Talking back to “Talking Therapy Can Literally Rewire the Brain”

This edition of Mind the Brain was prompted by an article in Huffington Post, Talking Therapy Can Literally Rewire the Brain.

The title is lame on two counts: “literally” and any suggestion that psychotherapy does something distinctive to the brain, much less “rewiring” it.

I gave the journalist the benefit of a doubt and assumed that the editor applied the title to the article without having the journalist’s permission. I know from talking to journalists, that’s a source of enormous frustration when it happens. But in this instance, the odd title came directly from a press release from King’s College London  (Study reveals for first time that talking therapy changes the brain’s wiring)which concerned an article published in the  Nature Publishing journal, Translational Psychiatry 

Hmm, authors from King’s College and published in a Nature journal suggest this might be a serious piece of science worth giving a closer look. In the end, I was reminded not to make too much of authors’ affiliation and where they publish.

I poked fun on Twitter at the title of the Huffington Post article.

literally twitter postThe retweets and likes drifted into a discussion of neuroscientists saying they really didn’t know much about the brain. Somebody threw in a link to an excellent short YouTube video by NeuroSkeptic on that topic that I highly recommend.

Anyway, I found serious problems with the Huffington Post article that should have been sufficient to stop with it.  Nonetheless, I proceeded and the problems got compounded when I turned to the press release with its direct quotes from the author. I wasn’t long into the Translational Psychiatry article before I appreciated that its abstract was misleading in claiming that there were 22 patients in the study. That is a small number, but if the abstract had stated the actual number, which was 15 patients, readers would have been warned not to take too seriously complicated multivariate statistics that were coming up.

How did a prestigious journal like Translational Psychiatry allow authors to misrepresent their sample size? I would shortly be even more puzzled about why the article was even published in Translational Psychiatry, although I formed unflattering some hypotheses about that journal. I’ll end with those hypotheses.

Talking To A Therapist Can Literally Rewire Your Brain (Huffington Post)

The opening sentence would raise the skepticism of informed reader:

If you can change the way you think, you can change your brain.

If I accept that statement, it’s going be with a broad stretching of it to meaninglessness. “If you can change the way you think..” covers lots of territory. If the statement  is going to remain the correct, then the phrase “change your brain” is going to have to be similarly broad. If the journalist wants to make a big deal of this claim, she would have to concede that reading my blog changes her brain.

That’s the conclusion of a new study, which finds that challenging unhealthy thought patterns with the help of a therapist can lead to measurable changes in brain activity.

Okay, we now know that at least a specific study with brain measurements is being discussed.

But then

In the study, psychologists at King’s College London show that Cognitive Behavioral Therapy strengthens certain healthy brain connections in patients with psychosis. This heightened connectivity was associated with long-term reductions in psychotic symptoms and recovery eight years later, according to the findings, which were published online Tuesday in the journal Translational Psychiatry.

“Over six months of therapy, we found that connections between certain key brain regions became stronger,” Dr. Liam Mason, a clinical psychologist at King’s College and the study’s lead author, told The Huffington Post in an email. “What we are really excited about here is that these stronger connections lead to long-term improvements in people’s symptoms and overall recovery across the eight years that we followed them up.”

A lot of skepticism is being raised. The article seems to be claiming that changes in brain function observed in the short term with cognitive behavior therapy for psychosis [CBTp] were associated with long-term changes over the extraordinary eight years.

The problems with this? First CBTp is not known to be particularly effective, even in the short term. Second, this a lot heterogeneity under the umbrella of “psychosis,” but in eight years, a person who has had that label appropriately applied will have a lot of experiences: recovery and relapse, and certainly other mental health treatments. How in all that noise and confusion can a signal detected that a psychotherapy that isn’t particularly effective explains any long-term improvement?

[Skeptical about my claim that CBTp is ineffective? See Effect of a missing clinical trial on what cochrane-slide-2we think about cognitive behavior therapy  and the slides about Cochrane reviews from a longer Powerpoint presentation.]

Any discussion of how CBT works and what long-term improvements it predicts has get past considerable evidence CBT doesn’t work any better than nonspecific supportive treatments. Without short-term effects, how can have long-term effects?

cbt cochrane 1

 

 

 

There is no acknowledgment in the Huffington Post article of the lack of efficacy of CBTp. Instead, we have a strong assumption that CBTp works and that the scientific paper under discussion is important because it shows that CBTp strongly works, with observable long-term effects.

The journalist claims that the present scientific paper builds on earlier one:

In the original study, patients with psychosis underwent brain imaging both before and after three months of CBT. The patients’ brains were scanned while they looked at images of faces expressing different emotions. After undergoing CBT, the patients showed marked increases in brain activity. Specifically, the brain scans showed heightened connections between the amygdala, the brain region involved in fear and threat processing, and the prefrontal cortex, which is responsible for reasoning and thinking rationally ― suggesting that the patients had an improved ability to accurately perceive social threats.

“We think that this change may be important in allowing people to consciously re-think immediate emotional reactions,” Mason said.

Readers can click back to my earlier blog post, Sex and the single amygdala: A tale almost saved by a peek at the data. The same experimental paradigms was being used to study the amygdala in terms of activity predicted changes in the number of sexual partners over time. In that particular study, p-hacking, and significance chasing and selective reporting were used by the authors to create the illusion of important findings. If you visit my blog post, check out the comments that ridiculed the study, including from two very bright undergraduates.

We don’t need to deter into a technical discussion of functional magnetic resonance imaging (fMRI) data to make a couple of points. The authors of the present study used a rather standard experimental paradigm and the focus on amygdala concerned some quite nonspecific psychological processes.

The authors of the present study soon concede this:

There’s a good chance that similar brain changes also occur in CBT patients being treated for anxiety and depression, Mason said.

“There is research showing that some of the same connections may also be strengthened by CBT for anxiety disorders,” he explained.

But wait: isn’t the lead author also saying in the Huffington Post article and the title of the press release as well that this is a first-time study ever?

For the present purposes, we need only to dispense with any notion that we’re talking about a rewiring of the brain known to be specifically associated with psychosis or even that there is reason to expect that such “rewiring” could be expected to predict long-term outcome of psychosis.

Reading further, we find that the study only involved following 15 patients from a larger study, un like the misleading abstract that claims 22.

Seriously, are we being asked to get worked up about a fMRI study with only 15 patients? Yup.

The researchers found that heightened connectivity between the amygdala and prefrontal cortex was associated with long-term recovery from psychosis. The exciting finding marks the first time scientists have been able to demonstrate that brain changes resulting from psychotherapy may be responsible for long-term recovery from mental illness.

What is going on here? The journalist next gives free reign to the lead author to climb up on a soap box and proclaim his agenda behind all of these claim:

The findings challenge the “brain bias” in psychiatry, an institutional focus on physical brain differences over psychological factors in mental illness. Thanks to this common bias, many psychiatrists are prone to recommending medication to their clients rather than psychological treatments such as CBT.

But medication has been proved to be effective with psychosis, CBTp has not.

“Psychological therapy can lead to changes in the mechanics of the brain,” Mason said. “This is especially important for conditions like psychosis which have traditionally been viewed as ‘brain diseases’ that require medication or even surgery.”

“Mechanics of the brain”?  Now we have escalated from ‘literally rewiring’ to “changes in the mechanics.” Dude, we are talking about a fMRI study. Do you think we have been transported to an auto repair shop?

“This research challenges the notion that the existence of physical brain differences in mental health disorders somehow makes psychological factors or treatments less important,” Mason added in a statement.

Clicking on the link takes one to Science Daily article which churnals (plagiarizes) a press release from Kings College,  London.

The Press Release: Study reveals for first time that talking therapy changes the brain’s wiring

There is not much in this press release that is not been regurgitated in the Huffington Post article except for some more soapbox preaching:

Unfortunately, previous research has shown that this ‘brain bias’ can make clinicians more likely to recommend medication but not psychological therapies. This is especially important in psychosis, where only one in ten people who could benefit from psychological therapies are offered them.”

But CBT, the most evaluated psychotherapy for psychosis has not been shown to be effective, by itself. Sure, patients suffering from psychosis need a lot of support, efforts to maintain positive expectations, and opportunities to talk about their experience. But in direct comparisons between such support provided by professionals or by peers, CBT has not been shown to be more effective.

The researchers now hope to confirm the results in a larger sample, and to identify the changes in the brain that differentiate people who experience improvements with CBT from those who do not. Ultimately, the results could lead to better, and more tailored, treatments for psychosis, by allowing researchers to understand what determines whether psychological therapies are effective.

Sure, we are to give a high priority to examining the mechanism by which CBT, which has not been proven effective, works its magic.

Translational Psychiatry: Brain connectivity changes occurring following cognitive behavioural therapy for psychosis predict long-term recovery

[This will be a quick tour, only highlighting some of the many problems that I found. I welcome readers probing the open access article and posting what they find.]

The Abstract misrepresents the study as having 22 patients, when it actually only had data from 15.

The Introduction largely focuses on previous work of the author group. If you bothered to check, none of it involves randomized trials, despite making claims of efficacy for CBTp. No reference is made to a large body of literature finding a lack of effectiveness for CBTp. In particular, there is no mention of the Cochrane reviews.

A close reading of the Methods indicates that what are claimed to be “objective clinical outcomes” are actually unblinded, retrospective ratings of case notes by the two raters including the first author. Unblinded ratings, particularly by an investigator, are an important source of bias in studies of CBTp and lead to exaggerated estimates of outcome.

An additional measure with inadequate validation was obtained at 7 to 8 year follow-up:

Questionnaire about the Process of Recovery (QPR,31), a service-user led instrument that follows theoretical models of recovery and provides a measure of constructs such as hope, empowerment, confidence, connectedness to others.

