In a disturbing article in the New York Times, Amy Harmon chronicles the tale of a brave county councilman on the island of Kona, Hawaii, who refused to be steamrolled by those who categorically believe that genetically modified organisms (GMOs) are dangerous and should be banned across the board. He actually took the time to look into the scientific research, to consult with scientists who know about this, and he attempted to draw a reasonable conclusion. He is faced, however, with a group of true believers, who keep repeating obscure claims based on long-discredited "research." They shout down their opponents and make outlandish claims that have no scientific basis or rationale. They demonize their opponents, and constantly shift the arguments when faced with scientific facts. Most disturbing of all was the refusal of his fellow council members to even allow scientists to testify, instead giving the floor repeatedly to unqualified zealots who continued to make broad, unsupportable statements.
It turns out, then, that it's not only climate-change deniers and birthers who maintain passionately held beliefs that have no scientific basis. Worse, it shows how repeating false claims becomes a sort of echo chamber for those with similar beliefs. Finally it shows that such behavior is not limited to Tea Party fanatics or religious zealots, but applies equally to so-called progressives on the left side of the political spectrum. I write about this because it applies as well to too much in the fields of psychotherapy, behavior change and addiction treatment.
We tolerate too much of this type of thinking in our field. How many treatment centers offer "holistic" therapies such as yoga, energy field work, Reiki, or massage, or worse, "nutritional treatment" that is not only unsupported, but may well be harmful? Why are state agencies still allowing such centers to obtain licensure? Why are people paying for brain scans or quantitative EEGs or neurofeedback? And, of course, why do so many people cling to the fiction that 90x90 is effective for most people, or that 12-step approaches are 100% effective if you follow directions? (What treatments for human maladies, short of penicillin for strep throat, can claim 100% effectiveness?)
I'm not arguing that an absence of evidence of effectiveness is evidence of ineffectiveness. There is lots we all do that hasn't been studied well, simply because it is impossible to conduct a large randomized controlled trial on every possible therapy. However, in addiction treatment we have a very large and very strong evidence base from which to draw. It's actually far better than in many other areas of health care. In order to include an approach in a licensed program, at the least, we should require 1) a scientifically plausible rationale for a treatment, 2) that unsupported treatments should not be likely to cause significant harm or cost a significant amount of money, 3) that there is not significant evidence that the approach is not effective, and 4) that there is not a well-supported approach already available.
I'm also not suggesting that yoga, meditation, Reiki, energy field work, reflexology, acupuncture, massage, etc., may not be experienced as beneficial to some people. I recently underwent Rolfing, for example, which I found to be very helpful (if painful). But I didn't expect my health insurance to pay for it, and I reject any large claims concerning what it and similar approaches might accomplish. Such approaches might be made available to clients (at their own expense), but not as presented as a scientifically based health practice.
I have been surprised at how trendy the psychotherapy community is in general, not just in addiction treatment. One current example is the spread of dialectical behavior therapy (DBT) beyond its proven focus on borderline personality disorder. It seems that it's being applied to anyone and for every condition short of psychosis. Another trend is "trauma informed therapy" using eye-movement desensitization and reprocessing therapy (EMDR), DBT, prolonged exposure, or mindfulness. All of a sudden, everyone has "trauma" for which these are appropriate treatments, even though many do not meet criteria for post-traumatic stress disorder (PTSD.) What was psychoanalysis if not focused on trauma? For that matter, "mindfulness" is another trendy approach, with practitioners charging for something the Buddha gave away 2600 years ago and which can be had for free at your local Buddhist meditation center.
At the same time, I seldom encounter high quality cognitive-behavior therapy (CBT) being applied to co-existing anxiety or depressive disorders, in spite of a mountain of evidence supporting their effectiveness. And too many in our field still believe that "I don't believe in it" is an adequate reason to not support anti-relapse medications that also have a strong evidence base. When we have such well-supported therapies, why aren't we using them? Why are we instead embracing half-baked ideas and approaches? Why do we tolerate so much scientific ignorance? Why do we tolerate lack of informed consent, where clients are not given information about what the evidence supports and what it does not, but instead receive biased and incorrect information that deprives them of the opportunity to make an informed decision?
