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.