Concerned About Unconventional Mental Health Interventions?

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

Wednesday, March 30, 2011

From Oneborneveryminute.com: Adoption and the Corpus Callosum (no kidding)

There’s a most remarkable interview at http://www.growninmyheart.com/an-alternative-therapy-for-the-child-who-has-been-adopted. If you consider the treatment they describe there to be plausible, I have a nice bridge to offer you at a reasonable price. The person who is interviewed, one Susan McCrossin, specializes in or perhaps has invented a treatment called Brain Integration Technique (BIT). This treatment, she says, deals with stressed brain circuits, which develop when blood leaves the brain to go to the extremities and enable flight or fighting, a situation resulting from a frightening experience like meeting someone who is in a bad mood. As a result of this, the cortex with its reasoning capacities turns off. The same thing will happen when you meet that person again, even if now he or she is in a good mood, and only your emotional functions will be left working. Although this all sounds as if brain functions turn on and off again (someone correct me if I’ve become confused), McCrossin apparently feels that a turn-off can be permanent or at least long-term. She states that for adopted children, the “abandonment factor” (not defined) turns off the corpus callosum and affects the brain’s development, causing (?) the amygdala to become overactivated. By touching your head in three places, waiting for the pulses to synchronize, and… something else involving acupuncture points and energy… McCrossin can fix this and raise your brain’s stress tolerance. On her website www.crossinology.com she provides some unpublished research reports in which she tested people, touched their heads etc., and tested them again, and not only did they do better on tests, they also all said they could learn better afterwards. (I don’t know whether they learned not to get involved in this kind of thing any more. That would be a step in the right direction.) Asked whether insurance would pay for her services, McCrossin opined that because this was an alternative technique, insurance companies might not have heard of it yet. Let’s examine “Crossinology” under a strong light. The first issue, I think, is to decide whether these statements about brain functions are meant literally or metaphorically. One of the difficulties is the fact that the cortex has a lot of functions-- thinking and reasoning are only some of them. Vision, hearing, the skin senses, and motor control are all associated with parts of the cortex. Turning off the cortex would mean loss of a great deal more than impaired reasoning, so unless McCrossin can support what she has said, her perspective can’t be dealing literally with brain functioning. I’m willing to accept it as a metaphorical approach, but I don’t see that it adds anything to what we could say quite simply and parsimoniously: if you get really scared, it’s hard to think straight. If someone or something scared you enough, you’ll remember that on another occasion and probably find your thoughts somewhat confused as a result. I know that’s not such a scienterrific way to put the matter, but it’s a lot more accurate and thus leads to fewer untrustworthy and speculative associations about how people’s brains work. What about the adoption issue? First of all, let me repeat what I’ve said in other posts: this “abandonment factor”, if it means distress about separation as I think it does, will not be present until the baby is at least six months old. It’s irrelevant to early-adopted children. Second: the corpus callosum. I would like to save myself some trouble and just say “you’re kidding”, but I know this foolish idea is still out there after half a century or more. Yes, the corpus callosum plays an important role in transmitting information from one side of the brain to the other in most people. However, there are several other “bridges” like the structure of the optic nerve that allow information to be available to both sides simultaneously. In the case of hearing, there are 8 or 9 crossover points between the cochlea and the auditory cortex. In addition, there are people born without a corpus callosum, but whose functioning is perfectly normal. There are many aspects of the brain where back-up systems make sure that important tasks are done, and this may be one of them. I have no idea what speculation brought the amygdala into this picture. However, the idea that the callosum plays some critical role in functioning dates back quite a way. It was involved with the belief that mixed hand and eye dominance would cause reading difficulties (actually, about 50% of people have mixed dominance, and far fewer have trouble reading.) In the 1960s, Robert Zaslow, who invented Attachment Therapy, published a report linking left-handedness (which involves less strong dominance) to resistance and non-compliance in children. The attachment therapist Elizabeth Randolph stated in a self-published book about ten years ago that she could diagnose Reactive Attachment Disorder be seeing whether children were able to crawl backward on command, an ability she related to the corpus callosum. Therapeutic techniques using the “cross-crawl”, which I recently mentioned on this blog, are without supportive evidence and are again related to the belief that the callosum plays some extraordinary part in personality and behavior. How about the touching-your-head treatment? In order to believe this could have an effect, McCrossin must be convinced that she is able not only to detect an unidentified life energy within each person, but that in some way her touch alters that energy. In other words, she and her followers posit some form of event that is outside the study of the physical and biological sciences-- what one can only call a supernatural event. Acceptance of such an idea puts McCrossin’s practice into the realm of religious ritual rather than of methods whose effectiveness can be investigated scientifically. One more point. Do insurance companies fail to pay for things because they didn’t hear of them “yet”? Actually, they are fairly careful about making these decisions. Look at the Aetna website, for example, and you’ll see discussion of the evidence about specific practices and the decisions that are made about paying for them. I’m no more a fan of these corporations than anyone else, but I believe it’s deceptive to represent them as failing to pay just because they haven’t caught up with progress. The Brain Integration Technique presented by McCrossin appears to be nothing more nor less than nonsense based on popular misunderstandings of brain functioning and of the emotional life of children. If you have an adopted child whose mental health is problematic, there are some excellent, evidence-based interventions that can actually help you. Please don’t fall for the idea that magic touches can fix real problems.

