Yesterday I gave a talk at the University of San Fransisco, Quito about the reproducibility crisis in psychology (and most science). This was at the invite of the Quito Brain and Behaviour Lab. I decided to give this talk rather than one on my own research as I think it’s really important for all researchers, but especially those at the beginning of their career.
Psychology faces serious issues and they need to be fixed. The good news is that we can fix the most serious of these issues relatively easily, if we actually try. There is some resistance from some in the old guard, but this can be overcome. Anyway, I’ll expand on this in an update, for now the purpose of this entry is mostly to make the slides available for those who were at the talk.
Here they are: Repro Crisis They will be updated as and when I revisit them.
After reading this, your brain will quite simply never be the same again. My ideas, transformed by my brain into a series of muscle stimulating electro-chemical nerve impulses and transferred by my fingers into my computer’s systems, will have been launched across the internet’s intricate web, eventually spawning a torrent of photons that will have streamed though your eyes and onto your retinae, unleashing another chain of bio-electro-chemical reactions of almost unimaginable complexity.
Your brain networks will have been activated and deactivated; hormones secreted and metabolised; neurotransmitters released, sucked up, converted and degraded; your genome read; proteins synthesised, cut up and stuck back together, synapses formed and broken – and at the trendy edge of science, your brain cells will have experienced epigenetic change. None of this is fully reversible. You’ll likely never be able to completely forget that you read this, no matter how hard you try. In fact, the harder you try to forget, the more these words will worm their way into your biology.
Sorry about that.
Of course, although this is all incredible, it’s also absolutely normal. There is nothing very special about these words. Your brain is being changed all the time, by everything and anything that stimulates any of your various different senses. And should you for any reason, find yourself in a sensory deprivation tank, well, your brain will self-stimulate to a quite worrying extent. The cascades of psycho-bio-electro-chemical events will never stop.
None of this is to say that the science behind these headlines is not interesting or important. It often is. Almost as often as it’s misrepresented to get the most advertising revenue possible.
(By the way, if you doubt that my words permanently altered your brain, ask yourself, if they did not, how it is that you can still remember what I wrote, and how is it that you’ll most likely still recognise those words in a year’s time?)
Now this blog post has been at the back of my mind for a while. I was finally inspired to actually write it today when I read Vaughan Bell’s critique of ‘Critical mental health‘. Which brings me to the ever present question of ‘Biological’ Vs. ‘Psychological’.
I’m often asked whether a problem is biological or psychological in origin, and quite often, when I first see a client, they tell me that their doctor told them something along the lines of:
“You have a chemical imbalance in your brain, which we can try and fix with this medication”.
This is the kind of thing that upsets me*. For me, it’s a problematic misuse of ‘biological’ theories of mental function, and I have a number of concerns with this kind of explanation:
Firstly, the doctor has absolutely no idea whether what they said is true. Setting aside the wider debate about whether antidepressants and anxiolytics do what they claim to do, without running a test, one cannot know whether another person’s brain chemicals are ‘unbalanced’ (whatever that might mean); and frankly, we don’t even have any meaningful tests to tell us whether this might be true. It occurs to me, that the doctor in this case is misusing science to convince their patient to take a medication.
Secondly, and connecting back to the beginning of today’s blog, it feeds into a wider problem, which is the tendency to separate the biological and the psychological. I don’t see this as the doctor’s fault, it’s simply a tendency we have in today’s society, and which is reflected in every article expressing surprise that hiking, sex or meditating changes the brain.
There are significant consequences of labelling a problem ‘psychological’ or ‘biological’ and these vary from problem to problem, culture to culture and person to person. It’s hard to know how an individual may respond to the idea that their brain is unbalanced and needs medication to make it better (hopefully a doctor will also indicate that psychology might also help this person, but that’s certainly not a given). For some, it may be useful to have a ‘biological’ explanation, but for others, it may take away any sense of agency, any sense that they can do something about their condition other than take a medication (a good topic for a post to come).
