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.

1 comment:

  1. Excellent post, Professionals who say they champion service user experience and meaning, but who dismiss that meaning when it is inconveniently too close to the medical model, aren't doing service users any favours, given some of us find the medical model useful. The truly radical position in psychology at the moment is the one that can properly hear the widest range of experiences and meanings. It's good to see someone taking a radical, complicated, middle position.