All patients came from clinical studies conducted by the author group that did not involve randomization. Rather, assignment to CBTp was based on provider identifying patients “deemed as suitable for CBTp.“ There is considerable risk of bias if it patient data is treated if it arose in a randomized trial. I previously raised issues about the inadequacy of routine care provided to psychotic patients both in terms of its clinical adequacy and an meaningfulness as a control/comparison group because of its lack of nonspecific factors.

All patients assigned to CBTp were receiving medication and other services. A table revealed that receipt of other services was strongly correlated with recovery status. Yet the authors are attempting to attribute any recovery across the eight years to the brief course of CBTp at the beginning. Obviously, the study is hopelessly confounded and no valid inferences possible. This alone should have gotten this study rejected.

There were data available from control subjects at follow-up, including fMRI data, but they were excluded from the present report. That is unfortunate, because these data would allow at least minimal evaluation of whether CBTp versus remaining in routine care had any difference in outcomes and – importantly – if the fMRI data similarly predicted the outcomes of patients not receiving CBTp.

Data Analysis indicates one tailed, multivariate statistical tests that are quite inappropriate and essentially meaningless with such a small data set. Bonferonni corrections, which were inconsistently applied, offer no salvation.

With such small samples and multivariate statistics, a focus on p-values is inappropriate, but the authors do just that and report p<.04 and p<.06, the latter being treated as significant. The hypothesis that this might represent significance chasing is supported when supplementary data tables are examined. When I showed them to a neuroscientist, his first response was that they were painful to look at.

longitudinalI could go on but…

Why did the authors bother with this study? Why did King’s College London publicize the study with a press release? Why was it published in Nature’s Translational Psychiatry without the editor or the reviewers catching obvious flaws?

The authors had some data lying around and selected out post-hoc a subset of patients and applied retrospective ratings and inappropriate statistics. There is no evidence of a protocol for a priority hypothesis being pursued, but strong circumstantial of p-hacking, significance chasing and selective reporting. This is not a valid study, not even an experimerciasl, it is a political, public relations effort.

soao box 2Statements in the King’s College press release echoed in the Huffington Post indicate a clear ideological agenda. Anyone who knows anything about psychiatry, neuroscience, cognitive behavior therapy for psychosis is unlikely to be persuaded. Anyone who examines the supplementary statistical tables armed with minimal statistical sophistication will be unimpressed, if not shocked. We can assume that as a group, these people would quickly leave the conversation about cognitive behavior therapy for psychosis literally rewiring the brain, if they ever got engaged.

The authors were not engaging relevant audiences in intelligent conversation. I can only presume that they were targeting naive vulnerable patients and their families having to make difficult decisions about treatment for psychosis. And the authors were preaching to the anti-psychiatry crowd. One of the authors also appears as an author of Understanding Psychosis, a strongly non-evidence-based advocacy of cognitive behavior therapy for psychosis, delivered with a hostility towards medication and psychiatrists (See my critique.) I did know that about this author until I read the materials I’ve been reviewing. It is an important bit of information and speaks to the author’s objectivity and credibility.

Obviously, the press office of King’s College London depends a lot, maybe almost entirely, on the credibility of authors associated with that institution. Maybe next time, they should seek an independent evaluation. Or maybe they are  just interested in publicity about research of any kind.

But why was this article published in the seemingly prestigious Nature journal, Translational Psychiatry? It should be noted that this journal is open access, but with exceptionally pricey Article Processing Costs (APCs) of £2,400/$3,900/€2,800. Apparently adequate screening and appropriate peer review are not including in these costs. These authors have purchased a lot of prestige. Moreover, if you want to complain about their work in a letter to the editor, you have to pay $900. So the authors have effectively insulated themselves from critics. Of course, is always blogging, PubMed Commons and PubPeer for post-publication peer review.

I previously blogged about another underpowered, misreported study claiming to have identified a biomarker blood test for depression. The authors were explicitly advertising that they were seeking commercial backers for their blood test. They published in Translational Psychiatry. Maybe that’s the place to go for placing outlandish claims into open access – where anybody can be reached – with a false assurance of a prestige protected by rigorous peer review.

 

The Holocaust intrudes into conversations about psychiatric diagnosis: Godwin’s rule confirmed

peter_kinderman_140x140The President-elect of the British Psychological Association drops the N word and invokes the Holocaust in denouncing mental health professionals who embrace the biomedical model.

The conversation concerning Understanding Psychosis and Schizophrenia  (hereafter UPS) took another wrong turn with extended references to Nazism and the Holocaust in a blog post by Peter Kinderman, Me, my brain and baked beans. Goodwin’s rule is once again confirmed.

please removePeter Kinderman is one of the main spokespersons for the British Psychological Society UPS document. The blog further identifies him as a Professor at University of Liverpool, and the President-elect of the British Psychological Society.

Godwin’s Rule or Godwin’s Rule of Nazi Analogies is “As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches 1.“ Michael Godwin elaborates on it in I Seem To Be A Verb: 18 Years of Godwin’s Law:

I created Godwin’s Law and began to repeat it in online forums whenever I encountered a silly comparison of someone or something to Hitler or to the Nazis…. My feeling is that “Never Again” loses its meaning if we don’t regularly remind ourselves of the terrible inflection point marked in human culture by the Holocaust. Sure, there has been genocide before that point and genocide after it, but to see an advanced, highly civilized nation warp itself into something capable of creating such a horror—well, I think Nazi Germany does count as a first in that regard. And to a great extent, our challenge as human beings who live in the period after that inflection point is that we no longer can be passive about history—we have a moral obligation to do what we can to prevent such events from ever happening again. Key to that obligation is remembering, which is what Godwin’s Law is all about.

Those horrified by the Holocaust as a unique historical event see invoking it casually in political or professional rivalries as a “gross misappropriation of the past and an obscene misuse of history.”

The continued misuse  and trivialization of the word prompted Elie Wiesel, Nobel laureate and chronicler of the Holocaust, to discontinue using it. “Whatever mishap occurs now, they call it ‘holocaust,'” Wiesel said. “I have seen it myself in television in the country in which I live. A commentator describing the defeat of a sports team, somewhere, called it a ‘holocaust.'”

This will be a long read edition of PLOS Mind the Brain because of extensive direct quotes from BPS President-elect Kinderman. His statements strain all credibility. I don’t want any ambiguity as to whether I made them up.

Readers are encouraged to retrieve Kinderman’s blog post and see for themselves. It is posted at the anti-psychiatry blog, Mad in America.

A résumé of what his blog reveals

  1. President-elect Kinderman has unusual psychological experiences which he traces to growing up in a family environment with a harsh, unloving mother.
  2. In ways that frighten him, he fantasizes about winning Nobel or Pulitzer prizes and being awarded knighthood. And “I lurch forwards and jump to conclusions in my mental logic.” He is prone to tangential connectivity and abstract, ‘clang’ associations.
  3. He believes that these experiences would have caused him to be castrated if the Nazis had won World War II.
  4. He believes that those who adhere to what he terms a disease model of psychological disorder are essentially following the Nazis.
  5. He believes the connection is obvious to friends and colleagues, who consider him brave in making it public.
  6. He makes extensive references to the Holocaust in developing his argument.
  7. Kinderman is particularly frightened by advocates of this disease model because of the rise of right-wing political parties in Europe.
  8. He ends with a plea “don’t use the ‘disease-model’ as a framework.”

A résumé of my commentary

  1. Kinderman sees his unusual experiences as giving him privileged status to condemn those who accept the biomedical model of psychopathology.
  2. He invokes the Holocaust and Nazi analogy to bolster his argument in what he sees as a turf war between his supporters and psychiatrists. Actually, the overwhelming majority of academic mental health professionals accept some version of a biomedical model.
  3. He has long been caricaturing psychiatric diagnosis in reductionist terms,  referring to the biomedical model as a “genetic disease” model. But by invoking the Holocaust and the Nazis, he is excluding himself from participation in any subsequent conversation.
  4. Until President-elect Kinderman apologizes to the larger community which accepts the need to protect the memory of Holocaust from such desecration, the credibility of the British Psychological Society remains damaged. The BPS Board of Trustees should condemn him or accept responsibility for having such a spokesperson.
  5. Kinderman indicates that his blog is “a slightly longer version” of an article published elsewhere. The earlier article lacked any reference to the Holocaust or Nazis and he expresses appreciation to Anne Cooke for editing the transition. She therefore shares responsibility with Kinderman for the references to the Holocaust and Nazis. She is similarly disqualified as a participant in any conversation in the social media until she apologizes.
  6. In place of scientific evidence, Kinderman’ frequently claimed the authority of personal eminence associated with his professorship. This is disallowed by his references to the Holocaust and Nazism, which place him outside of academic discourse.
  7. UPS was explicitly aimed at influencing mental health service users and policymakers. Vigorous debate should continue, but critics should not require the authors to engage them. After all, what do you expect from somebody who considers you a Nazi? And to get back into the conversation, the authors of Understanding Psychosis have to address Kinderman putting the Holocaust and Nazism on the table.

I hope that these résumés will inform, but do not satiate you. I  hope they encourage you to read further in what will prove a fascinating discussion. But regardless, begin asking yourself what responsibility the trustees of the British Psychological Society have in dealing with the situation that Kinderman has now created. Or does it really matter that the President-elect of this organization has written such things?

Kinderman’s Me, My Brain, and Baked Beans

beans_on_toast430x300Kinderman starts off with a statement of annoyance but gives no indication where he is going.

