I have been amusing myself thinking of all the players in mental health care as characters in the Game of Thrones. WARNING, if you haven’t been got by GoT you wont want to read this post.

Long ago, the first men, from Plato and Aristotle, to Mesmer, Pinel, Gall, Weber, Gage, Darwin, Broca, Galton, Wernicke,  explored the untamed lands of the human brain and mental processes. The children of the forest unwittingly created the first white walker (1878, Hall) by plunging a piece of dragon glass into his heart and declaring the brain and not the heart as the organ to study, and building a wall.

Was Freud the first Targarean? Their reign was strong, incestuous and peppered with occasional  madness. Until the rebellion.

So our story starts as it has always, with the field of psychology saying “winter is coming” The southerners (Psychiatry) mock this doomsday prophecy, but are themselves recovering from the era of the mad King.

Standing guard, the watchers on the wall, protecting the realm from Wildlings (aka counsellors, mental health workers, case workers). We discover they are actually people too with their own set of skills and resourcefulness. And they cope pretty well with the winter. But still, the common people are told stories that ignite fear perpetuated by the raiding parties as Wildlings fight for their survival. Despite their skill set they are thought of as lesser beings.

In the capital, the Crown is half a kingdom in debt to the Lannisters, so decisions get made, not for the good of the people, but to assuage the self interests of the investors. So too in psychotherapy research. If you think Prozac was made by the Lannisters you won’t be too far wrong. If you are going to spend their money you’d better make sure they look good.

Now the Starks were an honourable bunch, with great integrity, and so they didn’t last long. Ned stark, however, before his beheading inadvertently created the Brotherhood Without Banners, a rebel group sworn to protect the small folk from anyone preying on them.

Enter the activist for trustworthiness and transparency in science, calling out vested interests and conflict of interests in big Pharma and unfounded claims of miracle treatments. Yet sometimes their methods leave a lot to be desired.

John Snow, arguably the most loved character, who’s honour is only matched by his courage and creativity was willing to admit when he was wrong and change directions, including taking risks that were politically and personally dangerous. ( See Scott Miller, Bruce Wampold and their clan folk) Alas, killed as a traitor by his own men, though only mostly dead, he rose again, readying to reclaim territory stolen by the Boltons, aka CBT! (A bit harsh maybe, but it did invade Sweden and cause great suffering)

On a different note, Mance Rayder, the King beyond the wall United the Thenns, Hornfoots, WIldlings, Ice River Clans as none had done before. Probably learned this from Jeff Zeig bringing the field together at  the evolution of psychotherapy.

Milton Erickson of course inspired the three eyed Raven, and many might wish to be his disciple, but of course I’d say it was Rob McNeilly

In further speculation, was Jay Haley  Maester Aemon, and Michael Yapko  Jeor Mormont

G.R.R Martin created a brilliant story, but, despite the many fans of his books it was HBO TV that really brought it to the masses. So too attempts to bring science to the masses began in the media, but like the arming of the faith militant, things went terribly wrong. Someone, somewhere must have thought it was a good idea, but what followed was alarming. Using the power of persuasion, poor studies with low power, small sample sizes, undisclosed analytic flexibility, impossible to reproduce findings too weak to build theories on, were sold as tantalizing certainties based in science and so became armchair truths to the ordinary people.

As we wait for the next exciting installment, we know, that the best is yet to come.

As a General Practitioner, working in mental health I try to keep abreast of all aspects of patient care. Looking at the evidence about best practice of psychotherapy has been an interesting and often frustrating pursuit, but some clarity is emerging, and to speed up the journey for those who come after I thought I’d write some travel tips.

If you’ve started on this journey as a non-psychologist, then like me, you are probably surprised by the academics who believe one model is best. It is surprising to an outsider because the data from decades of research can’t be clearer. All models perform the same.

Rarely do you find a more reproducible finding with so many supporting studies, often with studies that actually set out not to support it, but still supported it.

