Thursday, 5 July 2018

How splitting became the patient's problem

I have a paper out in Psychoanalytic Psychotherapy about mental health team splitting in relation to the diagnosis of borderline personality disorder. The paper is a critique of the way that clinicians have come to think and write about the idea of splitting. 

What is splitting in this context? When clinicians say that someone is "splitting" they usually mean that an individual is doing something to a team to make it split. Here (from the paper) is my attempt at a formulation of what splitting is supposed to be:
An individual is said to have split a treating team when their differential behavior toward different members precipitates polarized feelings and opinions about their care and concomitant professional discord. Such a split can manifest in a number of ways, but commonly a staff team becomes organized into two starkly opposed groups. Individuals in these camps may come to have strong positive or negative feelings toward the patient and hold opinions about them that are radically different from those of their colleagues.
I remember when I first heard about splitting. In my first job in mental health I was asked for something by one of the residents. A colleague took me aside and said in hushed tones "she's splitting!" I had no idea what she was talking about.

I have kept on hearing about splitting ever since, and it seems clear to me that, although there is often something important happening when the term is used, the way we think about it is hopelessly over-simplified. I have seen situations where the identification of splitting takes on the quality of an accusation, and seems to function to absolve staff of any responsibility they have for being kind or thoughtful. I have even seen instances of frank cruelty by staff that are later explained away as being produced by the patient through their splitting.

The argument in the paper is that what was once thought of as a complex social phenomenon involving multiple actors has come to be seen as a discrete action that is perpetrated on a team by a particular sort of person. The use of psychoanalytic terminology (which describes complex phenomena but is prone to reification) has helped this process along. To get a feel for how the discussion can presented, here is an illustrative title page from a 1985 article:

It wasn't always like this. In early descriptions of team splits (Tom Main's "The Ailment" is often cited as the first appearance of the concept in the literature), you tend to see a complex description that takes into account the ways that we are all prone to intense emotions and the resulting interpersonal disputes. Main's essay describes a phenomenon that he observed in a hospital whereby the emotions of staff and patients interacted with one another in a complex way to produce splits. He invokes the emotions of staff, and explicitly says that splits are not caused by patients. 

Main's observations morphed as they were recounted by subsequent authors. The jargon heavy language of psychoanalysis increasingly entered the picture and splitting became understood as a distinctive set piece that could be seen as originating in the patient. The 1980s were a turning point. An article by Glen Gabbard from 1989 appears to have been particularly influential in cementing the view that splitting is driven principally by the use of projective identification by a patient and counter-transference responses in clinicians. Both of these are somewhat useful concepts, but they can end up putting a lot of responsibility on patients and absolving clinicians for their emotions and behaviors. 

Projective identification tends to be written and spoken about in magical ways (talk of people "putting feelings into" one another, which the psychoanalyst Morris Eagle once noted would be considered delusional in some contexts), and counter-transference has that useful "counter" prefix, which implies that the therapist's feelings really belong to the patient (they are just a "counter" to their "transference"). In fairness to Gabbard, he does try to emphasize the role of staff psychology but the language used seems to imply that splitting is centered, in an important way, on the activity of the patient.

Although there are likely sensitive clinicians and sensitive understandings of splitting, the mainstream clinical literature has been influenced by an increasingly succinct formulation of what is happening when staff splits get going. Here are two relatively recent examples:
“Conflict can arise as a consequence of consumer splitting or projection, whereby the staff act out (externalize) the internal good-bad and blaming dynamics of the person with borderline personality disorder” (Horsfall, 1999, p.428) 
“these patients selectively divide or split the nurses into good or bad persons. The conflicts and splitting of the nursing staff can carry over to the treatment team, and polarization of staff can occur, particularly as transference and countertransference reactions evolve” (Bland & Rossen, 2005 p.510).

