Thinking about Care with Care

Bob Fancher, PhD
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When critics reveal that science doesn’t show what biological psychiatrists claim it does, we get a bit unhappy. As well we should.  We don’t like being misled. We don’t like being put at risk on the basis of misinformation.

But weak science and exaggerated reports of discovery aren’t the special province of biological psychiatrists.  We don’t really understand much about the suffering that brings people into care. None of the science underlying mental health care could withstand the sort of scrutiny biological psychiatry is beginning to endure.

As one example, consider “attachment theory”—the idea that mental health depends on infants “becoming attached” to reliable caretakers. Countless therapists believe, and teach their patients, attachment theory. They devise innumerable interventions on the assumption that they can improve attachment. A huge research industry studies attachment, and claims a variety of important discoveries.

But outside the realm of its own believers, that science generally isn’t all that highly respected. The Harvard psychologist Jerome Kagan showed long ago that some research methods of attachment theorists simply don’t prove what they claim.   Behavioral geneticists have shown fairly well that many correlations attachment theorists attribute to attachment actually have mainly to do with genes, not parent/child interactions. No one denies that kids need good care, and neglected kids suffer for it. But it’s far from clear that “attachment” is the issue.

We don’t hear an incensed outcry against attachment theorists, though. Criticisms of attachment theory—Steven Pinker had some unflattering things to say about it in The Blank Slate—don’t get any traction.

As another example, consider the fact that few cognitive neuroscientists would agree with CBT’s account of how minds work. A consensus in the field holds, in effect, that the “distortions” that CBT theorists claim cause pathology are basic to how normal minds work. Nobel Prize-winner Daniel Kahnemann’s new book, Thinking, Fast and Slow, offers an exhaustive account of the research that led to such alarming accounts of how minds normally work.

That we’re not seeing an outcry against CBT is especially odd, since this work on fundamental irrationality has gotten an enormous amount of attention in the last twenty years—think of the bestselling books Predictably Irrational, Nudge, Sway, How Doctors Think, and the seemingly interminable outpouring of similar works.

One more example. We all hear, all the time, that CBT is “scientifically validated.” I’ll be looking at that claim over time—there’s much less to it than meets the eye. For now consider this: CBT research almost never looks at the side effects of treatment. We do not even know what kind of effects, beyond manipulation of moods, CBT has on how people live.  Completely ignoring the unintended consequences of one’s work would be considered bad science in any other realm of health care.

We get up in arms about the side effects of medications, but we don’t seem to care that CBT doesn’t study its side effects at all.

What’s my point? That we should stop criticizing biological psychiatry, since the rest of us do no better scientifically? That we should all go out of business because our scientific basis is much weaker than we claim?

Neither. My point is that we need to study the beliefs that we like as critically we study the ones we don’t. We don’t have to pipe down about the sins and shortcomings of biological psychiatrists—so long as we’re willing to be equally relentless in self-examination.

In truth, we don’t understand much about the suffering that brings people into care. We lack an adequate science of suffering. But when people need help, they need it, and we have to do what we can.

We need to cast our nets wide for any form of reliable knowledge. That may come from sciences outside the clinical realm—sociology or social psychology, for instance. It may come from at least some of the humanities disciplines—philosophy or history, certainly. Some astute observers of the human condition have cast their wisdom into literature.  Even a few journalists have noticed important things about how life works.

We learn, and use, rigorous methods of logical and evidentiary analysis and use them when we listen to our clients and parse what they’re saying. We need to know the difference between what we’re hearing and what we’re making of it. We need to know when what we’re hearing really doesn’t hang together. Many of those methods are better learned in the disciplines of communications, rhetoric, and logic than in psychiatry or psychology.

We can think through the severe limitations the conditions of care impose on what we can know about particular patients or clients, so that we’re less likely to offer things no one knows, or could possibly know, in the clinical setting. Philosophers are probably better than anyone else at analyzing what can and can’t be known under various conditions.

We can do all this from a position of humility, not authority. We can be honest with patients and clients rather than passing on our interpretations, instructions, and advice as if they were deliverances of Truth.

Recognizing the weak knowledge base of mental health care doesn’t have to be the occasion for despair. We can distinguish better from worse thinking even where we lack strong conclusions. We can distinguish the more likely from the improbable, the rash from the judicious, even when we’re not sure how a line of inquiry will play out.

As this blog goes forward, I will invite you to share with me the effort to do just that. I invite you to join me in the effort to think about care with care—to think carefully.

14 COMMENTS

  1. “For now consider this: CBT research almost never looks at the side effects of treatment. We do not even know what kind of effects, beyond manipulation of moods, CBT has on how people live. Completely ignoring the unintended consequences of one’s work would be considered bad science in any other realm of health care.”