Reactive Attachment Disorder on the Internet: Confident, but Wrong

Reactive Attachment Disorder is a genuine diagnosis, code 313.89 in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). Young children who receive this diagnosis are either unusually friendly to strangers for their age, or unusually clingy and concerned about separation from familiar people, and they have histories of poor and inconsistent care early in their lives. Appropriate treatment for this condition involves helping caregivers increase their commitment, or investment in an enduring relationship with the child, and become more sensitive to the child’s signals of interest and affection toward the caregiver (see Bernard, K., & Dozier, M. [2011]. This is my baby: Foster parents’ feelings of commitment and displays of delight. Infant Mental Health Journal, 32, 251-262). Interestingly, although parents are often very concerned about “disinhibited attachment”-- the child’s willingness to approach strangers-- by the time they reach adolescence, many “disinhibited” children receive social approval for their good social skills and ease of engagement with other people. You’d never know any of this if you got your information about attachment and mental health from http://www.attachtrauma.org. Although this web site lists the DSM criteria for Reactive Attachment Disorder, it also provides a checklist for something else called “Attachment Disorder”. This problem (not to be found in DSM) is said to include the following, among other things: poor eye contact, firesetting, cruelty to animals, toileting issues, unusual speech patterns, and lack of cause and effect thinking. Attachtrauma.org attributes angry moods and behavior to a failure to experience something they call the “bonding cycle”, a series of events in which a caregiver calms, helps, or gratifies a child. This “bonding cycle”, which is almost never mentioned in modern conventional discussions of attachment, resembles the original Freudian view of attachment as “cupboard love”-- a positive emotional response to being fed. As I mentioned earlier, effective treatment for attachment problems of young children focuses on their caregivers’ emotional skills and behavior. The child’s emotional development is considered to depend to a considerable extent on the quality of social interactions and communications with the parent. The attachtrauma approach is much more concerned with treating the child himself or herself, although it includes strong resistance to the idea that the child might receive any treatment without the parents’ involvement. My concern today is with the parts of attachtrauma.org that reject conventional psychological interventions in favor of unconventional approaches like Attachment Therapy, cranial-sacral therapy, neurofeedback, and EMDR-- all methods with weak or no evidence supporting their effectiveness. But attachtrauma.org does not spend time arguing why these unorthodox practices are desirable, which would be hard to do. Instead, the site presents claims against “traditional psychotherapies” (by which they mean “talk” therapies) and against behavioral therapies. In each case, the rejection of the treatment is argued not in terms of systematic evidence but in terms of what would be the case, if certain assumptions happened to be correct. Here’s what the attachtrauma site says about traditional psychotherapies: “[they] don’t work [by the way, “working” is undefined-- JM] with children with RAD [Reactive Attachment Disorder]. The reason is that traditional therapies all depend on a relationship of trust between the child and therapist and/or child and parent. A child with RAD is by definition a child without trust. Therapies that involve the parents and work toward building the trust between parent and child are the kinds of therapies that work. Therapies that don’t involve the parents are WRONG [caps sic] for and usually damaging to a child with RAD.” Let’s look closely at this statement. As I pointed out, what it means for a treatment to “work” or not remains unstated. I can only assume that the desired outcome is what is stated on another attachtrauma page as indicating attachment-- that the child is obedient but not overly submissive, etc., etc. In other words, the focus is not on the attachment relationship at all, but on the child’s obedient behavior, including affectionate actions when desired by the parent. Conventional therapies would not necessarily share these goals and would consider appropriate goals to be different for different ages and circumstances. To go on: do traditional therapies depend on a relationship of trust? No, of course they do not assume that the child or adult patient comes in prepared to hand over trust to a therapist. Building a therapeutic relationship and establishing trust are part of the process. As for the idea that a child with RAD is by definition a child without trust-- this is the definition attachtrauma.org has created for its own purposes. If anything, children with the RAD diagnosis who show disinhibited attachment could easily be described as too trusting, as they are willing to behave toward every adult as they do toward familiar people. But in the next sentence I believe we get to the crux of this matter, as the anonymous author goes on to refer to “therapies that involve the parents”. Conventional therapies like Parent-Child Interaction Therapy do involve parents, of course, and there is much evidence that PCIT (for instance) “works”. However, it’s not at all clear that those are the kinds of treatments attachtrauma is referring to. Is not their concern that a child may talk to or work with a therapist independently and establish a relationship which, however beneficial to the individual, does not give priority to the parents’ needs and wishes? Surely such a relationship would be most helpful in the cases in which parents have difficulty processing the child’s feelings or past history; this might well apply to Russian-adopted children who before adoption had received weekly visits from parents they knew very well. As a final glance at the claims about “traditional” therapies, it’s important to look at the unsupported statement that such therapies are “usually damaging” to children diagnosed with RAD. This is an exceedingly strong statement and goes far outside the normal boundaries of professional criticism, particularly when no systematic evidence is offered to support the argument. There is no doubt that some psychological interventions are ineffective, and even that some are potentially harmful treatments. But this claim, made without evidence, and with the apparent purpose of attracting clients to an unconventional form of treatment, is a shocking departure from ethical conduct in either the medical or the mental health area. There is no meaningful information presented here; on the contrary, as my mother used to say, it’s all an old saying that they just made up. Similar issues appear in the attachtrauma.org statement about behavioral methods, in which we see that “Children with RAD do not respond to rewards”. This is indeed a remarkable statement and suggests that the children in question (either the clingy ones or the ones who follow strangers) function differently from any other known animal right down to flatworms. Attachtrauma also says “Some children see these rewards as another way to trick their parents and prove how stupid adults are”. Here we have an internally inconsistent argument that claims simultaneously that the children cannot respond to a reward, and that they are rewarded by an opportunity to “trick” others. Once again, the author of this material has presented a set of claims based only on unsupported assumptions and has relied on proof by assertion of most unlikely and even paradoxical statements. If you’ve been reading www.attachtrauma.org, or any other website supporting Attachment Therapy, do use your own critical cognitive ability. And, while you’re at it, take a look at the list of therapists approved by that site. If they’ve been willing to have their names associated with the confident assertion of incorrect statements, maybe you should do a little critical thinking about them too.

