Providentia

How Effective is Cognitive Rehabilitation in Schizophrenia?

Cognitive rehabilitation is becoming an increasingly popular intervention in treatment programs for people with schizophrenia. Despite this increased acceptance, however, the actual evidence concerning its effectiveness is not impressive. Considering the evidence of cognitive recovery in patients treated with medication or other evidence-based psychosocial interventions who do not receive cognitive rehabilitation, It is not clear whether cognitive rehabilitation is worth the expense in time and resources. An article in a recent issue of Schizophrenia Bulletin provides an overview of recent research examining the value of cognitive rehabilitation strategies in treatment schizophrenics.  The authors argue that the slow progress in the field of cognitive rehabilitation of schizophrenia is related to failure to address several critical issues: (1) the importance of manipulating stimulus and context structure in rehabilitative interventions; (2) the need to base a cognitive rehabilitation of schizophrenia on cognitive neuroscience as opposed to neuropsychology; (3) the importance of systematically addressing motivation, self-esteem, and affective factors when designing cognition-enhancing interventions; (4) the need to move beyond one-size-fits-all interventions and develop individualized treatments; and (5) the need to address abnormalities in the experience of the self when designing interventions to optimize cognitive and behavioral performance.  Cognitive rehabilitation works best as part of a structured approach that combines different strategies for improving cognitive functioning including use of real-time feedback methods to reinforce gains.  The potential value of cognitive rehabilitation in helping treatment-resistant schizophrenics is only beginning to be understood.

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Jail Term Sought For Botched Circumcision

"You're just taking advantage of me because I'm poor.  You're taking advantage of me because I didn't have money to compel rabbis and other experts to come here and testify. What you're doing is rotten and wicked. This is a miscarriage of justice."  This outraged reaction to a Crown Attorney's cross-examination highlighted the trial of a British Columbia in a sentencing hearing over the botched circumcision of a then-four year old boy.  The defendant, who can only be identified as D.J.W. has already been found guilty of criminal negligence and is facing a one to two year jail term and a three-year probation period. 

According to evidence presented in the original trial, DJW's son (known only as DJ) was born prematurely and couldn't be circumcised at birth because of his low birth weight.  A former Jehovah's witness, DJW attempted to circumcise himself in 2004 or 2005 after reading the books of Richard Hoskins who advocates circumcision and a "Biblical" lifestyle.  Despite medical complications which required suturing in a hospital, DJW investigated having his son circumcised and was told that it wasn't advisable for a four-year old boy.  He was also told that the operation would cost $2000-5000 (circumcisions aren't covered under provincial health plans).   

In April 2007, he decided to do the circumcision himself.  After telling DJ that the operation would give him "extra special protection from God", he laid down garbage bags on his kitchen floor and gave his son honey wine for anesthetic.  He then used a razor blade to cut away the boy's foreskin but, due to complications, the circumcision was later completed in a hospital.  Police charged DJW with criminal negligence causing bodily harm after the incident.

The sentencing hearing has been adjourned until March 25 until a new psychiatric assessment report can be prepared.  The sentencing judge has not ruled out the possibility of a conditional sentence.

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The Reluctant Hangman

John Radclive never planned to be a hangman.

Born and raised in England, he would later state that he had originally intended to become a clergyman, "but I was no hypocrite and I gave it up".  After years of military service,  he was stationed in various parts of the world before coming to Canada with his wife and four children in 1887.  Sometime between leaving the military and coming to Canada, John Radclive had been apprenticed to William Marwood, the U.K.'s official executioner.  Through his work with Marwood, Radclive became a proficient hangman although he abandoned the trade when he settled in Toronto.  Working as a steward at Toronto's fashionable Sunnyside Boating Club, Radclive quickly realized that the salary was inadequate to support his large family so he decided to engage in a bit of moonlighting.  Advertising his services as a hangman to local sheriffs, he quickly found work (but only on a part-time basis).

While he still worked as a steward, his strange double life cost him that job quickly enough.  One day at the boating club, a powerful member (who also happened to be an inspector with the Northwest Mounted Police) recognized Radclive and told the club's owners that he didn't appreciate having his drinks served by a "common hangman".   Radclive had never kept his sideline secret (and he never wore the traditional hangman's mask when working).  The club owners eventually fired him for his "lack of discretion" and Radclive was forced to carry out the hangman's trade on a more regular basis.  By 1892, he became Canada's first professional hangman.

