Five Halloween Costumes to REALLY be Scared of

This time of year has come to be marked by a familiar woe as various costume companies and theme parks market a peculiar brand of offensive mental health paraphernalia in the name of Halloween entertainment. From experiential tours of a "scary Asylum" to "mental patient" fancy-dress, if you want to spend a surprising amount of money buying into stereotypes that are deeply hurtful to a large number of people, then there is a company which can help you do it. I won't catalogue examples here as Sectioned has a good page detailing comprehensively the various offenders. Instead, I am going to do my bit for mental health stigma by offering some alternative fancy dress options for anyone seeking to truly terrify their friends this Halloween. All of these are far scarier than any imagined "mental patient" and are made more so by their ubiquity and relative invisibility. Here are 5 Costumes to REALLY be scared of this Halloween:

1. The Pharmaceutical Sales Rep:

Aaaarrrggghhh!!!!

The Pharmaceutical Sales Rep's only job is to flog medicines to healthcare organisations Although a science background can "boost your credibility", it is by no means a requirement in a field which principally requires that you "sell sell sell" and raise the profile of your brand. The pharmaceutical sales rep is the perfect example of the shady figure tacitly manipulating the minds of others to see that his ends are met. He is especially scary because although his knowledge might be low, his influence can be high. Some doctors may be unable to resist his creepy powers of mind control!

You Will Need : A grey suit and a bland tie. 

2. The Healthcare Administrator:

Nooooooo!!!!!!

The Healthcare Administrator makes life and death decisions about whether to fund particular treatments and services. Poised between the world of political decision making and healthcare provision, he is aptly positioned to draw on the worst of both. Although the healthcare administrator is capable of using his powers for good, he is also capable of much evil. Last seen in a helicopter over Connecticut, deciding whether to pay for a 9 year old's cancer treatment.

You Will Need : A grey suit and a bland tie. 

3. The Public Relations Expert:

UUUuuuUUuuUuurGHhhhhh!!!!

The Public Relations Expert's job is to present something as good, even if the thing itself is not that good; even if it is actually rather bad. While there's nothing scary about doing the promo material for, say, a poorly written book, the work this guy will do to help people cover up fairly egregious errors (and get wealthy in the process) is a little more sinister. 

You Will Need : A grey suit and a bland tie. 

4. The Arms Dealer:

Urryhhhhlllghhllgg!!

Let's ramp things up a notch. If you are insufficiently scared by the murky antics of the Sales Rep, the Administrator and the PR Expert, you can't fail to be terrified by the downright horror of the Arms Dealer. Utterly unconcerned by anything other than turning a profit, the Arms Dealer will happily sell weapons to anyone willing to pay. The ideal scenario for the Arms Dealer is a protracted and bloody war in which he can offer his wares to both sides over the longest possible period, getting rich as his customers shoot one another indefinitely. As a major player in most western economies, the Arms Dealer is seriously scary! 

You Will Need : A grey suit and a bland tie. 

5. David Cameron:

AaaAAAAAARRRRGGGGHHH!!!!!

He's real, he's the Prime Minister, and he's coming for YOU!

You Will Need : A grey suit and a bland tie. 

From "Diagnosis" to "Characterisation"

What a lot of difficulty there is in trying to talk about psychiatric diagnosis. We try to say one thing but can easily end up meaning something else.

I have often taken a position that defends the value of diagnosis in mental health. People have often refuted that position by citing the failings of the DSM project, as though diagnosis and the DSM were the same thing. For a while I tried to resist this by pointing out (over and again) that I was not necessarily referring to that complex and troubled manual but to something like "classification plus a probable explanatory story". The point has never stuck, and I have to face the possibility that some of the fault is mine.

Why persist in talking about diagnosis? Why not seek a word that doesn't alienate people? Diagnosis seems to suggest "knowing", which it isn't if we're honest.