In mental health, resolving the relative contributions of our biology and genetics and how these interact with social and environmental factors (our parenting, peer-relationships, learning, and experiences of both abuse and nurturing) is more than an intellectual puzzle. I’m occasionally annoyed by what appears to be a rather simplistic suggestion that, if there’s a biological, even heritable, element, to a psychological phenomenon, then we’re inevitably discussing an illness, a disease.

A Difficult Childhood

He soon gets to depicting his early family environment and readers can again ponder ‘where is this taking us?’

After my mother’s death, we discovered that, when she had confessed to a religious mentor that she was in danger of loving her children more than God, there was a subsequent process of re-adjustment … she was encouraged to practice loving her children less. My parents rejected the material world as merely a stepping-stone to heaven (or hell) and paid little attention to worldly pursuits. I remember opening a letter from Cambridge University confirming an offer of a place as an undergraduate. I told my mother, whose reply was; “Very nice dear, now, do you want baked beans on toast for breakfast?”

Kinderman’s point seems to be that he and his siblings were not reared in a loving and accepting environment. His mother’s religiosity was pivotal. Kinderman discourages us from having any sympathy for the mother. But now that he has brought her up, we can nonetheless wonder about how she might have been suffering.

An astute reader with a sense of history might also wonder if we are being set up for a simplistic refrigerator mother explanation of psychological problems in offspring.

In the 1990s, Irish motivational speaker Tony Humphreys  drew upon his own adverse childhood experiences to extend a discredited theory of the refrigerator mothers of children with autism to explain schizophrenia and diabetes. He was subsequently censured by the Irish Psychological Society.

Humphreys was following up on the 1940s work of Leo Kanner  who coined the phrase in describing mothers of autistic children as “just happening to defrost enough to produce a child.”

refrigerator motherAs an antidote to this nasty mother bashing, I strongly recommend Refrigerator Mothers,  an hour-long movie freely available on the Internet. It provided an opportunity for mothers with autistic children to talk back against the stereotype of them.

 

Once isolated and unheard, these mothers have emerged with strong, resilient voices to share the details of their personal journeys. Through their poignant stories, Refrigerator Mothers puts a human face on what can happen when authority goes unquestioned and humanity is removed from the search for scientific answers.

Kinderman claims to be an expert by experience

Kinderman then describes his unusual psychological experiences and behavior.

So I am emotionally labile; my self-esteem and emotions are very fragile and very much dependent on what I imagine other people are thinking. Or, at least, I think I am; my observations of my own behaviour are themselves subjective, and it’s possible that others do these things as much as I do. I frighten myself (given my relative’s experiences) by fantasising about… winning Nobel prizes, winning Pulitzer prizes, being elected to this and that, being awarded knighthoods… and that’s frightening because I’ve seen self-referent fantasies ruin other people’s lives.

…And, perhaps most saliently, I lurch forwards and jump to conclusions in my mental logic. So, if you give me the sequence “A, B, C” and ask me to complete the sequence, I’ll say Z. Maybe that’s a bit of a joke (a pun on ‘complete’), and it’s unequivocally good for me in my academic career. A creative professor is a good professor. I also and simultaneously make abstract and surreal connections. It’s a recognised part of my teaching style – I’ll veer off on a tangent. Again, perhaps useful in an academic and possibly engaging or at least entertaining for students (if they can keep up…). But jumping to conclusions, tangential connectivity and abstract, ‘clang’ associations all have very interesting connotations in the field of mental health.

Too much information. What shall we to make of these deeply personal and out-of-place disclosures from the President-elect of the British Psychological Society? Kinderman claims benefit from it these experiences and does not want to discredit himself. Yet he is giving live ammunition to critics who have long been frustrated with his distinctive torrents of scrambled anecdata and pomposity. No worry, Kinderman is about to discredit himself more thoroughly.

But for a bit, Kinderman continues quite reasonably:

So I am very interested (and, I hope, open-minded) about what it is, if anything, that we inherit. How do I differ from other people? What proportion of the variance in these traits can be accounted for by genetic differences? What proportion of the variance in these traits comes from being brought up by repressed religious extremists? What proportion comes from being reinforced, through my childhood, for being academic? Which elements of my upbringing were different other people’s anyway?

Kinderman brings in the Nazis

Out of context, this appears a reconciliatory statement that invites agreement from critics. But there is a disaster ahead. Kinderman’s train of thought transports unknowing readers to the death camps of the Holocaust with contemporary psychiatrists branded Nazis. Kinderman apparently thinks his friends and colleagues will consider him brave for exposing this obvious connection.

…I think it’s perfectly possible to be intelligent and open-minded about the contribution of genetic and environmental factors in our mental health. We can intelligently and respectfully discuss how experiences and heritable traits can interact to produce the wonderful variety of human experience. This, I think, is a much more accurate and helpful way to conceptualise what’s going on than to say that some of us – but only some of us – have ‘mental illnesses’. Labels such as ‘schizophrenia’ not only suffer from the validity problems that we’ve discussed elsewhere, but also obfuscate these important considerations. I don’t think it’s helpful to consider how I have managed to avoid developing ‘schizophrenia’, or whether I have ‘attenuated psychosis syndrome’. To do that, to reduce these discussions to binary considerations of the presence or absence of disorders, necessarily constrains the scientific debate. It can also sometimes have frightening consequences in the real world. When I’ve mentioned some of these issues before in less public settings, friends and colleagues have often told me that I’m being brave, and that it’s a potentially risky topic of conversation. So why might that be?

The eradication of undesirable genetic traits

Part of the reason that people might be reluctant to talk about such issues is that we have a very poor track record in this area. This is a difficult topic, but I think it is important to remember the infamous 1933 Nazi Law for the Prevention of Genetically Diseased Offspring (Gesetz zur Verhütung erbkranken Nachwuchses). Arguments of genetic science not only led to the drafting of this law (which permitted the compulsory sterilisation of any citizens who were judged to possess a ‘genetic disorder’ which could be passed onto their children) but indeed led German-American psychiatrist Franz Kallmann to argue that such a policy of sterilisation should be extended to the relatives of people with mental health problems (in order to eradicate the genes supposedly responsible). The notorious Action T4 ‘eradication’ programme was the logical extension of these policies.

From Kinderman’s Me, my brain and baked beans.

Adolf Hitler’s order for the Action T4 programme
Adolf Hitler’s order for the Action T4 programme.
Reich Law Gazette on 25 July 1933: Law for the Prevention of Genetically Diseased Offspring

 

 

 

 

 

 

 

 

 

 

 

 

Kinderman accuses Franz Kallmann of being a war criminal. Kinderman should have spent more time at Google University learning about Kallmann who fled the Nazis in the 1936.

Considered a Jew by the Nazis although not by himself, he could not publish his work, and had to rely on friends at Munich to read his papers for him. He could only get his statistics into print by quotation in papers of others’ authorship.

… Despite of all obstacles, he succeeded in organizing the first research department in psychiatric genetics in the United States at the New York State Psychiatric Institute. This department became the main source of intellectual support of psychiatric genetic research in the U.S. for a generation.

Kinderman’s description of Kallmann as a “German-American psychiatrist” is used to smear all of contemporary psychiatry with the taint of Nazism.

At the Bath Conference on Understanding Psychosis, Kinderman refused to engage other members of the panel. It is too bad that the event was not recorded and that the BPS insisting on editing a journalist’s account. But those who were there will recall Kinderman closed with a rambling, incoherent rant about the horrors of mental health professionals telling psychiatric patients that they had a genetic disease.

Perhaps uncomfortable with having invoked the Nazis, in his blog he tries to shift to fascism. He introduces a non sequitur in claiming that if schizophrenia represents “a biological problem, we can dismiss any further troubling considerations.” Then he insists in a most extraordinary way on his privileged status talk of the Holocaust because of its personal relevance and threat.

Of course, a focus on biological aspects of mental health problems is not in any sense necessarily synonymous with fascism. But for many of us, there are echoes of blame, of stigma, when we identify the pathology within the genetic substrate of the person. I’m reminded of Eric Pickles’ notorious throw-away comment to a voter campaigning about the abuse she’d experienced that she should “adjust her medication”. If the pathology lies in the person, and particularly if it is a biological problem, we can dismiss any further troubling considerations.

So one way to understand these kinds of experiences is to diagnose some form of ‘subclinical’ syndrome, perhaps attenuated psychosis. If the Nazis had won the second world war, I would have been castrated as a first-degree relative of a ‘schizophrenic’. Disease-model, eugenic, thinking is a direct threat to me personally, especially given the recent rise of UKIP and other far-right parties in Europe. I am interested in whether the traits that make me a good professor may also be related to the traits I listed earlier, and on their impact on my emotions. I am interested in whether they may have emerged from a similar mix of genes and environment that led my relative to experience psychosis. I am very interested in the practical implications; I have always, for example, avoided certain classes of street drugs. It is absolutely possible to discuss gene × environment interactions, but – please – don’t use the ‘disease-model’ as a framework.

Why Peter Kinderman and Anne Cooke are excluded from further discussions of Understanding Psychosis until they publicly apologize.

“A good rule in most discussions is that the first person to call the other a Nazi automatically loses the argument.”  This has been elaborated in Godwin’s Law FAQ:

godwin faq

Nonetheless, gratuitous references to the Holocaust in Nazis regularly occur around the world, highlighting all the more the need to insist on them being obscene.

The memory of six million Jews and the eleven million other human beings who died in the Holocaust is too sacred for calculating politicians and their paranoid cheerleaders to be turned into a semantic missile.

Republican presidential candidate Mike Huckabee is incorrigible. In 2014 he said

 

If you felt something incredibly powerful at Auschwitz and Birkenau over the 11 million killed worldwide and the 1.5 million killed on those grounds, cannot we feel something extraordinary about 55 million murdered in our own country in the wombs of their mothers? Does that not speak to us?