    Are you kidding me? Seriously? We are to treat talk therapy as being capable of producing side effects like drug treatment? Maybe CBT can cause movement disorders? Diabetes? Brain damage? Suicide? Uh oh, I sure do hope that those talk therapists start studying the side effects of their treatment before too long.

    Is this what it has come to? Psychiatrists defending themselves by paralleling the harm they cause to that of non-biological therapists?

  2. “We get up in arms about the side effects of medications, but we don’t seem to care that CBT doesn’t study its side effects at all.”

    Seriously, are you saying that a non-biological treatment could INDUCE side effects? It’s TALK THERAPY! It doesn’t intrude on the body and make any changes at all! To have a side effect from CBT would be no different then the “side effects” of talking to a spouse or going for a walk. Can you really compare a drug that alters, sometimes permanently so, the functioning of the brain to that of talking therapy?

    I am completely blown away. I never thought I’d hear this one. “Sure, psychiatric treatments have side effects, like tardive dyskenisia, diabetes, suicidal and homicidal ideation, and early death but talk therapists don’t even study their side effects!”

    smh

  3. Saturday evening there was an audience of about 700 people in a UBC lecture hall to hear a renowned philosopher lecture on “Neuroscience and Morality”. There was an hour on ancient anthropology and neuroscience and the audience was left to marvel on how oxytocin (the hormone released in especially large quantities during childbirth and lactation and credited with mother and child bonding) in mammals leads to altruism and morality.

    During the following Q&A, the philosopher did not hesitate to speculate on the possible clinical uses of oxytocin nasal spray as treatment for schizophrenics. Why? Because, in spite of possible side effects and risks, it’s such a devastating condition so it’s worth trying.

    Wow. Are “Schizophrenics”, whatever the latest definition of whom that net may catch today, really such eager “consumers”?

    Perhaps the humility you mention should be of most important in our responses to others’ distress. Is that humility more common among philosophers than it is of psychiatrists?

  4. I think there is a good point to study adverse effects of talk therapies. Studies of their effectiveness to not often take account any adverse effects that participants may experience. While I think CBT is considered pretty safe, with possible adverse effects include therapeutic failure, loss of funds/time, and discouragement, talk therapies are interventions like pharmaceutical ones, and their negative effects need to be studied in order to make reasoned decisions to utilize them.

    There are many kinds of talk therapies that have been shown to actually me more likely to leave people worse off than they did before they start. Adverse effects, therapeutic mistakes, and negative therapeutic reactions are common enough in psychodynamic/analytic theory and practice, and even evidence-based psychotherapies are not always effective for participants and can have adverse effects. The harm is not biologically toxic, but it can make depressions, anxieties, psychoses, etc. more severe and unbearable, make it less likely for people to seek help in the future, and can lead to new clinical concerns (suicidal ideation, paranoia, etc.).

    Whether treatment is somatic or psychological, it needs to be informed by quality science and at the very least show that it does not cause harm. While I am not very hopeful we are going to have a strong enough understanding of “suffering” to effectively target interventions individually, we can at least assess whether treatments based on whatever theories (be they biological psychiatry, attachment theory, psychoanalytic theories, cognitive theory, etc.) are helpful for people well beyond the risk of harm.

    Dr. Scott Lilienfeld has done some interesting work on potential harms of psychotherapy.

  5. While i agree that all sorts of disciplines should be rigorously scrutinized and held under a probing light, you omit the fact that SO much harm has been done in the name of biological psychiatry. I would argue a genocidal amount of harm has been done. Biological psychiatrists are the true charlatans of our day at best, if not outright crooks and eugenists.