Look at the way this is framed: "Conflict can arise as a consequence of consumer splitting" and "these patients selectively divide or split the nurses into good or bad persons." In this language we have inherited an idea that I call "the borderline as splitter." When a person is viewed this way, whatever caveats are added, they are easily viewed as doing something nefarious on purpose. A better model would be to consider how strong emotions impact groups of people. While clincians and theorists may sometimes pay lip service to the complexity and interpersonal quality of professional disagreement (but often don't), the temptation to blame it entirely on a patient's emotions is strong, especially when the alternative would entail acknowledging your own emotional responses and vulnerabilities . 

The "borderline as splitter" idea is plainly a fiction. Think about all the things that have to happen (or fail to happen) in order for a staff team to disagree about a person under their care and for this to escalate into an dysfunctional dispute. It is constitutive of a process like splitting that it involves more than one person. It takes two to tango, and it takes an entire team to split. 

Wednesday, 13 June 2018

Diagnostic underwriting

We have become accustomed to the idea of diagnostic overshadowing, where the presence of a psychiatric diagnosis causes doctors to miss physical health problems. A pain or swelling, or a lack of energy is regarded as being the result of a mental health issue and an altogether clearer medical cause is missed (overshadowed).

Anecdotally it seems that people are especially vulnerable to diagnostic overshadowing when they have received a diagnosis of borderline personality disorder. Because clinicians tend to associate this diagnosis with the classical idea of "hysteria" - the supposed eruption of emotional distress into the realm of the physical symptom - physical complaints or apparently neurological signs are apt to be considered psychosomatic. Thus a person with this diagnosis may have clear medical causes of physical pains that fail to get discovered.

We may need a similar terminology for what happens when a diagnosis alters other aspects of our self understanding; when the thing obscured is not a diagnosable medical illness, but a particular understanding of - or relation to - a mental state. 

Consider what can happen when someone is diagnosed with depression (though we could configure this example differently to make it applicable to other diagnoses); the diagnosis changes their understanding of the nature of their mood. What it means to be clinically depressed is for your mood to be significantly down, and for this to be attributable to a process lying beyond your more quotidian miseries. The depression is an illness, or a reaction, or a response, or something that makes the diagnosing clinician feel that it should be treated and not just lived.

But of course even without a depression in the picture, deep feelings of sadness, grief and despair are a part of our lives. We accept this and we live through our sorrows. They teach us about who we are and what our life is. Without a diagnosis of depression, our experience of such feelings is seen as part of the mix of ourselves and our context.

Diagnostic underwriting would occur where a depressed person's ordinary feelings of misery are mistakenly attributed to their depression; chalked up to a disorder that appears to account for things that it can't.

It might look like this: You feel hopeless all of a sudden, or guilty. You would have done regardless of diagnosis; it was something you experienced, thought or did that made it so. But because you have the diagnosis on hand, you don't understand it as a part of yourself but as a part of something else that has attached itself to you. You have attributed part of your experience to a phenomenon it doesn't belong to. Diagnostic underwriting has occurred. 

Note that what I am suggesting here is that an individual with a disorder could come to attribute their ordinary feelings to pathology. I am not making the nearby claim (which might be made by committed opponents of diagnosis) that it is constitutive of psychiatric diagnosis that all emotions in this case are "ordinary" and are being misattributed. For the opponent of diagnosis there are only "understandable" feelings. In the case  of diagnostic underwriting, there are feelings that are linked to the diagnosis and there are feelings that should not be. The diagnosis tracks something real, but it also has an impact on how we see other mental states.

Note too that diagnostic underwriting might be imaginable in theory but impossible to discern in reality. Who can say what really is me and what is really is my disorder? Who can really discern between ordinary and pathological feelings? In any case aren't these false distinctions? There is no safe place to stand in teasing this out, but the idea would be to talk about what happens as you claw your way out from under the emotional cloud of an alien experience.

Scared to feel and to trust what they feel, the individual recovering from a mood disorder has a twinge of emotion: "is this sadness OK, or is it going to be the start of my fall back into depression?" The answer may be practically unknowable, but the question is still an important one to grapple with. 

Thursday, 10 May 2018

The nightmare of eclecticism.

