Monday, January 17, 2011

On "Pasta"

My systems and theories class was rather... interesting. I had a number of difficulties with the class, not the least of which involved the professor. That said, one of the ongoing assignments was worthy of note.

For many of the "theories" we covered, we were expected to write a little summary, answering a series of ten questions. I've already posted one set of my answers to these here. At the end of the class, however, we were expected to answer these questions for ourselves. The professor called this "making pasta". I call the process of "making pasta" from assorted theories along the lines which he suggested "highly unethical", "academically dishonest", or "bullshitting" -- depending on what, exactly, you intend to do with this "pasta" after you "make" it.

That said, I did answer the questions anyway. I just didn't pick up elements willy-nilly from assorted "theories" based on their personal and ideological appeal.

It occurs to me that these answers may be of interest to assorted and sundry readers of this blog. So, without further ado...

1-How does the theory conceptualize the basic beliefs about people? Does the theory see people as "good", "bad", neutral, capable of growth, proactive or reactive to the environment?

Theories and theoretical positions are valid within a clinical environment to the extent that they either are supported by the available empirical evidence ("are accurate") and/or have been demonstrated to improve client outcomes ("are useful"). Theories which possess accuracy but have yet to demonstrate utility can be justified on the grounds of improving understanding; theories which have demonstrated utility but lack accuracy can be justified on the grounds of the ethical principle of benevolence. Theories that have neither property have no business anywhere near clients in a clinical environment.

While some basic propositions about humanity are answerable by the currently available evidence (e.g. the available research on education, development, and cultural differences strongly supports the idea that people are capable of learning), others are not. By definition, answers to such questions are speculation or assumptions; representing them as other than this, if done for financial or academic gain, constitutes fraud.

2-How does the theory describe the function of personality? What is the purpose of our "personality"; what needs does the personality meet?

Assumptions about human nature are dangerous for counselors and their clients. They should be avoided whenever possible. At the moment, the available empirical evidence does not even begin to answer this question. No clinical technique should be predicated on answers which do not exist.

3-How does the theory describe the "structure" of personality? What IS our personality? What does it consist of?

The current state of knowledge about personality and individual differences are such that we can say things about it (e.g. that extroversion typically remains fairly constant over time; that people who report that they prefer showers over baths statistically tend to be more extroverted than those who do not) but cannot say much beyond that. Again, assumptions hurt clients and should be avoided where possible.

4-How does the theory describe how we develop into a "normal person"?

While developmental psychologists have done a fairly good job of mapping out the general bounds of the developmental path which a statistical majority of people follow from the context of Piagetian constructionism, assumptions such as the belief that deviation from this path must necessarily be harmful are, by their nature, both biased and bigoted.

Generally speaking, mental health isn't – in the sense that it is impossible to define "mental health" except as an absence of and lack of vulnerability to problems. This same problem is why medicine is defined as the science and practice of treating and preventing disease rather than as the promotion of good health.

Assumptions such as the regularly-made assumption that an individual must conform to some preconceived notion of "functioning" to be "healthy" have no place in clinical practice.

5-How does the theory describe how we develop into "abnormal" people?

Problems with psychological components can arise from a variety of sources.
These can be environmental in nature (e.g. exogenic depression induced by parental mortality), biological in nature (e.g. forgetfulness induced by traumatic brain injury), social in nature (e.g. lack of assertiveness and ability to self-advocate induced by pervasive prejudice and paternalism), historical in nature (e.g. emotional scars left by traumatic experiences), or have a completely different nature which I couldn't think of when writing this. Assumptions in this regard have a distinct tendency to harm clients (i.e. assumptions on the cause of a specific problem can be and often are wrong, and treatment methods selected based on incorrect assumptions tend to be unnecessarily ineffective and/or harmful).

6-How does the theory conceptualize the process of counseling? How does it work, in general?

Counseling is defined (Merriam-Webster) as "professional guidance of the individual by utilizing psychological methods especially in collecting case history data, using various techniques of the personal interview, and testing interests and aptitudes".

Or, in other words, counseling someone means finding out what the problem is and helping them decide on a course of action to take about it. In common use, assisting or guiding the person in implementing the course decided on is also considered part of the counseling process.

