This was the title of a talk by the philosopher and journalist Robert Rowland Smith, at London’s School of Life two days ago.
I have known Robert for a couple of years, during which he has published two books exploring how philosophy is relevant to the everyday dilemmas of modern life: Breakfast with Socrates and Driving with Plato.
The essence of the talk, I think, was that despite regular reminders throughout history of humanity’s less than fully rational nature, we still tend to overestimate our self-control. The constant development of technology not only distracts us from evidence to the contrary, but creates neurotic
dissatisfaction which we tend to worsen by seeking relief in materialism rather than by improving our interpersonal relationships.
I’m not sure that Robert is right in seeing the Western rational “Enlightenment” as perhaps now needing some sort of counter in the form of an Endarkenment”, because I think that contemporary philosophies and psychotherapies, as well as older Romantic Western culture, offer a whole range of ways to explore what Jung called our “shadow aspects”. And some people who are stuck in over-rational ways of life are suffering from biologically-based problems such as depression (1) or autistic spectrum disorders: they may need medication or other treatments to fully take part in philosophical or psychotherapeutic discourse.
It might seem odd that medical technology is sometimes necessary to enable a less technologically-dependent life. But in my view this is just a particular case of science liberating rather than oppressing (2). Philosophy too contains many paradoxes of this kind, such as Wittgenstein’s recommendation that we should simply stop chattering about “things of which nothing can be said”: his non-silence was required first, so that therapeutic silence could follow.
(1) In general the more severe and long-lasting the depression the greater is the need for medication. But some severe depressions may respond well to psychotherapy and/or philosophy, and some mild depressions may respond only to medication.
(2) Of course, technology and science are often used oppressively, or at least with neglect, whether deliberately or by mistake. Antidepressants prescribed after a ten-minute consultation with a GP (rather than a much longer consultation with a GP, psychiatrist or clinical psychologist), including little or no discussion of psychotherapy, amounts to state-sanctioned neglect in my view.
Oliver James (see the previous Blog piece, 4th February) is unpopular with many people and parents affected by ADD / ADHD. Not a big surprise, given his strong view that genes have been over-emphasised, and early parenting neglected, as causes of all the common mental and behavioural disorders. Also his rampant anti-Americanism (1) (it is probably significant that ADD / ADHD diagnosis and treatment, especially for adults, has largely developed in the US).
I think that he is largely wrong on those key issues, but also that his books still contain interesting and sometimes valid points. He is right, for example, to suggest that many people can gain as much “insight” from “work, sport or art”, as from psychotherapy (2).
There is no magic formula to reveal who will, or will not, be helped by psychotherapy. And James even implies that “therapy culture” could make you worse (3), although this is more of a comment on reality television than ordinary professional practice.
His linking of the Positive Psychology movement with materialism and consumerism is doubtful to say the least, because academics like Seligman have constantly stressed the primacy of interpersonal relationships for promoting happiness and preventing depression. I wonder if James was trying to make a somewhat different point about the limits of his own “Affluenza” argument: below a certain level of material provision family and social life become difficult, and psychotherapy of any kind should not collude in denying that.
As for ADD / ADHD, it is disappointing that books written in 2002 and 2007, while recognising that autism may be substantially genetic, do not accept the same might apply to other developmental conditions.
Where I agree with Oliver James most of all, in these books, is the sense that exploration of the past through psychotherapy is an uncertain process, and that objective sources such as accounts from others, or school records, should be sought wherever possible. His recommendation to “Interview your mother or father or a sibling or an adult who was close to the family when you were small” (4) sounds close to a description of the diagnostic history-taking approach used by psychiatrists and clinical psychologists.
Therefore I think it a bit of a regression when he appears to suggest, in Affluenza, that psychotherapy may reliably uncover buried memories from childhood (5). Despite a clear non-endorsement of transference-based reconstruction (6), he fails to offer any warning about the possibility of “false memories”, either overly negative or positive, being created in the psychotherapy process itself.
(1) They F*** you up (2002) paperback: p228 (2) p259 (3) p246 (4) p182
(5) Affluenza (2007) paperback: p442: “…help with directly recalling what went on in my childhood”
(6) p442: Avoid the therapist “…if they fob you off with ‘We will investigate how your past is affecting you through the way you relate to me’”
I only share James’ views about using transference as investigation: the therapeutic technique may be useful for some people, as long as the therapist does not make claims for reliable historical reconstruction.
Thanks to Andrew Lewis and Richard Sherry for comments on these two pieces.
Over the last three weeks the BMJ has published several articles by the investigative journalist Brian Deer, and an editorial co-written by a leading GMC member, alleging that ex-Doctor Andrew Wakefield’s research linking MMR to autism was a fraud.