  6. Thank you for your useful thinking. I was trained as a psychopharmacologist adult psychiatrist mostly in France and also for 6 very formative months as a research registrar in Oxford (GB)and a little in BCT. It has been many years now that I have considered that biological psychiatry had let the clients and the physicians down.
    But the Big Pharma marketing and physicians overprescribing is no excuse – you are right there- for talking therapists to exaggerate their claims of scientifically proven efficacy for their trade, to decline to look at side-effects of talking therapy and even of the indication for talking therapy any time a client consult a psychologist or a psychiatrist (in my own experience, I found that the Royal College of psychiatrist leaflet to give to client after the death of a dear one is often sufficient treatment after I have given reassurance that it was normal to behave strangely after the death of a dear one and sometimes changing school or class when a gifted child is bored at school or a child is bullied without the teachers paying attention might be enough to solve behavior problems in the classroom).
    Plus – to give an example- some Asperger persons just do not agree on ABA or for other ABA for a long time- being useful to them and we badly need clinical trials there.
    In France, the hopes in biological psychiatry had been fueled in large part by the sadistic views of talking therapists who accuse the mothers ‘feeling toward a child (sometimes the fathers’) of being responsible for schizophrenia and autism and more or less anything. Even today in France some influential people are very happy with psychoanalysts’ talking care and there is a strong pro psychoanalysis lobby and a mother’s behavior toward an autistic child (or a father’s occasionally) can still be accused of provoking autism in children. A documentary film letting the psychoanalysts expose freely their views had been suffering from a French judges ‘s decision on the 26th of January 2012 when that documentary reflect the suffering of so many French families from talking therapists:
    http://www.nytimes.com/2012/01/20/health/film-about-treatment-of-autism-strongly-criticized-in-france.html?_r=1
    http://www.lemonde.fr/m/article/2012/01/13/autisme-la-psychanalyse-au-pied-du-mur_1628735_1575563.html
    In the latter link (le monde)you have access to the documentary and the link to the judgment is:
    https://docs.google.com/viewer?a=v&pid=explorer&chrome=true&srcid=0B7s8QJ-76JxVYTkyNTkzODUtMGQxMy00ZTM4LWJmZGEtZDY0MzUyOTQyOGU4&hl=en_US
    But of course , you were not thinking of the French sad situation and to give two examples of side-effects of talking BCT therapy I heard personally about in public at medical conferences : at a conference on diets and CBT treatment of obesity and binge eating in Paris , I heard therapists questioning a lecturer on CBT telling her that the prescribing for obese clients of slow eating delicious meals in restaurant (may be a French way)had sometimes produced for their clients too much money spending for fine rather expensive restaurants where they went too often. One of the lecturers dismissed that concern “of side-effects” saying that those people spending too much on restaurants – after having be told by their therapist to go and dine in gastronomic restaurants and eat slowly there enjoying the beautiful tasting and beautiful look of the moderate in amount food served in most Paris fine restaurants- were suffering from TOC or other personality disorder and should be treated also for it. Not necessarily false but still the family budget went into the red for those clients or the family had to make cuts on something else…
    Also, I heard at an addiction Conference at saint-Cloud a woman who had become peer-helper for alcohol addiction sufferers said that a talking therapist saw her for a very long time once a week (for 100 Euros a session) when her alcohol addiction was getting worse and worse over the months. She told us that her therapist knew, for instance, that she ended up drinking very bad quality wine because it was sold in plastic containers who , once empty are just little plastic, when she couldn’t have drank as much from glass bottles of wine without her husband and children noticing the many empty bottles. She was adamant that despite a weekly therapy session her alcohol addiction problem was not addressed properly until she collapsed in the street and her talking therapist told her -when she phoned him from the emergency room of a general hospital where the police had brought her – that he could do nothing for her at that time and certainly not visit her at the hospital because of his busy schedule. She went then from the emergency room to an addiction clinic in saint-Cloud located in a hospital close to her home as an in-patient. After the cure as an in-patient , she wanted to receive an outpatient follow up in that addiction clinic (with a strong component of peer-help from successfully dry former clients of that clinic ) instead of going back to her former talking therapist. She concluded that she wished that she had had benefit earlier from that addiction treatment and felt that she had lost a lot of time and money with a talking therapist who was too reassuring about her alcohol addiction and she felt that had she become and stay dry earlier, she might have saved her marriage and job and for sure she will not have made her children seeing her too intoxicated to function every evening for a very long time.
    May be those are not the kind of side-effects you had in mind but I think they had arisen mostly because the talking therapists were so sure of doing good and safe and best.

  7. Truth to tell, there are side effects of talk therapies, especially when poorly done. Sometimes people’s traumatic memories are triggered but not discharged, and they can become very anxious or despondent or even aggressive and hostile. So by all means, we should address “side effects” of therapy.

    But I agree, there is really no comparison between talk therapy and drugs in terms of potential damage. This is all the more concerning, as these “therapies” are being PUSHED with lies and distortions of fact that serve to create permanent clients and billions in profits while minimizing or ignoring the damage to patients. In short, the power base for the biological model, as well as the range of potential harm, far outstrips anything that psychotherapy can do, if only because of the incredible scope of the problem. That’s why people get more upset about the drugs – they ARE doing a lot more damage!

    But in my view, the drugs are merely the “side effect” of a much more serious problem that affects all quarters of the mental health industry – the belief that people can be categorized by their symptoms into “diseases” or “disorders” without any understanding of the source of the “disease.” “Attachment disorder” is a cultural construct, but so is “schizophrenia,” “ADHD,” and “Bipolar disorder.” Not to say that people don’t suffer from the described symptoms, but who said that someone is “ill” because they won’t sit still in school? And who says that all kids don’t sit still for the same reasons? The DSM diagnostic criteria are the core evil that needs to be eradicated, because that is what makes questionable or downright corrupt “science” seem valid, whether you’re talking about drug therapy, CBT, or any other therapeutic intervention.

    I agree with the author’s call for humility. It starts with not pretending that because we can name something, we know what it is we’re naming.

    —- Steve

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