I recently came across this 2001 article by Thomas Szasz arguing that mental illness is for psychiatry what phlogiston was for chemistry. The much derided and marvellously named phlogiston was a hypothesized substance, supposed to exist within flammable objects and make it possible for them to burn. As a theory it was initially quite useful, but came under pressure when it failed to accurately predict that burnt metals increased rather than decreased in weight. Ultimately phlogiston theory was supplanted in the 1770s when Lavoisier discovered Oxygen, helping to lay the ground for modern chemistry.
Phlogiston is often cited as a neat example of a defunct scientific theory, and Szasz seems to be using the idea to deride psychiatry for retaining the idea of mental illness; phlogiston is an analogy for anachronism. Mental Illness was always, for Szasz, an idea in urgent need of retirement.
However, the lessons phlogiston theory offers psychiatry are more complicated than Szasz allows.
Hindsight is a wonderful thing but, as Kuhn points out in The Structure of Scientific Revolutions, phlogiston theory had plenty of predictive power and much value for understanding the world in the late 17th and early 18th centuries. Still now it presents a philosophical puzzle. Phlogiston turned out not to exist, but the early chemists who spoke about it were on to something. Did the term describe, to some extent, the nature of the world? After all, it turned out that something had existed all along (Oxygen), but no-one had possessed the conceptual apparatus to describe it.
Talk of Kuhn is apt in this connection, for the field of mental health has seen recent calls for a “paradigm shift” in relation to how it conceptualises its objects of study. This call has met resistance, some of it organized around the feeling that diagnoses, and the concept of mental illness still have some value in mental health care. Perhaps mental illness isn’t the same as physical illness (it certainly attracts more animus), but there are ways in which illness as a heuristic plays a role in recognizing the ways that people can be overwhelmed psychically by psychosis, mania and swingeing depressions.
Nonetheless, if you subscribe to Kuhn’s vision of how inquiry proceeds, a paradigm shift is always essential for the successful development of science, and certainly we are presently confronted with a host of conceptual difficulties when discussing mental illness. Just look at this article by the psychologists who run the DOTW blog, and then this response by Guardian blogger Dean Burnett. Read both of them and see if you too get a sense that both perspectives have something important which should not be lost; the ambivalence you're feeling is a sure sign of the conceptual uncertainty under which we currently labour.
Unfortunately paradigms are not just things to be shifted, they are ideas that give order to programmes of research, allowing the accumulation of useful knowledge. They do not get chased out of academic discourse by activists, but wither up and die on the vine when something better comes along. Phlogiston-theory suggests that it takes a superior replacement ideas, not just criticism, to put paid to inaccurate concepts.
Thomas Szasz was more right than he knew.
Tuesday, 13 January 2015
Saturday, 20 December 2014
Idiosyncratic Transformative Experiences
Every year at about this time, I make a point of watching Frank Capra's legendary Christmas feel-good tale It's a Wonderful Life. In the film, Christmas becomes a time to be transformed, to have an eye-opening, life-changing epiphany and live forever after with a renewed sense of perspective and mental balance. James Stewart's George Bailey is at the brink of suicide, but through the ministrations of Clarence (AS2: Angel, Second Class), realises that life is wonderful after all; that friends and love matter more than adventure or worldly success.
It's an affirming message, and every year I wallow tearfully in the gorgeously choreographed sentimentality. Of course, the story is redolent of that other seasonal tale "A Christmas Carol" where Scrooge is changed forever by the realisations he has in the course of a single night. Stories like these show us the sort of hopes we have pinned to Christmas, even in a largely secular time where the average person is more likely to be found in a retail outlet than a church on Christmas Eve.
These magnificent psychic changes are also the sort of thing we hope for in human relationships. Perhaps most of all they are also central to how we as a culture view the process of psychotherapy. It's the same dream that allows us to venerate self-help gurus and appoint "therapeutic masters" to follow like tribal elders. One neat filmic example of this collective cultural dream of therapy is that final scene in Good Will Hunting where Robin Williams repeatedly bombards Matt Damon with the phrase "it's not your fault". Will's defences are broken down, revealing the vulnerable boy underneath and he bursts into cathartic tears, forever changed for the better.