Saturday, March 19, 2011

Who Gave David Brooks a Psychology Book? A Threnody

Stand up, the person who encouraged the columnist David Brooks to quote bits of psychological research! I have a rod in pickle for you, or at least I wish I did. Somebody deserves a few of the juiciest for whatever they did that led to www.brooks.blogs.nytimes.com and its repeated visits to the cherry orchard.

Brooks’ approach is to choose a study, report its outcome briefly, and draw a conclusion or two from it. In his column today, he notes magisterially that “one study is never dispositive”-- but that’s not much help when he’s just given highly simplified outcomes for a series of unrelated single studies.

Psychologists as a group may be pleased that Brooks is hanging around the journal corner-- I heard this referred to several times at the recent Eastern Psychological Association conference. As for me, I’m concerned that Brooks’ remarks suggest to the public that reading the abstract of a journal article puts one in a position to state an important conclusion. According to today’s column, his new blog is intended to celebrate “odd and brilliant studies from researchers around the world”. This would be fine if the emphasis were on the oddness (“isn’t this weird? Wonder what anyone else has found about it?”), but to combine the odd and the brilliant seems to isolate these findings from the rest of the extensive psychological research literature.

But these are peer-reviewed journals he’s quoting, right? If so, what can be wrong? I’m not saying that anything is wrong with the studies themselves (although the peer review process is certainly no guarantee that everything in a journal is unimpeachable). What I am saying is that when you’re dealing with the complexities of research on human beings, you need more than one study to create reasonable confidence in the results. In guidelines about evidence-based practice, it’s suggested that there must be an independent replication of a study-- by researchers other than the original authors-- before we can conclude that there is clear research support for a practice. The same idea can well be applied to other types of psychological research.

