A science-based medicine skeptic struggles with his as-yet medically unexplained pain and resists alternative quack treatments

Paul: “For three years I kept my faith that relief had to be just around the corner, but my disappointment is now as chronic as my pain. Hope has become a distraction.”

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Chronic pain and tragic irony…

Paul: “For three years I kept my faith that relief had to be just around the corner, but my disappointment is now as chronic as my pain. Hope has become a distraction.”

Paul Ingraham is quite important in the Science-Based Skeptics movement and in my becoming involved in it. He emailed me after a long spell without contact. He wanted to explain how he had been out of touch. His life had been devastated by as-yet medically unexplained pain and other mysterious symptoms.

Paul  modestly describes himself at his blog site as “a health writer in Vancouver, Canada, best known for my work debunking common myths about treating common pain problems on PainScience.com. I actually make a living doing that. On this blog, I just mess around.  ~ Paul Ingraham (@painsci, Facebook).”

Some of Paul’s posts at his own blog site


on fire


Paul’s Big Self-Help Tutorials for Pain Problems are solidly tied to the best peer-reviewed evidence.

Detailed, readable tutorials about common stubborn pain problems & injuries, like back pain or runner’s knee.

Many common painful problems are often misunderstood, misdiagnosed, and mistreated. Made for patients, but strong enough for professionals, these book-length tutorials are crammed with tips, tricks, and insights about what works, what doesn’t, and why. No miracle cures are for sale here — just sensible information, scientifically current, backed up by hundreds of free articles and a huge pain and injury science bibliography.



Paul offered me invaluable assistance and support when I began blogging at the prestigious Science Based Medicine. See for instance, my:

Systematic Review claims acupuncture as effective as antidepressants: Part 1: Checking the past literature


Is acupuncture as effective as antidepressants? Part 2. Blinding readers who try to get an answer

I have not consistently blogged there, because my topics don’t always fit. Whenever I do blog there, I learn a lot from  the wealth of thoughtful comments I received.

I have great respect for Science Based Medicine’s authoritative, well documented and evidence-based analyses. I highly recommend the blog for those who are looking for sophistication  delivered in a way that an intelligent lay person could understand.

What’s the difference between Sciencebased medicine (SBM) versus evidence-based medicine (EBM)?

I get some puzzlement every time I bring up this important distinction – Bloggers at SBM frequently make a distinction between science-based- and evidence-based- medicine. They offer careful analyses of unproven treatments like acupuncture and homeopathy. Proponents of these treatment increasingly sell them as evidence-based, citing randomized trials that do not involve an active treatment. The illusion of efficacy is often created by the positive expectations and mysterious rituals with which these treatments are delivered. Comparison treatments in these studies often lack this boost, particularly when tested in in unblinded comparisons.

The SBM bloggers like to point out that there are no plausible tested scientific mechanisms by which these treatments might conceivably work. The name of  blog,  Science-Based Medicine calls  attention to their higher standards for considering treatments efficacious: to be considered science based medicine, they have to be proven as effective as evidence-based active treatments, and have to have a mechanism beyond nonspecific, placebo effects.

Paul Ingram reappears from a disappearance.

Paul mysteriously disappeared for a while. Now he’s reemerged with a tale that is getting a lot of attention. He gave me permission to blog about excerpts. I enclose a link to the full story that I strongly recommend.

Paul Ingram title


A decade ago I devoted myself to helping people with chronic pain, and now it’s time to face my ironic new reality: I have serious unexplained chronic pain myself. It may never stop, and I need to start learning to live with it rather than trying to fix it.

I have always been “prone” to aches and pains, and that’s why I became a massage therapist and then moved on to publishing PainScience.com. But that tendency was a pain puppy humping my leg compared to the Cerberus of suffering that’s mauling me now. I’ve graduated to the pain big leagues.

For three years I kept my faith that relief had to be just around the corner, but my disappointment is now as chronic as my pain. Hope has become a distraction. I’ve been like a blind man waiting for my sight to return instead of learning braille. It’s acceptance time.

Paul describes how is pain drove him into hiding.

… why I’ve become one of those irritating people who answers every invitation with a “maybe” and bails on half the things I commit to. I never know what I’m going to be able to cope with on a given day until it’s right in front of me.