By all accounts, Radclive existed in a kind of purgatory.  He was never a civil servant and carried out his hangman duties on a fee-for-service basis along with a basic retainer from the Federal Government.  He traveled across much of Canada by train, conducting executions in small jails around the country (executions were always under the jurisdiction of local authorities). The procedure was usually the same for execution: Radclive receiving a telegram informing him where and when he was needed followed by his prompt arrival by second-class coach (he paid his own way).  There was no official licensing or government authority associated with his carrying out the hangings, it was simply an unpleasant duty that only someone of Radclive's reputation could be trusted to do.  Of course, Radclive probably added to his notoriety by often selling pieces of rope as souvenirs after the hangings (they were popular with the crowds that gathered to watch the public executions of the time - especially the high-profile ones).

It's hard to say for sure when Radclive's drinking began.   Alcoholism tended to be an occupational hazard for executioners given the stress associated with the job.  One double hanging that Radclive carried out in Montreal in 1899 (a man and a woman) was followed by a near-riot among the spectators.   Police had to control the crowds until the bodies were cut down and Radclive was so unnerved by the spectacle that he spent the night in the prison with a bottle of brandy for comfort.  He would need that brandy more and more in the following years and often got into drunken brawls at local pubs before and after the planned hangings.  Although the drinking didn't usually interfere with his duties, his absences became more frequent in his later years.

One of the most astonishing executions that Radclive ever had to carry out was on an elderly man at the jail in St. Scholastique, Quebec.  While the condemned man was being taken to the gallows, he suddenly died of a heart attack. To Radclive's astonishment, the sheriff pointed out that the actual hanging still needed to be carried out according to the execution order.  Despite his protests, Radclive was forced to hang a dead man (the corpse was tied to a chair to keep him in position on the gallows).  Suffice it to say that Radclive likely did a lot of drinking that night.

Many who knew him described Radclive as a robust man who seemed to revel in his sinister reputation and the gawking crowds that often gathered to see the notorious "Ratliff" arrive by train to carry out local executions. He always made it a point to stay informed about the details of each case to reassure himself that the person to be hanged was actually guilty.  Although he never refused to carry out an execution, the prospect of bungling a hanging or otherwise prolonging the suffering of the condemned was always with him.  He even experimented with better ways of hanging people although his innovations never really caught on (the traditional gallows was too popular).   As Radclive complained to one journalist, political concerns ensured that he kept on dealing with, "all them long steps which he'd had to drag some poor snivellin' bastard cryin' for his ma".  

By 1911, John Radclive had hit rock bottom.  Suffering from cirrhosis of the liver from his long years of drinking, he was left penniless and alone in his final days.  His wife had long since left him and took their two youngest children back to England (whether due to the drinking or the hanging is still unclear). While his two oldest children still lived in Toronto, he was largely estranged from them.  Shortly before his death on February 26 of that year, he told an interviewer, "My family deserted me and changed their names, but I kept right on with the job, because I argued with myself that if I was doing wrong then the government of the country was wrong.  I held that I was the minister of justice at a hanging and that if I was was a murderer, then he was also a murderer".  

The last two executions in Canada were carried out on December 11, 1962 at the Don Jail in Toronto.  The actual identity of Canada's last executioner (known only by the pseudonym of "Camille Blanchard") has never been made public.  Capital punishment was formally ended in Canada with the passage of Bill C-84 in 1976.

B.F. Skinner's Daughter Responds

Following the post I wrote about B.F. Skinner and his experiences in using the air-crib for his daughter, Deborah, I was pleased to get an email from Deborah Skinner Buzan herself.  She kindly permitted me to reprint her email as follows:

 Hello.

