05/30/17

Psychoanalysis Without Freud

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An article in STAT News on Freud and psychoanalysis, “Saving Sigmund,” caught my attention. It described how psychoanalysis is trying to “reinvigorate” itself. In the process, psychoanalysts are trying not to be “unduly fixated” on Freud’s stages of psychosexual development or his tripartite psyche of the id, ego and superego. One psychoanalyst said assuming she was Freudian was “like asking a modern-day nuclear physicist whether he’s Copernican.” While much of what Copernicus said was not true, it was a helpful foundation.

The analogy is a bit over the top and seems to be an attempt to distance current psychoanalysis from the rejection of many of Freud’s ideas. Writing for STAT, Carter Maness pointed to what may be the foundation of the need to reconceptualize psychoanalysis: only 15% of the members of the American Psychoanalytic Association (APA) are under 50. Traditional Freudian analysis is a dying art. “Lying on a couch, talking about your childhood, day after day for years — is widely seen as a musty relic, far too expensive and intensive to fit into modern life.”

The 1945 film Spellbound, directed by Alfred Hitchcock, captured Freudian psychoanalysis at the zenith of its popularity. The movie’s producer, David O. Selznick wanted Hitchcock to make a movie reflecting his own positive experience with psychoanalysis. Selznick even brought in his own analyst as a technical advisor for the film. The advisor clashed frequently with Hitchcock. Of course in a pro-Freudian movie like Spellbound, there was a dream sequence, which was designed by the artist Salvador Dali. In it, the Freud look-a-like character encouraged Gregory Peck to continue recalling the details of his dream—“the more cock-eyed, the better for the scientific side of it.”

Freud saw himself as a pioneering scientist and repeatedly asserted psychoanalysis was a new science. In his work, An Outline of Psycho-Analysis, Freud said conceiving mental life as a function of the psychical apparatus of id, ego and super-ego was “a scientific novelty.”

We assume that mental life is the function of an apparatus to which we ascribe the characteristics of being extended in space and being made up of several portions—which we imagine, that is, as resembling a telescope. . . . we have arrived at our knowledge of this apparatus by studying the individual development of human beings.

However, Freud’s claim that psychoanalysis was a science of the mind is the subject of continuing debate. As was pointed out in the article on Sigmund Freud in the Internet Encyclopedia of Philosophy, the scientific status of psychoanalysis is undermined since it cannot be falsified. Karl Popper’s criterion of demarcation between the scientific and the unscientific is that for something to be scientific it must be testable and therefore falsifiable.

 It is argued that nothing of the kind is possible with respect to Freud’s theory–it is not falsifiable. If the question is asked: “What does this theory imply which, if false, would show the whole theory to be false?,” the answer is “Nothing” because the theory is compatible with every possible state of affairs. Hence it is concluded that the theory is not scientific, and while this does not, as some critics claim, rob it of all value, it certainly diminishes its intellectual status as projected by its strongest advocates, including Freud himself.

Psychoanalytic thought finally lost its stranglehold on psychiatry in the 1980s with the reformulation of the Diagnostic and Statistical Manual (DSM). That was also the beginning of the rise of biological psychiatry. The heroic figures of psychoanalytic therapists in movies like Spellbound, The Snake Pit (1948), and The Three Faces of Eve (1957) changed. Psychiatric treatment began to be seen through the lens of movies like One Flew Over the Cuckoo’s Nest (1975) and Frances (1982).

Modern popular thinking on Freudian thought is satirically captured in the 1991 comedy, What About Bob? Bill Murray plays Bob Wiley, the unstable patient of an egotistical psychiatrist, Leo Marvin, played by Richard Dreyfuss. Unable to cope on his own, Bob Wiley follows and befriends Dr. Marvin’s family when the family leaves for a month-long vacation. Ultimately this pushes the good doctor over the edge and there is a role-reversal of sorts. Look for the appearance of a bust of Sigmund Freud in several scenes throughout the movie. By the way, Dr. Marvin’s son is named Sigmund. Here is a clip of the therapy session at the beginning of the film.

In order to reinvigorate their profession, psychoanalysts are repackaging the concepts underlying analysis and introducing them to school kids. A past president of the APA said: “We’ve started applying psychoanalytic ideas outside of our offices—in schools, in agencies, in business . . . . We’ve made social issues much more on the minds of our membership.” Project Realize, an alternative school for at-risk teenagers in Cicero Illinois, has treated more than 400 students expelled from regular school for aggressive and dysfunctional behavior. Now in its 12th year, it is said to have lowered rates of violence and improved graduation.

Training requirements have been altered somewhat. In the past, would-be analysts had to first earn an MD, a PhD, or an LCSW (a license to practice social work). Then they had to complete four years of coursework in psychoanalysis AND 200 hours of clinical training. In addition, they had to undergo analysis (four sessions per week) for at least two years.

One psychoanalyst in private practice remarked those requirements fit the 1950s, when every psychologist wanted to be an analyst. “If you’re doing a MD or a PhD or an LCSW, the conditions of starting a private practice and having a job don’t fit with analytic training anymore. Candidates find their analytic voice at 50. That’s nuts.” When Mark Smaller became the president-elect of the APA at 62, he said he could have been considered “a Young Turk.”

Freud has been dethroned as the king of psychotherapy and classic psychoanalysis is increasingly seen as a dying art. Now there is a two-year training for “psychoanalytic psychotherapy” offered by some training centers. It incorporates Freudian ideas about motivation and the unconscious and offers an easier and cheaper way to train as an analyst. And recent studies of Freud have suggested new, and intriguing perspectives into the man and the development of his theories.

In The Freudian Fallacy, E.M. Thornton said Freud’s personal use of cocaine was not just limited to his late twenties and early thirties, between 1884 and 1887.  She presented evidence that Freud resumed using cocaine in the latter half of 1892, “the year coinciding with the emergence of his revolutionary new theories, and asserts that these theories were the direct outcome of this usage [of cocaine].”

The false prophet of the drug world can propagate his message with as much conviction and authority as the true and his manner will have the same burning fervor and sincerity. In common with other victims of brain pathology, Freud would still have been able to reason skillfully from his false premises and so hide his psychotic traits from his followers. And yet, over the years, one by one, most of Freud’s inner circle of early disciples left him.

Paul Vitz developed a fascinating thesis that Freud had a strong, life-long positive identification and attraction to Christianity in Sigmund Freud’s Christian Unconscious. Vitz said there was also a concurrent secondary influence of unconscious hostility to Christianity seen in his preoccupation with the Devil, Hell, and the Anti-Christ.

All of this very substantial Christian (and anti-Christian) part of Freud should provide an understanding of his ambivalence about religion. It should also furnish a new framework for understanding major aspects of Freud’s personality, and allow us … to re-evaluate Freud’s psychology of religion.

As a young child, Sigmund had a Catholic nanny from around the age of one until he was two years and eight months old, maybe longer. It is likely that given that his mother had two pregnancies and births, and took care of a sick child who died during this time, that the nanny was also his wet nurse. Freud himself admitted that his nanny told him a great deal about God and hell. In a letter to his friend Wilhelm Fiess, he said:

I asked my mother whether she remembered my nurse. “Of course,” she said, “an elderly woman [Freud’s mother was 21 at the time of his birth], very shrewd indeed. She was always taking you to church. When you came home you used to preach, and tell us all about how God conducted His affairs.

In “Reassessing Freud’s Case Histories,” science historian Frank Sulloway said the intellectual quicksand upon which Freud built his theories and assembled his “empirical” observations was extensive. “His controversial clinical methods only served to magnify the conceptual problems already inherent in his dubious theoretical assumptions.” The training methods he supported were “highly influential” in removing psychoanalysis from academic science and medicine. “As a result, the discipline of psychoanalysis, which has always tapped considerable religious fervor among its adherents, has increasingly come to resemble a religion in its social organization.”

In “Why Freud Still Isn’t Dead,” John Horgan pointed out how there has been a recent trend in trying to find common ground between neuroscience and psychoanalysis. From one perspective, this fits as Freud originally trained as a neurologist and tried to base his theory of the psyche on an evolutionary sense of brain development. Here he followed the thought of Ernst Haeckel, who theorized the soul/psyche evolved biologically. In his classic 1892 work, Monism as Connecting Religion and Science, Haeckel said:

What we briefly designate as the “human soul,” is only the sum of our feeling, willing, and thinking—the sum of those physiological functions whose elementary organs are constituted by the microscopic ganglion-cells of our brain. Comparative anatomy and ontogeny show us how the wonderful structure of this last, the organ of our human soul, has in the course of millions of years been gradually built up from the brains of higher and lower vertebrates.