I have had a rather idealised vision of how a clinical psychologist would go about being a therapist. Rather than just being one type of thing ("a CBT therapist" say), I would seek to possess a sort of mental toolbox that contains skills relevant to a range of issues. Prepared in this way, I would be able to adapt to different problems by drawing on a range of techniques. This is the approach that seems to be promoted by the idea of empirically supported treatments (ESTs). You meet a person with a particular sort of problem, you reach into your toolbox for the requisite tool, and you get to work. Sometimes I might engage in some necessary systematic desensitization; at others I might follow associations to understand more about the emotions a person has not yet been able to access.

This is an integrative inclincation. It seems to offer hope for my desire to incorporate the insights of psychodynamic therapies with those of cognitive-behavioral treatments. We are, I think, animals with a prediliction to act without full knowledge of our own motivations, defending ourselves from coming to know the truth about ourselves. We are also learning machines, creatures of habit who are open to some degree of rational and behavioural rejigging. Why not hold both visions in mind at once? I don't like the idea of retreating to the familiar and unattractive warring poles that we see in certain forms of therapeutic modality bashing.

But I'm coming to think that it can't easily work this way. While some different forms of therapy sit relatively easily alongside one another (many of the acronym therapies feel like they are means to the same end, with emphases on different skills) not all do. The more time I spend talking with and listening to people from different therapeutic positions, the less hopeful I feel. The difference between psychodynamic psychotherapy and CBT is not only a difference of technique, it is also a difference of aim.

For advocates of most ESTs, the overriding ethic is that the person seeking therapy should come to feel better as efficiently as possible. This sort of improvement is to be demonstrated concretely by changes in symptom scores. The sine qua non of therapy here is the rapid reduction in a symptom that can be measured in an outcome questionnaire. Some advocates of psychodynamic therapies take this to be the aim of their work too. Jonathan Shedler has repeatedly argued that psychodynamic psychotherapy can be at least as effective (and in the same way) as CBT.

But many other dynamically oriented therapists simply aren't interested in that sort of game. For these people, the overarching ethic is that the person seeking therapy should come to understand themselves as thoroughly as possible, and live in greater freedom as a result. The distinction was drawn rather nicely by Allan Young in his Harmony of Illusions:

Simply put, different doctrines can give different meanings to the same outcome. While behaviorists and cognitive therapists say that a technique is efficacious when it produces enduring changes in disvalued behavior patterns, psychodynamic therapists, particularly clincians oriented to psychoanalytic perspectives, locate the meaning of altered behaviors elsewhere - in etiologies, symbolic content, and psychological processes.  Simply reducing the intensity of symptoms can be countertherapeutic and may signal the formation of more effective psychological barriers to insight into etiological conflicts. Real efficacy means releasing a potential for inner growth and maturation and enhancing the ability to establish and sustain gratifying social relationships. In these circumstances, the behaviorist and the psychodynamic valuations would be not simply different but incommensurable: they could not be measured by a common set of standards. (p.181-182)
We can see then that therapeutic orientation is essentially an ethical question, not an empirical one. Consider the point raised by the philosopher Charlotte Blease, discussing the treatment of depression by CBT in the light of the phenomenon of depressive realism: "well-being is not synonymous with being realistic about oneself," she points out. Blease has an ethical qualm: certain sorts of therapist might value improvement in the mood in their patients over their having an accurate view of their life situation. Psychodynamic therapists might value the realism over the improvement in mood.

This is the "nightmare" of my title. Not only is there a practical difficulty entailed in deciding what sort of therapy to do (which technique is most effective in this situation? - a hard enough question); there is a basic ethical choice that needs to be made. Once the decision is taken you have to remain consistent. You could be a CBT therapist in some parts of your career, and a psychodynamic therapist in others - but it will be potentially incoherent to pursue them within the same treatment. When moving from open ended exploration to symptom relief, how would you know that it was because it was therapeutically indicated and not better understood as a countertransference enactment? How do you maintain the inevitable frustration that is required to encourage internal reflection, when the patient has come to expect active intervention from you. The move between worldviews requires a dramatic gestalt shift.

