Wednesday, 18 November 2015

In Defence of the Psyche

There is an admirable current tendency in my profession (described passionately and elegantly here by Masuma Rahim), toward an appreciation of the many environmental factors which contribute to bringing people into our offices. It's as though the headshrinkers are only just learning that people aren't just miserable in isolation; things happen and make us miserable. This truism is ubiquitous at the moment, and has even become something of a slogan:

The corollary of this environmental turn is an increasing appetite for the rejection of diagnosis or an "illness" way of thinking; an assertion that facts about the individual are ultimately less important than facts about their past. Despite feeling closely aligned with this politicised version of my profession, I also feel some unease. Is there a baby somewhere in the bathwater? I suggest there is, for despite the indisputable importance of the outer world we all also inhabit a unique inner world, the land of the psyche. If there is one idea psychologists should be interested in it is surely this.

Right now hundreds of thousands of people are flooding out of Syria, escaping from some of the most harrowing events imaginable. Their journeys to asylum will not necessarily be any better. While we know that many refugees survive and even thrive in their new lives, many others will be psychologically devastated. Nobody can say why that is but inter-individual differences in the psyche have to be important. This is more than just to say that some people get lucky in the great individual-differences lottery. The psyche is important in understanding why life's horrors so completely overwhelm some people, but is also what accounts for why something as impractical as psychotherapy could make a difference to the lives of those who have suffered them.

Why do I say any of this? Clinical psychology has spent most of its past in denial of the environment. If we overcorrect at the expense of the psyche, several risks emerge:

1. A focus on the environment to the exclusion of the psyche is liable to promote a sort of therapeutic nihilism. If we believe that people in dire material straits can only be helped by material changes to their lives, we risk neglecting them. Ultimately we are capable of astonishing changes to our own lives. How we think plays a huge role in doing so. 
2. Following on from the issue of therapeutic nihilism is the issue of professional burnout. If you believe meaningful change is possible only through means which are beyond you, cynicism and overwhelm will not be far away. Therapists who lose all faith in their capacity to help people are on the road to confirming their own worst fears. 
3. Too great an emphasis on the environment is a form of reductionism analogous to "biologising". Just as a restrictive "disease" model leads to the belief that all should get medication, a restrictive environmental model could lead to the neglect of individual differences in therapeutic need. Some people's misery is intelligible almost entirely in terms of things which have happened to them. For most of us, the struggle is in the complex and all-too-human dance between problems foisted on us and problems we make for ourselves. 
One model for what I am pointing to is bereavement counselling. While we recognise that not everyone who experiences death is in need of it, we readily accept that some of us can be so rocked by the resulting grief that it is helpful to see a therapist. This does not entail that only immortality can stem the tide of human misery. Some miseries are best adjusted to. Even those miseries which are not best adjusted to (such foes as discrimination, economic inequality and political violence) are nonetheless pervasive.

Perhaps there is an argument in the near vicinity that I will be accused of making: that psychologists should not be political, but should get on with the job in hand. I am not making that case at all. Psychologists should be highly political, just as should any profession which takes people seriously. To the extent that society makes victims of some of its members, we should change it. However if the history of humanity has anything to teach us, it's that suffering is inevitable. To think otherwise is not political, it's utopian.

Politics come in part from theories about human nature, and psychologists have those in spades. There is simply no incompatibility between believing in large scale political action, while simultaneously asserting the value of small-scale individual change. Just as our social world impacts on our psyche, so too our psyche impacts on our social world.

Saturday, 7 November 2015

The Hickey-Lieberman Test

Phil Hickey has an interesting post over at his blog about what happened when Jeff Lieberman was asked if psychiatry over-medicated people:

Absolutely.  I had an experience with my own son.  I have two sons.  My older son was going to nursery school, and they said he’s not paying attention and were concerned.  ‘You should have him tested.’  We had him tested.  The neuropsychologist said, ‘Well there’s some kind of, you know, information processing problems, you should see a pediatric psychiatrist.’  I said, “Well, I am a psychiatrist, but I’ll take him to see a pediatric psychiatrist.’  We took him to see a pediatric psychiatrist, spent twenty minutes with him, and he started, you know, writing a prescription for Ritalin.  I said, ‘Why?’ and he said ‘Well, he’s got ADHD.’   I said, ‘I don’t think so.’
So, long story short, he ended up graduating from University of Pennsylvania, law school at Columbia, he’s in a top law firm.  So, yes, it happens, and part of that is social pressure.

There is something very telling about this story. I think one intuitively sides with Lieberman's sense that ADHD is an unnecessary label under the circumstances. But how can one avoid such undesirable clinical encounters? It's tempting to prescribe a healthy dose of "common sense", but this is a questionably useful. I am sure the paediatric psychiatrist in the story felt they were applying common sense in their work by applying a DSM diagnosis, so invoking it only leads to a conflict between two people's notions of what is meant by that rough and ready notion.

I want to propose we use Hickey's report of Lieberman's anecdote to formulate a test for ourselves as mental health professionals. I call this the "Hickey Lieberman test" to recognise the role of Jeff Lieberman in articulating the problem, and Phil Hickey in transcribing Lieberman's story. The Hickey-Lieberman test should be applied in any situation in which a psychiatric or mental health intervention (be it diagnosis, prescription, therapeutic plan, change in living circumstance, or really any substantive change) is being considered. It consists of four questions the intervening clinician(s) should ask themselves before taking action.

The Hickey Lieberman Test: 
1.How would I react if this intervention was to be applied to me, or to someone I cared about?
2. What would be the basis of that reaction?
3. If I would react negatively to this intervention, can I nonetheless justify it in terms of converging lines of evidence that it is an appropriate course of action?
4. If the answer to 3 is no, what would I change about this intervention to make it more reasonable for the person toward whom it is directed? 

The Hickey-Lieberman test is hardly water tight. If you agree with my reservations about "common-sense" then you will notice that this proposal also contains a great deal of subjectivity. However, a formal test does demand at least a moment's thought. When people act in ways they think are concordant with "common-sense", they may often be rationalising after the fact rather than thinking in advance. Much like the "reasonable person" test applied in legal settings, the Hickey-Lieberman test draws on the notion of a shared agreement about what it means to behave sensibly, which isbetter than nothing.