7-How does the theory conceptualize the specific techniques of counseling?

Evaluation procedures, regardless of their theoretical origins, are acceptable to the extent that they have been shown to produce valid data. Therapies are acceptable to the extent that they have been shown to improve client outcomes. Tests and therapies which are not supported by the available empirical evidence should be considered inaccurate and/or harmful by default and have no business being practiced in practice outside of an IRB-approved research protocol.

8-How does the theory conceptualize the roles/responsibilities of the counselor?

The counselor's role is, by definition, to help the client arrive at a solution to the presenting problem.

9-How does the theory conceptualize the roles/responsibilities of the client?

The client's responsibility is to arrive at a solution to the presenting problem.

10-What is the utility of the theory -- strengths, weaknesses, limitation, applicability?

Theories are valid to the extent to which they explain existing data and predict future data. Good theories possess two properties which most of those we've studied have lacked: domain-specificity and falsifiability. A theory which possesses domain-specificity attempts to explain only a limited set of information; grand, over-arching theories of everything tend to be wrong more often than not. A theory which is falsifiable is testable and does not attempt to explain away data which does not fit its predictions. Good theories are typically constructed to fit the data they are attempting to explain rather than according to the author's ideological prejudices.

When evaluated by this standard, which is considered incredibly basic in the field of detecting pseudoscience and health fraud, the vast majority of the theories we've studied in this class come out extremely poorly. In the absence of good theories, the best option is generally to practice as atheoretically as possible.

There are some things which I'd change if I were writing this today. There are many more things which I wouldn't. In any case, there are many little nuggets of interest in here...

Saturday, January 8, 2011

And Then There's These... People

When you work with one of the most vulnerable populations in America, you quickly start to realize just how nasty the human race can be. While I don't know who said it, there's a rather famous quote which about sums it up: "There is no such thing as an inhuman act, for there is no act so vile that you cannot find a human willing, even eager, to commit it."

Some of the things I have seen defy description. The things I've seen news coverage of are worse. This was rather spectacularly demonstrated yesterday, with an article from the LA Times that highlights this in a truly awful fashion.

I've tried to write out the story several times. I can't, as hard as I try. As such, I'll just quote the article -- which really does speak for itself.

The package mysteriously left at Los Angeles County Sheriff's headquarters shocked even some of the department's most grizzled detectives: A hundred hours of video footage showing severely disabled women, many in diapers, being sexually assaulted by anonymous men.

The attacks appeared to have taken place at residential care centers, authorities said, and most of the attackers are believed to be employees. One suspect appears to be a paraplegic patient, hoisting himself off his wheelchair, before removing his diaper and that of his victim's, and beginning his assault.

The footage, dropped off in March, has left detectives with few leads. Though authorities are confident the scenes were shot in residential care facilities, it's unclear if they are located in Los Angeles County. Much of the footage is so grainy that only the faces of four of the estimated 10 men could be made out.

Authorities Thursday asked for the public's help in identifying the men, releasing screenshots and composite drawings of the attackers.

"Maybe they can identify these people," said Sgt. Dan Scott. "Maybe they can identify the room."

Detectives are also hoping the tipster who dropped off the package will come forward. The footage left at sheriff's headquarters in Monterey Park came with a note explaining how he discovered the video. He had been commissioned by a man to scrub a computer hard drive, but before he did, he burned 100 hours of video files onto DVDs.

Detectives said the women in the videos appear to be between 20 and 40 years old, some appearing almost entirely unresponsive. The men appear to also be between 20 and 40. The footage, detectives said, appears to be a collection, with some men appearing in more than one scene. Some of the footage was shot with a handheld camera, with the rest appearing to be captured by a security camera, detectives said.

Enhancing and analyzing the video took several months, authorities said. Detectives have not contacted local residential care centers yet, an official said.

Anyone with information is asked to call Special Victims Bureau detectives at (866) 247-5877. Anonymous tipsters can call (800) 222-TIPS.

As I said, the story speaks for itself. The photos can be found here.

Friday, January 7, 2011

On Wakefield and Fraud

On his blog, the rather well-known blogger and commenter, Harold Doherty, writes:

I was aware that a medical society tribunal in the UK had found problems with the MMR study but I was unaware that a court of law, or governing medical society tribunal, had found Wakefield guilty of the serious offence of fraud.