Now Huckabee is being condemned by Israel for saying the Iran nuclear deal is “marching the Israelis to the door of the oven.”  Israel does not need that kind of support.

Why did Kinderman destroy his credibility by publishing this?

For the same reason that Mike Huckabee made the comparison between abortion and the Holocaust. He believes these things, he has bad judgment, and he thought he wouldn’t be caught.

Huckabee speech was captured on a videotape in 2014 and subsequently distributed by Right Wing Watch, a non-profit working to expose the Far-Right’s extreme and intolerant agenda. Otherwise most of us would not have learned of his statements.

Kinderman similarly may have thought that he was in a closed environment where he could express views that would resonate with an important part of his constituency. He surely would not have made them at an international scientific psychology gathering.

The long thread of comments Kinderman elicited at the blog site showed little indignation and tacit acceptance that psychiatrists are Nazis. He seems to have only tweeted once about this blog post and probably didn’t think it would come to the attention of the larger community.

He may be a professor at University of Liverpool and President-elect of the British Psychological Society, but he plays to a constituency that is neither academic nor professional.

Dealing with the offense to all comes first

Even before the references to the Holocaust and Nazis aside, there there have been many reasons be offended by Kinderman’s promotion of the BPS UPS.

  • Serious academics have been outraged by Kinderman’s arguments without evidence against diagnosis, his claim that antipsychotic medication is toxic and ineffective, his crass emotional appeals, and his slandering of the large other side on an important issue. UPS simply not does not adhere to academic standards in terms of logic and reference to evidence and would not pass independent peer review.
  • Mental health service consumers and their family members have been upset that issues that concern them are being framed in such a misleading and irrational way by a professional. They are unrepresented and silenced by the carefully selected clinical examples in the UPS. Treatment options have been misrepresented in ways intended to frighten them. They have legitimate concerns about having to be diagnosed or treated by psychologists who hold such warped views.
  • Many members of the British Psychological Society are embarrassed by the organization sinking to this level. They would not want to be asked in a public gathering if UPS represents solid science. Many UK psychologists who are not members of BPS are upset that the organization that supposedly speaks for them is associated with such ridiculous statements.

All who are offended should feel free to speak out. But the preemptive issue is before the larger community is that Kinderman has behaved in an unacceptable manner. Kinderman is out of the discussion. His license is revoked and he needs to reapply.

If Kinderman or Anne Cooke pop up in these discussions, they should simply be asked “Don’t you have a problem with desecrating the memory of the Holocaust?” and then ignored.

The dilemma facing the British Psychological Society

Kinderman blurs any distinction between his personal views and those of the organization with which he incessantly claims to speak, often in forums only available because he represents BPS. It’s incumbent upon the BPS to clarify where they stand on what is now a game-stopping issue. Do they condemn Kinderman or are they left implicitly condoning him?

Here is a list of members of the Board of Trustees and some of their email addresses I was able to obtain from the internet. Readers might want to individually and collectively inquire about where the board stands about Kinderman casually invoking the Holocaust and Nazism in a context where references to these historical events have no place.

  • President Professor Jamie Hacker Hughes CPsychol CSci FBPsS profjamiehh@gmail.com
  • Vice President Professor Dorothy Miell CPsychol FBPsS d.e.miell@ed.ac.uk
  • Honorary General Secretary Dr Carole Allan CPsychol Csci FBPsS Carole.Allan@glasgow.ac.uk
  • Honorary Treasurer Professor Ray Miller CPsychol FBPsS
  • Chair Education and Public Engagement Board Professor Catriona Morrison CPsychol AFBPsS c.morrison@hw.ac.uk
  • Chair Research Board Professor Daryl B O’Connor CPsychol AFBPsS D.B.O’Connor@leeds.ac.uk
  • Chair Professional Practice Board Dr Ian Gargan CPsychol AFBPsS
  • Chair Membership Standards Board Dr Mark Forshaw CPsychol CSci FBPsS FIHPE

It is fair game to raise the issue of Kinderman’s transgression when members of the BPS Board of Trustees appear at public gatherings. I intend to do so when Daryl B O’Connor shows up at the European Health Psychology Conference in Cyprus and encourage others to do so as well. “Hey Daryl, about Kinderman’s references to the Holocaust and Nazis…”

BPS President Jamie Hacker Hughes announced the launch of Understanding Psychosis on Twitter and then unsuccessfully tried to squelch discussion when it turned negative.

hacker huges exchangeIt was foolish for the BPS President to insist that conversation about a document that could not conceivably pass independent peer review be confined to venues gated by peer review. It would be a disaster for him to adopt this strategy in trying to squelch the conversation about what Kinderman has done.

The other authors of UPS and Kinderman’s bringing in the Holocaust and the Nazis

Anne Cooke is given credit for the transition for an earlier blog post by Kinderman that lack references to the Holocaust and the Nazis to the present one.

Acknowledgement: Thanks to Anne Cooke for helpful comments and advice on earlier drafts.

She also edited UPS. Some of the contributors  have expressed previously extreme anti-psychiatry sentiments in public. Now that Kinderman’s blog post is distributed, they need to get clear on where they stand on desecrating the memory of the Holocaust.

UPS Contributers

The conversation about Understanding Psychosis and Schizophrenia

From its launch, critics of Understanding Psychosis and Schizophrenia lots of abuse. Their own blog posts have been spammed with threats and demands the blog posts be taken. There have been hit and run attacks on blog comment threats and Twitter by pseudonymous commentators who morph and disappear from the internet. Often, outrageous comments are left and elicit responses, only to later be removed,leaving whole threads incoherence.

The day of the official launch of Understanding Psychosis and Schizophrenia, Keith Laws, Alex Langford, and Samei Huda posted a detailed critique that became one of the most viewed posts at Mental Elf ever. Angela Wilson Ursery posted a comment attacking the three as engaging in mutual masturbation and bragged about it on Twitter. The moderator at Mental Elf quickly edited her comment, but Kinderman retweeted her announcement and Anne Cooke favored it.

welcome circle jerk full

So, Kinderman has now gone from endorsing the views of UPS critics as masturbating each other, to expressing worries about being castrated, and now tying in the Holocaust and Nazis. Very strange for a President-elect of the BPS

At 1Boring Old Man  psychiatrist Mickey Nardo unflinchingly takes aim at NIMH Director Thomas Insel and American Psychiatric Association President Jeffrey Lieberman. Mickey approvingly quotes long statements from the Critical Psychiatry Network and engaging its representatives in long threads of comments on his blog posts. But he has grown frustrated trying to deal with the authors of UPS and their followers.

I’ve sort of stopped responding to comments myself because they focus on anything I say as evidence of my being some insensitive psychiatrist who holds people back and snows them with medication. I’m not that…The cases of psychotic illness I followed in my practice were treated much in the same way as the BPS Report suggests, though my attitude about medications changed over time because of frequent relapses.

But I don’t think the responders want to know what my objections really are, and would prefer to keep me in the bad guy role. I’m not interested in being defensive. If my writings about this aren’t clear, ask me a question. If you prefer to see me as some doom-sayer, that’s your call…

Well, now you know, Mickey, some of them think you are a Nazi.

The conversation about UPS must continue, without Kinderman and Cooke

BPS offered UPS as

A resource for people who work in mental health services, people who use them and their friends and relatives, to help ensure that their conversations are as well informed and as useful as possible. It also contains vital information for those responsible for commissioning and designing both services and professional training, as well as for journalists and policy-makers”.

UPS is chock-full of posturing in what its authors see as a turf war, misinformation, and simple nonsense. We should continue to provide mental health service uses, policymakers, and other professionals with evidence-based alternative information. From the first day of its launch, the UPS authors have not been keen on sustained evidence-based exchanges. We should continue without them, despite Kinderman having seriously damaged the debate.

 

DISCLAIMER: I am grateful for PLOS blogs providing me the space for free expression. However, the views I present here are not necessarily those of PLOS nor of any of my institutional affiliations.

 

Barney Carroll on domesticating psychosis

Although posted only a couple of days ago, my presentation from Royal Edinburgh Infirmary, Division of Psychiatry, University of Edinburgh is now passing the benchmark of over 1000 views.

chrys
Chrys Muirhead

You can also find an interesting Storify of my lecture by a mental health activist and correspondent for the Critical Psychiatry Network, Chrys Muirhead. I’m sure she’ll also be presenting an alternative view of my lecture at her blog.

In one of my introductory slides , I acknowledge a number of go-to’s to whom I am indebted. I actively engage with the go-to’s through social media with questions and requests for feedback. They have kept me from what would have been embarrassing gaffes.  They allow me to present and write smarter than I am, when I let them. However any excesses or inaccuracies in my work are entirely my own.

One of these go-to’s is Bernard “Barney” Carroll. In future blogs I will be saying a lot about his influence on me, although we have never actually met. In hindsight, it’s too bad that my decade at the University of Michigan Mood Disorders Program that he developed started only after he had left.

Barney has

made major contributions to research on the biology and treatment of depression. He is best known as a pioneer of the neuroendocrine research strategy for depression, and as developer of the field of laboratory markers in psychiatry.

Barney often says profound things with a relaxed elegance, particularly when engaging in debate. Long before Kris Kristofferson, I’m sure those with whom he disagreed saw him as the original silver tongued devil.

I realize this comment dates me, because few of my younger readers even know Kris Kristofferson is, not even that he wrote Me and My Bobbie McKee that Janis Joplin made famous. So, here, distract yourself with some 70s music.

