Thursday, 22 May 2014

20 years on: Finally our myopic brain obsession is on the wane

Professor John Read, back in the UK after a long period away, is struck by some important changes in the way we view mental health problems

Has how we talk about mental health changed?
Illustration: Mend the Mind
It’s good to be back in the UK after twenty years in New Zealand – well, apart from the weather, the political, economic and spiritual state of England, and the endless phone calls to India to get someone from up the road to install a phone. Amid it all I’m writing my first ever blog! What an antiquated old prof.

As regards mental health research, the difference I notice most is how far people’s thinking has moved on from the old, simplistic, ‘blame-the-brain-for- everything-and-medicate’ idea. 

Two papers I’ve published since returning will both, I hope, contribute to this on-going development.    The first was published with colleagues from Scandinavia and the USA in the journal Neuropsychiatry With the snappy title ‘The Traumagenic Neurodevelopmental Model of Psychosis Revisited’  it reports on 125 papers that support a model  we first put forward in 2001 outlining how psychosis can be related to  trauma. This model is a challenge to those I call ‘contextless brain researchers’: people who when they find a difference in the brains of two groups of people, assume that they have found the cause of the difference.  It rarely seems to occur to them to ask a vital (and some might say obvious) question: ‘what might have happened to make the groups different?’ I would not for a moment dispute that such researchers are well-intentioned folk. They may have a deep knowledge of neurology and access to some very fancy technology. However, they often don’t seem to grasp the simple fact that a primary function of the brain is to respond to the environment.

One of the findings underpinning our model is that there are some striking similarities between the brains of traumatised young children and those of people diagnosed with schizophrenia. Perhaps the most important is in the way that the nervous systems (the ‘HPA axis’, to be precise) of the two groups respond to stress. We’ve been told for decades that the reason that people who experience ‘psychosis’ are sensitive to stress is genetic.  It now seems that for many people the cause of such heightened sensitivity may lie elsewhere: in early trauma.

This goes to the heart of whether the much touted ‘bio-psycho-social model’ and its alter ego the ‘stress-vulnerability model’ really do what it says on the tin, and offer a genuine integration of nature and nurture.  I argue in my book Models of Madness   that these terms can sometimes disguise what is still fundamentally a biological explanation of our experiences.  We’re told that stress can play a role, but only in people who already have a supposed genetic predisposition. Life events, even serious and  traumatic ones,  are relegated to the role of ‘triggers’ of an underlying genetic time bomb. Bio-genetics enthusiasts claim that the ‘vulnerability’ part of the equation must be genetic. This conveniently ignores the fact that the inventors of the model, Joseph Zubin and Bonnie Spring, stated in their seminal 1977 paper that the vulnerability can be acquired from early life events. As Michael Caine used to say, ‘Not a lot of people know that’.

This all reminds me that a few years back Robin Murray, Professor of Research at London’s Institute of Psychiatry, announced from a Canadian conference stage that ‘The schizophrenia wars ended in the 1970s’. I couldn’t help raising my hand and pointing out that the occupying force in a colonial war is usually quick to announce the end of hostilities, and that the war would not be over until the occupying forces withdrew to the appropriate boundary.

It is remarkable then that the relationship between trauma and psychosis – heresy just 15 years ago - is now one of the strongest and most consistent findings in our field. How times have changed – and how quickly. I now hear people saying ‘What’s all the fuss about? We always knew that - nothing controversial there’. Some of the most scathing critics of our first few papers are now happily putting their names on papers confirming the relationship.  I was moaning about the ‘hypocrisy’ of all this to my colleague Richard Bentall recently and he replied ‘John, John, - you’ve won and you’re still bitching!’

The ‘victory’ had never felt so real as when I heard some wonderful news from New Zealand towards the end of last year. An abuse survivor had twice been denied financial aid in relation to subsequent mental health problems because two ‘experts’ - employed by the agency responsible for making such payments - had stated that there is no evidence that child abuse can cause psychosis. However, in the final appeal a psychiatrist summarised the substantial literature which attests otherwise. The judge upheld the appeal  and I’ll admit I took some naughty pleasure in the NZ’s national Sunday newspaper quoting me as saying that the first two psychiatrists, ‘either knew nothing about the many studies documenting the relationship between child abuse and psychosis or were trying to mislead the judge’.

