The Continued Evolution of Trauma

In appreciation that Bessel val der Kolk, trauma expert, will be speaking at the Evolution of Psychology conference this week, I’m posting this:

Bessel van der Kolk, M.D., internationally renowned trauma expert, spoke at the Los Angeles County Psychological Association (LACPA) convention this past Saturday. It was an engaging and thought provoking presentation. His seminal article “The Body Keeps the Score: Memory and the Evolving Psychobiology of Post-Traumatic Stress“(1994) caught the attention of both clinicians and researchers alike — appropriate, as van der Kolk has a foot in each camp.

Psychobiology, psychotherapy.
With a solid background in neuroscience and physiology, one of van der Kolk’s basic assertions is that traumatic memories are hard wired into somatic (body) memory. As such, these “memories” are associated with primitive areas of the brain, inaccessible to talk therapies. The speech centers of the brain are located in the left hemisphere, in the cerebral cortex, on the very surface of the brain. It is generally believed that the cerebral cortex is the most recent product of human evolution. In contrast, the parts of the brain that regulate bodily sensations, temperature, respiration, and so on, are in the primitive, reptilian lower brain. Inaccessible to talk therapies.

Clinicians and researchers: Debate over EMDR.
That simple assertion, that traumatic memories rest in a part of the brain unaffected by talk therapies, causes a stir, among both researchers and clinicians. Both find van der Kolk’s espousal of Eye Movement Desensitization and Reprocessing (EMDR) as trauma treatment provocative, for different reasons.

Is talk therapy effective?
Clinicians bridle at the idea that traditional talk therapies might be ineffective, or at least less effective, than a therapy that involves waving one’s fingers in front of the patient’s face. But van der Kolk’s assertions relate chiefly to the treatment of trauma, usually under the diagnosis of what is known as post-traumatic stress disorder (PTSD). Nevertheless, drawing inferences from van der Kolk’s statements would give any clinician pause for reflection: Just how effective is talk therapy?

How to establish “treatment of choice.”
Researchers have disputed whether the finger waving has anything to do with the outcome of EMDR, though it seems at this point it has been established that EMDR has outcomes as good, if not better than, the “standard” or “evidence-based” treatment. (Controversy has been good to EMDR — it is perhaps the most researched therapy in history.) Cognitive-behavioral “exposure” therapy is conventionally supposed to be the “treatment of choice” for PTSD. (An exposure treatment involves gradually introducing an unpleasant stimulus — a spider for instance — until it can be tolerated more easily.)

Is trauma in a category of its own?
Even a cursory look at van der Kolk’s presentation and his work raises many questions: What is trauma? Is talk therapy appropriate for treating trauma? Who decides on the evidence in “evidence-based” treatment? What makes good research — and who funds it? What makes an effective psychotherapy?

Please click on the green button if you enjoyed this post. Thanks.

Kalea Chapman, Psy.D.

Newsweek on Therapists’ Aversion to Science

In the psychological community this article is relatively old news, but it has stirred up a very lively debate. For the moment, I’m just posting Ken Pope’s summary of the article:

It’s a good thing couches are too heavy to throw, because the fight brewing among therapists is getting ugly.

For years, psychologists who conduct research have lamented what they see as an antiscience bias among clinicians, who treat patients.

But now the gloves have come off.

In a two-years-in-the-making analysis to be published in November in Perspectives on Psychological Science, psychologists led by Timothy B. Baker of the University of Wisconsin charge that many clinicians fail to ”use the interventions for which there is the strongest evidence of efficacy” and “give more weight to their personal experiences than to science.”

As a result, patients have no assurance that their “treatment will be informed by science.”

Walter Mischel of Columbia University, who wrote an accompanying editorial, is even more scathing.

“The disconnect between what clinicians do and what science has discovered is an unconscionable embarrassment,” he told me, and there is a “widening gulf between clinical practice and science.”

The “widening” reflects the substantial progress that psychological research has made in identifying the most effective treatments.