Horgan observed that science has failed to produce “a theory/therapy potent enough to render psychoanalysis obsolete once and for all.” Neither Freudians nor proponents of “more modern treatments” can point to any unambiguous evidence that psychoanalysis works or doesn’t work. “Until science yields an indisputably superior theory/therapy for the mind, psychoanalysis–and Freud–will endure.” Here’s the rub. When psychoanalysis asks “fundamental questions” like, “Why do people do the things they do,” it goes beyond the limits of what can legitimately be investigated by science. So science will never be able to develop unambiguous evidence for ANY theory/therapy for the mind.

Psychoanalysis may not be dead as a therapy, but it is not the science Freud thought it was. In a world dominated by the DSM, neurotransmitter dysregulation, and the search for the biomarkers of mental disorders, there is increasingly less room for Freudian constructs like psychosexual development and the id, ego and super ego. We might even say that Freudian thought is in danger of being overcome by its own death instinct.

05/26/17

Preventing the Relapse Process, Part 1

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Relapse is a terrifying experience for an addict or alcoholic to go through. And what seems to be most terrifying, is not being able to see it coming. Hindsight will recognize a few obvious mistakes, but often there is a haunting question: “What am I missing?” Learning to understand relapse and how to prevent it are essential pieces to the recovery puzzle. Relapse doesn’t have to be part of recovery, but recognizing the process when it occurs is essential.

Gerald finally agreed to admit himself to an addictions treatment center. He had relapsed into active drug and alcohol use two years ago after having eight years of abstinence. At the time of his relapse, he was the manager of a sober living residence that housed 10 to 12 men who needed a supportive living environment in early recovery. He didn’t recognize any one thing or event that triggered his relapse. But the guilt after picking up was more intense then he imagined was possible. He was the guy at meetings who always said he put his recovery first.

He acknowledged he had been going through the motions for a while. But that had happened to many others he knew who didn’t pick up. There was the usual recognition of slacking off on going to meetings and growing more impatient with others asking him if he was “all right.” But he honestly couldn’t pick out any one thing or a series of events that led to his relapse.

He had wracked his brains trying to think of what he should have done differently, but he couldn’t see where he went wrong. Privately he was terrified. What if it happened again and he didn’t see it coming that time either? He was afraid he wouldn’t make it back again.

There is no better place to start helping Gerald than with the resources developed by Terence Gorski for understanding and preventing relapse. His Relapse/Recovery Grid has been one of my most regularly used tools when I work with individuals to address their alcohol or drug problems. You will find it in at least two places. The first is within his book, Passages Through Recovery and the second is in his booklet, The Relapse/Recovery Grid. Another helpful resource is Terry Gorski’s Blog, where Terry has made a wealth of his material available. I haven’t seen a reproduction of the 8 ½ by 11 inch Relapse/Recovery Grid available on his blog, but in several articles like “Understanding Relapse and Relapse Prevention,” you will get a good synopsis of the Relapse Process summarized on the bottom half of the Relapse/Recovery Grid.

Gorski said relapse is like knocking over a line of dominoes. It is a process of one unresolved problem leading to another, and then another and another—until you have a major crisis, where using alcohol or drugs to deal with the pain seems like a reasonable choice. “The answer to avoiding relapse is to learn how not to tip over the first domino, and take care of the little problems in life.” If the dominoes have already begun to fall by the time you realize what’s going on, then you want to stop the chain reaction quickly, “before the dominoes start getting so big and heavy that they become unmanageable.”

One way the domino analogy is not always accurate is in the amount of time involved in a relapse process. Someone with stable recovery can take a long time to move through the stages of a relapse process before they ultimately use drugs or alcohol. By stable recovery, I mean someone who is in what Gorski calls the Maintenance Stage of the recovery process. This is where the person is maintaining a recovery program, coping effectively with day-to-day issues in life, continuing to grow personally and spiritually, and coping effectively with the crises and transitions that occur in life. I’ve known an individual who said her relapse process started four years before she actually used drugs again.

Perhaps a bit counter intuitively, this longer time for relapse to result in active drinking or drug use can be helpful IF the person recognizes the problem (or stuck point in Gorski’s discussion of the relapse process) and copes effectively with it. This necessitates the use of RADAR to address the stuck point: Recognizing there is a problem; Accepting that it’s normal to have problems and get stuck in recovery; Detaching or backing off to gain perspective on an unsolved problem; Accepting help from others—asking them for help with your problem; and Responding with positive action will help you get over the stuck point and avoid a further slide into the relapse process.

Failing to address a stuck point leads to ESCAPE: Evading or denying the problem or stuck point; failing to cope with the Stress that comes with evading the problem; turning to Compulsive behaviors to cope with the pain and stress; Avoiding others, especially those who see and tell you about your ineffective strategies for dealing with the problem; developing new Problems from the process of stress, compulsive behavior and isolation; and ultimately Evasion and denial of the new problems—see how it’s been working so well for you so far.

Instead of recognizing you are stuck and need help, you try to tell yourself everything is okay; you are coping effectively. But there is a buildup of pain and stress that can result in using other compulsive behaviors to cope.

To cope with the pain and stress, we begin to use other compulsive behaviors. We may begin overworking, over-eating, dieting, or over-exercising. We can get involved in addictive relationships and distract ourselves with sex and romance.  These behaviors make us feel good in the short run by distracting us from our problems.  But they do nothing to solve the problem.  We feel good now, but we hurt later.  This is a hallmark of all addictive behaviors.

Then something happens. Usually it’s something you would handle without getting upset. But this time you’ve had it; you’ve hit your limit and something snaps inside. Gorski said one person said it was like a trigger going off in your gut and you go out of control. But this is not actively drinking or using … yet. “When the trigger goes off, our stress increases, and our emotions take control of our minds. . . . When emotion gets control of the intellect we abandon everything we know, and start trying to feel good at all costs.”  There was just one too many stressors that weren’t addressed, so a trigger event initiates the internal dysfunction of the Relapse Process.

The Relapse/Recovery Grid lists several high-risk lifestyle factors that increase the likelihood of something triggering the Relapse Process. “These high-risk factors don’t cause relapse; they simply increase the likelihood that it will occur” by making you vulnerable to trigger events. The high-risk factors include personality stressors (perfectionism; or controlling); high-risk lifestyles (trying to do too much or doing too little; or doing the wrong things); social conflict and change; poor health maintenance (poor nutrition, a lack of exercise, relaxation or socializing) or other illness; an inadequate recovery program. “The ‘wrong things’ could be occupations, activities, and people that don’t fit with natural preferences and talents.” Gorski said these high-risk factors were identified from research into the lifestyles of people who had relapsed.

The trigger events listed in the Relapse/Recovery Grid include: high stress thoughts, painful emotions, painful memories, stressful situations and stressful interactions with others. Gorski said that just about anything could become a trigger event, but these five things trigger internal dysfunction more than others.

Some recovering people put themselves under increasing amounts of stress, and they keep adapting to it as they go along. As their tolerance goes up, they block their awareness of stress. Suddenly they hit their limit. They experience one stressor too many, and become dysfunctional.

Irrational thinking is the most common trigger. All-or-nothing thinking, black-and-white thinking fits here. When something goes wrong, you think Nothing ever goes right. If there is a risk of failure in doing something, you quit before it happens. This kind of thinking is irrational.

Emotional pain can point to something wrong with how you are thinking or acting. It signals “a need to examine what is wrong.” If you dismiss painful emotions for too long, they often come back with a vengeance.

People will often experience stressful or traumatic events in an active addiction that cause them extreme emotional or physical pain.  Being reminded of these events can lead to disorientation, confusion, anxiety or other symptoms for no apparent reason. This will then increase stress and trigger internal dysfunction.

“Any situation that a person is not prepared to cope with may be stressful.”  Recognize this reality and seek to avoid them, if at all possible, by being prepared. The level of stress is inversely related to your preparation: it goes down as your preparation goes up. In situations where you can’t be prepared, learn some stress reduction skills, such as relaxation breathing. See “Using Stress Management in Relapse Prevention Therapy (RPT)” and  “Stress Self-Monitoring and Relapse” for more on this.

