Yet Another Example of Over-the-Top Woo

I just discovered that some people are selling levodopa as a dietary supplement.

Yes, levodopa -- arguably the world's most infamous anti-antipsychotic. Yes indeed, legal home psychopharmacology has reached a new low. Just when I think the quacks can't get any more outrageous...

For those of you who don't understand my reaction, levodopa, also known as L-dopa, is a particularly infamous anti-Parkinson's drug and the basis of Dr. Oliver Sacks's well-known book, "Awakenings". It is an extremely potent drug with a host of known side effects which include (but are not limited to):

• Nausea
• Gastrointestinal bleeding
• Disorientation and confusion
• Auditory and visual hallucinations
• Drowsiness and narcolepsy
• A condition which strongly resembles stimulant psychosis
• Hair loss
• Emotional effects (it tends to make emotions more "extreme" or "vivid", which wouldn't be such a bad thing if anxiety and libido weren't the aspects most notably/commonly amplified).
• Cardiac arrhythmia

And then there are the effects of chronic use. This is not a safe drug.

And yet people are selling it as a dietary supplement, completely absent any sort of real regulation. Thank you very much, DHSEA.

On Freudian Psychoanalysis

As part of my theories and practice course, we're being asked to summarize the various theories and modalities of therapy by answering a series of questions. We started with classical Freudian psychoanalysis.

The following are the questions and my answers -- somewhat cleaned up.



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?

Based solely upon extremely low-quality evidence of dubious validity, Freud believed that we were unaware of the majority of our mind's content and essentially at the mercy of forces beyond our direct perception. As such, Freudian psychoanalysis views people as the deterministic result of conflicts between postulated and reified constructs that exist within a non-falsifiable system. To the extent that people are able to grow within this context, it is the result of the client coming to exert control over these constructs and derivative reified "forces".


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

In essence, the ego serves to regulate forces/instincts, to manage anxiety, to plan, and to maintain reality focus.


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

In essence, Freud believed that the "self" (ego) serves to mediate between a person's "higher" desires (superego) and "lower" desires (id). As such, one's personality is determined by one's ability to balance and control these often-reified constructs and resulting also-reified "forces".



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

Freud believed that there was one true course of development (all departures necessarily being harmful) which could be described as going through a series of "psychosexual stages". Specifically, one passes (or should pass) through the oral stage during infancy, the anal stage during early childhood, the phallic stage during preschool, the latency stage during early school-age, and the genital stage during adolescence and onward. The oral stage accounts for the ability to delay gratification and to trust others. The anal stage accounts for independence, the ability to manage and express negative emotions, and acceptance of personal power. The phallic stage accounts for sexuality. The latency stage accounts for socialization and the ability to form relationships. The genital stage, once reached, accounts for all post-adolescent development.


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

If one is derailed from this one true path of healthy development, one develops a number of problems (which may or may not actually be problems). These include (but are not limited to) mistrust and rejection of others, an inability to form intimate relationships, obsession over rules, a lack of appropriate sexuality, and a lack of relationships.



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

Freud believes that one developed in therapy by coming to understand and believe in the existence of constructs of questionable validity (except, perhaps, as a metaphor) which describe phenomena which probably can't be appropriately generalized to them, as well as developing control over these phenomena ("achieving insight" or "strengthening the ego", respectively).



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

Generally speaking, the techniques of psychoanalysis include maintaining a consistent analytic framework and a reliable therapeutic environment, engaging in free association (i.e. having the client talk about whatever (s)he wants without inhibition) in order to allow the therapist to make logical leaps regarding what is within the client's questionably existent unconscious (i.e. interpretations) and to teach the client to accept these conclusions as real, engaging in possibly inaccurate analysis of the content of dreams for meaning which may or may not actually exist in order to teach the client to accept the conclusions of these analyses as accurate, helping the client to overcome any resistance to the acceptance of the therapist's view of who the client is and what the client's problems are, and engaging in possibly-inaccurate analysis of the feelings the client develops towards the therapist during this process (analysis and interpretation of transference).



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

Classical psychoanalysis views therapists as "blank screens" for clients to project their feelings for past individuals onto. If the therapist maintains a neutral demeanor and does not engage in self-disclosure, any feelings the client develops toward the therapist are largely assumed to be the client projecting feelings for other people onto the therapist. Additionally, the therapist must listen closely to the client as (s)he free-associates, analyze what is said, and occasionally make interpretations of what (s)he hears, teaching the client to accept the existence of the various constructs created by Freudian theory and to assign causal attribution for feelings and beliefs in a manner consistent with Freudian theory. By aligning the client's view of his self with the therapist's frame of reference and beliefs in Freudian theory, "progress" is achieved.