Bad news for the early career psychologist who doesn't like joining therapeutic teams. But perhaps there is one positive upshot. Psychodynamic and CBT authors could stop their often unseemly squabbling. They aren't necessarily pursuing the same goals.

Friday, 23 March 2018


The psychologist's interest in boundaries is the source of much well deserved mockery. Apart from the jargonistic deployment of "boundaries" as a justification for various therapeutic prohibitions (second only, perhaps, to the use of "inappropriate"), the enforcement of a boundary often looks like an effective way of keeping a genuine relationship at bay.

Of course there is a certain necessity to boundaries. Apart from the fact that a professional relationship has to begin and end somewhere (you really don't want your therapist following you home), the moments when a boundary is pushed can provide a useful source of discussion. Take the example of a clear start time for psychotherapy sessions. If someone is repeatedly 15 minutes late for therapy, that is something to be interested in. Sometimes life gets in the way and people are late. No one should be getting too hung up on lateness - we're all adults. But if someone is repeatedly late then something might be going on. A polite person, reluctant to hurt a therapist's feelings, might be having reservations about the sessions. Noticing the lateness and discussing it is a way of drawing attention to something that might be important.

But boundaries can definitely be a fetish for psychologists. There is a deliciously daft example of this in Allan Young's "Harmony of Illusions," a history and anthropology of PTSD and its treatment. Young spent some time conducting fieldwork in a VA hospital during the 1980s. As part of this work he sat in on trauma focused psychotherapy groups where Vietnam veterans were encouraged to broach the atrocities they had witnessed or participated in. Because the therapeutic model put a high value on disclosure, the group members were expected to stay with the difficult content of the sessions and not engage in avoidance. Young describes how the group entered a crisis when it seemed to the psychologists that one of the members was going to the bathroom rather a lot during the discussions.

Because these frequent bathroom trips looked (to the psychologists) a lot like avoidance, the psychologists felt they had to address them. A rule was put in place - no bathroom trips during the group sessions. If that sounds unreasonable to you then you can imagine the reactions of group members. There was something of a revolt and, stuck between the need to stand their ground (notice the power struggle that has immediately snuck in) and the need to be reasonable  the facilitators had to find a solution. The apparently face saving solution elected was for group members to urinate into wastepaper bins in the group room. This met the ordinary human need to urinate without sacrificing the psychologists' insistence on staying in the room to engage with trauma narratives.

Of course, urinating into a bin in a group therapy room is not only undignified, it is patently absurd. It is hard to imagine that the vets in this group weren't aware of this, and Young describes how they availed themselves of the opportunity to relieve themselves with what became an unsustainable frequency. There is a kind of check-mate that has happened here. The staff's desire to focus so heavily on rules over good sense allows the veterans to adhere to the letter of the law while ignoring its spirit. If the facilitators felt any horror at their proximity to increasingly full buckets of pee, they had only themselves to blame.

Versions of this kind of struggle are the bread and butter of inpatient mental health care. It is par for the course that protocols will be set and violated, and that this kind of thing will be grist for discussion. But the descent into naked power struggle is far too frequent. When this happens the staff have the double advantage to setting rules (however unreasonable) and then blaming patients for their violation. If you must leave the room to pee then it has to be your avoidance/aggression/personality disorder that is to blame. This is getting things all wrong. Yes, boundary transgressions (and isn't the language of boundaries so accusatory!) should be discussed. But if some sort of staff/patient power struggle emerges, it is the job of the staff to see this unfolding and to sidestep it. This may have to involve a climb-down and a dose of good old fashioned humility. Of course people go to the bathroom as a form of avoidance (at least, I know I do). If that starts happening then discussion is a better way out than ad hoc rule creation. Any sensible polity can only implement laws that don't burden its participants unreasonably.

Tuesday, 6 March 2018

Eight signs you might be a clinical psychologist

The following criteria for the newly proposed disorder "being a clinical psychologist" have been leaked from the early planning discussions for the DSM-6. They are subject to revision and the committee in charge is apparently still taking suggestions:


A. On hearing an acronym like VAT you assume that someone has devised a new form of therapy.

B. When someone is referred to as "dynamic" you expect them to wear tweed and smoke a pipe.

C. You are extremely concerned about issues of power in healthcare, but you couldn't wait to get "doctor" into your social media profile.