Stressful interactions with others are common for recovering addicts and alcoholics. They often have high stress people in their lives, meaning people who cause them stress. Often these high stress interactions occur with family members or people the addict or alcoholic is close to. Their stressful behavior, ironically, is often caused by their fear of a relapse with the addict.

This is the first part of my article, “Preventing the Relapse Process.” Part two will describe the four phases of the Relapse Process and it can be found here.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, “Terry Gorski’s Blog”, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and websites.

05/23/17

Medieval Myths of Religion & Science

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“When Columbus lived, people thought the earth was flat.” That was supposedly what everyone believed during the Middle Ages and what the brave Columbus disproved by sailing west from Spain to get to the East Indies. As the legend goes, Columbus was one of the few who believed the earth was round. The trailer for the 1992 Ridley Scott film, 1492: Conquest of Paradise,” illustrates the common belief that in a time of “rigid faith and restless doubt”, Columbus challenged the forces of fear and ignorance. Except it seems that saying the Middle Ages believed the earth was flat, is itself mythical.

Yet this myth has been a “truth” taught to American school children for over 100 years. Emma Miller Bolenius, who wrote several schoolbooks for American children, wrote the above quote in a 1919 text. She said people in Medieval times believed the Atlantic Ocean was full of monsters and fearful waterfalls that their ships would plunge over and be destroyed. “Columbus had to fight these foolish beliefs to get men to sail with him. He felt sure the earth was round.” In reality, it was a biography of Columbus by Washington Irving, the American author of the famous short stories, “The Legend of Sleepy Hollow” and “Rip Van Winkle,” who first introduced this idea to the world.

The Middle Ages was supposed to have been a time of ignorance and backwardness. People in these so-called “Dark Ages” were thought to be so ignorant (or deceived by Catholic priests) that they believed the earth was flat. To say something today is “medieval,” is to slur it as backward or ignorant. Belief in a flat earth is equated with willful ignorance, while an understanding that the earth was spherical, as with Columbus, was a sign of the beginning of modernity. This is an almost an axiomatic view that many people today take for granted.

But in her essay on the belief “That Medieval Christians Taught that the Earth Was Flat,” Lesley Cormack said that early church fathers such as Augustine (d. 420), Jerome (d. 420) and Ambrose (d. 420) all agreed that the earth was a sphere. Thomas Aquinas (d. 1274), Roger Bacon (d. 1294) and Albertus Magnus (d. 1280) also believed in a round, spherical earth. She said: “From the seventh century to the fourteenth, every important medieval thinker concerned about the natural world stated more or less explicitly that the world was a round globe.” Many of these even incorporated Ptolemy’s astronomy and Aristotle’s physics into their work.

Cormack said that in the nineteenth century, scholars who were interested in “promoting a new scientific and rational view of the world.” They claimed that medieval churchman suppressed the belief of the ancient Greeks and Romans that the world was round. One of these individuals was the American historian and scientist John William Draper, who believed that Columbus ushered in modernity by proving the earth was round.

Cormack began her essay with a quote from Draper’s 1874 book History of the Conflict between Religion and Science. In chapter six of his book, Draper said the traditions and policy of Roman Catholic Church “forbade it to admit any other than the flat figure of the earth.” The belief in a flat earth continued until “the question of the shape of the earth was finally settled by three sailors, Columbus, De Gama, and, above all, by Ferdinand Magellan.”

In the Introduction to Galileo Goes to Jail and Other Myths About Science and Religion, Ronald Numbers pointed out how Draper focused much of his condemnation upon the Roman Catholic Church partly because it then composed the majority of Christendom, partly because its demands were the most pompous, and partly because it sought to enforce those demands by civil power. But there was a more personal reason that seems to have influenced Draper in his prejudicial view of the history of the Roman Catholic Church and scientific progress. Draper never mentioned it publically, and it only came to light after his death.

Drawing from a biography of Draper by Donald Fleming, John William Draper and the Religion of Science, Numbers related a conflict that arose between Draper and his sister Elizabeth, who had converted to Catholicism. For a time, she lived with the Drapers. When her eight-year-old nephew William, one of the Draper’s children, was dying, she hid one of his favorite books, a Protestant devotional, “which he cried for.” After William’s death, she laid the devotional on Draper’s breakfast plate. “He met this cool challenge by ordering her out of the house.” He never forgave her. Numbers concluded Draper blamed the Vatican “for her unChristian and dogmatic behavior.”

Another often repeated medieval myth is that the church of the Middle Ages prohibited human dissection. As Katherine Park related, the myth “That the Medieval Church Prohibited Human Dissection” had its classic statement in another nineteenth century church and science polemic by Andrew Dickinson White, A History of the Warfare of Science with Theology in Christendom. White said a serious stumbling block to the beginnings of modern medicine and surgery was a belief in “the unlawfulness of meddling with the bodies of the dead.” He said Augustine held anatomy in abhorrence, while it seems Augustine actually had a more nuanced opinion.

In The City of God Augustine discussed “The Blessings with Which the Creator has filled this life.” After discussing the blessing of the mind, by which the human soul becomes capable of knowledge and receiving instruction, he turned to the gift of the body. Augustine said while every part of the body had been created for utility, they also contributed something to its beauty. Reflecting then current medical knowledge, he said this would be all the more apparent if we could see beyond the surface. No one, Augustine thought, could discover that beauty and utility. “For as to what is covered up and hidden from our view, the intricate web of veins and nerves, the vital parts of all that lies under the skin, no one can discover it.”

Anatomists, who dissect bodies of the dead, and sometimes sick persons who die under their knives (surgery?) have “inhumanly pried into the secrets of the human body.” It seems Augustine objected to those who disregarded that the human body was part of the image of God in their pursuit of knowledge, treating it like the body of a beast. He questioned the wisdom of seeking to discover the utility of parts of the body like the web of veins and nerves, which he thought could never be done. He abhorred dissection when it treated the human body like that of an animal, disregarding its intimate connection to the soul in the image of God. Katherine Park suggested another possibility here: Augustine saw the fascination with dismembering corpses as an unhealthy curiosity about matters irrelevant to salvation.

In chapter nine where White discussed “The Scientific Struggle for Anatomy,” he acknowledged that there were pockets of medical science where dissection was permitted, particularly at the greater universities “which had become somewhat emancipated from ecclesiastical control.” White singled out Andreas Vesalius, often referred to as the father of modern human anatomy, as a particular hero in this war between science and religion. White said Vesalius was charged with dissecting a living man and directed by the Inquisition to undertake a pilgrimage to the Holy Land, “as the great majority of authors assert,” to atone for his sin of doing such a dissection. He was shipwrecked and died on his return.

Modern biographers dismiss this as a myth; Vesalius was not on pilgrimage due to pressures of the Inquisition. The story originated with Hubert Lambert, a diplomat under Emperor Charles V and then under the Prince of Orange. Lambert claimed in 1565 that Vesalius had performed an autopsy on an aristocrat in Spain while the heart was still beating, which led to the Inquisition’s condemning him to death. Philip II had the sentence commuted to a pilgrimage. “The story re-surfaced several times over the next few years, living on until recent times.” See the Wikipedia entry on Andraes Vesalius for more information.

Park said human dissection was not practiced with any regularity before the end of the thirteenth century “in either pagan, Jewish, Christian, or Muslim cultures.” Greek and Roman avoidance of dissection seems to be due to the belief that corpses were ritually unclean. While early Christian culture rejected the idea of corpse pollution and did not prohibit its practice in the early Middle Ages, “there is no evidence for its practice.”  The above-discussed disapproval by Augustine may have played a role, but it was also influenced by the generally undeveloped state of medical learning “after the fall of the western Roman Empire in the fifth century.”

The myth of the medieval church prohibiting human dissection is as strong now as when it was first invented by John Dickinson White. The late U.S. Senator, Arlen Spector, referred to it as he spoke in favor of S. 2754, the Alternative Pluripotent Stem Cell Research Enhancement Act of 2006. He cited a 1299 papal bull by Pope Boniface VII, wrongly saying it had banned the practice of cadaver dissection. “This stopped the practice for over 300 years and greatly slowed the accumulation of education regarding human anatomy.”