 

domesticating-page-0Anyway, on slide 37 of my presentation, I used Barney’s term domesticating psychosis as a heading for some direct quotes from Understanding Psychosis and Schizophrenia, the British Psychological Society Division of Clinical Psychology document that I  critiqued in coming slides. Here is the elaboration on that graphic phrase that Barney provided on my Facebook wall July 27, 2015.

Barney Carroll, in his own words:

I guess I am the person who gets the credit for characterizing the BPS report Understanding Psychosis and Schizophrenia as domesticating psychosis. Ronald Pies called it romanticizing psychosis and Joseph Pierre termed it trivializing psychosis.
The BPS folks, and Lucy Johnstone in particular, deserve all the frowns and brickbats that are coming their way for this misstep. It is an appalling document: Self-neglect due to impaired frontal executive function is niced down to “When people are in a state of distress and confusion they can sometimes need help to maintain an adequate diet, or look after their home.” That does not begin to capture the clinical reality of decompensating psychotic patients smashing furniture to stop the voices, smearing faeces, living in filth, going to the streets, eating out of dumpsters…. The report’s pervasive focus on just hearing voices as emblematic of psychosis is a domesticating strategy: One hallucination does not a schizophrenia make. This domestication distracts attention from the more serious features of psychosis such as negative symptoms, social and occupational decline, first rank positive psychotic symptoms, formal thought disorder, formal language disorder, catatonia, cognitive impairment, affective lability, delusions, and loss of ego boundaries in psychotic decompensations. These get short shrift in the terminal niceness of the BPS report.

fear my squirreley wrathI can only agree with James Coyne that the BPS folks, and Lucy Johnstone in particular, have been squirrelly in their responses to challenges. We saw that earlier this year. Look at the threads linked here on the 1Boringoldman blog: http://tinyurl.com/q7lw8md; and http://tinyurl.com/nq4ws5b. They are especially reckless in their glossing over of completed suicide in psychotic states. I discussed that on Joseph Pierre’s blog earlier in the year: see the several comments on this thread – http://tinyurl.com/ofcsr4j.

1 Boring Old Man » which side of the street?…

You can read Barney’s set of comments at Mickey Nardo’s 1 Boring Old Man website, along with Barney’s engagement with critics. But here’s an excerpt

… This approach is what I call domesticating psychosis. The BPS document fails adequately to convey the range of symptoms and associated behaviors in psychosis/schizophrenia. Even when these are mentioned, they are not addressed in a way that matches their clinical salience. Thus, decompensating psychotic crises are discussed unhelpfully in the framework of poor sleep habits. Acute inpatient psychiatric units are discussed in a patronizing way and are faulted as being unhelpful for some patients – never mind their rescue function. Catatonia as a common feature is not acknowledged. Psychotic terror and panic are not acknowledged. Formal thought disorder with truly crazy speech is not acknowledged. The 10% lifetime incidence of suicide among schizophrenic patients is not acknowledged. Core negative symptoms are brushed away as demoralization or as neuroleptic drug side effects. All of the recommendations made in the BPS document for improvement of psychological and social services are admirable but none are really new – they all fall within the traditional biopsychosocial model of psychiatry. We can all agree that psychiatry has not implemented that model consistently, in large measure because of underfunding, but that does not invalidate the model.

Their intellectual bias is further evidenced by their halfhearted endorsement of the need for antipsychotic drugs. They go out of their way to emphasize that, even though these are sometimes helpful, “… there is no evidence that (the drugs correct) an underlying biological abnormality.” Well, bless my heart, we can say the same of most drugs used in medicine: steroids for autoimmune diseases; bronchodilators for respiratory diseases; anticonvulsant drugs for seizure disorders … So, what is their point here, exactly, beyond gratuitous negative innuendo? It seems to me that the BPS document is a manifesto in the professional turf wars, heavily slanted towards gaining funds from the U.K regulators, rather than driven by an understanding of the classic psychotic disorders

Well said.

From Where's NAMI?
From Where’s NAMI?

How Understanding Psychosis could have been more credible and trustworthy

hanging out the truth
Click to enlarge

As promised, this issue of Mind the Brain explains how the British Psychological Society Division of Clinical Psychology ’s Understanding Psychosis could have been much more credible and trustworthy.

I point to well-founded skepticism about like-minded, self-selected groups representing single professions lacking any cultural diversity trying to tell clinicians and policymakers about how health services ought be re-organized. The folly of Division of Clinical Psychology’s way of doing things is compounded by excluding key consumer stakeholders. I will provide some standards and procedures that were blatantly ignored in the writing and dissemination of their recommendations.

The Division of Clinical Psychology is preparing a companion document about depression. I hope there is time for their adopting international standards. But they would have to open themselves to diversity and desegregate, allowing ethnic minorities, especially African and British Blacks a seat at the table. I will explain why their systematic exclusion of this group from the deliberations is particularly egregious, given gross inequalities in the services they receive, often from almost uniformly white clinical psychologists.

I take seriously the authors claim that they wanted to be provide an authoritative source of information for to mental health service users, their family members, and other professionals and policymakers and members of the community attempting to decide what the best policies for dealing with persons described as suffering from psychosis or schizophrenia. But I don’t accept the document simply because the authors claim they are experts or that they are creating a paradigm shift.

Skepticism should be raised when professional groups crow too loudly about their expertise and creating a shift in paradigm. Rhetorically, professionals fare better when they show what they have to offer and leave for others to decide whether they should be labeled “experts” or that they are causing a paradigm shift.

paradigm-shift-cartoon

I recall Dan Haller, former editor of Journal of Clinical Oncology poking fun at authors submitting manuscripts that they claimed represented paradigm shifts. Maybe in hindsight, Galileo, and, over Einstein deserve that label, but no paper he had ever reviewed about chemotherapy, radiation treatment, for immunotherapy earned it. Haller felt authors’ claim of making a paradigm shift simply embarrassed themselves.

When I subjected the 180 page document to my usual skeptical, critical scrutiny, its credibility and trustworthiness simply didn’t hold up. It seemed to be a collection of carefully selected and edited quotes and minimal, but unsystematic reference to the literature. It seemed to crassly sacrifice the well-being of persons with psychosis and schizophrenia – white, African and British black, and other groups – to professional self-interests of a small group of psychologists.

To an American like me, Understanding Psychosis seems like a bit of old-fashionedBengal-governor-during-British-rule colonial administratorBritish colonial administration. Clad in pith helmets, the British clinical psychologists went out and recruited a few supporters who shared their views and suppressed silenced the rest of service users and their families – pretending they don’t even exist – who would be so affected by their proposals. And as I noted in my last blog post, there are grounds to doubt that a good proportion of the supporters whom they quote are even service users.

When I raised the issues of consensus and process in Understanding Psychosis on Twitter in November 2014, I got an immediate response from the official Division of Clinical Psychology Twitter account

Click to enlarge

To which I replied

Please click to enlarge

My “debunking” – if that’s what@DCP wants to call it – involves systematic gathering relevant evidence and evaluating it by transparent standards that others have agreed upon. When I formally do this in peer-reviewed articles, I typically involve other people as a check on my biases, as well as procedures by which readers can decide for themselves on the validity of my conclusions. When I am flying solo, that needs to be taken into account, and readers should start with greater skepticism. I am more dependent on sufficiently documenting my evidence in order to persuade them.

Some questions are clearly defined enough to proceed with a systematic search for relevant evidence: “the screening for psychological distress improves patient outcomes?”

But many questions like “do we abandon psychiatric diagnosis” or “how do we best organize services to ensure better patient outcomes?” involve potentially controversial decisions about how to sharpen the questions in order to gather relevant evidence. It’s best to get a diversity of opinions of both professionals and service consumers to define the range of possibilities. There need to be some checks on biases, with the hope that these can be overcome by some consensus process among people starting with clear differences of opinion. That is not just an ideal, that’s a necessity if some professional group is going to claim authority for its recommendations. I am typically not operating in that context, and so the credibility of what I in my co-authors come up with the strength of evidence, and we leave for others decisions about how or whether  recommendations will be implemented.

There are some widely accepted standards for bringing relevant stakeholders together, reviewing available evidence, and formulating recommendations. There is lots of evidence about the consequences when these procedures are followed.

But before getting into them, let me describe how I came to be appreciative of both the necessity for the standards for professional organizations formally making policy recommendations and the existence of rules by which they should proceed and be evaluated.

Our 2008 JAMA systematic review and meta-analysis of screening for depression in cardiac patients and reactions from the American Psychiatric Association.

Our paper was

Thombs, B. D., de Jonge, P., Coyne, J. C., Whooley, M. A., Frasure-Smith, N., Mitchell, A. J., … & Ziegelstein, R. C. (2008). Depression screening and patient outcomes in cardiovascular care: a systematic review. JAMA, 300(18), 2161-2171.

Our international group of authors had published key papers and chapters in a book onscreening for depression the topic of screening for depression, as well as the role of depression in cardiovascular disease (CVD). We neither proclaimed ourselves “experts” nor had the endorsement of a professional organization backing up our conclusions. But we identified and followed well defined standards for turning clinical and policy issues into topics for systematic review and meta-analysis. And we were quite transparent in what we did and how it conformed to international standards.

Our conclusion was

The high prevalence of depression in patients with CVD, the adverse health care outcomes associated with depression, and the availability of easy-to-use case-finding instruments make it tempting to endorse widespread depression screening in cardiovascular care. However, the adaptation of depression screening in cardiovascular care settings would likely be unduly resource intensive and would not be likely to benefit patients in the absence of significant changes in current models of care.

The JAMA editors liked the paper enough to invite some of the authors to participate in a live webinair with participants able to telephone and email questions.. The editors of BMJ nominated the paper is one of the eight top papers of the year to be considered in a competition for the top paper.