D. The worst public denunciation you can imagine giving of something is to say that it is "very concerning."

E. You own (and have read) at least three books from list 1. and you own (but have not read) at least one book from list 2.

Oliver Sacks - The Man Who Mistook His Wife For a Hat
Irving Yalom - Love's Executioner
Victor Frankl - Man's Search For Meaning
Kay Redfield Jamison - An Unquiet Mind
Norman Doidge - The Brain that Changes Itself
Anything by Jon Kabat-Zinn

Judith Beck - Cognitive Behaviour Therapy: Basics and Beyond
Muriel Lezak - Neuropsychological Assessment
RD Laing - The Divided Self
Carl Rogers - On Becoming a Person
Anything by Sigmund Freud

F. You long to be referred to by someone else as a "geek."

G. You have an unusually intimate knowledge of the surface of raisins.

H. You use the following words or phrases with approximately 46 times their average frequency in ordinary human speech: "narrative"; "coping"; "psychoeducation"; "third wave"

Thursday, 11 January 2018

Of paradigm shifts and professional rifts

It's been nearly five years since the BPS Division of Clinical Psychology (DCP) published a position paper advocating a "paradigm shift" in thinking about mental health. That document might be regarded as a promissory note, with the much-trailed Power Threat Meaning Framework (due to be unveiled within hours of me writing this) representing a more ambitious attempt to make the shift happen. The moment of the PTMF's arrival seems a good time to reflect on some conceptual ambiguity in the paradigm shift idea.

At its most straightforward, a paradigm shift may just mean something like a change of perspective or change of emphasis. This is a good idea. Concerns about the validity of many DSM categories, the inappropriateness of an illness framework for many mental health problems, and the general theoretical paucity of chalking mood difficulties up to chemical imbalance all make a shift of emphasis seem important. Such a shift might mean an increased focus on socio-economic context, historic life events and psychological mechanisms. For sure some have argued (see this post by Paul Salkovskis) that such a change of emphasis is not needed in clinical psychology, and that the DCP is out of touch with how psychologists are trained. But given the overwhelming dominance of the DSM model in mental health in general, a focus on psychosocial factors seems desirable.

However "paradigm shift" also connotes a more specific conceptual frame of reference: Thomas Kuhn's Structure of Scientific Revolutions. Kuhn's argument offered a historically and sociologically inflected re-writing of scientific progress. Science - under this view - doesn't proceed in increments, rather there are periods of tidy problem solving (normal science) punctuated by large shifts in understanding that usher in a new framework and render the old one redundant.

I have seen periodic hints that the Kuhnian sense of paradigm shift is what the DCP document is promoting. The clearest example is the closing passage from this paper, co-authored by contributors to the DCP position statement:

In the history of science, Kuhnian shifts have occurred where a radical development in knowledge made it impossible to think about things in terms of an old theory. Phlogsiton theorists and oxygen theorists were battling over the same territory, engaged in a scientific zero sum game. Once you are in possession of the theory of oxygen, the theory of phlogiston cannot also be true. Similarly with the Copernican revolution. Once you accept that the evidence suggests the earth rotates around the sun, it cannot also be true that the sun revolves around the earth. In short: if one group was right the other had to be wrong.

The current situation in mental health doesn’t resemble anything like this. Yes there is a difference between the idea of a predominantly genetic or biological illness vulnerability that is triggered at some point, and a normative trauma response that makes sense primarily in psychodynamic terms. These are no doubt radically different ways of viewing one sort of problem. But the sprawling field of mental health is not centered on just one sort of problem, it contains multitudes. Different problems will be more or less well understood under different frameworks.