Because of concerns about chance outcomes in single studies, it’s common nowadays to carry out procedures that pull together the results of multiple studies. Systematic research syntheses examine the literature on a topic and consider both the quality of the studies and their outcomes. In clinical areas, world-wide projects use trained volunteers to examine published research on treatments and report the evidence about their effectiveness. The Cochrane Collaboration does this in medicine and the Campbell Collaboration in psychology and education. In addition to this approach, it’s possible to use statistical meta-analyses to combine the data from a number of studies and draw a conclusion about the results of this large data set.

The very existence of systematic research syntheses and of meta-analyses tells us that cherry-picking single studies is not regarded as a suitable way to learn from psychological (or other) research.

There’s more to this issue, though. Whether a given study gives us any meaningful information is to a considerable extent a matter of the study’s design. Clinical topics give us some clear examples of the complexity of this issue. For instance, in a study of the effectiveness of a psychotherapy, we need to have a comparison group who do not receive the treatment in question. (If we just looked at people before and after treatment, we would have no idea whether any changes were caused by the treatment or by multiple other factors.) But what should be the nature of the comparison group? Are they people who get no treatment at all? Are they people who are put on a waiting list and will receive the treatment later on? Are they people who get the current “standard” treatment for their problem? Do you set up different comparison groups of each of these types?

The outcome of psychotherapy research can depend on which of these designs is chosen. For example, there would probably be a bigger difference between a treatment group and a comparison group who received no treatment at all, than between a treatment group and a comparison group who received the current standard treatment. But this example shows what happens in other areas of research as well, and that’s the point: even when there’s no issue about possible treatments, the way a comparison is built into the study can make a great deal of difference to the outcome. That means that anyone who is interpreting a research report needs to consider the extent to which the design makes a conclusion possible. So far, very little of that has appeared in Brooks’ blog, although I have to give him credit for knowing that correlational studies can’t tell us about causation.

I recognize that most readers will prefer the simple David Brooks version of psychological research to my version with its statistics and research design. That’s exactly what worries me. Brooks’ approach may please some psychologists by calling attention to published research, but I believe its oversimplification can deceive readers about specific topics and about the field of psychology itself.

Friday, March 18, 2011

Pseudosymmetry: Adoption, Attachment, Vaccination, and Misinformation

Pseudosymmetry is a useful word, invented by the anthropologist Christopher Toumey some years ago, and used to describe a maddening journalistic phenomenon. It’s a way of reporting news that gives the false impression that opinion is divided on topics that have little or no scientific support on one side and plenty on the other. “Symmetry” suggests that there are arguments of equal weight on both sides; “pseudosymmetry” suggests the practice of making arguments appear equal when they are actually far from equally supported.

We wouldn’t put up with pseudosymmetry in areas where there is immediate danger and where it makes a good deal of difference whether we make one decision or another. What would you think of an article about the Japanese nuclear reactors that described bad possible outcomes, but added that some nuclear scientists thought there was no problem? There well may be some such people-- suffering from dementia, or recently too ill to have seen what is happening-- but it would be deceptive to suggest that their existence means there is any real disagreement about the reactor problems. We would lose all confidence in a news source that gave this false impression.

When the danger is less immediate, though, we are not surprised when a news source gives the “other side” even though few knowledgeable people accept it. In those cases, some may even give credit for high moral standards to people who strive to tolerate someone’s right to unsupported beliefs. Any report about global warming in the popular media will be attacked for unfairness if it omits to say that there are non-believers-- even though the proportion of global warming believers to non-believers among scientists is probably 1000:1 at best.

We are also used to seeing “controversiality” (a word that is a red flag for pseudosymmetry nearby) introduced in any media report on child development. I remember being asked by a reporter at the time of the Candace Newmaker trial, after the child died under the ministrations of Attachment Therapy practitioners: “what do you think about this controversial therapy?” I replied, “it’s not controversial”, and I explained that it couldn’t be controversial if practically no clinical psychologist had ever heard of it, and those who had heard of it rejected it wholeheartedly. “Controversy” is a term that suggests that there are two schools of thought of equal weight, and therefore two opinions that are equally legitimate. When this is not true, “controversy” is a word that gives a false impression-- but it’s so often used by reporters who don’t want to be told they’re unfair, and do want to convey excitement about their topic. Saying something is controversial when it isn’t is a kind of pseudosymmetry.

I suppose one of the reasons for pseudosymmetry in discussions of early development is the idea that it will be a long time before children grow up. Therefore, we needn’t worry about any immediate problem even if we give the wrong impression about an issue-- if we suggest that a well-supported statement is only tentative by including an unsupported opinion shared by a very small number of people. Journalists may decide in these cases that to appear fair by including unsupported beliefs is more important than taking care not to delude readers or judging the likelihood of one of two opinions.

