Thursday, 11 January 2018

Of paradigm shifts and professional rifts

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

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

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

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

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

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

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

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

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

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