This post is based in part on my thoughts regarding Doidge's book on neuroplasticity.
Psychoanalysis is a type of psychotherapy in which patients usually attend sessions almost every day (3-5 days per week, 50 minutes each time). The details of theory and practice vary, but in general psychoanalysts tend to believe that early childhood events and memories are very important to examine and understand, and that these events (e.g. relationships with mother) have direct causal links to adult personality traits and psychological symptoms. Also psychoanalysts tend to believe that the relationship with the therapist is a setting in which prior relationship dynamics recur, in the form of "transference." Most psychoanalysts assume a relatively quiet or passive stance, tending not to have active conversation or "problem solving" dialogs with patients. Also most psychoanalysts would tend to interpret various types of phenomena, such as dreams, behavioural habits, etc. as laden with meaning. A course of psychoanalysis might take years, and in general the model would be that the patient would "work through" various childhood conflicts, including as they might be transferentially manifest in the therapy, and that the patient might come to understand the various themes at play in their lives, as manifest in dreams, habits, and interpersonal behaviour. This process of understanding and "working through" is thought to lead to symptom relief and life change.
Doidge himself is a psychoanalyst. One of the chapters in his book describes psychoanalysis as a "neuroplastic therapy." (chapter 9, Turning our Ghosts into Ancestors). Part of the support for his claim comes from a case study (a type of evidence characteristic of psychoanalytic thinking). And part of his support comes from briefly describing the life and work of Eric Kandel, the great nobel laureate neuroscientist.
Kandel's work brilliantly demonstrated some of the specific anatomic and molecular changes that happen in neurons as memories are formed.
Kandel himself has been an advocate of incorporating recent biological scientific knowledge into the practice of psychiatry and psychoanalysis (see: http://www.hhmi.org/bulletin/kandel/), and had apparently planned to become a psychoanalyst himself.
I consider it not to be particularly relevant to mention Kandel at all, other than to quote someone important who probably considers psychoanalysis a good thing. It is a common sales tactic to mention an important person's name while trying to convince someone of something. Also it is common in medicine and psychiatry--but especially in alternative medicine--for there to be some mention of something that sounds "scientific" to bolster the public opinion of a product, while the science itself, if looked at closely, is only obliquely related. For example, many questionably effective naturopathic remedies, sold at quite a profit, include advertising laden with some kind of biochemical jargon, much of which, at close examination, lacks substance, but which sounds impressive.
I believe that psychoanalysis can be a powerful and transformative experience. However,I also strongly suspect that there are elements of dogma contained within the theory which are irrelevant to its beneficial effects, and which at times could make it an inefficient therapy.
Consider this thought experiment:
Suppose the beneficial effects of psychoanalysis are due to the following factors:
1) meeting with someone for an hour per day, who will listen and try to understand life problems
2) finding an "explanation" for symptoms. In the case of psychoanalysis this explanation tends to come from an examination of early life events.
Suppose that it is the belief in the explanation that causes symptom improvement, therefore that if some alternative "explanation" for symptoms could be developed, then it would lead to the same symptom improvement. Therefore, suppose that the psychoanalytic theory of character and symptom development is actually a fiction, akin to a dogmatic religious belief system, but that adherence to this belief system, and the resultant faith and conviction, would be the causes of symptom relief and character change.
A way to test this would be to conduct a randomized study of two types of intensive, long-term psychotherapy. Both would be 5 sessions per week, 50 minutes per session, lasting 5 years.
Group 1 patients would have psychoanalysis.
Group 2 patients would receive the same intensive, empathic, sessions, with intelligent and thoughtful, well-boundaried therapists. But let us imagine that some other belief system would underlie the therapy for group 2. For example, astrology. Or some form of religious fundamentalism (of any variety). Here, interpretations would be based on the positions of stars & planets, or on passages from religious texts.
A condition for this type of experiment would be that the patients in both groups would have to lack any differences in bias for or against the style of therapy. So, for example, patients in group 1 would have to have a similar level of belief that psychoanalysis is a valid and culturally-accepted system of thought, and have similar respect for the therapist, compared to the beliefs about therapist and therapy style of patients in group 2 (regarding astrology or fundamentalism, etc.).