I have pseudosymmetry on my mind because of a recent e-argument with an organization in upstate New York. I won’t name names because, although I believe these people are in the wrong, they politely listened to my concerns and made an effort to discuss a pseudosymmetrical matter. Here was the deal: a communications professor at a small college became involved in the development of a series of public education videos about adoption. Professor knew nothing about the topic and depended on contributors to make the content acceptable. One contributor, an adoption agency staff member, provided an interview on attachment with an “adoption therapist” as a segment on attachment issues in adoption.

The attachment segment is the part of the series that brings up the issue of pseudosymmetry. The “adoption therapist”-- a marriage and family therapist whose information on the Internet suggests that he is also a homeopathic practitioner—concentrated on the role of grief in adoption and attributed this to the emotional attachment he believes to occur prenatally; this view, of course, is quite opposite to the conventional and evidence-based idea that emotional attachment of infant to adult occurs at some time in the second six months of life. The therapist also alluded to the existence of auras as an indication of personality and emotional concerns, a belief that is certainly no part of conventional psychotherapy or personality study. While none of the therapist’s practical suggestions were harmful or out of line with ordinary practice, the belief system he communicated was one with implications that could well lead adoptive parents to wrong assumptions and expectations.

So, why do I connect this matter with pseudosymmetry? Why don’t I just say they were wrong and should not have been spending public money this way? Here’s what the professor told me in an e-mail: “We decided that this issue was one that appears to have some validity in spite of the perspective and that [the therapist] didn’t present the matter as though there was only one, valid perspective. [Our medical adviser] pointed out that a similar situation exists in the medical field in regards to immunizations.”

In other words, professor believes that the presentation is acceptable because it does not present the matter as if there is only one, valid perspective. The fact that indeed there is only one substantiated perspective, and that the other material presented was factually incorrect, is seen as irrelevant. To top off the pseudosymmetrical efforts, he quotes an individual who draws a parallel between this and views of vaccination, an area in which there is one perspective with clear scientific support and another that is factually incorrect and rife with fraudulent and self-aggrandizing counterclaims. Pseudosymmetry apparently demands that we give equal time to opponents of vaccination and to reliable evidence supporting vaccination, and uses that model to declare that unsupported claims about the thoroughly-researched subject of attachment should be included along with evidence-based information.

To be tolerant and kind to other people who have different ways from ours is a good idea-- indeed, we would do well to do more than tolerate, and encourage those cultural differences. But that is a far cry from tolerating the promulgation of claims that are well-known to be wrong. What is it all about, anyway? Why is pseudosymmetry so beloved of journalists and others? Part of it, I’m sure, is the belief that it’s “not nice” to criticize or to suggest that someone else’s work or beliefs could use some fine-tuning. Another part-- and a far less admirable one-- may be plain old mental laziness. Why try to think through a difficult problem when it’s easier to avoid it and you also get moral credit that way? It’s hard work to examine the facts, and it’s also hard to summon the ego strength to deal with others’ objections to your decision that one idea is more supportable than the other.

Pseudosymmetry is an easy way out of the dilemma, if you don’t mind thinking that adoptive families may have troubles, or children may die of contagious disease, because you have created a false impression.

Monday, March 14, 2011

Ja, das ist ein Snoezelen-Bank; or, There's One Born Every Minute

Looking for the funnies in the Philadelphia Inquirer (AKA Fluffya Inkwire) this morning, I was surprised to come across an article about a practice I hadn’t met for quite a few years: snoezelen (see http://www.philly.com/philly/health_and_science/20110314_A_Dutch_therapy_that_stimulates_the_senses_seems_to_soothe_dementia_patients.html). Snoezelen (a made-up word) is the term for giving a patient experiences in a room that contains a variety of different scents, sights, sounds, and touch experiences-- a multisensory environment that may involve music, color changes, bubble tubes, and all sorts of real bells and whistles.

I first encountered snoezelen about 10 years ago when I was first inquiring into unconventional psychotherapies of various kinds. At that point, snoezelen rooms seemed to be intended for fun and entertainment-- a sort of elaborate form of disco ball or lava lamp. I don’t recall whether marijuana was suggested as a way to intensify the experience, but that was certainly the sort of thing it made me think about. A plate of hash brownies would seem to fit right in. That such an arrangement could be considered as a serious form of treatment was not mentioned at that time, as far as I know.

