Sunday, 22 December 2013

Giving an Account of Myself

At a time of year for reflection, and in the light of this lovely news, perhaps some explanations are in order. It's been a fascinating 9 months. At the start of this year I had no notion of starting a blog. My one previous attempt (a brief foray into documenting my life in a very depressing post-university bar job) had no structure, poetry or intrigue. I got no hits, I saw no point in the enterprise. But halfway through my first year in a clinical psychology PhD programme in New York, I found I kept having recurring ideas around the same themes; nagging ideas that I kept picking over and couldn't straighten out satisfactorily. My thoughts yearned to be written out and discussed with people. Was I the only one having them?


If a brief dalliance with the writings of the preposterous Stalinist/Lacanian showboater Slavoj Zizek, taught me anything, it's that when we are trying to understand the broader meaning of a debate's structure, a dialectic framework can be immensely helpful. What do I mean in saying this? Take a look at almost any political or ethical debate; the structure works like this: one side puts forward a case, a counterargument is proposed and the two protagonists fight it out in a bid to be the triumphant winner. Unfortunately, given the intractable nature of many such disputes and the near unshakable attachment of people to their chosen side, it is rare for one or the other side to "win" per se. Instead, the best possible outcome is the emergence of a third position in which the disagreements can be dissolved and for a "synthesis" to be achieved. This is not some politically correct peace agreement in which everyone goes home polite but silently furious, it's a genuinely new way of looking at the situation that finds and integrates some of the truth from both positions.

A Debate Which Stretches into Infinity...

In the case of the mental health debates I was trying to enter in starting this blog, the dialectic structure seemed to be framed as something like this; first there was powerful, scientific psychiatry penetrating the gloom of madness with its rational gaze, then along came plucky independent, socially aware clinical psychologists, activists and service users to show that in fact the psychiatrists were perpetrating all manner of heartless alienating abuses behind a mask of objectivity and reason. From where I was standing this structure had become sterile, leaving people on both sides repeating the same (or sometimes more extreme versions of) arguments over and  again "you're not socially engaged" ; "you're not empirically validated".

Pattern Recognition:

It's what the more psychodynamically inclined observer might call an enactment, in which two sides endlessly slip back into roles they are familiar with (like the way you feel like a 12 year old as soon as you spend any time with your parents). The trouble with enactments is that they are a form of behaviour we never learn from. Instead they reinforce our own prejudices as our expectations fail to be violated and we lurch back into the same old defensive pattern. Cognitive psychologists have filled long fascinating books with the sorts of biases we deploy to sustain these comforting positions.

Sonic Youth: Pattern Recognition

This blog has been my response to what I felt was a dialectic impasse in mental health. I knew that psychiatrists numbered among some of the kindest and most socially and psychologically adept people I have encountered. I knew that psychologists have vested interests, not just doctors, and I knew that "service users" are simply far too heterogeneous, complex and raucous to be held together by convenient notions that they all want exactly the same thing.

It was this complexity I wanted to honour by writing here. There are so many problems with how we look after people when they are confused, miserable and frightened, and yet the predictable chorus of complaints laying the fault at the door of diagnosis, medication and "biogenetic explanations" seemed rather simplistic. That these things play some role in alienating, angering and even harming people seems to be undeniable, but in the rush to descry them none of the detractors seemed to be interested in a conversation about how we could use them constructively. More importantly perhaps, it also strikes me that the way we talk about these common explanations may be stopping us from moving forward. Are we overlooking the possibility that part of why we aren't very good at providing effective mental health care is that it is hard, complicated work? Are there not other social factors-fear, sadism and ineptitude to name just a few-which might be playing as big, if not a greater role?

I am delighted that some within the community of "bloggers" and "tweeters" in mental health have read and engaged with this rambling and indecisive collection of ideas. It has been an addictive and educational joy to argue with and learn from people, to have my factual errors and failures of politeness pointed out to me. Social networks and the "blogosphere" allow for a plurality of views that other media cannot sustain. Thanks to the "Mentally Wealthy" blog for their efforts to coordinate some of this diversity, and thanks to everyone who has shown an enthusiasm for thinking (and helping me think) about the ideas we need to grapple with.

Wednesday, 18 December 2013

Just Like You: The Temptations of Over-Identification

A supervisor of mine told an amusing story recently. He had been talking to another psychologist who had said that in his work he gets to know his clients at a deep level, coming to understand them in a profound way. For the man in question it seemed, psychotherapy was about a sort of extreme human empathy, listening so intently that you are something like "at one" with the person you are talking to. My supervisor was skeptical, and the anecdote was delivered to me as a lesson in the dangers attendant in assuming we know more about people than we really do. It went on in alarmingly sinister detail: "I really get inside my patients" this psychologist had told my supervisor "just as I'm inside you now". Recounting this all with a pained expression of simultaneous horror and amusement, my supervisor narrowed his eyes and said "so I told him, 'get the fuck out of me!'"

There is a movement afoot in mental health to emphasise the extent to which mental health problems are "understandable" responses to the stress of the environment, an ethos is captured in the dictum that mental health professionals should ask "not what's wrong with you, but what's happened to you". This can be the handmaiden of a certain therapeutic arrogance, but there is still-it seems to me-a great deal of inherent value in placing more focus on giving people the space to talk about how they have made sense of their lives.


Getting to Know You:

Nonetheless, the "understand-ability" assumption, though well intentioned, is subject to problems. At the most basic level it has epistemological difficulties; how well can you ever "know" another person's experience, to what extent is one person "like" another? Even if we assume that our normal intuitions about being able to empathise with others are substantially accurate we still need to remain conservative in estimating what we know. Just as there is arrogance in assuming that a diagnosis tells you all you need to know about a person's experience, there is arrogance in assuming you can basically figure someone out on the basis of your interpretation of their story.

"Just Like You"- a confused sentiment: is anyone really "just like" anyone else?


The "Me-too" Fallacy:

An "experience based approach" seeks to reel back from a psychiatry which prescribes people pills or brutally restrains them without consideration for what those experiences are actually like. You don't need an evidence base to argue for the position that people's experiences should be given high priority in arranging how they are cared for and paying attention to experience seems a plausible guard against needless institutional cruelty.

However, over-identification with the plight of another can cause havoc with our intuitions. Experiences can appear "understandable" even when they are not. As is so often the case with sloppy clinical thinking, Paul Meehl articulated this problem 40 years ago with his description of the "me too" fallacy:

If, like me, you have some residual aesthetic discomfort with Meehl's notion that people can be "mentally healthy" and "mentally unhealthy", it is worth remembering that we do not do anyone any favours by ignoring the possibility they are in need of more than just basic human kindness or even the best-available psychological help. Even if you reject a clear boundary between those who are "well" and those who are "unwell", there still exist mental health problems so severe that they benefit from recognition as illness and medical intervention. To suggest otherwise is a failure to take experience seriously and seems, ironically, rather un-empathic.

