Walk with Vaughan Bell between the Maudsley and the Tavistock clinic

The important details:

“11am, near the Maudsley Hospital in Denmark Hill, Saturday 19th September, to walk to the Tavistock Clinic in the leafy suburb of Belsize Park for about 4-5ish.”

And:

The walk is about 8 miles but I’m planning for a few minor detours for interesting sites (grounds of the old Bedlam Hospital, now the Imperial War Museum, St Thomas’ Hospital and the like) and with stops for lunch and maybe the occasional pint.

More info over here.

Wish I was in London to join this!

Bentall on the “Kraepelinian paradigm”

Bentall, R. Madness explained: why we must reject the Kraepelinian paradigm and replace it with a `complaint-orientated’ approach to understanding mental illness. Medical Hypotheses, 2006, 66, 220-233:

“Instead of attempting to explain mythical diagnostic entities, we should try and explain the actual complaints that patients bring to the clinic, such as hallucinations, delusions, disordered communication and mania. This strategy assumes that, once these complaints have each been explained in turn, there will be no ‘schizophrenia’ or ‘bipolar disorder’ leftover to account for.”

“a simple list of a patient’s complaints contains much more useful information than a Kraepelinian diagnosis, and takes less effort (because complaints have to be assessed in order to generate a diagnosis). In fact, cognitive-behaviour therapists have long argued that lists of this kind – the ‘problem list’ in the jargon of the approach – is the best starting point for clinical intervention… A complaint-orientated approach implies that treatments should be delivered according to patients’ needs.”

Security through obscurity

Vaughan at Mind Hacks writes:

“Almost every psychological test relies on the fact that the person being assessed has no foreknowledge of the material.”

There is an assumption that psychologists are out to trick people into revealing their psychological traits.  Undergraduate students, for instance, often complain that personality questionnaires are rubbish because it’s obvious what they’re asking or what the answers should be.

I don’t think it’s a problem if what is being tested is transparent.  For instance take selection for a job or a university.  The point should be that a good selection process benefits both the candidate and the folk making the selection.  If you cheat your way into a job or onto a course you’re not capable of doing by obsessively practising a test, then it won’t be long until the pressures of performance will force you out.

Oh okay. This assumes that tests used for selection have predictive validity. And… well you can imagine how this argument would continue, how some jobs might require people who are good at pretending, how validity might depend on people being motivated enough to try some practice IQ tests—acquiring foreknowledge might (unknowingly to the tester) be part of the test, how, er, capitalism needs to be destroyed, and so on…

I find it frightening that tests used in clinical diagnosis should somehow trick patients into revealing their complaints. There is a diagnosis tool for autism spectrum conditions which works basically by tricking people into revealing how socially inept they are by various “social presses”, including during a period which appears to be a break between testing sections. The most frightening part of this was the obvious power trip the person who explained this test to me was on every time she used it.

Admittedly it’s a bit messy, but be suspicious of tests which are designed to trick people.

More on approaches to psychological therapy

I think you can get the gist of the two main arguments from Vaughan’s title, if you don’t want to read the articles.

Psychological Therapies NOS Development Project

(Follow up to this post.)

  • Link to background and documents
  • An article by Andrew Billen in the Times
  • Three replies. I particularly like what Malcolm Allen, Chief Executive Officer, British Psychoanalytic Council, has to say: “Psychoanalytic psychotherapy is taking its place as an effective, evidence-based intervention within contemporary mental health provision. We are not helped by those who try to make psychoanalysis into a mystery cult.” (Emphasis mine.)

Psychotherapists and councellors probably should be registered to practice

Ian Parker wrote an article for psychminded.co.uk on how psychotherapists and councellors should refuse registration. I’m neither a psychotherapist nor a councellor, but I for what it’s worth I disagree with what he says.

I fail to see why it is a bad idea to control who is permitted to engage in psychotherapy.  Of course the registration of psychiatrists has not guaranteed no abuse.  And not all registered GPs are fit to treat patients.  But importantly there are—and should be—mechanisms in place to ensure that clinicians practice in the way they ought to practice.  It’s possible to complain about inept GPs.  There are surely bad ways of deciding what drugs to prescribe, and bad ways of delivering therapy.  It is the reduction of bad practice, not over-control of demonstrably good practice that should be encouraged by the state.

Those who are not registered could of course continue to see patients. To continue the parallel with GPs, I am delighted that random people are unable to prescribe drugs.  This does not mean that those without a training in medicine cannot help people who are ill.  Caring for the ill requires more than medical treatment.  Helping those with mental health problems requires a rich network of support and need not be reduced to counselling or therapy.

I fail to see how state regulation would harm radical approaches in psychotherapy.  What it would do is require that there is evidence to support such approaches.  This, I accept, is non-trivial, and we need to move away from tick-box questionnaires trying to assign a number to each person summarising how distressed they are.  But evidence is a good thing when dealing with therapeutic approaches.  There are other aspects of a person’s needs which do not require this approach: friendship, for instance.  One doesn’t need to be a therapist to be a friend.

Why is psychoanalysis necessarily outside the state?  Why is it not possible to be a regulated psychotherapist and still supportive of the user movement?  I’d suggest that if one really wants to remain unregulated, then it’s necessary to remove the status label of “psychoanalysist” or “psychotherapist”.  Maybe then it is really possible to align oneself with “users” (or is a better term, “people”?).

General and useless

Wise words(?) from The Last Psychiatrist:

Please do not say the words “dopamine” and “nucleus accumbens” anywhere near me, I still have my old sack of doorknobs.  These explanations could not be more general and useless.  Using those two in support of a common addiction pathway is like involving “gasoline” and “spoons” in the diathesis for serial rapes.  Even though these are involved in various “addictions”—cocaine, alcohol, internet, sex—these “addictions” and their associated behaviors are so disparate that the pathway serves no useful clinical target.  Haldol blocks dopamine in the nucleus accumbens, but you can’t cure alcoholism with it, can you?

I’m not denying that such a pathway exists, I’m doubting the utility of this information, even if true.  Call me when science catches up to your lies.

Psychotherapy and the brain

If you accept—or assume—that there’s no mystical funny business and that the brain, in response to the environment, generates your behaviour and how you feel, then you’d expect psychotherapy, not only pharmacotherapy, to be associated with changes in the brain.  Some evidence that this is the case is reviewed by David Linden (2006).

For instance he reports interesting work on obsessive-compulsive disorder (OCD) . Many studies reportedly found increased activity in the right caudate in people with OCD. A  study examining the neural effects of successful cognitive behaviour therapy (CBT) showed decreased activity in the right caudate; this was also seen in patients who were successfully treated using SSRIs.

Linden, D. E. J. (2006). How psychotherapy changes the brain – the contribution of functional neuroimaging. Molecular Psychiatry 11, 528–538