Considera che non sono esperto dell’argomento e questi sono solo alcuni pensieri del momento.
Penso che i progressi delle neuroscienze porteranno necessariamente a riflettere sempre più a fondo su questi temi (ed altri). Un po’ di tempo fa ho scritto che non credo nel libero arbitrio, di fronte a casi come quelli che descrive Eagleman è difficile non chiedersi se, così come il comportamento di Charles Whitman è determinato da un tumore, anche il nostro non sia determinata dai geni, o comunque dal substrato biologico.
In generale però io (che non sono neuroscienziato, ma cerco di studiare psicologia) tendo a pensare che a volte le neuroscienze sottolineino troppo la biologia, e il rischio è quello di un riduttivismo biologico che non rende conto della complessità dei contesti in cui i comportamenti umani si verificano. Voglio dire che i comportamenti non sono determinati solo dalla biologia, ma anche dall’ambiente. Per esempio, perchè casi come quello di Charles Whitman, o le stragi nelle scuole, sono fenomeni che, sebbene piuttosto frequenti negli Stati Uniti, non si verificano quasi mai in altre nazioni?
Oggi è la giornata internazionale per l’eliminazione della violenza contro le donne, se si studia la violenze contro le donne (io un po’ l’ho studiata) ci si rende conto i contesti sociali influiscono in modo molto forte. Se accettiamo che non siamo agenti razionali dotati di libero arbitrio, ma che il nostro comportamento è sempre determinato da molteplici fattori, ha senso continuare a parlare di uomo violento? (Ovviamente questa non vuole essere una giustificazione per la violenza, un uomo che picchia una donna è uno stronzo, in qualsiasi contesto sociale sia).
Però, le neuroscienze hanno qualcosa di concreto da far vedere ad una giuria. Possono mostrarci le risonanze magnetiche funzionali, e indicarci le parti del cervello più attive. Questa non è una cosa di poco conto. Per esempio (adesso non trovo l’articolo, ma fidatevi che c’era) in alcuni esperimenti è stato visto che le persone sono più predisposte a credere ad un affermazione del tipo “uno studio di neuroimaging dimostra che” piuttosto che semplicemente “uno studio dimostra”. Il fatto che si faccia riferimento al substrato biologico ci influenza, ed influenza anche le giurie ed i giudici.
C’è un aspetto dell’articolo che mi lascia particolarmente dubbioso, quando Eagleman parla dell’efficacia delle cure farmacologiche. A mio avviso la fa troppo semplice, se la depressione si curasse semplicemente con una pillola, non staremmo ancora a parlare di depressione. E così per il resto. Non sto dicendo che i farmaci non sono utili, sto dicendo che Eagleman semplifica un po’ la questione.
I miei dubbi aumentano ancora quando accosta la persona depressa al bambino che va male a scuola “perché la sua un’incapacità ad apprendere ha una base neurobiologica”.
Ho lavorato per un anno in un centro che si occupa di disturbi dell’apprendimento, e in tutti i bambini che ho visto non ce n’era nemmeno uno per cui non trovassi spiegazione alle loro difficoltà in fattori relazionali. Ho seguito per esempio un bambino per un anno, durante il quale una volta sono andato con la direttrice del centro a parlare con le insegnanti del bambino. Usciti dalla scuola la direttrice cominciò a fare un discorso sul fatto che bisognava fare una nuova risonanza magnetica a questo bambino, perchè anche se non avevano trovato nulla qualche cosa ci doveva pur essere (non ho idea di cosa cercassero). Per me invece, dopo aver parlato con le insegnanti, era chiarissimo perchè quel bambino aveva difficoltà a scuola. Queste insegnanti erano convinte di lavorare in una scuola “speciale” e privilegiata, un piccolo paradiso con le loro classi di pochissimi alunni, tutti molto ben educati. Non riuscivano assolutamente ad affrontare gli unici due bambini che, semplicemente, erano più vivaci degli altri. Il problema non era l’incapacità ad apprendere (di origine neurobiologica) del bambino, ma l’incapacità delle insegnanti di confrontarsi con bambini per cui è noioso stare in silenzio, stare seduti, e che preferirebbero giocare piuttosto che fare i compiti.
Quando parlo di queste cose mi viene sempre da pensare a questo passaggio di un libro di Steven Rose, un neurobiologo inglese:
[…] il disturbo da deficit di attenzione/iperattività (attention deficit hyperactivity disorder o ADHD) si suppone colpisca fino al 10 per cento dei bambini (principalmente maschi). Il “disturbo” è caratterizzato da basse prestazioni scolastiche e dall’incapacità di mantenere la concentrazione in classe o di sottostare ai controlli dei genitori ed è ritenuto una conseguenza di un disordine delle funzioni cerebrali associato ad un altro neurotrasmettitore, la dopamina. Il trattamento prescritto è un farmaco anfetamino-simile chiamato Ritalin. Vi è una crescente epidemia mondiale di uso di Ritalin. Si dice che probabilmente i bambini non trattati corrono maggiori rischi di diventare criminali ed esiste una letteratura sempre più diffusa sulla “genetica del comportamento criminale e antisociale”. Si tratta di un adeguato approccio medico-psichiatrico a un problema individuale, o solo di un rimedio a basso costo per eludere la necessità di interrogare le scuole, i genitori e il più ampio contesto sociale di educazione?