Brian Deer, The Sunday Times and Channel Four’s Dispatches should be congratulated. The current BMJ editor is right to say that medicine needs more investigative journalism, and to highlight the need for wider vaccination against measles.
But several problems remain. The neutral observer might well ask how the “good” investigative journalism of Mr Deer is to be reliably distinguished from the “bad” of the Daily Mail, the Daily Telegraph and Private Eye (1). Is it really just the detail, the lengths to which Mr Deer went? I am not convinced that if the Mail’s Melanie Phillips (say) had spent the same amount of time on the story, she would have ended up believing Andrew Wakefield to have been fraudulent, or even deliberately dishonest.
Mr Deer himself seems to recognise the limits of his three BMJ pieces. In a Press Gazette interview last year he indicated that there is no real distinction between scientific journals, newspapers and magazines. He stated in a Guardian Blog (12th January 2011) that the BMJ was part of an “insidious cartel”. What difference does it make, then, that his first BMJ piece was “peer reviewed”, anonymously as usual? Perhaps it would have been more consistent for him to decline such a closed process.
The Lancet’s Richard Horton is alleged to have acted from largely “medical establishment” motives. But in my view there are two significant flaws in the Deer/BMJ account, across the several pieces and editorials. First, it distorts and minimises the history of the “autistic enterocolitis” construct, which developed from a decade or more of speculative but “peer reviewed” research, and not merelyWakefield’s undisclosed legal action.
Second, it ignores the wider context in which the worldwide anti-vaccinationist movement has grown. The British Medical Journal and the Lancet have both played an important role in the current debate, following Vioxx and other cases, about “industry” conflicts of interest and the right balances between openness, promotional claims, and business interests.
However, the BMJ has gone much further, even at the height of the MMR scare in the UK, in promoting scepticism about the “inappropriate domination of the Western view of mental health”, a process in which “doctors and the pharmaceutical industry” irresponsibly push both “Western cultural ideas” and “a rapid growth in the numbers of children diagnosed with conditions such as attention deficit hyperactivity disorder and autism” (Timimi, BMJ, 2005).
Two days after Brian Deer’s second article, a Blog piece entitled “How to stop the medical arms race” by a former BMJ editor revealingly set out the default position of the journal (Smith, BMJ, 13th January 2011): select evidence of “technology” and “doctors” leading to worse outcomes, not better. That Richard Smith’s Blog piece was typically urbane and self-deprecating might suggest that here, rather than in the Lancet, lie the real views of the “medical establishment”.
The BMJ has also published many opinion pieces by the “No Free Lunch” campaigner Des Spence which strongly criticise Western medicine. For example: “big pharma use[s] political lobbying to pervert the course of medical justice” (11th March 2009), and “A medicated childhood is blunt, defies reason, and is just bad medicine.” (21st July 2010).
Dr Spence has stated that because of the need to “protect the consumerist patient from themselves”, he and other GP’s suggest “complementary treatment, and even placebos” (4th February 2009). This seems to be a lesser-evil approach, but I have been unable to find any acknowledgement that such GP behaviour, rather than patients’ “health neurosis” (2), could cause the rejection of MMR vaccination (29th July 2009).
Taken together, when some parents, journalists and politicians read views like this, in the light of their own experience of the indifference shown by the “medical establishment” to neurodevelopmental disorders (3), it is not very surprising that they prefer a different version of events: Andrew Wakefield’s continued fight against Western medicine’s vaccine industry, which scored a temporary victory during the fitness to practise (FTP) panel’s 45 days of deliberating in secret (to use Brian Deer’s preferred term, rather than the GMC’s euphemistic in camera). The Wakefield FTP hearing transcript is still not publicly available on the GMC website (4), despite the BMJ’s declaration two weeks ago that it had been published.
Finally, the eminent “evidence-based medicine” expert Professor Trisha Greenhalgh appears to risk inflaming the situation further by repeating a comparison of the MMR sceptics with “flat-earthers” (rapid response, 18th January). This perhaps shows how remote the BMJ is perceived to be from the concerns of ordinary patients, and the “front-line” staff who do not have the luxury of engaging with pro-MMR families only.
If medical journals are really just newspapers with mystique, might it follow that a way out would be for medicine to become an honest trade rather than a dodgy “profession”? No doubt the size of the financial transaction between the BMJ and Brian Deer was small; and it remains open whether the journal’s new policy of modestly remunerating “good” investigative journalism at the expense of “bad”, will have the desired result in respect of the larger dragons of commercialised medicine, which the BMJ appears to see as its mission to slay.
