End Stage

Is nothing sacred? Michael Shermer, Scientific American's Skeptic columnist, reports in the November issue that one of the icons of psychology, the five stages of grief, has been debunked.

Launched by Elizabeth Kubler-Ross in her book On Death and Dying (1969), the model of denial-anger-bargaining-depression-acceptance is one of the most widely known paradigms in modern psychology. But, according to Shermer's sources, there appears to be no evidence that most people most of the time go through most of those stages in that order, or any other order.

The five stages of grief, along with similar "stage" theories, Shermer says, satisfy people's craving for simplicity and predictability. Unfortunately, the scientific basis for them is just not there. And they can also impose feelings of guilt and shame on people who are not feeling what they think they should. And, in today's world, people who follow the simple "stages" narrative are the exception, while diversity and individual variation are the rule.

Good grief! What's next? Are we going to learn that there is no evidence that most people recovering from addiction go through a certain well known set of steps?

Genetics of mental illnesses: More is Less

Genetic research into psychiatic disorders appears to be undergoing a systemic deflation not unlike that in the financial markets. As I posted a couple of weeks ago, a survey article in the then-current Scientific American showed that genetic studies of human intelligence had labored mountainously and brought forth a 0.4 per cent mouse. Today comes a special issue of Nature Neuroscience dedicated to the neuropsychiatric diseases, and it's the same story. The initial radiant hope that today's mega-billion dollar genetic research apparatus would nail the culprit genes responsible for schizophrenia, autism, bipolar disorder, or depression, has dimmed to a faint glimmer. The more we can see, the less we find.

In the roundup article, Steven Hyman (Department of Neurobiology, Harvard) works hard at sounding upbeat, but has little to work with. Family studies, rich in anecdotal material, suggest that autism, schizophrenia, bipolar illness, and major depression must have major genetic components. Therefore it should be a simple matter to find the genes, and then to develop medications that target those genes.

Over the past two decades, however, efforts to identify risk-conferring alleles for the common forms of neuropsychiatric disorder have largely been unrewarding. Despite the significant role for genes highlighted by aggregate measures of their influence (Table 1), the underlying genetics of common neuropsychiatric disorders has proved highly complex, as attested by unpredictable patterns of segregation in families, lack of Mendelian ratios in twin studies and serious difficulties in replicating genetic linkage studies.

Anecdotes notwithstanding, the given illness frequently appears in people without the suspected genetic traits, fails to appear in people with the traits, and appears in people with other traits believed to be associated with an entirely disparate disorder. Current technology can easily identify "highly penetrant" genetic variations that cause a narrow subset of disorders, such as some types of Alzheimer's disease and macular degeneration, but the candidate genes involved with the most common psychiatric disorders make only a very slight dent in the etiology. It doesn't help that the clinical definitions of the psychiatric disorders tend to lack objective physiological markers, so that diagnosis rests ultimately on clinicians' opinions, which may vary widely.

Neither Hyman's article nor the remaining items in the special issue of Nature Neuroscience focus on addictive substance abuse, but you could substitute "alcoholism" into the paragraphs just quoted and come out with the same result. I've summarized the research on that topic in my forthcoming book. By April, when the book comes out, it should be amply clear that the deflation of the genetic myth in alcoholism is only part of a larger panorama of reassessment. The better our genetic research tools become, the more clearly we can see, the more obvious it becomes that we cannot blame our genes for our disorders, nor can we hope for a magic pill to set us right. It's just not going to be that easy.

Genetics: The more we see, the less there is

In the concluding chapter of my forthcoming book (link), I look at the evidence for an alcoholism gene.  My research showed that the more powerful our tools become, the less we find in the way of genetic causality.  Modern genetic research has wiped away any basis for the idea that alcoholism is a genetically transmitted disease.  The most that can be said is that some people appear to inherit a lower responsiveness to alcohol, so that if they drink, they must drink more to get the same high.  For details, see my book, due out in April.  

