When is a Parachute Just a Parachute?

There is a great joke about the use of randomly controlled trials to test the efficacy of parachutes. Gordon Smith and Jill Pell, an obstetrician and an epidemiologist respectively, published a "systematic review" in the BMJ in 2003 examining the use of parachutes to prevent "major trauma" resulting from "gravitational challenge". They conduct a literature search, find no relevant studies and satirically conclude "the basis for parachute use is purely observational, and its apparent efficacy could potentially be explained by a “healthy cohort” effect." 

It's a sharp paper; funny and immediately clear about what it is mocking. Parachutes are not "evidence-based" and we cannot point at statistics to validate their use. Should we really go on using them ? Of course! It is in the nature of parachutes that we can see quite clearly that they work and why. Try asking anyone to jump out of a plane without one and see what they tell you.

Coldplay's Parachutes: Not Evidence Based,

Not Effective, just Dismal.

Smith and Pell's paper is an explicit call for "common sense" in the evaluation of interventions. Rather than mindlessly rely on the absence or presence of "data" or "evidence" when making an intervention, we need to be open to the idea that sometimes our understanding of the world, and the use of observation will allow us to gauge whether an intervention "works".

What is a Parachute?

In clinical psychology the parachute-RCT example is sometimes used to defend the idea that not everything we do can or even should be subjected to research-validation. Variations on the argument occur frequently, even when the paper itself is not cited. Smith and Pell are surely basically correct about the fact that an "evidence-base" is not always essential in order to know what is the right thing to do, but that is the easy part. The question which inevitably arises next is which sorts of interventions are "parachutes" and which are not.

We meet a great literary example of parachute failure in Will Self's 2000 novel "How The Dead Live". Mr Khan is a drab seeming data-obsessed Clinical Psychologist who approaches the novel's narrator Lily Bloom, an elderly lady who is at that moment dying of lung cancer on a hospital ward:

Excerpt from How The Dead Live. More available here.

Khan appalls us with his complete failure of common sense, common decency and basic human empathy. Whatever it is that people need when they are dying on a hospital ward, this psychologist is failing to provide it. Rather than hold himself open in some way to the despair and loneliness faced by the dying Lily, he cravenly avoids it and goes about his seemingly trivial data collection. We who read this (especially those of us who fancy ourselves to be caring clinicians) feel we could do something, anything, that would be more helpful. We can plausibly be correct about this; you don't need an RCT to learn kindness.

The fear of being a "Mr Khan" may well play a role in a more generalised skepticism about evidence-based practice in Clinical Psychology. Despite the importance of the "scientist-practitioner" paradigm, an ongoing uncertainty about when we do and when we don't need statistical evidence rumbles in the profession. Some have gone so far as to suggest that non-clinicians shouldn't do therapy research, as they just don't get that intangible common-sense-something that makes therapy helpful. 

Perhaps it's no Wonder New York's Needs Adapted
Treatment Service is Called "Parachute"

To be sure, there are parachutes in mental health. Some fairly influential ideas from psychotherapy seem to fit the bill: Carl Rogers' "unconditional positive regard"; Winnicott's "holding", Sullivan's "evenly hovering attention". What binds these ideas together is their view of an almost ethical stance clinician takes towards client, listening to them, taking them seriously as a person. This post by Gordon Milson on time in mental health services is another example; perhaps, he argues, the EBP movement runs the risk of forgetting that different people need different amounts of time before they can bring themselves to form a relationship with their therapist. Waiting for someone, being patiently there for them, might well be a parachute.

When is a Parachute Not a Parachute?

Alas, not everything is a parachute. While some of the things that psychologists and psychiatrists do are simply ways of breaking a fall, other interventions are intended to be active flying machines. These cases cannot be allowed to slip in under the radar, but should be empirically assessed to see which of them flies and which is are little more than hot air.

Sometimes a Parachute is not a Parachute.