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

Generally speaking, the responsibilities of the client in a Freudian framework are to cooperate with he therapist as he engages in his responsibilities, to attempt to overcome resistance to his or her acceptance of the therapist's view of who the client is, and to help the therapist develop such a view based on analyses of dubious reliability and validity.



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

While our text discusses a number of comparatively minor limitations, these are largely secondary to the lack of empirical validation for large portions of psychoanalytic theory, the non-falsifiable (and thus unscientific) nature of the psychoanalytic framework, the lack of adequate empirical validation of the benefits of therapy (I am unaware of even a single well-controlled RCT which shows a beneficial effect for Freudian psychoanalysis relative to simply having someone to talk to), the focus on teaching the client to accept the analyst's questionable analyses as accurate, the (occasionally realized) potential for severe harm due to this emphasis, and vague criteria for termination of therapy which require therapist/client agreement (and therefore are subject to the various financial disincentives for the termination of a therapist/client relationship).

In terms of strengths, psychoanalysis recognizes the possibility of bias due to a limited set of factors (e.g. countertransference, racial stereotypes) and attempts to teach therapists to counter these. It emphasizes the necessity of a therapist recognizing and accepting who he or she is, recognizes humans as individuals, and emphasizes the importance of understanding the client and the client's problems, and teaches about the importance of a person's history in determining their present. Additionally, it was chronologically the first of the major therapeutic modalities and many of its techniques have contributed to their development.

Also, the couch can be relaxing.

A Recent Assignment

My abnormal psychology class has assigned "critical thinking exercises". In practical terms, this means weekly essays on some topic or another. The first one, which I just turned in, was a response to the question: "What do you feel are the most salient and valid criteria of abnormality? Why?"

While posting this essay, I found several typographical errors that I somehow managed to miss while proofreading it for submission. I've corrected them and added some HTML links to provide explanation and further reference. This said, my essay is as follows:


This is a pretty difficult question for me to answer, mostly because I believe the question itself is both flawed and loaded. To begin with, our textbook grossly misuses the term "abnormal", equating abnormality with dysfunction and defining the term "abnormal behavior" as synonymous with the concept of a psychological disorder (cf. p. 2). In actuality, however, the term "abnormal" simply means "not normal" and is synonymous with the term "atypical". As such, any behavior which differs from the norm is abnormal… and atypicality is the only criterion with any relevance.

While it is possible to argue that our book uses "abnormal" and its derivatives in a special sense, the use of this term in such a fashion is a gross violation of both medial bioethics and clinical ethics in general. Specifically, it violates both the principles of benevolence and non-maleficence through its effects both on informed persons who accept this equation (i.e. students learning from the book) and the effects of regarding this sort of linguistic equivocation as acceptable on society as a whole.

I certainly do not believe in linguistic determinism, but it is very difficult to deny the existence of a relationship between language and thought. How we think affects the sort of language we use, and there is a good bit of evidence that the sort of language we use effects the way we think (e.g. Tan et al., 2008). The existence of several named logical fallacies related to this (e.g. equivocation, amphiboly, fallacy by semantic shift) tends to support this general idea. Given the state of the knowledge in this arena and the precautionary principle, there is an ethical obligation to avoid this sort of issue.

Moreover, there is the matter of laypersons who hear discussions using this sort of misused terminology. It is unlikely that such persons will be aware of the issues surrounding the constructions used, and we live in an era in which the technical literature is becoming increasingly available to such people (as evidenced by publications such as PLoS and the policies of PubMed Central).

Even if the issue of the false equivalency created by this abuse of the English language is ignored, the criteria laid out in the book are problematic on other grounds. Simply put, they have been used to justify outright bigotry and abusive "treatments" which were only "justified" by this bigotry (e.g. Cartwright, 1851; Lovaas, 1987; O'Malley, 1914; Rekers & Lovaas, 1974; Chapter 14 of our book). The use of our book's criteria as sole and sufficient demarcation for what is and isn't a mental disorder is flawed, highly unethical, and not what is actually done in practice.

Furthermore, the entire construct of "mental illness" is of dubious validity and has been extensively challenged (e.g. Szasz, 2008). Even if we can't demonstrate that mental illness objectively exists, however, there remains one potential justification for the use of the concept: utility.

Simply put, we can justify describing something as a mental illness if we can demonstrate that the concept – and the medical-model approach which goes along with it – is useful. Doing so in a clinical environment, however, would require a demonstration of improved patient outcome, and it is very difficult to conduct a rigorous randomized controlled trial of the use of a concept.