It seems that Mondino de’ Liuzzi didn’t get the memo, because he produced the first known anatomy textbook based on human dissection in 1316. It remained “a staple of university medical instruction through the early sixteenth century.” Dissection was confined to Italian universities and colleges for a time. But by the late fifteenth century it had spread to northern Europe, “and by the sixteenth century it was widely performed in universities and medical colleges in both Catholic and Protestant areas.”

The essays by Leslie Cormack and Katharine Park can be found in Galileo Goes to Jail and Other Myths About Science and Religion, edited by Ronald Numbers.

05/19/17

Another Brick in the Wall

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A Task Force for the American Psychological Association said that if clinical psychology was to survive in the heyday of biological psychiatry, it had to emphasize the strength of what it had to offer, namely “a variety of psychotherapies of proven efficacy.” So it proceeded to develop criteria to identify empirically validated treatments. Yet outcome research has regularly shown over the past forty years that “when treatments intended to be therapeutic are compared, the true difference between all such treatments is zero.” This has been referred to as the “dodo bird effect,” reflecting the observation made in 1936 by Saul Rosenzweig that common factors were responsible for the efficacy of various psychotherapies. Barry Duncan remarked: “the task force not unlike the pigs in George Orwell’s Animal Farm, continues to assert that some therapies are more equal than others.”

The APA Task Force on Promotion and Dissemination of Psychological Procedures noted that treatment manuals have become a required element of psychosocial treatment research. The standardization in treatment manuals reduces the methodological problems caused by “variable therapist outcomes.” Since no treatment will work for all problems, “it is essential to verify which treatments work for which types of problems.” Following this rationale, the Task Force suggested criteria for Empirically Validated Treatments (EVT) for two categories: Well-Established Treatments and Probably Efficacious Treatments.” You can see the criteria for each in Tables 1 and 2 in the above link.

In “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” Duncan commented that although the APA had good intentions in trying to preserve a section of the therapy market for the psychology profession, “declaring an approach to be an EVT and suggesting that it should therefore be the prescribed treatment of choice is empirical bankruptcy.” The EVT approach equates the client with the problem and describes the treatment as if it is isolated from what has been shown to be the most powerful factors that contribute to therapeutic change—the client’s resources and the therapeutic relationship of client and therapist.

The EVT position virtually ignores 40 years of outcome data about common factors and the veracity of the dodo bird verdict. Model factors are pale in comparison with client and relationship factors; efficacy over placebo is not differential efficacy over other approaches.

Duncan said the EVT “house of cards” was built on the medical model of “diagnosis plus prescriptive treatment equals symptom amelioration.” He pointed back to a 1949 conference in Boulder when psychology’s training guidelines was framed with medical language and concept of mental disease. Later, when the National Institute of Mental Health (NIMH) decided to apply the same methodology it used in drug research to evaluate psychotherapy—randomized clinical trials (RCT)—it had profound effects. This methodology meant a study had to include manualized therapies (to approximate drug protocols) and DSM defined disorders to be eligible for an NIMH-sponsored research grant.

The result was that funding for studies not related to specific disorders dropped nearly 200% from the late 1980s to 1990. “Force fitting the RCT on psychotherapy research is empirical tyranny and bereft of scientific reasoning.” It takes what is a human relational method of change and tries to cram it into a series of operationally defined behavior modifications.

The RCT compares the effects of a drug (an active compound) with a placebo (a therapeutically inert or inactive substance) for a specific illness. The basic assumption of the RCT is that the active (unique) ingredients of different drugs (or psychotherapies) will produce different effects with different disorders. The field has already been there and done that—the dodo bird verdict is a reality, and the active ingredients model (or drug metaphor) borrowed from medicine does not fit.

Among the problems when the RCT methodology is used for psychotherapeutic research is that the findings are profoundly limited because they do not generalize to the way psychotherapy is conducted in the real world. “Efficacy in RCTs does not equate to effectiveness in clinical settings; internal validity does not ensure external validity. . . . Experienced therapists know psychotherapy requires the unique tailoring of any approach to a particular client and circumstance.” When therapists do psychotherapy by the book, it doesn’t go very well. Duncan said doing therapy by manual was like having sex by a manual.

The EVT position is not only selective science at its worst, it is another brick in the wall of medical model privilege in psychotherapy. The end result of our Faustian deal with the medical model: Psychotherapy is now almost exclusively described, researched, taught, and practiced in terms of pathology and prescriptive treatments and is firmly entrenched in our professional associations, licensing boards, and academic institutions. It is so taken for granted that it is like the old story about a fish in water. You ask a fish, “How’s the water?” and the fish replies, “What water?”

Then the more structured a therapeutic relationship is (as with manualized therapy), the less room there is for a real relationship to develop between the client and the clinician. This structure inevitably leads to the client being viewed as the problem, rather than part of the solution. And it implicitly applies a medical model to psychotherapy: “diagnosis plus prescriptive treatment equals symptom amelioration.” It ignores a 40-year body of empirical evidence that indicates how common factors of various therapies, centered on the client and the therapeutic relationship, are far more indicative of therapeutic efficacy than whether or not a particular psychotherapy is an empirically validated treatment.

For more information on therapeutic power of common factors and the dodo bird effect, see “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird,” by Barry Duncan, which is linked above. Also read the Wampold et al. article, “A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, ‘All Must Have Prizes’”, or “The Dodo Bird Effect” on this website.

05/16/17

Trouble with Tramadol

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Regularly in the U.S. we hear news about the opioid epidemic. There is an ever-growing use of powerful opioids such as fentanyl, which is 50 to 100 times the strength of morphine; and carfentanyl (used as a sedative for large land animals) whose strength is 10,000 times that of morphine. Recent CDC data released on December 30, 2016 indicated that 60.9% of the overdose deaths in 2014 involved an opioid. Between 2014 and 2015 drug overdose deaths increased by: 11.4%.  The CDC suggested this increase was largely driven by synthetic opioids, most likely fentanyl, and heroin. While the opioid epidemic is not uniquely a US problem, it has a different face in other countries, such as Egypt, where the opioid of choice for abusers is tramadol. Yes tramadol, which is one-tenth the potency of morphine.

The Economist said tramadol use in Egypt was everywhere. Taxi drivers used them to stay awake. Wedding guests receive them as token gifts. Petty government officials even accept them as bribes. “Tramadol has become Egypt’s favourite recreational drug, supplanting heroin and cannabis.” Taha, a bank teller, said the drug helps him work. “It just makes you feel relaxed. Even if there are two men fighting to the death beside you, you wouldn’t care.”

There is no social stigma attached to tramadol use. It’s seemingly more religiously acceptable than alcohol or marijuana. Ibrahim began using half a tablet of tramadol because he felt socially awkward at the age of seven. “I found myself feeling unusually outgoing and positive.” Ten years later, he was using ten tablets daily.

Until recently, tramadol sold for the equivalent of 15 to 30 cents per pill. Tramadol use accelerated after the 2011 uprising in Egypt, partly because of the weakened state controls. Ehab El-Kharrat, an Egyptian doctor, said the tramadol came largely from India or China. Customs inspections began to tighten and the price rose sharply. At one point the price reached $1 to $3 a pill. “Since then we have seen a flood of people seeking help.”  The head of a Cairo rehabilitation center said at least 40% of those attending his clinic are addicted to tramadol.

Yet enforcement is poor. Court cases are thrown out because of shoddy police work. Officers are often in cahoots with the drug dealers, or are themselves drug-users. And even if the government succeeds in restricting the supply of tramadol, there may be unintended consequences. If the pills become more expensive, users may switch to stronger heroin. Some worry that the worst of Egypt’s drug problem is yet to come.

The Daily Beast also reported on the tramadol problem in Egypt. A taxi driver threw up the first time he tried tramadol. But now he takes for or five doses daily. He justified his use by saying its one of the few ways to dull the pain of Egypt’s weak economy and trying political circumstances. “Food, gas, everything is so expensive. People are exhausted and take things like tramadol just to keep going.” Young cash strapped males form the core of its users.

A UNODC (United Nations Office on Drug and Crime) official estimated that 90% of the illicit tramadol in Egypt is produced in India, and then smuggled into the country. One supplier said it’s never been easier to keep stocked up on tramadol. Because of its ready availability, its use has begun to spread from younger working class males into the more affluent areas of Cairo, which doesn’t make drug dealers very happy. “It’s not good when [those] people buy tramadol, because it means they won’t buy more expensive things. . . But with the economy and everything, this seems to be what Egyptians want right now.”