Perhaps instead of diagnosis, we could talk of "characterisation". When someone understands a problem in a particular way they characterise it, describe it as having a particular nature. "Your avoidance of parties is a social phobia, exacerbated by your ongoing avoidance and we can expect forms of exposure therapy might help." or "Your mood changes are like those that have been called "Bipolar", and when people have taken this or that drug they have found them easier to live with."

This way of talking can resemble formulation (the first example) or it can resemble diagnosing (the second), but it isn't supposed to be more like one or the other. Formulation tends, in this debate, to mean the idiosyncratic and "intelligible"; the formation of "meaningful narratives" (Boyle and Johnstone, 2014). Diagnosis tends to emphasise the regularities across cases, with "intelligible" referring to explanation in terms of medical as well as psychological processes (Hayes and Bell, 2014).

The idea of characterisation is consistent with either of these approaches. You can characterise a problem as psychosocial, as medical, or as a combination of both. If what we are doing is characterising, then we can take seriously the idea that someone is unwell when their mood consigns them to their bed for a fortnight. We can benefit from pattern recognition (Characterising the problem as a depression), without appearing to commit ourselves to belief in an entity that we can't yet describe (the "underlying" illness).

Characterising is more than classifying (because it speaks to how you view the classification), but less than diagnosing. It is a bit like formulating, but without the assumption that the explicable processes take place at the level of meaning. It's a clunky term, and not one that can be expected to "catch on", but when I talk about the value of diagnosis, it is this I am trying to describe.

How to Critique the DSM

I've just finished reading Rachel Cooper's excellent, and remarkably unsung new book "Diagnosing The Diagnostic And Statistical Manual of Mental Disorders". It came out in May and it's hard to believe I hadn't run across it until now. In a debate that becomes polarised and heated with alarming speed, Rachel Cooper is a calm and insightful voice. Her book (replete with a brilliantly irreverent cover, which makes you wonder at first if it's part of the "official" series of companion texts published by APA) is only 60 pages, but it packs more substance into that space than many of the books on psychiatry I have read recently.

Given the book's relatively low profile (at least, apparently, in clinical circles), here is a summary of the its arguments:

- Cooper is unsure about what to call those protagonists in her story who receive diagnoses. She finds "survivor" "too angry" (something I like about a certain strain of philosopher is that they openly admit the role of personal temperament in their thought) and makes the point that "client" can be disingenuous. The nature of mental health care is such that, in many instances, it simply isn't the case that an individual is paying, in the manner of client, for a service that they straightforwardly want to receive. She opts for "patient".

-Cooper is skeptical about the APA's own attempts to manage the financial relationship between the DSM and the pharmaceutical industry. Limiting the present pharmaceutical interests of clinicians involved in the DSM is simply inadequate when the relationship between doctors and drugs companies is ongoing over the course of a career. Such relationships are more like what anthropologists call a gift relationship where "gifts are given and received over time, and thereby create real but non-explicit obligations for reciprocation in the future" (p. 15). Cooper suggests that only complete independence from the pharmaceutical industry can save the DSM from this sort of malign influence, but that this sort of step would require "nothing less than a revolution" in the way research is funded.

-The APA invited patient involvement for the creation of DSM-5, but this was, in Cooper's view, largely tokenistic. How informative can it really be for the working groups to hear information in the random, bitty way invited by the online-comment feedback structure it provided? Drawing on the sociology of science Cooper points out that the questions that get researched, and the conclusions that are drawn are partly a function of who does the asking. She advocates for the presence of "patient researchers" who are trained to do research but also happen to be patients. This seems a sound proposal, though it is hard to imagine some critical mass of patient-researchers being reached without an extraordinary recruitment drive. Perhaps the best model is Hearing The Voice, which tries to amalgamate the tools of researchers with the priorities and subjective experience of people with first hand encounters. Charles Fernyhough describes the project in this Lancet article.