In both groups, I suspect that subject matter would come up in the sessions, which would require the therapists to respond either empathically or interpretively. There would probably be dreams that would come up, probably interpreted quite differently--or not at all-- in both groups. The process of therapy, dream interpretation, feelings of closeness with therapist, etc. might well be experienced similarly between groups.
My hypothesis is that both the groups would show similar improvement in a 5 year course of therapy, with only a slight advantage for group 1. I believe this is because the core effect of such therapy is not from the theoretical belief system, but from the process, which is caring, consistent, empathic, understanding, and interpretive. Failed therapy experiences may happen in both groups, some of which because the patients do not like the style or belief system which is being introduced, some of which because life problems can be treatment-resistant at times, some of which because the patient did not feel well-matched with the therapist. I think group 1 would do very slightly better than group 2, because despite the dogma involved in psychoanalytic theory, the underlying process is more intellectually open (at its best).
Unfortunately, I think there is a substantial risk for people in both groups to come out of the experience with stronger dogmatic beliefs, irrespective of any therapeutic improvement. In a more mature psychoanalytic frame, I think this risk would be diminished, as the process would hopefully be more intellectually open.
I do believe that we as intelligent creatures should always seek the "truth" as best we can know it, and therefore we need to challenge our dogmas. The best therapies, in my opinion, need to seek such truths without being restricted by dogma. This is consistent with the underlying theme of psychoanalysis, which I think is about liberation (liberation from symptoms, liberation from past harms or traumas, etc.).
I am reminded now of Joseph Campbell, the comparative mythologist, who might argue that the different styles of therapy are something like different mythologies, none of which are literally "true", but perhaps all of which might contain core aspects of wisdom about the human condition. He might also argue that dogmatic, literalistic adherence to any system of belief could obstruct its underlying message. But he would also agree, I think, that one has to have "faith"--a sense of trust, engagement, and belief--in order to have a transformative experience from anything.
In psychoanalysis, I think it is immensely valuable to seek meaning by examining early childhood events, and by searching for meaning and themes in dreams and nuances of behaviour. But I think it can be can be obstructive to believe, literally, for example, that specific non-traumatic events or patterns of engagement with one's mother at the age of 2, are the causes of specific adult symptoms. I consider the greatness of psychoanalytic interpretation to lie in its focus upon a human life as though it is a great novel or work of art, and that the therapy is partly an experience of understanding, analyzing themes, interpreting, looking at context, in order to enrichen the experience of the art.
A weakness in psychoanalytic practice can, in my opinion, be due to its passive approach at times, which can render it less efficient. Another weakness can be due to a dogmatic or literalistic over-absorption with the theory, causing the therapy to digress--sometimes for years--into an examination of early childhood events, when the core elements of therapeutic need lie solidly in the present, or in the more recent past. I think modern psychoanalysis needs to much more actively incorporate ideas from cognitive and behavioural therapies, from social psychology, as well as from behavioural genetics, etc., and to actively question its dogma.
From a "neuroplastic" point of view, I think the immense advantage of psychoanalysis is in the frame, which is intense (5 days per week), long-term (over years), intellectually open (anything that passes through one's mind is encouraged to be spoken), and consistent. If one was taking language or music lessons, we would see MUCH more "neuroplastic change" in the brain (and, much more importantly, we would see much more language or music learning), if the lessons took place 5 times a week for 5 years, rather than just once a week for 6 months. The consistency and discipline of the psychoanalytic frame is powerfully motivational, just as is any other consistent and disciplined educational framework.
Tuesday, March 17, 2009
Drum Circles
Drum circles are groups where people gather to pound drums together: producing, hearing, and appreciating rhythms.
The perception of rhythm is one of the core elements of human experience.
Over hundreds of thousands of years of human evolution--even before the development of culture--the perception of rhythm must have been a very important part of daily life experience.