This famous moment simply doesn't ring true. Though it is possible to imagine psychotherapy working in this way, it is certainly not the modal experience. To believe otherwise is to imbue the mental health professional with a kind of magic healing power, and this can be dangerous, both for therapists and the people who seek their help. To believe too strongly in your own personal myth is hubris, opening the way to cruelty and even bullying. It can close down options rather than open them up, compromising autonomy in the service of an unrealistic ideal. Why should a person try to develop their own ways of living when the psychotherapeutic approach is the truest path? How can a person be trusted to know what they need if they haven't consulted an expert? Therapists and the therapy industry must forever guard against becoming what Christopher Bollas called the Transformational Object, the mental place-holder for all our hopes about how we and our lives could be different.
I'm not denying the potential transformative power of therapy, but much as professionals might like to be omniscient ghosts, wandering into the lives of those we help and changing them with our deep personal wisdom, for the most part we must accept a humbler aim. Therapy is slow and kind and painstaking. It is about being careful and attentive and accepting human limitations. Perhaps it can increase the likelihood of these idiosyncratic total transformations, but it is neither necessary nor sufficient for them. As yet there is simply no algorithm that can guarantee human change, which often comes at odd moments in our lives; on journeys, in conversations, reading, solitary moments of contemplation, at our lowest ebb.
Psychotherapy can be a wonderful thing, but its power can also be exaggerated, unduly raising our expectations and setting us up for disappointment. If it goes too badly wrong it can put people off for life (a bit like Christmas). That said, there are concrete things we can do to enhance its success. We should approach it gently, expecting to work at it, and prepared for perplexity and confusion as well as illumination. If it doesn't work in the way that we hoped, we might be prepared to try again another time. Above all, we should remember to respect the lives we are intruding upon because, unlike Clarence the angel, there is so much we cannot know.
I'm not denying the potential transformative power of therapy, but much as professionals might like to be omniscient ghosts, wandering into the lives of those we help and changing them with our deep personal wisdom, for the most part we must accept a humbler aim. Therapy is slow and kind and painstaking. It is about being careful and attentive and accepting human limitations. Perhaps it can increase the likelihood of these idiosyncratic total transformations, but it is neither necessary nor sufficient for them. As yet there is simply no algorithm that can guarantee human change, which often comes at odd moments in our lives; on journeys, in conversations, reading, solitary moments of contemplation, at our lowest ebb.
Psychotherapy can be a wonderful thing, but its power can also be exaggerated, unduly raising our expectations and setting us up for disappointment. If it goes too badly wrong it can put people off for life (a bit like Christmas). That said, there are concrete things we can do to enhance its success. We should approach it gently, expecting to work at it, and prepared for perplexity and confusion as well as illumination. If it doesn't work in the way that we hoped, we might be prepared to try again another time. Above all, we should remember to respect the lives we are intruding upon because, unlike Clarence the angel, there is so much we cannot know.
Friday, 14 November 2014
Formulating Formulation
This month I have a review in Clinical Psychology Forum of Lucy Johnstone and Rudi Dallos' standard text "Formulation in Psychology and Psychotherapy" (thanks to the editors at CPF for the invitation!). Doing the piece was an opportunity to spend more time than usual thinking about formulation; what it is and how it is supposed to be helpful. However, the resulting article is just 400 words; space enough only to develop a few ideas, and not in much depth. This post is a more extended reflection on the book and the ideas it prompted.
My review is principally positive. I praise the book for being practical (the new chapters especially deal with issues that can only have been identified my psychologists in multi-disciplinary teams in the NHS); for being ambitious (psychologists are given excellent advice on what to expect when formulating in teams) and unique (there is no other book that meets the needs of NHS psychologists in this way). Here's an overview and elaboration of conceptual points in the CPF Review I wished I could extend:
The book is not afraid to address concerns about formulation's validity. Formulation is not "evidence-based", (partly because it is difficult to know what that would look like) and although there have been attempts to hold it to an external standard (coding formulations' content for quality), that simply raises the question of how to empirically validate the standard. I wonder if formulation-enhanced therapies would be amenable to validation by RCTs (therapies that are vs. therapies that are not guided by a formulation), but that may be unworkable.
However, as is pointed out, any given formulation is less an entity, diagnosis or instrument (which can be easily tested for reliability etc.) than a process for making inferences and predictions. Inferences are more or less valid, depending on their premises and how they are drawn. Predictions can be more or less valid/useful depending on how testable they are. This brings us to an important role formulation could have in a "local clinical scientist" model of clinical psychology.