The Expert Committee on Drug Dependence of the World Health Organization (WHO) gave an Updated Review Report on tramadol at its thirty-sixth meeting in June of 2014. The report noted how Egypt had up-scheduled tramadol in 2009 because of its increasing rate of abuse. There was also growing evidence of tramadol abuse in other African and West Asian countries, including: Egypt, Gaza, Jordan, Lebanon, Libya, Mauritius, Saudi Arabia and Togo. In most countries it is a prescription-only medicine.

Marketing authorizations for tramadol are held by dozens of companies. The WHO Report listed around thirty-five companies as examples. Corresponding to this, it also goes by dozens of trade names, literally from A (i.e., Acerna, Amanda, or Astradol) to Z (i.e., Zamadol, Zentra, or Zodol). The common formulas in the US are: ConZip, Ryzolt and Ultram.

Overall, tramadol has been seen as having a low potential for drug dependence. However, in the last few years, new data suggests that dependence may occur when it is used daily for more than a few weeks or months. The WHO finding here is consistent with the above reported abuse of Tramadol in Egypt. It is listed as a controlled or scheduled substance in several countries, including: Australia, Iran, Sweden, Venezuela, Ukraine, China, the United Kingdom, Jordan, Saudi Arabia, and Egypt. Since the WHO Report was published, tramadol has become a Schedule IV controlled substance in the U.S.

In summary, the data on the dependence potential of tramadol show that tramadol has a relatively low dependence potential and that dependence is associated with the use of tramadol over an extended period of time (more than a few weeks to months). The data also show a higher risk profile in former drug abusers and in medical staff personnel than in pain patients. Several studies indicate that the incidence of tramadol dependence may differ between countries and within different regions of countries, which may be associated with the availability and prescription practice for tramadol, and with the availability of alternative psychoactive substances for drug abusers.

DrugAbuse.com described tramadol as a fully synthetic opioid originally synthesized by a German company in 1962. It was finally brought to market as Tramal in 1977. It was not until 1995 that it became available in the U.S. as “Ultram.” Initially it was not a controlled substance. By 1996 the FDA revised the product label to require warnings about the potential for abuse. In 2009, the FDA again changed the product warning, now the alert of the possibility of a life-threatening condition, serotonin syndrome.

Between 2005 and 2011, emergency department visits related to non-medical tramadol use rose over 250%. Between 2008 and 2013, prescriptions for tramadol increased by 20 million. In 2014 another increase of 44 million prescriptions of tramadol occurred, possibly a reaction to the rescheduling of Vicodin from Schedule III to Schedule II. Also in 2014, tramadol was made a Schedule IV controlled substances by the DEA.

In 2009, Sansone and Sansone gave a good summary of some of the health risks with tramadol, including a description of serotonin syndrome (SS), and the risk of seizures if it was used concurrently with antidepressants, both tricyclics and SSRIs. There was a “Dear Healthcare Professional” letter distributed by the manufacturer warning of the potential adverse drug event of seizures when using tramadol and antidepressants. A follow up study noted a small and insignificant change in the prescribing habits after the release of the warning letter.

Serotonin syndrome was more common with excessive use/overdose of tramadol or coadministration with other medications, particularly antidepressants among the elderly. SS has been reported with combinations of tramadol and the following: fluoxetine (Prozac),sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa),  fluvoxamine (Luvox),venlafaxine (Effexor),and TCAs (tricyclics). Rimeron was implicated in one case study of tramadol use with elderly residents in a long-term care facility. They summarized their conclusions as follows:

In primary care settings, tramadol is a commonly prescribed synthetic analgesic. Two potential adverse reactions of tramadol are seizures and SS. Either of these reactions may occur with tramadol monotherapy, but both appear to be much more common with either abuse/overdose or in combination with other drugs, particularly antidepressants. These adverse reactions appear to be more common in the elderly. The majority of commonly prescribed antidepressants have been implicated in both of these adverse reactions. Clinicians are advised to be mindful of these potential adverse sequelae when prescribing antidepressants to patients on tramadol, particularly in the elderly and/or those who might be at a heightened risk (i.e., individuals with epilepsy, head injuries, neurological dysfunction). If coadministration is undertaken, we advise careful monitoring for these two particular hazards. Tramadol is a remarkable drug, but like all drugs, effective use entails balancing the benefits versus the risks.

Then on April 20, 2017, the FDA restricted the use of tramadol (and codeine) in children. They also recommended against the use of these medicines in breastfeeding mothers. Tramadol is contraindicated (the FDA’s strongest warning) to treat pain in children younger than 12 years old and for pain in children younger than 18 after surgery to remove tonsils and/or adenoids. “These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be used in these children.”

05/12/17

Einstein’s God

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Albert Einstein had one of the most original scientific minds in human history.  Curiously, one his most famous quotes was, “God does not play dice.” This had led some to glibly assert: “He believed in God.” For example, in 2015 an auction-house in California put up 27 letters written by Einstein for auction claiming they revealed the personal side of his story—“how he advised his children, how he believed in God.” The founder of the auction house said the letters were on sale from $5,000 to $40,000 each. He thought the total take could be between $500,00 and $1 million. But exactly what did Einstein believe about God?

A brief article that appeared in The Washington Times, “Albert Einstein was no atheist, said the 27 letters up for auction showed ‘he believed in God.’” Hermant Mehta noted how this was a classic example of taking something out of context. In “Did Albert Einstein Believe in God or Not?” Mehta said that if Einstein had been alive today, he would likely seek to avoid religious labels. While he would reject being called a New Atheist, he wouldn’t spend time praying or thinking about God. Einstein didn’t believe in a personal God.

Einstein’s religion, if you have to put a label to it, is a sort of nebulous Deism: Maybe God played in role in creating the universe — because nature inspires such awe and the universe seems perfectly guided by mathematics — but that God has no direct affect on our lives today.

In The Ultimate Quotable Einstein by Alice Calaprice, Einstein said he could not conceive of a personal God “who would directly influence the actions of individuals.” Rather, he believed in Spinoza’s God, “Who reveals Himself in the lawful harmony of the world, not in a God who concerns himself with the fate and the doings of mankind.”  His understanding of God came from “from the deeply felt conviction of a superior intelligence that reveals itself in the knowable world.”

He said he often read the Bible, but its original text was beyond his reach. He wanted to know how God created this world. His religiosity consisted in “a humble admiration of the infinitely superior spirit that reveal itself in the little that we can comprehend of the knowable world.” The deeply emotional conviction of the “presence of a superior reasoning power, which is revealed in the incomprehensible universe, forms my idea of God.”

Try and penetrate with our limited means the secrets of nature and you will find that, behind all the discernable concatenations, there remains something subtle, intangible, and inexplicable. Veneration for this force beyond anything that we can comprehend is my religion. To that extent I am, in point of fact, religious.

It was this sense of God and religion that Einstein brought to his understanding of the relationship between religion and science. And we get a clearer picture of that understanding in these three articles written by him: “Religion and Science,” “Science and Religion,” and “Religion and Science: Irreconcilable?” All three are available here. See the link for information on where they were originally given or published.

In “Religion and Science,” originally published in 1930, Einstein described three stages to religious thought and belief. The initial, almost animistic stage was a religion of fear. “At this stage of existence understanding of causal connections is usually poorly developed, the human mind creates illusory beings more or less analogous to itself on whose wills and actions these fearful happenings depend.” Securing favor from these beings was by actions and sacrifices, which led to the emergence of a priestly caste as a mediator between the people “and the being they fear.”

The second stage was one of moral religion, where social impulses crystallized another type. This was “the God of Providence, who protects, disposes, rewards and punishes.” This god loved and cherished the life of the tribe or the human race; or even life itself. He comforted in sorrow and unsatisfied longing; he preserved the souls of the dead. Einstein commented how the Jewish scriptures illustrated the development from the religion of fear to moral religion, which continued into the New Testament.

“The religions of all civilized peoples, especially the peoples of the Orient, are primarily moral religions.” Although the development from a religion of fear to moral religion is a great step, Einstein urged caution. “The truth is that all religions are a varying blend of both types, with this differentiation: that on the higher levels of social life the religion of morality predominates.” A common factor in all these types is “the anthropomorphic character of god corresponding to it.”