Another area where research is challenging the simplistic medical model type thinking in mental health is that of interventions.   More and more studies are giving the lie to the pharmaceutical company propaganda which would have us believe that their products are targeted, specific ‘treatments’ for identified brain problems.   My second recent paper  reported an online survey of 1,829 people taking antidepressants.   It revealed some astonishing levels of psychological and interpersonal adverse effects. For example, 60% of people reported feeling emotionally numb, 42% said that the drugs reduced positive as well as negative emotions, and 39% felt that they cared less about others whilst on the drug. Other effects are already well documented but we were surprised at their sheer frequency: 62% reported sexual difficulties (rising to 72% for men), and 39% reported feeling suicidal, rising to 55% in 18-25 year olds. Withdrawal effects, often dismissed as rare or imagined – were reported by 55%. Those who had been more depressed when the drugs were first prescribed were no more likely than others to experience these effects, suggesting that they were drug-related rather than symptoms of the depression itself.

Although biologically-rooted explanations of distress and pharmaceutical treatments are still prevalent, it seems that both professionals and the public are increasingly exploring alternatives. All over the world – with the sole exception of the USA – surveys reveal that the public, including service users and carers, tends to take the common-sense view that mental health problems are related much more closely to the events and circumstances of our lives than to biological factors such as genetics or brain chemicals. When it comes to help the public also strongly prefer psychological and social approaches over drugs, electroshock therapy or hospitals.  Only a minority of professionals seem intent on continuing to ignore experience and push the idea that mental health problems are essentially problems with our brains.   And those people are getting older by the minute. Things have changed unbelievably in 20 years. Hopefully, if we all keep pushing, in whatever way our circumstances allow, our mental health services will finally become evidence-based, effective and humane. 


John Read is Professor of Clinical Psychology and Director of the Clinical Psychology Programme at Liverpool University. You can follow him on Twitter @ReadReadj

12 comments:

  1. Wonderful post - and glad to know that attitudes may be shifting away from context-less, mind-less reductionism and misinterpretations of brain scans. I've just written a short piece on "Neuroreductionism about Sex and Love" trying to make a similar point: https://www.academia.edu/7045354/Neuroreductionism_about_sex_and_love

    Best,
    Brian D. Earp
    University of Oxford

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  2. Great stuff, thanks so much for sharing your wisdom, John.

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  3. Unfortunately, this is not so the case in the space of a recent 'conversational style, discussion between researchers, clinicians and service users and families'. (Perth Au) The event was to bring people together and set the research agenda for mental health. There was no pre determination to discuss the impacts of trauma on the brain or the notion of recovery. Was a very clinical event where the importantance of finding new psychiatric treatments were more than priortised. As a service user and advocate of recovery and trauma informed practice, I was left feeling empty, disappointed but more attached and committed to recovery and trauma informed practice than ever. Thank you for sharing these thoughts and congratulations on your first blog, I hope to read more from you! Warm regards Tracey

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  4. The relationship between neuroscience and mental health is a complex one. Whether it is hearing voices, experiencing low mood, or executive difficulties, a complex interaction is usually present. We should guard against any simplistic cause-effect relationship, whether we are citing the cause as neurological, trauma or any other single factor. We need to view all people as individuals with individual stories Sometimes the brain and neuroimaging can display those experiences through scans. At times those scans are the paintbrush which paints the experience, other times they are simply the canvas on which experiences are painted. Often it is a combination of the two. Just as a simple cause-effect perspective is rarely the case, simple answers are rarely the solution. We are complex people, and often need individualised support. Thanks for the thought-provoking post.

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  5. The main thrust of this article is "…how far people’s thinking has moved on from the old, simplistic, ‘blame-the-brain-for- everything-and-medicate’ idea." John does point out that the term biopsychosocial model and the stress-vulnerability model are not always what they seem, and that they "…can sometimes disguise what is still fundamentally a biological explanation of our experiences."

    But by way of a hopeful contrast, John expresses the belief that the relationship between trauma and psychosis has become widely accepted and "…is now one of the strongest and most consistent findings in our field." John doesn't explicitly state that this notion is accepted by psychiatrists, but I think that's the implication, especially in that he describes this development as a "victory."

    Whilst I am by temperament an optimistic person, and believe that our ideas will one day prevail, I don't entirely share John's optimism with regards to the current state of affairs. For instance, John writes:

    "Only a minority of professionals seem intent on continuing to ignore experience and push the idea that mental health problems are essentially problems with our brains."

    Admittedly my perceptions are rooted in the American context, but I think the great majority of professionals, including virtually all psychiatrists, are still heavily invested in the broken brain notion. Psychosocial concepts, when they are admitted at all, are seen as either helping people acquire behaviors/habits to compensate for their supposedly broken brains or, more often, as systems to pressure and encourage people to take their "meds."

    Psychiatry's spurious concepts have been so thoroughly exposed in the past ten years or so that they are keeping a lower profile than formerly in this regard. But in PR and self-promotion they have redoubled their efforts. An integral part of this psychiatric spin is the co-opting of opposition ideas, repackaging them as psychiatric insights, and ensuring that their potential to challenge psychiatric orthodoxy and hegemony is effectively neutralized.