-It is not just big pharma that drives the inclusion of new diagnoses. Hoarding Disorder is new in DSM-5 and was, Cooper argues, the result of a combination of public awareness (Hoarding has become quite popular on Channel 4 in recent years) and of the development, by Randy Frost, of a specific CBT protocol, replete with inclusion criteria. Cooper suspects Hoarding Disorder is a bad thing, and suggests that it is more analogous to an "unwise" habit like eating unhealthily than a psychiatric disorder. As such, it might be better suited to interventions which bear a resemblance to Weight Watchers than to the ministrations of health professionals.

-Fascinatingly, the standards for reliability seem to have shifted quite a lot between DSM-III and DSM-5. In 1980, Spitzer and his colleagues set a kappa (a metric for estimating reliability) of 0.7 as the "acceptable" threshold. In the field trials for the latest edition, the goalposts have shifted and kappas in the order of 0.5 and 0.6 are now regarded as acceptable (the issue is handled more extensively in this post by 1 Boring Old Man, which Cooper herself cites). Cooper suggests this may be the result of greater attempted precision in the latest manual, but her main concern is how to make sense of the question of reliability. In her survey of the changes in the definition of "acceptable" reliability, Cooper brings out the sense of how little agreement there is over how to use this metric. More work is needed on what, for a psychiatric diagnosis, constitutes reliable enough.

-Ultimately Cooper concludes that the DSM's days are numbered; not because an anti-psychiatric tide will wash away psychiatric diagnosis for good (Cooper explicitly distances herself from anti-psychiatric positions), but because of the likely rise of other classification systems in research (like the RDoC) and of other psychiatric jurisdictions in which mental health care is expanding (such as in China). She advocates not the abolition of diagnosis, but a more flexible thinking along the lines of philosopher John Dupre's "promiscuous realism". Interestingly Richard Bentall has recently advocated this in the case of psychosis.

This is a refreshing and constructive book. One approach to the DSM is to reject diagnosis altogether, but this sets up a seemingly unbridgeable divide between those who do and those who don't reject diagnosis. Cooper's approach is more painstaking. There is plenty wrong with the DSM and Cooper has thought hard about it. Not content with critique, she also tries to envision remedies.

Putting the "C" into "CBT": What is a "Cognition" Anyway?

CBT will be familiar to almost all readers of this blog. It is a model for therapy that has spread with immense success since its inception in the early 1960s. The theory is clear, and fairly intuitive. When I first came across it as an undergraduate I was impressed; its basic premise seemed to accurately describe a surprising degree of variation in my own mood. Here is an overview of that basic premise, taken from Judith Beck's standard text:

"Automatic thoughts" are a key concept in this approach; rising like bubbles from our underlying beliefs, and interfering adversely with our emotional lives. Note the proposed order of events: I have an automatic thought and then I feel a certain way. This is not uncontroversial; surely it is sometimes the case that we think something because of how we feel. However, I'm not concerned with that argument here. Classic CBT seeks to intervene at the level of thoughts (although more recent "3rd wave" approaches get interested in affect too). Whether that process has a downstream effect on feelings (as per this model), or whether it manages to work backwards (a modified thought changing the mood from which it was derived), if it helps it helps. There is a more interesting problem for CBT, not necessarily a barrier to its use, but a conceptual tangle which is hard to resolve: what is a thought?

We all have thoughts, and all of us will have had them automatically "popping into our heads". Often they are verbal (these linguistically articulated inner experiences are what CBT trades in), but often they are not, and here lies a problem that reveals the messiness of reality when compared to the simplicity of a treatment manual. We all know a propositional statement when we see one, but when it comes to defining a thought things get very tricky indeed. 

CBT instructional texts often rely on the neatly articulated automatic thoughts of straightforward seeming cases: "I'm no good"; "I will never get a job" and so on. These can form hypotheses which we test (and inevitably fail to confirm) in the process of "collaborative empiricism". However, in reality, when we ask ourselves (or the people we are working with) the central question--"what just went through your mind?"-- we need to be prepared for the answer "nothing in particular", or more commonly to hear that, whatever it was can't really be articulated.