Thanks to clinical trials as rigorous as those for, say, cardiology, we now know that cognitive and cognitive-behavior therapy (teaching patients to think about their thoughts in new, healthier ways and to act on those new ways of thinking) are effective against depression, panic disorder, bulimia nervosa, obsessive-compulsive disorder, and posttraumatic-stress disorder, with multiple trials showing that these treatments–the tools of psychology–bring more durable benefits with lower relapse rates than drugs, which non-M.D. psychologists cannot prescribe.

Studies have also shown that behavioral couples therapy helps alcoholics stay on the wagon, and that family therapy can help schizophrenics function.

Neuroscience has identified the brain mechanisms by which these interventions work, giving them added credibility.

You wouldn’t know this if you sought help from a typical psychologist.

Millions of patients are instead receiving chaotic meditation therapy, facilitated communication, dolphin-assisted therapy, eye-movement desensitization, and well, “someone once stopped counting at 1,000 forms of psychotherapy in use,” says Baker.

Although many treatments are effective, they “are used infrequently,” he and his coauthors point out.

“Relatively few psychologists learn or practice” them.

<snip>

When confronted with evidence that treatments they offer are not supported by science, clinicians argue that they know better than some
study what works.

In surveys, they admit they value personal experience over research evidence, and a 2006 Presidential Task Force of the American Psychological Association–the 150,000-strong group dominated by clinicians–gave equal weight to the personal experiences of the clinician and to scientific evidence, a stance they defend as a way to avoid “cookbook medicine.”

A 2008 survey of 591 psychologists in private practice found that they rely more on their own and colleagues’ experience than on science when deciding how to treat a patient.

<snip>

If public shaming doesn’t help, Baker’s team suggests a new accreditation system to “stigmatize ascientific training programs and practitioners.”

(The APA says its current system does require scientific training and competence.)

Two years ago the Association for Psychological Science launched such a system to compete with the APA’s.

[end excerpts]

The article is online at:
<http://www.newsweek.com/id/216506/output/print>

Internet-Driven Loss of Human Connection

That’s not the gist of the article, actually. It’s a phrase taken from a brief piece on Salon.com by Charles Barber, the author of Comfortably Numb: How Psychiatry is Medicating a Nation. The book is a very interesting read, as is the article. The Salon piece is a brief note on the medicating-a-nation-for-profit theme: If psychiatric drug use has doubled, why aren’t we happier?

Here’s the link.

And an excerpt:

But there is something dark and undeniable shifting in our cultural mood, too. Sure, there is manipulation in the advertising and confusion about what constitutes legitimate “serious and persistent mental illness” (a formal term to describe the afflictions of the very small percentage of people who suffer from severe bipolar disorder, major depression or psychotic disorders) as opposed to the far more normative, if often very painful, stressors and issues of living life in the early 21st century. Yet I would also say that misery and — if one were to use a slightly more clinical word, anxiety — are at one of their periodic high points. Arguably we have entered a new age of anxiety, a term associated with the post-World War II era through the 1960s, when the prevailing belief was that the world might blow up at any moment (and on the medication front, Valium was king). Maybe there’s some weird synchronicity that the hottest thing in our present cultural moment, “Mad Men,” is set firmly in that era. In any case, I have written widely about mental health and have traveled the country in the last couple of years and, given the nature of my writing, have been sought out by all kinds of troubled souls. I can claim confidently that there is, right now, a high-water mark of worry and suffering on numerous fronts — economic, of course, but also social, with our ever-increasing isolation and Internet-driven loss of human connection and the ongoing trauma of wars and crises that just don’t seem to end.

iPods for Autism?

Here’s an interesting piece from the Boston Herald. I got wind of this through Ken Pope’s listserv. The edits are his, too:

Sue Pederson knows that the teenage boys in her treatment program have trouble making conversation.

They may not know what to talk about; or once they get started, when to
shut up.