Friday, 22 November 2013

What Do Therapists Actually Do? Views from a Trainee

Part of my job is to sit in a room with people regularly and talk to them. We talk about what is on their mind, what is going on with their lives and how it all causes them distress. It is a strange and humbling sort of thing to do because even more than with reading, teaching and writing (the other components of my training) there is contention over how to do it successfully and limited information available about what it looks like when I do. I get little immediate feedback and some unknown proportion of that is necessarily misleading. Supervisors are amazingly helpful but they don't have the benefit of hindsight or unbiased vision, and can't be there in the room. Improvement I see in someone I work with may be a self serving illusion on my part ("of course they improved after I helped them") or may be attributable to something else.

In conversation, people ask me about "delivering therapy" with a hint of bemusement and incredulity. "What are you actually doing in there" is the implicit question underlying these queries. It is a very pertinent one. People who work in most jobs can describe almost everything they do with greater or lesser success. Therapists hover around in a weird hinterland, doing something which threatens professional vertigo and demands constant re-evaluation. I realised the other day that I think about it nearly all the time.

It is easiest of all to say what I don't think I am doing. I don't view myself as "healing" people, that is too Christ like. In matters psychological "healing" is a metaphor. Wounds heal when scabs form and bones start to re-grow. Subjectively experienced minds are what it feels like to be conscious and so when people say that their mind feels healed, although I have no reason to doubt it, I leave that sort of language to their discretion. Maybe someone might speak to me sometimes and feel healed. I would even hope for that to be the case, but it isn't my prerogative.

If I don't think I heal, I certainly don't think I "cure". People are cured of illnesses-to my mind-when the body has overcome an internal pathogen successfully. I might think someone seems better, but how do I know if the unseen underlying problem doesn't remain in some meaningful sense? Some forms of sadness may never leave us. "Cured" is what we say when we can be sure we have banished an affliction. I don't think I can confidently say I cure people.

I don't think I can generally be thought of as "training", "coaching" or "teaching" people, though I might talk in a pedagogical register from time to time. It seems useful to deliver information in an educational way under certain circumstances ("you know lots of people lose their appetites when they have been through what you have") but I don't feel knowledgeable enough to be a teacher, and I reserve a special distaste for the portmanteau "psycho-educational". I don't think I specialise in helping people to "find themselves" or to "self-actualise". In America's hyper-speed therapy-marketplace I see people describe themselves as "self-actualization consultant" or "life coach". Life and the self are huge and baffling ideas. I wouldn't want to shy away from talking about them, but the quasi religious quality of "self-actualisation" (as though one had found a higher purpose) seems an unlikely fit for the sort of thing people generally manage to do simply in order to be less miserable (or be miserable in less self-destructive ways). However, like "healing" I would still be very happy if someone felt they had been "self-actualised" (see, it doesn't even seem to be a transitive verb-phrase) after meeting me.

With ever increasing numbers of descriptions rejected, I find myself left with only quite workaday verbs to talk about what I do. I certainly try to listen sympathetically, to reserve judgement, and to speak a little bit from time to time. This seems insufficient though. Those things aren't therapy, that's just what we call "having a conversation". Therapy is a conversation, but it isn't just a conversation. When I sit and listen and speak, I do so in a more structured way than I do when I'm not working. I try (if working with someone in a psychodynamic way) to point out things that seem interesting to me about what the other person has said and how they've said them. I hope that in so doing I will call to their attention things that inform us both about what they are avoiding, or find themselves unable to say. Other sorts of things I might notice (when working within the framework we call "CBT") are over-generalisations or abstract statements whose accuracy we can both agree may be contestable. We can never successfully put our lives entirely into words, and finding new ways to systematically describe them can thus be very helpful. I could list other helpful ways of talking, but it would detract from the purpose of the post, and I would never be able to be as comprehensive as I would like.

These different sorts of conversational style sound easy and organic here, but I can't claim to be undertaking them this smoothly in person. There are instructions about how best to make these kinds of comments effective. We practice them in a more or less structured way depending on whom we are working with and what we set out to achieve. They get gathered together into manuals and books about "technique". Different styles and combinations of them are labelled with the notorious Three-Letter-Acronyms (TLAs). This is a necessary way of trying to find out which sorts of conversation help more than others, and we need to bunch styles together to try and keep understanding what works, when and for whom. However words like "technique" and, even "therapy" itself, can easily distract from the reality of what is going on, giving it an undeserved and magical power.

Whenever we say that we are "delivering therapy" we are always talking about two (or more) people having a conversation in a room. We hope the conversation will be helpful, and there are ways of talking that have been shown to be more helpful than others. If they get bottled and marketed as "cures", conversations can acquire a mysterious sense of magic, which may be unwarranted. It is better to remind ourselves that we can only ever be people who talk sensitively and intelligently with others. This is not to deny conversations their power; they can be very helpful indeed, but our claims for them should not strain the limits of credibility. Conversations can even be unhelpful too, perhaps devastating. You don't need to have had one with a therapist to know that.

Friday, 8 November 2013

The Headclutcher Strikes Again

In May I posted this about the peculiar tendency for newspapers to run a "headclutcher" image with any story about mental health issues. Silly though these pictures are, their use raises some interesting questions. How do we see people with mental health problems? Who are the acceptable faces of mental health in the mainstream media? What representations of distress are we prepared to look at when we scroll through the news? These questions are linked to the issue addressed in this pertinent New Statesmen article by Glosswitch, that not everyone with mental health problems will fit into a comforting "normal" image.

Today there has been a brief flurry of activity around the headclutcher below, which was originally used to accompany this article about voice-hearing by Charles Fernyhough and Eleanor Longden. Though still certainly a headclutcher, this lady has a more aggressive, scary presentation than usual. She is trying to block her ears in a flamboyant over the top way and appears to be shouting in anger or distress. We may note that the Guardian chose a red-head, perhaps seeking to bring to mind the lazy associations people have about their being tempestuous or hot tempered

Fernyhough immediately expressed discomfort with the Guardian's choice of image on Twitter, and he and Longden appear to have had words with the article's editor. The piece is now garnered with a tasteful screengrab from Longden's recent TED Talk.

Though they may sometimes seem a mere distraction from the main event, the media's use of illustrative pictures is important in the public consumption of mental health stories. Stigma is a huge problem and recent experiences with Asda's "mental health patient" halloween costume and Thorpe Park's "Asylum" have shown that it takes sensitive and thoughtful people to notice the implicit messages that are finding their way through to us. Headclutchers are not stigmatising in the same way as tasteless Halloween products but they are embarrassing and lazy; a form of journalism that is subtly derogating its subject. It's time the media thought a little harder about what images they used to accompany such important stories. 

Friday, 1 November 2013

The Scientist and the Practitioner: Some thoughts on A Vexed Relationship

The first thing I ever knew about clinical psychology was that it was based on the "scientist-practitioner" model. This paradigm, dating from a conference in Boulder Colorado in the 1940s (just as clinical psychology was taking off after the second world war), has largley defined the profession on both sides of the Atlantic ever since.

