Monday, 27 August 2012

Mental health research: Are you contributing to paradigm stagnation or paradigm shift?


“Normal science does not aim at novelty but at clearing up the status quo. It discovers what it expects to discover.” – Thomas Kuhn.

I was struck by this quote from Thomas Kuhn last week when reading a Guardian blog about the influential philosopher of science. It’s a simple statement suggesting that so-called ‘normal science’ isn’t going to break any new ground, isn’t going to change the way we think about something, but probably will reinforce established ideas, and – perhaps even more importantly – will entrench what scientists think are the important questions that need answering. Filling in the gaps to clear up the status quo is probably a job that 95% of scientists are happy to do. It grows the CV, satisfies your Dean of School, gets you tenure and pays the mortgage.

But when I first read that quote, I actually misread it. I thought it said “Normal science does not aim at novelty but aims to maintain the status quo”! I suspect that when it boils down to it, there is not much difference between my misreading of the quote and what Kuhn had actually meant. Once scientists establish a paradigm in a particular area this has the effect of  (1) framing the questions to be asked, (2) defining the procedures to answer them, and (3) mainstreams the models, theories and constructs within which new facts should be assimilated. I suspect that once a paradigm is established, even those agencies and instruments that provide the infrastructure for research contribute to entrenching the status quo. Funding bodies and journals are good examples. Both tend to map on to very clearly defined areas of research, and at times when more papers are being submitted to scientific journals than ever before, demand management tends to lead to journal scope shrinkage in such a way that traditional research topics are highlighted more and more, and new knowledge from other disciplinary approaches is less likely to fertilize research in a particular area.

This led me to thinking about my own research area, which is clinical psychology and psychopathology. Can we clinical psychology researchers convince ourselves that we are doing anything other than trying to clear up the status quo in a paradigmatic approach that hasn’t been seriously questioned for over half a century – and in which we might want to question it’s genuine achievements? Let’s just take a quick look at some relevant points:

1.         DSM still rules the way that much clinical psychology research is conducted. The launch of DSM-5 in 2013 will merely re-establish the dominance of diagnostic categories within clinical psychology research. There are some who struggle to champion transdiagnostic approaches, but they are doing this against a trend in which clinical psychology and psychiatry journals are becoming more and more reliant on diagnostic criteria for inclusion of papers. Journal of Anxiety Disorders is just one example of a journal whose scope has recently shrunk from publishing papers on anxiety to publishing papers on anxiety only in diagnosed populations. DSM-I was published in 1952 – sixty years on it has become even more entrenched as a basis for doing clinical psychology research. No paradigm shift there then!

This doesn’t represent a conspiracy between DSM and journals to consolidate DSM as the basis for clinical psychology research – it merely reflects the fact that scientific journals follow established trends rather than create new spaces within which new concatenations of knowledge can emerge. Journals will by nature be a significant conservative element in the progress of science.

2.         There is a growing isolation in much of clinical psychology research – driven in part by the shrinking scope of clinical research journals and the adherence of many of them to DSM criteria for publication. This fosters a growing isolation from core psychological knowledge, and because of this, clinical psychology research runs the risk of re-inventing the wheel – and probably re-inventing it badly. Some years ago I expressed my doubts about the value of many clinical constructs that had become the focus of research across a range of mental health problems (Davey,2003). Many of these constructs have been developed from clinical experience and relate to individual disorders or even individual symptoms, but I’m convinced that a majority of them simply fudge a range of different psychological processes, most of which have already been researched in the core psychological literature. I'm an experimental psychologist by training who just happens to have become interested in clinical psychology research, so I was lucky enough to be able to bring some rather different approaches to this research than those who were born and brought up in the clinical psychology way of doing things. What must not happen is for clinical psychology research to become even more insular and even more entrenched in reinventing even more wheels - or the wheels on the bus really will just keep going round and round and round!