Steven Rose, Il Cervello nel XXI secolo, 2005, pagg. 9-10.
Dico questo anche per un altro motivo: le profezie che si auto-avverano.
È stato osservato da diversi ricercatori che le etichette psichiatriche, sotto forma di diagnosi, possono alterare le relazioni sociali, generando conseguenze negative, perchè agiscono come profezie che si auto-avverano. Le persone possono provare vergogna di sè, avere sentimenti di self-stigma, temere il rifiuto degli altri, evitare il contatto sociale o non cercare il supporto sociale. Inoltre le spiegazioni del comportamento che si rifanno ad un’origine biologica hanno l’effetto di rappresentare un comportamento come un tratto stabile e immutabile. È la natura, è così, non ci posso fare nulla: sono timido perchè ho i geni della timidezza, non posso parlare con le persone.
Ma è veramente così? Eagleman scrive che “se siete portatori di un particolare insieme di geni, le probabilità che possiate commettere un reato violento sono quattro volte più alte”
Probabilità. Perchè non tutti quelli che sono portatori di quei geni sono criminali violenti? Non siamo di fronte ad un determinismo causale: ad uno specifico gene corrisponde necessariamente un comportamento specifico.
Io penso che i fattori in causa sono molti, e che non ne comprendiamo ancora abbastanza, sebbene gli incredibili progressi delle neuroscienze qualche volta ci inducano a credere di avere risposte definitive per il comportamento umano.
Penso che i sistemi giuridici farebbero bene a prendere consapevolezza delle scoperte delle neuroscienze, ma per farlo adeguatamente c’è bisogno che si avvii un dialogo serio fra sistemi giuridici e scienziati.
Consider that I’m not an expert and these are only some thoughts of the moment.
I think that with the advances in neuroscience there will be the need to reflect more deeply on these issues (and others). Some time ago I wrote that I do not believe in free will, and in the face of cases such as those described by Eagleman it is hard not to wonder if, like Charles Whitman’s behavior that was determined by a tumor, even our behavior is determined by our genes, or in general by our biology.
I’m not a neuroscientist, I try to study psychology, so in general I tend to think that sometimes neuroscience emphasizes too much the biological explanation of behavior, and the risk is a biological reductionism that does not account for all the complexity of the of human behavior. I mean that behaviors are not only determined by biology, but also by the enviroment, the context in which the behavior occurs. For example, for cases like that of Charles Whithman, (or shooting in schools) I can’t help but wonder why these phenomena, quite common in the United State, almost never happen in other nations.
Today is the International Day for the Elimination of Violence against Women. If you study violence against women (I’ve studied it a bit) you realize that the social context influences very strongly this phenomenon. If we accept that we are not rational agents with complete free will, but that our behavior is always determined by multiple factors, does it make sense to continue to talk about violent man? (It’s obvious I’m not saying that this a justification for violence against women, a man who hit a woman is an asshole, in whatever social context he is).
But, neurosciences have something in concrete terms to show to a jury. They can show us fMRIs, and point out the most active parts of the brain. This is not a trivial matter. For example (now I can’t find the article, but trust me it exists) some experiments have shown that people are more inclined to believe a statement like “a neuroimaging study shows that” rather than simply one like “a study show”.
The fact that there is a reference to the biological substratum influences us, and also the juries and the judges. There is an aspect of the article that leaves me in a state of uncertainty, when Eagleman talks about the efficacy of pharmacological treatments. In my opinion he oversimplifies, if depression could be cured with one pill, we wouldn’t still be here talking about it. The same goes for everything else. I’m not saying that drugs are useless, I’m saying that Eagleman oversimplifies the matter.
My doubts arise again when Eagleman compare the person who is depressed with the child that do poorly at school “because there is a neurobiologically based learning disability”
I worked for a year at a center with children with learning disabilities, and of all the children I saw and I worked with, there was none for who I couldn’t find an explanation for his difficulties in some relational factors (school, family or whatever). I once went with the director of the center to speak with a child’s teachers. When we came out of the school, the director began to talk about the need to do a new MRI to this child, because even if the first time they hadn’t found anything, “there must be something” ( I have no idea what they were looking for). For me instead, after talking to the teachers, it was clear why this child had difficulties in school. These teachers were convinced to work in a “special” and privileged school, a small paradise with their classes with few students, all very well behaved. They were not able to deal with the only two children who simply were more lively than others. The problem was not the inability to learn (with a neurobiological origin) of the child, but the inability of the teachers to deal with children that consider boring to sit and be silent, and that would rather play than do homework.