I occasionally look myself up to see if there are any interesting or (more usually) annoying comments about my father or the aircrib. I was very impressed to read 'Heir Conditioner', as there's more information in there than I knew, though admittedly I haven't ever done much research about the early years of 'the box'. My father never intended to make me or any other air crib babies more independent but otherwise as far as I can tell, 'Heir Conditioner' is accurate. I thought you - or whoever wrote the piece - might like to know about one episode that was behind a lot of the rumours about me. Edwin Boring, head of department at Harvard when my father was there, did have a daughter who was institutionalized because she was psychotic or something. A psychologist at another university (who specialized in child development), on hearing that the daughter of 'a prominent Harvard psychologist' had mental problems, assumed the psychologist in question was that horrible man Skinner who put his daughter in a box. After my father tracked down who was behind at least some of the rumours, the psychologist sent a letter of apology. But of course word continued to spread. I'm glad the article mentions my anger that Slater never tried to contact me. That's probably what really infuriates me most about her book. She visited my sister who had passed on contact details to many journalists before and would have been more than happy to put Slater in touch with me. But of course her chapter would then have left the reader questioning my sanity/suicide.

Yours sincerely,

Deborah Skinner Buzan

I'm happy to have the opportunity to have Ms. Buzan tell her side of the story.

Singing The Body Electric (Part 3)

Continued from Part 2

By the turn of the 20th century, there were new hucksters in the electrotherapy trade. Heracles Sanche (who proclaimed himself the "Discoverer of the Laws of Spontaneous Cure of Disease") began marketing a new device which he called the "Electropoise". According to his ads, "the Electropoise supplies the needed electrical force to the system, and by its thermal action places the body in condition to absorb oxygen from the lungs". Along with the healing power of electricity, Sanche also stressed that disease could be cured by forcing more oxygen into the body. His second great invention, "the Oxydonor" was basically a carbon-filled metal cylinder that supposedly emitted life-giving ozone for curing disease (ozone's healing powers were already well advertised).

The leading figure of 20th century electrical quackery had to be Albert Abrams. Born in San Francisco in 1863, he earned his medical doctorate from the University of Heidelberg and became professor of pathology at Cooper College before it was absorbed into Stanford University Medical School (later skeptics disputed his medical credentials.  Although his early medical career seemed orthodox enough, Dr. Abrams went in a different direction by 1910. After publishing two books focusing on the role of spinal treatment in curing disease, Abrams began training other doctors in Spondylotherapy, i.e., manipulating the spine to treat various medical conditions (Abrams had a strong influence on the chiropractic movement).

A few years later, Abrams branched into electrotherapy. He proposed that every disease had a signature electronic vibration that could be measured with the right instrument. With the invention of the dynamizer, Abrams was able to launch his Electronic Reactions of Abrams diagnostic system (ERA for short). Basically, ERA worked by putting drops of the patient's blood onto blotting paper (the blood was first "cleansed" by treating it with a horseshoe magnet) and then placing it into the dynamizer. A wire was then placed on the forehead of a second, healthy person who stood on grounded plates (this second subject was known as a "reagent"). The reagent was stripped to the waist and placed facing westward. When the dynamizer passed the vibrational frequency of the blood sample to the reagent, Abrams or one of his disciples tapped the reagent's abdomen. Based on the tapping, Abrams claimed to be able to pinpoint the nature and location of any disease in the patient's body.

Abrams didn't stop with simply diagnosing disease. His next great invention, the oscilloclast, was a boxlike gadget with electrodes that he could place on the patient's body. Using his invention, Abrams claimed to cure patients by "duplicating and neutralizing the signature vibration of disease". Through aggressive marketing, Abrams recruited various "electronic practitioners" who treated disease using machines leased from Abrams' company. The actual training that these therapists (such as it was) would become a factor in later lawsuits.

It was quite a lucrative business for a while. Not only did Abrams become a favourite of osteopaths and chiropractors of the time, but he also made numerous friends in the media.His supporters included novelist Upton Sinclair and Pearson's Magazine. The years immediately following World War I represented the peak of Abrams' popularity and his electronic vibrational data was even accepted for evidence in a paternity suit. Abrams also found a way to profit from Prohibition when it began in 1920. He claimed that his devices could duplicate the vibrational frequency of alcohol to produce an "electrical high" without the hangover.