Here are some examples of rhythms that have been part of life experience for millions of years:
-The rhythmic pounding of ocean waves
-The beating of the heart (as perceived by feeling the pulses through touch, by feeling a throbbing, excited heart in the chest, or sometimes by hearing one's own or someone else's heartbeat)
-The rhythm of breathing (regular and soft in a calm state, rapid or erratic in anxious or excited states, irregular in various particular ways as a person is crying or sobbing; or when a person is dying, e.g. Cheyne Stokes respiration)
-The chirping of crickets or the croaking of frogs (these rhythms being affected by human proximity)
-The rhythm of work tasks (e.g. preparing some kind of meal or building some kind of structure would involve repetitively pounding, picking, or working with a material, and if this was a monotonous, laborious task, a rhythm would naturally form to help the person "get into it")
-The rhythm of human footsteps (steady and strong when feeling confident and certain, rapid or timid when frightened, stomping when angry)
-The rhythms of the human voice. Before the development of languages over 50 000 years ago, probably a great deal of communicative content between humans would have been based on "non-verbal" vocalizations, which would have emphasized tonal quality but also rhythm. Today vocal rhythms are most obviously part of the expressive content in poetry and song.
-Part of rhythm includes silence. It is the "empty space" between sounds. There was a lot more silence in pre-modern cultures.
Upon the development of human culture, starting perhaps 50 000 years ago, rhythms would have been generated spontaneously as a part of creative expression, as celebration, or as ritual.
In modern culture, perhaps a lot of the ancient, prehistoric aspects of rhythmic perception have been "drowned out". In urban environments, we have a lot of cacophonic, industrial sounds, or multiple sources of sounds all coming at us at the same time. There may not be very much silence at all. I suspect that this cacophony is a contributing factor to life stress, and one of the variables increasing the rate of mental illness (there are certainly many studies showing increased prevalence of various mental illnesses in urban environments). As a corollary, I believe that spending time developing one's musical and rhythmic experiences is beneficial to mental health.
As a therapeutic modality, drumming could help people in various ways:
1) as a form of meditative focus
2) it involves physical action: it is a form of exercise as well as a form of tactile stimulation
3) it helps to focus attention: it is a form of mental exercise, as well as a means to distract mental energy away from anxiety or other negative emotions
4) it can be an endless source of intellectual stimulation, with hearing or producing increasingly complex rhythms and cross-rhythms. This can evolve to become a source of esthetic enjoyment, also leading to appreciating rhythm in other aspects of life and music more richly.
5) it can be a social activity, in which other members of the group can be guides or teachers: in drum circles, individuals need not be skilled in drumming or in generating complex rhythms--exposure to the group permits a social learning experience
6) similarly, a drum circle could be a good setting to deal with performance anxiety or social anxiety, in the comfort of an encouraging and accepting group
7) it can simply be a healthy, enjoyable form of stress management
8) drum circles can be a means to build community: the experience combines elements having to do with conformity (maintaining the same rhythm together) and with individuality (each person may have a separate or special rhythmic role or task) -- both such elements are required to have healthy community life
In Vancouver, I know of one regular drum circle group, which has been open to anyone interested. The leader of this group, Lyle Povah, has done interesting work with drum circles as part of an inpatient eating disorders treatment program. Here's his website:
http://lylepovah.com/
There may be similar groups in other communities across the world, and I encourage people to research this, and to consider checking one out.
The perception of rhythm is one of the core elements of human experience.
Over hundreds of thousands of years of human evolution--even before the development of culture--the perception of rhythm must have been a very important part of daily life experience.
Here are some examples of rhythms that have been part of life experience for millions of years:
-The rhythmic pounding of ocean waves
-The beating of the heart (as perceived by feeling the pulses through touch, by feeling a throbbing, excited heart in the chest, or sometimes by hearing one's own or someone else's heartbeat)
-The rhythm of breathing (regular and soft in a calm state, rapid or erratic in anxious or excited states, irregular in various particular ways as a person is crying or sobbing; or when a person is dying, e.g. Cheyne Stokes respiration)
-The chirping of crickets or the croaking of frogs (these rhythms being affected by human proximity)
-The rhythm of work tasks (e.g. preparing some kind of meal or building some kind of structure would involve repetitively pounding, picking, or working with a material, and if this was a monotonous, laborious task, a rhythm would naturally form to help the person "get into it")
-The rhythm of human footsteps (steady and strong when feeling confident and certain, rapid or timid when frightened, stomping when angry)
-The rhythms of the human voice. Before the development of languages over 50 000 years ago, probably a great deal of communicative content between humans would have been based on "non-verbal" vocalizations, which would have emphasized tonal quality but also rhythm. Today vocal rhythms are most obviously part of the expressive content in poetry and song.