A version of this piece was submitted as a “rapid response” to the last of Brian Deer’s articles, on the day of it’s publication (18th January). Four days later, no “rapid responses” had been published, which will only add to the suspicion that the BMJ is attempting to rig the debate. [The BMJ published an edited version of my “rapid response” in the 12th February print edition:
, and a longer online version on 4th February:
All the BMJ quotations can be searched for at
(1) I attribute this simplistic good/bad dichotomy to the BMJ. It is not my own view, as it should be clear from the rest of this piece that I consider the BMJ itself to have partly caused what is now denounced. The current Private Eye health editor, Phil Hammond, has said that the magazine should not have reported on the Wakefield/MMR issue in the way that it did.
(2) [“Health neurosis” is a quotation from Dr Spence’s 28th July 2009 article: note added 28th February.] This could be called “blaming the victim”, although Des Spence would perhaps argue that the “neurotic”MMR-sceptic is primarily the victim of Western medicine, rather than some GPs’ well-meant promotion of homeopathy and other alternatives.
(3) The prominent vaccine specialist Paul Offit acknowledges this, in the latest introduction (readable with Amazon’s “look inside”) to his book Autism’s False Prophet’s. [Notes 2 and 3 were incorrectly transposed in original: corrected 28th February]
(4) Searching for “Wakefield transcript” or even just “Wakefield”, on
Why is Scrooge “secret, and self-contained, and solitary as an oyster”: does he have a developmental disorder such as autism?
At the end of A Christmas Carol, “some people laughed to see the alteration in him”. Presumably, such a dramatic change was seen as unlikely. But does that mean we should be so sceptical as to conclude his “self-contained” nature is biologically-based, and therefore unable to be altered?
When he revisits his early adulthood, with the first ghost, he sees himself as having been not at all solitary then: the younger Scrooge happily helps to get ready for Fezziwig’s party, and joins in the dancing, eating and drinking, along with everyone else (1).
It is only a few years later that Scrooge begins to be dominated by his “master-passion” for money. At the same time, he loses interest in ordinary human relationships, although he is arguably right about the hypocritical and (un-) “even-handed dealing of the world”.
So he is not autistic, at least in the sense which would fully explain “old Scrooge”, in terms of a continuous, life-long, pattern of thoughts and behaviour.
Of course, he is only a fictional character; and some might find the description, of his early adulthood, to be as implausible as his later transformation.
At the end, he is still Bob Cratchit’s boss, and although he promises that he will “endeavour to assist your struggling family”, we have to trust Dickens that Scrooge followed up the impulsive gift of a ”Turkey…as big as a…boy”, by really being “better than his word”.
(1) I refer to Dickens’ original 1843 book. All quotations can be found in the text at
. Film and television adaptations have often subtly altered the story.
(2) On Christmas Day, Dr Who: A Christmas Carol was broadcast by the BBC. Loosely based on Dickens’ classic, the Scrooge-like central character needs the intervention of the time-travelling Doctor, altering his young adult past to include non-solitary experiences and memories. The dramatic force of the Dr Who story perhaps depends on the fact that film, television and stage adaptations have tended to omit the original content pointed out in my piece. Note added 27th December.
“…the scan which will enable doctors to diagnose autism more cheaply and quickly. The rapid test has already proven more than 90 per cent accurate in adults…”
“What the computer can do very quickly is to see that a patient has autism…even though their brain, to the naked eye, looks very normal.”
These bold statements appear on the website of the Maudsley Hospital’s national specialist services department (1). They appear to have been recycled from press releases and media interviews back in August, after publication of a study which looked at computerised pattern recognition of MRI brain scans, in adults with autism.
At the time, the “90% accurate” claim, and the suggestion that the scan could replace current clinically-based diagnoses, was heavily criticised by the head of the authoritative Oxford-based Centre for Evidence Based Medicine (2). A very different “5% accurate” was Dr Carl Heneghan’s view.
The key issue is that because the scan gives a “false positive” result in 20% of people without autism, it is unlikely ever to be useful, on its own, for diagnosis. If the prevalence of autism in the whole adult population is around 1%, then the “false positive rate” of the test would probably have to be at most 0.1% (3).
I wish the researchers (based at the Maudsley’s academic partner, the Institute of Psychiatry) the best of luck in getting their false positive rate down from 20% to this extremely low figure. I won’t be holding my breath.
What may be more feasible, and is implied by some of the comment back in August, is to combine the scan with a shorter (and cheaper) clinical assessment than the one which the Maudsley uses currently.
But I think patient groups, particularly the large and influential National Autistic Society (NAS), would want to see proper testing of such an approach.
Following the criticisms in August, the lead researcher responded: “we have clearly stated that we are not yet ready to make our approach available in the NHS just yet.” (2) (4).
So I was surprised to see the Maudsley website piece, dated November 4th, say “Adults who are interested in being scanned will need to ask their GP, consultant or health professional for a referral letter to the Behavioural Genetics Clinic. Privately funded assessments or scans are not available.” (1). There is no mention of any research showing the “Autism Scan” to have been improved.