He struggled to define the problem:

Mostly widespread soreness and joint pain like the early stages of the flu, a parade of agonizing hot spots that are always on the verge of breaking my spirit, and a lot of sickly fatigue. All of which is easily provoked by exercise.

But there was a dizzying array of other symptoms…

Any diagnosis would be simply a label, not an explanation.

Nothing turned up in a few phases of medical investigation in 2015 and 2016. My “MS hug” is not caused by MS. My thunderclap headaches are not brain bleeds. My tremors are not Parkinsonian. I am not deficient in vitamins B or D. There is no tumour lurking in my chest or skull, nor any markers of inflammation in my blood. My heart beats as steadily as an atomic clock, and my nerves conduct impulses like champs.

Paul was not seriously tempted by alternative and complementary medicine

I am not tempted to try alternative medicine. The best of alt-med is arguably not alternative at all — e.g. nutrition, mindfulness, relaxation, massage, and so on — and the rest of what alt-med offers ranges from dubious at best to insane bollocks at the worst. You can’t fool a magician with his own tricks, and you can’t give false hope to an alt-med apostate like me: I’ve seen how the sausage is made, and I feel no surge of false hope when someone tells me (and they have) “it’s all coming from your jaw, you should see this guy in Seattle, he’s a Level 17 TMJ Epic Master, namaste.” Most of what sounds promising to the layperson just sounds like a line of bull to me.

Fascinating how many people clearly think Paul’s story was almost identical to their own.

All these seemingly “identical” cases have got me pondering: syndromes consist of non-specific symptoms by definition, and batches of such symptoms will always seem more similar than they actually are… because blurry pictures look more alike than sharp and clear ones. Non-specific symptoms are generalized biological reactions to adversity. Anxiety can cause any of them, and so can cancer. Any complex cases without pathognomic (specific, defining) symptoms are bound to have extensive overlap of their non-specific symptoms.

There are many ways to be sick, and relatively few ways to feel bad.

Do check out his full blog post. http://www.paulingraham.com/chronic-pain-tragic-irony.html

Using F1000 “peer review” to promote politics over evidence about delivering psychosocial care to cancer patients

The F 1000 platform allowed authors and the reviewers whom they nominated to collaborate in crafting more of their special interest advocacy that they have widely disseminated elsewhere. Nothing original in this article and certainly not best evidence!


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A newly posted article on the F1000 website raises questions about what the website claims is a “peer-reviewed” open research platform.

Infomercial? The F1000 platform allowed authors and the reviewers whom they nominated to collaborate in crafting more of their special interest advocacy that they have widely disseminated elsewhere. Nothing original in this article and certainly not best evidence!

I challenge the authors and the reviewers they picked to identify something said in the F1000 article that they have not said numerous times before either alone or in papers co-authored by some combination of authors and the reviewers they picked for this paper.

F1000 makes the attractive and misleading claim that versions of articles that are posted on its website reflect the response to reviewers.

Readers should be aware of uncritically accepting articles on the F 1000 website as having been peer-reviewed in any conventional sense of the term.

Will other special interests groups exploit this opportunity to brand their claims as “peer-reviewed” without the risk of having to tone down their claims in peer review? Is this already happening?

In the case of this article, reviewers were all chosen by the authors and have a history of co-authoring papers with the authors of the target paper in active advocacy of a shared political perspective, one that is contrary to available evidence.

Cynically, future authors might be motivated to divide their team, with some remaining authors and others dropping off to become nominated as reviewers. They could then suggest content that had already been agreed would be included, but was left off for the purposes being suggested in the review process


F1000Research bills itself as

An Open Research publishing platform for life scientists, offering immediate publication of articles and other research outputs without editorial bias. All articles benefit from transparent refereeing and the inclusion of all source data.

Material posted on this website is labeled as having received rapid peer-review:

Articles are published rapidly as soon as they are accepted, after passing an in-house quality check. Peer review by invited experts, suggested by the authors, takes place openly after publication.

