Good Science, Bad History, in the British Journal of Psychiatry

By Neuroskeptic | February 10, 2012 8:40 am

The latest February 2012 issue of the British Journal of Psychiatry features a paper about the association between child abuse and later mental health problems. I haven’t read it yet, but it looks pretty good.

However, it also includes an editorial from John Read and Richard Bentall which argues that:

Just 20 years ago, however, it would have been difficult to get the paper published. Mental health professions have been slow, even resistant, to recognise the role of childhood adversities in psychiatric disorder… Until very recently the hypothesis that abuse in childhood has a causal role in psychosis was regarded by many biologically oriented psychiatrists as heresy…

Really? I checked the BJP from exactly 20 years ago. The February 1992 issue contained:

  • A paper about child sexual abuse in female psychiatric patients.
  • A letter praising a different article, on the same topic.
  • A review of 11 studies on psychosocial family interventions as treatments for schizophrenia.
  • A paper looking at the effect of the social environment on symptoms of schizophrenia.

Four strikes and they’re out. It’s not true that this kind of thing wasn’t being discussed 20 years ago.

Such grandstanding is bad for science. Few would deny that psychiatry in recent years has undervalued psychosocial factors and overvalued genetics and neuroscience, but it’s actually quite a complicated story, not a Punch and Judy show with bad guys on one side and good guys on the other.

Rhetorical flourishes like this editorial certainly get attention but in the long run, down that road lies madness.

    ResearchBlogging.orgRead, J., and Bentall, R. (2012). Negative childhood experiences and mental health: theoretical, clinical and primary prevention implications The British Journal of Psychiatry, 200 (2), 89-91 DOI: 10.1192/bjp.bp.111.096727

    • http://www.blogger.com/profile/12525104555859213125 Socrates

      Nicely done…. As they say in Germany: Neuroskeptik ist die Hammer!

    • http://www.blogger.com/profile/13357814651026663080 MikeB

      This comment has been removed by the author.

    • http://www.blogger.com/profile/13357814651026663080 MikeB

      I suspect that the role of abuse (sexual, physical) is overstated.

      It ticks me off to hear “psychoanalysts” call childhood sexual abuse a “red flag” that could mean a “cycle of abuse” could continue.

      They're abusing children a second time by stigmatizing them this way.

      It is my opinion that victims of abuse are LESS likely to become abusers. After all, they have suffered. They know what it's like.

      Do people who have been burgled have a higher tendency to become burglars themselves?

      Let's dump this harmful belief into the rubbish.

    • Ivana Fulli MD

      Thank you Neuroskeptic,

      I wonder where that attitude comes from:

      Competiton for academic positions and money for research making people refusing to consider that they might be reinventing the wheel?

      or making them ready to cheat on the intellectual property of others?

      How long does it take an author of editorial -or an editor of a prestigious Journal (only as far as psychiatry is presstigious of course) to find the embarrassing evidences in our electronic age?

      Of course, we are happy to have bright and generous people like you and Ben Goldacre – when you are not soulessly attaking homeopathy of course-but

      NB: being an editor in an important Journal is full of advantages- be it only that you have the priviledge to know about your competitors' brightest ideas before publication; and you get attention and friendship from colleagues who know that you are to decide who will give an evaluation on their research work submitted for publication and that you might be the arbiter in case the reviewers disagree between themselves.

      Like the “agomelatine” outragous claims of efficacy and safety in “The Lancet” you wrote a post about did for opinion paper, this problem makes one think that editorials also have to be submitted for peer review.

      Either there is not anymore great experts with morals and knowledge able to write editorials putting research publication on perspective or such a class of academics never existed and internet makes it obvious.

    • infinidiv

      @MikeB – Well, first of all, the main point isn't that the abused become the abusers, but that they often, if not usually, come out of abuse with psychological problems. About them becoming abusers, your view may be one option, but often that is not the case. And pretending like this isn't a problem isn't doing them any favors either.

