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.

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