Next week I am meeting with a board member (7) of DANDA (Developmental Adult Neuro-Diversity Association) (5), and will suggest that patient groups might want to clarify these apparently inconsistent statements (6) before recommending the “Autism Scan” to their members and supporters.
(3) That would mean about 1 false positive diagnosis in 1000 people, which I think would be the most any ordinary clinician would allow. To demonstrate such a small false positive rate would also require a much larger study than the one reported. Because the “Autism Scan” is said to be “90% Sensitive”, 9 people in 1000 with autism will be diagnosed correctly, while 1 person with autism will be “missed”.
Dr Heneghan does not mention the issue of the lack of so-called “confidence intervals” in interpreting the false-positive and false-negative figures from such a small study (20 patients with autism, and 20 controls without), but this seems important to me, especially for a test being offered to the NHS.
(4) Two “yet”’s in the original.
(5) The study also looked at whether the Scan could distinguish between autism and ADHD. It could, but even less well than between autism and no-autism. DANDA is concerned with the overlaps between autism, ADHD, dyslexia and dyspraxia, so I think this will be of interest to them.
(6) In addition to the other points, the 4th November piece (quoted in my first line) states “more than 90 per cent accurate”, but the abstract of the research paper (link from (1)) has “sensitivity…of up to 90%” [my italics]
(7) Changed from “the acting head” on 3rd December. My thanks to Erika Musselwhite of DANDA for pointing out that noone has yet taken over the national coordinator role which Mary Colley so energetically pursued until her recent much-regretted death.
Last weekend I was asked a difficult question: “do you diagnose dyspraxia?”. My answer can hardly have inspired confidence: “well, I never have, but I’m thinking of doing so in the future.”
The question came in a workshop (1) I was giving at the annual conference of DANDA (Developmental Adult Neuro-Diversity Association), an organization which supports the concept of dyspraxia in adults, alongside the much better-known conditions of autism, ADD / ADHD and dyslexia.
I think I have only seen one or two people with a main diagnosis of dyspraxia, as compared with at least a dozen with dyslexia. DANDA recognises that many people have different combinations of these developmental conditions, and the conference was, for me, a useful opportunity to catch up with some of the literature (2) on DCD (developmental coordination disorder, as some prefer to call it).
The problem, from DANDA’s point of view, is that very few specialists are prepared to diagnose dyspraxia in adults. Talking with the workshop participants, I began to see how, although many people with dyspraxia have interpersonal and organisational issues which I would usually see as either falling into the autistic spectrum on the one hand, or ADD / ADHD on the other, the “dyspraxia” concept is most meaningful for them. Perhaps this is because problems are experienced as much more within the body, and not just the mind.
Anyway, in the closing discussion I did give something of a promise that within six months I would be able to give a more definite “yes or no” answer to whether I diagnose DCD. For the moment my “official” position is “maybe…but do you think you might have anxiety, depression, ASD, ADD / ADHD…etc…as well?”
(1) “Managing anxiety and depression in neuro-developmental disorders” Workshop at DANDA annual conference, London, Saturday June 19th 2010
(2) Such as Living with Dyspraxia: A Guide for Adults with Developmental Dyspraxia (2006) by Mary Colley
“Autism is a serious, lifelong and disabling condition” (1) according to the chief executive of the National Autistic Society (NAS), which continues its excellent work in raising awareness about developmental disorders. But I wonder sometimes if this all-or-nothing headline message might discourage people from seeking treatment, when they see themselves as having milder problems.
The idea that autism is a spectrum not just of how it presents, but also of how severe it is, shading into normality in both respects, has been around for a while now. I have recommended Simon Baron-Cohen’s book The Essential Difference to several patients, because I thought it might be helpful to see how one leading researcher into autism views this issue.
It is likely that there are many people who are functioning, perhaps working, but not really doing very well, who probably have mild autistic spectrum disorders. Traditionally, psychiatry has assumed that “perfectionism” or “rigidity” are fixed and untreatable personality traits. This has been challenged by many studies now, and this week a report from researchers in Lyon, France (2) adds to the evidence that medications can improve the core features of autism.
Treatments (or “interventions”) in severe or moderate developmental disorders do not usually cure in the sense of moving the features of the condition into the spectrum of “normality”. A change from severe to moderate, or moderate to mild, would be considered a good response. But by starting off with a mild disorder, and moving towards normal functioning, whatever that is, you might have good reason to think that you had been cured of your disability.
(1) The Times, February 6th, page 29. Also at:
(2) Andaria et al (2010), early epublication of abstract at:
I will talk about non-medication-based approaches for autistic spectrum disorders in a future posting(s).