Most of what psychotherapy aspires to is surely not a parachute, though this is sometimes skirted around by describing it as simply "talking to people". If psychotherapy were no more than this then it wouldn't be necessary to test it. Talking to people (and, more importantly, listening to them) is often an inherently good thing, but we should not conflate psychotherapy as an opportunity to do good with psychotherapy as itself inherently good. Psychotherapy as an activity is designed to be a form of talking that changes people's minds and behaviours. Where the mechanisms that make parachutes work are clear and obvious (you don't need a PhD in aerodynamics to understand them well enough) the putative mechanisms that make psychotherapy effective are hotly contested. Being kind and empathic might be quite simple, but effectively helping someone overcome a psychological problem is assuredly not. Calls for "common sense" in our discipline are limited by the fact that there is rarely much that is "common" to how different people see the mind.

If psychotherapy can do good then it can presumably do harm as well. What is more, psychotherapy is expensive, meaning that if you are going to provide it you need to show there is more to it than the proverbial chat with someone lacking those crucial qualifications. By introducing the notion of a "parachute" into the vernacular, Smith and Pell found a way to call out Evidence-Based-Practice enthusiasts when they reach levels of absurdity. If we are to continue to find the idea helpful we need to establish some sense of when their argument does and does not apply.

Notes on the Sociology of Evidence in Clinical Psychology

When I was an assistant psychologist in an inpatient mental health service I delivered group CBT for psychosis interventions. My colleagues and I were encouraged to feel like part of a groundswell; clinical psychology slowly but surely upsetting the apple cart with new promising treatments for the distress associated with psychosis. I was part of various email listservs and used to receive  updates about this or that latest study on CBT for psychosis. As a rather self-doubting sort, I felt it important to see for myself what the evidence was for our intervention so I would follow the link and scour the report for its results section. What does this effectiveness look like in numbers? I was always disappointed, I could never see the change clearly laid out in the tables, and yet there was the headline or email subject line, proclaiming CBTp's efficacy. Unfortunately, and again, as a rather self doubting sort, I would suspect the failure to see the change arose from my own inability to read and understand the figures properly. Our confidence in ourselves can be dangerously undermined when we think someone else knows better.

Now I am in clinical training. Over the last few months I have been part of a seminar in which we discuss and critique research that reviews the evidence for various psychotherapeutic interventions. Learning in greater detail how to read RCTs and meta-analyses has been a pleasingly rigourous experience. When my turn to present came I reviewed an effectiveness RCT for a treatment which was being compared to a "Treatment as Usual" condition. Reading the details of what this involved, it became clear the TAU was a rather paltry control; brief monthly check in appointments "as needed" as opposed to the structured and regular meetings of the treatment. When I pointed this out as one of the things to consider in assessing the evidence, the leader of the class (an advocate of a competitor treatment) gave a knowing smile. "They were crafty weren't they. It makes me wish we'd thought to do that".

"What a man believes upon grossly insufficient evidence is an index into his desires 

-- desires of which he himself is often unconscious." Bertrand Russell

This sense of allegiance has its merits. Research needs to be critiqued, and who better to do it than researchers who are passionately invested? People who care very deeply about how something is presented will do their damnedest to launch as strong a defence or as strong an attack as is required by the current situation. It can lead to the best sort of forensic examination. When you have researchers in different groups paying very close attention to the work of other groups you can be sure they will spot any unfairness arising from discrepancies in therapy-adherence ratings, dropout rates in different arms of an RCT or anything appended to the actual treatments which might boost effect sizes. Sometimes "opponents" have even been party to useful information on the very studies they are critiquing.

Ultimately though, the facts about how effective an intervention is all needs to tumble out somewhere, and practitioners need to come to some plausible consensus. Allegiance is great for critique but becomes embarrassing when it amounts to rejectionism. I don't know how light-hearted our seminar leader was being, but I do know that it was indicative of a real phenomenon in therapists; the belief that what they are offering works and the desire to "prove" it. If they can't do this, then the fault must lie with the research methodology rather than the treatment.

Quietly, without anyone drawing too much attention to it, therapists draw themselves into teams defined by orientation and specialization. It seems always to have been this way; from Freud's expulsion of dissenters, through to the "Controversial Discussions" in the British Psychoanalytic Society, to Hans Eyesenk's encounters with psychotherapy and to the current controversy over CBTp. Say something critical of a therapist's approach and you can be sure to raise hackles, as has been shown in the extraordinary vehemence of the CBTp debate. This is part of why I chose to be a clinical psychologist rather than a different form of psychotherapist; the thing which surely sets us apart from psychoanalysts or counsellors is our training in research and our pragmatic openness to following the data wherever it leads us rather than getting caught up in modality cliques. If this gets compromised, what do we really have to offer?

