally goading him and his colleagues. This might be how the discussion comes across, but the point of Laws' blogs is always to query the data rather than attack the people behind it. This is more than can be said for Bentall's response. There is a difference between knowingly allow yourself to bruise egos, and launching an attack that is based solely on someone's purported motivations.

Mental Health research is unavoidably political and I would like to continue seeing psychologists advocating outside of the academy, but Laws doesn't have a horse in this race in the same way that CBTp researchers do. He is not outgunning the clinicians, he is keeping us honest.

Friday, 10 May 2013

What Would Freud say?

I came across this quote from Instincts and Their Vicissitudes last night. This is Freud defending the scientific utility of his theory of drives, but it could just as easily be applied to psychiatric diagnostic categories:
"We have often heard it maintained that sciences should be built up on clear and sharply defined basic concepts. In actual fact no science, not even the most exact, begins with such definitions. The true beginning of scientific activity consists rather in describing phenomena and then in proceeding to group, classify and correlate them. Even at the stage of description it is not possible to avoid applying certain abstract ideas to the material in hand, ideas derived from somewhere or other but certainly not from the new observations alone. Such ideas—which will later become the basic concepts of the science—are still more indispensable as the material is further worked over. They must at first necessarily possess some degree of indefiniteness; there can be no question of any clear delimitation of their content. So long as they remain in this condition, we come to an understanding about their meaning by making repeated references to the material of observation from which they appear to have been derived, but upon which, in fact, they have been imposed. Thus, strictly speaking, they are in the nature of conventions—although everything depends on their not being arbitrarily chosen but determined by their having significant relations to the empirical material, relations that we seem to sense before we can clearly recognize and demonstrate them. It is only after more thorough investigation of the field of observation that we are able to formulate its basic scientific concepts with increased precision, and progressively so to modify them that they become serviceable and consistent over a wide area. Then, indeed, the time may have come to confine them in definitions. The advance of knowledge, however, does not tolerate any rigidity even in definitions. Physics furnishes an excellent illustration of the way in which even ‘basic concepts’ that have been established in the form of definitions are constantly being altered in their content." -p.117-8
Freud, S. (1915). Instincts and their Vicissitudes. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV (1914-1916): On the History of the Psycho-Analytic Movement, Papers on Metapsychology and Other Works, 109-140

Wednesday, 8 May 2013

Why the Argument From "Uniqueness" is Correct, but Only Gets us so Far

It is often said of diagnosing people that it is "putting them into boxes"; "labelling them", "pigeonholing them", and that doing it cannot account for the richness and uniqueness of personal experience. I call this "The Argument from Uniqueness".

I would make a single modification to the argument, while nonetheless agreeing with it: diagnosis does not actually prevent us from acknowledging a person's uniqueness or from getting to the roots of this particular person's problem at this particular time. However, it can lead to an excessive focus on the purported "disorder" at the expense of other aspects of their psychology, and this needs to be guarded against. The Argument from Uniqueness then is correct, but its correctness only gets us so far.

It is unclear to me, in the first place, why diagnosis is supposed to be doing the work of informing clinicians about people's individuality when there exist other sources of  information (like psychological formulation) to do the job for us. Somehow, in the field of physical healthcare, practitioners manage an inclusive approach where diagnosis and more detailed information are considered important. In mental health they are considered to be mutually exclusive.

Anti-nosologists reject diagnosis per se and are thereby implicitly advocating a kind of starting-from-scratch with every individual they meet. If you are perfectly empathic and omniscient, this kind of building from the ground up would work. Unfortunately, the rest of us need to draw on the hard won lessons of other people's research and clinical insights if we are to be clinically effective. People (with problems and without) are often hard to understand, behaving in seemingly counter-intuitive ways, and responding to situations with emotions different, or differently expressed, from our own.

I will fall back on the illuminatingly controversial case of "Borderline Personality Disorder". So called "BPD" is a misnomer. It's less a disorder than an understandable response to complex childhood trauma. The appropriate treatment is systemtic and empathetic psychotherapy. I don't like the idea that it is called "Borderline Personality Disorder", which is essentially a comment about your entire personality and thus an insult, but notice, even with the scare quotes, I am referring to an "it", a nameless concept that we assume exists in some abstract way. This something is the referent when even progressive mental health practitioners and activists want to talk about the misdiagnosis and mistreatment of a particular group of people. It is correctly asserted that "it is a trauma reaction", but unless there is something to fill the place of that "it" in that sentence, this statement is de-facto meaningless. What's a trauma reaction? Any given case of whatever it is, as far as a screening clinician is concerned, could be a biological disorder, a psychological problem or a simple instance of malingering.