      @Neuroskeptic – While grandstanding is certainly often a problem (and you showed how easily they could have gotten their facts straight) we also have to allow for the very different attitudes prevalent in different institutions, which is what the authors may have been originally confronted with. While today people can easily get access to that information, 20 years ago it would have been relatively easy for a research center or group to have a specific ideology, focus on those publications that agree, and pass it on to a “naive” next generation.Especially considering how often that still happens today…

    • Ivana Fulli MD

      Mike B,

      The scientologists are famous for separating persons from their family with psychological “interventions” convincing them that they have forgotten an incest they suffered in their youth.

      It is also known that most incest sufferers -often needing reassuring information on that fact – are not likely to rape children and are often likely to prevent their own children to be raped.

      Anyway, the childhood traumas psychoatrists and psychologists are revisitating are not limited to sexual molestations for the definition of the trauma nor it is “sexual cycle of abuse” that those “reinventing the wheel” researches are about.

      You can read:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2632300/:
      Schizophr Bull. 2007
      « Environment and Schizophrenia: Environmental Factors in Schizophrenia: Childhood Trauma—A Critical Review”

      “The term childhood trauma has been used to capture a range of severe adverse experiences, including sexual, physical, and emotional abuse, and neglect. A recent survey in the United Kingdom estimated the prevalence of childhood sexual abuse at around 11% and physical abuse at around 24%.1 In the United States, estimates tend to be higher.2 The adverse long-term consequences of childhood sexual and physical abuse have been well documented and include increased risk of adult depression,3 personality disorders,4,5 suicide,6,7 posttraumatic stress disorder (PTSD),8 and drug and alcohol dependence.9 It is possible, moreover, that specific forms of abuse are linked to particular disorders. For example, sexual abuse shows strong correlations with later depression3 and borderline personality disorder4 and physical abuse with antisocial personality disorder.10,11
      This review is concerned with the question of whether childhood trauma increases the risk for adult psychosis or, more specifically, schizophrenia.”

    • http://www.blogger.com/profile/13357814651026663080 MikeB

      infinidiv: “About them becoming abusers, your view may be one option, but often that is not the case. And pretending like this isn't a problem isn't doing them any favors either.”

      Where's the evidence? (see below as well).

      Ivana: “The term childhood trauma has been used to capture a range of severe adverse experiences, including sexual, physical, and emotional abuse, and neglect.”

      And:

      Quote: “The adverse long-term consequences of childhood sexual and physical abuse have been well documented and include increased risk of adult depression,3 personality disorders,4,5 suicide,6,7 posttraumatic stress disorder (PTSD),8 and drug and alcohol dependence.9 It is possible, moreover, that specific forms of abuse are linked to particular disorders.”

      When you have a definition of “abuse” that is so broad, and a list of “disorders” that is so lengthy (plus a little “post hoc, ergo propter hoc” fallacy) you essentially have non-falsifiable hypothesis.

      I still say “crap.”

    • Ivana Fulli MD

      MikeB 10 February 2012 14:49

      Earlier today, I cited the writing of Craig Morgan and Helen Fisher in their article in “Schizophr Bull. 2007 January; 33(1): 3–10.” doi: 10.1093/schbul/sbl053 I gave the references to:

      “Environment and Schizophrenia: Environmental Factors in Schizophrenia: Childhood Trauma—A Critical Review”

      NB: To my mind it is not crap to come back to childhood traumas as a possible cause of mental illness symptoms in some people.

      And it is not to come back to Freudian thinking just to take some distance with the simplistic view of mental illnesses being heriditary deseases requiring only Big Pharma drugs in every case like a type 1 diabetic client needs insulin.

    • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

      Socrates: Don't thank me, thank the B J Psych's comprehensive online archive.

      Seriously when I read the 20 years ago line, I thought, it's a long shot but wouldn't it be funny if the Feb 1992 issue had an article on child abuse. I never expected it to go as well as it did.

    • http://www.blogger.com/profile/13357814651026663080 MikeB

      “…the simplistic view of mental illnesses being heriditary deseases requiring only Big Pharma drugs in every case like a type 1 diabetic client needs insulin.”

      “Simplistic” is your opinion.

      If it turns out to be the case that, indeed, mental illnesses can be treated like diabetes, what shame is there in that?

