Psychoanalysis and the Scientific Imagination

This post is about the part of psychology that has maybe caused more disagreement than any other. Doomed and tragic, dogmatic and sometimes foolish, psychoanalysis has been derided and "killed off" multiple times over. Like a religion it inspires dogged loyalty among followers which embarrasses people of a more skeptical mindset. Nonetheless, I retain an ongoing fascination with psychoanalysis as a way of thinking.

As an undergraduate I was discouraged from even thinking about picking up a book by Freud. His work was taken as the paradigmatic example of how NOT to do psychological science. The prototypical psychology undergraduate who makes assured statements of the form "Freud has all been disproven" has not really got it right (could they even say what it would mean to disprove such a huge body of work?), but they are not wrong either. How can I be both empirically minded and interested in the metaphysical suppositions of a patrician doctor from fin de siècle Vienna?

The privilege of "Sciencey-ness":

Here's the source of one potential form of mistaken thinking about the science of therapy. Contrary to intuitions, psychoanalytic theory is no less capable than cognitive theory of leading to treatments that can be manualised and tested. We may assume Cognitive Behavioural Therapies are more appropriate for modern clinical settings because the language of "cognition"; "schema" and so forth lends an additional superficial "sciencey-ness". However, the real litmus test of a therapy is neither its sciencey-ness nor its poetic intuitive appeal, but its ability in clinical trials to effect the sort of changes it claims to be able to make.

Unfortunately, it is a shabby truth that psychoanalytically inclined clinicians have resisted seeing RCTs as a legitimate way to validate their insights. Where they have (Fonagy and Bateman's Mentalisation Based Therapy and Clarkin and colleagues Transference Focused Psychotherapy-both interventions in the field of "Borderline Personality Disorder") they have produced some promising results. Some service users have reported that DBT, with its talk of "emotion regulation" can feel infantalising and restrictive. If alternative approaches can avoid these complaints then that would seem an important advance in the direction of greater choice for a group of people who are often otherwise offered very little.

Psychoanalysis and Science:

"Basic" psychological science isn't just a set of methods for verifying theoretical statements. Although such tools for verification are the main subject matter for philosophers of science, we also need a way to generate theories and new ideas to test. This requires creativity, imaginative flair and some familiarity with what you are trying to study. Einstein's creative thought experiments are lauded by the popular imagination because they challenged the conventional wisdom about how energy worked. If we view psychoanalysis as a rich field of imagination-stimulating ideas about the mind, its utility to science comes more to the fore. Nobel prize winning brain physiologist Eric Kandel has called psychoanalysis "the most coherent and intellectually satisfying view of the mind", albeit in the context of a plea to its practitioners that they up their game in terms of scientific theory development. Another Nobel winner Daniel Kahneman tells a fascinating story here about the value of reading Freud closely to generate new ideas for experimental testing:

In thinking scientifically about the way the world works we perhaps need to start with a proliferation of theories and ideas which we only later cut down to size through empirical investigation. If nothing else, psychoanalysis has been provocative and stimulating in developing detailed ideas about what sort of things minds are.

Psychoanalysis and "the ecstasy of truth":

Somewhere beyond the deliberately limited and precise technical vocabulary of scientific psychology there lies an explanatory and expansive language of mind to which we aspire. Novelists and poets have the ultimate privilege in this domain, they deal in fiction and verse, which provides the ultimate disclaimer for saying whatever you want and sometimes landing upon something that feels deeply and wonderfully true. 

Werner Herzog explains the distinction between two different views of truth

Psychologists have a duty to write and think in a different way if they have any hope of saying things which are verifiably and usefully accurate. We are-nobly I think-purveyors of what Werner Herzog would call the "accountants' truth". The price we pay for this is that we limit our capacity to get at the fullness of "the ecstacy of truth"; the truth of what it is and means to be human. Nonetheless we all surely want, at least in some part of ourselves, to go beyond cautious psychometrics and deploy words that really get at what it is like to feel and think. Why otherwise would we have become psychologists?

Psychoanalysis is not just a theory, it is a different way of having theories; a different way of writing about people. It is also a phenomenology. When Freud differentiates mourning and melancholia by saying that in the former it is the world which has become "poor and empty" while in the latter it  is the Ego itself; when Winnicott speaks of "annihilation anxiety" or of "holding" as a metaphor for the way that a clinician can help bear disorganising feelings of dread, these sorts of descriptions would seem to bring us close to lived experience in a way that technical scientific writing cannot.

Psychoanalysis is surely a dying art, surrounded by obfuscation, obscured by shroud waving, but for me it retains a valuable intellectual core. Freud was a staggeringly good writer (arguably too good; his capacity to convince and convert people can be viewed as intellectually problematic) and he developed a beautiful and detailed view of the psyche. Unfortunately for us, the truths that are contained in the enormous corpus of psychoanalytic writing are fleeting and hard to pin down. Some might suggest that analysis and analytic training can help you grasp them more firmly. I dislike the hierarchy and authoritarian nature of psychoanalytic "received" truths, but many of its texts are poetic, imagination expanding and enriching nonetheless.

Agendas and Anxieties: CBT for Psychosis

I have been watching discussion about the latest CBTp trial with interest and some weariness. If you haven't kept up, at least 3 expert blogs have painstakingly critiqued the results and reporting of a new study in the Lancet. Their work may have led the BBC to water down initially highly enthusiastic but inaccurate coverage:

Before and after: The BBC's shifting versions of the same study

I remain a fairly novice methodologist so I have nothing of value to add to this dispute. However, one striking and familiar pattern has emerged, apparently driven by particular anxieties upon which it is interesting to speculate.