On a Certain Queasiness Regarding the Word "Diagnosis".

Once again I have started having Twitter conversations about psychiatric diagnosis. It is like Tetris used to feel. "This is fun...I need to stop...oh go on, just one more round."

I am thoroughly confused about people's feelings around diagnosis. The DSM is widely disliked and mistrusted, and for very good reasons, but that dislike and mistrust extends beyond the DSM itself, infecting words and concepts in the vicinity and undermining the foundations of our discussions. We are encouraged to think there is a fight going on, with "diagnosis" in one corner and "psychological understanding" in the other. In my head this all starts to unravel when the meaning of diagnosis is brought into play. A conversation begins with a call to abolish psychiatric diagnosis. Later in the same conversation it is said that the problem with the DSM is that its classifications are not sufficiently similar to a diagnosis. Confused? You ought to be.

Another brick in the wall...or another drop in the ocean?

Allow for sake of argument that our knowledge of psychological causes and processes is excellent, far better than it is now. Imagine when are confronted with an experience like paranoia or depression that we can take a life history and determine with a high degree of accuracy what are the importance of various factors in it's aetiology ("you started to feel different when you were bullied at school; it made you withdrawn and quiet. Later in life this changed how people responded to you and you began to feel they didn't like you either, making you feel more depressed and more anxious") With this superior knowledge might we not start to notice that people with different sorts of problem would respond differently to different sorts of help? What we would have would be a way of knowing the nature of aetiology, the processes it fed into and how they became the presentation we see before us. Would not such knowledge equate to a diagnosis (in any widely accepted sense of the term)? 

Now perhaps we would be reluctant to call it a diagnosis. "Diagnosis" we might reason "sounds too much like something a doctor does. We aren't doctors, we want to think of different ways of helping". This may or may not be a sensible decision to make, but that is beside the point, it is a decision, and an aesthetic one at that. If we don't like the word "diagnosis" then we don't like it. I don't like the word "treacle" but if someone shows me a jar of something sweet, brown and viscous, I may have to concede at least its accuracy. So too with diagnosis. There are many reasons to feel funny about the DSM, one of them is that it fails to do what a diagnosis ought to, but isn't it rather strange then to simultaneously abhor the DSM and to abhor the thing it is failing to be?

The Sacred Whole: More Than the Sum of its Parts?

We have so frequently have reason to talk about the "whole person" in psychotherapy, but what is this sort of talk aiming to achieve?

In clinical settings, the appeal to "the whole person" is most often an effort to remind us that the people we care for have dignity, agency and rights. We can easily think of situations in which the rights of people have been effaced in a bid to attack what were thought of as illnesses inside them; ice packs, insulin comas, lobotomies. All of these were attacks on a part of a person that failed to acknowledge their wholeness. This same effacement seems to have been part of what people were objecting to recently during the satire of the DefeatAutism Twitter hashtag. "By trying to defeat Autism",  people protested, "you are trying to defeat me".

For some people, psychologist Bruce Hood is an example, the very idea of a self is an illusion. I'm not that compelled by Hood's thesis, which doesn't touch on the broader metaphysical questions about the experiences that arise out of the psychological processes he describes. In any case, in the early part of his book he points out himself that just because something is an illusion, it doesn't follow that it is not having a powerful real effect. So much for a putative lack of self, we still have something like "selfi-ness", and that is what we usually take to be important.

Not that kind of selfi-ness

But if we people are whole in some way, we are also made up of parts, definable, measurable and manipulable. In many cases we have some sovereignty over our parts (I find I can often improve my mood by thinking about how wonderful my life is going to be when I finish my PhD) but this is not total. Our parts can impact us in surprising and stupid ways. Behavioural activation is an example of this stupid direction of causality. Simply getting up and doing something can, to a limited extent, have knock on effects for our global level of self esteem; a "part" intervention that has ramifications for the "whole".