There are indeed meaningful ways in which we can say a mental health difficulty may have a significant ‘biological’ cause (as in psychosis and chromosome 22q11.2 deletion syndrome, which Vaughan references), or may have a clear ‘environmental’ trigger, such as when a person develops Post Traumatic Stress Disorder (PTSD) following a trauma**.
Yet when it comes to ‘psychological’ vs ‘biological’, there is no sensible way to separate the two. As I hope I may persuaded you earlier, anything and everything that you experience changes your biology, both temporarily and permanently . If this was not the case, you’d experience nothing, you’d have no memories of what happened to you, and psychological therapy would have no purpose.
Thus I believe that we should stop trying to separate the biological from the psychological and learn to always recognise the two as different levels of explanation for the same thing. Perhaps if we can do that, we might finally stop being surprised that exercise could make a person not only fitter, but also mentally healthier, and that this would be reflected in changes in the brain. And perhaps it would stop us giving trite explanations like ‘your brain chemistry is unbalanced’.
(As usual, feedback of any polite kind very welcome. That includes comments on writing style, grammar, spelling, as well as agreements and disagreements. Be as pedantic as you like).
* Of course I never know exactly what the doctor has said, and of course, I’m sure they have done it with the best of intentions.
**As always, in nature vs nurture, in both cases, the story is likely more complex.
In today’s Guardian there is a lovely short article by ‘Anonymous’ about what it is like to hear voices. Well worth a read for those struggling with the same issues, or those trying to understand the experience of voice hearing.
The author’s story is very familiar to me, the stress of going university seemingly bringing on a severe depression while later, with the added stress of exams, the voices appear. I’ve been told this story many times, often by people who I interviewed for the Maudsley Bipolar Twin Study, and then more recently by my clients. My recollection is that the majority of those who’ve related this particular sequence of events were women, but perhaps this was random or recall bias.
The author, via some combination of medication and therapy reports that she no longer hears voices, and that she has found a way to cultivate a supportive inner voice in their place. No point in me saying more, read what she has to say!
(I assumed the author was a woman from the photo, but it’s just a stock image, so who knows).
Today, a colleague sent me a press release for an exciting new treatment for psychotic symptoms based on a compound extracted from cannabis (CBD – Cannabidiol). This work by GWPharm follows up on some work I was vaguely involved in at the IoPPN, King’s College London. Encouragingly it suggests that CBD might be a much more tolerable and effective treatment for psychotic symptoms than the medications we already have.
But that’s not really the point of this article. The point is that in the press release we see the following:
… in 88 patients with schizophrenia who had previously failed to respond adequately to first line anti-psychotic medications.
This is one of my big bugbears. Glossing over the fact I’m not keen on the diagnosis ‘schizophrenia’, what’s the problem? This language is normal, this is how medical professionals really talk about their patients and their drugs. I’ve heard it hundreds of times in ward rounds, read it hundreds of times in papers.
The problem is that the patient did not:
FAIL to RESPOND.
FAILED to WORK
The patient was not inappropriate for the drug, the drug was inappropriate for the patient. Drugs are supposed to be designed to target specific difficulties faced by a patient, whether that be insulin to replace what is missing in diabetes or aspirin to prevent pain transmission or blood clotting. In ‘schizophrenia’ we face the problem that we still don’t know the aetiology of the person’s problems, and each person is different, probably because ‘schizophrenia’ simply does not exist in the same way as type I diabetes. The simple fact is, that if the drug does not work, it’s because it is targeting the wrong mechanism.
A random story by way of analogy: I once went on a camping trip with my brother. When we put the borrowed tent in the car, I remarked to my brother that the tent, which came in two bags, was remarkably light and small. For the next six hours, I thought nothing more of it; not until we turned up at the campsite, and started to set up camp next to our relatives’ warm cosy camper van. Exited to be out camping, I pulled the first part of the tent from its bag – it looked remarkably like a folding chair. Somewhat desperate, I hoped the the tent was even smaller and more lightweight than I’d imagined, and tried the second bag. A second chair popped out. We were left out in the Devon cold, with two chairs to shelter us from the elements.