I was caught off guard when just a few weeks later a paper appeared on the Internet labeled as a American Heart Association Science Advisory with a list of impressive committees signing on to its conclusions and the American Psychiatric Association prominently listed as endorsing the advisory.

The recommendations directly contradicted ours:

Although there is currently no direct evidence that screening for depression leads to improved outcomes in cardiovascular populations, depression has been linked to increased morbidity and mortality, poorer risk factor modification, lower rates of cardiac rehabilitation, and reduced quality of life.  Therefore, it is important to assess depression in cardiac patients with the goal of targeting those most in need of treatment and support services.

And

In summary, the high prevalence of depression in patients with CHD supports a strategy of increased awareness and screening for depression in patients with CHD.

Politics versus rules of making evidence-based decisions

Our conclusions were based on best evidence and transparent rules for evaluating that evidence. The AHA Science Advisory was based on a consensus of professionals – psychologists and psychiatrists – who had vested interests in promoting screening because it would increase their professional opportunities in cardiology settings.

Although publicity for our article had some momentum, the promoters of the AHA Science Advisory jumped into the media with a lot of political power to counter our conclusions, while usually failing to acknowledge who we were and where we had published. The American Psychiatric Association actually assigned a pediatric psychiatrist to become a media contact for their point of view.

I had naïvely thought that best evidence would trump consensus of professionals with obvious self-interests at stake. The weight of evidence was clearly on our side. But one of our cardiologist co-authors, Roy Zigelstein was not at all surprised by the carefully orchestrated reaction.

Roy negotiated us an opportunity with American Heart Journal and Journal of the American Academy of Cardiology to explain the differences between us and the AHA Science Advisory. Although we were up against strong vested interests, cardiologists themselves were not necessarily in agreement with the science advisory.  Actually, the American Heart Association continually updates its evaluations of factors correlated with cardiovascular outcomes as causal factors. To this day, it still has not accepted depression as a causal factor, only a risk marker. The implication is that making changes in depression may not necessarily affect cardiac outcomes.

In our commentary at American Heart Journal, we noted the discrepancy between the results of our meta-analysis and systematic review versus the conclusions of the AHA Science Advisory. We also noted that we were not alone in expressing concern about guidelines issued by the American Heart Association increasingly being based on simple professional consensus and not a systematic review of the evidence. Consequently many of them were not “best evidence.”

“In guidelines we cannot trust”

Our skirmishing with the AHA Science Advisory and American Psychiatric Association occurred at a time when recognition was already growing that the recommendations of professional organizations were untrustworthy. There was documentation of numerous instances in which they were often not evidence-based, but served their self-interests, often at the expense of patient outcomes. Many of the recommendations were for billable procedures from the professional groups who created them that were unnecessary and even harmful to patients.

The title of a later article captured the rampant skepticism of the time:

Shaneyfelt T. In guidelines we cannot trust. Arch Intern Med 2012;172:1633-1634.

There were lots of proposals for reform, like a series that included

Fretheim A, Schunemann HJ, Oxman AD. Improving the use of research evidence in guideline development: 5. Group processes. Health Res Policy Syst 2006;4:17.

guidelines we can trustBut discontent gut all the way to the U.S. Congress, which authorized that the Institute of Medicine (IOM) be given the resources to organize a panel with wide representation to come up with, as the final 250 page document was titled, Clinical Guidelines We Can Trust. You can download a free PDF here.

The rationale for specific procedures spelled out, but in terms of the final product:

To be trustworthy,  guidelines should

  • Be based on a systematic review of the existing evidence.
  • Be developed by a knowledgeable, multidisciplinary panel of experts and representatives from key affected groups.
  • Consider important patient subgroups and patient preferences, as appropriate.
  • Be based on an explicit and transparent process that minimizes distortions, biases, and conflicts of interest.
  • Provide a clear explanation of the logical relationships between alternative care options and health outcomes, and provide ratings of both the quality of evidence and the strength of the recommendations.
  • Be reconsidered and revised as appropriate when important new evidence warrants modifications of recommendations.

understand coverThe standards seem eminently reasonable in the deliberations by which they were reached is carefully documented. Yet Understanding Psychosis fails miserably as a set of credible policy recommendations by not meeting any of them. It’s because the process of writing the document was so flawed:

  • The British Psychological Society Division of Clinical Psychology professionals did not engage other professionals with complementary viewpoints and expertise.
  • Key stakeholders were simply excluded – primary care physicians, social workers, psychiatrists, , police and corrections personnel who must make decisions about how to deal with disturbed behavior,  and –most importantly- the family members of persons with severe disturbance.
  • There was no clear explicit process to minimize bias and distortion and no transparency as to how the group arrived at particular conclusions.
  • There was no check on the psychologists simply slanting the document to conform to their own narrow professional self-interests.
  • Recommendations were presented without clear grading of the quality of available evidence or strength of recommendations.
  • While there was a carefully orchestrated “show and tell” rollout, it did not involve any opportunities for feedback and modification of recommendations.

In one of a number of passages plagiarized from an earlier paper, Peter Kinderman recently told clinicians from other disciplines to adopt the recommendations of Understanding Psychosis

To return, then, to the issue of communication between professionals; for clinicians, working in multidisciplinary teams, the most useful approach would be to develop individual formulations; consisting of a summary of an individual’s problems and circumstances, hypothesis about their origins and possible therapeutic solutions. As with direct clinical work, such an approach would yield all the benefits of the traditional ‘diagnosis, treatment’ approach without its many inadequacies and dangers. This would require all clinicians— doctors, nurses and other professionals—to adopt new ways of thinking.

Why should these professionals do the bidding of a small group of self-serving psychologists? They were not involved in the process of constructing these recommendations and the psychologists failed to provide appropriate evidence. There is no evidence that this would improve patient outcomes.

A special pleading for marginalized and silenced Black African clients who were getting poor care.

Enter “African” as a search term in the 180 page Understanding Psychosis and you come up with only a brief mention on page 46 that fails to acknowledge the poor outcomes that tradition African Black are disproportionately achieving in outpatient care. Even if there are few, if any black members of the BPS Diision of Psychology and even if there were no blacks involved in the writing of Understanding Psychosis, surely there was some awareness of the gross disparities in outcomes that are achieved in outpatient care for psychosis and schizophrenia. A recent paper added further evidence to what was already known:

  • Early Intervention Services (EIS) have little effect on the much higher admission and retention rates of Black African clients.
  • There are low rates of GP involvement and high rates of police detention.
  • Poor outcomes were most marked in Black African women (7-8x  greater odds than White British women).
  • A post-hoc analysis showed that pathways to care and help-seeking behavior partially explained these differences.

Overall

In an increasingly outcome-driven and evidence-based era, EIS need to demonstrate a significant positive impact on detecting and treating psychosis early, across all groups. Our findings, when compared with UK studies from the pre-EIS era [5], suggest no improvement in the inequality between Black African patients with FEP and White British patients in terms of experiences of admission and detention. The high rates of detention and hospital admission overall are likely to have substantial implications for continuing engagement. The rate of detention is particularly elevated in Black African patients at 60% (Table 2). A disconcerting finding is of even higher rates in certain groups than prior to introduction of EIS, especially in women. While there is overall evidence that the EIS model is a cost-effective [31] means of engaging hard-to-reach young people, it would seem not all groups are being reached in ways that minimise stigma and trauma. Of note, a recent systematic review of initiatives to shorten DUP [32] concluded that establishing dedicated services for people with FEP does not in itself reduce DUP. This is despite evidence that longer DUP is associated with poorer outcomes [33],[34].

“In an increasingly outcome-driven and evidence-based era,” the British Psychological Society Division of Clinical Psychology had better involve a broader and more ethnically diverse range of opinions and more careful consideration of available evidence if they are going to be taking seriously.

Counterpoint from Richard Pemberton, UK Chair of the British Psychological Society Division of Clinical Psychology:

Your approach to debate and tendency to personalise professional differences however means that many senior people don’t take you seriously and/or aren’t willing to get in the same room as you. Describing the very senior and prestigious group of researchers who were co-authors of our recent psychosis publication as either ‘stoned or drunk’ is a case in point? Doing this in private would be testing but putting this out into the public domain certainly breaches UK professional ethical codes. I am sure that you sincerely believe that the report is deeply flawed and highly problematic but I doubt that you actually believe that we are all sitting around under the influence of drugs and alcohol producing 180 page publications.

“Understanding Psychosis and Schizophrenia” and mental health service users

understand coverDoes Understanding Psychosis and Schizophrenia exploit, disrespect, and marginalize service users?

Genre confusion.

The 180-page Understanding Psychosis and Schizophrenia produced by the British Psychological Society Division of Clinical Psychology is a puzzling document. We need to know its genre to decide what standards we apply in evaluating it. The authors tell us:

The report is intended as a resource for people who work in mental health services, people who use them and their friends and relatives, to help ensure that their conversations are as well informed and as useful as possible. It also contains vital information for those responsible for commissioning and designing both services and professional training, as well as for journalists and policy-makers. We hope that it will help to change the way that we as a society think about not only psychosis but also the other kinds of distress that are sometimes called mental illness.

“Well-informed” by what or whom? How is the information “vital”? Does “vital” assume “trustworthy” and “credible”?

