Sunday, August 28, 2016

Healing Prayer and the Brain: Not a Match Made in Heaven


Activity of the medial prefrontal cortex after psycho-spiritual healing (Baldwin et al., 2016).


Everything we do and feel and experience changes the brain. Psychotherapy, juggling, taxi driving, poverty, reading, drugs, art, music, anger, love. If it didn't we'd be dead. Why should prayer be any different? The trick is to accurately determine the structural or physiological changes that are unique to a specific activity. And when assessing the effectiveness of clinical interventions, how the changes compare to an adequately matched control intervention. Plenty of high profile studies have failed to do that, including a recent one on emotionally focused therapy.1 

I feel bad about criticizing a study on the neural correlates of healing prayers. I'm not one of those smug atheists who lord their intellectual superiority over the unwashed religious masses. Certain atheist organizations claim they're all about promoting scientific literacy and a secular worldview. But I think these New Atheists are detrimental to science literacy, since they alienate the vast majority of the population.

So why am I blogging about a prayer intervention for depression? It's not to sneer at the authors. And it's especially not to sneer at the participants, who were recruited from Houston-area churches. My interest is the unholy alliance between brain imaging and a psychological intervention with no control condition. As I've said before...
...neuroimaging studies of psychotherapy that have absolutely no control conditions are of limited usefulness. We don't know what sort of changes would have happened over an equivalent amount of time with no intervention. More importantly, we don't know whether the specific therapy under consideration is better than another form of psychotherapy, or better than going bowling once a week.

Healing Prayer, Trauma, and Forgiveness

This is especially true for a treatment that is based on faith and a strong belief that the intervention will work — a Christian form of prayer focused on forgiveness and psycho-spiritual healing (PSFH). A prayer minister “led the subject through three different phases: (1) a prayer of forgiveness for the perpetrator of the hurtful event; (2) a prayer of blessing on the perpetrator; and (3) a prayer to heal the emotional damage caused by the traumatic event.”



Study design for the 6 week healing prayer intervention (Baldwin et al., 2016).

The 18 participants had moderate to severe levels of depression on the Hamilton Depression Scale (HAM-D). Oddly, post-traumatic stress disorder (PTSD) was not assessed before or after the intervention. This was a major weakness, given that the purpose of the intervention was to forgive the perpetrator of childhood abuse and to heal from emotional trauma. In this sense, PSFH is akin to more formalized psychotherapies such as forgiveness therapy.

It's no surprise that a non-randomized, unblinded prayer intervention in religious persons resulted in dramatically reduced HAM-D scores in the 14 participants who completed the study (11 of whom were available for a one year followup).


Who am I to criticize a practice that helps suffering people? I won't do that.

What I will do is point out difficulties in task design that make it nearly impossible to interpret some aspects of their fMRI study. The task used a symptom provocation paradigm using 3 key words to evoke memories of the traumatic event (15 seconds) and feelings of the traumatic event (15 seconds), separated by a 2 second blank screen.2 Is it possible to separate traumatic memories from the feelings they evoke, and to switch between them on such short notice? Certain therapies (such as prolonged exposure) are designed to do just that. The authors stated that anecdotally, this appeared to be the case here as well:
In this and our previous study, subjects frequently mentioned informally that PSFH results in a separation of the traumatic memory and associated feelings: while the memory remains intact, it no longer associates with traumatic feelings.


Activity of the precuneus to Bad Feelings was higher before psycho-spiritual healing (Baldwin et al., 2016).


It is, however, difficult to interpret a 23 voxel decrease in precuneus activity in 14 subjects as a reflection of such a complex therapeutic change, especially since this brain region is involved in both self-referential processing and episodic memory retrieval.

But to be even more fair, the authors listed ten caveats to their admittedly preliminary study.3 When all is said and done, how can this study reveal ANYTHING about the neural correlates of healing prayer?




Or in this case, nothing fails like a non-randomized, unblinded, not-placebo-controlled fMRI study of prayer. Or of any other intervention, for that matter.

Nothing-Fails-Like-Prayer image by Henry Ruddle


Footnotes

1 Johnson SM, Moser MB, Beckes L, Smith A, Dalgleish T, Halchuk R, Hasselmo K, Greenman PS, Merali Z, & Coan JA (2013). Soothing the threatened brain: leveraging contact comfort with emotionally focused therapy. PloS one, 8 (11).

Also see two blog posts by Dr. James Coyne.

2 These Bad Memory/Feeling blocks were also compared to Neutral Memory/Feeling blocks that evoked memories and feelings about a neutral topic (e.g., the weather). This is the pre/post contrast shown in the first figure of the post.