Did I blame the chairs for not being tents? Of course not! When we were left cold and demoralised, did I blame my body for not responding to the ‘tents’? Of course not, I blamed the provider (me, my brother or the friend who lent the ‘tent’, depending on my mood) for not providing the right solution for the problem at hand.
What are we doing when we say the patient did not respond? We are clearly placing the blame on the patient. Yet we should be placing the blame on the state of the science, or on our poor understanding of the patient’s condition.
If the drug does not work, it’s not actually the drug’s fault (drugs are not sentient as far as I know), but I’d much rather say that the drug did not work, than the patient did not respond. This places the onus on us to improve our treatment
Before I finish, therapy does not get a free pass. We can also find papers that say: “the patient did not respond to therapy”. Rubbish! The therapy did not help the patient. It was the wrong therapy, the therapy was delivered incorrectly, or it was some other of the many factors that can affect the outcome of therapy.
If you are a medical professional who uses such phrases, I implore you to think about the implications of this stultified, automatic way of speaking and writing. Further I encourage you to suggest your colleagues do the same. Language is important, it shapes our beliefs and our actions, it shapes the way we see ourselves, and it shapes the way we see patients.
(PS. As we are talking about language. When I wrote this blog, I used the word patients, because that’s what we see in the literature. Re-reading, that word somewhat stood out to me. Health professionals often use ‘clients’ or ‘service users’, or when it makes more sense, just ‘people’. They do this for a variety of reasons, including to try and break down unhelpful power dynamics, feelings of ‘them’ and ‘us’ and the sometimes dehumanising effect of the words we use. Language is always changing, and it’s an ongoing struggle to make sure our use of language is as helpful as possible.)
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Just about everything in Quito comes with its own special challenges. The altitude and climate provide plenty of scope for things to go pear-shaped, and mean that, from boiling an egg though to baking and gardening, nothing can be taken for granted.
In Quito, there can be downpours for days, followed by weeks with no rain at all. The sun is powerful and evaporation is faster due to the lower pressure. This all makes gardening a challenge, especially for pots and planters, which can dry in a matter of hours.
But all is not lost. Step up SIPs! SIPs = Sub Irrigated Planters.
What is a SIP?
Wikipedia’s page is pretty poor, but there are plenty of resources to be found around the web and a community of avid enthusiasts. And this enthusiasm is not surprising, because SIPs are amazing! I’ve enjoyed the process and the results so much I’ve become an evangelist (hence this entry).
A SIP is any method of watering plants where the water is introduced from the bottom, allowing the water to soak upwards to the plant through capillary action (Wikipedia).
So, why SIP?
SIP because you don’t want to water everyday.
SIP because you don’t want to waste water.
SIP because you don’t want to kill your plants through under or over watering.
SIP because you’re lazy.
SIP because you just want to.
The basic principles of SIPs:
Essentially a SIP aims to emulate to some extent the way plants work naturally. Plants generally suck up water from below, taking what they need. Traditional pots and planters turn this upside down, with the water introduced from the top. This is rather foolish, maximising evaporation and risking both over and under-watering. One consequence of this is that we’re sensibly advised to water in the evening to reduce evaporation. With a SIP, you can water effectively anytime.
There are lots of different designs for SIPS, but the best take into account the following priciples:
Water is fed in through a tube which feeds a reservoir in the base of the planter.
This tube also allows air to enter into the reservoir, this enters the soil via small holes.
An overflow is provided just below the top of the reservoir, this prevents overwatering and maintains an airspace.
A wicking material (cloth, newspaper or just soil) allows the water to reach the plant via capillary action.
Where appropriate, a mulch or newspaper should cover the soil to further prevent evaporation.