Showing posts with label philosophy. Show all posts
Showing posts with label philosophy. Show all posts
Wednesday, January 8, 2014
Sunday, December 8, 2013
MMT and 12-Step Groups: Stigma Persists
In his latest contribution to the academic literature, William L. White and colleagues turn their focus on 12-Step participation among patients in methadone maintenance treatment (MMT). Rates of self-reported Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) attendance were very high; however, participants frequently reported that their MMT status prevented them from taking part in many of the "key ingredients" of the groups that most members take for granted. When asked about the experience, nearly half of all respondents who had attended NA or AA reported that they had "received negative comments about methadone use" and nearly "a quarter (24.4%) reported having had a serious problem within NA or AA related to their status as a methadone patient."
The following table from the report details the "frequency with which respondents faced particular challenges":
Table 4: NA and AA Responses to MMT Patient Status NA AA
Response to MM Patient Status: (n=228) (n=142)
Received negative comments about methadone use 43.0% 45.1%
Were pressured to reduce the dose of methadone 21.9% 23.2%
Were pressured to stop taking methadone 32.9% 34.5%
Were denied the right to speak at a meeting because of being
in methadone treatment 14.5% 14.1%
Were denied the right to become a sponsor because of being 8.8% 9.9%
in methadone treatment
White and colleagues implemented this small study at not-for-profit opioid treatment program (OTP) in the Northeastern US. A total of 322 respondents answered a 53-question survey about their participation in recovery support groups. Of the 322, 259 (80.4%) reported a primary affiliation with a recovery support group. Of these, 88.8% reported it to be in some way a 12-Step group. Importantly, 66% of respondents reported past-year NA/AA participation, with 88-89% reporting the group was "helpful".
Despite these figures, the authors found MMT patients had low rates of participation in the "key ingredients" that seem to be critical influencers of long-term recovery outcomes: having a home group (50%), having a sponsor (26%), sponsoring others (13%), attending 12-Step social events (23%), and active step work (21%).
Anecdotally, we see a lot of patients at Alltyr who have a hard time finding a place in the local 12-Step scene. We even began compiling a list of medication-friendly meetings in the Twin Cities as we learned about them, but the stigma associated with maintenance is still prevalent. Could it be that we are on the verge of another breakthrough in medication acceptance? After all, there was a time when you weren't considered "sober" if you were on antidepressant or antipsychotic medications (but now, as Dr W likes to say, you're more likely to be referred to the psychiatrist by your sponsor than by anyone else). We would be interested to hear reader stories about this experience - or opinions on the topic. Are things changing - or not?
See the full paper by White, et al., here: http://www.williamwhitepapers.com/pr/2013%20Co-participation%20in%2012-Step%20Groups%20and%20Methadone%20Maintenance.pdf
The following table from the report details the "frequency with which respondents faced particular challenges":
Table 4: NA and AA Responses to MMT Patient Status NA AA
Response to MM Patient Status: (n=228) (n=142)
Received negative comments about methadone use 43.0% 45.1%
Were pressured to reduce the dose of methadone 21.9% 23.2%
Were pressured to stop taking methadone 32.9% 34.5%
Were denied the right to speak at a meeting because of being
in methadone treatment 14.5% 14.1%
Were denied the right to become a sponsor because of being 8.8% 9.9%
in methadone treatment
White and colleagues implemented this small study at not-for-profit opioid treatment program (OTP) in the Northeastern US. A total of 322 respondents answered a 53-question survey about their participation in recovery support groups. Of the 322, 259 (80.4%) reported a primary affiliation with a recovery support group. Of these, 88.8% reported it to be in some way a 12-Step group. Importantly, 66% of respondents reported past-year NA/AA participation, with 88-89% reporting the group was "helpful".