Unlike Phlogiston vs. Oxygen, it is not the case that one form of explanation makes the other unthinkable or impossible (i.e. “because people have psychological reactions to trauma and to ongoing relational/political experience of poverty if follows that no one has a mental illness”), but rather that a range of different types of psycho-social-physiological phenomena exists and no one can quite agree on how much explanatory weight to place where. What we see in mental health is not a steady march towards the new integrative paradigm, but a slow iterative process of deciding that such and such a thing is more disease-like or more socially-determined.

Why is this important? The idea of the Kuhnian paradigm shift creates a worldview on which you are either with progress or against it. Conceive of your experiences as illness? Too bad for you, the historical bandwagon ain't stopping. Your particular psychosis results from an as-yet poorly understood neurological problem? Get with the programme! This attitude can be exclusionary. For all that many are liberated by discarding individualising ideas like personality disorder, there are others whose problems cannot be understood by appeal to life events or social circumstance. 

It can seem that would be paradigm-shifters want to have their theoretical cake and eat it. One the one hand the argument relies substantially on the (to my mind essentially correct) point that DSM-categories lump together disparate phenomena and are thus “invalid” as descriptions of “real” entities. On the other, the assertion is then made that these things (meaning these problems that we used to call schizophrenia, depression, bipolar disorder or what have you) are not illnesses at all, but normative reactions to circumstance. The first hand bestows a sort of complex pluralism (not everything that gets called “schizophrenia” is actually a brain disease) but the second takes it away.

Wednesday, 25 October 2017

The ethical dilemma of transformative psychotherapy

Psychotherapies - it is often said - are unlike other medical interventions. Where most medical procedures are targeted at bodies and their sub-personal mechanisms, psychotherapies happen to people. We can get up a debate about how consistently this is true. Some psychotherapists target only specific behaviors, and many medical interventions have profound rippling effects on persons, but there is something to the distinction. After some experiences of therapy people make all sorts of unpredictable changes. Relationships are ended, jobs are left, and entire patterns of living might shift. The hope is that these changes will be positive but that is not always the case. There is an emergent literature (example here) on the negative side effects of therapy. Additionally some (this letter being an example) have questioned the shift in role that takes place in the creation of psychotherapy patients, making them "psychologically dependent on their therapists and their therapists [...] financially dependent on them." Psychotherapy changes us in all sorts of ways - some of them dramatic.

The philosopher L.A. Paul raises an interesting problem for what she calls Transformative Experiences. In a nutshell the problem is this: when you make decisions about your life, you are choosing for a future version of your self whose preferences you can broadly anticipate. I decide to book a holiday in the mountains because I know myself well enough to know that I will enjoy the scenery, the walking and so on. But this is not true, Paul argues, for all the decisions we make. Some experiences are transformative, meaning that our entire preference structure is altered when we have them. This makes some decisions radically different in type. Among other examples Paul raises the experience of having a baby. When you decide to become a parent you make a decision that may make you into a version of yourself you could not have anticipated. You don't just have to reckon with the question "what will it be like?" but also "what will I be like, and will the future me be happy?"

If psychotherapy ever fits the bill as an example of one of Paul's transformative experiences, then there is a special problem in the vicinity, because it is a process that is subject (in some jurisdictions) to the provision of informed consent. Informed consent is an important way of respecting the autonomy of people who enter into psychotherapy. a person cannot meaningfully agree to something they haven't had the chance to understand. The Wiley Encyclopedia of Clinical Psychology (linked to a few sentences ago) sets out part of the obligation thus: "psychologists should inform clients at the earliest possible point in time about numerous aspects of the treatment, including its nature and  expected course." Expected course? What should you say to someone embarking on a process that could change not only their lives but also their self? The person entering therapy might welcome the changes, but will that also be true of the person left over when the changes have been made?

Psychotherapy presents many of the same ethical worries as more straightforwardly medical interventions. It's outcomes will never be completely predictable, and it can do harm as well as good. But it is unusual among clinical activities in that its aims sometimes include changes to whole personalities. L.A. Paul's work on Transformative Experiences illustrates the way that psychotherapy presents both a personal dilemma ("should I embark on psychotherapy given I can't predict my preferences once it has finished?") and a professional one ("should a clinician recommend psychotherapy given the limits on the possibility of informed consent?")