3.         OK I'm going to be deliberately provocative here – clinical neuroscience and imaging technology costs a lot of money - so its role needs to be enshrined and ring-fenced in the fabric of psychological knowledge endeavor, doesn’t it? Does it? If that’s the case – then we’re in for a long period of paradigm stagnation. Imaging technology is the Mars Rover of cognitive science while the rest of us are using telescopes - or that's the way it seems. There are some clinical funding bodies I simply wouldn't apply to for experimental psychopathology research – ‘cos if it ain’t imaging it ain't gonna get funded - yet where does the contribution of imaging lay in the bigger knowledge picture within clinical psychology? There may well be a well thought out view somewhere out there that has placed the theoretical relevance of imaging into the fabric of clinical psychology knowledge (advice welcome on this)! There is often a view taken that whatever imaging studies throw up must be taken into account by studies undertaken at other levels of explanation - but that is an argument that is not just true of imaging, it's true of any objective and robust scientific methodology.

Certainly - identifying brain locations and networks for clinical phenomena may not be the way to go - there is growing support for psychological constructionist views of emotion for instance, suggesting that emotions do not have either a signature brain location or a dedicated neural signature at all (e.g. Lindquist,Wager, Kober, Bliss-Moreau & Barrett, 2012). There are some very good reviews of the role of brain functions in psychological disorders -but I'm not sure what they tell us other than the fact that brain function underlies psychological disorders – as it does everything! For me, more understanding of psychological disorders can be gleaned from studying individual experience, developmental and cognitive processes, and social and cultural processes than basic brain function. Brain images are a bit like the snapshot of the family on the beach - The photo doesn't tell you very much about how the family got there or how they chose the beach or how they're going to get home.

But the point I’m trying to make is that if certain ways of doing research require significant financial investment over long periods of time (like imaging technology), then this too will contribute to paradigm stagnation.

4.         When tails begin to wag dogs you know that as a researcher you have begun to lose control over what research you can do and how you might be allowed to do it. Many researchers are aware that to get funding for their research – however ‘blue skies’ it might be – we now have to provide an applied impact story. How will our research have an impact on society? Within clinical psychology research this always seems to have been a reality. Much of clinical psychology research is driven by the need to develop interventions and to help vulnerable people in distress – which is a laudable pursuit. But does this represent the best way to do science? There is a real problem when it comes to fudging understanding and practice. There appears to be a diminishing distinction in clinical psychology between practice journals and psychopathology journals, which is odd because helping people and understanding their problems are quite different things – certainly from a scientific endeavour point of view. Inventing an intervention out of theoretical thin air and then giving it the facade of scientific integrity by testing to see if it is effective in a controlled empirical trial is not good science – but I could name what I think are quite a few popular interventions that have evolved this way – EMDR and mindfulness are just two of them (I expect there will be others who will argue that these interventions didn't come out of a theoretical void, but we still don't really know how they work when they do work). At the end of the day, to put the research focus on ‘what works in practice’ takes the emphasis away from understanding what it is that needs to be changed, and in clinical psychology it almost certainly sets research priorities within establishment views of mental health.

5.         My final point is a rather general one about achievement in clinical psychology research. We would like to believe that the last 40 years has seen significant advances in our development of interventions for mental health problems. To be sure, we’ve seen the establishment of CBT as the psychological intervention of choice for a whole range of mental health problems, and we are now experiencing the fourth wave of these therapies. This has been followed up with the IAPT initiative, in which psychological therapies are being made more accessible to individuals with common mental health problems.  The past 40 years has also seen the development and introduction of second-generation antidepressants such as SSRIs. Both CBT and SSRIs are usually highlighted as state-of-the-art interventions in clinical psychology textbooks, and are hailed by clinical psychology and psychiatry respectively as significant advances in mental health science. But are they? RCTs and meta-analyses regularly show that CBT and SSRIs are superior to treatment as usual, wait-list controls, or placebos – but when you look at recovery rates, their impact is still far from stunning. I am aware that this last point is not one that I can claim reflects a genuinely balanced evidential view, but a meta-analysis we have just completed of cognitive therapy for generalized anxiety disorder (GAD) suggests that recovery rates are around 57% at follow-up. Which means that 43% of those in cognitive therapy interventions for GAD do not reach basic recovery levels at the end of the treatment programme. Reviews of IAPT programmes for depression suggest no real advantage for IAPT interventions based on quality of life and functioning measures (McPherson,Evans & Richardson, 2009). In a review article by Craske, Liao, Brown & Vervliet (2012) that is about to be published in Journal of Experimental Psychopathology, they note that even exposure therapy for anxiety disorders achieves clinically significant improvement in only 51% of patients at follow-up. I found it difficult to find studies that provided either recovery rates or measures of clinically significant improvement for SSRIs, but Arroll et al (2005) report that only 56-60% of patients in primary care responded well to SSRIs compared to 42-47% for placebos.