That’s one of the striking features of people with Asperger’s syndrome: They struggle with the social skills that come so naturally to others.

But about a year ago, Pederson, a psychologist, and her colleagues at the Fraser Child & Family Center in Minneapolis found a new way to reach these students — right through their headphones.

They’re using iPods, which play music and videos, to teach them how to fit in.

It may have started out as a form of entertainment, but Pederson says this kind of technology is turning into an unexpected boon for children and teenagers with special needs.

The devices, it turns out, can be crammed with the kind of information
they need to get through the day.

While it’s still experimental, she said, “I think it’s going to spread
like wildfire.”

With Asperger’s, a form of autism, people lack the inner voice that
tells them what is, or is not, appropriate behavior.

At Fraser, Pederson’s staff came up with the idea of programming iPods
to act as an electronic substitute for that missing voice.

In this case, the staff helped students create a series of short videos and slide shows on how to behave in different social settings.

Some are barely 30 seconds long: How to carry on a conversation (“Let the other person talk AND change the topic … “); how to respect other people’s boundaries, and think before they speak (“Use your filter!”).

In the world of special education, these scripts are known as “social stories,” used to teach basic social skills.

“It’s a mental checklist for things to think about when you’re interacting with other people,” explained Mandy Henderson, who works with Fraser’s Asperger’s program.

As part of the Fraser project, the students can transfer the videos onto their iPods, and replay them over and over, to drive the lessons home.

Jack O’Riley, of Eagan, Minn., said it’s just what his 15-year-old son
P.J. needed.

“This really hit the mark,” he said. Like many kids with Asperger’s, P.J. is baffled by the normal rhythms of social interaction: in conversation, he may blurt out too much information, or say nothing at all, his father says.

At the same time, P.J. is easily distracted and has a hard time staying
on task, another common trait of Asperger’s.

For years, O’Riley posted laminated signs around the house to remind his
son how to get through the day — take a shower, brush his teeth, get ready for school.

Now, with the videos developed at Fraser, “we can plug this stuff into his little ‘extended memory,’ ” O’Riley said. P.J. is building a library of videos on his iPhone, so they’ll be at his fingertips. “He can pull up a topic on his ‘to do list’ and find everything he needs to know, his father said.

Barbara Luskin, a psychologist with the Autism Society of Minnesota, agrees.

“Adolescents with Asperger’s, like all adolescents, don’t want to look
different,” she said.

If the device just blends in with everyone else’s, she said, “you’re much more likely to use it.”

So far, there appear to be few commercial products aimed at this market,
but that may be changing.

The Conover Co., a special-education software company in Appleton, Wis.,
recently adapted its “Functional Skills System” for the iPod Touch.

But the package, which sells for $3,500, is mainly marketed to schools and other organizations.

Fraser, meanwhile, is hoping to get another grant to expand its iPod program.

Ball, of the Autism Society, predicts this is just the beginning. “I think that technology is limitless in its potential for working with kids,” he said.

DSM-V Badly Off Track

According to Ken Pope, that’s the title of an interview with Allen Frances at Psychiatric Times. Dr. Frances was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke. I’m passing on the excerpts that Dr. Pope culled from the article:

Q: This is the first time you have commented on DSM-V. Why did you decide to speak up now?

A: We have already gone past the midway point of the time allotted for the preparation of DSM-V. I realized that not enough has been accomplished and that most of what is being suggested is headed in a very wrong direction. Particularly troubling is the almost total lack of recognition that changes in an official manual of diagnosis can have devastating unintended consequences. Before it is too late, I feel a responsibility to help DSM-V avoid mistakes by sharing the lessons learned during the past 30 years working on the 3 previous revisions of the DSM. Perhaps my comments may help the DSM-V Task Force avoid some of the hidden landmines I think they are dancing around.

Q: In your opinion, what has gone wrong in the DSM-V process?