Fast-forward 10 years, and we see more than the suggestion that snoezelen is a treatment for dementia, autism, and so on. We also see a number of public-spirited companies that will provide the makings of a snoezelen room for about $15,000. According to the Inquirer article, one of these companies sold such rooms to over a hundred nursing homes and other facilities in the United States last year.

Do you suppose those nursing homes used state or Federal funds to buy their snoezelen equipment? Do you suppose their administrators thought or were told that the use of snoezelen was an evidence-based practice, as is generally required for such funding? If so, we’re looking at a sticky situation (and I don’t mean in a multisensory way). There is presently no evidence basis for the use of this kind of treatment, and it would be difficult (though not impossible) to achieve one.

Stacey Burling, the Inquirer reporter, pointed out that “three major teaching hospitals in Philadelphia were unable to find experts who felt qualified to talk about” snoezelen; in fact,it’s likely that none of those highly-trained people had ever heard of it. She also noted that the Dutch, who were the originators of snoezelen, did not do outcome research on the practice or even regard it as anything but amusement. However, Burling went on to comment on the apparent positive outcomes of some informal local studies, while reminding readers of some real research difficulties.

It would not be impossible to do serious outcome research on snoezelen, but it would be expensive and labor-intensive. One issue would be the need to make the experience exactly the same for each patient so that we would know what factors were the possible cause of a given outcome. This requirement, called intervention fidelity, is important in all studies of psychological treatments because differences in patient experiences are a factor that can seriously confuse our understanding of cause and effect. In the case of snoezelen, the practice of tailoring or fine-tuning treatments for different patients makes it difficult to know whether one or all of the treatments are effective.

For example, one individual interviewed by Burling commented that somewhat fewer doses of medication were used for dementia patients in the course of some weeks of snoezelen treatment than had been used before. The patients also had fewer falls, possibly because of the reduced medication. But these points bring up additional research issues. It would appear that staff were giving medication when they felt that patients’ mood or behavior warranted it. Of course this is perfectly legitimate, but the problem is that the medication decision rests on staff members’ judgments, and those judgments can be influenced by staff awareness of the availability of snoezelen treatment. If it’s about snoezelen time, a staff member may decide against administering medication, whereas the same patient mood or behavior may be seen as needing medication under other circumstances.

Research on treatment outcomes ideally involves blinded designs, in which staff members making evaluations or medication decisions (for instance) would not know which patients were receiving snoezelen treatment and which were not. This kind of design would prevent staff expectations from affecting the way they assess or treat patients--- whether a staff member thinks snoezelen is silly or is effective cannot cause different treatment if the person does not know what therapy a patient is getting. As long as research is unblinded and staff members know which patients receive which therapies, it is difficult to be sure that any patient changes are due to the therapy rather than other factors. This is currently a problem for snoezelen.

It’s very difficult to see how 15 to 20 minutes per week of snoezelen (as noted by Burling) could create a measurable change in the behavior or mood of dementia patients or others. Because there seems to be no obvious way that such a change could occur, it’s especially important that reliable research evidence showing good outcomes should be in hand before public funds are spent on this or similar treatments. Private institutions or families also owe it to their patients and themselves to investigate the effectiveness of all treatments before investing resources that might be much better spent. Let’s all use our ability to think these matters through before giving too much consideration to commercial claims.


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Thursday, March 10, 2011

Understanding Prenatal Life: For Best Results, Choose Your Sources

Ideas about the experiences of babies before and during birth are a part of some ways of thinking about mental health and about psychotherapy. Some treatments, like regression therapies, focus on the belief that prenatal experiences help to determine individual development and may need to be recalled and processed so a person can move beyond lifelong difficulties. Practitioners of these treatments often claim that they know what prenatal life was like-- even back to conception (or before!)—and can help patients understand and recover from problems that result from that early part of life.

What makes anyone think that they know the experiences of an unborn child, particularly of one who is still constituted of a small number of cells? Major claims about this have come from people who believe that their experiences when taking LSD were accurate depictions of what they had experienced in the earliest parts of their lives. Frank Lake, the author of Clinical Theology, considered that experiences resulting from LSD represented the trauma of birth as well as of separation from the mother. His colleague Stanislav Grof , again using LSD revelations as sources, proposed that there were four stages of experience before birth. The first is at least potentially blissful, although it may be spoiled by the mother’s smoking, drinking, etc. This period lasts until the birth process itself begins, when the infant is said to feel stuck and under inescapable pressure as the uterus begins to contract rhythmically. Third, the passage through the vagina is experienced as a life-death struggle which may also be ecstatic. Finally, birth itself is experienced ecstatically, with a sense of release of pressure and radiant light (although paradoxically some of Grof’s followers have emphasized birth as involving a sense of loss as the physical connection with the mother is broken.)