However, despite the fact that the science of psychology has expanded wildly since 1949, the scientist practitioner model seems ever less central to the profession. There are instances of outright disregard for the "scientist" part evident in many quarters and I find myself in interesting debates with psychologists and other therapists, trying to figure out how to define the role of "evidence" in that cumbersome phrase "evidence based practice". For many I detect a current of hostility to thinking in data and a general preference for using common sense and seeing the person with whom you are working. Data, by some accounts, is the kind of thing upon which we can become "hung up". Perhaps people are wary of becoming cold hearted Spocks:

"I'm Listening"

Although I have previously been scornful of the woollier arguments used against evidence in psychology, I have sympathy for some of what people are (I think) trying to express in these reservations. This post is an attempt to persuade them there is less disagreement than they fear.

Basic Problems:

Let's put our hands up right away and get a few things straight about the science of therapy. First, what gets called "evidence based practice" is not necessarily always (or even most of the time) living up to the lofty ideal of the name. For some institutional bodies, the existence of plausible seeming figures in some journal is good enough to plough ahead and recommend a therapy. I have even seen people make quite important decisions on the basis of a single pie chart (of unknown provenance) in a promotional brochure:

Even Data Can be Meaningless

Equally, much research is compromised by financial interest and driven by large pharmaceutical companies. Furthermore, the terms under which research is conducted are largely defined by political considerations of what is in vogue or popular. CBT gets more attention than any other modality, especially ones that don't sound snazzy or mysterious (like ordinary "befriending" or "supportive therapy").

Empathy and Therapeutic Skill:

There are definite limits for the role of science in the practice of therapy. The skills and considerations of an effective therapist can probably be determined by data, but perhaps their cultivation is a separate thing. I am sure there is no contradiction between being an empathic, kind and effective therapist and being statistically competent to assess efficacy, but I am aware of no reason to believe that proficiency in one automatically helps with the other. Whatever it is we do to cultivate kindness and empathy (an empirical question), it seems pretty clear we should do it.

The Role of Values and Outcomes:

The question of what kind of society we wish to have cannot always be answered empirically. A neat example of this is in a debate I recently had with a friend. In New York, unlike London, people have to pay to get into museums. In a basic way this doesn't feel right to me and I was trying to articulate why. "Societies just seem better when their art and culture is accessible to anyone" I argued. "Can you prove that?" asked the friend, and of course I couldn't. There may exist some quantitative indications that free cultural activities are good for people, but I doubt they are very robust, and in any case I am not interested in them. Even if you couldn't show conclusively that free access to culture improved people's lives, I would still maintain it was a social good. This is because it is not a question of tangible effects, but of what kind of society I want to live in.

To transpose this onto the field of mental health and social care; at least some proportion of what is at stake in the debates cannot be settled by data. Walking onto a mental health ward for the first time, I was struck by a sense of how cold and cruel it seemed. Apparently abandoned residents walked about in distress and staff members callously (so it seemed to me) bossed and condescended to them. Leaving the place behind felt like a palpable relief. Who knows how you would begin to quantify what it is like to live in such places; what kind of impact it would have on your sense of self. This is not to say that we shouldn't try, nor that we can ignore good quality data, but we can't depend on quantitative data to know everything we feel to be worth knowing. Sometimes the feelings that philosophers call "intuitions" are worth listening to. Debates outside of science, about what we should value are worth having too.


However, none of these readily acknowledged limitations is straightforwardly an argument against the centrality of the scientist practitioner position. I see a definite tendency to martial the limitations of science-based practice and attempt to assemble them into a case against data, but that way danger lies. One line of attack is to identify a scientific persuasion as a kind of arrogance. The logic apparently being that the scientifically oriented are vulnerable to using data to somehow over-ride the immediate experience of the service user, perhaps by steadfastly maintaining that they continue to do something (take a pill, undergo a form of therapy) when it is not working for the individual. This is indeed a risk of following evidence-based recommendations blindly, but it would in fact be a deeply unscientific thing to do. Reasoning from samples to individuals is probabilistic, and even if an intervention worked for 95% of cases, there are still 5% for whom it won't. The rational scientist-practitioner treats every case as a new instance of reality and pays attention to what is and is not working. This is what Jacqueline Persons (here) calls "Treatment as Experiment".  People who say that therapy is an "art" or that clinicians need to "be confident enough not to need to know all the answers" can, I hope, see a direct parallel with what they are proposing. 

Therapy, like most complex human behaviour, can probably be described as an art, but that doesn't mean it can ignore science. Is architecture an art? Plausibly yes, but if architects ignore the principles of engineering and physics, their buildings will kill people.

Monday, 21 October 2013

No the DSM is not like Astrology

I am genuinely ambivalent about the broad line of arguments we can call "the case against the DSM". I don't mean ambivalent in the modern sense ("a bit confused and unsure what to think"), I mean ambivalent in the classic psychoanalytic sense; harbouring strong feelings in both directions. On the one hand there is the interesting and essential level of critique which brings to our attention the experience of feeling labelled and the unsettling bureaucratisation of medical terminology. This line of argument I feel very positive about and engaged with. On the other there is the ever resounding echo chamber of over-confident assertions about the malign intentions of the APA and the total unusability of the DSM for research or clinical purposes. One recurring theme in the latter category is the quip that the DSM is no better than astrology. It appears in this (otherwise excellent) piece by Edward Shorter, in this interview with Richard Bentall, and in many other places besides.

DSM diagnoses would be just like the signs of the zodiac 
if  it weren't for the fact they're very different in many ways.

In the Bentall profile, the New Scientist interviewer opens by asking if comparing the DSM with astrology isn't "a bit strong". "No" says Bentall. I happen to agree with him, but not with the reasons he gives. Comparing the DSM with astrology isn't "a bit strong" (criticism of something you dislike should be strong) it's wildly off the mark. Why? Well although you can derive some superficial comparison between the categories of the DSM and the signs of the zodiac (both describe classes of people; both aspire to some degree of reliable prediction) there are also clear differences.

The most obvious and important difference is the way the way the categories are derived and assigned. The signs of the zodiac are assigned to people on the basis of their date of birth and based upon the idea that these dates are linked to personality characteristics in a meaningful way. Meanwhile DSM diagnoses are applied on the basis of set of criteria describing patterns of behaviour. Someone designated as having, say, OCD, can be expected to resemble a particular broad set of clearly defined features. However a Libra is not just someone who is "on an even keel" (which may way not be an unreasonable classification in itself) but someone who was born between the 22nd September and 23rd October and is regarded as "on an even keel" in virtue of this fact. In short, astrology makes a needless jump--the linking of birth dates and personality traits--that the DSM doesn't.

Why does this matter? It's not as though it puts the DSM above criticism after all. My answer is that the debate about mental health and diagnosis is very important, but if we want a serious discussion about DSM's flaws we need to accord some respect to considerations of plausibility. You can hate the very guts of the manual and its creators and still martial the strongest possible case against it. If you spin off into crowd-pleasing claims and ignore reality people will stop listening.