Gillian Butler’s statement that a formulation is a set of “hypotheses to be tested” is often cited in the literature on formulation, and this text is no exception. A hypothesis can be tested if it can theoretically be falsified, so in the review I wonder whether formulation based on the principles of “risky prediction and refutation” could play a role in yielding valid psychological knowledge.
Another key issue running through the text is the distinction between “usefulness” and “truth”. The implication seems to be that formulation is about the former while diagnosis aspires to the latter. This seems to reflect a leaning toward a "constructivist" theory of knowledge (a respectable enough position) but I don't think we need a strong commitment to that position. On the contrary, I suspect “truth” tends to bring “usefulness” along with it, such that the more we know about a particular individual (and they about themselves) the more able we are to help them.
However, I assume the "usefulness vs. truth" distinction is made because psychologists want to avoid "imposing" their felt certainty on their clients. One way to do this is to say (quite correctly) that there are no basic, easy-to-articulate "truths" about human experience. We make our own meanings for ourselves, and any health professional should have respect for this project. So far I agree. However, things get tricky when we want to extend this way of thinking beyond existential-phenomenological "truths" and into the realm of aetiology. If formulation were just a meaning-making process, a constructivist theory of truth would go most of the distance, but it is not. Formulation also purports to be a description of a person's problems with an inbuilt theory about how they came about. Some stories will be closer to than others to reality, and we shouldn't be afraid of that.
If this sounds like I am advocating an authoritarian view of how to do therapy, I am not. While there is probably something like "the truth" about causes, it is vital that practitioners stay in touch with the tremendous uncertainty we have to face in knowing, for any given person, what that is. Such knowledge as we do have is based on the proportions of variance derived from large N samples. It does not generalise straightforwardly to an individual, whom we have to take with all the idiosyncrasy, and uncertainty, they deserve. This uncertainty is characteristic of science, not inimical to it, so for me the spirit of much of this book is perfectly compatible with a "scientist-practitioner" model.
We can then, believe in the value of multiple constructions AND in a basic underlying reality. The text itself makes a similar point. In the discussion in Chapter 10, "Using Formulation in Teams", the point is made that clinicians can be insufficiently-aware of the prevalence of sexual abuse, leading to the failure to consider this as a factor. Here is a stark fact about reality we are encouraged to face; abuse happens, it has often has devastating consequences and formulation should acknowledge it wherever appropriate. There are obviously limits upon how constructivist to be about abuse (no-one seriously advocates the construction of a truth in which we pretend it hasn't happened), and the same is presumably true for other aetiological factors. The reason all the chapters in this gloriously eclectic text can be helpful is that they can help the clinician formulate different aspects of social and psychic reality in different ways that need not be mutually exclusive.
So much for the points in my CPF review. In addition to these ideas, I have some other broad thoughts on the place of formulation within clinical psychology, which I will get to below, but before I do, here are two problems I had with aspects of the book:
To my mind formulation is at least partly about re-imagining what is going on when people approach mental health services. Whatever you think about diagnosis, it is a fact that it represents an extremely limited way of describing people, and one which alienates many of its recipients. Formulation affords the luxury of a more open and inclusive language; a way to aid the clinician in their understanding of subjective experience. For this reason I am surprised at the continued use, in Rob Leiper's chapter on Psychodynamic formulation, of the term "primitive defences". Sure enough this terminology reflects a longstanding tradition in psychoanalytic discourse, but it seems clearly pejorative, at least as much so as any DSM-diagnosis. What is more, it is increasingly outmoded. In her book on psychoanalytic diagnosis, Nancy McWilliams adopts "primary" defences rather than "primitive", a preferable option to simply placing ironic quote marks around the latter word, as though that were enough to mitigate its influence on the clinician's thinking. Even then the implied developmental trajectory ("primitive" is supposed to mean "developmentally primitive") is probably bogus, as Drew Westen pointed out 25 years ago.
One of the difficulties in thinking about "psychiatric diagnosis" is to know what we are and are not talking about. DSM-diagnoses obviously fit the bill, but what about other categorisations? Is Judith Herman's "Complex PTSD" a psychiatric diagnosis? What about neologisms that might arise from the patterns which formulations reveal? In Johnstone's final chapter, "trauma reaction" is approvingly suggested as a useful linguistic shortening-but how do we recognise one of those when we see it? If there are criteria for "trauma reactions", and if an aetiology is strongly endorsed, in what way is this different from psychiatric diagnosis? We might say that psychiatric diagnoses are those which posit an "underlying" disease mechanism, except this is false. Psychiatry is plainly interested in entities which are not considered "diseases" by any metric. Perhaps then psychiatric diagnosis is anything which is done by a psychiatrist, but if psychiatric diagnosis is undesirable by definition this seems a little unfair on that profession, whose practitioners are damned whatever they do.