The backlash wasn't long in coming for Abrams' movement. The American Medical Association denounced Abrams' machines and declared him to be, "easily ranked as the dean of twentieth century charlatans". One skeptic took a sample of chicken blood to an Abrams-trained therapist who diagnosed it as being from a patient with cancer and tuberculosis. Other trials with bird and animal blood had the same result. Robert Andrews Millikan, prominent physicist and Nobel laureate, testified in a case that Abrams' machines had "no value whatsoever". When told that a researcher found no evidence of an electric current passing through one of his machines, Abrams reportedly laughed and replied, "Of course not, the machines are electronic, not electric". Scientific American launched an intensive, year-long, investigation into Abrams and his theories.

By 1923, Abrams had resigned from most medical organizations but was still active in defending his theories when he fell ill. He died of pneumonia on January 13, 1924, just days before being scheduled to testify in another case brought against him. His front-page obituary in the San Francisco Examiner declared that, "worry over attacks launched on his theories in all parts of the civilized world by members of the medical profession led to a breakdown in his health three months ago". Although Abrams had left instructions in his will to use his substantial estate to found the "Abrams College of Electronic Medicine", his family members broke the will and the planned college never materialized. Abrams still has his supporters but the kindest epitaph for him came from one science writer who stated that he was, "a magician who believed in his own magic".

Abrams' passing also marked the end of an era for electrotherapy. The use of electricity in medicine led to legitimate (and some controversial) medical advances while the hucksters had more difficulty in selling their miraculous wares. The AMA and other medical organizations became more aggressive about investigating suspected quackery while the Food and Drug Administration began regulating medical devices in the 1930s. While improvements in conventional medicine made the electrical option less appealing, quack purveyors were forced to find new ways to separate desperate patients from their money.

For those of you who were wondering, I have no plans of using my new electrical toy with my own patients. Leaving aside issues of self-respect and professional reputation, there's just too much competition these days in the quackery industry.

Is Bipolar Disorder Chronic?

Bipolar spectrum disorders have traditionally been thought to be chronic in course. However, recent epidemiological research suggests that there may be developmentally limited forms of bipolar disorder. An article published in the August 2009 issue of Journal of Abnormal Psychology presents the results of two large, nationally representative studies that challenge existing perceptions about the prevalence of bipolar disorder over time.   The results reveal a strikingly high prevalence of bipolar disorders in emerging adulthood (5.5%–6.2% among 18–24-year-olds) that appear to resolve substantially during the latter half of the 3rd decade of life (3.1%–3.4% among 25–29-year-olds). There is potential bias due to early mortality, institutionalization, incarceration, and homelessness that may account for some of this reduction, the prevalence distribution suggests a high incidence in late adolescence and emerging adulthood that appears to resolve spontaneously in most cases. There were very few differences across age groups in symptom endorsement and comorbid diagnoses, suggesting that 18–24-year-olds that meet criteria for bipolar diagnoses experience clinically significant impairment and associated consequences of the disorder. Better longitudinal research is needed to determine whether developmentally limited forms of bipolar disorder exist and, if so, what markers might distinguish these forms of the disorder from more chronic courses.

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Self-help Course Linked to Fatal Psychosis

In 2005, 34-year old Rebekah Lawrence signed up for a four-day course titled, "The Turning Point" that had been recommended for her by friends.  The course, promoted as a "journey to the core of the human spirit" was run by People Knowhow in the Sydney suburb of Cremorne.  Designed to help participants establish a dialogue between their adult and child selves, the course instructors trained the participants in childhood regression therapy.  Her husband, David Booth, reported that she came home from the course in a "dreamlike state-almost like someone on drugs" and that the usually gentle woman began to show alarming behavioural changes Despite her worsening psychological problems following the course, the instructors running the program, none of whom had professional training, were unable to help her.

On December 20, two days after the course ended, Rebekah Lawrence arrived late for work at her job as assistant for the CEO of the Royal Australasian College of Physicians in Sydney, Australia.  A coworker later described her as "quite unstable in a manner in which I had never seen before".  After stripping naked, she then screamed and acted "like a child having a tantrum".  She began screaming, "I love you David", climbed out a second-story window and then jumped. There was no history of mental illness and no trace of drugs or alcohol was found in her system.