      Also, having lived with a diabetic for 26 years, I can testify to the mood swings and disorders that are physical in origin.

    • http://www.blogger.com/profile/08801634278850835168 MikeSamsa

      @Ivana Fulli MD:

      “I wonder where that attitude comes from:

      Competiton for academic positions and money for research making people refusing to consider that they might be reinventing the wheel?

      or making them ready to cheat on the intellectual property of others?”

      I had John Read as a lecturer for a few courses when I was back in university, and whilst my perspective is clearly subjective and anecdotal, I just wanted to point out that John is a genuine guy who is passionate about what he believes in. His position and the arguments he makes aren't an attempt at grandstanding, or selling books, he truly believes that he is on to something that has been ignored and not taken seriously for a long time.

      He started out as a nurse in a mental institute (I think, he might have been an orderly?), and part of what inspired him to move into the career he's in was that he felt people's feelings and claims were being ignored, or treated simply as symptoms of biological disease, rather than people actually sitting down and listening to them. I think he feels this position was justified by the Rosenhan experiment.

      With this particular example from the article, I think what he's getting at is that not only can environmental factors contribute to the development of mental disorders, but they can be the direct cause of them. This, as a general claim, isn't a particularly controversial claim (especially these days) but he makes stronger claims like the idea that hallucinations, delusions and schizophrenia itself may be largely a product of environmental factors, and that the biological data is flawed and has largely been exaggerated over the years. He views schizophrenia as essentially being a form of PTSD, formed directly from child abuse. And this is the claim that the mental health community is resistant to (arguably because the evidence suggests that such a position is wrong).

      His position is obviously quite radical, but I think part of the reason he makes claims like, “Just 20 years ago, however, it would have been difficult to get the paper published. Mental health professions have been slow, even resistant, to recognise the role of childhood adversities in psychiatric disorder.” is because he has received a lot of negative feedback and abuse for his position, beyond simple professional criticism, so inevitably his perspective of how accepted these ideas are in the community have been heavily skewed by these experiences.

      (Just in case anyone was particularly interested, my post here is mostly to defend him as a person and his motivations. In regards to the validity of his position, I find some of his arguments interesting and he sometimes makes good points, but I do think he exaggerates the issues sometimes and can reach entirely faulty conclusions).

    • Ivana Fulli MD

      mike b,

      As Ben Goldacre put it in one of his “Bad Science ” post in “the guardian” you are everyone is entitled to its own opinion but, sadly, not to its own facts.

      Mental illnesses are just not identical in anyway to type one diabetis, a real biological illness with an etiological treatment.

      And having to live with and manage a chronical illness like type 1 diabetis manageable with a rigid and delicate treatment with insulin to submit oneself to – with a death risk if overdosing insulin (and a psychologist might think you have got psychosis and need antipsychotics instead of a lump of sugar)

      being a little on the rigid side as a character helps to survive longer with all your toes and a good vision between other things.

      Congratulations, then.

    • Ivana Fulli MD

      Mike Samsa,

      Your comment was very informative indeed. Thanks.I knew nothing of the first author.

      You gave water to my mill -as the French saying goes- by writing:

      ///(…)a genuine guy who is passionate about what he believes in(…) but I do think he exaggerates the issues sometimes and can reach entirely faulty conclusions///

      That kind of “genuine believers in themselves” -and groupies – have made possible for psychoanalysis and biological psychiatry to let the clients down and psychological research to devote a lot of itself to futile enough subjects.

      It will be time to accept to consider different school of thinking at the same time to help psychiatrists and psychologists clients and get journals up to medical ethics publication standards.

      When, on the contrary and to take an example I know about- as Pr Laurent MOTTRON put it -autistic people got rid of the tsars of psychoanalysis to suffer the Josef Stalin of ABA.

      To prescribe hormones for mood disorders is a challenge for a psychiatrists when it works sometimes beautifully

      To prescribe homeopathy put you under the wreath of hubris from those deluding themselves in thinking that they are doing hard science with medical research.