My recent Google Scholar alert call attention to an article posted on F1000

Advancing psychosocial care in cancer patients [version 1; referees: 3 approved]

 Who were the reviewers?

open peer review of Advancing psychosocial care

Google the names of authors and reviewers. You will discover a pattern of co-authorship; leadership positions in international Psycho-Oncology society, a group promoting the mandating of specially mental health services for cancer patients, and lots of jointly and separately authored articles making a pitch for increased involvement of mental health professionals in routine cancer care. This article adds almost nothing to what is multiply available elsewhere in highly redundant publications

Given a choice of reviewers, these authors would be unlikely to nominate me. Nonetheless, here is my review of the article.

 As I might do in a review of a manuscript, I’m not providing citations for these comments, but support can readily be found by a search of blog posts at my website @CoyneoftheRealm.com and Google Scholar search of my publications. I welcome queries from anybody seeking documentation of these points below.

 Fighting Spirit

The notion that cancer patients having a fighting spirit improves survival is popular in the lay press and in promoting the power of the mind over cancer, but it has thoroughly been discredited.

Early on, the article identifies fighting spirit as an adaptive coping style. In actuality, fighting spirit was initially thought to predict mortality in a small methodologically flawed study. But that is no longer claimed.

Even one of the authors of the original study, Maggie Watson,  expressed relief when her own larger, better designed study failed to confirm the impression that a fighting spirit extended life after diagnosis  of cancer. Why? Dr. Watson was concerned that the concept was being abused in blaming cancer patients who were dying there was to their personal deficiency of not having enough fighting spirit.

Fighting spirit is rather useless as a measure of psychological adaptation. It confounds severity of cancer enrolled dysfunction with efforts to cope with cancer.

Distress as the sixth vital sign for cancer patients

distress thermometerBeware of a marketing slogan posing as an empirical statement. Its emptiness is similar to that of to “Pepsi is the one.” Can you imagine anyone conducting a serious study in which they conclude “Pepsi is not the one”?

Once again in this article, a vacuous marketing slogan is presented in impressive, but pseudo-medical terms. Distress cannot be a vital sign in the conventional sense. Thr  vital signs are objective measurements that do not depend on patient self-report: body temperature, pulse rate, and respiration rate (rate of breathing) (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.).

Pain was declared a fifth vital sign, with physicians mandated  by guidelines to provide routine self-report screening of patients, regardless of their reasons for visit. Pain being the fifth vital sign seems to have been the inspiration for declaring distress as the sixth vital sign for cancer patients. However policy makers declaring pain  as the fifth vital sign did not result in improved patient levels of pain. Their subsequent making intervention mandatory for any reports of pain led to a rise in unnecessary back and knee surgery, with a substantial rise in associated morbidity and loss of function. The next shift to prescription of opioids that were claimed not to be addictive was the beginning of the current epidemic of addiction to prescription opioids. Making pain the fifth vital sign is killed a lot of patients and  turned others into addicts craving drugs on the street because they have lost their prescriptions for the opioids that addicted them.

pain as 5th vital signCDC launches

 Cancer as a mental health issue

There is a lack of evidence that cancer carries a risk of psychiatric disorder more than other chronic and catastrophic illnesses. However, the myth that there is something unique or unusual about cancer’s threat to mental health is commonly cited by mental health professional advocacy groups is commonly used to justify increased resources to them for specialized services.

The article provides an inflated estimate of psychiatric morbidity by counting adjustment disorders as psychiatric disorders. Essentially, a cancer patient who seeks mental health interventions for distress qualifies by virtue of help seeking being defined as impairment.

The conceptual and empirical muddle of “distress” in cancer patients

The article repeats the standard sloganeering definition of distress that the authors and reviewers have circulated elsewhere.

It has been very broadly defined as “a multifactorial, unpleasant, emotional experienceof a psychological (cognitive, behavioural, emotional), social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms and its treatment and that extends along a continuum, ranging from common normalfeelings of vulnerability, sadness and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation and existential and spiritual crisis”5

[You might try googling this. I’m sure you’ll discover an amazing number of repetitions in similar articles advocating increasing psychosocial services for cancer patients organized around this broad definition.]

Distress is so broadly defined and all-encompassing, that there can be no meaningful independent validation of distress measures except for by other measures of distress, not conventional measures of adaptation or mental health. I have discussed that in a recent blog post.