At a recent inquest into Rebekah Lawrence's death, Deputy State Coroner Malcolm MacPherson ruled that her psychotic state and subsequent suicide could be linked to the self-help course and called for greater regulation and training to oversee the content of counseling or psychotherapy-oriented courses  He called for the health minister to enact legislation to set up a system of registration, either at the national or state level.  During the course of the hearing, the director of the Turning Point program conceded that the program had "inadequate" safeguards both in screening participants or in following up with them afterward.  Although the course provider's lawyers suggested that preexisting mental problems may have been to blame for Ms. Lawrence's death, there was little evidence to support the claim.  Mr. McPherson concluded that childhood regression therapy was "intrinsically unsafe" and played a clear role in the death.

Members of Rebekah Lawrence's family, including her husband David Booth, expressed satisfaction with the inquest's findings and urged that proper legislation be enacted to prevent future tragedies.  David Booth has not ruled out litigation against People Knowhow and the Turning Point program.

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Singing The Body Electric (Part 2)

Continued from Part 1

The dean of 18th century electrotherapy was undoubtedly Dr. James Graham.  Also known as an early pioneer of sexology, he received medical training in Edinburgh but left before completing his degree.  After studying electricity in Philadelphia, he left America before the American Revolution to return to England.  A determined self-promoter, Graham advertised his electrotherapy services to cure a vast range of diseases and quickly attracted numerous celebrity patients.  While conventional physicians dismissed him as a quack, Graham opened a clinic in one of the most exclusive London neighbourhoods which he dubbed the "Temple of Health".  Patients to Graham's clinic were often awed by the elaborate electrical equipment on display, not to mention the various "trophies" of former patients.  This included the various walking-sticks, crutches, spectacles and ear-trumpets prominently displayed on clinic walls.  Graham proudly claimed that grateful patients had left them behind after he cured them of their ailments.

Graham's electrical devices included an enormous Leyden jar (for display only) and a vast prime conductor nearly three meters high.  Not only was there a large throne where as many eight patients could sit at a time for their treatment sessions but also a metal shelf for the various medicines that Graham "electrified".  He made these potions in his own laboratory and testified to the purity of the ingredients that he used.  Once electrified, the medicines were used to "enter patients and work medical miracles".  There were other prime conductors throughout the clinic as well as discreet alcoves where Graham and his assistants could meet with patients privately.  James Graham also maintained a free clinic where poor patients could be treated (usually in full view of more well-to-do visitors and prospective patients).  Graham was definitely a showman.

The most well known feature of Graham's clinic was his "Great Apollo Apartment".  A large domed chamber, stunningly decorated, the dominant themes were fertility and bliss. Patients sat on magnetic seats with their bare feet resting on sulfur while music played in the background.  Graham himself said of the Apartment that, "words can convey no adequate idea of the astonishment and awful sublimity which seizes the mind of every spectator".  The truly multi-sensory experience that patients received guaranteed return visits and Graham declared that, "there is no fever, rheumatism, cramp, spasm, or convulsion” that would not yield to this treatment, often in less than a minute".   For infertile couples who could afford his fee, he also offered a "Celestial Bed" which was, basically, a canopied bed where couples could “bask in a genial, invigorating tide of the celestial fire, ” where, he insisted, they could not fail to produce “strong, healthful, and most beautiful offspring".

As you may have gathered, the conventional medical establishment wasn't happy with James Graham and the feeling was mutual.  He often condemned conventional medicine and maintained that most treatments advocated by physicians were "fundamentally and in their nature wrong".  He accused these doctors as being corrupt as well as incompetent.  Considering the often brutal treatment methods that 18th century physicians were capable of inflicting on patients, Graham's criticisms won him even more praise, except for the fact that his own treatments didn't really work (suggestion can only get you so far).  By the time of his death in 1797, James Graham was largely discredited and deeply in debt.  Even the electrical apparatus at his beloved Temple of Health had long since been sold off.

While traditional physicians may have breathed a sigh of relief at Graham's passing, electrotherapists were still practicing their trade (if not as flamboyantly as Graham).  In addition to pain treatment, they offered relief for a variety of "women's problems" including hysteria, depression, menstruation problems and, possibly, even induced abortions (for obvious reasons, this particular service was never advertised).  It wasn't all quackery though since the value of electrotherapy in resuscitating some heart attack and drowning victims made it a standard tool for medicine (the actual work of resuscitation was usually left to "medical assistants"-possibly the earliest version of paramedics).   Specialized electrical devices were developed for use in cases of "suspended animation" which eventually evolved into our modern heart defibrillators - with considerable trial and error along the way. 