Despite this, it is possible to evaluate the consequences of medicalization via the epidemiological evidence and comparing the prognosis of various syndromes in countries that have widespread access to medical treatment for mental illness and those that do not. It is also possible to do this by comparing outcomes across time-periods in a similar fashion.

Scizophrenia is the most "extreme" of the DSM mental disorders, and it is a major mainstay of psychiatry. As such, it makes intuitive sense to begin by evaluating the utility of the concept of a psychological disorder in reference to schizophrenia. Moreover, there exists a single randomized, controlled trial of psychiatry as a whole in the treatment of schizophrenia: the Soteria Project.

None of these approaches yield evidence in favor of the utility of a medical model approach to schizophrenia: World Health Organization data indicates that schizophrenia has better prognosis in developing countries than in developed countries; the best outcomes to be found for the treatment of schizophrenia here in America can be found in those non-medically treated by Quakers in the 19^th century; and the findings of the Soteria Project were very much damning in regards to the effects of psychiatric intervention (see Whitaker, 2002 for review).

Or, in other words, the concept has yet to demonstrate utility in regards to treatment. If and when it does, I'll start to consider medical-model approaches ethically justified.

References

Cartwright, S. (1851). Report on the diseases and physical peculiarities of the negro race. New Orleans Medical and Surgical Journal, 7, 691-715.

Lovaas, O. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9.

O'Malley, M. (1914). Psychoses in the colored race. American Journal of Insanity, 71, 309-337.

Rekers, G. & Lovaas, O. (1974). Behavioral treatment of deviant sex-role behaviors in a male child. Journal of Applied Behavior Analysis, 7, 173-190.

Szasz, T. (2008). Psychiatry: The Science of Lies. Syracuse, NY: Syracuse University Press.

Tan, L., Chan, A., Kay, P., Khong, P., Yip, L., & Luke, K. (2008). Language affects patterns of brain activation associated with perceptual decision. Proceedings of the National Academy of Sciences, 105, 4004-4009.

Whitaker, R. (2002). Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. Cambridge, MA: Perseus Publishing.

Edit: Corrected one more typo...

A Few Changes

Classes have started up again, and I am now once again a grad student. My blog's byline has been altered back to its original to reflect this. Expect a bit more free-ranging commentary from me, as I once again use my various coursework as inspiration for blog posts.

Also, due to some recent events in the online autistic community, I'm preemptively adding a policy against personal attacks in the comments here.

Autism's False Prophets

As most of my readers are probably aware, Paul Offit's famous (or infamous, depending on who you ask) book, Autism's False Prophets, came out in paperback last month. As most of my readers are probably unaware, this finally gave me the opportunity to buy a copy and read it in its entirety.

This was actually my first time doing so. I hadn't done so until now for reasons that had nothing to do with a lack of desire -- I simply haven't had the time or money to do so until now (and getting a copy of the hardback edition would stretch my budget a bit too much).

That said, it was well worth reading. Even though I already knew most of the story it told, having read many of the original sources that Offit cited, I still managed to learn some new things (e.g. the true story behind Dr. Geier's claim that testosterone binds to mercury). By and large, the information contained within the book is good, and the writing is highly accurate.

That said, I did find one factual error in the book. Specifically, on page three (of the paperback edition; it may be different in the hardcover), Offit refers to Bettelheim as "the first to offer a cure for autism". This is not only false, but pretty blatantly so... and even if the statement was true, it is something which would lie beyond Offit's ability to establish. It is true that Bettelheim was a the first highly visible, highly influential person to do so who is remembered (with much venom) today, but that's about it.

First off, America has a very long history of medical con-artistry and quackery. Establishing that Bettelheim was the first would require establishing that no snake-oil salesman had ever approached the parents of an autistic child and offered a faux cure prior to Bettelheim's publication of his book.

Secondly, Bettelheim initially published The Empty Fortress in 1967. This is significant -- falsifying the claim that Bettelheim was the first to offer a cure for autism would simply require demonstrating that someone else had tried an allegedly curative treatment on an autistic child prior to this.

Of course, autism was conceived of as a form of schizophrenia at the time; the realization that this belief is drastically wrong is only a relatively recent development... and the belief that they're the same thing (or related) is still periodically revived in a wide variety of forms. Moreover, a large number of treatments have been hailed as curative for schizophrenia, and many of these were tried on autistic children. In fact, you don't even have to look past Kanner's original sample to see this phenomenon.