Monday, 14 October 2013

Aberrant Salience and a New Meaning of "Lynchian"

Fans of the director David Lynch have a clear sense of what it means for something to be "Lynchian", but if we are pushed to put into words what this adjective captures we confront an extremely difficult task. Urban Dictionary gives us this: "having the same balance between the macabre and the mundane found in the works of filmmaker David Lynch." but that definition seems almost circular. Lynch isn't the only person to balance the macabre and the mundane (see also the ubiquitous slasher films of the late 70s and 80s) and we are left with a sense that the word just means "Lynch-like". David Foster Wallace had a go at a definition in the essay here, but was still forced to admit that it is "ultimately definable only ostensively – i.e., we know it when we see it."

There is something that unites all Lynch films for me, and that is the sense that one is being invited to take as significant and sinister various encounters in the plot which turn out to have no ultimate explanation or meaning. I have been struck how this reminds me of the Aberrant Salience account of psychosis. The aberrant salience theory arose out of a brilliant review by Shitij Kapur positing that the mesolimbic dopamine system regulates the salience of elements of our environment, and that it is this process which becomes dysregulated in psychosis and gives rise to phenomena like delusions. When faced with a feeling that something is inexplicably salient or significant humans, story telling creatures that we are, cook up a story to account for the feeling. Part of the beauty of the theory is the way it offers a means for thinking about the interaction between the biological and the psychological. Kapur's language also makes the idea wonderfully intuitive:

By Kapur's account, a dysregulated dopamine system is "the wind of the psychotic fire" and helps us to understand how people can get wrapped up in terrifying implausible stories, but what does any of this have to do with David Lynch? 

Lynch's films, by my account, do a similar thing with our tendency to tell ourselves explanatory stories. Lynch can't dysregulate your dopamine system for you (that's a bit too "This is Your Brain on Cinema" for me), but what he can do is obey nearly all of the conventions of straightforward story telling while artfully ignoring others. Thus we have a series of wonderfully opaque and seemingly significant moments throughout Lynch's oeuvre. Each one seems to add something highly meaningful to the plot, but we can't be sure what. Who is the Cowboy who appears to Adam Kesher (Justin Theroux) in Mulholland Drive to tell him how to cast his film? We don't know, but the exchange has all the hallmarks of a plot-changing moment and we wait eagerly to find out what sinister forces lie behind this sinister man's authority: 

Mulholland Drive's Cowboy: A Vagueness we Are Forced to Explain

What we are doing here, filling in a story in the absence of being let in on its details, bears a striking similarity to what Kapur describes in the formation of a delusion. Something salient has happened and our minds go into overdrive to impose meaning on it. Something similar takes place when Betty and Rita visit Club Silencio and are moved to uncontrollable sobbing as they watch the singer's rendition of Llorando:

Club Silencio

The sense of significance is reinforced by the appearance in Betty's hands of a locked blue box, which appears to be a key clue for understanding the entire film. Unfortunately, no clear resolution exists, and we are left with a plurality of efforts to untangle the multi-layered plot. Film critics have tried but can't agree, and the Internet is home to an endless quantity of logorrheic accounts cooked up by obsessive fans. 

Mulholland Drive is just one example of the way an entire Lynch plot can feel like it hangs on a meaningless symbol. Apparent clues abound in nearly everything Lynch makes. In Twin Peaks, agent Dale Cooper solves the mystery of the death of Laura Palmer after a dream in which he is told "that gum you like is going to come back in style":

The Red Room

Has he solved the crime, or is he just subject to the feeling that something highly significant has happened? What about the severed ear on the lawn which opens Blue Velvet? To the viewer here is a moment that seems so macabre that it must explain something. Whose ear is it? Why was it cut off and by whom? The human tendency to paranoia goes into overdrive and is never resolved.

Blue Velvet's Ear on a lawn: The Macabre and the Banal in spades

Lynch's last film, Inland Empire, consisted almost entirely of such floating signifiers; bedside lamps and bizarre unconnected characters; extended sequences with rabbits talking gibberish. As Laura Dern navigates this confusing world she finds herself outside Room 47, which seems (from the horrified look on her face and the lingering camera work) like it must be a scene of some highly significant event. 

Inland Empire: One Long Paranoid Detour

But like the rest of the film, there is little in the way straightforward resolution to this encounter. Something profoundly creepy happens right afterwards (I'll let you find the clip on YouTube if you're curious) but with no explanation as to why. In many ways Inland Empire was the logical end point of Lynchian cinema. Over the last few films he had eroded the coherence of his plots and emphasised the apparent meaningfulness of moments, symbols and exchanges. The two most recent films especially look like an exercise in discovering how much you can ask the viewer to fill in for themselves. Because of the reliable beauty of Lynch's imagery, and his mastery with creating salient episodes, we go along with him. The resulting experience is an exquisite paranoia, more chilling and rich than almost any other thriller. 

Monday, 7 October 2013

Useful Guides Which Limit our Thinking

This quote is a follow on from this previous post. I came across it while reading Heinz Kohut and Ernest Wolf on Self Psychology. Like the earlier Freud quote, it has relevance to the modern debate on psychiatric diagnosis:
"The best efforts of the past [...] are no exception to the rule that the simplified correlation of specific patterns of manifest behaviour with universally present psychological conditions which of necessity forms part of any such typology will, in the long run, impede scientific progress. Why then, do we persist in the attempt to devise characterologies? The answer is that such classifications, even though we must be aware of the fact that they may eventually limit our thinking and stand in our way, can for a while be valuable guides in psychological territory in which we feel not yet at home."
 Kohut, H., Wolf, E.S. (1978). The Disorders of the Self and their Treatment: An Outline. Int. J. Psycho-Anal., 59:413-425.

Sunday, 29 September 2013

6 Effective Ways to Avoid Engaging With Quantitative Data in Mental Health

1. Imply that Quantitative Data is Inherently Flawed:

One of the most effective ways to undermine anyone trying to appeal to principles of empirical research is to remind them and everyone else that the whole project of obtaining supposedly "objective" data is doomed to begin with. We all know that all research in psychiatry is hopelessly biased by its connections to Big Pharma, so be sure to muddy the waters and block further discussion by asking profound sounding rhetorical questions like "what research? conducted by whom?" Ignore the fact that questions about prospective bias, methodology and misuse of statistics are already central to the effective interpretation of any research and that some of the most effective ways to guard against them are statistical procedures.

If you don't feel that accusations of an inevitable and pervasive bias are a strong enough slur against the principle of empirical data collection, be sure to make bold assertions to the effect that the whole principle of obtaining quantitative data on people is an act of "violence" on the holistic truth about humanity.

2. Remember that a Focus on Subjective Experience is the Only Worthwhile source of Knowledge:

Researchers are supposed to be interested in experience right? So why are they all faffing around with experiments and longitudinal surveys? There are plenty of people around who have actually had experiences and their testimonies should be entirely sufficient. Be sure to remind researchers of this whenever they suggest the spurious use of numbers to try and figure things out.  You are more than just a number!