The individual feels the futility of human desires and aims and the sublimity and marvelous order, which reveal themselves both in nature and in the world of thought. Individual existence impresses him as a sort of prison and he wants to experience the universe as a single significant whole. The beginnings of cosmic religious feeling already appear at an early stage of development, e.g., in many of the Psalms of David and in some of the Prophets. Buddhism, as we have learned especially from the wonderful writings of Schopenhauer, contains a much stronger element of this.

Religious geniuses of all ages are known by this kind of religious feeling. It has no dogma and no God conceived in man’s image. “There can be no church whose central teachings are based on it.” Both heretics and saints of every age were “filled with this highest kind of religious feeling.” Without dogma or a church, this “cosmic religious feeling” is communicated from one person to another by art and science. “In my view, it is the most important function of art and science to awaken this feeling and keep it alive in those who are receptive to it.”

Seeing science and religion as irreconcilable antagonists is thus easy to see with this sense of religion and science, according to Einstein. The individual who takes the hypothesis of causality seriously, who is convinced of the universal operation of the law of causation, cannot entertain “the idea of a being who interferes in the course of events.” There is no room “for the religion of fear and equally little for social or moral religion.”

A God who rewards and punishes is inconceivable to him for the simple reason that a man’s actions are determined by necessity, external and internal, so that in God’s eyes he cannot be responsible, any more than an inanimate object is responsible for the motions it undergoes. Science has therefore been charged with undermining morality, but the charge is unjust. A man’s ethical behavior should be based effectually on sympathy, education, and social ties and needs; no religious basis is necessary. Man would indeed be in a poor way if he had to be restrained by fear of punishment and hopes of reward after death.

This mysterious “cosmic religious feeling” is completely separate from science, according to Einstein. And it is within this sense of religion and science that we can understand another quote of his found in Part II of his second article, “Science and Religion”:

For science can only ascertain what is, but not what should be, and outside of its domain value judgments of all kinds remain necessary. Religion, on the other hand, deals only with evaluations of human thought and action: it cannot justifiably speak of facts and relationships between facts. According to this interpretation the well-known conflicts between religion and science in the past must all be ascribed to a misapprehension of the situation, which has been described.

The conflict between science and religion stems from the religious concept of a personal God. “The main source of the present-day conflicts between the spheres of religion and of science lies in this concept of a personal God.”

The aim of science is “to establish general rules which determine the reciprocal connection of objects and events in time and space.” These rules or “laws of nature” require general validity; they are not proven to be so. The more a person is “imbued with the ordered regularity of all events,” the firmer becomes their conviction that there is no room left for causes other than this ordered regularity. Personal or divine will does not exist as an independent cause of natural events.

To be sure, the doctrine of a personal God interfering with natural events could never be refuted, in the real sense, by science, for this doctrine can always take refuge in those domains in which scientific knowledge has not yet been able to set foot.

The god of Einstein is not the God of Scripture. That God is clearly portrayed as a personal God, which Einstein consistently and repeatedly rejected. He did acknowledge the independence of science and religion, as well as the limits of what can be known through science. But his understanding of “God” fails to affirm the crucial Creator-creature distinction inherent in Christianity. His god is part of nature; it is more pantheistic than it is theistic. It has more in common with Ludwig Feuerbach, who believed that man’s God was man, “homo homini Deus est.”

Christian theology would see Einstein as deifying nature. Romans chapter one noted that the invisible attributes of the personal Creator God are clearly seen in the things that were made. Instead of knowing and honoring God, he affirmed the existence of a superior intelligence revealed in the knowable world. This “god” could be experienced through a mysterious “cosmic religious feeling.” There is no room for divine or personal will independent of the ordered regularity of natural events. Paul would say Einstein exchanged the truth of God for a lie (Romans 1:18-23).

So what about Einstein’s quote about God not playing dice? Another famous physicist, Stephen Hawking (among others) observed in “Does God Play Dice?” that Einstein was unhappy about the apparent randomness in nature, which he succinctly stated in his famous phrase of God not playing dice. Einstein thought the uncertainty in nature was only provisional. There had to be an underlying reality, where particles had well defined positions and speeds, and would adhere to deterministic laws. “This reality might be known to God, but the quantum theory of light would prevent us from seeing it.”

Hawking then noted Einstein’s view would today be called a hidden variable theory. “But these hidden variable theories are wrong.” A British physicist named John Bell devised an experimental test that would distinguish hidden variable theories. But when it was carefully carried out, the results were inconsistent with hidden variables. Hawking remarked that it seems even God is bound by the Uncertainty Principle. “So God does play dice with the universe.”

05/9/17

The Dodo Bird Effect

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In order to get dry after a swim, the Dodo in Alice in Wonderland proposed that everyone run a race. He said the participants could run anyway they want. They could even start and stop whenever they wanted. When the race was completed and the Dodo bird was asked who won, and he said: “Everybody has won, and all must have prizes.” Intriguingly, the Dodo’s announcement has been used as a metaphor when discussing the outcome research of psychotherapeutic approaches.

The metaphoric application of the dodo bird effect to describe the equivalence of effectiveness when comparing psychotherapies first occurred in a classic paper written by Saul Rosenzweig in 1936: “Some Implicit Common Factors in Diverse Methods of Psychotherapy.” The article was republished in the July 2010 issue of the American Journal of Orthopsychiatry, which you can read if you pay APA PsycNET $11.95. An alternative approach would be to read an article by Barry Duncan, “The Legacy of Saul Rosenzweig: The Profundity of the Dodo Bird” available for free under the link.

Duncan saw Rosenweig’s article as having a clairvoyant ability to predict the intervening years of research that underlies the argument for the common factors perspective of psychotherapeutic approaches. Essentially Rosenweig (and the common factors approach) attributed the positive outcomes of these approaches to factors common to the various therapies and not necessarily to the particular therapeutic approach itself. Michael Lambert made a significant contribution to the modern sense of the common factors perspective, according to Duncan, when he identified four therapeutic factors as the principle elements accounting for improvement in psychotherapy. Based upon Lambert’s work, Scott Miller and a team of researchers expanded the use of the term “common factors” from its traditional sense of nonspecific relational factors to include four specific factors: client, relationship, expectancy and placebo, and technique.

Clients have been typically portrayed as passive targets or recipients for the all-important technical intervention of a therapy. However, research by Tallman and Bohart demonstrated “that the client is actually the single, most potent contributor to outcome in psychotherapy—the resources clients bring into the therapy room and what influences their lives outside it.” Client attributes like persistence, openness, faith, optimism, supportive family members, or membership in a religious community might be important factors operative in the individual’s life before they enter therapy. “Assay and Lambert ascribed 40% of improvement during psychotherapy to client factors.” This is a departure from the conventional emphasis on the contribution of the therapist, the therapeutic model or technique.

Clients are the main characters, the heroes and heroines of therapeutic stage, and they are the most potent contributor to psychotherapeutic change. This common factor suggests that therapists eschew the five Ds of client desecration (diagnosis, deficits, disorders, diseases, and dysfunction) and instead find ways to enlist the client in service of client goals. Whatever path the psychotherapist takes, it is important to remember that the purpose is to identify not what clients need but what they already have that can be put to use in reaching their goals.

Regardless of the therapist’s theoretical approach, relationship variables account for 30% of successful outcome variance in therapy. “Next to what the client brings to therapy, the therapeutic relationship is responsible for most of the gains resulting from therapy.” Related to this, the client’s perception of the relationship is the most consistent predictor of therapeutic improvement.

The core conditions identified by Carl Rogers as “necessary and sufficient” conditions for personal change in therapy are accepted as important factors by most schools of therapy. These core conditions, accurate empathy, positive regard, nonpossessive warmth and genuineness, have been empirically supported. They are also consistently reported in client reports of successful therapy.

“Placebo, hope and expectancy” is estimated to contribute 15% to the outcome of psychotherapy. In part, the client’s assessment of the credibility of the healing rituals of the therapy’s rationale and related techniques play a role here. These curative effects come from the positive and hopeful expectations that accompany the use and the implementation of the therapeutic method. “Rituals are a shared characteristic of healing procedures in most cultures.” The procedures are not the causal agents of change. “What does matter is that the participants have a structure, concrete method for mobilizing the placebo factors. From this perspective, any technique from any model may be viewed as a healing ritual.”