I may be over-cynical, but it seems that the best that our state-of-the-art clinical psychology and psychopharmacological research has been able to achieve is a recovery rate of around 50-60% for common mental health problems - compared with placebo and spontaneous remission rates of between 30-45%. Intervention journals are full of research papers describing new ‘tweaks’ to these ways of helping people with mental health problems, but are tweaks within the existing paradigms ever going to be significant? Is it time for a paradigm shift in the way we research mental health?

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14 comments:

  1. Excellent research! Thank you for your time to write it and share it with us!

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  2. a-bloody.men..I am a qual researcher in family therap..persona non grata at times in our conservative clinical psychology scene downunder..thanx

    http://www.psych.usyd.edu.au/staff/paulr/

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  3. Not meaning to be unnecessarily provocative, but for the study of 'mental health' to undergo a Kuhnian paradigm-shift (revolution) - it has first to be in a state of 'normal science' - all working on the 'boring' but agreed stuff (using agreed methods)
    I suspect Kuhn would classify this area as prescience i.e. no agreed central paradigm, methods etc.
    So, unlikely that a paradigm shift will ocur until we *all* move to the position Popper described as: "...the activity of the non-revolutionary, or more precisely, the not-too-critical professional"....perhaps

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    1. Interestingly provocative! I'm sure organisations like NICE would contend the "pre-science" view. Perhaps a more critical issue is not so much that we don't have agreed methods in mental health research, but we don't have an agreed subject matter. DSM tries to impose what the subject matter should be and some journals won't accept anything that's outside that rather arbitrary definition. That really is a form of intellectual tyranny, and will define what is discovered about mental health problems within a very narrow and restricted area of research.

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    2. Dont get me started on NICE!!! How can we derive guidance from a committee about e.g. treatment of depression when they say "the most significant limitation is with the concept of depression itself. The view of the Guideline Development Group is that it is too broad and heterogeneous a category, and has limited validity as a basis for effective treatment plans."
      And then go on to tell us what they advocate as treatments for depression
      Or the CBT for schizophrenia NICE committee who have no grasp of the evidence at all! (IMHO) - and no issue at all with concept of schizophrenia! (cf Depression)
      I would argue one of the reasons that clinical psychology (& psychiatry) remains in a prescience state is precisely because groups like NICE impose false 'normal sceince' directives (I dont diagree with your view on DSM BTW), which has knock on for publishing and funding
      Too much emphasis in mental health research in UK influenced by (faux) scientific organisations and economic drivers over past 10-15 years

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    3. Keith, I wouldn't disagreed with anything you've said - imposing definitions of what is the "subject matter" whether its depression or mental health generally is horrendously reactionary - but is usually done for reasons other than science!

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  4. DSM prime function is to facilitate payments between health care payers and providers in Mental Health. An additional effect is that research will inevitably focus on DSMcategories as these dictate how the money flows
    Samei

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  5. How about psychoanalysis? Same recovery rate? It is supposed to be a paradigm shift.

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  6. In regards to #1, it has been 26 years since this Persons article on studying phenomena rather than diagnoses (http://psycnet.apa.org/journals/amp/41/11/1252.html), and it feels like zero progress has been made on that. The RDoC effort (http://www.nimh.nih.gov/research-funding/rdoc/index.shtml) is interesting, but I don't know enough about it to understand if it has taken root.

    Also, #4 is an interesting point in which I wholeheartedly agree on. I am fond of the Sechrest and Smith article arguing for psychotherapy as the practice of psychology (http://psycnet.apa.org/psycinfo/1994-34361-001), and I think in this vein, applied intervention research should be an extension of basic science research. A focus on identifying and researching mechanisms of change in therapies rather than looking at main effects of therapies would help ground this research back into basic science, as a mechanism of change should be determined as being such from basic science work, then applied to psychopathology as appropriate.

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