3. Remind People that You Aren't Interested in the Entity Being Studied:

"Not everything that counts can be counted, and not everything that can be counted counts" Einstein said that didn't he? Or was it Eleanor Roosevelt, or Winston Churchill? It doesn't matter, the principle is sound. Maybe researchers want to pigeonhole people into entirely irrelevant categories and measure things about them, but why should the rest of us give a stuff? They say that they are interested in learning about groups of people who meet a set of agreed upon characteristics, but it is pretty clear this is just a front for the propagation of a sinister medical model. Further proof of this can be seen in the fact that almost no researchers ever mention a strict biological conception of mental illness; they're keeping it under wraps!

4. Accuse Anyone Deploying Empirical Reasoning Of "Scientism":

This one is particularly effective because very few people actually know what it means. Sciencey people all hate religion don't they; so if you accuse them of an irrational faith in the power of science you can win any debate while simultaneously getting on their nerves. Ignore the fact that a belief in the use of the best available empirical evidence is not even close to being scientism proper, anyone who dabbles in science is unlikely to have retained their common sense and will almost certainly be out of touch with reality. If someone has used "Schizophrenia" or "Bipolar Disorder" in their work then they plainly believe these entities to be illnesses just like Hepatitis or diabetes and certainly don't have any curiosity regarding their ontological status. They are no better than mystics or astrologers, and anything they say can be dismissed.

5. Remind People of the Nazis:

Scientists always drift back towards biology and genetics, they can't help themselves. Even if they are only suggesting that genetics and constitutional physiology account for a relatively small proportion of variance in any given problem, there is no telling how long it will take before they drift towards a policy of eugenics and ethnic cleansing. You are only ever doing anyone a favour by reminding them of phrenology, eugenics and--ideally--the Nazis before they walk foolishly out onto this slippery slope.

6. ...Continue to draw on Data when it Suits You:

None of this should leave you feeling that you can't preface your own views with comments to the effect that "it has been shown..." or "data proves..." In fact, now that you have an arsenal of tools to discount any research that doesn't back up your own case, you are free to deploy research of any quality; it cannot be countered by anyone else's!

Thursday, 22 August 2013

At the Limits of Meaning

Here's a neat irony: so often is it said that psychiatric problems are"meaningful" that the statement itself is starting to sound rather meaningless. Used as a rallying cry to focus attention on the content of people's experience rather than viewing its form as a kind of pathology, the "distress is meaningful" idea has become diluted and distorted through careless use. This is a shame as, like most ideas in "critical" psychology and psychiatry, it has a worthwhile core which it is worth staying in contact with.

"Man's Search For Meaning":

Pareidolia: Making Meaning Where None Exists

To say "distress has meaning" can mean the tendency we have to imbue our health problems, like anything we experience, with special significance and form associations to them. In this sense even the most random or the most biologically determined forms of health-problem have "meaning". It is very meaningful to me that I am starting to notice the slow and inevtiable movement of my hairline towards my crown, but this doesn't mean I can halt it by "making sense" of it. More seriously, it is extremely meaningful when people with Alzheimer's start to lose their memory as a result of cortical atrophy, but this is because our grasp on our minds is very significant; it does not mean they are, say, trying to repress something.

The existence of this general sort of meaning making about our lives is uncontroversial and only a rather perverse and callous person would deny it. There is, however, another sense in which distress has been taken to "mean" something, and its conflation with the weaker form above has generated some confusion.

Symptoms as Messages:

Freud was prompted to develop the technique of Psychoanalysis when it began to seem to him that the symptoms of his patients weren't just manifestations of some physical problem ("degeneracy") but were a sort of communication about the contents of their minds.

Conversion Hysteria: Meaning's Search for Expression

Freud and Breuer had noticed that when they encouraged their patients to speak freely--and without the sorts of prohibitions that teenage Viennese girls were normally subject to--their symptoms cleared up (we'll leave for now the question of whether this really took place, and for the reasons they claimed). This led them to conclude that, in some circumstances, the body itself became a channel for communicating the sorts of emotions we normally communicate in speech. Although initially of interest in the case of "conversion hysteria" (a category which has fallen into relative disuse) Freud extended the principle to obsessional behaviour (where obsessions divert the energy created by resisting expressions of desire) and hallucinations (which acted to fulfill a resisted desire).

One result of the Freudian meaning of "meaningful" was that by the middle of the 20th Century, and especially in America, psychoanalysts came to be seen as a cabal of expert decoders, essential to tell us the real underlying meaning of our actions. With the decline of the dominance of this framework there has arisen a new skepticism about what our bodies and minds can ever be said to be telling us about our lives.

Nonetheless this meaning of "meaningful" has its modern counterpart in claims that (for instance) the voices heard in psychosis are expressions of emotions which the hearer has not yet dealt with; that bouts of intense paranoia reflect a feeling of danger which has its root in early experiences. I don't want to deny or defend these claims here, they appear to have their use in some situations and not necessarily in others. Instead, I want to draw attention to the fact that they form a stronger assertion than the more banal observation that everything means something to someone, and that these two can come to be thoughtlessly merged.

Psychoanalysts: The great decoders 

Why does this matter? The weak claim (that everyone's experiences come to have meaning) and the strong claim (that the meanings are central to the phenomena, which can be healed by the right kind of understanding) have different implications for treatment, but to carelessly fudge them allows us to overlook this. If you assert the weak form then you are simply saying we should pay attention to the meaning of people's distress and try to engage with the reasons for it. If you assert the strong form then you are claiming that the right sort of interpretation can essentially dissolve certain forms of distress. This belief can be expected to lead to an anti-medication ethic as people come to see the effects of medication as a violent denial of meaning. Such a belief (which virtually amounts to a superstition) should be kept separate from the very real problem of people being unnecessarily over-medicated and it should also be kept separate from the obvious fact that talking to people about what things mean to them is a kind and helpful thing to do.

Unless we are a bit more rigourous about this separation, it is unclear whether we are saying healthcare professionals should engage with the meaning of people's suffering or whether we are saying that healthcare professionals have a special access to its interpretation. The latter is a rather arrogant claim, promoting dependency on special interpreters with defintive answers, but it can be smuggled in alongside the more benevolent position if we don't look out.

Monday, 29 July 2013

Licensed to Ill?

Most of my posts on this blog attempt to reach some conclusion. Not this one. I haven't managed to come up with a neat propositional statement that does justice to what I think about the topic. This blog-post is about the term "Mental Illness", specifically the "Illness" bit, and more specifically the question "is it appropriate to say 'mental illness' to talk about the sorts of misery that some people experience under the rubric of 'mental health problems'?"

On one view it's an open and shut case: the answer is "No!" Virtually none of the experiences so inadequately described by the DSM can be regarded as "illnesses"; they are "problems" at most, and they are caused not by a brain malfunction, but by life experiences. This view is held by some to be the more sympathetic and humanistic one. Its advocates are fed up with being, or seeing others, fobbed off with a label and some pills. They're fed up with people being written off as "chronic" and with the lowered expectations that lock service users into institutionalised and restricted lives. I largely agree. I have seen how people get treated in hospitals; how badly resourced services warehouse them and are able only to offer paltry shadows of what we would properly call "care". Calling people "ill" can work the neat trick of attributing all that is wrong with a person to the illness, and overlooking the problems caused by the ways they have been treated.

How can we prevent the "illness" debate resembling a plane crash?