When I talk about these things I always think about what Steven Rose, an english neurobiologist, wrote:
[…] a disease called ‘Attention Deficit Hyperactivity Disorder’ (ADHD) is supposed to affect up to 10 per cent of young children (mainly boys). The ‘disorder’ is characterised by poor school performance and inability to concentrate in class or to be controlled by parents, and is supposed to be a consequence of disorderly brain function associated with another neurotransmitter, dopamine. The prescribed treatment is an amphetamine-like drug called Ritalin. There is an increasing world-wide epidemic of Ritalin use. Untreated children are said to be likely to be more at risk of becoming criminals, and there is an expanding literature on ‘the genetics of criminal and anti-social behaviour’. Is this an appropriate medical/psychiatric approach to an individual problem, or a cheap fix to avoid the necessity of questioning schools, parents and the broader social context of education?
Steven Rose - The Future of the Brain, 2005, pag.6
I say this also for another reason: self-fulfilling prophecies.
It has been observed by many researchers that psychiatric labels, in the form of diagnosis, can influence social relations, generating negative consequences, because they act like self-fulfilling prophecies. People can have feeling of self-stigma, they can feel ashamed of themselves, fear rejection of others, avoiding social contact or not seeking social support. In addiction, biological explanations of the behavior are often felt like they are something that cannot change. It is nature, it’s like this, there’s nothing we can do: I’m shy because I have shyness genes, I can’t talk to people.
But is it really so? Eagleman writes that “if you are a carrier of a particular set of genes, the probability that you will commit a violent crime is four times as high as it would be if you lacked those genes.”
Probability. So, we can ask why do not all those who are carriers of those genes become violent criminals?
We are not dealing with a direct causal determinism, it’s not: a specific gene leads necessarily to a specific behavior.
I think that many factors are involved, and we do not yet understand them enough, although the incredible advances in neuroscience sometimes lead us to believe that we have definitive answers for human behavior.
I think the legal system should be aware of the discoveries of neuroscience, but to do it properly, and to change the law according to science, we need the legal system to start a serious dialogue with scientists, because these issues are really not simple.
The majority of the researchers that investigate this area would say: yes.
My opinion is that internet (as well as other technology) does not change our cognition, it changes how we use our cognitive skills.
Anyway, there is some consensus that internet changes us for worse.
Maryanne Wolf is a developmental psychologist at Tuft University, she said: “We are how we read” and on the internet we are “mere decoders of informations” because the reading style promoted by internet si all about “efficency” and “immediacy” instead:
“In the quiet spaces opened up by the sustained, undistracted reading of a book, or by any other act of contemplation, for that matter, we make our own associations, draw our own inferences and analogies, foster our own ideas. Deep reading, as Maryanne Wolf argues, is indistinguishable from deep thinking.” 
Nora Volkow thinks that internet “is rewiring our brain” and some researches show that:
“Heavy multitaskers actually have more trouble focusing and shutting out irrelevant information […], and they experience more stress. And scientists are discovering that even after the multitasking ends, fractured thinking and lack of focus persist. In other words, this is also your brain off computers.” 
But let me take a simpler research and say something.
“The results of four studies suggest that when faced with difficult questions, people are primed to think about computers and that when people expect to have future access to information, they have lower rates of recall of the information itself and enhanced recall instead for where to access it. The Internet has become a primary form of external or transactive memory, where information is stored collectively outside ourselves.” 
One of the authors of this research said:
“Human memory is adapting to new communications technology” 
I think some of this results are instead biased by the way things were in the past (even the recent past). Memorize a lot of informations was a widely appreciated skill in school, but now teachers are more focused on how students can learn to learn, or learn to use that information. I think it is quite more useful to know how to find an information, rather then trying to store the entire human knowledge in my brain.
Clay Shirky wrote:
Every increase in freedom to create or consume media, from paperback books to YouTube, alarms people accustomed to the restrictions of the old system, convincing them that the new media will make young people stupid. This fear dates back to at least the invention of movable type. […]
In the history of print, we got erotic novels 100 years before we got scientific journals, and complaints about distraction have been rampant; no less a beneficiary of the printing press than Martin Luther complained, “The multitude of books is a great evil. There is no measure of limit to this fever for writing.” Edgar Allan Poe, writing during another surge in publishing, concluded, “The enormous multiplication of books in every branch of knowledge is one of the greatest evils of this age; since it presents one of the most serious obstacles to the acquisition of correct information.” 
I sorry to refer to some old articles, but I’m not very updated about the current researches.