-Part of rhythm includes silence. It is the "empty space" between sounds. There was a lot more silence in pre-modern cultures.
Upon the development of human culture, starting perhaps 50 000 years ago, rhythms would have been generated spontaneously as a part of creative expression, as celebration, or as ritual.
In modern culture, perhaps a lot of the ancient, prehistoric aspects of rhythmic perception have been "drowned out". In urban environments, we have a lot of cacophonic, industrial sounds, or multiple sources of sounds all coming at us at the same time. There may not be very much silence at all. I suspect that this cacophony is a contributing factor to life stress, and one of the variables increasing the rate of mental illness (there are certainly many studies showing increased prevalence of various mental illnesses in urban environments). As a corollary, I believe that spending time developing one's musical and rhythmic experiences is beneficial to mental health.
As a therapeutic modality, drumming could help people in various ways:
1) as a form of meditative focus
2) it involves physical action: it is a form of exercise as well as a form of tactile stimulation
3) it helps to focus attention: it is a form of mental exercise, as well as a means to distract mental energy away from anxiety or other negative emotions
4) it can be an endless source of intellectual stimulation, with hearing or producing increasingly complex rhythms and cross-rhythms. This can evolve to become a source of esthetic enjoyment, also leading to appreciating rhythm in other aspects of life and music more richly.
5) it can be a social activity, in which other members of the group can be guides or teachers: in drum circles, individuals need not be skilled in drumming or in generating complex rhythms--exposure to the group permits a social learning experience
6) similarly, a drum circle could be a good setting to deal with performance anxiety or social anxiety, in the comfort of an encouraging and accepting group
7) it can simply be a healthy, enjoyable form of stress management
8) drum circles can be a means to build community: the experience combines elements having to do with conformity (maintaining the same rhythm together) and with individuality (each person may have a separate or special rhythmic role or task) -- both such elements are required to have healthy community life
In Vancouver, I know of one regular drum circle group, which has been open to anyone interested. The leader of this group, Lyle Povah, has done interesting work with drum circles as part of an inpatient eating disorders treatment program. Here's his website:
http://lylepovah.com/
There may be similar groups in other communities across the world, and I encourage people to research this, and to consider checking one out.
Friday, March 13, 2009
Doidge (Neuroplasticity) review - part 3 (Schwartz)
Doidge devotes a chapter to discussing obsessive-compulsive disorder. He claims that a treatment developed by Jeffrey M. Schwartz is "plasticity-based". The implication is that other psychological treatments for OCD are NOT "plasticity-based."
Schwartz has published articles in the literature going back into the 1980's looking at OCD patients using PET imaging.
I do not find any good study in the literature about Schwartz's particular technique, as published in his book, in particular no study comparing his technique with CBT.
Also the theory is presented that OCD is caused by a failure for the caudate nucleus in the brain to "shift gears automatically", and that the therapy described is a means of "shifting gears manually." While there are a variety of brain metabolism changes in OCD, I think it is an overly strong statement to believe that this is literally true. One could use the idea of the "caudate gear box" as a metaphor, but it may be quite inaccurate, or at least poorly supported by clear evidence, to be taken literally.
So it concerns me that the chapter in Doidge's book about the "brain lock" approach is more of a book plug than something founded on solid evidence. Doidge could well have made the case that CBT is a type of "neuroplasticity-based treatment". In fact, there is good data to support such a case--including numerous imaging studies--and including a recent paper which Schwartz himself co-authored, which shows various regional changes in brain metabolism associated with improvement in OCD symptoms from intensive CBT:
http://www.ncbi.nlm.nih.gov/pubmed/18180761
Yet, I think it is important to be open about any new therapeutic idea--it may be that the "brain lock" therapy for OCD could be helpful to many people. It's just that Schwartz's book has been given an endorsement by Doidge without a convincing amount of good evidence, while minimizing the robust evidence favouring CBT.