The parts/wholes distinction is almost as old as clinical psychology (or possibly older), and as so often is the way, Paul Meehl has been there before. In his 1949 book Clinical vs. Statistical Prediction, Meehl anticipates the familiar argument that says that there is more to people than that which can be reduced to numbers:

“A cannon ball falling through the air is ‘more than’ the equation S= ½ g  , but this has not prevented the development of a rather satisfactory science of mechanics”.    

Meehl's point perhaps is that of course we should be interested in the "whole person", but that this does not preclude our being interested in measuring their parts. A caricature of quantitative psychotherapy research says that any interest in numbers or symptoms sees humans as "robots" or "microbes". This is no more the case for the psychotherapist than it is for the doctor who tries to impact someone's rich and complex life by monitoring simple changes in their temperature. 

Undeniably there is something crucial to what we call "bedside manner"; that form of empathy and consideration that keeps the patient's experience in view even while working on the problem they present with. There is equally a power to seeing the impact of changes at the "parts"-level. Have you ever noticed how a simple change in something that bypassed your complex engagement with your self (something as simple as having a glass of water when you were thirsty) seemed nonetheless to enhance the way you felt at a more profound level? This is the direction that "symptom reduction" tries to go in, reduce the amount of time someone spends feeling bad and you can have immeasurable and intangible effects on their self as well. 

People talk about psychotherapy research as though it should all have the descriptive quality of poetry or a novel. For sure, qualitative research and service user testimonials are an indispensable part of how we understand what is going on in the world, and when it comes to safeguarding people's dignity there is no substitute for individual narrative accounts. However, this approach (like all approaches) has its limits. The effort to "do justice" to people in all their complexity is not the only thing at stake in the effort to find out "what works" for them. Complicated creatures that we are, that complexity emerges from somewhere, and while we might feel like we are more than the sum of our parts, taking care of those parts can be surprisingly important. 

CBTp, Psychiatry and the "facts on the ground": Thoughts on the latest Maudsley Debate

Though it is rarely framed this way, the folk who critique CBT for psychosis and the folk who defend it have an important piece of common ground it seems worth talking about. Both are concerned about the way the “facts on the ground” can be at odds with an evidence base. 

"Facts on the ground” are what powerful people change without recourse to the necessary forms of law or reason. Putin changed the facts on the ground by annexing Crimea and stationing 10,000 troops on the border of Ukraine. This change was important precisely because the international community did not want to respond in kind; Putin changed the question from “how can we negotiate a diplomatic solution to Ukrainian unrest?” to “how can we negotiate a diplomatic solution to an invasion?” 

Vladmir Putin riding to a psychotherapy session.

“Facts on the ground” is usually a military term used to highlight a contrast with efforts at governance. In mental health, what actually happens to people are the facts on the ground, while the evidence base is our governance.

Those who propose (qua the Maudsley debate from 2nd April) that CBT for psychosis has been “oversold” see facts on the ground about CBTp that are at odds with the provision of evidence-based care. NICE (along with many mental health professionals) is promoting a therapy which, according to the highest quality available meta-analyses, appears to offer virtually no benefit.

Among those who opposed the motion, we hear much talk of the actually-existing alternatives; lifelong neuroleptic medications, forced restraint; traumatic and chaotic sectioning procedures. These too are facts on the ground, at odds not only with the evidence base (prescribing practices are frequently out of line with evidence) but with our sense of how it’s decent to treat people.

I have spent a lot of my career in mental health, some of it in a CBTp milieu, and I have come to feel wary of the team-affiliations and self-protection that allow for therapeutic orientations to flourish and self-promote un-troubled by the voice of skeptics from outside. Perhaps this constitutes its own form of bias (the zeal of the apostate?), but I can’t help but be persuaded by the meta-analyses that show CBTp to have miniscule treatment effects. I am also persuaded by my own experiences trying (often rather ineffectually it seemed to me) to change people’s thoughts about experiences which seemed to powerfully disruptive of their thinking. Show me anecdotally positive cases if you like, but if you follow the “I know someone who found it helped” research methodology, there is virtually no imaginable treatment that doesn’t make the grade.