Where's the debate then? Why would I even ask whether "illness" is a relevant term when there are so many people (perhaps you are one) for whom it very definitely isn't? Practically I don't generally have to adjudicate over whether people are ill, as a psychologist I am more concerned with understanding and influencing the things that they think. Thought can obviously be influenced by physical pathology but I am not medically qualified to treat that, so you can see how it might be in the professional interest of people like me to limit the use of the word "illness".

Theoretically I used to be convinced by the argument that disease or illness is what we say about problems where there are not only symptoms (unpleasant experiences) present, but also agreed-upon biological events which explain them. This argument is based on a definition sometimes attributed to Rudolph Virchow, who died over 100 years ago but it is arguably only relevant if you think that the criteria by which we decide can have been fixed back then for all eternity. Furthermore, it assumes that we can only say "illness" when we have agreed on the explanation.*

Unfortunately, it's a simple definition which no longer seems adequate for our purposes. What counts as an illness is not only a question of similarity to other things we already call illnesses, but also of how far we choose to extend the use of the word illness. As a clinician rather than a sufferer, I don't feel confident that I can define illness from the outside and the ultimate criteria for helping me to do so don't appear to exist. The dictionary definitions are circular and unhelpful:
Mirriam-Webster: "an unhealthy condition of body or mind"
Oxford: "a disease or period of sickness affecting the body or mind" "unhealthy condition; poor health; indisposition; sickness"
As if to make my point for me, there is an interesting symmetry at work. Activists seek to call some experiences "illnesses" even though there is doubt over whether they meet Virchow's definition. In the case of M.E., for example, sufferers are horrified when doctors suggest that there isn't a biological underpinning that would warrant an "illness" designation. They feel ill, and suggest that we should start from this place in determining the status of the diagnosis.

Meanwhile, in mental health, many first hand accounts describe something so like an illness that it just seems callous or pig-headed for an outsider not to agree. William Stryon describes his experience of depression thus:
“When I was first aware that I had been laid low by the disease, I felt a need, among other things, to register a strong protest against the word "depression"...a true wimp of a word for such a major illness." (Darkness Visible: A Memoir of Madness)
If Stryon seeks any redescription it is toward a more severe, more pathologising language which would honour the experience of being taken over by something that seems quite alien.

Kay Redfield Jamison is very firmly of the view that her Bipolar Disorder is an illness:
“No amount of love can cure madness or unblacken one's dark moods. Love can help, it can make the pain more tolerable, but, always, one is beholden to medication that may or may not always work and may or may not be bearable” (An Unquiet Mind: A Memoir of Moods and Madness)
Elsewhere she acknowledges the unique mixed quality that mental health problems have:
"It is an illness that is biological in its origins, yet one that feels psychological in the experience of it"(An Unquiet Mind: A Memoir of Moods and Madness)
Some people may agree with Jamison and Stryon, others may wonder if they're even on the same planet. I bring them to the table because they seem to be at odds with the first hand experiences so readily appropriated by those who seek to combat the medical model. If, like Boyle, you regard "illness" as something with a clear and agreed definition, you will recruit the service user accounts that flatter your own, and possibly stop hearing those that don't. Given the continued ambiguity in the debate, this seems an unwise maneuvre. Before we make assertions about what is and is not an illness, we need to decide what we want the word to do for us. In the meantime, I consider myself lucky that it isn't my decision to make.

* This paragraph has been corrected, it used to say: "Theoretically I used to be convinced by the argument (made, for example, by Mary Boyle) that disease or illness is what we say about problems where there are not only symptoms (unpleasant experiences) but also signs (biological events which explain them). This argument is based on a definition sometimes attributed to Rudolph Virchow, who died over 100 years ago but it is arguably only relevant if you think that the criteria by which we decide can have been fixed back then for all eternity." Mary Boyle, to whose "Schizophrenia: A Scientific Delusion?" I was referring, does not define signs and symptoms this way. 

Saturday, 20 July 2013

The Strange Case of Lucy Johnstone, Rufus May and the Mental Health Charities.

The Clinical Psychologists Lucy Johnstone and Rufus May have recently criticised mental health charities for their continued use of the word "illness" and diagnostic terms taken from the DSM:

May called out Time to Change on their use of "Mental Illness":

This is not the first occassion for such a debate, Lucy Johnstone and Mind had this exchage earlier in the year:

What are we to make of all this? The blogger and mental health nurse Phil Dore recently called it an "ideological pissing contest" (great phrase that) in a blog post concluding that Johnstone and May (and others) should pick their battles elsewhere. I am entirely sympathetic to this view, but in this post I would like to go a little bit further and ponder if there even is a valid battle to be picked.

The form of Johnstone and May's criticism is that these disorders "don't exist". Both clinicians are motivated by an admirable desire to raise consciousness of the contingent nature of DSM's construction. However, such a simple and categorical statement as "DSM Disorder X does not exist" is complicated by the fact that it has at least three meanings:
  1. The categories of the DSM do not exist in the sense that there is no biological illness process to which they can be said to refer. 
  2. The categories of the DSM do not exist in the sense that there is no emotional/psychological process/phenomenon to which they refer.
  3. The categories of the DSM do not exist in the sense that nobody uses them; service users do not get told they have them; services and interventions are not planned on the basis of them and they are not used to design and conduct clinical research.
I am pretty sure that Johnstone & May do mean to imply statement 1 but do not mean to imply statement 3 (I am unclear how they stand in relation to statement 2; perhaps they would like to comment on this post). The problem is that without clarification they are sending out a confusing message. More importantly, they are not acknowledging the legitimate reason for which the charities continue using the terminology they do.

Service Users and others who seek support & information from a mental health charity might reasonably expect to be able to find out what is known about the problem classification terms that they have heard in use. Whatever we think of those terms, there is a wealth of information available about which groups of problems are and are not amenable to which sorts of support. Off the top of my head:
  • People diagnosed with psychotic-problems should be able (without launching into a literature review) to find out that CBT has limited efficacy, but that research is ongoing and it is available on the NHS if they wish to try it for themselves. There are other psychological interventions being researched which may have better outcomes.
  • People with a diagnosis of Borderline Personality Disorder should be able to find out (without scouring the tedious NICE guidelines) that unless they are have received in-patient DBT, they haven't yet had exposure to one of the most intensive psychological interventions available on the NHS.
  • People with a diagnosis of depression should be able to discover (without having to delve into the enormous "common factors" literature) that a very wide range of psychological therapies have been effective in similar cases and are worth pursuing. If they don't like CBT, they can advocate for an alternative approach. 
Both May and Johnstone invoke the literature on stigma to endorse their claims, but the implications of this literature are not as simple as we might like them to be. First of all, the empirically validated existence of stigma does not change the fact that DSM terms have broad societal currency and organise the provision of mental health services. Second, the literature supports a complex picture of which terms are and are not stigmatising and in what ways. For instance, a recent study suggests the term "mental illness" is no more stigmatisting than "mental health problem" (seemingly refuting May's point). Another finding is that some terms ("Schizophrenia") are stigmatising while others ("Depression") are not.