How to buy/make a SIP?
Although you can, there is no need to buy a SIP. I highly recommend making your own, using the above principles, and drawing on the wealth of designs on the web. And if possible try to reuse and recycle to do so.
Let’s start simple and move on… Perhaps the most basic SIP is the single soda bottle SIP. Here’s my schematic:
And here’s the real world version (click on the image for a larger copy).
This design does, in the name of simplicity, violate my first principal of a good SIP, in that it has no tube to feed the reservoir
Here the SIP is growing oregano. Generally the occasional rain is enough to water it, the water passes through the soil and fills the reservoir; however sometimes I do need to add extra water – a tube would make this more efficient but would also complicate the simple, easy design.
I’ve also used this design for growing coriander from seed, this worked very well, reducing the chances of the soil drying out and the seedlings dying.
Ok, so what about more sophisticated designs? SIPs are pretty much only limited by your imagination, and provide a lovely opportunity to get creative. Following a few other attempts I I settled on this design for long planters. Here I’ve used a variety of old bottles and some old tubing. The three white bottles are all joined together and fill directly from the tube. I drilled small holes (with a Dremel, but they could be punched or cut) in the tops and sides. The top holes allow air to the soil, the side holes release water into the surrounding soil (added later!). The transparent bottles are not connected to the white bottles but fill up as water exits the white bottles.
Overflow. If you look closely, you’ll see that the vinegar bottle sticks though the side of the planter, thus acting as the overflow. Excess water from the soil enters into the three transparent bottles, and when it reaches the level of the exit hole (vinegar bottle top) it pours out of the planter, preventing overwatering. The nice thing about this design is that if for any reason you want to really soak the planter (perhaps you’re going away for a while), all you have to do is put the lid back on the vinegar bottle (remembering to remove it when the soil has soaked).
Fill Pipe. The fill pipe is topped by the top section of a plastic bottle. I generally join these to the pipe by cutting a hole in the lid, and then sealing the connection with a glue gun.
For the finished product, see the top of the article!
For me this is pretty much the beginning, there are plenty of ways of improving these systems, including developing a way to make a truly self watering SIP (again, there are plenty of ideas around on the web). The bigger project is to make a large self watering planter using rain water. I’ll update when I’ve made some progress! In the meantime, try for yourself, and let me know how you get on.
Over the last few years some of you will have seen a viral video of a man singing along to Rhianna on the tube. If you’ve not seen it, all the better, have a watch (below) and as you do just have a little think about what’s going on. What are your first impressions of the singer and his audience?
The video was first recorded surreptitiously and posted on youtube in 2012, becoming a viral hit with over 2 million views. What was his audience thinking? For his fellow tube travellers we’ll have to entertain ourselves by interpreting their expressions. Youtube however, gives us a little more to go on…. some people found the video amusing:
Trying so hard not to bust out in uncontrollable laughter
…others admired his confidence.
Lol. Kudos to him, as funny as it is, I do love how ppl have such cofidence in themselves to do such things. As its nit in the norm to sing aloud on the subway/rail, whether you have a good voice or not.
….some gave their support:
Awesome! Keep on singing Alika. Let the stiff upper-lipped boring people jeer all they like. You are London.
….and sadly many others were just nasty or racist. Youtube’s comments section can be a dark place.
Yet, few if any of the comments really indicate any attempt to question what was going on in the man’s head (beyond those who accused him of showing off).
So what was going on? Well we don’t know exactly, but that man on the tube, Alika, has got together with Rethink (in a video) and the Independent (in an article) to tell us a little bit about what he was experiencing (Have a read and a watch, and perhaps compare your reaction to when you saw the first video). As he tells us in the Independent.
That year  a number of events in my personal life had taken their toll on my mental health. In just twelve months, my auntie died, my five year relationship crumbled, my savings were stolen, and two friends of mine were killed in violent attacks. It all started to overwhelm me, and I began to feel and behave differently.