Later in his career, Lake gave up the LSD method and depended on re-enactments of birth and deep breathing exercises to induce experiences that he believed were representations of prenatal life and the birth experience. His follower William Emerson ( 2002; Somatotropic therapy. Journal of Heart-Centered Therapies, Vol. 5, pp. 65-90) clarified some of this belief system when he stated that one “of the central concepts in this field is the notion that mind pre-exists the nervous system; that there is a level at which the conceptus is aware of essential qualities of feeling present in its inception; and that this awareness records its struggles to survive the hazards of implantation, the history of its gestation, and the detailed drama of its birth at an energetic and cellular level”.

Looking at these ideas, we see that the notion of distinct memories going back to conception is based not on scientific study of early development but on drug-induced experiences and fantasies during group re-enactments. We also see that such beliefs are related to the idea of a soul or nonmaterial animating entity that exists prior to, and separate from, the material body. In addition, we see that these beliefs reject the function of the nervous system as holder of memories and instead ascribe memory to a nonmaterial energy (perhaps the World Soul or some other form of “nonlocal mind”) and to properties of individual cells outside the nervous system.

Anyone considering prenatal experience from the psychological or other science-based viewpoint would reject the perspective I’ve just described. The experiences of adults, however vivid or interesting, would not be taken to indicate anything about the nature of prenatal experience. No nonmaterial entity would be included in a discussion of either prenatal or post-natal functioning, and it would be assumed that all such functioning has the potential to be understood from a materialist viewpoint, even if it is not presently well understood. Memory, in particular, would be thought of as a function of the nervous system and not of other body parts or of nonmaterial elements.

One particularly important assumption about the psychology of prenatal life would be that until injury, disease, or old age interfere, development goes from a less advanced to a more advanced state. In other words, adults have more capacities than children, older children more capacities than infants, and infants more capacities than unborn babies. As a consequence, if an infant does not have the capacity to remember an experience, an unborn baby, who is less advanced in development, will not have that ability either. So, for instance, as a young baby does not have the capacity to understand many adult motives and wishes (like the ones Emerson called “essential qualities of feeling present at its inception”), an unborn infant will also be unable to perceive or remember such adult mental states. Although the baby could be affected by the mother’s physical condition, by stress hormones, etc., it would not actually be able to respond to the mother’s pleasure or displeasure about the pregnancy.

The capacities of newborn babies to show some recognition of sounds they heard a few weeks before birth are of great interest, and no one who has an interest in early development would argue that the fetus is “anesthetized” in some way, or that sensation and memory suddenly and instantly emerge when the baby takes its first breath. But those early abilities are a far cry from the telepathic communication of adult emotion sometimes claimed, and the evidence for them is a far cry from descriptions of drugged states.

Wednesday, March 2, 2011

Hey Good-Lookin': About Newborns Recognizing Their Mothers

I recognized a friend at a restaurant last night. We walked quickly toward each other, hugged, called each other by name, and began to dish the gossip. Other people watching (if any) would have agreed-- yes, they recognized each other.

But, of course, people who say newborn babies recognize their mothers don’t mean they do any of those grown-up things. I want to take some space here to talk about exactly what they do mean.

The first issue is what things babies can do that could let us tell whether they recognize someone. Their hearing is quite good, normally. Even before they’re born they show that they have heard something by sudden movements. After they’re born, they can choose a sound to listen to if we give them an artificial nipple rigged so their sucking can trigger one sound or another. Their vision is not as good as their hearing at birth-- detail vision is not what it will later be, and the clearest images they get are of objects about 12 to 18 inches from the eyes. They have some preferences for what they look at, and show those by looking longer at certain things, especially faces. They have excellent capacities for smell and taste, too, but those are much more difficult to work with because a particular smell or taste may linger for quite a while and is not so easy to change.

Newborns have another highly relevant ability: they are able to habituate and dishabituate to a sensory stimulus. This is a cognitive skill that may be the foundation of all other thinking. Basically, a baby habituates when he or she stops looking at or paying attention to a sight or sound that has been going on for a while. Dishabituation occurs when a new stimulus replaces the old one and the baby begins to look and pay attention once again. Young babies are much interested by novelty and on the whole pay more attention to unfamiliar than to familiar things-- a much different situation than we see in older children or adults, who like to examine familiar things very closely.