The Oedipus complex is the psychic representation of a central, instinctually motivated, triangular conflictual constellation of child-parent relations (Loewald, 2000).
It was proposed by Freud in his theory of psychosexual development. He believed that different elements of sexual drive converge at the age of 4–6 in the genital organization, where the components of pregenital instincts (oral and anal) are subsumed under the genital domination. The aim of all infantile wishes at that age is the sexual intercourse with a parent of the opposite sex and so the parent of the same sex is becomes a dangerous rival ( Borovecki-Jakovlje & Matacić, 2005). The essence of the Oedipus complex is just this desire on the part of the child to have a sexual relationship with the opposite sex parents and feelings of hostility toward the other. Freud argued that between the ages of 4 and 6, a child start having fantasies involving a sexual intercourse with the opposite sex parent. A boy believes that the father will become aware of his desire and to punish him, he will castrate him. The castration anxiety results in the end of Oedipus complex. The young female believes she has been castrated, so she has a penis envy, but this desire for a penis is replaced by a wish to have her father’s baby. The female child gradually abandons this desire and the oedipal fantasy diminishes (Kupsefsmid, 1995). This female equivalent of the Oedipus complex is often called the Electra complex, but many feminists authors have shown that the Electra Complex is a poorer explanation of the women sexual development, and it’s probably biased by Freud’s ideas on gender ans sexual roles.
Oedipus Complex had a major importance in the history of psychoanalysis, in fact Freud stated that it is the genesis of all neurosis. With the evolving of the psychoanalytic theory, there was a waning of the Oedipus complex, due the fact that many psychoanalysts put more and more clinical attention and theoretical interest in the pre-oedipal phase, in the infant-mother dyad, the issues of separation-individuation and on the self and the narcissism (Loewald, 2000).
Today few psychoanalysts thinks at the Oedipus complex in the terms Freud and his contemporary did.
The Oedipus complex is named after the famous Sophocles’ tragedy, Oedipus Rex, here’s how Freud himself described this story:
Oedipus, the son of Laius, king of Thebes, and Jocasta, is exposed as a suckling, because an oracle had informed the father that his son, who was still unborn, would be his murderer. He is rescued, and grows up as a king’s son at a foreign court, until, being uncertain of his origin, he, too, consults the oracle, and is warned to avoid his native place, for he is destined to become the murderer of his father and the husband of his mother. On the road leading away from his supposed home he meets King Laius, and in a sudden quarrel strikes him dead. He comes to Thebes, where he solves the riddle of the Sphynx, who is barring the way to the city, whereupon he is elected king by the grateful Thebans, and is rewarded with the hand of Jocasta. He reigns for many years in peace and honour, and begets two sons and two daughters upon his unknown mother, until at last a plague breaks out-which causes the Thebans to consult the oracle anew. Here Sophocles’ tragedy begins. The messengers bring the reply that the plague will stop as soon as the murderer of Laius is driven from the country. But where is he?… The action of the play consists simply in the disclosure, approached step by step and artistically delayed (and comparable to the work of a psychoanalysis) that Oedipus himself is the murderer of Laius, and that he is the son of the murdered man and Jocasta. Shocked by the abominable crime he was unwittingly committed, Oedipus blinds himself, and departs from his native city. The prophecy of the oracle has been fulfilled (Freud, 1938).
The Oedipus complex in the contemporary psychianalysis by Borovecki-Jakovlje & Matacić, 2005.
The interpretation of dreams by Sigmund Freud, 1938.
The waning of the Oedipus complex by Hans W. Loewald, 2000.
Does the Oedipus complex exist? by Joel Kupsefsmid, 1995.
Today I was reading in the news from the blogs I follow in my feed reader, and there was this post talking about an italian blogger, B-Log (0), who wrote two articles about homeopathy, and then received a threat of lawsuit from a big corporation that claims that those articles were defamatory.
This really makes me angry.
I thought I should write something about it.
I know there are a lot of people who believe homeopathy works. Obviously there’s a lot of people who believe crop circles are messages from aliens.
I know that there are very few possibilities that I can make them change their idea.
So, I’m not going to write an article on why homeopathy doesn’t work. You can find good information and articles better than what I could ever write.
But this post is not on why homeopathy doesn’t work, chemists, physicians, and pharmacologists can do a better work in explaining that.
This post is about how, and why, homeopathy works.
This could sound silly.
It is strange, indeed, to talk about this when I want to discourage people to use homeopathy products, but I try to study psychology, and I think there are other reasons rather than opportunism, marketing and ignorance explaining why people believe in homeopathy.
One of this reasons is that homeopathy seems to work.
To understand this topic we should say something first: medicine isn’t perfect. (for medicine I mean “western medicine”, I’m not talking about CAM, complementary and alternative medicine)
Health care systems are far from perfect, we all know that.