I was going through depression, anxiety, manic episodes, self-harm, and voices and illusions in my head. But I kept it all to myself, and over time I became more withdrawn and erratic. Singing on the tube was a way to drown out my problems and escape. When you’re in the middle of a manic episode, you don’t think about what you look like or how you come across.
….A story very familiar to clinical psychologists working with bipolar disorder and psychosis. While some of my clients become ill without any clear stressors, they are in the minority. Most of the people I’ve seen have worked with have entered a manic phase following difficult life experiences. Alika’s story may seem extreme, yet it’s not at all uncommon among clients with mania and psychosis. We all have different breaking points, and these may depend on a mixture of our past experiences and our genetics. Cities like London do not help, feelings of alienation, racism, insecurity and violence are not uncommon, and are a particular problem for those from less privileged backgrounds (black Londoners are at particular risk of experiencing psychosis, for possible reasons that need another article).
But back to the comments…. the comments for Alika’s Rethink video are in stark contrast to those in the original video. There are not so many yet, but to give a flavour, here’s just one:
Brother am soo sorry when world star posted it people thought it was funny me being one of them if knew what you were going through i would have not even dare to laugh at that video.respect you for what you have done i too have anxiety when i am in public but its only getting better and better i will let my friends know about this soo they can apologize as well.:)
For me, this is a reminder that empathy is rarely automatic. We are generally quick to judge by what we see on the surface, but rarely take the time to imagine what lies under the surface, to ask ourselves what might be going on for that person opposite us on the bus or tube, or even over the breakfast table. We often jump to one conclusion and stick with it, that singing man is what? Selfish? Annoying? Super laid back and open? Cool? Attention seeking?
As Alika puts it (kindly).
I don’t want to make people feel bad if they laughed at the video of me singing on the Tube. I can see the funny side too, but I’d like to move on now. Viral videos have a life of their own and capturing someone’s behaviour for a few seconds in a day doesn’t ever show you the full picture.
Jumping to Conclusions (JTC) is something that is supposed to be particularly common in people with psychosis, yet in reality, we all do it, all the time. And just as it can be helpful for my clients to think of other explanations for their experiences, it can be useful for the rest of us too. On a bad day, we may tend to jump to negative conclusions, which just make that day worse. A classic example used in therapy is to imagine someone we know ignoring us when they walk past us on the street. What’s going on? On a bad day, well that person is clearly a total ass; on a good day, clearly they were preoccupied and did not see us.
Alika’s second video and article give us context, they give us a way of connecting to Alika. Suddenly, Alika is no longer a cartoon but a deeper, three-dimensional character. It’s no longer so easy to apply just one adjective. Now we are forced to consider Alika as a person with a past, present and future. It’s harder to be unkind, and easier to be kind. We have understanding , we have empathy.
Alika was kind and brave enough to give us that connection. The challenge is to make that connection more often and with less help.
A little while back I was asked by Amy Dron to give my opinion and thoughts on the medicine/drug/spiritual aid, Ayahuasca. Amy wanted to write an article on the subject due to the experiences of a friend, who demonstrated a significant change in behaviour around the time she was taking Ayahuasca.
I’ve long been interested in the use of psychoactive medications, and have an interest in how medications are used across cultures, especially in light of the rather contradictory approach to different substances in my own country. Travelling in Colombia and Ecuador I had the opportunity to talk to a variety of people about their experiences, and also to take part in ceremonies in both countries. I’ve been meaning to write up some of my thoughts for a while now, but in the meantime, here’s some of them from a conversation I had with Amy Dron shortly after I returned from South America in 2013.
In researching for a lecture on bipolar disorder, I came across this video. It’s simply text, set to Samuel Barber’s Adiago For Strings (perhaps the ultimate emotional induction music).