If we restrict “distress” to the more conventional meaning of stress or negative affect, we find that any elevation in distress (usually 35% or so) associated with onset diagnosis of cancer tends to follow a natural trajectory of decline without formal intervention. Elevations in distress for most cancer patients, are resolved within 3 to 6 months without intervention. A residual 9 to 11% of cancer patients having elevated distress is likely attributed to pre-existing psychiatric disorder.

Routine screening for distress

The slogan “distress is the sixth vital sign” is used to justify mandatory routine screening of cancer patients for distress. In the United States, surgeons cannot close their electronic medical records for a patient and go on to the next patient without recording whether they had screened patients for distress, and if the patient reports distress, what intervention has been provided. Clinicians simply informally asking patients if they are distressed and responding to a “yes” by providing the patient with an antidepressant without further follow up allows surgeons to close the medical records.

As I have done so before, I challenge advocates of routine screening of cancer patients for distress to produce evidence that simply introducing routine screening without additional resources leads to better patient outcomes.

Routine screening for distress as uncovering unmet needs among cancer patients

 Studies in the Netherlands suggest that there is not a significant increase in need for services from mental health or allied health professionals associated with diagnosis of cancer. There is some disruption of such services that patients were receiving before diagnosis. It doesn’t take screening and discussion to suggest that patients that they at some point resume those services if they wish. There is also some increased need for physical therapy and nutritional counseling

If patients are simply asked a question whether they want a discussion of the services (in Dutch: Zou u met een deskundige willen praten over uw problemen?)  that are available, many patients will decline.

Much of demand for supportive services like counseling and support groups, especially among breast cancer patients is not from among the most distressed patients. One of the problems with clinical trials of psychosocial interventions is that most of the patients who seek enrollment are not distressed, and less they are prescreened. This poses dilemma: if you require elevated distress on a screening instrument, we end up rationing services and excluding many of the patients who would otherwise be receiving them.

I welcome clarification from F 1000 just what they offer over other preprint repositories. When one downloads a preprint from some other repositories, it clearly displays “not yet peer-reviewed.” F 1000 carries the advantage of the label of “peer-reviewed, but does not seem to be hard earned.


Slides are from two recent talks at Dutch International Congress on Insurance Medicine Thursday, November 9, 2017, Almere, Netherlands   :

Will primary care be automated screening and procedures or talking to patients and problem-solving? Invited presentation


Why you should not routinely screen your patients for depression and what you should do instead. Plenary Presentation






“ACT: The best thing [for pain] since sliced bread or the Emperor’s new clothes?”

Reflections on the debate with David Gillanders about Acceptance and Commitment Therapy at the British Pain Society, Glasgow, September 15, 2017

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Reflections on the debate with David Gillanders about Acceptance and Commitment Therapy at the British Pain Society, Glasgow, September 15, 2017

my title slideDavid Gillanders  and I held our debate “ACT: best thing since sliced bread or the Emperor’s new clothes?” at the British Pain Society meeting on Thursday, September 15, 2017 in Glasgow. We will eventually make our slides and a digital recording of the debate available.

I enjoyed hanging out with David Gillanders. He is a great guy who talks the talk, but also walks the walk. He lives ACT as a life philosophy. He was an ACT trainer speaking before a sympathetic audience, many who had been trained by him.

Some reflections from a few days later.

I was surprised how much Acceptance and Commitment Therapy (along with #mindfulness) has taken over UK pain services. A pre-debste poll showed most of the  audience  came convinced that indeed, ACT was the best thing since sliced bread.

I was confident that my skepticism was firmly rooted in the evidence. I don’t think there is debate about that. David Gillanders agreed that higher quality studies were needed.

But in the end, even I did not convert many, I came away quite pleased with the debate.

Standards for evaluating the  evidence for ACT for pain

 I recently wrote that ACT may have moved into a post-evidence phase, with its chief proponents switching from citing evidence to making claims about love, suffering, and the meaning of life. Seriously.

Steve Hayes prompted me on Twitter to take a closer look at the most recent evidence for ACT. As reported in an earlier blog, I took a close look.  I was not impressed that proponents of ACT are making much progress in developing evidence in any way as strong as their claims. We need a lot less ACT research that doesn’t add any quality evidence despite ACT being promoted enthusiastically as if it does. We need more sobriety from the promoters of ACT, particularly those in academia, like Steve Hayes and Kelly Wilson who know something about how to evaluate evidence. They should not patronize workshop goers with fanciful claims.