Where do we go from here?

This seems to be where most discussions of this topic leave off, but that is a highly unsatisfactory state of affairs. There is only so much interest to be gleaned from me telling you that, as things stand, I see little that is active or helpful in CBTp. What role should psychology have in psychosis?

We hear so often that being detained, locked up, forcibly medicated and released with no aftercare is traumatic and unhelpful. This ought to come as no surprise. Some people see psychiatry and psychology as by their very nature set up to create this kind of experience. I am more optimistic. What both professions ought to have in spades is ideas about how they could be different, and the research understanding to discover how.

It is surely structural changes that hold the most hope. With imagination we can structure services so people are checked in on more often, professionals are better supported and transitions from the community to hospital can be calmer and better planned. The Open Dialogue approach, which seeks to involve entire families in the early stages of a psychotic crisis is one way to re-imagine the point of entry. It is getting a tentative start here in New York, and from what I understand it is principally concerned with giving genuine respite in a time of crisis and bolstering the support given to people going through crisis.

Such structural changes are promising even if you are agnostic about the nature of psychosis. “Brain disease” or “trauma reaction”; both sorts of problem should respond to well structured well integrated care. Whether we decide CBTp has been “oversold” or not seems less relevant than the question of whether we can do something better than what is currently available. You’d have to be quite a pessimist to think that the answer to that is no.

Unravelling Sane Privilege

It is increasingly common to see calls for people to check their privilege. This is apparently hard for some to understand, but at least most have some semblance of the fact that our society is generally racist, generally sexist and generally hetero-normative, and that we should bear in mind when we speak to each other that our prejudices and privileges have in impact on our worldview. Our society is sanity-normative too, and this is more difficult still for us to get to grips with. Being "mad" in some sense is something that we generally take to be undesirable, and the existence of mental health services is testament to the fact that society seeks to limit the misery and misfortune which accompanies experiences of psychosis, mood-disorders or "personality disorder". Hoping to affect an improvement in the lives of people with mental health problems should not, however, spill over into the assumption that everything about such individuals is a "deficit" to be fixed, or a "vulnerability" to be managed.

With the rise of identity politics as a lens for thinking about mental health, the languages of anti-(hetero)sexism and anti-racism have been finding their way into the discourse of "mad-chat" too. What does it mean for their to be a "sane" or an "insane" identity, especially when it seems so hard for us to pin down a hard distinction? Just as race, gender and sexuality can become concrete (even sometimes unwanted) identities in spite of considerable fluidity, so too can one's identity as "mental-patient" or "sufferer". Medical histories hang over us, and mental health histories follow people into domains of their lives they had never anticipated. Such individuals acquire "mad" identity. Unlike people of "sane" identity, the question then arises-do I embrace this, or minimise its significance?

If white-privilege, male-privilege and straight-privilege can act as blinkers to participation in online debate, then so too can "sane-privilege", speaking from a position of comfort and failing to consider the ways in which your ideas or suggestions have missed the point or caused offence. As a straight white male who is training to be a psychologist, I am a prime candidate for this sort of oversight, and I have probably made my fair share of blunders in conversations on Twitter where the comforting boundaries keeping professionals and academics safe no longer pertain.

As an exercise in checking my own sane-privilege, I had originally intended to do my own version of Peggy McIntosh's "Unpacking the Invisible Backpack", but I discovered that someone else had already done that much better. Instead, here are some additional ideas about what it might mean, specifically in online discussions:

1. Sane-privilege is communicating only in the set of academic-linguistic rules we have learned in our professional or academic training.

2. Sane-privilege is being able to get angry and express it, without having it taken for a sign of problems with our mental health.

3. Sane-privilege is the freedom to exhibit erratic, playful, explicit or irrational behaviour in online social forums, without the assumption that it is undesirable and beyond our control.

4. Sane-privilege is the freedom to pontificate about whether disorders really exist, drugs or therapies really work or whether ideological positions are or are not superior to others, and not have our hearts sink because the outcome of these debates matter deeply to our well-being.

5. Sane-privilege is the presumption that you can tell other people what else they can try to help them with their mental health and that they should give a damn.