I say all this not because I seek to "save" the medical model (whatever that even is), but because I seek to complicate the criticisms and defend, on pragmatic grounds, the actions of these charities. Given the present confusion about the ontological nature of mental health problems, all recipients of a diagnosis should certainly be offered the information that there are good reasons to call the classifications into question and a lively debate about whether they are even appropriate. To somehow "ban" DSM terms from the public discourse would not be as helpful a step as it first appears; some people would be delighted, others profoundly alienated. It remains unclear why some service users find diagnoses powerfully explanatory while others reject them altogether. For as long as we are stuck with a muddled mix of languages in which to discuss these issues, the dogmatic promotion of "one true God" (Phil Dore's phrase again) is entirely premature.

Wednesday, 17 July 2013

Making a Straw Man of the DSM

I have now twice made the same mistake in print. In a letter to The Psychologist I said that the DSM entailed assumptions about "medical-genetic underpinnings". In an article for Clinical Psychology Forum, I said that "DSM-5’s authors are erroneously committed to considering them [mental health diagnoses] as ‘brain diseases’".

Neither of these statements is true. Here is how the DSM-5 defines a mental disorder:

"A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved responses to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."
Further to that, here is how the DSM suggests a clinician should determine the cause of any given "disorder":
"The case formulation for any given patient must involve a careful clinical history and concise summary of the social, psychological, and biological factors that may have contributed to developing a given mental disorder. Hence, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis. Although a systematic check for the presence of these criteria as they apply to each patient will assure a more reliable assessment, the relative severity and valence of individual criteria and their contribution to a diagnosis require clinical judgement. The symptoms in our diagnostic criteria are part of the relatively limited repertoire of human emotional responses to internal and external stresses that are generally maintained in a homeostatic balance without a disruption in normal functioning...The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is informed by the individual's cultural and social context."

The intention of both of my pieces of writing was to complicate and critique the arguments that get made against diagnosis, so how have I fallen into the cognitive trap of making a straw man? Presumably the answer is that when you spend enough time engaging with a group and absorbing its norms, you develop a sort of false consciousness. So often we hear it said that it is the intention of the DSM to medicalise the field that we can easily start believing it without actually reading the manual. It looks like I might actually be falling prey to the first and second of the three myths I have written about here.

Over-medicalisation is problematic when it represents a needless simplification of reality and stands in the way of our responding effectively to mental health problems. It certainly goes on, and the DSM certainly plays a role in facilitating the process. However, the culturally prevalent idea that any given "disorder" has a single simple cause cannot just be laid at the door of the DSM. If we got rid of the manual we would not see a rapid disappearance of the assumption. Instead, the simplification arises from a complicated network of research findings, news articles, educational experiences, drug promotion and "common sense". When an aspect of our reality is as hard to understand as mental health, we can be expected to latch onto any explanation we can understand. When we dislike the results of this heuristic bias, we can be expected to find a culprit. The DSM is an easy target.

Tuesday, 9 July 2013

Improving Mental Health Care: 3 Myths to Avoid

The Struggle of Good vs. Evil:

No Grey Areas Here

Howard Zinn’s massive book on American history is a gripping account of the ways in which the poor and dispossessed of the country have been oppressed and undermined by the financial interests of the financial and political elite. It has one major flaw; a tendency toward painting those elites as a coherent unit of baddies, explicitly motivated to work against the interests of the common man and actively choosing to do so at every turn. For this it was voted one of the least credible books by a poll on the History News Network. The charge is not that Zinn misrepresents the social consequences of financial injustice, but that he falls into the easy trap of inventing a coherent group of people whose malign intent is the cause of those consequences. In fact history is messier; events are caused by isolated individuals, subject to circumstance and acting in what seem to be their best interests at the time.

People on both sides of the debate about psychiatry persistently fall into the same trap and the Manichean narrative erupts all the time in unexpected ways. Jeffrey Lieberman does it here, drawing an unfortunate parallel between anti-psychiatry (which undoubtedly contains some ill thought through positions) and "racism, sexism and homophobia". His piece contains a reasonable point about the nature of debate over DSM; some people seem opposed to diagnosis and psychiatry as a matter of principle, but he can't resist his own anger at the way psychiatry is being criticised.

As if to make Lieberman's point for him, the psychologist and blogger Phil Hickey maintains a fairly constant stream of angry diatribes at his site Behaviorism and Mental Health. His posts (here's one about Lieberman himself) are characterised by an uncompromising rejection of any argument that gets made in psychiatry's favour, assuming it is necessarily being made cynically. Hickey's position is to start from the premise that psychiatry, drugs and diagnosis can never be a good thing and it is surprisingly influential. In debates with qualified clinical psychologists on Twitter I have been called a "pseudo psychiatrist" (as though that in itself were an insult) and seen genetic research into mental health baldly equated with "Nazism".

There is certainly a corrupting influence of big pharma on psychiatry. For my money this was described rather well in Richard Bentall’s Doctoring The Mind: Psychiatrists are treated to glamourous and all expenses paid international conferences; some people make hundreds of thousands of dollars, calling themselves "educators" to promote these drugs. However, this is not the result of some grand concocted scheme by a unified overarching "Psychiatry", it emerges through the collected actions of more or less well intentioned individuals, many of whom fall prey to cognitive biases and self-deception. There is an evil in such a state of affairs, but unfortunately it does not lie where it would be easiest to see and avert.

The notion of the Sacred:

Beware Sacred Cows!

One consequence of thinking in terms of an almost cosmological good and evil is that some ideas come to be seen as inherently unspeakable; a breach of the sacred (or at the very least, of simple common sense and decency). The result over time is that ideas are received, left unchallenged and assume the level of a received truth. This habit is evident among just as many of those who associate the "medical model" with all that is evil as among those that defend it.

Witness the final sentence of the fourth paragraph in this article by Susan Inman, the author of a book about having a child with mental health problems: "Books linking schizophrenia to capitalism have become bestsellers" she sighs. Inman may very well feel this line of sociological inquiry is a waste of everyone's time, but it is never enough to register it in a taken-for-granted tone of indignation. Why not link Schizophrenia to capitalism? If it turns out to be a crappy idea, explain why and show your workings. 

On the other side, all manner of sacred truths abound; diagnosis is "one of the worst things one human can do to another", "bio-genetic explanations" cause stigma and medical treatments do more harm than good. There are important facts that underlie these positions (diagnosis can cause social harms; certain bio-genetic explanations are overly simple and chemical/brain interventions often have damaging effects) but that they too easily become sacred cows which stop us from hearing evidence which contradicts our position. Become too attached to a position and you are vulnerable to the confirmation bias, our tendency to seek out evidence which affirms a position we have already decided is correct. 

Revolutionary Promise:

The Revolution Will Not be Tranquilised

There is no getting away from the fact that psychiatry and clinical psychology offer little consolation of a complete resolution of the problems they take on. We may talk of “treatments” in our field but any mention of “cures” prompts justifiable cynical laughter from practitioners and service users alike. Mental health problems are sufficiently complex (and involve a sufficient mixture of the bio-psycho and social in their cause) that any suggestion that we have discovered that miraculous silver bullet should be taken with a healthy dose of scepticism.