David Gillanders talked a lot about the philosophy and values that are expressed in ACT, but he also made claims about its research base, echoing the claims made by Steve Hayes and other prominent ACT promoters.

Standards for evaluating research exist independent of any discussion of ACT

There are standards for interpreting clinical trials and integration of their results in meta analysis that exist independent of the ACT literature. It is not a good idea to challenge these standards in the context of defending ACT against unfavorable evaluations, although that is exactly how Hayes and his colleagues often respond. I will get around to blogging about the most recent example of this.

Atkins PW, Ciarrochi J, Gaudiano BA, Bricker JB, Donald J, Rovner G, Smout M, Livheim F, Lundgren T, Hayes SC. Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement. Behaviour Research and Therapy. 2017 May 29.

Within-group (pre-post) differences in outcome. David Gillanders echoed Hayes in using within-group effects sizes to describe the effectiveness of ACT. Results presented in this way are better and may look impressive, but they are exaggerated when compared to results obtained between groups. I am not making that up. Changes within the group of patients who received ACT reflect the specific effects of ACT plus whatever nonspecific factors were operating. That is why we need an appropriate comparison-control group to examine between-group differences, which are always more modest than just looking at the within-group effects.

Compared to what? Most randomized trials of ACT involve a wait list, no-treatment, or ill-described standard care (which often represents no treatment). Such comparisons are methodologically weak, especially when patients and providers know what is going on-called an unblinded trial– and when outcomes are subjective self-report measures.

homeopathyA clever study in New England Journal of Medicine showed that with such subjective self-report measures, one cannot distinguish between a proven effective inhaled medication for asthma, an inert substance simply inhaled, and sham acupuncture. In contrast, objective measures of breathing clearly distinguish the medication from the comparison-control conditions.

So, it is not an exaggeration to say that most evaluations of ACT are conducted under circumstances that even sham acupuncture or homeopathy would look effective.

Not superior to other treatments. There are no trials comparing ACT to a credible active treatment in which ACT proves superior, either for pain or other clinical problems. So, we are left saying ACT is better than doing nothing, at least in trials where any nonspecific effects are concentrated among the patients receiving ACT.

Rampant investigator bias. A lot of trials of ACT are conducted by researchers having an investment in showing that ACT is effective. That is a conflict of interest. Sometimes it is called investigator allegiance, or a promoter or originator bias.

Regardless, when drugs are being evaluated in a clinical trial, it is recognized that there will be a bias toward the drug favored by the manufacturer conducting the trial. It is increasingly recognized that meta analyses conducted by promoters should also be viewed with extra skepticism. And that trials conducted with researchers having such conflicts of interest should be considered separately to see if they produced exaggerated.

ACT desperately needs randomized trials conducted by researchers who don’t have a dog in the fight, who lack the motivation to torture findings to give positive results when they are simply not present. There’s a strong confirmation bias in current ACT trials, with promoter/researchers embarrassing themselves in their maneuvers to show strong, positive effects when their only weak or null findings available. I have documented [ 1, 2 ] how this trend started with Steve Hayes dropping two patients from his study of effects of brief ACT on re-hospitalization of inpatients with Patricia Bach. One patient had died by suicide and another was in jail and so they couldn’t be rehospitalized and were drop from the analyses. The deed could only be noticed by comparing the published paper with Patricia Bach’s dissertation. It allowed an otherwise nonsignificant finding a small trial significant.

Trials that are too small to matter. A lot of ACT trials have too few patients to produce a reliable, generalizable effect size. Lots of us in situations far removed from ACT trials have shown justification for the rule of thumb that we should consider effect sizes from trials having less than 35 patients per treatment of comparison cell. Even this standard is quite liberal. Even if a moderate effect would be significantly larger trial, there is less than a 50% probability it be detected the trial this small. To be significant with such a small sample size, differences between treatments have to be large, and there probably either due to chance or something dodgy that the investigators did.