      NB: In France the psychoanalysts tsars still reign but the French revolutionary are mostly ABA Stalinists. Even on the site in defense of the documentary on French treatment of autism “Le Mur” you get a scientist complaining about Pr Mottron “premature views on autism”.

      It works for my pro bono few autistic clients that plural offer but I have better shut up because even psychotherapy are political nowadays.

    • http://www.blogger.com/profile/13357814651026663080 MikeB

      Hi, Ivana.

      No one said “mental illnesses were identical to Type 1 diabetes.” Mental illnesses could very well be “biological,” but somehow people think there is something wrong with that. It's going to depend on the type of illness. And that doesn't mean I believe that no environmental factors are at play.

      I'm questioning how broad, and at times absurd, the definition of “abuse” is, and how everything but everything seems to be viewed as a “symptom.”

      I encounter this in my work as an EMT. After a particularly bad call (when children die, when there's multiple traumas, etc.) we rescue workers are REQUIRED to attend “debriefings” because somehow witnessing “traumatic” events can fuck you up.

      These are people, mind you, who volunteer to work at such events, who are trained to deal with accidents, etc.

      But no matter. We have to sit around and talk, talk, talk. And afterward they pass out pamplets that list “possible symptoms of PTSD,” and that list is LONG and ridiculous…headaches, sleeplessness, changes in eating habits, irritability…in short, everything.

      And we're advised to “call one of their counselors” if we experience any of these “symptoms” after witnessing trauma.

      Post hoc, ergo propter hoc.

      It's a bullshit method to get people to buy into talk therapy.

    • http://www.blogger.com/profile/08801634278850835168 MikeSamsa

      @Ivana Fulli:

      “That kind of “genuine believers in themselves” -and groupies – have made possible for psychoanalysis and biological psychiatry to let the clients down and psychological research to devote a lot of itself to futile enough subjects.”

      Well, it's not quite that bad. He exaggerates in opinion pieces, talks and so on, but he's a more than capable scientist who attempts to back up his position with objective evidence gathered through rigorous experimentation. He's not exactly a psychoanalyst spouting any old crap that can't be tested or supported.

      “When, on the contrary and to take an example I know about- as Pr Laurent MOTTRON put it -autistic people got rid of the tsars of psychoanalysis to suffer the Josef Stalin of ABA.”

      ..What? Are you saying you agree with Mottron's claim that ABA – the massively successful and evidence-based field that has single-handedly saved (I understand the emotive implications of the word but I use it because I feel that no other word is accurate enough) the lives of countless people – is comparable to a fascist regime which killed millions? Or were you bringing Mottron up as another idiot who engages in exaggeration and needs to be dismissed in the same way psychoanalysis is dismissed? If the latter, then I certainly agree. People like Mottron and Dawson are hugely damaging to psychology and autism research, and we do need to reject their politics in favour of science and evidence.

    • Ivana Fulli MD

      Mike B,

      Actually, we are just saying the same thing.

      I agree paternalistic psychotherapists convinced that they have other people's answers without taking the precaution to ask other people if they want them, can be difficult to bear with; and editors in Journal publishing “science” should be careful before letting them claim that those ” preventive action” you described are useful at all – and necessery for you.

      Use the internet, you will find papers stating that debriefing after traumas make things worth.

      .

    • Ivana Fulli MD

      Mike samsa,

      Here you are right into the belief in ABA being The only treatmentbut
      the scientific community uses a variety of systems to categoriese interventions for autism. One of the most widely accepted is that used by Charman and Clare (2004).

      Psycho-educational

      Interventions which use educational, behavioural and other teaching techniques, to change behaviours. Includes

      * Applied Behavioural Analysis
      * Art Therapy
      * Cognitive Behavioural Therapy
      * Daily life therapy
      * Discrete Trial Training
      * Drama therapy
      * Early Intensive Behavioural Interventions
      * Functional Communication Training
      * Incidental teaching
      * Joint Action Routines
      * LEAP
      * Milieu training
      * Music therapy
      * Occupational Therapy
      * Physiotherapy
      * Picture Exchange System
      * Pivotal Response Training
      * Play Therapy
      * Responsiveness Training
      * Sign Languages
      * Social Groups
      * Social Skills Groups
      * Social Stories
      * Speech and Language Therapy
      * TEACCH
      * Theory of Mind training
      * Video Modelling
      * Visual schedules