In Persuasion and Healing, Jerome Frank said the therapeutic enterprise has a strong expectation that the client will be helped. He suggested that an underlying factor to all the different approaches to psychotherapy, like the placebo in medicine, is that people are offered hope that something can be done to help them. Sometime merely the name of a therapeutic procedure mobilizes a person’s hope of relief. “For therapy to be effective, patients must link hope for improvement to specific processes of therapy as well as to outcome.” Frank said:

Despite differences in specific content, all therapeutic myths and rituals have functions in common. They combat demoralization by strengthening the therapeutic relationship, inspiring expectations of help, providing new learning experiences, arousing the patient emotionally, enhancing a sense mastery or self-efficacy, and affording opportunities for rehearsal and practice.

Therapeutic models and techniques account for 15% of improvement in therapy. Conceived broadly, model/technique factors can be understood as therapeutic or healing rituals. From this perspective, even therapies like EMDR, eye-movement desensitization response, offer nothing new. When a therapist tells a client “to lie on a couch, talk to an empty chair, or chart negative self-talk,” they are engaging in healing rituals.

Because comparisons of therapy techniques have found little differential efficacy, they may all be understood as healing rituals—technically inert, but nonetheless powerful, organized methods for enhancing the effects of placebo factors.

Rosenzweig said it mattered little whether the therapist talked in terms of psychoanalysis or Christian Science. What counted was “the formal consistency with which the doctrine used is adhered to, thereby offering a systematic basis for change and an alternative formulation to the client.”

And yet, the therapy field continues to be “model maniacal,” according to Duncan. He quoted Arthur Bohart as saying the dodo bird effect is ignored because it is so threatening to special theories. “The data call for a change in how we view therapy, but the field continues to stick to the old technique-focused paradigm.” Another reason is the ongoing search for the GUT—the Grand Unified Theory—of therapy that cures all or most suffering individuals. But the cure always seems just around the corner or just out of reach.

Self-proclaimed experts present mysterious scans of brains showing incontrovertible truth that “mental illness” exists and medical science is on the verge of conquering it. But when reality sets in, therapists know that they can never produce the epic transformations witnessed on videos or reported in edited transcripts. Psychotherapists painfully recognize that colorized brain images will not help when they are alone in their offices facing the pain of people in dire circumstances.

The final reason the dodo bird effect is ignored is because clinicians are too invested in the privilege model perpetuated by graduate schools, professional organizations and managed care companies. Psychiatrists are one example, particularly with their hegemony of targeting particular drugs as treatments for specific disorders. Drawing from the medical example of evidence-based practice, there are a growing number of evidence-based or evidence-verified treatments. But the EVT position essentially ignores the 40 years of outcome data about common factors and the truth of the dodo bird effect.

The dodo bird effect means that the client and what they bring to the therapeutic encounter is the most important factor for its effectiveness, rather than the therapist or the therapy. The next most important factor is the therapeutic relationship of client and clinician. Consequently, relationship skills such as acceptance, warmth and empathy are fundamental for establishing a good therapist-client relationship. A therapist with these skills will ensure their practice doesn’t go the way of the dodo bird, which went extinct in the 1600s.

05/5/17

The Evolution of Neurontin Abuse

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Not long ago a Columbus Ohio television station, Fox 28, noted the Ohio Substance Abuse Monitoring Network (OSAM) issued an alert about a pill doctors say is now being abused by heroin addicts. It’s not an opioid or a benzodiazepine; it’s not even a controlled substance. Yet it was the number one dispensed medication in Ohio in December of 2016, “at a 30 percent higher rate than Oxycodone.” Can’t guess? Would you be surprised to know that drug was Neurontin?

In February of 2017 OSAM published “Neurontin© Widely Sought for Illicit Use.” The OSAM report said Neurontin (gabapentin) was first identified as drug of abuse by law enforcement in January of 2014, in Dayton, Ohio. Over the last three years of reports there has been illicit gabapentin use in seven of eight urban regions in Ohio. See Table 1 in the OSAM bulletin for more information.

Preliminary analysis of OSAM’s most recent data for July to December 2016, found street availability and illicit use of Neurontin® to be moderate to high in six of the eight OSAM regions. In Athens, a participant commented, “It seems like everyone is on Neurontin®.” A law enforcement officer noted, “Enormous Neurontin® abuse right now.”

Gabapentin, known by its brand name of Neurontin®, is an anticonvulsant medication approved by the FDA as adjunctive treatment of partial seizures and to manage neuropathic pain from shingles. It has a variety of touted off label uses, and was referred to as “the snake oil of the 20th century” in an internal Pfizer email.  It is currently seen as having a low abuse profile and is not scheduled as a controlled substance by the DEA. But that may need changing.

It is also used to by opioid users to self-medicate through withdrawal and as a high in itself. One individual in Ohio said his attraction to Neurontin® was that it intensified his methadone: “So if you take your methadone and you go buy 10 Neurontin® and you take all 10, it’s sort of like you tripled your dose.” Others said they get a “semi-euphoric feeling” if they abuse it. Some recent studies: “Abuse and Misuse of Pregabalin and Gabapentin” and “Gabapentin Misuse, Abuse and Diversion: a Systematic Review” said gabapentin is most often abused by individuals with a history of drug abuse, especially opioids. And it is “being misused internationally.”

An article in Pharmacy Times indicated the number of prescriptions written for gabapentin was at an all time high. “According to a report by IMS Health, 57 million prescriptions for gabapentin were written in the United States in 2015, a 42% increase since 2011.” Alone it has a low abuse potential, but when combined with muscle relaxants, opioids of anxiety medications “gabapentin’s potential for abuse and addiction significantly increasing and ultimately gets those individuals high.” A study of Florida inmates found it was being crushed and snorted like cocaine. “Out of 96 prescriptions, only 19 were actually in the hands of an inmate that was actually prescribed that drug.”

An article in Pain News Network noted a study of urine samples from patients being treated at pain clinics found that 22% (70 out of 323) were taking gabapentin without a prescription. Researchers found of those patients taking gabapentin illicitly, 56% were taking it with an opioid; 27% with an opioid and a muscle relaxant or anxiety medications like benzodiazepines. The medical director of ARIA Diagnostics in Indianapolis, Indiana said the high rate of misuse was surprising as well as a wake up call for prescribers. Doctors don’t usually screen for gabapentin abuse when making sure patients are taking medications as prescribed.

Little information exists regarding the significance of Gabapentin abuse among clinical patients. Until recently, it was considered to have little potential for abuse however this review has shown that a significant amount of patients are taking Gabapentin without physician consent. This could be due to the fact that recent studies have revealed that Gabapentin may potentiate the ‘high’ obtained from other central nervous system acting drugs.

In the UK, gabapentin and pregabalin (Lyrica) prescribing is getting scrutinized more closely. At least 38 deaths involving pregabalin and 26 involving gabapentin were reported in the UK between 2012 and the end of 2015. The UK Advisory Council on the Misuse of Drugs (ACDMD) recommended they be reclassified as Class C controlled substances. “Both pregabalin and gabapentin are increasingly being reported as possessing a potential for misuse. When used in combination with other depressants, they can cause drowsiness, sedation, respiratory failure and death.”

Pregabalin may have a higher abuse potential than gabapentin because of its rapid absorption, faster onset of action and higher potency. It also causes a high or elevated mood in users. The side effects can include chest pain, wheezing, changes in vision and less frequently, hallucinations, Gabapentin was said to produce feelings of relaxation, calmness and euphoria. If snorted, its high is similar to using a stimulant.

The use of gabapentin and pregabalin by the opioid abusing population either together or when opioids are unavailable reinforces the behavior patterns of this high-risk population. There is a high risk of criminal behavior stimulated by the wish to obtain gabapentin and pregabalin.

Lyrica (pregabalin) is Pfizer’s top selling drug, with $6 billion in 2014 sales. Pfizer said reclassifying its drugs could harm patients. “Controlling the supply of these products across the whole UK, would be a disproportionate measure that would impact on patients and their quality of life.” An Irish study found pregabalin abuse a “serious emerging problem.” Recreational users in Belfast call the drug “Budweisers because it induces a state similar to drunkenness.” Gabapentin has received more attention as a potential drug of abuse in the US.