3 To shorten and paraphrase the overly honest Limitations section of Baldwin et al. (2016):
  • the number of subjects was small (n=14) 
  • recruitment was largely done at churches, which might affect generalizability
  • individual minister effects could not be ruled out
  • there was no control population receiving an alternative therapy
  • only subjects who completed the study were included, which may have skewed the results
  • life events such as changing employment status, marriage stability, family, health, and economic changes were not assessed
  • possible confounding effects between the role of PSFH and intercessory prayer for the participants by others [NOTE: some of us may discount this as a confounder]
  • cannot rule out an effect of being exposed to the task in the MRI twice
  • demand characteristics participants answered worse at the beginning and better at the end to fulfill researcher’s expectations 
  • outcomes were rated by non-blinded observers

Reference

Baldwin, P., Velasquez, K., Koenig, H., Salas, R., & Boelens, P. (2016). Neural correlates of healing prayers, depression and traumatic memories: A preliminary study Complementary Therapies in Medicine, 27, 123-129 DOI: 10.1016/j.ctim.2016.07.002

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2 Comments:

At February 17, 2017 11:57 AM, Blogger Ramiro Salas said...

Hi,

Thank you for your blog. I am one of the authors, and I feel I can shed some light here. I want to “defend” our work as I think your criticism has several fatal flaws.

Your first mistake, I believe, is when you say “I feel bad about criticizing a study on the neural correlates of healing prayers. I'm not one of those smug atheists…” The paper has no reference to the existence or lack of existence of god. Why do you start with a comment about atheism is therefore a mystery to me: you should criticize the science, which has nothing to do with theism.

Next you say “neuroimaging studies of psychotherapy that have absolutely no control conditions are of limited usefulness”. We did have a control condition, by assessing participants before and after an intervention. Although a randomized trial is definitely better (and would probably be necessary before we advocate to start using the intervention clinically), pre-post intervention studies have value: the controls are participants before the intervention.

Next, “we don't know whether the specific therapy under consideration is better than another form of psychotherapy, or better than going bowling once a week”. While this is true (we didn’t directly compared), millions of depression patients could testify that bowling or any other activity including no intervention as you suggest, have no effect on their disease. If you think that 14 people can magically go down from HAM-D ~20 to HAM-D ~4 you are probably deluded and not very serious about what we know about depression.

“This is especially true for a treatment that is based on faith and a strong belief that the intervention will work”. You make that assertion with nothing to back it. In fact, the strong belief that the intervention will work may be extremely important here, and perhaps one of the reasons why the intervention worked and the associated brain changes. Nothing wrong with that. Your comment sounds a little like “believe me, this is especially true…” with nothing to back it up.

Next you go to “Oddly, post-traumatic stress disorder (PTSD) was not assessed before or after the intervention. This was a major weakness, given that the purpose of the intervention was to forgive the perpetrator of childhood abuse and to heal from emotional trauma.” I would invite you to read the paper again. We did not recruit participants looking for people who suffered childhood abuse, in fact we were surprised that all but one (adolescent trauma) had childhood trauma. In addition, we could have measured PTSD (a good idea in retrospect), but we used HAM-A to measure anxiety, which if anything, is more general.

Will finish later as there is a character limit.

 
At February 17, 2017 11:57 AM, Blogger Ramiro Salas said...

Next: “It's no surprise that a non-randomized, unblinded prayer intervention in religious persons resulted in dramatically reduced HAM-D scores in the 14 participants who completed the study (11 of whom were available for a one year followup).” Although there are many studied of interventions in depression, our data is still surprisingly strong. If you can point me to other studies with similar results, with replication (I guess you noticed that the intervention had been studied before, this paper was only to add the MRI component), I’d appreciate that.

Your next criticism is “It is, however, difficult to interpret a 23 voxel decrease in precuneus activity in 14 subjects as a reflection of such a complex therapeutic change, especially since this brain region is involved in both self-referential processing and episodic memory retrieval.” I absolutely agree, and part of this is mentioned in the paper as a caveat.

You were too kind to mention that we did write down a list of caveats. And I agree with your comment “possible confounding effects between the role of PSFH and intercessory prayer for the participants by others [NOTE: some of us may discount this as a confounder]”. The literature does not seem to support that intercessory prayer works, but we were careful not to explicitly say "intercessory prayer that is not known to the participant". So again, you seem blinded by your beliefs and didn't really read what the paper says.

Finally, the cartoon, while funny, has no scientific value and is not applicable to our study.

So, given the fact that we understand and acknowledge the caveats of our study, what would you propose? Not to publish it? I think that would be a disservice to science. What we say is that if this intervention is as good as it seems we should study it, which I hope you agree with. If so, your criticisms are irrelevant as we criticized the work at least as harshly as you did.

Best,
Ramiro

I could not find your name or email in the blog. I'd like to be able to say "dear xxx" to start this!

 

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