Despite these figures, the authors found MMT patients had low rates of participation in the "key ingredients" that seem to be critical influencers of long-term recovery outcomes: having a home group (50%), having a sponsor (26%), sponsoring others (13%), attending 12-Step social events (23%), and active step work (21%).
Anecdotally, we see a lot of patients at Alltyr who have a hard time finding a place in the local 12-Step scene. We even began compiling a list of medication-friendly meetings in the Twin Cities as we learned about them, but the stigma associated with maintenance is still prevalent. Could it be that we are on the verge of another breakthrough in medication acceptance? After all, there was a time when you weren't considered "sober" if you were on antidepressant or antipsychotic medications (but now, as Dr W likes to say, you're more likely to be referred to the psychiatrist by your sponsor than by anyone else). We would be interested to hear reader stories about this experience - or opinions on the topic. Are things changing - or not?
See the full paper by White, et al., here: http://www.williamwhitepapers.com/pr/2013%20Co-participation%20in%2012-Step%20Groups%20and%20Methadone%20Maintenance.pdf
Monday, January 7, 2013
Counseling Adds Nothing to Buprenorphine Alone for Opioid Addiction
In a surprising new study, David Fiellin and his colleagues at Yale found that adding cognitive behavior therapy (CBT) to buprenorphine plus medical management along did not change outcomes. That's right, folks, nothing. This adds to the growing evidence that the primary reason people get better with Suboxone (buprenorphine is the primary ingredient) is the drug not the counseling. In another recent study, Roger Weiss and colleagues with the NIDA Clinical Trials Network found that the intensity of counseling made no difference in outcomes. Of course, they also found that after 11 weeks of Suboxone maintenance, when subjects were tapered off, the relapse rate within 8 weeks was more than 90%.
Here's a graph showing the final comparative outcomes. Note that in the first 12 week, pharmacotherapy management along (PM) actually had better outcomes, although not significantly so.
This will be hard to hear for many who are deeply committed to and believe passionately that it's the other way around, that counseling is the primary ingredient of treatment. That's why SAMHSA and others have tip-toed around this issue, calling treatment with Suboxone or methadone (another drug used to treat opioid addiction) Medication Assisted Treatment. Well, guess what? With opioid addiction it's the other way around: Counseling Assisted Medication. Or maybe: medical treatment with counseling as needed for problems other than opioid addiction. Hhhhmmmm. Sound familier? Let's see now, isn't that how we treat diabetes, hypertension, heart disease, stroke, allergies, whatever?
So for all you flat-earthers out there who cling to 12-Step or other counseling as the Holy Grail, I suggest you consult The Farmers Almanac, your horoscope, the I Ching, tea leaves, Tarot cards and the Mayan Calendar for guidance. Because you certainly don't seek any from science.
MW
References:
Here's a graph showing the final comparative outcomes. Note that in the first 12 week, pharmacotherapy management along (PM) actually had better outcomes, although not significantly so.
This will be hard to hear for many who are deeply committed to and believe passionately that it's the other way around, that counseling is the primary ingredient of treatment. That's why SAMHSA and others have tip-toed around this issue, calling treatment with Suboxone or methadone (another drug used to treat opioid addiction) Medication Assisted Treatment. Well, guess what? With opioid addiction it's the other way around: Counseling Assisted Medication. Or maybe: medical treatment with counseling as needed for problems other than opioid addiction. Hhhhmmmm. Sound familier? Let's see now, isn't that how we treat diabetes, hypertension, heart disease, stroke, allergies, whatever?
So for all you flat-earthers out there who cling to 12-Step or other counseling as the Holy Grail, I suggest you consult The Farmers Almanac, your horoscope, the I Ching, tea leaves, Tarot cards and the Mayan Calendar for guidance. Because you certainly don't seek any from science.