As I will cover in a later blog issue, the document strikingly lacks the transparency that it would need to be taken seriously.  Understanding Psychosis conforms to none of the well-defined processes and standards – checks and balances – expected to be met by professional organizations producing a report aimed at policy-makers and the general public.

mental ellf1For now, note these psychologists did not engage other professionals with complementary viewpoints and expertise. And the writing  was closed to anyone not already expressing strongly held particular opinions. When critics nonetheless provided a detailed analysis of some crucial points at the popular blog, Mental Elf, the authors of Understanding Psychosis retweeted and favorited a denunciation of them as a “circle jerk,” i.e., mutually masturbating.

circle jerk
Please click to enlarge

how vulgar

Key stakeholders were simply excluded – primary care physicians, social workers, psychiatrists, police and corrections personnel who must make decisions about how to deal with disturbed behavior, and –most importantly- the family members of persons with severe disturbance. There was no check on the psychologists simply slanting the document to conform to their own narrow professional self-interests, which we are asked to accept as “expertise.”

Is Understanding Psychosis evidence-based?

Understanding Psychosis occasionally cites some empirical findings, but can’t be seen as evidenced-based. That would require transparent, systematic strategies for gathering, interpreting, and integrating evidence that are simply not there.

Indeed, I think it is an excellent document for PhD students and trainees to practice debunking the creation of false authority by selective citation and miscitation and ignoring of contradictory studies. I suggest that they arm themselves with Google Scholar and tools provided in

Greenberg, S. A. (2009). How citation distortions create unfounded authority: analysis of a citation network. BMJ, 339.

Then start checking the citations provided for seemingly evidence-based statements in Understanding Psychosis. Ask questions like “What relevant studies are not cited? What studies are misinterpreted or simply cited for findings they did not contain?” Go to Google Scholar or Web of Science and find out.

For instance, take the opinion

In view of the problems with diagnoses, many researchers and clinicians are moving away from using them, and recent high-profile reports have recommended this. 55 56.

Check the references and see that the authors of Understanding Psychosis are the “many researchers and clinicians.” They are praising their own opinion pieces as “high-profile.”

55. British Psychological Society (2013). Division of Clinical Psychology position statement on the classification of behaviour and experience in relation to functional psychiatric diagnoses: time for a paradigm shift. Leicester: British Psychological Society.

56. Division of Clinical Psychology (2011). Good practice guidelines on the use of psychological formulation. Leicester: British Psychological Society.

The authors of Understanding Psychosis would have embarrassed themselves if they stated outright “It is our opinion that…and we consider our opinion high-profile and you should be duly impressed.” They depend on readers not checking references.

Argument from cherry picked quotes.cherrypicking

Understanding Psychosis is a collection of quotes. We might be inclined to interpret this as a strength, a sign of collaborative  participatory research.

Or maybe this represents qualitative research allowing  people to speak for themselves, rather than requiring that their experiences be processed through others’ filters and concepts.  But bona fide, credible qualitative research requires that biases of  investigators not intrude upon what they report.  Some controls must be visibly present preventing the investigators from doing so.

Quotes are carefully selected to support by the psychologists opinions expressed before the document was prepared – like 15 years ago in their Recent Advances in Understanding Mental Illness and Psychotic Experiences.

Many quotes are not from people suffering from schizophrenia. In most instances, we are not given sufficient information to determine this.  The authors systematically withhold information that would allow readers to determine who is and who is not a service user.

In this issue of Mind the Brain, I examine implications of this heavy dependence on these particular quotes. I will question whether Understanding Psychosis involves using and even exploiting service users, pitting more highly functioning ones against those who are functioning less well and their families who have to deal with them when they cannot take care of themselves.

Where do the quotes in Understanding Psychosis come from?

Some quotes were simply pasted in from the 2000 Recent Advances in Understanding Mental Illness and Psychotic Experiences.

Presumably people had relevant experience in the interim for our grasping the relevance to what it like living with schizophrenia and other psychoses – if that was actually their circumstances. Unfortunately, no follow-up is provided. The authors did not respond to repeated inquiries to asking whether they even obtained permission to use these quotes.

The quotes also have been trimmed of most details about their context that are available in original sources. Going to the original sources, we find the sources deliberately sampled people who were not service users.

Yup, people stripped of their identities are paraded out without the benefit of information that would render their experiences meaningful. Readers can’t independently assessment the uses to which the psychologist authors of Understanding Psychosis put these quotes.

What is not at issue is whether people with unusual experiences can get our attention when they talk about them. What is at issue is that a group of professionals take these quotes out of context and insist that they be accepted as the primary basis for – as their title states – our understanding of psychosis and schizophrenia.

Some of the quotes come from sources like

Jackson, L., Hayward, M. & Cooke, A. (2011). Developing positive relationships withvoices: A preliminary grounded theory. International Journal of Social Psychiatry, 57(5), 487–495.

Freeman, D., Garety, P.A., Bebbington, P.E., Smith, B., Rollinson, R., Fowler, D. et al. (2005). Psychological investigation of the structure of paranoia in a non-clinical population. British Journal of Psychiatry, 186, 427–435.

Heriot-Maitland, C., Knight, M. & Peters, E. (2012). A qualitative comparison of psychotic-like phenomena in clinical and non-clinical populations. British Journal of Clinical Psychology, 51(1), 37–53.

Jackson et al report

Five men and seven women were recruited through local NHS services, community advertisement and the local branch of the Hearing Voices Network.

Freeman  et al report

An anonymous internet survey [was]… e-mailed the address of a website where they could take part in a survey of ‘everyday worries about others’.

Heriot-Maitland et report interviewing 12 participants, who reported “psychotic-like ‘out-of-the-ordinary’ experience (OOE) in the past five years.”

The quotes come from persons who are lucid enough to be recruited for small studies of , highly selected articulate persons. They certainly don’t display the distorted thought and behavior disorder and simple incoherence of many people with acute and chronic schizophrenia.

I agree with the Understanding Psychosis authors that few people who have ‘psychotic-like’ experiences meet criteria for a diagnosis of schizophrenia. But should we accept a carefully cherry-picked and edited group of quotes as the basis for revising our understanding of people who do meet criteria?

A number of quotes sound like people who are high functioning and showing an unusual degree of  fantasy-proneness:

P 29 I work four days a week in a professional job; I own my own house and live happily with my partner and pets. Occasionally I hear voices – for example when I have been particularly stressed or tired, or I have seen visions after a bereavement. Knowing that many people hear voices and live well, and that some cultures see these experiences as a gift, helps me to never catastrophise or to worry that it may be the start of a breakdown. Although I am lucky that the experiences have never been as upsetting as some people’s, if someone had told me it was madness I could have got into a vicious cycle and struggled to get out.

Some of the quotes seem to represent clinically significant distress, but probably not psychosis or schizophrenia.

p 53 One thing that you might hear a lot about is that anxiety is a trigger of suspicious thoughts. I have never been that good at recognising my own anxiety. Quite a high level of anxiety is pretty normal for me. So normal that I wouldn’t normally do anything about it, but I now recognise that it sets the background for the expected potential threats in any situation, and so the suspicious thoughts and ideas of reference can pop right in there. I find people as having the most potential as a source of threat and because of that I am prone to suspicious thoughts about others. So now what I do is try to address the level of anxiety I feel in these situations. Adam

We’re not provided any information suggesting this suspiciousness is the psychotic symptom, paranoia.

P 43 After being almost killed by my ex-boyfriend when I was 16 I have had OCD. I have also developed paranoia about someone trying to kill me. If I have conflict with someone over anything I worry they are going to kill me or have someone come and kill me. I wake up worried someone is in my bedroom. I think about trying to be ready to protect myself if someone comes at me. I don’t think I would have this if I had not been traumatised half my life ago.  Josephine

Yale Professor Joan Cook and other colleagues and I recently published  a mixed method study of a national sample of psychotherapists providing residential treatment to veterans for posttraumatic stress disorder.  A number reported difficulties deciding whether the “voices” that some veterans describe represented schizophrenia or vivid re-experiencing symptoms consistent with posttraumatic stress syndrome, for which exposure therapy is indicated.

The authors of Understanding Psychosis express a clear disdain for making diagnostic distinctions. But,  it is important for clinicians to decide about the nature of clients’ distress in order to decide how to treat it. They best do so by formulating a hypothesis based on evidence tied to diagnoses, and then sympathetically probing.  Gradual exposure to past trauma would likely tame the distress of someone meeting criteria for PTSD. But this could prove absolutely terrifying and decompensating for someone whom additional information suggested a diagnosis of psychosis. So clinicians have to have some evidence-based ideas to probe and make decisions or proceed blindly.

Some quotes probably refer to brief psychotic reactions. Responding to Understanding Psychosis, Allan Frances noted

Brief psychosis is considered a mental disorder, but it is just a transient one with excellent prognosis and no reason to expect long-term impairment. The symptoms emerge suddenly in response to stress and usually disappear just as suddenly (especially if the stress is removed), often never to reappear. This is common in many cultures, and I have seen it fairly often in college students away from home for the first time, in travelers in strange lands, and in people who have had something terrible happen to them. Antipsychotic medicine is needed only briefly, if at all.

Quotes were selected to fit the authors’ conviction that what other professionals call psychosis or schizophrenia is an understandable reaction to life events. But if we go to the larger literature, the associations between adverse experiences and psychosis, even in a meta-analysis of one of the authors of Understanding Psychosis, are not large enough that would suggest such strong causality.  Adverse experiences are linked to lots of negative outcomes, but generally do not lead to psychosis or schizophrenia, even if there is a significant, but not overwhelming correlation.

Understanding Psychosis is not a transparent, systematic review of available evidence. Authors are mustering quotes to fit their preconceived notions. And leaving out quotes and details that don’t fit.