What then are we asking people to do? Thoughts don't straightforwardly exist. You can't see them, and often when you try to write them down they are entirely elusive. What do we mean when we say "thought"? It looks like there is a philosophical tangle at the heart of CBT that isn't being addressed*. This conceptual difficulty is not (as far as I can see) a deep practical flaw in CBT, though it is a superficially unnerving question in the context of a task that takes linguistic content so seriously. Thinking about its implications carefully might have positive ramifications for practice.

To help think this one out, here is a list (not comprehensive and not in any particular order) of things that can reasonably be said to exist (stolen entirely from Paul Meehl's ontology, about 70 minutes and 15 seconds into video #4 here):

1. Substances
2. Structures
3. Events
4. States
5. Dispositions
6. Fields

Minds are abstract entities, but to the extent that we have them, they must arise out of things in the world like this. Which of them corresponds to a thought? A "thought" doesn't seem as though it can be mapped onto a specific substance or structure. Equally it doesn't seem quite plausible that a thought is the result of a specific brain-state either; thoughts seem dynamic in a way that states are not. It might then be reasonable to say that any given thought could be re-described as something like an event (meanwhile, another of CBT's concepts, "attitudes", sound like they could be re-described as dispositions).

The Numbskulls: Thoughts as Instructions

We have the experience of a verbal, or pictorial (or whatever) "thought", and what is going on at that moment is an event in our mind. So when we ask a person "what went through your mind just then", perhaps we are asking them a version of "how would you describe your subjective experience of the event which just took place?". This helps us around the potential objection that there was no obvious automatic-linguistic-proposition ("I will fail the exam") to report.

My re-description is a bit over-the top, and won't usually be necessary in practice (despite the conceptual complexities, most of us have a working definition of "thought"), but I wonder if it helps us to get around the apparently perplexing challenge raised by the question guiding this post. The failure to locate neatly verbalised "thoughts" could be unsettling for someone new to CBT, therapist or client, raising the spectre that the process won't "work" because it's not proceeding as it does in the book. Having a more flexible sense of what is meant opens up the space for productive questions within the therapy about just what both parties are trying to get at.

-Richard Gipps has posted a fascinating and beautifully written whole book chapter offering a philosophical critique of CBT on his Clinical Philosophy blog. 

*I have heard it suggested that CBT is more generally silent on these broad conceptual questions, and that it only appropriated the moniker "cognitive" as a way of trading on the enormous success of the "cognitive science" framework that came to dominate psychology after the late 1950s. 

Schizophrenia as a "Disjunctive Category": Does it Matter?

Among the commonly articulated criticisms of the concept of Schizophrenia is Don Bannister's claim from the late 1960s that the diagnosis is unfit for scientific research because it is a "disjunctive category". This point recently raised its head again in the comments section of an article about the findings of the Schizophrenia Genetics Consortium (see David Pilgrim's third comment). What does it mean for us to say that Schizophrenia is "disjunctive"? Here is a quote taken from a Schizophrenia Bulletin paper by Bannister (published a few years after the BJPsych piece Pilgrim mentions):

Essentially Bannister is concerned about the fact that any given pair of people with a diagnosis of Schizophrenia can have entirely different behavioural presentations. On the face of it this looks very problematic; Schizophrenia is behaviourally defined, so it seems a little counter-intuitive that the definition can-in theory- capture radically different sorts of behaviour without any overlap among them. Bannister's "disjunctive" point therefore seems to land a blow on those who do research into Schizophrenia, and it provides critics with a nifty sounding slogan for their claims ("Schizophrenia is a disjunctive concept, so there!"), but to what extent should the "disjunctive" argument actually be a worry?

Although Schizophrenia is defined behaviourally, it has been a key assumption throughout the term's history that there is something behind that behaviour that requires explaining. Psychoanalytic theories have put more emphasis on a loss of ego boundaries and self-integration while biological theories traditionally focus on the action of neurotransmitters. Modern trauma theories put more stock in the notion that dissociation may play a role. What all these explanatory ideas have in common is that they attempt to explain the diverse range of behaviours that lead to a diagnosis.

