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Pammy does dependence

14/07/2015

“You can believe in people supporting and helping one another, that you don’t have to have a Ph.D. or an M.D., that if people care about each other that they can provide emotional and physical support better than any so-called authorities. Or you can believe that unless you have a degree or expertise that you can’t help anybody.” – Bruce E Levine

In yesterday’s Guardian psychotherapist and former comedian Pamela Stephenson-Connolly is posed a tricky question. The letter writer’s boyfriend was raped and bashed by a former girlfriend and still suffers from trauma. In particular the writer is concerned about the impact the experience has on their sex life and asks Ms Stephenson-Connolly what she can do to help him.

This guy is clearly in a difficult spot and can expect little sympathy. Some people would consider his experience suitable material for ribald jokes. Others would tell him to grow a pair and get over it. Yet others would doubt his account of events, though many of them would express righteous outrage at any skepticism directed towards female rape victims. He’s lucky to have a concerned partner with a sincere desire to help.

Pamela immediately kyboshes her altruism.

“Unless you are an experienced, trained psychotherapist, you can’t [help him]”, she insists in her opening sentence. She later reiterates that only expert therapy is appropriate and says without it he will probably remain sexually and emotionally crippled for the foreseeable future. Her final twist of the thumbscrew reads “He – and you – deserve far better”.

The letter writer deserves far better advice.

It’s customary for mental health professionals to tell their patients they’re seriously disabled and can’t expect to cope without long-term expert assistance; often for life (ka-ching!). This isn’t necessarily a bad thing. It can validate their suffering and justify their cries for help. It often results in much-needed attention, sympathy and assistance. Many psychological problems are caused or aggravated by dysfunctional family dynamics and getting loved ones to back off a bit can sometimes be a useful intervention, though there are no grounds for assuming it applies in this case.

But it also fosters dependency on someone who will only ever see a tiny fraction of the patient’s life circumstances. It degrades their social identity, subjects them to ongoing stigma and robs them of agency over their own lives. And in cases like this it can deny them valuable help from those who may be in a better position to offer it than a stranger in a consulting room who sees them for an hour or so per month (if they can afford it).

If the mental health industry truly had the answers perhaps that wouldn’t be a problem. But there’s little reason to believe it does.

Few psychotherapies can be shown to work significantly better than placebos (which actually work quite well for emotional problems). Many have serious side-effects and some seem to do more harm than good. According to the WHO, those suffering psychological disturbances in third world countries who are forced to rely on family and community networks for support have better long-term prognoses than first world patients with access to the best professional help available.

In the case of post-traumatic stress disorder (PTSD) – which is what this man seems to be suffering, going on the very limited information available – there are some professional interventions that apparently help around 50% of sufferers. Desensitisation therapy through controlled exposure has a pretty good evidence base. This was the method I used to overcome the trauma of my 1980 car accident. Without any professional assistance I might add, though I’d studied it at university so I guess I wasn’t a complete novice. Several years earlier I’d instinctively used similar methods to dispel the phobias that gripped me after a pack of large sharks joined a surf race I was swimming in. When you fall off a horse get straight back on. You don’t need an expert to tell you that (though it might be an idea to get some x-rays first).

There’s reasonable grounds to expect that by gently and gradually exposing the man to the circumstances that trigger anxiety and flashbacks associated with his assault those triggers will steadily lose their power over him. Given the apparent nature of his problems it’s likely his girlfriend would be in a better position to help him than would a therapist behind a desk.

But most PTSD therapies have little evidence for their efficacy. Some, such as post-trauma debriefing, actually seem to aggravate the problem. What’s worse is that many clinicians show little regard for the evidence base underlying their preferred treatments. So we still see psychologists crawling all over disaster areas trying to convince people they will suffer long-term damage without professional help, despite indications this increases the incidence of PTSD among victims and slows their recovery.

Though lack of research is a problem a bigger one is that many studies that were done suffer from poor design and low rates of independent reproducibility. So, for example, while Francine Shapiro, inventor of eye movement desensitisation and reprocessing (EMDR), has carried out numerous studies demonstrating its superiority to other PTSD treatments, independent researchers most often find it has no advantages over normal desensitisation therapy, which it incorporates. All of that waving a pencil back and forwards in front of a patient’s face seems to be useless mumbo-jumbo without even the benefits you would expect from a placebo. That hasn’t stopped EMDR from becoming the fastest growing PTSD therapy in the world.