Schwartz has published articles in the literature going back into the 1980's looking at OCD patients using PET imaging.
I do not find any good study in the literature about Schwartz's particular technique, as published in his book, in particular no study comparing his technique with CBT.
Also the theory is presented that OCD is caused by a failure for the caudate nucleus in the brain to "shift gears automatically", and that the therapy described is a means of "shifting gears manually." While there are a variety of brain metabolism changes in OCD, I think it is an overly strong statement to believe that this is literally true. One could use the idea of the "caudate gear box" as a metaphor, but it may be quite inaccurate, or at least poorly supported by clear evidence, to be taken literally.
So it concerns me that the chapter in Doidge's book about the "brain lock" approach is more of a book plug than something founded on solid evidence. Doidge could well have made the case that CBT is a type of "neuroplasticity-based treatment". In fact, there is good data to support such a case--including numerous imaging studies--and including a recent paper which Schwartz himself co-authored, which shows various regional changes in brain metabolism associated with improvement in OCD symptoms from intensive CBT:
http://www.ncbi.nlm.nih.gov/pubmed/18180761
Yet, I think it is important to be open about any new therapeutic idea--it may be that the "brain lock" therapy for OCD could be helpful to many people. It's just that Schwartz's book has been given an endorsement by Doidge without a convincing amount of good evidence, while minimizing the robust evidence favouring CBT.
Doidge (Neuroplasticity) review - part 2 (Taub)
Doidge devotes a chapter to the work of Edward Taub. I think Taub's ideas are simple but brilliant. He developed a treatment called "constraint-induced movement therapy" which appears to be remarkably effective to help with recovery from strokes and other injuries.
The simple idea is to restrain the normal limb, almost continuously, for at least weeks at a time, after a neurological injury. Otherwise, the normal limb will compensate for the affected limb. If the normal limb is constrained, the brain itself will develop new pathways to improve the function of the affected limb.
This treatment has good evidence-based support:
http://www.ncbi.nlm.nih.gov/pubmed/18077218
{this 2008 study is from Lancet Neurology, one of the top journals in neurology}
http://www.ncbi.nlm.nih.gov/pubmed/17077374
{another very important study from 2006 in JAMA}
I'm curious about the applications of this sort of therapeutic idea to psychiatry. Psychiatric symptoms can be like other neurological impairments, and the psychoanalytic phenomenon of "defences" may be analogous to the tendency for a neurologically-injured person to favour the non-affected limb, while the affected limb loses more and more function. A psychological therapy which challenges defences may be something like a Taubian "constraint-induced movement therapy" for the mind.
Importantly, in order for Taub's therapy to work, the constraint has to be applied almost continuously during waking hours, for at least weeks at a time. It is an immersive experience. It is an interesting challenge to find more psychological therapies that can be "immersive" in this way.
The simple idea is to restrain the normal limb, almost continuously, for at least weeks at a time, after a neurological injury. Otherwise, the normal limb will compensate for the affected limb. If the normal limb is constrained, the brain itself will develop new pathways to improve the function of the affected limb.
This treatment has good evidence-based support:
http://www.ncbi.nlm.nih.gov/pubmed/18077218
{this 2008 study is from Lancet Neurology, one of the top journals in neurology}
http://www.ncbi.nlm.nih.gov/pubmed/17077374
{another very important study from 2006 in JAMA}
I'm curious about the applications of this sort of therapeutic idea to psychiatry. Psychiatric symptoms can be like other neurological impairments, and the psychoanalytic phenomenon of "defences" may be analogous to the tendency for a neurologically-injured person to favour the non-affected limb, while the affected limb loses more and more function. A psychological therapy which challenges defences may be something like a Taubian "constraint-induced movement therapy" for the mind.
Importantly, in order for Taub's therapy to work, the constraint has to be applied almost continuously during waking hours, for at least weeks at a time. It is an immersive experience. It is an interesting challenge to find more psychological therapies that can be "immersive" in this way.