Developments like DBT and MBT have targeted the particular sorts of difficulties that emerge in cases of this sort of problem, and it has opened the field to an understanding and optimism that was sorely lacking before (and still is in some quarters). However, unless we are able to talk about the issue to which these developments apply, its benefits cannot be felt. How, without something resembling diagnosis, can a GP pick out people who belong to the group we used to call "Borderline" and refer them to an appropriate treatment? How, without diagnosis, can we ensure that the victims of child abuse aren't just bunged on Benzodiazepines and told there's nothing else available?

It is never acknowledged that the anti-nosology case itself relies on the essential epistemological short cuts that are currently clumsily provided by a diagnosis. We don't need DSM categories, but we do need some way of talking about mechanisms, aetiology and approaches to help that are likely to be useful. Perhaps this situation has some role in explaining why diagnostic systems like DSM persist even in the face of overwhelming resistance. Whatever the industrial/financial forces that feed the chemical-imbalance/drug* model, the underlying concept of a diagnosable problem (as opposed to a biological or medical one) is not only hard to shake, but apparently impossible to do without.

*I have adapted this sentence to better reflect what I intended to say. It used to read "whatever the cynical political trends that feed the medical model"

Friday, 3 May 2013

Some thoughts on NIMH's abandonment of DSM

You have almost certainly already seen the news that the National Institute of Mental Health, America's main federal mental health research body, has abandoned the DSM as a guiding framework for mental health research. In a recent blog it's director Thomas Insel explained that the organisation will now seek to support "research projects that look across current categories – or sub-divide current categories – to begin to develop a better system."

This is a hugely important shift in the politics of mental health, and even though, as Vaughan Bell has pointed out at Mind Hacks, it won't effect a sudden change in how people are diagnosed, it will have positive knock on effects for how we conceptualise mental health problems.

Most researchers in clinical psychology (I can't speak for psychiatry) are aware of the limitations of the DSM. The fact that it is written by consensus and is full of categories that are reliable rather than valid is a widely acknowledged source of embarrassment and frustration for people trained in the methodology of a field in which validity is a central theoretical concern.

The problem is that in America, a country which has such an important influence on research around the world, the NIMH is an extremely important source of money for people who wish to do serious long term research into mental health. In the major research universities here, faculty members in clinical psychology departments need to attract serious grants to continue their research and to get tenure. That often means NIMH money.

With even the best intentions it has been difficult to do studies which ignore the boundaries that already exist in psychiatric practice. This is part of how we end up with the perpetuation of terms like "Borderline Personality Disorder". Several academics I know find it an offensive term, and yet they continue to publish papers with the name in the title. Why? Because it is an unfortunate label for a useful concept (i.e. a population of people who's self regulation has been disrupted by traumatic and invalidating experiences) but people's research needs to adopt a common language if studies are to effectively "speak"to one another, so the cognitive dissonance goes on. Perhaps this is why Insel's post explicitly states that the DSM, so often referred to as the "bible" of psychiatry, is better considered a dictionary. What the NIMH propose, with their alternative the "Research Domain Criteria", is a new dictionary.

I've seen some pessimism already from mental health activists, and they might be right. The funds that NIMH disburses have been historically connected to the Federal Government's "decade of the brain" programme, and this ethos is still dominant, not least in the ongoing use of the term "disease". But there is reason for optimism too. The NIMH's strategic vision is broad, and incorporates research which examines gene-environment interactions, environmental risk factors and personalised psychosocial interventions. Most significantly, a move away from automatic acceptance of terms like "OCD" or "Schizophrenia" opens up the conceptual field to research that focuses on mechanisms rather than categories.

It will be a long time before service users see the tangible effects of this; Vaughan Bell compared the time frame to a Mars mission. However, unlike NASA's journey to Mars, this is a research programme that may end up helping us see humans again.