The distinction persists in Johnstone's chapter, which contains a discouragement against using the shortened formulations of psychoanalytic character diagnosis (Obsessional personality; Narcissistic personality etc.). These terms closely resemble formulations in that they put an emphasis on the ways that life events train someone to become the character they are, so why are they ruled out? Because they are "medical" Johnstone claims. Given the extent to which psychoanalytic clinicians lament the rise of the medical model as a challenge to their own approach, calling their system of diagnosis "medical" strikes me as contestable. True enough their descendants, the personality disorders, have found their way into the DSM, but that tells us more about the powerful influence psychoanalysis still had in 1980s American psychiatry than it does about the impact of the "medical model". There are good reasons to be wary of character diagnosis (alongside the usual questions of validity are very real concerns that the terminology is rather insulting) but its putative "medicalness" is not one of them.
Those two issues both get to the heart of why I started this blog, but perhaps they are marginal when it comes to the business of really understanding and articulating the role of formulation. Here is my final section, containing a reflection on the book and the thoughts it prompted about why psychologists should "formulate", and why this book can help them:
There is a distinction to be made between the generation of ideas, and their validation. It is a distinction that Herbert Feigl talks about in his 1949 paper Philosophical Embarrassments of Psychology:
The clearest way I can think of to articulate the value of formulation is in terms of how it helps the clinician to generate ideas. When we do therapy with people we would like to know when our pet theories are right and when they are wrong. The standard caricature of Freud is that he believed everything came down to sex. If you took seriously his ideas about the dynamic unconscious (that an idea could stand for its opposite and denial by an analysand can really represent confirmation), you could accommodate virtually any evidence into his scheme. Hence Karl Popper's famous idea about theories needing to be refutable in order to be testable.
However, much as we need a system for eliminating possibilities, we also need a system for generating them. This is what struck me about the variety of this book, which references multiple psychological frameworks, including one (Personal Construct Psychology) that I hadn't heard from since it was referenced in an undergraduate social psychology class. As people who work with people, we need to be able to think our way into the experiences of others, and to be imaginative in understanding why they have the problems they have. Minds are weird and elusive, experiences often half digested or unformulated. Out of this confusion, a therapist seeks to draw some order.
However, our personal frame of reference, our own system of metaphor and interpretation will almost certainly be entirely inadequate to this task. What we need is to listen to people with the utmost respect for their own "construction" of their lives, and with a willingness to jointly forge sense. Where people struggle to make sense of their own experiences, we need to have the flexibility and imagination to frame things in ways that can help. We need to be open to being wrong, and we need to be open to putting things differently. This sort of task is something this book is superbly set up to encourage, and is surely its great strength.
My review is principally positive. I praise the book for being practical (the new chapters especially deal with issues that can only have been identified my psychologists in multi-disciplinary teams in the NHS); for being ambitious (psychologists are given excellent advice on what to expect when formulating in teams) and unique (there is no other book that meets the needs of NHS psychologists in this way). Here's an overview and elaboration of conceptual points in the CPF Review I wished I could extend:
The Validity of Formulation:
However, as is pointed out, any given formulation is less an entity, diagnosis or instrument (which can be easily tested for reliability etc.) than a process for making inferences and predictions. Inferences are more or less valid, depending on their premises and how they are drawn. Predictions can be more or less valid/useful depending on how testable they are. This brings us to an important role formulation could have in a "local clinical scientist" model of clinical psychology.
Gillian Butler’s statement that a formulation is a set of “hypotheses to be tested” is often cited in the literature on formulation, and this text is no exception. A hypothesis can be tested if it can theoretically be falsified, so in the review I wonder whether formulation based on the principles of “risky prediction and refutation” could play a role in yielding valid psychological knowledge.
"Usefulness vs. Truth"
Another key issue running through the text is the distinction between “usefulness” and “truth”. The implication seems to be that formulation is about the former while diagnosis aspires to the latter. This seems to reflect a leaning toward a "constructivist" theory of knowledge (a respectable enough position) but I don't think we need a strong commitment to that position. On the contrary, I suspect “truth” tends to bring “usefulness” along with it, such that the more we know about a particular individual (and they about themselves) the more able we are to help them.