      Psycho-pharmacological

      Interventions which use chemical compounds, including medications, to affect the mind. (…)

      ComplementaryWide range of interventions which complement traditional, medical treatments and therapies. Includes

      * Animal therapies
      * Anti-fungal medications
      * Assistance dogs
      * Auditory integration training
      * Chelation
      * Chiropractic
      * Coloured filters
      * Computer applications
      * Digestive enzymes
      * DIR Method
      * DMG
      * Dolphin therapy
      * Dore method
      * Essential fatty acids
      * Facilitated Communication
      * Feingold Diet
      * Gentle Teaching
      * Glutathione
      * Gluten-free, casein-free diet
      * Holding Therapy
      * Hyperbaric therapy
      * Immune globulin
      * Ketogenic diet
      * Lightwave stimulation
      * Massage
      * Melatonin
      * Online commmunities
      * Oxytocin
      * Patterning therapies
      * Probiotics
      * Reciprocity Training
      * Relationship Development Intervention
      * Restricted Environmental Stimulation Therapy
      * Secretin
      * Sensory integration therapy
      * Son-Rise program
      * Special diets
      * Specific carbohydrate diet
      * Sulphation
      * Testosterone regulation
      * Vitamins and minerals
      * Vitamin A
      * Vitamin B6
      * Vitamin B9
      * Vitamin B12
      * Vitamin C
      * Vitamin D
      * Voice output communication aids
      * Weighted items
      * Yeast-free diet
      http://www.autism.org.uk/living-with-autism/strategies-and-approaches.aspx:

      I cite the NAS:While there is no 'cure' for autism, there are some approaches that people use to help with various difficulties they may experience. Below are some of the main approaches we use at The National Autistic Society.

      There are many approaches, therapies and interventions, making it difficult to make decisions about which one is right for you, or for your child. No two people with autism are the same and what may work for one person may not work for another.

    • Ivana Fulli MD

      Mike Samsa,

      Here you are.

      ABA is not the only educational intervention available and every autistic person is different.

      Plus, many aspies just cannot bear ABA for a long time. might be much better than SPEACH or the social pictures or whatever for non speaking autistic persons

      http://www.autism.org.uk/living-with-autism/strategies-and-approaches.aspx

      The NAS says:

      “There are many approaches, therapies and interventions, making it difficult to make decisions about which one is right for you, or for your child. No two people with autism are the same and what may work for one person may not work for another.

      Research Autism exists to research into interventions. “

      NB: Pr L Mottron and M Dawson are very very bright and they have the right to have their say although their thinking is often provocative and not as easy to understand as other theories.
      It does not mean that they are wrong.

    • http://www.blogger.com/profile/08801634278850835168 MikeSamsa

      @Ivana Fulli:

      “ABA is not the only educational intervention available and every autistic person is different.”

      Both claims above are true. However, to the first, ABA is one of the few interventions that has evidence supporting it, and the only one that has evidence strong enough to justify large scale government support (noting that approaches such as PECS, video modelling, discrete trial training, cognitive behavioral therapy, etc, all falls under ABA).

      As for the second claim, yes every autistic child is different, which is why ABA is such a powerful approach – as it is individualised to suit the specific needs of the child involved. You won't find many therapies or interventions in any other area of science or medicine which are as individualised as ABA.

      “Plus, many aspies just cannot bear ABA for a long time.”

      I'm not quite sure what this means. I think it's referring to the guideline that for the most effective results, intensive training consisting of 40 hours a week is recommended. However, this is flexible according to the child's needs. If their issues are not too serious, or if we need to cut back training to maintain interest and not overwork the child, then that's no problem. ABA is not a cookie-cutter approach, it changes as it needs to, and since therapists constantly collect data and analyse their work using single-subject statistics, they are still able to determine whether what they are doing is working or not.

      “NB: Pr L Mottron and M Dawson are very very bright and they have the right to have their say although their thinking is often provocative and not as easy to understand as other theories.
      It does not mean that they are wrong.”