MW
References:
David A. Fiellin, MD, Declan T. Barry, et al., A Randomized Trial of Cognitive Behavioral Therapy in Primary Care-based Buprenorphine. The American Journal of Medicine, Volume 126, Issue 1, January 2013, Pages 74.e11–74.e17
Weiss, R. D., J. S. Potter, et al. (2011). "Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence: A 2-Phase Randomized Controlled Trial." Arch Gen Psychiatry: 68: 2011-2121.
Thursday, October 25, 2012
Determinism, Neuroscience and Free Will: A Conversation
I've recently been having a conversation with a colleague about implications of recent neuroscience research and free will (and therefore blameworthiness, or responsibility for our actions.) Thought you might be interested. My colleague is Steven P. Gilbert, Ph.D., ABPP, LP. He is married to Anne Fletcher, who recently published a wonderful new book (more on that in a later post) called "Inside Rehab." If you haven't read it, you'll want to. There's nothing else like it on the planet.
MW
Mark,
Anne sent me your blog below about the frustrations of appealing to reason in argumentation. I thought you might be interested in both the column I've included below entitled "Reasons Matter (When Intutitions Don't Object)" and the attached PDF, both by psychologist Jonathan Haidt.
I think Haidt's work is brilliant. He demonstrates how evolutionary-based instincts shape our morality and thus our politics (see also How Evolution Has Turned Us Into Liberals and Conservatives<http://blogs.
It all fits perfectly with Benjamin Libet's classic research in neuroscience which found that unconscious neuronal processes precede and potentially cause volitional acts which are retrospectively felt to be consciously motivated by the subject (disturbing research because it challenges the notion of free will).
Steve
Steve, I couldn't agree more. I've always been an "intuitionist," as Haidt puts it, and I've always found much of academic psychology to be sterile and meaningless, in part because of the emphasis on rationality as the basis for decision-making. But my time at NIH is what really convinced me, as I became intimately acquainted with Kahneman's work, among many others, concerning Systems 1 and 2. Many years ago, I concluded that determinism is fundamentally correct, but irrelevant, because we still have to reason and act accordingly, it's how we're made. Also, it's irrelevant because quantum physics tells us that you can't know the precise location, mass and trajectory of every particle in the universe, because there isn't one. Therefore, you can't predict the future, although you could suggest probabilities of various outcomes (50% chance of showers today.)
MW
Mark,
Anne sent me your blog below about the frustrations of appealing to reason in argumentation. I thought you might be interested in both the column I've included below entitled "Reasons Matter (When Intutitions Don't Object)" and the attached PDF, both by psychologist Jonathan Haidt.
I think Haidt's work is brilliant. He demonstrates how evolutionary-based instincts shape our morality and thus our politics (see also How Evolution Has Turned Us Into Liberals and Conservatives<http://blogs.
It all fits perfectly with Benjamin Libet's classic research in neuroscience which found that unconscious neuronal processes precede and potentially cause volitional acts which are retrospectively felt to be consciously motivated by the subject (disturbing research because it challenges the notion of free will).
Steve
Steve, I couldn't agree more. I've always been an "intuitionist," as Haidt puts it, and I've always found much of academic psychology to be sterile and meaningless, in part because of the emphasis on rationality as the basis for decision-making. But my time at NIH is what really convinced me, as I became intimately acquainted with Kahneman's work, among many others, concerning Systems 1 and 2. Many years ago, I concluded that determinism is fundamentally correct, but irrelevant, because we still have to reason and act accordingly, it's how we're made. Also, it's irrelevant because quantum physics tells us that you can't know the precise location, mass and trajectory of every particle in the universe, because there isn't one. Therefore, you can't predict the future, although you could suggest probabilities of various outcomes (50% chance of showers today.)
Another body of work that convinced me of that, although I'm not truly familier with it, is that of social psychologists, who repeatedly find that our "freely made decisions" are strongly affected by our social, internal and external environments, although we are almost never conscious of that.
That said, I'm concerned about the popularization of what is essentially another metaphor for the id, ego and superego, the idea that we have to tame the reptilian monster through reason and religion. Hair shirts, anyone, or flogging, perhaps?
