Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Thursday, June 24, 2010

Fires in Crowded Theaters

A few days ago I appeared in court to defend myself against a suit claiming that I had defamed and interfered with the business of a clinical psychologist in another state. It was true that I had stated in pointed fashion my disapproval of the advice my opponent has given to parents-- advice that I consider potentially dangerous and without any evidence basis. I “won” the lawsuit, in the sense that the other person was unable to show evidence that any injury had been done, but did not have a chance to show that my statements had been based on fact.

This experience brought back to my mind an article I co-authored some years ago (Kennedy, S.S., Mercer, J., Mohr, W., & Huffine, C. [2002]. Snake oil, ethics, and the First Amendment. American Journal of Orthopsychiatry, Vol. 72, 5-15). In that paper, we discussed the responsibilities of psychologists, nurses, physicians, and other professionals with respect to speaking out against practices they deem dangerous or lacking in validation.

Professionals have the same First Amendment rights as other citizens, and may exercise freedom of speech within reasonable limits. A common example of boundaries on freedom of speech is that people should not shout “Fire!” in a crowded theater when there is no fire. Neither should professionals say “X treatment can kill you” when there is no evidence that this is true. Although only the situation in the crowded theater is likely to prove tragic, harm can also be done by making unsupported negative statements about other professionals’ practices. There is always a trade-off or balance to be calculated between the rights of the individual and the rights of the community. Even commercial speech is protected to a considerable extent. These matters have been debated at length in the search for some slackening of the tension between individual and group rights.

We often forget that people who have rights also have obligations to their community. The two are alternative ways of looking at the relationship between the individual and the social group. Citizens share obligations like paying taxes and obeying traffic laws. But what about professionals? Do professional groups take on additional obligations to their community, by reason of the unusual rights and privileges they enjoy? Is there something professionals should do in response to those whose cries of “fire” take the form of fraudulent statements and may lead others to avoid conventional treatments or seek potentially dangerous ones?

An initial point to be considered is that professionals have a fiduciary responsibility. This term, although it is often used to refer to financial dealings, actually has a much broader application. A fiduciary responsibility involves any position of trust or stewardship in which one makes decisions for the good of another person. Professionals, who are by definition likely to be much better-versed in their own subject than their clients are, make or contribute to decisions that are intended for the good of the client, who cannot decide so effectively for herself.

This fiduciary role involves a special group of rights and obligations, beginning with the famous “first, do no harm”. But we need to ask the following question: does doing no harm include preventing harm from being done? Does it mean acting in a way that protects the public from potentially dangerous treatments? And, if this is the case, how should that be done? Is it possible for professionals to manage this task without the negative consequences associated with unfavorable publicity or litigation (of the type I mentioned at the beginning of this post-- or worse)? Can the job be done in an effective, comprehensive manner rather than the current case-by-case, ad hoc style, carried out by a small number of concerned people?

It could be done, yes-- but only if large organizations pulled together to support public debate on the question of harmfulness. Such actions would be fiduciary indeed in their protection of the public and of individual professionals too. Yet they do not happen, except in the case of very occasional resolutions vaguely condemning isolated practices.

As a psychologist and student of child welfare issues, I believe I see one problem standing in the way of the comprehensive response that should be organized by national groups like the American Psychological Association. This is the view, almost endemic to the helping professions, that it’s “not nice” to say things that are “not nice”. On the whole, neither individual professionals nor professional organizations want to get caught being critical of colleagues who are assumed to be well-intentioned and competent. Neither does anyone want to decide how to deal with the professional who proved to be not well-intentioned, or not competent--- unless some form of sexual activity was involved, which leads to a quick decision. Like a defense attorney I came across recently, who argued that abusive treatment of a child was trivial because there was no sexual abuse, professional organizations are (justifiably) quick to condemn sexual contact with a client, but (unjustifiably) very slow to recognize other ways in which harm can be done.