    We've seen numerous examples of this lately. We said for years that the chemical imbalance theory was specious, but psychiatry went on promoting it. Now that it is thoroughly exposed as fraud, psychiatrists (e.g. Ronald Pies [1]) are saying: we never really said that, or if we did, we didn't really mean it. For years we mental illness "deniers" said that the condition known as schizophrenia is not a unified phenomenon. Today psychiatrists are saying that there are many schizophrenias. We critiqued DSM. Today they're saying DSM isn't so hot, but it's the best we have. And so on. But, I suggest, the apparent rapprochement is less than skin deep.

    If one accepts that disempowering life experiences such as poverty and discrimination play a causative role in the creation of the problems known collectively as schizophrenia, then social workers, job coaches, educators, case managers, etc. are front-line workers in the amelioration of these problems. But the psychiatrically-dominated mental health centers routinely relegate these workers to ancillary status, and subordinate their work to the "real" treatment activity of administering drugs. A great many case managers, especially those assigned to the so-called "chronics," spend almost their entire work time ensuring that clients are keeping their "med check" appointments, filling their prescriptions, and dutifully taking their "meds." Similarly, a great deal of social worker time is spent helping "schizophrenic" clients apply for disability benefits – arguably the worst possible use of their time. Job coaches are notoriously under-used in this area because psychiatric "wisdom" had dictated for decades that schizophrenia is a brain disease whose "victims" should be protected from the stress of seeking, and pursuing, gainful employment.

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  6. 2. And, meanwhile, the drugs are still selling like the proverbial hot cakes.

    Here in the US, psychiatry is pushing for what they call early intervention (i.e. drugging children), and for the integration of psychiatry, of the broken brain variety, with primary care (a mental health worker in every GP's office). We have children as young as two years of age on methylphenidate for ADHD (a "confirmed" brain illness) and on neuroleptics for temper tantrums (disruptive mood dysregulation disorder).

    Henry Nasrallah, MD, is a very eminent psychiatrist. He is Professor of Psychiatry and Neuroscience at the University of Cincinnati, and according to his bio, has authored hundreds of articles and abstracts, and 16 books. He is Editor-in-Chief of the journals Schizophrenia Research and Current Psychiatry, and co-founder of Schizophrenia International Research Society. In 2010 (which is not that long ago) he conducted a pharma-sponsored speaking tour of New Zealand promoting second generation injectable neuroleptics. The content of his presentations – complete with colored pictures of brains! – was written up by Research Review [2], an independent New Zealand publishing company. Here's a quote:
    "The chemical imbalance in schizophrenia is correctable by medications and choice of medication formulation is critical for a full long-term remission. Adherence is the single greatest reason for relapse and deterioration. Finally, a comprehensive biopsychosocial approach to treatment is vital and has proven very beneficial in schizophrenia." [Obviously they meant non-adherence, though it's an interesting slip. It's also pretty clear from the context and from the overall tone of the article that the "biopsychosocial approach" is being offered as a sop to the opposition rather than as a serious causal or treatment consideration.]
    Another example of the very-much-still-alive-broken-brain-theory can be seen on Jeffrey Lieberman's video clip [3] titled "Causes of Depression." The clip was published on June 19, 2012, at which time Dr. Lieberman was President-elect of the American Psychiatric Association. The video starts with the title on screen, and a rotating brain, with background music. At eight seconds in, Dr. Lieberman comes on-screen and speaks. Here's a complete transcript:

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  7. 3. "Major psychiatric disorders in general, involve a disturbance in a specific area of the brain that is involved in regulating mood, or mediating mental functions like cognition or perception. So it's like, you know, if you have a little stroke or a seizure, if your stroke is in an area of the brain that affects your motor function, you'll have weakness in one arm or one leg. If it affects your sensory perception, you won't be able to feel things. If it affects your speech area you won't be able to talk or understand. In psychiatric disorders, the disturbance is in an area that regulates emotion or affects mental functions like cognition, perception – thinking. And frequently, the disturbance is of a neurochemical nature, meaning that the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated. And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to mediate. So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion. Everybody in life has a range of emotions – sadness, happiness, anger, tranquility. And we experience sort of fluctuations in our emotions depending on what's happening. If we're at a party we're in a good mood. You know, if we have to do a lot of homework, or, we have, you know, an unpleasant encounter with our boss, we're in, maybe in a bad mood, but we bounce back. With people who get depressed, because of this disturbance, or this vulnerability to develop a disturbance, in the neurochemical effects that are mediating their mood regulation, they over-react to an extreme, and they can't bounce back. So they get stuck."