Defenders of CBTp have emerged in the comments of these blogs angrily seeking to discredit its critics without providing much substantive defence of the data. Among the more striking things about these comments is their tone; irritable and impatient, levelling accusations of personal agendas and talk of "cabals". Perhaps for the most part, this can be attributed to the familiar fact of modality-affiliation-bias on the part of defenders. People want CBT to be effective for psychosis because they have invested time and energy in it as a cause. The same bias of course motivates overly-enthusiastic defences of any treatment. 

I think there is another anxiety present too however, one which, however misguided, is perhaps more noble. This other anxiety arises out of the current topography of the mental health debate, which appears to pit "medical"/"evidence-based" interventions against "intangiable"/"humanistic" interventions. With these binary goggles on it can look as though CBT is just about the only "humanistic" intervention that has any chance of passing the stringent hi-tech tests of an atomistic neoliberal psychiatry. Discrediting CBT is not just about one intervention; it entails a further discrediting of any provision of psychological care in this field. 

This reasoning doesn't follow, and I am not trying to motivate a case in favour of CBTp of the back of it. Why then have I said it is "noble"? Well, whatever the evidence for different specific interventions in psychosis, we would seem to want to provide in addition to them  "old-fashioned" "holistic" "person-centred" (call it what you will) care. Care, as it were, in the straightforward "folk" sense of the word rather than in the jargony bureaucratic sense. One person I interact with on Twitter has suggested calling it "psychiatric palliative care". Although I can anticipate some protests at this idea ("palliative" implies pessimism; a degenerative, fatal trajectory) I understand where she is coming from and think it's a neat coinage. Care is about a sort of ethical responsibility and it draws on a certain instinctual sense that people ought to look after and love one other. It is the sort of care which Jenni Diski recently eulogised in the LRB, sad to realise that the loss of Victorian asylums (good riddance) had also entailed the loss of "asylum" in contemporary society's treatment of mental health.

It would be misguided to rally to a therapy that cannot substantiate its claims to efficacy. We should be advocating treatments that really help people, and it is a strange thing when we don't. We need to understand why we get into such ruts if the debate is to progress. At least some of the problem is an unspoken fear: that if we see all of our caring efforts simply as testable technologies, we might lose them altogether. 

Making the Case: Thoughts on Social Construction in Psychiatry

I have written a post for the blog maintained by the Salomons Clinical Psychology course. The piece is available here and some really interesting comments are unfolding "below the line".  

3 Questions (and 3 answers)

At this point in the "psychodiagnosticator" project, I keep meaning to review my thoughts on psych diagnosis. So far I have never found a good organising structure for a post; there is lots I want to say as a sort of recap but my ideas have been too sprawling. Then, last week @agteien posed three questions on Twitter and cc'ed me in for a response. I have taken the opportunity to write a self-indulgent review of where my thinking is at the moment.

1. To you who are positive to keeping today's psych diagnosis system. What are the main reasons that you are?
— Anne Grethe Teien (@agteien) January 10, 2014

I am not especially positive towards existing diagnostic structures-I see that it is insulting and disempowering to speak of "personality disorders", that Schizophrenia is probably not an unitary illness construct, capturing people with divergent (not always pathological) experiences; that the DSM is still too embedded in its past (American psychoanalytic psychiatry) to claim "theory neutrality". Equally, once I started interrogating the case-against, I found that the most sound arguments seemed to be for revisions to particular diagnoses, additions to the diagnostic system, possibly a new way of diagnosing. Critics who put all these elements together into a general call to reject diagnosis entirely are trying to make a case which is more than the sum of its parts. In some versions of the debate, the idea of diagnosis per se seems to become a blank screen onto which all the angers and frustrations of mental health get projected, with the accompanying promise "if only we stopped diagnosing people, then we could have a humane mental health system". I don't buy it. I am not especially positive toward keeping today's psych diagnosis system, but I think it has acquired a near-mystical status of evil in some people's eyes, and that stymies interesting debate.

2. To you who want a new (psych) diagnosis/categorisation system. What kind do you want - and why?
— Anne Grethe Teien (@agteien) January 10, 2014

Maybe this one is the question best fitted to me, I not only struggle to imagine doing without some form of classification, I think that DSM's critics can't do without one either. In his new year "message from the chair", Richard Pemberton of the DCP reflected on the division's statement against the DSM-5 back in May. In the same paragraph he announced forthcoming DCP publications "understanding depression" and "understanding psychosis". You don't, of course, need to construe depression or psychosis as medical "illnesses", but the DCP's use of these terms raises an interesting question about what we necessarily do when we classify. If we reject an illness model of mental health problems but nonetheless continue to speak of them as distinct entities then we are not travelling very far from the position of diagnosing. Depression and psychosis remain things that are worth talking about and "understanding"; they remain things about which clinical psychologists presume to write and explain. If we think we can develop an understanding of their causes, course and potential interventions, in what way are we doing anything radically different from those who "diagnose"? To recognise a problem and believe you can generalise from other similar cases to provide help is, to my eyes, to confer a diagnosis. The broad rejection of diagnosis starts to look more like a turn away from a specific type of diagnosis and it's historical/theoretical implications.

3. To you who want complete abolishment of any "psych" diagnosis system: Why? What's your alternative? Are you against "somatic" dx as well?
— Anne Grethe Teien (@agteien) January 11, 2014

In the spirit of a debate that is a bit more developed than can be allowed on Twitter, I would encourage people to whom this last question is aimed to reply to it in the comments section on this post; I too would be interested in the answer.

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?

Pseudo-dialectics?

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.

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.

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.