Despite from what we see on TV shows, physicians are women and men, like everyone else. They are not demi-gods, they are often tired, bored and unmotivated, they can be cold and unsympathetic. They have a lot of work to do, so the time they can spend with a patient is very limited.
There are these and many other problems.
The patient-doctor relationship is often considered as secondary to the “real” treatment. What matters is the drug, isn’t it?
Micheal Balint, used to say that the doctor is the drug. He was a doctor and a psychotherapist who explored the importance of doctor–patient relationship in his book ‘The Doctor, His Patient And The Illness’.
Nowadays scientific research demonstrated that doctor-patient relationship is a central aspect of the cure. When I first started to think about a project for my thesis, I thought it would be interesting a research on how the doctor-patient relationship influences the perception of illness. I found out that in the scientific literature there are thousands of research about how doctor-patient relationship has an effect on health.
Why all this premise?
Let’s start talking about Shang et al (2005) meta-analysis:
We compared the effects of homoeopathy and conventional medicine that are seen in placebo-controlled trials, examined the presence of bias resulting from inadequate methods and selective publication, and estimated results in trials least affected by these biases. We assumed that the effects observed in placebo-controlled trials of homoeopathy could be explained by a combination of methodological deficiencies and biased reporting. Conversely, we postulated that the same biases could not explain the effects observed in comparable placebo-controlled trials of conventional medicine. Our results confirm these hypotheses: when analyses were restricted to large trials of higher quality there was no convincing evidence that homoeopathy was superior to placebo, whereas for conventional medicine an important effect remained. Our results thus provide support for the hypothesis that the clinical effects of homoeopathy, but not those of conventional medicine, are unspecific placebo or context effects.
The clinical effects of homeopathy are unspecific placebo or context effects. What does it mean?
Context effects can influence the effects of interventions, and the relationship between patient and carer might be an important pathway mediating such effects. Practitioners of homoeopathy can form powerful alliances with their patients, because patients and carers commonly share strong beliefs about the treatment’s effectiveness, and other cultural beliefs, which might be both empowering and restorative.
Thompson and Weiss (2006) ”explored literature on the placebo effect, universal anthropological models, psychotherapeutic practices and psychological models such as disclosure theory” and studied 18 patient at the Bristol Homeopathic Hospital. These patients attended “a ‘package of care’, consisting of an initial consultation and four follow-up appointments over an eight month period, with one of three allocated homeopathic physicians.”
Thompson and Weiss were interested not in proving the efficacy (or inefficacy) of the treatment, they wanted to understand what are the active ingredients of the homeopathic process.
They identify various active ingredients, here I quote only the first ones.
- The role of patient expectations:
Classical placebo theory predicts that patients’ responses to an intervention are based on their expectation of likely benefit – their “belief” in the treatment. For instance branded aspirin is more effective than pharmaceutically identical generic aspirin […]
All the patients recruited were optimistic, they believed the treatment would be benefit to them and expectation of benefit was also generated during consultations.
- Openness to the mind-body connection:
According to the authors, “not only are there alternative therapies but also alternative patients who bring with them a predisposition to respond to CM” (Complementary Medicine).
The homeopathic worldview favors an integration of mind and body and one might predict that patients who come to homeopathy open to this dynamic will fare better than those expecting a conventional pharmaceutical approach.
In the findings of Thompson and Weiss there’s something that, at first, seems very curious:
[…] data suggest that empathy is necessary for good outcome but there was no correlation between empathy levels and outcome. Indeed, peculiarly, the opposite was true. Those that did well clinically rated their doctors as less empathic within this small sample. These findings do not enforce the widely held view that it is the empathic nature of the consultations that governs their success.
If we leave aside the “widely held view”, we can suggest at least one, simple explanation for this finding: even patient in homeopathic treatment are more comfortable when the doctor match their expectation on how a medical consultation should be. In normal medical consultation, empathy has a minimum role so that patients are led to expect that real doctors do not show empathy.
The authors suggest that at least some of these active ingredients are not specific of the homeopathy. They suggest also that
[…] traditional healing and western psychotherapy have roughly the same structure. In each the suffering patient attends the healer/therapist who listens to their lament and persuades them it can be understood in terms of a shared cultural myth. The healer/therapist then attaches the patient’s emotions to “transactional symbols” particularized from the general myth and manipulates the symbols to allow the patient to “transact” these emotions. In the case of homeopathy the transactional symbol would be the remedy, which is manipulated through the expectations applied to it and the intricacies of the prescribing regimen. The further the homeopath goes into the state of the patient, the more apposite the symbol will be and the more powerful will be the healing response.
The psychotherapist as shaman is a common metaphor although it’s wrong.
There is a major difference: whatever way the practice of psychotherapy is conceptualized, a psychotherapist knows what he’s doing, he knows that he’s working with the emotions, motivations, expectations, representations, etc, of the patients. He doesn’t think he’s doing something else, and by accident, he helps the patient with something he is not aware of.