Without any prejudice as to aetiology or mechanism therefore, we can say that the behaviour of a person with a diagnosis of Schizophrenia is not meant to be the main fact about them that determines the presence of Schizophrenia. Instead, the diagnosis is conferred when the behaviour of the patient gives the clinician some reason to hypothesise that the underlying process (aberrant dopamine signalling; disintegration of the self/other boundary) is taking place in the mind or body of the person being assessed.

We can of course argue that the diverse presentations of Schizophrenia are not in fact caused by a single underlying process, but that is an empirical matter.  If there is a single underlying process (or family of interconnected underlying processes), then the fact of Schizophrenia's being behaviourally "disjunctive" is no more interesting than the fact the fact that the same virus can lead to both diahorrea and vomiting. If there is no underlying process (or family of interconnected underlying processes) then that speaks against a single "Schizophrenia" whether or not it is "disjunctive" in Bannister's sense.

Now, just because the "disjunctive" argument may be a red herring, it does not follow that the concept of Schizophrenia can have a free pass in the clinical and scientific lexicon. There are many reasons to be dissatisfied with Schizophrenia-talk, both from a scientific perspective and from a political/social care perspective. My point is not to defend all the ideas associated with one limited reading of "Schizophrenia", nor is it to seek necessarily to preserve its use as a term. Rather it seems we should focus our attention on thinking about what sort of thing or things we really believe "Schizophrenia" refers to.

Many researchers are well aware of the contested nature of Schizophrenia and their work is about understanding how viable a category it is and what is actually going on with people who get the diagnosis. They know that the Schizophrenia of the 1960s is radically different to the Schizophrenia of the 1980s, which has in turn evolved between then and the present day. The fact that a research programme is oriented around the broad family of issues that goes under this name should not be taken the a sign of institutional myopia that many believe it to be.

Cycle-diagnosticator

There is nothing like it. One of the world's great cities flies by as you rove through it on the back of a bicycle. In London, most journeys can be completed more quickly on a bike than on public transport. When I lived with an old university friend in Cricklewood I used to race him home from Bloomsbury. The Jubilee Line against my silver hybrid. The bike always won. 

You could be walking, but it takes wearying hours to cover any substantial proportion of a large city on foot. I have tramped London and New York's streets for hours at a time, but it is a different enterprise; more involved, more ponderous. What is more, being on foot places you right in the middle of a tedious melee you are not always in the mood to battle through. The cyclist can be a simple observer to life on the pavement, catching snippets of conversation and gliding on. The tube is a sickly-neon assault on the senses; the bus is a trying stop-start rattle, dragging itself lazily between bus-stops and traffic lights.

Newly Installed Bank of "Boris Bikes", Waterloo early 2011

At one point I was travelling around 36 miles a day, from the north-west of London to my job a Young Offenders' Institution in the south-east, and back again; all on a bike I had bought for £140 from an old colleague. You can't keep up that sort of distance for long (after 3 months I moved, cutting my commute to 7 miles each way), but for those few months each day began and ended with a journey of almost epic proportions. While other people commuted, I ventured, carrying a half-eaten Soreen in my bike-bag to feed the aching hunger that never failed to grow as I pedalled.

I would reach Constitution Hill at around 7:00 each morning, joining a huge group of cyclists at Hyde Park Corner. Many of us burst spontaneously into thrilling races along the Mall. London's cyclists (sometimes dubbed a "community" by people more in touch with it than I ever was) can be very serious people indeed. From the Mall I skirted round the south side of Trafalgar Square, and during the winter I was sometimes on Waterloo Bridge just as the sun rose.

Sunrise, Waterloo Bridge, October, 2010

On the way back the roads were always busier. I negotiated my way between taxis and double decker buses on the Strand, weaving through changeably sized gaps and watching more daring riders (there is always someone more daring, more foolish, than you) to see if they could get their handlebars between two wing mirrors.