It’s been posted by Brian Miller (Parhamscan, bminternet43), on his youtube channel . It’s a relatively short film which covers a little of Miller’s early life and then details a manic episode, which led to his sectioning and hospitalisation. Miller’s is a story that is perhaps familiar to many others with a bipolar diagnosis, although his first major manic episode was probably later than average.
For the mental health professionals, the video would probably make a great resource for bipolar support groups, teaching, ward groups and perhaps in individual therapy. The comments below, as so many times when people share their experiences, reveal how valuable it has been for other people.
An interesting short film about Sue Morgan’s artistic way expressing and processing her experiences, as well as some of the science helping us to understand these experiences from a neuroscience perspective (in terms of changes in levels of oxygen in the brain, BOLD, the thing we think we measure with functional MRI).
As someone with a fair bit of experience in brain imaging, two things thing struck me straight away about this film. The first is the power of imagery, the second is how, it seems to me, imagery is working in very different ways for Sue Morgan and for the clinical researcher and the film maker.
For Sue Morgan, getting her thoughts out of her brain and down on to paper is a perhaps a means by which she can reduce the power of her experiences and make sense of them. For the film maker, images of brain scans and MRI machines perhaps help to convey a sense that the research is important, that it is ‘real’ and ‘scientific’. For psychiatrist and researcher Sukhi Shergill, seeing the activation on a brain scan, helps him to say that he believes that these experiences are real, and do so genuinely.
The film also makes me wonder about the strange tricks that filmmakers like to play. What we see here is not an image of a real MRI scanner, but a fake scanner. Putting a laptop into a real scanner would result in nothing less than a very unhappy laptop, and possibly, carnage. When Sukhi Shergill points at his bank of computer screens, he is presumably supposed to be in the middle of some serious hardcore scientific thought, while he’s probably mostly feeling a bit uncomfortable about having to make gestures at a touch screen whilst being filmed (conjecture of course). The visual language here is presumably supposed to make us take the message more seriously, to engage more with the film. Personally, if there’s no pictures of the scientist walking moodily down a long corridor, I don’t buy it. Or with less sarcasm, please filmmakers, more content, less nonsense.
There is however, a very important message in this short film, the experiences of people with psychoses are real. They are not made up, the person is genuinely hearing voices, seeing things, or experiencing the feeling that people are out to get them. This is why, when these experiences are appraised as negative, they can be genuinely terrifying. Out clients, have of course, been telling us this forever. All too often, professionals fail to grasp this, and this leads to a collapse in the relationship. In a sense, we should not need MRI scans to tell us this, they are simply correlates of our ‘lived experience’, they help us understand at another level, but they are no more valid that what the person is telling us about their experience. Yet, if brain scans can help professionals develop more empathy and understanding, great.
This house believes that CBT for psychosis has been oversold.
I’m glad to say that it was a well mannered and reasonable debate, with those on both sides presenting interesting cases. Although the actual question is perhaps not that interesting, the myriad of underlying issues are. Things like:
Does CBT for psychosis actually work?
If so, for what does it work best?
Which version of CBT for psychosis is most effective?
Which outcomes should we be measuring?
How do we match clients to therapies?
Does CBT for psychosis have to change the topology of positive or negative symptoms of psychosis to be useful? Or might it be enough to change a person’s relationship with their experience?
Are there other interventions that we would be better focussing on instead?
In the end, the motion was defeated resoundingly, with a large shift from the first vote at the beginning of the debate. Those for the motion, put this down to a triumph of anecdote over statistics. Of course, as psychologists and philosophers may say, it’s not events that matter, but what we believe about them and how we respond. An alternative belief is that perhaps the audience actually don’t think CBT for psychosis has been sold very strongly at all, regardless of its effectiveness. Or, perhaps people thought that the issues of CBT for psychosis are too complex to be encapsulated in the particular meta-analyses that were the primary focus of the speakers for the motion. There are many reasons why the vote could have gone this way, and without doing a survey, I could not tell you!
Response to Keith Laws.