A: The most fundamental errors have been its completely inexplicable secrecy and the lack of openness to outside influence and criticism. I simply can’t recall a single moment of work on the DSM-III, DSM-III-R, or DSM-IV when there was anything remotely worth keeping secret. Restricting the free flow of ideas creates enormous blind spots that greatly increase the risk of damaging unintended consequences. Specifically, it was a huge mistake to require that the DSM-V work group members sign a confidentiality agreement. It was also unwise to avoid having any institutional memory of how and why decisions were made in prior revisions. The advisory group is far too small and select to reduce, rather than encourage, heated debate. In producing a new edition of the DSM, your harshest critics eventually turn out to be your best friends because they are most likely to help you avoid pitfalls. My own highly critical comments on DSM-V are offered, and I hope will be taken, in this spirit.

Q: What are the risks you are so concerned about?

A: The work on DSM-V suffers from the unfortunate combination of being heavy on ambitious goals for change and light on the methodological rigor necessary to avoid the many problems that such change may cause once the system is in wide use. Unless DSM-V changes course dramatically, it will introduce numerous new, relatively untested categories that will greatly jack up the rates of mental disorders. Many people will be inappropriately identified as mentally ill and will receive excessive treatment. The pharmaceutical industry will have a field day. Two necessary forms of protection should have been established to prevent this: (1) a requirement that all changes be supported by a high threshold of systematically gathered empirical evidence, and (2) a careful risk-benefit analysis of the potential negative impact of each and every change.

DSM-V: A New Animal?

A few interesting tidbits I got from Ken Pope’s digest of a Los Angeles Times article on the current construction of the new Diagnostic and Statistical Manual:

But all agree that the so-called bible of psychiatry is expected to be considerably more nuanced and science-based than the last edition, DSM-IV, published in 1994.

Brain imaging and other technologies, plus new knowledge on biological and genetic causes of many disorders, have almost guaranteed significant alterations in how many mental afflictions are described.
….

The book will describe disorders in more detail, acknowledge variations that haven’t been viewed as part of “classic” illness and explain how conditions differ based on age, race, gender, culture and physical health, Kupfer said.

What that looks like in practice is anybody’s guess. But what seems clear is that DSM-V is going to be a different sort of animal. Ties to the pharmaceutical industry remains the biggest problem with the work. Here is another excerpt, again courtesy of Ken Pope, that typifies the justifiable concerns that have been raised many, many, many times:

Over the last two decades more medications have become available to treat mental disorders, and some doctors worry that the text may be written in a way that expands the market for drug therapies.

A study published online in the current issue of the journal Psychotherapy and Psychosomatics found that of 20 work group members writing clinical practice guidelines for the treatment of bipolar disorder, schizophrenia and major depression, 18 had at least one financial tie to industry.

A commentary in the May 7 New England Journal of Medicine said that 56% of DSM-V task force and committee members have industry ties.

DSM-V committee members have been asked to abide by conflict-of-interest rules, including agreeing to receive no more than $10,000 annually from industry sources during the period they serve on the committee.

But that isn’t going far enough, said Lisa Cosgrove, lead author of the Psychotherapy and Psychosomatics analysis and an associate professor and clinical psychologist at the University of Massachusetts.

“There are currently work groups where every single person has ties,” Cosgrove said. “It doesn’t seem like genuine progress has been made.”

Doubt Is Our Product

Here’s a brief quote from a Psychology Today interview with David Healy, author of Let Them Eat Prozac. I got wind of the interview from the ever vigilant Furious Seasons, and these are excerpts from that website:

“Well, I think what Donna’s story above illustrates is that pharmaceutical marketing departments are actually the postmodernists par excellence. They treat the human body (including its disorders and complaints) as texts to be interpreted one way this year and in just the opposite way a year or two later.

“In contrast, when it comes to the hazards of these drugs—just like the tobacco companies before them—the motto of Pharma has become ‘doubt is our product’-—they simply refuse to concede that their drugs are linked to any hazard at all . . . until the drug goes off patent. You cannot get a better definition of postmodernism than “doubt is our product.’”