In 2012, “Has Gabapentin Become a Drug of Abuse?” appeared in Medscape, but the problem seems to have been somewhat downplayed. The article said: “a small number of postmarketing cases report gabapentin misuse and abuse,” but went on to say the rationale for abuse was unknown. Yet one of cited references for the Medscape article, “Abuse, dependency and withdrawal with gabapentin: a first case report,” did note that consumer websites reported several experiences of gabapentin misuse in order to feel high. “According to these consumer reports, gabapentin effects are close to those of marijuana and can appear with low doses.” Then the article reviewed several articles noting problems with abuse, misuse and withdrawal with gabapentin, essentially what has been reported above. In its conclusion, the article said:

 On the basis of case reports and postmarketing reports, there appears to be potential for abuse, dependency, and withdrawal symptoms associated with gabapentin use. Patients involved in this misuse and abuse were using gabapentin at doses greater than those recommended, to relieve symptoms of withdrawal from other substances, and for uses that are not FDA-approved.Providers should assess patients for drug abuse history when prescribing gabapentin, as well as monitor patients for any signs of misuse or abuse. Prescribers and pharmacists should monitor patients for the development of tolerance, unauthorized escalation of dosing, and requests for early refills or other aberrant behavior. Prescribers should consider requesting testing for the presence of gabapentin in urine drug screens if abuse is suspected.

I’ve personally been hearing reports from individuals in treatment for opioid drug problems consistent with the above information for several years. On one occasion, a woman said after she had told a psychiatrist she has a history of abusing gabapentin, but he prescribed it to her anyway. If you’re interested, a previous article I wrote, “Twentieth Century Snake Oil” reviews a history of Neurontin (gabapentin) that may surprise you. Another article, “The Dark Side of a Pill to Cure Addiction” reviewed mixed findings when gabapentin was used to treat alcohol withdrawal.

05/2/17

Beyond the Risen Son

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BioLogos published a series of articles that critiqued New Atheism and the movement’s use of flawed reasoning in its portrayal of religion and science. The series reviewed an essay by Stephen Snoblen, a historian of science, about New Atheist views of science and religion. One article in the series, “Science, Religion and New Atheism: Introduction,” made a distinction between the militant atheism of New Atheists and more moderate atheists. Snoblen said that many of the moderate atheists seek to distance themselves from the perceived excesses of the New Atheists. So what he asserted in his essay applied primarily to New Atheists. Snoblen thought some of the best, and most sympathetic, studies of the relationship between science and religion were written by individuals who would be moderate atheists, skeptics or agnostics.

The November 2006 issues for Wired magazine ran an article entitled, “The Church of the Non-Believers” which Snoblen said was important in canonizing the name and mission of what is called “New Atheism.” Not so coincidentally, The God Delusion by Richard Dawkins had just been published the month before. By early December, it had reached number four on the New York Times non-fiction bestseller list; it went on to sell millions of copies. There have been many others besides Dawkins articulating the central tenant of New Atheism, which Snoblen succinctly stated as: science is good and religion is evil. There is no afterlife; no heaven; no hell. “Religion must be abolished. The only thing that matters is science.”

While this is based upon views of “religion” and “science” that fit nicely with its atheistic worldview, it is not universally accepted as true. The New Atheist sense of religion is one that sees any acceptance of the supernatural as “religious.” And “science” is necessarily positivistic and materialistic. Within the above-linked article, “The Church of the Non-Believers,” Dawkins was quoted as saying the “big war” between science and religion is not between evolution and creationism. Rather, it is between naturalism and supernaturalism. “Sensible” religious people believe in supernaturalism; however “That puts me on the other side.”

This sense of religion is based upon the views of the founder of British anthropology, Edward Tylor, who theorized that all religions were based on animism. He defined religion as “the belief in spiritual beings.” According to Tylor, animism had two components: a belief that the human soul survived bodily death, and a belief in other spirits, including deities. The belief in spirits and deities was an outgrowth of believing in souls. There was a progressive development from the veneration of objects within nature (animals, trees, etc.), to venerating specific spirits that were less attached to objects (gods, devils, fairies, angels). As these gods were associated with good and evil, or as “first causes” of creation, they were seen as highly powerful beings—and even as a Supreme Being. Tylor said: “Animism has its distinct and consistent outcome, and Polytheism its distinct and consistent completion, in the doctrine of a Supreme Deity.”

Another problem lies with a New Atheist sense of faith that further distorts religion. Famously articulated by Dawkins in his 1976 book, The Selfish Gene, he said faith “means blind trust, in the absence of evidence, even in the teeth of evidence.” This is a definition that few religious believers would accept. It is unquestioning belief; faith as belief with a complete absence of evidence.  Snoblen said the New Atheist definition of faith was a straw man, applied to Christianity “with hostile intent.” The geneticist and former Head of the Human Genome Project, Francis Collins, said this sense of faith was not the real thing.

[Dawkins’s definition] certainly does not describe the faith of most serious believers throughout history, not of most of those in my personal acquaintance. While rational argument can never conclusively prove the existence of God, serious thinkers from Augustine to Aquinas to C.S. Lewis have demonstrated that a belief in God is intensely plausible. It is no less plausible today. The caricature of faith that Dawkins presents is easy for him to attack, but it not the real thing. (Francis Collins, The Language of God, p. 164)

A better definition of faith suggested by Snobler would be “Faith is belief in the absence of complete evidence.” Conceive of faith as existing on a continuum. On the one side is blind faith; faith with no evidence. Snobler said he was not aware of any believer whose faith could be defined that way, but it was a logical possibility. At the other extreme would be positivism, which argues there can be no belief without evidence. “Somewhere on the continuum between these two extremes we could place ‘informed faith,’ belief with partial evidence.”

As Ian Barbour discussed in his book, Religion and Science, science is not as objective as positivists believe; and religion is not as subjective. He said positivists portray science as objective, meaning its theories are “validated by clear-cut criteria” and tested by their agreement with “indisputable theory-free data.” Both the criteria and the data are held to be “independent of the individual subject” and not affected by cultural influences. Religion, on the other hand is seen as subjective. But since the 1950s, these contrasts have been increasingly challenged. Science was no as objective as had been claimed by positivism.

Scientific data are theory-laden, not theory-free. Theoretical assumptions enter the selection, reporting, and interpretation of what are taken to be data. Moreover, theories do not rise from logical analysis of data but from acts of creative imagination in which analogies and models often play a role. Conceptual models help us to imagine what is not directly observable. (Religion and Science, p. 93)

Barbour said many of the same characteristics are present in religion. While religious beliefs are “not amenable to strict empirical testing,” they can be approached in a similar way. “The scientific criteria of coherence, comprehensiveness, and fruitfulness have their parallels in religious thought.” Following the thought of Thomas Kuhn in The Structure of Scientific Revolutions, Barbour said religious traditions could be seen as “communities that share a common paradigm.” Kuhn’s book asserted that both theories and data in science were dependent upon the ruling paradigms of the scientific community.

In the choice between paradigms, there are no rules for applying scientific criteria. Their evaluation is an act of judgment by the scientific community. As established paradigm is resistant to falsification, since discrepancies between theory and data can be set aside as anomalies or reconciled by introducing ad hoc hypotheses.

In The Big Question, Alister McGrath said New Atheism was really an antiquated rationalism “which has failed to catch up with the philosophical revolution of the twentieth century” in the pivotal works of philosophers such as Martin Heidegger, Ludwig Wittgenstein and Hans-Georg Gadamer. McGrath said this was good news for both science and religion, which were both now free of the rationalist dogma “that human reason can lay down what the universe is like. It does not, and cannot.”

Reality is too complex to be comprehended by any form of intellectual tunnel vision. We need multiple windows on our complex world if we are to appreciate it to the full and act rightly and meaningfully within it. Now there is nothing wrong with seeing only part of the truth, so long as we realize that this is an incomplete vision. The problems begin if we think that reality is limited to what one tradition of investigation can disclose, and refuse to listen to any other voices than our own. (The Big Question, p. 205)

McGrath gave an interesting lecture at Lanier Theological Library on Richard Dawkins, C.S. Lewis and the meaning of life. Addressing the question of whether faith was reasonable, McGrath noted Dawkins thought we could only believe what can be proven by reason or science. His above quote on faith illustrated this. But Lewis believed most of the important things in life were beyond rational or scientific proof. He famously said: “I believe in Christianity as I believe that the Sun has risen, not only because I see it, but because by it, I see everything else.”