However, I assume the "usefulness vs. truth" distinction is made because psychologists want to avoid "imposing" their felt certainty on their clients. One way to do this is to say (quite correctly) that there are no basic, easy-to-articulate "truths" about human experience. We make our own meanings for ourselves, and any health professional should have respect for this project. So far I agree. However, things get tricky when we want to extend this way of thinking beyond existential-phenomenological "truths" and into the realm of aetiology. If formulation were just a meaning-making process, a constructivist theory of truth would go most of the distance, but it is not. Formulation also purports to be a description of a person's problems with an inbuilt theory about how they came about. Some stories will be closer to than others to reality, and we shouldn't be afraid of that.
If this sounds like I am advocating an authoritarian view of how to do therapy, I am not. While there is probably something like "the truth" about causes, it is vital that practitioners stay in touch with the tremendous uncertainty we have to face in knowing, for any given person, what that is. Such knowledge as we do have is based on the proportions of variance derived from large N samples. It does not generalise straightforwardly to an individual, whom we have to take with all the idiosyncrasy, and uncertainty, they deserve. This uncertainty is characteristic of science, not inimical to it, so for me the spirit of much of this book is perfectly compatible with a "scientist-practitioner" model.
We can then, believe in the value of multiple constructions AND in a basic underlying reality. The text itself makes a similar point. In the discussion in Chapter 10, "Using Formulation in Teams", the point is made that clinicians can be insufficiently-aware of the prevalence of sexual abuse, leading to the failure to consider this as a factor. Here is a stark fact about reality we are encouraged to face; abuse happens, it has often has devastating consequences and formulation should acknowledge it wherever appropriate. There are obviously limits upon how constructivist to be about abuse (no-one seriously advocates the construction of a truth in which we pretend it hasn't happened), and the same is presumably true for other aetiological factors. The reason all the chapters in this gloriously eclectic text can be helpful is that they can help the clinician formulate different aspects of social and psychic reality in different ways that need not be mutually exclusive.
All White and Predominately Female: Clinical Psychologists
So much for the points in my CPF review. In addition to these ideas, I have some other broad thoughts on the place of formulation within clinical psychology, which I will get to below, but before I do, here are two problems I had with aspects of the book:
1. "Primitive" Defences:
2. "Medical" vs. non-medical:
One of the difficulties in thinking about "psychiatric diagnosis" is to know what we are and are not talking about. DSM-diagnoses obviously fit the bill, but what about other categorisations? Is Judith Herman's "Complex PTSD" a psychiatric diagnosis? What about neologisms that might arise from the patterns which formulations reveal? In Johnstone's final chapter, "trauma reaction" is approvingly suggested as a useful linguistic shortening-but how do we recognise one of those when we see it? If there are criteria for "trauma reactions", and if an aetiology is strongly endorsed, in what way is this different from psychiatric diagnosis? We might say that psychiatric diagnoses are those which posit an "underlying" disease mechanism, except this is false. Psychiatry is plainly interested in entities which are not considered "diseases" by any metric. Perhaps then psychiatric diagnosis is anything which is done by a psychiatrist, but if psychiatric diagnosis is undesirable by definition this seems a little unfair on that profession, whose practitioners are damned whatever they do.
The distinction persists in Johnstone's chapter, which contains a discouragement against using the shortened formulations of psychoanalytic character diagnosis (Obsessional personality; Narcissistic personality etc.). These terms closely resemble formulations in that they put an emphasis on the ways that life events train someone to become the character they are, so why are they ruled out? Because they are "medical" Johnstone claims. Given the extent to which psychoanalytic clinicians lament the rise of the medical model as a challenge to their own approach, calling their system of diagnosis "medical" strikes me as contestable. True enough their descendants, the personality disorders, have found their way into the DSM, but that tells us more about the powerful influence psychoanalysis still had in 1980s American psychiatry than it does about the impact of the "medical model". There are good reasons to be wary of character diagnosis (alongside the usual questions of validity are very real concerns that the terminology is rather insulting) but its putative "medicalness" is not one of them.