Until mental health and child welfare professionals correct these problems, we are in a position where we may see that the theater is smoldering, but we have no way of evacuating the place before someone gets burned. It’s “not nice” for professionals or the public to get singed just because we have failed to develop an organized response.

Taking a Little Walk: What Factors Make a Difference to Toddlers?

The “Question” feature in the New York Times Science Times section today focused on an issue about babies’ early attempts at walking alone. A reader inquired whether what she had been told was true-- that babies could actually walk much earlier, except that their vestibular systems were not developed enough to control their balance until about a year of age. The “Question” editor, C. Claiborne Ray, reported on the inquiries he had made and noted the need for development of the nervous system and its control of the leg muscles.

There’s actually a lot more to walking than that answer implies. Perhaps the first point to examine involves the facts about development of the vestibular system. This system, embedded in the skull near the inner ear, and sending messages along the 8th cranial nerve as the auditory system does, is actually one of the first sensory systems to come “on line” in the course of development. It’s a primitive system which we share with some fairly simple living creatures, and essentially it signals information about the pull of gravity and about the movement of the head. Lean forward or tip your head sideways, and the changed direction of the pull of gravity on parts of the vestibular system signals parts of the brain about the new position. Turn your head, or undergo rotation as you do when going around a corner in a car, and that information is also detected and sent. There is little or no conscious awareness of vestibular activity, but messages from the system enable the body to stay upright by changing muscle tension to counteract accidental movement. They also enable us to know when an object is really moving in front of our eyes, and when an image is moving across the eyes because of head or body rotation. A great deal of vestibular function is already present at birth, and you can see it at work if you hold a young baby in a horizontal position and suddenly move her downward a few inches. The Moro reflex, a movement pattern governed by vestibular activity, causes the baby to fling her arms outward in a grabbing movement.

So , we see that the newborn has almost-mature vestibular function, but she can’t walk (though she can display a stepping reflex when held in the right position). What’s the problem? Why can’t the baby bear her own weight on her legs? Part of the difficulty is the factor mentioned in the Times “Question”: the immaturity of the myelin coating of nerves in the lower part of the body makes conduction of messages poor, and signals from the brain do not effectively control muscle contraction and relaxation. Like other aspects of development, this one follows a cephalocaudal pattern, with the head end maturing more rapidly than the “tail” end. It’s usually about a year before the baby has voluntary control over the legs (and by the way, that developmental pattern also means that toilet-training is not really possible in the first year of life, because voluntary control over the lower part of the body is needed for that purpose).

We haven’t finished yet. There are more factors that enter into the walking equation. One important one would be obvious to us if we were talking about adults, but we tend to forget that it works for babies too: muscle strength. Young babies don’t have strong leg muscles. For them, as for adults, muscle strength increases with exercise. Chances to push with the feet or pull to stand help to strengthen the leg muscles until they have the power to support the weight of the body. In fact, the late and much-respected developmental scientist Esther Thelen showed that a “baby treadmill” that exercised the legs could improve the age at which Down syndrome babies walked-- an event that is ordinarily delayed for these children.

Even when independent walking is achieved, we can see from watching toddlers that they do not yet have a mature gait. Their large heads and relatively short legs make it hard for them to keep their balance when walking, and they compensate by bending their knees a bit and placing their feet far apart to lower the center of gravity and stabilize their position. As their ankles are not yet very strong, toddlers often keep the foot extended and hurtle, from place to place on tip-toe, a gait that has its problems but helps compensate for ankle weakness. (Ideally, they get to use and strengthen those muscles by walking barefoot rather than in hard, unbending “baby shoes”.)

Their first walking experiences have enormous fascination for small children-- so much so that they may not even notice painful results. I have a vivid memory of seeing my older son at 11 months, prancing barefoot over painfully prickly holly leaves, then a month later, when the excitement had worn off, yelping when he stepped on one. That joy of early mastery must be included as one of the factors that helps walking emerge as a new skill.