      I can't comment on their 'brightness', as I've only read their work as it relates to behaviorism and ABA, but I certainly wouldn't try to argue that they are wrong simply because they are provocative. Instead, I argue they are wrong because they don't understand the field of ABA and yet they try to attack it. Their views are simply horribly mistaken, probably dishonest, and importantly they are dangerous. Some parents with autistic children listen to what they say, and fail to put their kid through an ABA program, and by the time they realise that Mottron and Dawson didn't know what they were talking about, it's too late for the kid.

    • Anonymous

      what scientific researchers overstate the role of sexual abuse, in what papers, in what journals?

      can you point to a meta-analysis or some other rigorous study of how prevalent or strong the claim is in psychiatric literature these days?

      i think there's some chance you're overestimating how overstated it is. i don't think most researchers or clinicians believe it's deterministic of anything.

      they believe childhood abuse can present people with peculiar challenges that are reflected in aggregate outcomes. better understanding that can make them better researchers and clinicians. and better able to help people.

      hopefully not many are confusing statistically significant correlations with mechanistic causation. hopefully.

    • Anonymous

      “Mental illnesses are just not identical in anyway to type one diabetis, a real biological illness with an etiological treatment.”

      I suspect that diabetes was not regarded as a “real biological illness” by a large segment of the medical community either — right up until the time it was discovered that it was.

      RH

    • Ivana Fulli MD

      Anonymous RH 11 February 2012 17:28

      “”I suspect that diabetes was not regarded as a “real biological illness” by a large segment of the medical community either — right up until the time it was discovered that it was.”"

      When a young healthy person got ill and died rapidly from type one diabetis

      it is with a stricking clinical picture of drinking a lot and peeing clear but sweet tasting urines (sorry about that)even the ancient Egyptians ang ancient Greek made the diagnosis.

      Praxagoras de Cos 384-322 av.J.C. Hippocrate for sure wrote about the sweet taste of the urine (before sugar was known other than in honey)of those poor people

      suffering of the “water traversing accross their body illness” the ancient Egyptians knew and wrote about XV century before Christ in a “Leipzig manuscript”-

      NB: marketting guys from Big Pharma have no more morals than culture.

    • http://notsobigsociety.wordpress.com Zarathustra

      Richard Bentall engaging in overblown hyperbole about the dominance of the medical model? We are shocked, shocked I tell you. :)

    • Anonymous

      I am not a professional however, Dr. Charles Whitfield is and his article in the International Journal of Risk and Safety in Medicine from 2010 is well worth reading on trauma and it's effects and the negative effects of Standard Psychiatric Treatment on some people who are traumatized by the negative effects of psychiatric drugs.

      http://nhne-pulse.org/wp-content/uploads/2010/12/Psychiatric_Drugs_As_Agents_of_Trauma_JRS508.pdf

    • Anonymous

      Sorry, I can't access the full paper to be sure what they did, but it seems like another one of those “diagnosed people report childhood troubles” things. If it's not, please scrap the comment. But if it is, then it fails to take account of how much undiagnosed people (indeed, those in quite a fine mental state) might report various childhood “negative events”. But, most importantly, what if people who end up with psychiatric illness (and diagnoses) were in fact weird kids to begin with, and got in trouble in some part related to that? That would be more of a triumph for the “inhuman” biological-neuroscience-genetics approach to psychiatry than they wished for: Innate personality tendencies that contribute causally to other people's abusive behavior while gradually developing into psychosis. It sounds like blaming the victim, I know, but it's human interaction we're talking about. And if the kid's weird it's likely to get some negative childhood events.

    • Paul

      @neuroskeptic

      I know John, and to a lesser extent Richard, and I know the field. While I appreciate your point, I think you would come across as more collegiate if you attempted to address the strongest version of their argument.*

      This might be something like:
      “it was much more difficult to conduct and report on this type of research, around 20 years ago.”

      It would also have been more interesting if you had addressed this stronger claim – which may or may not be accurate.

      *http://en.wikipedia.org/wiki/Principle_of_charity

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    Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.

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