Those two issues both get to the heart of why I started this blog, but perhaps they are marginal when it comes to the business of really understanding and articulating the role of formulation. Here is my final section, containing a reflection on the book and the thoughts it prompted about why psychologists should "formulate", and why this book can help them:
Generative Thinking and Eliminative Thinking: In Defence of Formulation:
The clearest way I can think of to articulate the value of formulation is in terms of how it helps the clinician to generate ideas. When we do therapy with people we would like to know when our pet theories are right and when they are wrong. The standard caricature of Freud is that he believed everything came down to sex. If you took seriously his ideas about the dynamic unconscious (that an idea could stand for its opposite and denial by an analysand can really represent confirmation), you could accommodate virtually any evidence into his scheme. Hence Karl Popper's famous idea about theories needing to be refutable in order to be testable.
However, much as we need a system for eliminating possibilities, we also need a system for generating them. This is what struck me about the variety of this book, which references multiple psychological frameworks, including one (Personal Construct Psychology) that I hadn't heard from since it was referenced in an undergraduate social psychology class. As people who work with people, we need to be able to think our way into the experiences of others, and to be imaginative in understanding why they have the problems they have. Minds are weird and elusive, experiences often half digested or unformulated. Out of this confusion, a therapist seeks to draw some order.
However, our personal frame of reference, our own system of metaphor and interpretation will almost certainly be entirely inadequate to this task. What we need is to listen to people with the utmost respect for their own "construction" of their lives, and with a willingness to jointly forge sense. Where people struggle to make sense of their own experiences, we need to have the flexibility and imagination to frame things in ways that can help. We need to be open to being wrong, and we need to be open to putting things differently. This sort of task is something this book is superbly set up to encourage, and is surely its great strength.
Wednesday, 5 November 2014
In Favour of Objectivism about Psychotherapy Outcomes
A lot of people in my field dislike the use of quantitative measures to determine the value of what they are doing. Some of the emotional intensity of this view can be seen in the conversation I had on Twitter after posting a link to an article by Richard Gipp. The idea seems to be that objective measures "miss" something that can only
be framed in language. People's psyches are fragile and complicated, and
using a numerical scale is somehow riding roughshod over this, or doing
to violence to the subjectivity of the other. This post is a response to (though not straightforwardly an argument against) Gipps' piece, which contained many fascinating points I don't really speak to here. My aim is to persuade you that "objectivist" approaches to measuring psychotherapy outcome are a good thing.
I am not making a rational argument (though I hope it's not irrational); that has been done consistently over the past 60 to 70 years and it is fairly widely acknowledged that numerical information has its own self-contained logic. This is an attempt at polemic. I want to convince you at a gut level that the use of numbers works for people who use services, that it can actually be quite noble in all the ways that certain forms of clinical writing claim to be. Furthermore, I want to suggest that, for all its value, the most poetic and optimistic clinical writing can act to conceal reality in important ways, potentially giving a veneer of respectability to processes which have little meaningful impact. Conversely, just because there is something rather prosaic about the notion of an "evidence-based-therapy", it is in fact perfectly compatible with all the beauty and subtlety we see in more "subjectivist" approaches.
In regard to the first point, the promise of insight, self knowledge or a deep connection with someone else does not necessarily carry along with it the promise of "feeling better" in important ways. I have learned a lot about myself through experiences of psychodynamic therapy or supervision, but to some degree one can separate the process of self-understanding (itself, in my view, an extremely valuable thing) and the process of feeling substantially less rotten about one's life. Although I find it invaluable to have the head-space to wonder about my relationship to my desires and my personal history; to think about the way they rebound in the minutiae of my social interactions in the present, I am not always sure how essential these are for my capacity to continue getting out of bed in the morning or avoid feeling like I want to kill myself.
Getting somehow "better" (and better is necessarily a vague word, in psychotherapy outcome research. It has ended up meaning whatever is indicated in the questionnaire you choose: "less anxious"; "less depressed" by a certain number of points on a scale) is not always a beautiful process. Something could be good for you psychologically without necessarily reaching your subtlest places. Some of the times I have made the most important changes in my well-being or happiness have been of the "crass" variety; events I could re-describe as "behavioural activation" or "cognitive restructuring". These are not Orwellian portents of a psychotherapy devoid of the human factor, they are clumsy attempts to describe ways we can change ourselves (in the right context) rapidly and effectively .
More importantly, there is simply no incompatibility between a blunt (but objective) measure of psychotherapy outcome and a fine-grained "appreciation" of the unique and subjective aspects of the experience. Something could be useful in the crass numerical sense (indexed by a clinically interesting drop in an Anxiety measure) while also being moving, poignant, invigorating, thought-provoking, inspiring and so on.