Instead, homeopathic practitioners (and patients) think (or they say they think) that it’s the remedy that heals.
Now, this is a thing I think I know a little bit. I’m writing a thesis on the negative effect of psychotherapy, so I’m aware of what are the risks of establishing a therapeutic relationship without the necessary awareness of its mechanisms.
If we examine just the simplest aspect: this type of relationship encourages the patient to expect a beneficial effect from something that has no effect. This belief reduces the ability of the patients to make informed decisions about their health.
Sehon and Stanley (2010) suggest this example:
Suppose, for example, that a particular patient, call her Jane, takes a homeopathic remedy and recovers quite quickly from condition X; but suppose that we also know that approximately 10% of patients with X also exhibit a similar recovery, and that nobody knows why. So there are two questions, a particular question and a general one:
Why did Jane recover from condition X?
Why do 10% of patients recover in this fashion from X?
The homeopathic theory can answer the particular question about Jane, for the homeopath claims that the homeopathic remedy explains Jane’s recovery. But conventional medicine will also have something to say in answer to the particular question: ‘Jane recovered for the same reason as the approximately 10% of patients with X recover; Jane’s case is not unique.’ So both homeopathy and allopathy answer the particular question, but neither currently has an answer to the second and more general question. So, in terms of the number of unanswered questions, the homeopath and the conventional doctor are on a par. Thus, individual cases of dramatic recovery will not create new unanswered questions for conventional medicine, at least when it is known that similar recoveries occur with some frequency even in the absence of homeopathic remedies.
Of course, practitioners of homeopathy have seen more than the occasional isolated case, for they have seen hundreds or thousands of patients, and have presumably heard from many patients that their conditions improved after homeopathic treatment. In accord with the simplicity principle, such results surely count as some evidence unless there is an alternate explanation for these results. But the problem with such unsystematically gathered evidence is that various alternate explanations seem, at least at a general level, to be available:
• patients tend, on average, to improve regardless of treatment;
• memory is unconsciously biased in favor of positive results, particularly when one considers that the entire livelihood of practitioners is on the line;
• selective reporting (e.g. patients who don’t improve might be expected to forego further visits to the homeopath, and thus their negative reports will not be heard), and
• the placebo effect.
The placebo effect might be especially strong in the case of visits to homeopathic practitioners for a couple of reasons. First, judging from information gathered from websites of practitioners and other sources, initial visits to homeopathic practitioners tend to be long, detailed interviews, and second, they are costly […]. The high cost could be relevant in a surprising way: Waber et al. found that the analgesic response to placebo pills was greater when subjects were told that the pills were more expensive.
Thus, from the standpoint of the simplicity principle, case series evidence and other observational studies do not provide incredibly strong evidence, for the observations made (viz., patients whose conditions improved after taking homeopathic medications) are not significant unexplained mysteries for the alternative theory.
What is the simplicity principle?
Given two theories, it is unreasonable to believe the one that leaves significantly more unexplained mysteries.
Given that the homeopathic theory hasn’t said anything so far that comes close to providing valid answers for the mysteries behind the presumed functioning of the homeopathic remedies, we must reject the homeopathic theory as an explanation for phenomena like the Jane’s case. Psychological explanation seems to be far more convincing, given for example the growing amount of data regarding placebo effect, doctor-patient relationship. In fact if we accept the homeopathic theory ”answering those mysteries would appear to require massive revision of standard chemistry and physiology.“
But let’s face it: we would need a massive revision of standard chemistry and physiology only to confirm the homeopathic theory, refusing the overwhelming evidence that the reality is another.
This post isn’t about a recent research at all, in fact the article I’m going to discuss is from 1988, but I write about it because this research has given life to an entire line of studies of which you we can find traces even today.
Pennebaker, Kielcolt-Glaser e Glaser, had conducted a research (‘Disclosure of Traumas and Immune Function: Implication for Psychotherapy’, 1988) placed in the long tradition of psychosomatics and in the more recent health psychology.
The authors wondered whether psychotherapy could be effective in reducing health problems. At the time of the research there had been several studies that had identified, for example, that in individuals who underwent a psychotherapy the medical utilization decreased relative to non-psychotherapy control group, but wasn’t clear why.
Moreover, it was observed that psychological conflicts, anxiety and stress can cause physical symptoms, and had been consistently suggested that a reduction of conflict or stress would also reduce the disease.
The way in which individuals face a traumatic experience is predictive of the appearance or absence of disease, for example, individuals who have suffered a great upheaval such as the death of a spouse, are more vulnerable to a variety of illnesses. At the same time, the negative effect of stress may be buffered by social support.
A common theme in psychotherapy, since from the beginning, is that people can better deal with trauma if they can understand and assimilate it.