Habituation seems to apply to all senses and begins very early in life. For example, in one study, preterm babies held unfamiliar shapes in their hands longer than they did familiar ones (Lejeune, F. et al., [2010], The manual habituation and discrimination of shapes in preterm human infants from 33 to 34+6 post-conceptional age. PLoS ONE, Vol. 5, 1-7). And when it comes to measuring recognition, habituation is a real complicating factor, as ordinarily very young babies show more interest in unfamiliar things and less in familiar things, raising the possibility that “recognition” might be defined as ignoring something rather than paying attention to it. Nevertheless, studying habituation lets us see whether a baby responds differently to two faces or voices, and differences in response are enough to let us know whether there is recognition.... but not all research takes habituation into account or uses it as a way to understand the baby's reactions.

In one study, babies 2-4 days old showed different movements in response to their mothers’ voices and strangers’ voices, and also to their mothers’ voices speaking in an adult-directed way versus their mothers speaking “motherese” with its high pitch and exaggerated intonations. But when similar recordings were made of unborn babies (about 36 weeks gestational age) as they listened to their mothers’ or strangers’ voices from a speaker placed on the mothers’ abdomens, the babies did not react differently to mothers and strangers; on the other hand, they did react differently to the mother’s voice through the speaker and the mother’s voice when she was actually talking (Hepper, P.G., & Shahidullah, S. [1993]. Newborn and fetal rersponse to mother’s voice. Journal of Reproductive and Infant Psychology, Vol. 11, 147-153).

Anthony DeCasper is a researcher well-known for his 1986 work on recognition of mother’s voice and even of the “Dr. Seuss” story she read to her belly toward the end of pregnancy. He has continued to explore this topic and has found, not too surprisingly, that it’s all more complicated than it would appear. For example, in a recent study (Decasper, A.J., & Prescott, P. [2009]. Lateralized processes constrain auditory reinforcement in human newborns. Hearing research, Vol. 255, 135-141), he showed that the baby’s response to different sounds depends on which ear is being used, and therefore on which hemisphere of the brain is receiving messages about the sound. DeCasper provided the babies with a sucking device that could detect and record how fast the baby sucked. Faster sucking could produce one sound for the baby to hear, slower sucking a different sound. The sounds included an unfamiliar voice speaking, a recording of what the mother’s heartbeats sound like inside the uterus, and the mother’s voice speaking in either her native language or a different language.

Here are the complicated findings: When the baby had a choice between a stranger’s voice and the heartbeat, it chose the stranger’s voice only when listening with the right ear (through an earphone). It chose the heartbeats only when listening with the left ear. When the choice was between the mother’s voice and a stranger’s voice, or between the mother speaking her native language and speaking a foreign language, the baby chose the more familiar sound only when listening with the left ear. These findings suggest that when the baby is listening with both ears-- in its ordinary non-laboratory situation-- familiarity alone will not govern his or her attention and behavior. “Recognizing” does not seem to be such a simple matter.

Finally, I want to talk about a study that used habituation as part of its measure of babies’ looking preferences and ability to “recognize” (Figueiredo, B., et al. [2010]. Mother’s anxiety and depression during the third pregnancy trimester and neonate’s mother versus stranger’s face/voice visual preference. Early Human Development, Vol.86, 479-485). This study recorded how long a baby looked directly at its mother, who had spoken, as opposed to how long it looked at a stranger, who also spoke. (They were not present or speaking at the same time.) At the beginning of the study, the babies looked at the mothers for an average of 9.7 seconds, and at the strangers for an average of 6.8 seconds. When tested again a bit later, after habituation had taken place, they looked at the mothers for an average of 6.1 seconds and at the strangers (a different stranger than the one originally used was brought in for this) for 9 seconds. This suggests that they were socially competent enough to tell the difference between the mother and the stranger, but they had no overwhelming need to be attentive to the mother. Their recognition could be shown by the fact that they looked less at the mother rather than more.

A second, very interesting part of this study compared the behavior of babies whose mothers were anxious or depressed during pregnancy with that of those who were not. Newborns of depressed or anxious mothers showed much less “recognition” in the form of different amounts of looking toward their mothers and toward strangers. The impact of those differences on maternal attitudes and on the development of relationships may be a matter of concern, and suggests an emphasis on the transactional nature of development, in which mothers and babies influence each other in ways that change with time and experience.