Now comes an article in Scientific American, by science journalist Carl Zimmer,  reporting on modern research into the genetics of intelligence.  Here too, the conventional wisdom has been that genes play a major role.  But when the most powerful computer-assisted research tools are turned on the human genome, the supposed genetic factor all but evaporates.  Intelligence turns out to depend very weakly on a diversity of genes. The most influential of these genes contributes just 0.4 per cent (less than one half of one per cent), and this gene is believed to influence also a variety of other cell functions -- so that it is not specific to intelligence as such.  

Much of the myth of genetic causality rests on twin studies.  This is true both in alcoholism and in intelligence research, as well as in other fields (for example, autism).   Zimmer cites research showing that twin studies involving affluent families show a strong apparent genetic influence, while similar studies involving twins from poorer families show virtually no genetic factor at work.  The modern molecular genetic studies suggest that the apparent genetic influence reported in some twin studies may be a chimera due to false methodological assumptions.   Twin studies have been severely criticized, and some scientists consider them junk.  The SciAm article is in the October 2008 issue at p. 68; a link is (temporarily) here.

Spirituality strikes out

Two controlled trials of the effect of spirituality on addiction recovery showed no improvement for the patients given spiritual guidance as part of the usual treatment regimen, either in their addiction recovery or in their spiritual practices.  In fact, in one trial, the patients provided with spiritual guidance made less progress in overcoming depression and anxiety than the patients not given spiritual treatment.

Details are in the Journal of Substance Abuse Treatment, July 25 2008.  The abstract is here.  Thanks to David Kaiser Ph.D. for flagging the item.  

Invitation to Guest Authors

Guest authors are invited to contribute to this blog. I have to take another break until the end of June. I'm working on a book with a June 30 deadline.

Confrontation Therapy, R.I.P.

Two of my favorite scholars have combined to write a powerhouse of an article that everyone interested in addiction treatment will want to read. William R. Miller, co-author of the Handbook of Alcoholism Treatment Approaches (reviewed here), and William L. White, author of the monumental history Slaying the Dragon (reviewed here), have written what hopefully will be an obituary for an era, entitled "Confrontation in Addiction Treatment." It's in Counselor Magazine. Here are a few snippets from this substantial, strongly researched and comprehensive treatment:

The use of confrontational strategies in individual, group and family substance abuse counseling emerged through a confluence of cultural factors in U.S. history, pre-dating the development of methods for reliably evaluating the effects of such treatment. Originally practiced within voluntary peer-based communities, confrontational approaches soon extended to authority-based professional relationships where the potential for abuse and harm greatly increased. Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations. There are now numerous evidence-based alternatives to confrontational counseling, and clinical studies show that more effective substance abuse counselors are those who practice with an empathic, supportive style. It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate.

....

Early claims of the superior effectiveness of confrontation and counterclaims that it was ineffective and potentially harmful relied primarily on statement of opinion buttressed by anecdotes. With the emergence of more science-grounded treatment approaches in the 1980s and 1990s came studies that began to tip the scales of this debate. Two recent reports, however, suggest that confrontation still has its proponents. A 2001 study on staff attitudes toward addiction treatment found that 46 percent of those surveyed agreed that “confrontation should be used more” (Forman, Bavasso & Woody, 2001); and a 2004 ethnographic survey of adolescent addiction treatment in the United States commonly encountered programs that were “explicitly designed to demean and humiliate” (Currie, 2004).

...

There never has been a scientific basis for believing that people with substance use disorders, let alone their family members, possess a unique personality or character disorder. Quite to the contrary, research on virtually any measure reflects wide diversity of personal characteristics among people with addictions, who are about as diverse as the general population, or as snowflakes. Studies of defense mechanisms among people in alcohol treatment have found no characteristic defensive structure, and higher denial was specifically found in a clinical sample to be associated not with worse, but with better treatment retention and outcomes (Donovan, Hague & O’Leary, 1975).

...

Reviewing four decades of treatment outcome research, we found no persuasive evidence for a therapeutic effect of confrontational interventions with substance use disorders. This was not for lack of studies. A large body of trials found no therapeutic effect relative to control or comparison treatment conditions, often contrary to the researchers’ expectations. Several have reported harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism. This pattern is consistent across a variety of confrontational techniques tested. In sum, there is not and never has been a scientific evidence base for the use of confrontational therapies.