One reason I’m writing this, is that I rashly described (over twitter) one of Keith Laws’s assertions as intellectually dishonest, when perhaps I should have said he was loose with his wording. He understandably challenged me to defend this claim. So I will do so here on my blog (as I’m not a very familiar with twitter, and don’t think 140 characters is useful for discussion). Before I go any further, I should declare a conflict of interest, I’m a clinical psychologist and much of my workload involves CBT for psychosis.
Unfortunately I don’t have a recording of the debate yet, so I don’t have his exact words, thus I’m going to address what I thought his point was! I remember Laws saying that the evidence says that CBT for psychosis only helps 5% of people treated. For the moment, you can find a reference to this on Alex Langford’s live take on what was said here at storify, and the tweet of the claim in question here.
Cognitive-behavioural therapy has a therapeutic effect on schizophrenic symptoms in the ‘small’ range. This reduces further when sources of bias, particularly masking, are controlled for.
And finds that (for example), the effect size on overall symptoms falls from -0.62 to -0.15 (95% CI –0.27 to –0.03), when studies with insufficient and sufficient masking are compared. (Always note the confidence interval. Even here, at this significance level, the true effect size might be as low as -0.03 or as high as -0.27).
My claim is that even if we take no issue with the way in which the meta-analysis has been carried out (and of course we might), and even if we temporarily accept the figure of 5% (I’ll confess I’m not sure exactly where this came from, some NNT calculation?), Law’s conclusion that CBT only helps 5% of people seems flawed.
One key reason for this, is that the meta analysis includes both treatment as usual and control interventions as comparators. Thus a more valid conclusion would be that CBTp helps only 5% more people than a mixture of treatment as usual (TAU) and control interventions such as befriending. To me, this is a quite different thing. For instance, it is possible that the control interventions were also very effective and thus CBT had a hard job getting significantly better results. As an example, let’s say in a study, befriending had a 40% impact on symptoms and CBT had a 45% impact. This would not mean that CBT helped only 5%, but 5% more, although the difference between interventions was only 5%.
A second reason not to accept this interpretation is that our clients’ wellbeing can be quite independent of the number and frequency of their positive symptoms. A person can for instance, continue having auditory hallucinations, but completely change their relationship to them, and thus reduce depression and anxiety, and increase quality of life. Thus CBT may help clients in the absence of a change in positive symptoms (the meta analysis that Laws was an author on, did not consider other outcomes such as depression and anxiety – key issues for our clients). Equally, if a client asks us first to help them with their panic attacks, that is generally what we do, yet progress here will not necessarily show in a measure of psychosis symptoms.
I’m in agreement with Laws in some senses. The literature can certainly be improved upon. Clinically, we often seem to see remarkable change, yet the literature at large, does not necessarily reflect this. This may be because CBT is not adding much to treatment as usual, or other interventions, but that we wrongly interpret change as related to CBT. Or, it may be because there are many different types of CBT, some better than others. Or it may be because we are measuring the wrong things. Or it may be that we are looking at the evidence too simplistically.
Incidentally, it was argued in the debate that it would take a huge number of extra significant trials to improve the effect size of CBTp in meta-analyses. This to me, shows a misunderstanding of CBTp. CBTp is not quetiapine, which is always the same. CBT is evolving over time and comes in many forms (from individual to group, from classic CBT to taste the difference Mindfulness Based CBT, from CBT for general psychosis to CBT for command hallucinations). Lumping all studies together as if it were the same, is thus not necessarily a good idea.
Whatever the explanation, it behoves us to rethink the way we have run our trials to date, in order to capture those outcomes that are most useful to service users. (I suspect Laws may not appreciate how difficult it is to get funding to run sufficiently powered studies, which may also explain how many studies are at the right side of his forest plot, yet non-significant). We also clearly need to continue to refine our treatment protocols. We are beginning to do this, with targeted interventions such as the COMMAND trial (among others). It’s a hard slog, but I for one, think the future is bright.