On this line, Pennebaker and Beall (1986) conducted an experiment in which they asked healthy college students to write about a traumatic experiences or trivial topics for four consecutive days. Within one month of the experiment, subjects who had written about a traumatic experience, visited the student health center significantly less often than the others.
Psychoneuroimmunology research indicated also that the central nervous system can directly influence the immune system.
The research of the 1988 examined the effect of the writing about a traumatic experience on immune function.
Fifty healthy college students were randomly assigned to write about: either a personal traumatic experience or trivial topics for 20 minutes every day for four consecutive days.
To measure the immune response it was examined the response of lymphocytes to stimulation by substances foreign to the body (mitogens). The measurement of the proliferationof lumphocytes in response to the stimulus was considered a good in vitro model of the body’s response to pathogens such as bacteria and viruses.
In the research blood samples were taken on the day before the writing, the last day of the writing and six weeks after the writing. Other measures of health / disease such as visits to the clinic doctor, self-reported symptoms, and more, were also assessed.
The day before the writing session the subjects in group completed a battery of questionnaires, and, after having made them relax for 10 minutes, their blood pressure levels, heart rates and skin conductance levels were measured. After that the the first blood sample was drawn.
Over the next four days, the subjects participated to the writing sessions. Subjects in the trauma condition were informed as follows:
During each of four days I want you to write about the more traumatic and upsetting experiences of your entire life. You can write on different topics each day or on the same topic for all four days.The important thing is that you write about your deepest thoughts and feelings. Ideally, whatever you write about should deal with an event or experience that you have never talked with others in detail.
Instead, subjects in the no-trauma condition were asked to describe specific objects or events in detail without discussing their emotions or thoughts.
At the end of the fourth writing sessions, blood pressure, heart rate and skin conductance were measured again, then a second sample of blood was draw. After six weeks the subjects returned to undergo the same checks.
At the conclusion of the study the Health center provided data on the number of visits each student had made for illness for the five months before the study and for the 6 weeks of the study. Three months after the end of the writing a follow-up survey about stress and their daily habits (smoking, exercise), the same topics addressed by the questionnaire prior to the writing, was sent to the subjects.
Results were surprising, indicating that writing about a traumatic experience had a positive effect on the mitogen response, on automic levels, on subjective distress, and also evidenced a drop in visit to the Health center. The effect was more pronounced in those who had never discussed before with others they had written.
These effects were not observed in the control group.
The authors hypothesized that there is a stress that arises when you are not able to cope with trauma, in particular, to inhibit, the active gold back, thoughts, feelings and behavior is associated with a “fatigue” that in the long run may occur in illnesses. In this sense it seems that there is a positive effect on health resulting from a liberation of the traumatic content, which should no longer be actively kept away from consciousness.
But later, with new of studies on this subject, Pennebakers and other psychologists have proposed the idea that the mechanism that causes positive change is the reorganization of mental event, the production of a narrative, sometimes even a first narrative, other times a new, around the event.
Indeed in the 1988 research, the authors note for example that many of those who had written about the trauma changed gradually, through the sessions, their perspectives. They report, for example, the case of a woman, molested at age 9 by a boy three years older.
[…] Initially emphasized her feelings of embarassment and guilt. By the third day of writing she expressed anger at the boy who had victimized her. By the last day, she had begun to put it in perspective. On the follow-up survey 6 weeks after the experiment, she reported, “Before, when I thought about it, I’d lie to myself.. Now, I don’t feel like I even have to think about it because I got if off my chest. I finally admitted that it happende…I really know the truth and won’t have to lie to myself anymore”
Pennebaker and Francis (‘Cognitive, emotional, and language processes in disclosure’, 1996) have summarized what happens when you write down an experience: you assemble a coherent, sequential, narrative; causal connections are recognized; you consider other points of view, even in the perspective that there is a potential reader; you reflect on and you define, emotions and thoughts.
This research is especially important because underlines the positive effect of this process of narrative reorganization of experiences.
As I said, this research, together with the original by Pennebaker and Beall, has stimulated a whole line of research on the writing technique. From Pennebaker’s personal page, you can download a lot of articles about research he has conducted, and many other psychologists have carried out similar projects, not only in the United States, but also in Europe.
Dealing with anger and potentially violent behavior is certainly not easy. Even for psychotherapists managing the emergence of aggressive emotions or behaviour during a consultation may be difficult: the risk is that if such emotions are not recognized or adequately addressed, can have serious consequences. The fear of violence seems to be common among psychologists (Pope & Tabachnick, 1993), what’s very common: the fear that the client could attack them, that client could attack someone else, or that client could be attacked by someone else. Equally common is that psychologists feel angry about the behavior of the client towards someone else. Slightly less than 20% of the psychologists said he was assaulted by a client. About 60% of psychologists reported that a client has attacked someone else. Such behaviors frequently trigger psychologists’ fantasy of being attacked, and produce a series of reactions: from telling the client they’re scared, to report the thing to the police, to obtain a weapon for self-defence, to actually use the weapon (0.4 % of psychologists surveyed by Pope and Tabachnick).