If you've ever been exposed to confrontation therapy, or have a confrontational counselor now, by all means read this article, sure to be reprinted in textbooks and to become a classic.

If there's one defect in it, it's in glossing over the confrontational therapy element in AA itself. Dr. Harry Tiebout, whose psychiatric theorizing framed the confrontational approach, was hugely influential on Bill Wilson, and he was not alone. Dr. Silkworth echoed the theme, with his advice to Wilson to "give them the medical business, and give it to them hard." The "medical business" meant to convince the alcoholic that he was suffering from an incurable fatal illness. This revelation was designed to attack and to "shatter" the alcoholic's defenses, to "deflate" his ego, and render him hopelessly dependent on his "physician." The very first clause of step one, the foundation of the whole edifice, "powerless over alcohol," expresses a confrontational strategy, as thousands of counselors have found out in practice. To be fair, this is not the only element in AA; there are other strands that tend to counterbalance it. But the article is certainly wrong in claiming, as it does, that there is no attack therapy strand in AA at all. -- This cavil aside, the article is a masterful piece of work, by two giants in the field. Highly recommended.

Abstinence leads to rapid brain repair

Abstinence leads to rapid repair of gross brain damage seen in alcohol dependent persons, according to a review of neuroimaging studies by a group of Japanese researchers.

In uncomplicated alcoholic patients, a high incidence of cortical shrinkage and ventricular dilatation were reported using brain CT scans. In older alcoholics, prefrontal gray matter deficits were especially marked when compared with younger alcoholics. Reversibility of brain shrinkage is a common neuroimaging finding in patients with alcohol dependence.

Regrowth of shrunken brain areas was particularly vigorous during the first month of abstinence, the scans showed. Besides the gray matter, areas "with significantly greater recovery in abstainers were the temporal lobes, thalamus, brainstem, cerebellum, corpus callosum, anterior cingulate, insula, and subcortical white matter." Follow-up studies showed that the regrowth was not simply due to rehydration.

The study appeared in the Dec. 2007 issue of the Japanese Journal of Alcohol Studies and Drug Dependence. The abstract is here.

Brazil study: Does AA really work?

"Do Alcoholics Anonymous groups really work? Factors of adherence in a Brazilian sample of hospitalized alcohol dependents." -- That's the title of a study in the current issue of the American Journal of Addiction, published by a American Academy of Psychiatrists in Alcoholism and Addiction. A team of researchers headed by M.B. Terra followed 300 alcoholics committed to three hospitals in Puerto Allegre, Brazil. Results (from the abstract):

AA adherence was below 20%. The main factors reported by patients as reasons for non-adherence to AA were relapse, lack of identification with the method, lack of need, and lack of credibility. The factors reported by patients as reasons for adherence were identification with the method and a way to avoid relapse. Although AA is considered an effective intervention for alcoholism, its adherence rate was excessively low. The identification of these nonadherence factors could help health professionals in referring certain alcoholic patients to therapeutic interventions other than AA.

The result of this study is unsurprising; essentially the same finding was made in a meta-analysis almost two years ago reported in the Cochran Report (Source) What's noteworthy here is that patients were asked their reasons. It would be useful if the various threads in the responses (objections to the 12-step approach on the one hand, denial on the other) were explored in more depth and an attempt made to untangle them.

2007 Darwin Award Nominee: Alcohol Division

Michael was an alcoholic. And not an ordinary alcoholic, but an alcoholic who liked to take his liquor... well, rectally. His wife said he was "addicted to enemas" and often used alcohol in this manner. The result was the same: inebriation.

The machine shop owner couldn't imbibe alcohol by mouth due to a painful throat ailment, so he elected to receive his favourite beverage via enema. And tonight, Michael was in for one hell of a party. Two 1.5 litre bottles of sherry, more than 100 fluid ounces, right up the old address!