Mark
Mark,
Your observation the indeterminism of quantum mechanics (which has outsed Newtonian determinism) opens the door to free will –– is really interesting, though at the outer limits of my conceptual abilities in both physics and philosophy! Does knowing that God does in fact play dice, i.e., that there is always the possibility of Heisenbergian uncertainty (that no one can "determine" how I will act), really mean I have free will? If our actions are caused by chance, we lack control and if we lack control, then we don't have free will, do we?
Re taming the reptilian monster, my readings in evolutionary psychology suggest that emotions are merely "evolution's executioners," to quote Robert Wright. That is, emotions are essentially motivational dispositions which impel us to behave in adaptive ways, i.e. in ways which increase the likelihood of survival and reproduction (i.e., of having our genes replicated.) Lust (more specifically, male desires for a partner with physical characteristics that signal health and fertility and female desires for a partner with physical and psychological characteristics which signal skill at resource acquisition and a willingness for commitment), maternal love, drives to understand the world, all are in the service of our "selfish genes." Admitedly reductionistic, but true nonetheless, I think!
Steve
Your observation the indeterminism of quantum mechanics (which has outsed Newtonian determinism) opens the door to free will –– is really interesting, though at the outer limits of my conceptual abilities in both physics and philosophy! Does knowing that God does in fact play dice, i.e., that there is always the possibility of Heisenbergian uncertainty (that no one can "determine" how I will act), really mean I have free will? If our actions are caused by chance, we lack control and if we lack control, then we don't have free will, do we?
Re taming the reptilian monster, my readings in evolutionary psychology suggest that emotions are merely "evolution's executioners," to quote Robert Wright. That is, emotions are essentially motivational dispositions which impel us to behave in adaptive ways, i.e. in ways which increase the likelihood of survival and reproduction (i.e., of having our genes replicated.) Lust (more specifically, male desires for a partner with physical characteristics that signal health and fertility and female desires for a partner with physical and psychological characteristics which signal skill at resource acquisition and a willingness for commitment), maternal love, drives to understand the world, all are in the service of our "selfish genes." Admitedly reductionistic, but true nonetheless, I think!
Steve
Steve,
Re your first paragraph:
My primary point was that IMO the question of free will is moot, because we have to act as if we have it even if we don't in theory. That is, accepting determinism, how does one make a decision? "I" still have to "make a decision," and since no one can predict or understand all the pre-determinants, even if "my decision" was pre-determined, it doesn't change anything. Even trying to implement determinism doesn't work. For example, you could say, "It doesn't matter what "I" think because "my decision" is already determined. Therefore, I will flip a coin for every "choice" that "I" have to make" still doesn't help, because that is a "choice" itself, and "my mind" can (and probably will) change. I don't think there's a way out of this loop. If that's so, then we have "no choice" but to act as if we do have choice and make decisions. I think the recursive nature of consciousness and rational thought (system 2) is an evolutionary development. We don't need consciousness to have language, make calculations, or do anything else. So it could be argued (and has, by Skinner) that consciousness is simply an epiphenomenon, perhaps something that came along for the ride with some other more essential evolutionary development, and that we simply respond to reinforcement. I suspect that consciousness evolved because it does have evolutionary value, probably by monitoring System 1 and allowing non-instinctual decision-making. However, it also unleashed the uniqueness of human evils, by freeing us of the constraints of purely instinctive behavior. Wolves will typically fight fiercely for dominance, but when one of them surrenders, the dominant wolf will generally not kill the other one. Humans feel humiliation and shame, and go on killing sprees to punish those perceived as causing the humiliation. So whether consciousness will turn out to be advantageous in the long run remains to be seen.
Along those lines and pursuant to your second para, I've also come to believe that we are motivated to maintain homeostasis in our interoception, our awareness of our internal state, and that this drives all behavior. Emotions are combinations of thoughts and physical sensations, and there are other internal states This appears to be localized in the insular cortex, but it's not an area we hear much about in terms of research.
Mark
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