According to Gately and Stabb (2005) between 35 and 40% of psychologists run the risk of being attacked by a client. through the examination of literature, and the conducting of a direct survey, they have suggested that mental health professionals do not feel equipped to deal with violent behavior by client. In their research 26% of psychologists in their sample had been verbally assaulted, and 10% physically assaulted.
Based on these data, Walfish, Barnett, Marly and Zielke (2010), conducted a study, interviewing a sample of 162 psychotherapists.
The results show that it is quite common in the career of a psychotherapist to have a client who confess to have: physically attacked someone (69%), or sexually assaulted someone (33%).
Although not common, it is not infrequent that a psychotherapist has had a client self-disclose to them during a session that he or she had murdered someone. In this sample a large majority, 135 (83%) indicated that they had never had this happen in their consultation room. However, 21 (13%) indicated that this had occurred at least once (4% did not respond to the survey question). Of these 21 clinicians, 12 indicated that they had only heard this once during their career, 4 had heard this twice, 3 had heard this four times, 1 had heard this six times, and 1 estimated having heard this from 15 different clients. Of these 21 psychologists only 5 had been told about the mur- der in the context of a forensic evaluation.
In addition to these data, 64.2% of therapists said they did not feel adequately prepared to deal with these confessions of violence.
The authors, comparing their results with those of Pope and Tabachnick (1993) who reported that as 9 out of 10 psychotherapists were afraid that a client could attack someone, reflected that this might be a realistic fear, at least regarding physical aggression.
Echoing the conclusions of several studies Walfish and his colleagues emphasize the importance of the way in which the therapist responds to the experience of the confession of violent acts by a client. They note that in their investigation, psychotherapists are equally split between those who argue that the revelation of the violence has had a negative effect on therapy and those who believed to have had a positive effect.
While it is certainly possible that counter-transference reactions by the therapist influence the assessment of the negativity of the event, it’s also been proposed a model in which is proposed that client can benefit more from therapy, by keeping secrets (Kelly, 2000). The hypothesis is that revealing information that the therapist could disapprove might help constructing an unwanted self-image.
The authors conclude that further research should investigate the reason that leads some therapists to consider these confessions negative for therapy, and others not.
The reaction of a psychotherapist dealing with a patient who admits violent acts can trigger powerful counter-transferal reactions, which if not managed will certainly have a negative effect on treatment. The authors wonder if the fear of the clinicians in these situations, is more or less realistic. Data from several studies (Tyron, 1986; Barnstein 1981, Gately & Stabb, 2005) suggest that the risks should not be underestimated. Not always the fear of psychotherapists is a counter-transferal reaction due to unresolved conflicts.
The authors conclude that although psychotherapists in the consultation room must be prepared to hear any type of material, whether is it nice or not, and even if this may also inclued unprosecuted violent crimes, they must still pay attention to three factors: their emotional reaction to this information, their need for security, and their ethical and legal obligations *.
This research highlights a particularly complex issue which might arise in clinical practice, but I believe that focusing on the therapist (how he reacts, what he should do), leaves aside the possibility that these confessed violent acts could be not real.
When Freud began the practice of psychoanalysis, initially he theorized that the cause of neurosis, was the experience of a childhood seduction, because he regularly heard that in the stories of his patients. Later, however, he diverged from this assumption, suggesting that the stories of childhood seduction were in fact the expression of unconscious fantasies of the patient.
Thus, the data from this research suggest at least some doubts: how likely is it that 33% of those who go in psychotherapy has committed a sexual assault that was not pursued by police? How likely is it that 13% of those who go in therapy has committed a murder for which he was not prosecuted? If it is possible to generalize the results of the study, we are talking about quite large numbers.
Without taking a definite position, it seems nevertheless useful to recall that the distinction between fantasy and reality in psychotherapy is at least problematic; psychotherapists, in front of a confession like that, rather than reacting as if it was immediately clear, obvious, that this is a true story, that is an unpunished crime, maybe they should carefully reflect on the meaning that the confession has as a communication in the context of therapy.
* The article by Walfish and his colleagues also contains a long close examination of the legal/ethics issues on the subject, since the law is different in the U.S. and in Italy I have not thought of bringing that part of the discussion.
[ Walfish, S., Barnet, J., Marlyere, K., & Zielke, R. (2010). “Doc, There’s Something I Have To Tell You”: Patient Disclosure To Their Psychotherapist of Unprosecuted Murder and Other Violence. Ethics & Behaviour, 20 (5), 311-323. ]