American psychiatrist Bernard “Barney” Carroll slammed the arrogant response of President of the American Psychiatric Association President  Jeffrey Lieberman to media coverage of Understanding Psychosis. Barney called it over-the-top” and a “disservice to psychiatry.” Yet, this was not before he nailed the report for its “domesticating psychosis”:

Hallucinations become the experience of hearing voices; delusions become the experience of unusual beliefs; paranoid thinking becomes the experience of anxiety – never mind that the great majority of patients with clinical anxiety disorders are not at all paranoid in the way that psychotic patients are. They also make much of the fact that milder forms of these “experiences” are common in the general population – as are milder forms of many clearly medical symptoms. In short, they fail to acknowledge the state transition that demarcates mild or prodromal symptoms from outright psychotic illness.

… The BPS document fails adequately to convey the range of symptoms and associated behaviors in psychosis/schizophrenia. Even when these are mentioned, they are not addressed in a way that matches their clinical salience. Thus, decompensating psychotic crises are discussed unhelpfully in the framework of poor sleep habits. Acute inpatient psychiatric units are discussed in a patronizing way and are faulted as being unhelpful for some patients – never mind their rescue function. Catatonia as a common feature is not acknowledged. Psychotic terror and panic are not acknowledged. Formal thought disorder with truly crazy speech is not acknowledged.

A disclosure of my past.

I’m struck by the huge gap between the clear, articulate statements in the quotes provided in Understanding Psychosis and the incoherent mumbling and sometimes raging of people who are acutely psychotic.  I wonder how many of the authors have ever tried to conduct an interview with someone in that state.

cowboy entering belgium-1-page-001My clinical training involved six years of live supervision at the Mental Health Institute (MRI)provided by professionals widely recognized for their innovative work in analyzing the communication of persons considered as having schizophrenia –  Paul Watzlawick, John Weakland, and Richard Fisch – although they would have objected to that diagnostic label.

At the time, I probably was more anti-diagnosis than many of the authors of Understanding Psychosis are today. But then as Director of Research at Mental Research Institute, I witnessed the disaster of its Soteria Project. I’ll leave that for another time, but Wikipedia states

The Soteria project was admired by many professionals around the world who aspired to create mental health services based on a social, as opposed to a medical, model. It was also heavily criticized as irresponsible or ineffective. The US Soteria Project closed as a clinical program in 1983 due to lack of financial support, although it became the subject of research evaluation with competing claims and analysis. Second generation US successors to the original Soteria house called Crossing Place is still active, although more focused on medication management.

While Paul, John, and Dick were widely recognized for their work analyzing communication with severely disturbed persons, they operated with a sense that at some point the disturbance of thought and behavior could became too much to carry on a discussion. And talking to highly disturbed persons, they knew not to take what was being said literally.

Who was selected for inclusion in Understanding Psychosis and who was excluded and left silent?

Many patients with acute and chronic psychosis are essentially nonverbal and cannot communicate their distress. Sure, they can’t provide coherent quotes for the psychologists who assembled Understanding Psychosis, but it is irresponsible for those psychologists to pretend these people don’t exist or that the quotes they assembled represent their best interest.

Many patients who meet criteria for schizophrenia will times be unable to take care of themselves or to make basic decisions.  The burden of caring and decision-making will fall on family members if they are available. The alternative for persons with schizophrenia is to become homeless or go to jail or prisons because more appropriate beds and hospitals are not available. Nowhere in Understanding Psychosis are we reminded that persons with schizophrenia sometimes need sanctuary in hospitals.

Nowhere are we reminded that 10% of persons with schizophrenia will die by suicide. There is recent evidence that psychotic people may account for nearly 1/3 of suicide attempts with intent to die.

If I were a family member of someone with schizophrenia, I would be damn angry at the gap between the quotes in Understanding Psychosis what I knew about the person for whom I had to provide care. I’d also be angry that no one in my situation had been invited to participate as a stakeholder.

Psychologists in search of opportunities to work with YAVIS clients

purchase of friendshipThe carefully selected quotes suggest people who would be more satisfying to work with than many persons with psychosis and schizophrenia. Reading them, I was immediately reminded of William Schofield[‘s  50-year-old book Psychotherapy: The Purchase of Friendship in which he lamented the strong tendency of mental health professionals wanting to work with the YAVIS: clients who are young, attractive, verbal, intelligent, and successful.  One of the authors of Understanding Psychosis also co-authored the widely misrepresented Lancet study of cognitive behavioral therapy for psychosis and could tell us how difficult and ineffective  it was doing  therapy in  that study with the older patients who had more psychotic  episodes.

Despite the authors of the Lancet study having distanced themselves from earlier claims showed cognitive therapy had effects equivalent to antipsychotic medication, authors of Understanding Psychosis persist in making the claim to service users:

It would also appear that CBT can bring comparable benefits even when people choose not to take medication.

As we would expect from recommendations produced by tightly knit groups representing single professions, Understanding Psychosis is a bid for more resources for its authors to work with clients with whom they want to work.  But like any policy recommendations, we need to examine the evidence and look at where those resources would come.

Please click to enlarge
Please click to enlarge

I’ll leave that discussion to another blog post, but take a look at the graph on the left. It represents the dramatic shift in resources from inpatient beds to outpatient treatment settings. The profoundly disturbed persons who need those beds would undoubtedly be less suitable for the conversations that the Understanding Psychosis psychologists want to be having. The long term reduction in inpatent services represents not so much deinstitutionalization as transinstutionalization.  A lack of those beds means that persons in need of them are being relegated to jails and prisons. In the United States, the Los Angeles jails represent the largest mental health treatment facility in the United States and the conditions for the severely disturbed are abominable. Similar situations hold in the UK.

An inpatient psychiatrist recently wrote in the New York Times:

We also need to rethink how we care for another group of vulnerable patients who have been just as disastrously disserved by policies meant to empower and protect them: the severely mentally disabled.

He went on:

We have worked to minimize the use of restraint and seclusion on my unit, but have seen the frequency of both skyrocket. Nearly every week staff members are struck or scratched by largely nonverbal patients who have no other way to communicate their distress. Attempting to soothe these patients monopolizes the efforts of a staff whose mission is to treat acute psychiatric emergencies, not chronic neurological conditions. Everyone loses.

Professor-Simon-Wessely-007Somebody in the UK should be speaking up for the inarticulate vulnerable persons with schizophrenia needing inpatient beds who are silenced and marginalized by the authors of Understanding Psychosis.  Where the hell is Simon Wessely when they need him?

Promoting an unrealistic view of schizophrenia?

If the authors of Understanding Psychosis were truly interested in providing authoritative information for persons with schizophrenia or psychosis, their family members, and professionals who come into contact with them, they would’ve provided the latest evidence about long-term course and outcome.

For instance, a key English study provides a 10 year follow-up individuals with a first episode of psychosis initially identified in either southeast London or Nottingham.

Morgan, C., Lappin, J., Heslin, M., Donoghue, K., Lomas, B., Reininghaus, U., … & Dazzan, P. (2014). Reappraising the long-term course and outcome of psychotic disorders: the AESOP-10 study. Psychological medicine, 44(13), 2713-2726.

At follow-up, of 532 incident cases identified, at baseline 37 (7%) had died, 29 (6%) had emigrated and eight (2%) were excluded. Of the remaining 458, 412 (90%) were traced and some information on follow-up was collated for 387 (85%). Most cases (265, 77%) experienced at least one period of sustained remission; at follow-up, 141 (46%) had been symptom free for at least 2 years. A majority (208, 72%) of cases had been employed for less than 25% of the follow-up period. The median number of hospital admissions, including at first presentation, was 2 [interquartile range (IQR) 1–4]; a majority (299, 88%) were admitted a least once and a minority (21, 6%) had 10 or more admissions. Overall, outcomes were worse for those with a non-affective diagnosis, for men and for those from South East London.Conclusions Sustained periods of symptom remission are usual following first presentation to mental health services for psychosis, including for those with a non-affective disorder; almost half recover.

Put differently, overall

12% (9% for non-affective) of our sample recovered within 6 months of contact with services and did not have a further episode, 20% (14% for non-affective) never had an episode lasting more than 6 months, and around 50% (40% for non-affective) had not experienced symptoms in the 2 years prior to follow-up.

And then there is the most recent comprehensive systematic review and meta-analysis.

Jääskeläinen, E., Juola, P., Hirvonen, N., McGrath, J. J., Saha, S., Isohanni, M., … & Miettunen, J. (2012). A systematic review and meta-analysis of recovery in schizophrenia. Schizophrenia Bulletin, sbs130.

We identified 50 studies with data suitable for inclusion. The median proportion (25%–75% quantiles) who met our recovery criteria was 13.5% (8.1%–20.0%). Studies from sites in countries with poorer economic status had higher recovery proportions. However, there were no statistically significant differences when the estimates were stratified according to sex, midpoint of intake period, strictness of the diagnostic criteria, duration of follow-up, or other design features. Conclusions: Based on the best available data, approximately, 1 in 7 individuals with schizophrenia met our criteria for recovery. Despite major changes in treatment options in recent decades, the proportion of recovered cases has not increased.

One in 7 people with schizophrenia meet criteria for recovery, and the portion has not increased in recent decades. Compare that with the unrealistically cheery assessment offered in Understanding Psychosis:

Even if people continue to hear voices or hold unusual beliefs, they may nevertheless lead very happy and successful lives. Sometimes a tendency to ‘psychosis’ can be associated with particular talents or abilities.

And

p 30 People who continue to have severe and distressing experiences may lead happy and successful lives in all other respects, such as work and relationships.

Sure, the authors of Understanding Psychosis keep reminding us of the cliché that everybody is different. But they are asking us to make clinical and policy decisions that are life altering for some people and could be life-ending for others. We can’t afford to ignore a larger body of relevant data.

In light of the data from long term follow-up studies, Understanding Psychosis should be seen as a cruel hoax perpetrated against more typical severely disturbed mental health service users, their family, and policymakers