Eisenberg's 1956 followup of the children treated at Johns Hopkins (a superset of Kanner's sample) reveals a similar pattern. Eisenberg refers to a "full range of psychiatric treatment" having been used, including electroconvulsive therapy (ECT). Even a cursory review of the literature available at the time shows that ECT was hailed as curative for schizophrenia by many of its practitioners and supporters. Personally, I suggest reading the relevant chapters of Whitaker's Mad in America for review.

That's even without getting into the matter of the orgone box which was used on one child.

As the error is understandable and this is only one clause in an otherwise accurate book, the matter can be viewed as an extremely minor issue. The larger problem lies not within how the book is inaccurate, but rather in how the book is incomplete.

First off, the discussion of ways in which the anti-vaccine/quack movement impacts and has impacted research is missing a major factor. While the book wonderfully describes the personal attacks on researchers and the wasted research efforts which have characterized the movement, it misses more indirect and pervasive harms. For one example: what has the effect been on recruitment for treatment research? I once had the distinct pleasure of speaking to a research psychiatrist about why sample sizes in trials of psychiatric treatments of autistic children are so low. His answer was that -- among other factors -- that it was extremely difficult to get families to participate... and he blamed the quack industry for this. After all, researchers need to get informed consent -- which means, among other things, a realistic picture of the potential impact of the drug being studied -- and there's a 50% chance of being assigned to the placebo arm of a RCT. By contrast, there's a 100% chance of receiving a quack's latest "miracle cure". Assuming you trust both sources of information, which would you choose?

Never mind the question of which is actually the better choice -- decision-making is based on perception, not reality.

Secondly, and more conspicuously, the book utterly ignores both the autistic rights movement and the fledgling autistic community... and the anti-vaccination movement's impact on them. This means that a very large portion of the issue -- such as autistic people's perceptions of the entire affair -- is utterly ignored. The anti-autistic stigma created by the movement is brushed off at best. The damage inherently caused by a view of autistic people as mercury poisoned is only briefly covered... by quotes from Kathleen Sidel and Camille Clark, who are parents.

Thus, the very real hardships, dismissals, and stigma faced by autistics on a regular basis because of these people is largely dismissed throughout the book, only to be specifically covered in one chapter... and even then it is only from the perspective of parents. The work and views of Jim Sinclair, of Amanda Baggs, of Ari Ne'eman, of Michelle Dawson, among others... are ignored. This is -- simply put -- not acceptable. Not only does this serve to marginalize us and exclude us from consideration in a discussion about us, but it also detracts considerably from the book's message.

By failing to take into account a large part of the story, Dr. Offit also manages to exclude a large portion of the harm and damage caused by the anti-vaccine movement. I really don't understand why he'd do this in a book about the anti-vaccine movement and the harms it's caused.

To be fair, Camille is autistic. She, however, is one person... and is invoked largely as a parent. The story of the community is discarded.

In short, Autism's False Prophets is a very good book... with one glaring flaw. It could be so much better if it wasn't for that one thing... and I cannot help but mourn the book it could have been even as I enjoy the book it is.

On Yet Another Stupidly Harmful Therapy

"Helminthic therapy" is the treatment of autoimmune disorders via deliberate exposure to parasitic worms. I know this for two reasons: One, I live within easy driving distance of what is apparently the quack capitol of the United States. Two, the parents of the kids I work with often have no common sense whatsoever.


If you've reached the obvious conclusion, you are entirely correct. I now know more than I ever wanted to about this, including the name of a company that will ship whipworm eggs from Thailand.

Ugh.

There really isn't much on the 'net about helminthic therapy and autism as of yet, but what I have found is suitably disturbing. The rationale is discussed here and here. The first part of a three-part video lecture is available here (with parts two and three available here and here, respectively). A very disgusting blog post can be found here.

Any other sources would be greatly appreciated.

On a Recent Huffington Post Article

Around a week ago, this article was posted to the Huffington post.

Quite frankly, my initial reaction to it was to think that it was an April Fool's joke. The sheer absurdity of the juxtaposition involved in talking about healing divides while spewing hate speech is striking.

Yes, hate speech. It's pretty unambiguous. Reading through the comments, however, it quickly becomes apparent that people don't get it.

Well, some commentators do. Thanks, Kim! (And, of course, all of the other people who I don't know...)

At the moment, the commentators seem to be divided between those who engage in reification error and those who don't. This is... pretty typical, really.

In any case... let's see. The post characterizes the neurodiversity movement as being made up of "people with Asperger's Syndrome or higher functioning autism" (this is nowhere near true, and "high functioning" is considered insulting), describes ASAN as "a self advocacy movement for people with high functioning autism" (ditto), and ends by stating that "We aren't the enemies. Autism is." (Which qualifies as blatant hate speech).

I really don't know what to say here...