This fact is regularly rehearsed in relation to new biological treatments; anti-psychotics and anti-depressants are debunked as mere dampeners of experience and the internet genre of neuro-criticism (as exemplified by bloggers Neuroskeptic, Neurobollocks and Neurocritic). It is less often raised in response to the utopian claims of social constructivists. In blithely asserting that “we would halve the amount of emotional distress in this country if we had the more equal, relatively cohesive, less debt-ridden political economics of our European neighbours”, Oliver James all but torpedoed his own case by making it implausible. Any talk of revolutions or "paradigm shifts" in clinical psychology should be met with suspicion, not because revolutions are necessarily unwelcome (although it is true that their dangers are easily overlooked) but because they often represent a promise that is then dismally betrayed.

The best possible response to mental health problems probably doesn't lie just over some ever receding social horizon, it is an ongoing process of improvement and research, integrating more kindness and better understanding into our services. 

Wednesday, 26 June 2013

Accuracy vs. Stigma: Is There a Conflict?

Another day another paper (1) examining the links between stigma and the public understanding of mental health problems. The paper (a series of meta-analyses) concludes that "biogenetic explanations" can exacerbate stigma by increasing people's "pessimism" about the outcome of psychological disorders. On Twitter Keith Laws questioned the implications of the message:

Those who responded to this question on Twitter pointed out correctly that it is "absurd" and morally problematic to ignore or suppress the truth about the cause of mental disorder in favour of the narrative you want to tell. I agree, but these answers don't do justice to the most interesting possible ramifications of the research. In their conclusion to the paper, the authors make it fairly clear that they are not advocating the promotion of inaccurate accounts:
"Mental health professionals should not misinform their clients and the public by withholding information about the biogenetic factors that underpin psychological problems." (emphasis mine)
Unfortunately, the waters muddy somewhat when it comes to describing what they are advocating:
"However, our findings indicate that this must be done with considerable caution. Explanations that invoke biogenetic factors may reduce blame but they may have unfortunate side-effects, and they should not be promoted at the expense of psychosocial explanations, which appear to have more optimistic implications." 
What the second half of this passage sadly misses, in its haste to decry the dominance of "biogentic factors", is that the best explanations of the causes of mental health problems would accurately communicate the complexity of genetic causation. It is this complexity that can easily get lost in public debate and everyday healthcare. Having a genetic predisposition to a particular problem doesn't always mean the same thing in the public imagination as it does in reality.

Biology is one determinant of our thoughts, feelings and behaviour; at the same time we retain some quantity of agency (possibly itself biologically determined, but let's steer clear of that philosophical rabbit hole for now), which we are able to exercise to change them. This capacity is not limitless and it varies with the nature of mental health problems, but it is real. People are changed, to some degree, by how they think of themselves (this is what is meant by Ian Hacking's idea about the "Looping Effects of Human Kinds") and if they weren't, there would be no point in any psychotherapeutic intervention.

We can't know very much from this paper about the nature of the disorders or the explanations that are being studied, but it does raise two possibilities that should be further explored. When people with mental health diagnoses attribute their problems to "bio-genetic causes" they may be 1. failing to do justice to the richness of what this really means and 2. buying into an unwarranted therapeutic pessimism that impacts on prognosis.

I'd be among the first to point out that this sort of research gets hijacked and over-simplified by well-meaning advocacy groups who just want to replace one narrative with another, but the fact remains that what it means for genes to have an impact on behaviour is frequently misunderstood. Highlighting the potential public health ramifications of overly simple, overly certain forms of understanding is an important part of public science communication.

1: Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review.

Saturday, 22 June 2013

Diagnosis, Political Correctness and Identity

Names are of profound importance. Psychological research summarised in this lovely New Yorker article  suggests that the sight and sound of the words we read, indeed the very shape of the letters that comprise them, is having an impact on how we think about what they represent. The relevance of this to the words that are used in the purportedly neutral medical field is obvious. Look at the word "Schizophrenia" below. Consider the unusually dense package of consonants which opens the word and then the harsh angular "Z" which cuts it in two. The Greek derivation of the two component elements (Skhizein & Phrenos) leads to a baroque and unusual spelling, which in turn lends a mystical, "other" quality to the word:

This visual example is taken from a benign text book about how to manage the social effects of Schizophrenia, but it still has a difficult and severe (some would even say stigmatising) label emblazoned right on its cover. In mental health, these labels are all around us.

Apart from the visual quality of mental health labels, there is also the troubling habit of slipping into using them as metanyms. Metanym is the substitution of a proper name with an alternative which actually represents something with which it is associated. This is what is going on when a health-care professional refers to someone as, say, "the depressive in room 10". I have seen many people object to the use of "Schizophrenic", and they are right to. While someone may meet the criteria for Schizophrenia, no-one is a "Schizophrenic"; it is not what the word is for.

Political Correctness:

One response to these problems of language and thinking is the judicious application of Political Correctness. Political Correctness is often maligned (with the derogatory "PC brigade" operating as a powerful if unfair rebuttal to well intentioned campaigners), but I'm with Stewart Lee, who mocks the naysayers and points out that it's an "often clumsy negotiation towards a formally inclusive language":

A politically correct and formally inclusive language of mental health problems would presumably not use words that are themselves unpleasant and would carefully caution against the over-extension of the labels beyond their originally intended use. The implications of disease (which implies infection) and of mental health problems as in some way characterologically definitive (as in personality disorders, where a person is seen as in some way defined by the label) should be strenuously resisted if clinicians want to avoid their diagnostic labels becoming simple insults.

Identity Politics:

Another approach is Identity Politics. A fantastic example is contained in this marvellously strident tweet by @ukschizophrenic:

An alternative to "politically correct" re-namings of DSM terms is for service users to accept them; to take them on as identities in themselves and, from this position, to assert their right to experience things in a particular way. I am unclear whether this stands as a reaction against diagnosis or a tacit validation of it. However, the gist of this tweet seems to be that @ukschizophrenic identifies to some extent with "Schizophrenia" and is simultaneously unimpressed by the notion that it is something to feel ashamed of. Just as LGBT groups took ownership of "queer" and "dyke" in order to neutralise their toxicity, there seems to be an emergence of a mental health identity politics online; Twitter's "Schizo-Tribe" is a brilliant example.

This movement makes it difficult for anti-diagnosis campaigners to say that they have the monopoly on taking patient experience seriously. If diagnosis is a useful way for people to make sense of their experience (and proponents of formulation have already accepted that the criterion we're interested in is "usefulness" rather than "truth") then to highlight the problems with diagnosis' validity seems irrelevant. Meanwhile, by claiming that a diagnosis is "stigmatising" or "colonising", anti-nosologists are privileging one group's experience over another's.

We seem to be left with an impasse; some people dislike diagnosis aesthetically and politically; others don't. A politically correct renaming of diagnostic terms may be worthwhile, but existing terms sometimes accurately capture the experience of those who receive them. The debate will not be won or lost on this territory.