To assume otherwise is to place a peculiar store in one narrative version of events as though "the truth" about someone's subjectivity resides in one place and one place only. Truth is trickier than that. What is "the truth" about a person's experience of a depressive breakdown; their narrative of events? The narrative of the people they love? A measure of their moods on a series of psychological questionnaires? Or does the truth lie somewhere beyond all these, in an inarticulate mesh which can only be variously approximated by different representations?
One critical response to the varieties of a treatment like CBT is to regard them as a form of authoritarian "training" or "brainwashing". This is to take the language of CBT too seriously, to imagine that your experience of that language is identical with the experience of the therapeutic relationship in which its techniques are deployed. "Cognitive restructuring" sounds quite mechanistic, but depending on how it is conducted it can mean something closer to "helping someone consider alternative readings of their situation" or "expanding a person's psychic possibilities". One could experience cognitive restructuring and find the experience elevating and beautiful. One could experience it as an intrusion by an idiot who has no appreciation for how difficult your life is. Or your reaction could lie somewhere between those extremes.
Precisely the same is true for any modality of therapy. Psychoanalysis (for some reason the most poetically described form of therapy) can be constructed as a disintegration and reconstruction of the ego through a profound subjective attunement between analyst and patient. It can be beautiful (it can certainly be written about beautifully by clinicians). It can also be experienced as sadistic, or as pointless (For some reason this perspective is more frequently seen in the narratives of patients like Susanna Kaysen in "Girl Interrupted", or Jenni Diski than in the writing of psychoanalysts themselves).
These disconnects are why I like numbers and think you should too. Efforts to represent the truth are all around us. Although patient narratives ought to be taken very seriously, in clinical professional circles the narratives of practitioners (every clinical psychologist has a copy of Irving Yalom somewhere at home) are generally given more credence. Given this fact, it is nothing short of wonderful if a healthcare system can be organised around a system of aggregating numerical indices of individual experience. We can, if we want, say that quantitative measures are an impossible attempt to objectify the subjective, but their value doesn't rely on this vaunted ambition. Numbers are a simple and systematic language. You indicate how you feel at time 1, and when time 2 comes along, any observable difference can easily be registered. It is much harder for clinicians to deny the fact that more people report feeling worse at time 2 than it is for them to re-construct the whole encounter so as to undermine any testimony that doesn't fit with their own.
None of this is to say that quantitative measures should "trump" patient narratives, but the way that different decisions are made will mean that different sorts of information are prioritised. When a healthcare organisation decides to fund a treatment, it has to know whether said treatment represents a meaningful improvement over something cheaper. Numbers are easier in making this determination. However, when deciding if mistreatment is occurring in a care setting, a single person's narrative ought to all that is needed for substantive concerns to be raised. In the quotidian process of navigating psychotherapy, a clinician cannot hope to proceed without attending, to almost everything done or said by the person with whom they are working.
When it comes to statistical data, it is hoped that we can learn to love the numbers which many people find so alienating. Behind each number lies a person, so used correctly they are an excellent way of finding out important information about real lives and real experiences. Ideally we would be able to think in two registers at once; deploying the skills of the most technically competent statistician and the empathy and interpretative nous of a novelist or poet.
I am not making a rational argument (though I hope it's not irrational); that has been done consistently over the past 60 to 70 years and it is fairly widely acknowledged that numerical information has its own self-contained logic. This is an attempt at polemic. I want to convince you at a gut level that the use of numbers works for people who use services, that it can actually be quite noble in all the ways that certain forms of clinical writing claim to be. Furthermore, I want to suggest that, for all its value, the most poetic and optimistic clinical writing can act to conceal reality in important ways, potentially giving a veneer of respectability to processes which have little meaningful impact. Conversely, just because there is something rather prosaic about the notion of an "evidence-based-therapy", it is in fact perfectly compatible with all the beauty and subtlety we see in more "subjectivist" approaches.
In regard to the first point, the promise of insight, self knowledge or a deep connection with someone else does not necessarily carry along with it the promise of "feeling better" in important ways. I have learned a lot about myself through experiences of psychodynamic therapy or supervision, but to some degree one can separate the process of self-understanding (itself, in my view, an extremely valuable thing) and the process of feeling substantially less rotten about one's life. Although I find it invaluable to have the head-space to wonder about my relationship to my desires and my personal history; to think about the way they rebound in the minutiae of my social interactions in the present, I am not always sure how essential these are for my capacity to continue getting out of bed in the morning or avoid feeling like I want to kill myself.