Many claims for the effectiveness of ACT for particular clinical problems come from trials too small to generate a reliable effect sizes. I invite readers to undertake the simple exercise of looking at the sample sizes in a study cited has support of the effectiveness of ACT. If you exclude such small studies, there is not much research left to talk about.

Too much flexibility in what researchers report in publications. Many trials of ACT involve researchers administering a whole battery of outcome measures and then emphasizing those that make ACT look best and either downplaying or not mentioning further the rest. Similarly, many trials of ACT deemphasize whether the time X treatment interaction is significant in and simply ignore it if it is not all focus on the within-group differences. I know, we’re getting a big tactical here. But this is another way of saying is that many trials of ACT gives researchers too much latitude in choosing what variables to report and what statistics are used to evaluate them.

Under similar circumstances, showed that listening to the Beatles song When I’m 64 left undergraduates 18 months younger than when they listen to the song Karamba. Of course, the researchers knew damn well that the Beatles song didn’t have this effect, but they indicated they were doing what lots of investigators due to get significant results, what they call p-hacking.

Many randomized trials of ACT are conducted with the same researcher flexibility that would allow a demonstration that listening to a Beatles song drops the age of undergraduates 18 months.

Many of the problems with ACT research could be avoided if researchers were required to publish ahead of time their primary outcome variables and plans for analyzing them. Such preregistration is increasingly recognized as best research practices, including by NIMH. There is  no excuse not to do it.

My take away message?

ACT gurus have been able to dodge the need to develop quality data to support their claims that their treatment is effective (and their sometime claim it is more effective than other approaches). A number of them are university-based academics and have ample resources to develop better quality evidence.

Workshop and weekend retreat attendees are convinced that ACT works on the strength of experiential learning and a lot of theoretical mumbo jumbo.

But the ACT promoters also make a lot of dodgy claims that there is strong evidence that the specific ingredients of ACT, techniques and values, account for the power of ACT. But some of the ACT gurus, Steve Hayes and Kelly Wilson at least, are academics and should limit their claims of being ‘evidence-based” to what is supported by strong, quality evidence. They don’t. I think they are being irresponsible in throwing in “evidence-based’ with all the

What should I do as an evidence-based skeptic wanting to improve the conversation about ACT?

 Earlier in my career, I spent six years in live supervision in some world-renowned therapists behind the one-way mirror including John Weakland, Paul Watzlawick, and Dick Fisch. I gave workshops world wide on how to do brief strategic therapies with individuals, couples, and families. I chose not to continue because (1) I didn’t like the pressure for drama and exciting interventions when I interviewed patients in front of large groups; (2) Even when there was a logic and appearance of effectiveness to what I did, I didn’t believe it could be manualized; and (3) My group didn’t have the resources to conduct proper outcome studies.

But I got it that workshop attendees like drama, exciting interventions, and emotional experiences. They go to trainings expecting to be entertained, as much as informed. I don’t think I can change that.

Many therapists have not had the training to evaluate claims about research, even if they accept that being backed by research findings is important. They depend on presenters to tell them about research and tend to trust what they say. Even therapist to know something about research, tennis and critical judgment when caught up in emotionality provided by some training experiences. Experiential learning can be powerful, even when it is used to promote interventions that are not supported by evidence.

I can’t change the training of therapists nor the culture of workshops and training experience. But I can reach out to therapist who want to develop skills to evaluate research for themselves. I think some of the things that point out in this blog post are quite teachable as things to look for.

I hope I can connect with therapists who want to become citizen scientists who are skeptical about what they hear and want to become equipped to think for themselves and look for effective resources when they don’t know how to interpret claims.

This is certainly not all therapists and may only be a minority. But such opinion leaders can be champions for the others in facilitating intelligent discussions of research concerning the effectiveness of psychotherapies. And they can prepare their colleagues to appreciate that most change in psychotherapy is not as dramatic or immediate as seen in therapy workshops.

eBook_PositivePsychology_345x550I will soon be offering e-books providing skeptical looks at positive psychology and mindfulness, as well as scientific writing courses on the web as I have been doing face-to-face for almost a decade.

Sign up at my website to get advance notice of the forthcoming e-books and web courses, as well as upcoming blog posts at this and other blog sites. Get advance notice of forthcoming e-books and web courses. Lots to see at CoyneoftheRealm.com.