6. Sane-privilege is presuming to tell someone that even if they are sometimes knocked clean off their feed or chased into bed for days at a time by their own state of mind, they do not have an illness.

7. Sane-privilege is presuming to tell someone that even if they spend happy hours conversing with heard voices, or fervently arranging the cosmos into divine and self-referential order, that they do have an illness.

8. Sane-privilege is presuming to tell someone how significant their history of abuse should be to them.

9. Sane-privilege is telling someone how they could redirect their overwhelming desire to self-harm, in a way that won't disturb other people.

10. Sane-privilege is deciding which risks in a person's life are acceptable and which are not.

11. Sane-privilege is the ability to get as drunk, high, sleep-deprived or wired as you like, without it being assumed that you are "relapsing".

Calling out privilege should never be just a silencing tactic. In the contested field of power, dialogue is our only way to proceed. Social media has been excellent for this, putting greater numbers of people on a more equal footing than has been possible previously. It will often make us uncomfortable, especially those of us who are professionals used to speaking in particular languages; but this discomfort is to be positively embraced as part of the ongoing agitation and uncertainty that necessarily accompanies human affairs.

The Language of Mental Health

The language of mental health can be baffling for the most fluent speaker. Being new to the vocabulary must be overwhelming. In our field words get un-moored from their more familiar meanings and float into new configurations. While academics may delight in such shifts, a drift into jargon can be a sign that somewhere a plot is being lost. What follows is a half-baked and entirely partial view of some troublesome words:

"Bipolar": This may win the award for the topic with the most balls talked about it. Luckily ace blogger Charlotte Walker never seems to miss a chance to point out the excesses that surround Bipolar-talk. From the idea that it is "fashionable" because Stephen Fry has it, to the extraordinary presumptuousness of Darian Leader's views on the subject, Bipolar Disorder has had a funny recent history.

"Clinical Judgement": Much as clinicians would like to know the "correct" answer to any given ambiguity, we cannot avoid making judgements in clinical practice as in life. I judge that something I say will provoke aggression, I judge whether it would be good for someone to try this or that therapeutic intervention. Even when guided by evidence, our judgements involve reasoning from the general to the particular. Often these sorts of decisions get called "clinical judgement". While this may have a superficial accuracy (judgement about clinical issues is undeniably clinical in some sense) it also seems calculated  to cloak a professionals pronouncements with spurious authority. What lay-person can successfully argue against a "clinical judgment"? When do professionals start to acquire it? I am just 2 years into a clinical training program, but already I have been encouraged by mentors to use my "clinical judgement". I am not saying my judgements don't count for something, and equally they are presumably worth less than those of a seasoned professional who has seen hundreds of cases; but judgements can, by their nature, be contested. If offering them with the haughty prefix "clinical" makes that harder to do then something fishy is probably going on.

"Distress": We could here examine the words "disease" or "disorder" but they have been so thoroughly gone over by various mental health theorists that I have little to add. As a result of that ongoing contention, the safest way currently to talk about mental health problems is to call them "distress". This inoffensive term has banality on its side, but seems to equate the existential terror of a psychotic break with the frustration of having had a bad day at work. Unsatisfactory.

"Evidence Based Practice": A noble ideal, but seldom followed as closely as it might be, and utterly useless if the people who are supposed to provide it are under-qualified to interpret the very evidence upon which their practice is based.

"Formulation": I can't really argue with this use of language. A Psychological Formulation is roughly the same thing as a formulation in regular language use. Alright Formulation, you can go.

"Group": When I worked in mental health, any constructive-seeming activity that more than three people did together could be packaged up and classed as a "group" to make it sound like a bone fide mental health intervention rather than just some people doing something worthwhile. "Cleaning group"; "cooking group"; "young person's group" are all genuine examples. It drove me up the wall.

"Healing": I am extremely skeptical about "healing", which we can use describe our own experience, but not to make promises to others. Health interventions can be shown to change various sorts of "symptom scores", but I am not aware of a decent "healing" measure, in psychology at least, that has much construct validity. We should probably calm it on the "healing" talk.