When the rest of us have had enough, we either stop drinking or pass out. When Michael had had enough (and subsequently passed out) the alcohol remaining in his rectal cavity continued to be absorbed. The next morning, Michael was dead.

The 58-year-old did a pretty good job of embalming himself. According to toxicology reports, his blood alcohol level was 0.47%.

In order to qualify for a Darwin Award, a person must remove himself from the gene pool via an "astounding misapplication of judgment." Three litres of sherry up the butt can only be described as astounding. Unsurprisingly, his neighbors said they were surprised to learn of the incident. Source. Thanks, John C. (Goathouse) for the item.

Humility R Us [NOT]

It's been six years since AA Trustee Dr. George Vaillant's article in the AA Grapevine, saying that "It doesn't hurt at the level of the GSO for AA to have humility and understand that 60 per cent do it without AA." Source. He was talking about the research finding that 60 per cent of alcoholics who achieve at least five years of abstinence do it without using AA.

It's been six years, and Vaillant's plea for humility has either not been heard or already forgotten. In this months' issue of Addiction Professional, columnist Carlton Erickson reports that "fourteen experts" recently met at a "consensus conference" in Rancho Mirage CA to define "recovery," and came up with a definition that includes an implied endorsement for "peer support groups such as AA and practices consistent with the 12 Steps and 12 Traditions."

In other words, judging by Erickson's column, if you're part of the majority that are staying sober without AA you're not considered in recovery. But if you're a chain-smoking Big-Book thumper whose entire social, moral, and intellectual life is wrapped up in AA meetings, then you're a model of recovery. The mind boggles.

The panel's full report, published in the Journal of Substance Abuse Treatment, is considerably more balanced than Erickson's column makes it seem. The report says that "the founders of AA recognized that there were many paths to the same position ... and did not suggest that their specific methods were the only means to attain the overall goal." (Thanks Jason Schwartz for forwarding the full article.) The panel considered but expressly rejected the definition of recovery as "abstinence attained through adherence to 12-step principles."

That's progress. But the plug for AA and the 12 steps is highlighted in the report, and Erickson's column picked up on that highlight, as most hurried readers will.

This endorsement is completely gratuitous. It comes in the absence of any evidence cited in the report showing either (a) superior efficacy of 12-step over other paths in reaching long-term sobriety, or (b) a positive association between long-term participation in 12-step groups and measures of "personal health and citizenship."

The report admits that no validated instrument for measuring "personal health and citizenship" exists. Then what scientific ground is there for making the claim?

The implied beneficial effect of AA participation on "personal health" is indefensible given the notorious prevalence of nicotine addiction among AA members. The report takes note of the nicotine problem, including "significant rates of emphysema, cancer, and other terminal health conditions associated with these products among those otherwise in recovery" (read: in AA). But come to the bottom line, the panel tucked tail between legs and "considered it best to remain silent on tobacco use within the sobriety component of the recovery definition."

The next line is lovely: "It is admitted that there is no clinical justification for this position."

The claim that long-term AA participation enhances "citizenship" is equally dubious. The cited ground for it is the AA homilies for doing service, "giving back." But this "service," to the limited extent people actually do it, is in the nature of recruiting for the AA organization. AA has no outward-directed community service component on the order of the Masons, Shriners, Rotarians, and many other groups. So where does "citizenship" come in?

Trying to come up with a definition of recovery is a laudable project. The panel notes that recovery science (as distinct from addiction science) is a poorly developed field, and that the lack of a validated definition of 'recovery' is a significant obstacle. But when you enter the gates of science, the motto is "lasciare ogni sospetto" -- here drop all hesitation, abandon all fear. So long as recovery scientists keep genuflecting to the sacred cow in the room, little progress and considerable dung is to be expected.

Alcohol Killed 'The Prophet'

The excellent New Yorker continues its literary war on the alcohol-as-muse delusion. In the Jan. 7 issue is a thumbnail bio of Kahlil Gibran, author of the huge bestseller, The Prophet. After the success of this book, Gibran took to drinking heavily. Eight years after The Prophet, having produced nothing further of note, he died of cirrhosis of the liver, at age 48.