Doidge (Neuroplasticity) review - part 1 (Merzenich)
This post begins my review of Doidge's references from his book on neuroplasticity.
The first references I have looked through pertain to the work of Michael Merzenich. He has done very interesting research, dating back 4 decades, a lot of it having to do with studying the auditory cortex, and how it changes in response to stimulation of various sorts during different phases of development. Also he done major work researching and developing cochlear implants for treating hearing loss.
His 2006 article about using a "brain plasticity based training program" to improve memory in older adults (http://www.ncbi.nlm.nih.gov/pubmed/16888038) is interesting and encouraging, yet it warrants a close look at the actual results: the memory improvements from this technique were very modest (though significant), also the control groups were both quite passive (one group just looked at DVD videos, the other had no "intervention" at all). It would have been much more interesting to me to see an active control group in which the individuals would be doing simple memory exercises or other active intellectual stimulation for the same length of time. Because this type of active control was absent, the results may aggrandize the specific form of skill training described in the study; this skill training regimen is now being marketed, and money is surely disappearing from the pockets of many people, including many elderly people who may not have an abundant financial reserve. This makes me especially less enthusiastic about the results. I have no doubt that active mental exercise changes the brain through "plasticity" but I have to wonder if we have to sign up for the deal ("save 20% and get free ground shipping!") with this specific technique to achieve this. Perhaps signing up for a book club, memorizing poetry, and playing chess daily, would accomplish similar results. I would like to see what the evidence has to say about this. His website is interesting to look at, has a few mental exercises to check out, the style of which I think really is quite positive and imaginative. I will be curious to see if his approach--and variations of it-- could be specifically helpful in treating disorders such as autism. But I don't see good clinical data out there yet.
As an amateur musician, I have found that "ear training" is probably the most important, but often least taught or practiced, form of mental development for improving musicianship. Merzenich's exercises clearly focus on "ear training" as a significant component. Here's his website for you to check it out yourself: http://bfc.positscience.com/
Here's a link to a program you can acquire, designed for music students, which develops musical ear-training ability much more thoroughly, in my opinion (I recommend this to all musicians): http://www.earmaster.com/
The first references I have looked through pertain to the work of Michael Merzenich. He has done very interesting research, dating back 4 decades, a lot of it having to do with studying the auditory cortex, and how it changes in response to stimulation of various sorts during different phases of development. Also he done major work researching and developing cochlear implants for treating hearing loss.
His 2006 article about using a "brain plasticity based training program" to improve memory in older adults (http://www.ncbi.nlm.nih.gov/pubmed/16888038) is interesting and encouraging, yet it warrants a close look at the actual results: the memory improvements from this technique were very modest (though significant), also the control groups were both quite passive (one group just looked at DVD videos, the other had no "intervention" at all). It would have been much more interesting to me to see an active control group in which the individuals would be doing simple memory exercises or other active intellectual stimulation for the same length of time. Because this type of active control was absent, the results may aggrandize the specific form of skill training described in the study; this skill training regimen is now being marketed, and money is surely disappearing from the pockets of many people, including many elderly people who may not have an abundant financial reserve. This makes me especially less enthusiastic about the results. I have no doubt that active mental exercise changes the brain through "plasticity" but I have to wonder if we have to sign up for the deal ("save 20% and get free ground shipping!") with this specific technique to achieve this. Perhaps signing up for a book club, memorizing poetry, and playing chess daily, would accomplish similar results. I would like to see what the evidence has to say about this. His website is interesting to look at, has a few mental exercises to check out, the style of which I think really is quite positive and imaginative. I will be curious to see if his approach--and variations of it-- could be specifically helpful in treating disorders such as autism. But I don't see good clinical data out there yet.
As an amateur musician, I have found that "ear training" is probably the most important, but often least taught or practiced, form of mental development for improving musicianship. Merzenich's exercises clearly focus on "ear training" as a significant component. Here's his website for you to check it out yourself: http://bfc.positscience.com/
Here's a link to a program you can acquire, designed for music students, which develops musical ear-training ability much more thoroughly, in my opinion (I recommend this to all musicians): http://www.earmaster.com/
Subscribe to:
Posts (Atom)