"Identity Politics": I think that the notion of "mad" identity is fascinating, and has a long way to run in combating mental health stigma. How compatible is it with the movement against psychiatric diagnosis? On the one hand we have the notion of neurodiversity and a distinct "mad-identity", which calls for accommodation of a range of different neural-cognitive types. On the other hand, there's the tendency to focus on people's commonalities while denying that differences could be meaningfully "diagnosable". These two ideas are not incompatible, but they are very different directions of travel. Twitter's @SchizoTribe account is "run by Schizophrenics" for anyone "with a Schizophrenic illness". This makes me wonder if denial of the existence of an illness is no less an infringement of someone's identity than making a diagnosis; an idea with which I think psychologists have to engage more seriously.

"Manipulative": I once had the good fortune to work on an excellent female inpatient ward. Prior to the hospital's opening we were given a very good talk about how frequently it is said of people with personality disorders that they are being "manipulative". The take home lesson was that this word should not be used to describe the behaviour of vulnerable people as it stigmatises their actions. I agree entirely, and I would add that the feeling among staff of being-manipulated is nonetheless sometimes very real. If you feel like you are being manipulated then you are very likely in the presence of someone who is generally deprived of something they feel they desperately need. Your feeling manipulated is not the result of something perpetrated by conniving, dastardly-patients, it is a circumstance arising from an adaptive response to a subjectively desperate situation.

"Practice-Based Evidence": The rejoinder to Evidence Based Practice. This is espoused by clinicians who feel the information we can glean from "clinical experience" (see "clinical judgement") is marginalised by nomothetic research. Is this true? Maybe, but let's be clear, even the most experienced clinician does not have experience which equates to a meta-analysis of multiple RCTs documenting health outcomes for thousands of people. This is not just a numbers game either, it's about a long view and the systematic ruling out of confounds and examination for bias. Experience and case reporting is very valuable but it has a different, complementary, role to play in the development of reliable knowledge.

"Recovery": Imagine asking a doctor the following question: "Can you help me recover?" What would you hope for them to say? The answer would surely involve an estimate of how likely you are to feel better on the basis of information about your problem and likely interventions. In mental health recovery means...something else altogether. I would not descry the general thrust of "recovery-oriented" approaches, but the fact that we find it so hard a word to define suggests that our use of it is in a state of disrepair. There is a difference between the advocacy of therapeutic optimism alongside societal accommodation of the needs of a diverse range of people, and telling clients-regardless of their difficulties-that you can do something that will help them "recover".

"Service User": I have a personal dislike of this awkward little two word phrase. Who wants to be a "user" of anything, let alone anything so non-descript as a "service". Strictly speaking this usage ought to unite people who use oncology services, mental health services and those who go to a garage get their car checked over. In reality it seems mainly to apply in mental health, a field sufficiently fraught that it needs as banal a vocabulary as it can muster. I am not advocating some fightback for the word "patient" per se, instead I try as far as possible to refer to people as "person", "individual" or, ideally, whatever they feel comfortable with.

"Survivor": I wouldn't begrudge anyone the use of "survivor" as a way of talking about their identity; being a psychiatric patient seems a tremendous ordeal to say the very least. However this post by Natasha Tracy gives an alternative view on the ways this word has come to be used.

"Therapy": (See also "Group"). Examples: "eco-therapy" "insulin-coma therapy". If something sounds like a good idea (spending time in nature) then lets explore the reality of how helpful it can be. If it doesn't (putting someone into an artificial coma and seeing what happens when we bring them round) then that may tell us something too. As the Mental Elf's close relative the Mental Sprite might say: image is nothing, evidence is everything.

"Validity": Often used alongside the phrase "psychiatric diagnosis has no..." Less often (with notable exceptions) accompanied by a description of what sort of information would be taken to satisfactorily rebut the claim.

"Wellness": In a situation where you can't sensibly talk about "illness", you are equally debarred from a sensible discussion about what constitutes "health". Luckily the language of "wellness" is sufficiently elastic that mental health professionals can, if they choose, be both paternalistic (deciding what is and is not in line with "wellness") and hypocritical (denying they are engaging in value judgements). Enter "wellness" which, like "recovery", can mean everything and nothing all at once.