You see the strangest and loveliest things on a bicycle. On the day Tripoli fell to the Libyan rebels and NATO in 2011 I found myself behind a cyclist who had shrouded himself in the pan-Arabian tricolour. He was waving his fist in triumph at honking cars as we moved slowly through a summer Greenwich evening; lone celebrant linking a tranquil sun-bathed day with a North African revolution some two thousand miles away.

Revolutionary Enthusiasm: 
On August 24th 2011, the day Tripoli Fell

You might be gripped by a fleeting and beautiful moment that would have gone unseen behind the misted windows of a car; some vision that demands you pull over to the curb and take a photo. A sunset can briefly transform an ugly dual carriageway into an uncannily clear bending line of sharp orange. A row of cheaply built apartments that normally strikes you as mediocre may, this one day, loom magnificent out of the freezing winter gloaming.  

Sunset, Woolwich, 2010

Houses rise from a winter morning mist, Woolwich 2010

Not everything you see is pleasant. I was lucky enough to never have an accident in London, but I once watched in terror as a pedestrian stepped out from behind a car and in front of a cyclist on Holland Park Avenue. The cyclist was weirdly flipped up into the air, landing some feet away from her bike, dazed and weeping. The pedestrian ran off; the cyclist was in shock but happily otherwise unharmed. On another occasion a friend of mine experienced a bizarre accident; riding with cleats he slipped with his food un-clipped at a traffic light. The sharp pedal drove itself deep into his ankle and I got a text telling me he was in an ambulance. I feared the worst (every urban cyclist has thought about the possibility of getting knocked down by a car) so it was almost a relief when he cheerily sent me pictures of his mangled foot from a hospital bed.

If you are as lazy a journey planner as me, cycling in a city occasionally becomes untenable. The thick snow that covered London in December 2010 was swiftly tackled by teams of gritters on main roads, but my residential street in Cricklewood became a treacherous sheet of almost sheer ice. The cycle path that runs around the north west edge of Belmarsh prison was daily trampled into a thick mush of textured snow which thickly re-set each night into something nigh on impassable. 

South East London's gritters don't reach the cycle paths

The bike was also my ticket out of the city. I could pack it up with a tent and sleeping bag and cycle to Euston, and be up in the Lake-District by late on Friday after work, cycling to my sister and her boyfriend's place, breathing in great lungfuls of the cold clear air. It never stopped surprising me that transition from the rude urban capital to the crisp open spaces in the north. 

Trusty Steed: London-bike Northward-bound. 
At Euston for the Lakes, 2011

Moving to New York continues to satisfy my long held and mysterious urge to live in a big city, but for nearly the first two years here I went without a bike. Shipping over the old one had seemed gratuitous, and most of my regular commutes are fairly walkable. As a runner I have explored the area in a reasonable radius around my apartment, but running has a tendency to turn your attention inward, focusing on your breathing, on your plodding shifting step. I run when I need to think, but to really see the territory something else is needed. 

Finally this summer I have a bike again, in fact I have had one now for the last week and a half. It is a folding bike to boot, smart orange construction that can be packed up and tucked into the cupboard. I finished reading an Iris Murdoch novel just before the maiden voyage, and so cheerfully christened the new companion "Murdoch". I took Murdoch on a 17 mile ride out over the East River into Brooklyn and on to East New York. I lit out right across Brooklyn, my mind boggling at the endlessness of the eastward avenues leading away from Manhattan. Only later did I discover I had ridden through some of what are considered to be the city's most dangerous neighbourhoods, and acquired a deep red sunburn on my arms and neck on the way. But I didn't care; I had the city under my wheels again. 

A New Bike in a New Town: "Murdoch" by the 

Williamsburg Bridge on the Lower East Side. June 2014

All the photos in this post were taken on or near a bike using the same, increasingly decrepit, iPhone 3GS. 

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.