And yet, there are academics who actually believe with an almost religious fervor, that their model is best. They admit that the differences are very small, but they still claim they are statistically significant, and I think they actually believe that if we get clearer about categorizing mental health their hypothesis will be strongly supported as they discover which aspects of their model work on which bits of the disordered psyche. This is so strange to an outsider, because there is actually no evidence for that way of thinking, and yet it pervades the field and I think influences research in all domains in a detrimental way. I could go so far as to say this could be the reason why there have been no significant improvements in patient outcomes since clinical research began.

I have spent some time exploring their argument. It exists in psychologists more than any other group of professionals who work in mental health fields, so I suspect it’s roots are in their academic training. I suspect their beliefs are formed there, and I see some parallels with some of the beliefs that I picked up from my medical degree that were hard to shake even when they were found to be wrong.

There is an interesting phenomenon, that as a researcher your beliefs will influence your findings.

Recent controversies in Social Psychology have highlighted this phenomenon. Here is a nice article about the controversy about Amy Cuddy’s Power Pose research:

http://www.slate.com/articles/health_and_science/science/2016/01/amy_cuddy_s_power_pose_research_is_the_latest_example_of_scientific_overreach.html

The short version is that if you haven’t registered your study you are prone to let what you are looking for influence what you are seeing as the data emerges…. so of course your findings will be faulty and unreproducible…. but, in the case of The Power Pose study, they got some cool headlines and the most watched TED talk ever. Yikes.

The phenomenon is called p hacking, fishing, and the garden of forking paths. Andrew Gelman has written a very nice article about it:

Click to access p_hacking.pdf

It was by reading about this that I suddenly got it. This is the reason!

So, by p hacking, fishing, and the garden of forking paths, academics are perpetuating a defunct belief around model superiority, and continuing to instill it in their undergraduates and postgraduate students, leading to an enormous waste of resources.

Why is that important?

Well science is on hold. It is stuck in the transit lounge.

It’s strange to think that academia could actually become extinct, but the most interesting research is happening outside academia, in the clinical setting. Therapists who have managed to let go of this belief are free to explore how people get better. They are focusing on things other than models and working out how to improve.

In my work Ive been looking at the people who don’t get better and thinking that the one on one interaction of therapy is too limited for very isolated people and ventured out into our local community. Researching if anyone is doing any good work in this area I found there are grass roots initiatives cropping up everywhere that have given up on government policy and funding or non-government organisations and are looking for other ways.

That is just one area, and there are many other worthy areas of exploration, as the space to explore expands when once old, unworkable beliefs are given up.

 

 

 

Those of you who are Douglass Adams fans will recall The Hitchhikers Guide To The Galaxy where the great supercomputer Deep Thought spent 7 1/2 million years calculating the answer to the great question of life the universe and everything, and came up with the answer of 42.

Well so too, the “DSM 5 machine” developed to ground DSM in science, not rhetoric, and solve once and for all the validity and reliability issues that plagued it.

The answer….. the answer…… you’re not going to like it….. is…. is, well no diagnosis meets the gold standard for reliability and most are no better than chance.

As a practitioner, working at the coal face seeing clients, it seems glaringly obvious that the system is broken. The medical model just hasn’t worked for dealing with emotional issues in human beings. But the coal face can be a lonely place, so I was heartened to watch this talk by Psychiatrist Sami Timimi of the NHS and University of Lincoln UK.

Every other area of medicine has shown some kind of improvement in the last 50 years, but not so mental health.

Deep thought defends himself by saying, “well you never actually knew what the question was” and in true Douglass Adams form, he goes on to design a supercomputer so complex that organic life forms part of it’s operational matrices, and he names it “The Earth” and of course the mice are running it!

Seems familiar?

And if you think that is provocative, have a look at this. Professor Peter Gotzsche, who has a solid track record of research and published more than 50 papers in leading journals speaks about how most of what the drug companies do “fullfills the criteria for organised crime in U.S law”

Food for thought and a not so peaceful Sunday!