Really, the interview is worth checking out. The headline starts: Bipolar disorder and it’s biomythology.

Lexapro For Teens

Here’s an excerpt from Furious Seasons on why not antidepressants for kids:

Because anti-depressants represent America’s quick fix culture: compare our approach with the UK’s, where anti-depressants are mostly banned for anyone under 18 and where its own health care agencies (ie, NICE) recommend approaching depression treatment by going through watchful waiting, making sure patients are eating properly and exercising, psychotherapy and, then and only then, moving to anti-depressants. Since making that shift a few years ago in the nation’s depression treatment policies, I’ve heard no reports of British teens going through a suicide epidemic. In fact, the suicide rate went down over there when most anti-depressants (except Prozac) were banned for under-18s.

ADHD: Medicate or Nature Walk?

From a New York Times article on the importance of recess, an interesting assertion regarding the effectiveness of medication v. nature  walks for ADHD:

A small study of children with attention deficit hyperactivity disorder last year found that walks outdoors appeared to improve scores on tests of attention and concentration. Notably, children who took walks in natural settings did better than those who walked in urban areas, according to the report, published online in August in The Journal of Attention Disorders. The researchers found that a dose of nature worked as well as a dose of medication to improve concentration, or even better.

When Testing is Damaging: “Stereotype Threat”

From a Washington Post article by Shankar Vedantam “How a Self-Fulfilling Stereotype Can Drag Down Performance” on some research that suggests that standardized tests themselves effect their outcome. Make sure to read the last two paragraphs. The story was brought to my attention by and excerpted by Ken Pope:

Sociologist Min-Hsuing Huang recently decided to ask whether the race of the person administering the survey mattered: He found that when black people and white people answered 10 vocabulary questions posed by a white interviewer, blacks on average answered 5.49 questions correctly and whites answered 6.33 correctly — a gap typical of the ones found on many standardized tests.

Huang then examined the performance of African Americans who interacted with black interviewers: He found that black respondents then answered 6.33 questions correctly — the same as white ones. The reason African Americans scored more poorly on tests administered by white interviewers, Huang theorized, is that these situations can make the issue of race salient and subtly remind the test-takers of the societal stereotype that blacks are intellectually inferior to whites.

Huang’s findings, recently published in the journal Social Science Research, are only the latest in a body of research that has gone largely unnoticed by policymakers, parents and managers: Dozens of field experiments have found that reminding African Americans and Latinos about their race before administering academic tests, or telling them that the tests are measures of innate intelligence, can hurt their performance compared with minorities who were not reminded about race and not told that the results reflect inherent ability.

Psychologists such as Claude Steele at Stanford University came up with the term “stereotype threat” for the phenomenon:  When people are threatened by a negative stereotype they think applies to them, they can be subtly biased to live out that stereotype.

The threats do not have to take place at a conscious level: When volunteers in experimental studies that have found huge stereotype-threat differences in performance are told about the phenomenon afterward, they invariably tell researchers that the theory is interesting but does not apply to them.

Nor are the findings limited to blacks and Latinos. The same phenomenon applies to women’s performance in mathematics.

<snip>

In a soon-to-be-published study, researchers Gregory M. Walton at Stanford and Steven J. Spencer at Waterloo University in Ontario explored a question with even thornier implications.  What does stereotype threat tell you if you are a college admissions officer debating between a man and a woman who both have an SAT score of 1200?

<snip>

But in two meta-analyses involving nearly 19,000 students, Walton and Spencer found that when schools and colleges go out of their way to ameliorate stereotype threats, the performance of women and minorities soars — it’s as if these students are athletes who have been running against a headwind.  Without the headwind, Walton and Spencer found that minorities, and women in math and science, do not just do as well as whites and men with the same SAT scores — they outperform them.

“We would argue if you simply use test scores, you are building in discrimination into a system,” Spencer said.  ”The test scores underrepresent what minorities, and women in math and science, can do.”