In the late 1990s Justice Action began receiving reports from inmates of Mulawa Women’s Prison that they were being subjected to harmful psychological experiments. Inquiries revealed a large-scale trial of EMDR was underway there. Because the majority of women prisoners have extensive histories of abuse Mulawa was an ideal place to find captive guinea pigs. Ideal for the researchers that is, not for the prisoners. (I should emphasise that the subjects did sign consent forms, though as it emerged their consent was less than informed.)

NSW prisons are not the best places for delivering psychotherapy of any kind. Perhaps some of the women at Mulawa benefited from EMDR but those who contacted us sure didn’t. While waving things back and forwards in front of their faces the researchers encouraged prisoners to relive traumatic events from their past. Then the researchers went back to their homes and families while the subjects were locked in their cells. Needless to say, some of them had trouble coping with their dredged up memories and were unable to hide their distress. Acting out distress in a NSW prison can have Unfortunate Consequences.

Ever since the 1987 Muirhead Royal Commission into Aboriginal Deaths in Custody there has been a standard response to anyone prison officers feel may be at risk of self harm. They’re tossed into a strip cell (generally called a Muirhead by prisoners and staff). It’s a bare room with no hanging points and no furnishings bar a canvas covered mattress  and a fully exposed rubber toilet. The front wall is transparent except for a horizontal line a few feet from the floor to provide visual orientation. Fluorescent lights glare for 24 hours a day and the prisoner is kept under constant watch. As you might expect this removes most of the immediate suicide risk (though a few prisoners have still mysteriously died in strip cells and more have died immediately upon release) but it offers little relief for someone reliving a rape. It was those women and their families who called us.

A year or so later I attended a conference at which the lead researcher presented his findings. His horrific burn scars lent credibility to his claimed expertise in traumatic stress as he gave a glowing assessment of the effectiveness of EMDR upon his captive subjects. Nowhere in his speech nor in the papers he distributed was there any mention of the adverse reactions some prisoners suffered during the experiment. I was one of the first to raise my hand during the Q&A session but by then I was well-known at conferences such as this and wasn’t given the opportunity to ask him about it.

Few professionals enjoy as much power over their clients as do those in mental health. Few wield their power so irresponsibly or to so little benefit.

Despite the fact their diagnoses and therapies have little validity, psychologists and psychiatrists deploy many devices to delegitimise the opinions and actions of others. Mostly they’re bullshit and add to the harm of mental illness – especially stigma. Perhaps the most pernicious is anosognosia, a once valid medical term appropriated from neurology that referred to a measurable and physiologically verifiable condition suffered by victims of acquired brain damage, especially stroke. In the hands of psychiatrists it became a political term totally devoid of medical evidence or diagnostic validity. It simply means the patient doesn’t agree with the doctor’s diagnosis.

Yep, if you aren’t qualified and try to help yourself or another disturbed person you risk doing a lot of damage. So do those who are qualified but at least they’ve got the cult of the expert (and possibly malpractice insurance) to back them up. You can also do a lot of damage by not helping. Do you really believe a doctor who sees someone for a few hours and tries to reduce their lives to a DSM label with a one-size-fits-all treatment has more insight into that person’s suffering and what can be done to relieve it than does a loved one or the sufferer herself?

Seek advice wherever you can find it, but take personal responsibility for any help you offer. If the help is unwelcome, back off, no matter what your opinion of the consequences may be. Try to recognise and accept your limitations. Sometimes you just can’t help and sometimes you need to devote all your resources to caring for yourself.

Be sure to act from compassion not fear, heroics or the need to dominate.

You’ll make mistakes. You’ll cause pain and harm to yourself and your loved one. But you’ll probably do better than the mental health professions. It would be difficult to do much worse.

________________________________________________________________________

Postscript (6-Aug-2015): Recent NIMH research led by Andrew Holmes suggests that overcoming the emotional impact of memories that leads to PTSD may rely on a good link between the amygdala and the prefrontal cortex. One reason I call this blog Neurodrooling is because I think contemporary neuroscience lacks the robust theory of mind needed to justify many of its claims of links between brain physiology and mentation, so I take claims like Holmes’ with a big grain of salt. But if he’s correct it would have implications for how psychotic illnesses develop and how we treat PTSD.

One theory of psychotic illness is that it’s caused by an overload of signals between the limbic system (containing the amygdala) and the prefrontal cortex. Thus antipsychotic drugs target the dopamine D2 receptor pathway linking these two regions via the ventral tegmental area.

People with psychotic illnesses are also known to have much higher rates of early life trauma and PTSD than those without, suggesting they have been unable to suppress the emotional impact of traumatic memories. Holmes’ study hints that the hyperactivity of those signals is not a cause of psychosis at all, but a response to its causes. It’s a means of resolving the traumatic memories that are distressing the patient.