Despite the growing legitimacy of electrotherapy, the quacks still practiced their trade  (just not as flamboyantly as James Graham).  As electrical technology improved, electrical devices became more portable and affordable.  While devices such as my Davis & Kidder machine were usually harmless, they were often marketed in ways that were anything but harmless.  One famous 19th century vendor of patented electrical devices was "Professor" Isaac Lewis Pulvermacher who sold products under the slogan, "Electricity is Life".  Pulvermacher's most memorable invention  was the "Electro-Galvanic Chain" - basically adjustable belts which supplied "mild, continuous currents" for eight to twelve hours a day while the patient wore them.  When not in use, the belts were immersed in a weak vinegar solution to generate a current.  At a cost of twenty dollars U.S. apiece, the belts were hardly cheap but still more affordable than most medicines at the time.  Better yet, Pulvermacher's products were sold as "self-applicable for the cure of chronic disease without medicine".  Pulvermacher's methods spawned numerous imitators and his ads sternly warned customers to  "accept no substitutes".

Which brings us to the dawn of the 20th century...

Continue to Part 3

Searching versus Surfing: Is there a difference?

People have different ways of finding information online. Whether searching for specific information or simply coming across new facts while surfing at leisure, the end result should be the same in terms of how that new information is perceived. Or is it? A recent study published in a 2009 issue of Journal of Media Psychology describes a mixed-design experiment exploring differences between searching and surfing on cognitive and emotional responses to online news. In a sample ofninety-two participants recruited from an undergraduate marketing class, the participants were asked to read three unpleasant news stories from a website. Half of the participants acquired their stories by searching, meaning they had a previous information need in mind. The other half of the participants acquired their stories by surfing, with no previous information need in mind. Heart rate, skin conductance, and EMG measures were while participants read each story. Self-report measures of article relevance and accuracy in a later recognition trial were also measured. Stories acquired by searching elicited greater heart rate acceleration, skin conductance level, and EMG activity during reading. These stories were rated as more unpleasant, and their details were recognized more accurately than similar stories that were acquired by surfing. The authors conclude the paper by discussing the implications of these results for understanding how people process new information online.

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Mental Illness Linked to Shocking Family Murder

It was a shocking crime that was never supposed to happen in peaceful Merritt, British Columbia.  On April 8, 2008, Darcie Clarke found her three children dead in their family trailer.  Her daughter Kaitlynne, 10, had been stabbed to death while her 8-year old brother Max and 5-year old brother Cordon had been smothered.  After the murders, the children's father, 40-year old Allen Shoenborn, fled into the local woods and evaded capture until April 16.  He was later charged with three counts of first-degree murder while police were left baffled over his motive for killing his children. 

The police investigation and repeated forensic assessment have slowly unraveled a complex story of mental illness and domestic violence.  When questioned over his reasons for killing his children, Allen Shoenborn has maintained that his children were being sexually abused and was forced to kill them for their own protection.  Based on evidence presented by forensic psychiatrists, Shoenborn`s defense attorney maintains that his client is suffering from a delusional disorder that contributed to the killings.  The Crown is arguing that the killings occurred in a jealous rage due to fears that Darcie Clarke would leave and take their children with her.  Due to his long history of paranoid delusions and hallucinations going back years, social workers expressed concern at Shoenborn's escalating pattern of threatening behaviour toward his children.  They warned Darcie Clarke three days before the killings that they would intervene if she failed to take steps to protect them from their father. 

While Shoenborn is being held for trial at Kamloops Regional Correctional Centre, the nature of his charges require his placement in solitary confinement for his own protection. He told examining psychiatrists that he still speaks to his children wishing them a good morning when he wakes up and a good evening when he goes to sleep.  He also maintained that it was his duty to kill his children when they were threatened,  Due to his bizarre outbursts during the trial to date, he is kept in a Plexiglas-enclosed prisoner box while in the courtroom.  While he has pled not guilty, his attorney is attempting to have him declared not criminally responsible.

The trial is continuing.

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