    End of video. Screen becomes:
    NewYork-Presbyterian
    The University Hospital of Columbia and Cornell

    There's no ambiguity in these two quotes. And even a brief literature search will turn up lots more. The broken brain theory is alive and well. It's being packaged with a sprinkling of psychosocial terminology, but the substance is essentially the same: all significant problems of thinking, feeling, and/or behaving are medical illnesses, the amelioration of which is primarily, and in most cases, exclusively, a medical matter. The great majority of people who are prescribed psychiatric drugs, either from a psychiatrist or from a GP, receive no psychosocial support or intervention of any kind. It is simply impossible to reconcile this reality with the notion that psychiatry is genuinely moving to embrace psychosocial concepts and practices.
    . . . . . . . . . . . . . . . .

    A second concern that I have with John's paper is the assertion "… there are some striking similarities between the brains of traumatized young children and those of people diagnosed with schizophrenia." My concern stems primarily from the fact that the condition known as schizophrenia is a loose collection of vaguely defined behaviors, and that the people embraced by this term (the "schizophrenics") are not a cohesive, homogeneous group. John himself has endorsed this notion in Models of Madness (Read J, et al.) in the chapter Biological psychiatry's lost cause: "…'schizophrenia' is a label used to account for a range of different types of unacceptable or distressing behaviours." (p 58)

    Of course, in stressing the causative role of abuse, John may simply have meant that there's some overlap, but I think there's a danger of replacing the psychiatric dogma, that "schizophrenics" are people with broken brains, with a psychosocial dogma – "schizophrenics" are people with a history of trauma.

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  8. 4. I can certainly accept that a great many people who get labeled schizophrenic have a history of trauma. Indeed, to anyone who has worked in the field, this is pretty clear, and John has done great work in promoting and validating this concept, and bringing it back into focus. I also have no difficulty accepting that the link is causal in many cases. But in behavior there are always multiple paths to the same place. "Crazy" speech and activity can be learned, and incidentally, unlearned, in accordance with the ordinary principles of behavioral acquisition and in the absence of a history of marked trauma. This concept gained a good deal of currency in the 60's and early 70's, and underpinned some very successful behavioral interventions. But the concept was marginalized, and finally ousted by psychiatry, as the drugs became the dominant form of intervention, and broken brains became the dominant ideology.

    It is also true that certain disempowering life circumstances, even without a history of abuse, are conducive to the acquisition of "crazy" habits. Here again, John has been one of the most ardent proponents of this concept: e.g. Poverty, ethnicity and gender, another chapter in Models of Madness. (p 161-194)
    . . . . . . . . . . . . . . . .

    Of course it may just be that, living on this side of the Atlantic, I'm seeing more of psychiatry's spuriousness and destructiveness than John. I agree that we have made extraordinary strides in the last decade or so, but our gains are tenuous and could be swept away by an organized psychiatry that is becoming increasingly skilled in marketing and PR.

    I will, as John himself enjoins, "keep pushing."


    Reference:

    Read, J, Mosher, L.R., Bentall, R. (2004). Models of Madness. London, Routledge, Taylor & Francis Group

    Weblinks:

    1. http://www.psychiatrictimes.com/login?referrer=http%3A//www.psychiatrictimes.com%2Fpsychiatry-new-brain-mind-and-legend-chemical-imbalance

    2. http://www.behaviorismandmentalhealth.com/wp-content/uploads/2014/02/Narallah-2010.pdf

    3. https://www.youtube.com/watch?v=Il7VFP_ugjM

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  9. Interesting blog: thanks! As a service user by NHS default (ie. Anything we are unwilling, or don't have the resources to, investigate, must be psychological.), I must put in a plea against this becoming a polarised debate, with only one winner. As is frequently pointed out, psychiatric 'diagnoses' are mostly made on nothing better than opinions, and, in the UK, for certain, by the pre-eminence of the ironically-named, 'evidence-based medicine', which is really 'evidence deliberately not sought' medicine. Thus, a good percentage of people who, unfortunately, find themselves delivered into the presence of psychiatrists, *really are* suffering from undiagnosed physical illnesses, of which many *will* be 'brain illnesses'. The psychbiosocial model is the bane of all such unfortunate people: we are condemned to listen to patronising psychobabble while our physical illnesses are deliberately not investigated, because this 'encourages sickness beliefs'. This condemns many people to a living hell of both physical illness and psychological torture by the system me had been brought up to believe was there to help us. So please: put the horse before the cart, and get proper multidisciplinary, inpatient, diagnostic services established, so that the really brain damaged, or brain affecting illnesses are diagnosed out, before handing anyone over to psychiatry. It is very likely there are many fewer actual psychiatric illnesses that either group thinks.

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  10. Thanks John. Congrats on your first blog, I enjoyed this one. Keep blogging my friend! Good to see our New Zealand mentioned there. Like the humour. . Kia Kaha John. You are missed "down under"..

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  11. Thanks John extremely interesting. More please

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