If Holmes is correct, antipsychotic medication, which degrades communication between the amygdala and the prefrontal cortex, would prevent patients from dealing with traumatic memories, thus perpetuating psychotic illness and PTSD. Sure enough, an emerging body of evidence suggests those treated long-term with antipsychotics are less likely to recover from psychosis than those who are either never medicated or who are tapered off as soon as possible.

What Holmes’ study suggests is that not only those with psychosis but also those with PTSD who are prescribed antipsychotics may be having their natural recovery processes blocked by the drugs. But as they (always) say, more research is needed.

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From → DSM

8 Comments
  1. Pamela isn’t practising psychotheraphy, she’s making prophecies and casting spells.

    Like

    • Well, to be fair she was acting in her capacity as an advice columnist so I doubt even she thought she was practising psychotherapy. Unfortunately such columns emphasise her supposed qualifications without including caveats about trying to diagnose and advise people on the basis of a two paragraph letter. And her advice sucked.

      Like

  2. Well, I wonder how she’d go advising one of the boys from Westbrook, who were
    beaten and flogged almost daily. The were required to shout “Ooooh Sir” after
    each lashing administered by Isaac Roy Golledge.

    You have a half-decent mind, my fine feathered friend; why despoil it by
    dumpster-diving through the Guardian’s trash? Are you addicted to the rush
    of righteous indignation by any chance….not that there’s anything wrong with that.

    Like

    • I know what you mean – except for the bit about the half-decent mind. I’ve spent 53 years making it indecent and would be dispirited to think I was still only halfway there.

      But yeah, the Guardian sucks just as much as the rest of the mainstream media. More so, if you accept Chomsky and Hermann’s thesis about the liberal press (and given the Grauniad’s constant drum-beating for whatever war NATO’s planning next they seem to have a point).

      The problem is I’m like one of those recovering Christians who can’t keep his eyes off the god-botherers so he won’t miss an opportunity to launch another barrage of contempt at them. I was a Guardian fan up until ten or fifteen years ago and I’m still trying to exorcise the idiocy it implanted in me (like you and CAM?). My only excuse is I was so desperate to escape Fairfax and the ABC I ran straight into another swamp of journalistic swill. (I was also a bit of a Pammy fan back in the days of Not the Nine O’Clock News).

      Besides, how am I supposed to fool people like you into thinking I’ve got a good mind unless I keep comparing it to the sub-imbeciles who write for The Guardian? Or to my uncle’s sorry excuse for a noggin.

      I once read a novel by some South African shrink in which a young boy’s parents took him to an analyst because he showed signs of independent thought. Part of the exchange went something like this.

      Shrink: But you know you shouldn’t play with matches. You could have hurt your Daddy.

      Boy: *mumbles*

      Shrink: Did you set fire to Daddy’s Guardian because you secretly hate him?

      Boy: No!

      Shrink: Would you like to tell me why you set fire to Daddy’s Guardian?

      Boy: No!

      Shrink: How can we help you if you won’t tell us what the problem is?
      Why did you set fire to Daddy’s Guardian?

      Boy: *mumbles*

      Shrink: I can’t hear you. Why did you set fire to Daddy’s Guardian?

      Boy: I set fire to Daddy’s Guardian because it always tells you what to think …

      Shrink: Oh, I see.

      Boy: … just like Mummy!

      Like

      • For Fox Sake permalink

        I once read a novel by some South African shrink

        Remember the daze when african shrink meant you got a little head?

        I do exorcisms wholesale.
        Pay me in bananas.

        Like

        • Nah, it was indigenous South Americans who got into that sort of thing. When I was a kid I made a study of their methods. You never know when you might need a skill like that.

          Like

  3. For Fox Sake permalink

    (I was also a bit of a Pammy fan back in the days of Not the Nine O’Clock News).

    Besides, how am I supposed to fool people like you into thinking I’ve got a good mind unless I keep comparing it to the sub-imbeciles who write for The Guardian?

    I liked Pammy from those days too, when she seemed to have horse sense.

    Aggrandizing one’s self at the expense of sub-imbeciles gets you a sesame seed bunfight.

    I have figured out that the lyrics to Rocky Horror timewarp
    were inspired by how the knight moves on the chess-board.

    Like

    • You must be a very messy chess player.

      I once read a sci-fi called The Squares of the City that structured its plot on the moves of a famous 19th century chess game. Easily John Brunner’s worst book.

      Like

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