Getting somehow "better" (and better is necessarily a vague word, in psychotherapy outcome research. It has ended up meaning whatever is indicated in the questionnaire you choose: "less anxious"; "less depressed" by a certain number of points on a scale) is not always a beautiful process. Something could be good for you psychologically without necessarily reaching your subtlest places. Some of the times I have made the most important changes in my well-being or happiness have been of the "crass" variety; events I could re-describe as "behavioural activation" or "cognitive restructuring". These are not Orwellian portents of a psychotherapy devoid of the human factor, they are clumsy attempts to describe ways we can change ourselves (in the right context) rapidly and effectively .
More importantly, there is simply no incompatibility between a blunt (but objective) measure of psychotherapy outcome and a fine-grained "appreciation" of the unique and subjective aspects of the experience. Something could be useful in the crass numerical sense (indexed by a clinically interesting drop in an Anxiety measure) while also being moving, poignant, invigorating, thought-provoking, inspiring and so on.
To assume otherwise is to place a peculiar store in one narrative version of events as though "the truth" about someone's subjectivity resides in one place and one place only. Truth is trickier than that. What is "the truth" about a person's experience of a depressive breakdown; their narrative of events? The narrative of the people they love? A measure of their moods on a series of psychological questionnaires? Or does the truth lie somewhere beyond all these, in an inarticulate mesh which can only be variously approximated by different representations?
One critical response to the varieties of a treatment like CBT is to regard them as a form of authoritarian "training" or "brainwashing". This is to take the language of CBT too seriously, to imagine that your experience of that language is identical with the experience of the therapeutic relationship in which its techniques are deployed. "Cognitive restructuring" sounds quite mechanistic, but depending on how it is conducted it can mean something closer to "helping someone consider alternative readings of their situation" or "expanding a person's psychic possibilities". One could experience cognitive restructuring and find the experience elevating and beautiful. One could experience it as an intrusion by an idiot who has no appreciation for how difficult your life is. Or your reaction could lie somewhere between those extremes.
Precisely the same is true for any modality of therapy. Psychoanalysis (for some reason the most poetically described form of therapy) can be constructed as a disintegration and reconstruction of the ego through a profound subjective attunement between analyst and patient. It can be beautiful (it can certainly be written about beautifully by clinicians). It can also be experienced as sadistic, or as pointless (For some reason this perspective is more frequently seen in the narratives of patients like Susanna Kaysen in "Girl Interrupted", or Jenni Diski than in the writing of psychoanalysts themselves).
These disconnects are why I like numbers and think you should too. Efforts to represent the truth are all around us. Although patient narratives ought to be taken very seriously, in clinical professional circles the narratives of practitioners (every clinical psychologist has a copy of Irving Yalom somewhere at home) are generally given more credence. Given this fact, it is nothing short of wonderful if a healthcare system can be organised around a system of aggregating numerical indices of individual experience. We can, if we want, say that quantitative measures are an impossible attempt to objectify the subjective, but their value doesn't rely on this vaunted ambition. Numbers are a simple and systematic language. You indicate how you feel at time 1, and when time 2 comes along, any observable difference can easily be registered. It is much harder for clinicians to deny the fact that more people report feeling worse at time 2 than it is for them to re-construct the whole encounter so as to undermine any testimony that doesn't fit with their own.
None of this is to say that quantitative measures should "trump" patient narratives, but the way that different decisions are made will mean that different sorts of information are prioritised. When a healthcare organisation decides to fund a treatment, it has to know whether said treatment represents a meaningful improvement over something cheaper. Numbers are easier in making this determination. However, when deciding if mistreatment is occurring in a care setting, a single person's narrative ought to all that is needed for substantive concerns to be raised. In the quotidian process of navigating psychotherapy, a clinician cannot hope to proceed without attending, to almost everything done or said by the person with whom they are working.
When it comes to statistical data, it is hoped that we can learn to love the numbers which many people find so alienating. Behind each number lies a person, so used correctly they are an excellent way of finding out important information about real lives and real experiences. Ideally we would be able to think in two registers at once; deploying the skills of the most technically competent statistician and the empathy and interpretative nous of a novelist or poet.
Sunday, 26 October 2014
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:
You Will Need : A grey suit and a bland tie.
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.
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.
Tuesday, 21 October 2014
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.
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.
Tuesday, 14 October 2014
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.
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.
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