If anyone knows which court of law, or governing medical society tribunal, found Dr. Wakefield guilty of fraud could you post a link to this site please?

The "medical society tribunal" Doherty refers to was the British General Medical Council, (or "GMC"; see their website here). They are hardly a mere "medical society tribunal" -- they're a governing body established by legislative action. They have a direct government mandate... and the legal authority to control who can and cannot practice medicine in the UK.

I suppose you could call them a "governing medical society tribunal", per Mr. Doherty's instructions. I would not: they're a regulatory body tasked with a judicial function. They are not part of any medical society (although the memberships certainly overlap!).

In its sanction against Dr. Wakefield, the GMC found (among other things):

The children described in the Lancet paper were admitted for research purposes under a programme of investigations for Project 172-96 and the purpose of the project was to investigate the postulated new syndrome following vaccination. In the paper, Dr Wakefield failed to state that this was the case and the Panel concluded that this was dishonest, in that his failure was intentional and that it was irresponsible. His conduct resulted in a misleading description of the patient population. This was a matter which was fundamental to the understanding of the study and the terms under which it was conducted.

In addition to the failure to state that the children were part of a project to investigate the new syndrome, the Lancet paper also stated that the children had been consecutively referred to the Department of Paediatric Gastroenterology with a history of a pervasive developmental disorder and intestinal symptoms. This description implied that the children had been referred to the gastroenterology department with gastrointestinal symptoms and that the investigators had played no active part in that referral process. In fact, the Panel has found that some of the children were not routine referrals to the gastroenterology department in that either they lacked a reported history of gastrointestinal symptoms and/or that Dr Wakefield had been actively involved in the process of referral. In those circumstances the Panel concluded that the description of the referral process was irresponsible, misleading and in breach of Dr Wakefield’s duty as a senior author.

The statement in the Lancet paper that investigations reported in it were approved by the Royal Free Hospital Ethics Committee when they were not, was irresponsible.
In other words, the GMC found that Wakefield lied repeatedly in the Lancet paper. Moreover, he concealed financial interests in the results being what they were:

Regarding the issues of conflicts of interest, Dr Wakefield did not disclose matters which could legitimately give rise to a perception of a conflict of interest. He failed to disclose to the Ethics Committee and to the Editor of the Lancet his involvement in the MMR litigation and his receipt of funding from the Legal Aid Board. He also failed to disclose to the Editor of the Lancet his involvement as the inventor of a patent relating to a new vaccine for the elimination of the measles virus (Transfer Factor) which he also claimed in the patent application, would be a treatment for inflammatory bowel disease (IBD).

In summary of their findings, the GMC wrote:

The Panel made findings of transgressions in many aspects of Dr Wakefield’s research. It made findings of dishonesty in regard to his writing of a scientific paper that had major implications for public health, and with regard to his subsequent representations to a scientific body and to colleagues. He was dishonest in respect of the LAB funds secured for research as well as being misleading. Furthermore he was in breach of his duty to manage finances as well as to account for funds that he did not need to the donor of those funds. In causing blood samples to be taken from children at a birthday party, he callously disregarded the pain and distress young children might suffer and behaved in a way which brought the profession into disrepute.

As such (among other things):

The Panel concluded that Dr Wakefield’s shortcomings and the aggravating factors in this case including in broad terms the wide-ranging transgressions relating to every aspect of his research; his disregard for the clinical interests of vulnerable patients; his failure to heed the warnings he received in relation to the potential conflicts of interest associated with his Legal Aid Board funding; his failure to disclose the patent; his dishonesty and the compounding of that dishonesty in relation to the drafting of the Lancet paper; and his subsequent representations about it, all played out against a background of research involving such major public health implications, could not be addressed by any conditions on his registration.

In short, Wakefield was found to be a dirty, rotten liar who faked data for publication in The Lancet. In common scientific parlance, they found that the paper was a classic example of academic fraud.

Edit: Kev of LBRB does an excellent analysis of the issue here, focusing less on the legal findings and more on illustrating the fact that Wakefield's paper was fraudulent.