New BPS Guidelines on Diagnostic Language are a Move Against Pluralism

(A commenter on this blog-see below- has pointed out that I did not include reference to the scope and purposes of the document I am writing about. To try and address their concerns I have edited the post, striking out some sentences and inserting a few new ones in blue.)

Something incomprehensible and unpleasant happens to a person. It behooves them to make sense of it. Into this vacuum of understanding steps language: an attempt to give form to an experience in a way that allows them to live with it.

The BPS's Division of Clinical Psychology has released new guidelines on the use of language in official documents which pertain to such circumstances.

Consisting of three principles (guiding on language to avoid and language to adopt)  It is a clear statement that illness-talk and disorder-talk are out:

Such guidance is on a clear continuum with other efforts to discard the language of disorder, and concerns the organisation has raised about the DSM, a manual which can itself be viewed as a hyper-regulatory set of guidelines about how to talk. 

I am all for questioning the language of the DSM. Naming people "disordered" or "ill" is often experienced by them as an insulting effacement of subjectivity. What is more, once illness-language gets into the pool of possible interpretations it seems to hand power to the only people with sufficient expertise to deal with illnesses, the healthcare professionals (who of course stand to gain from their status as knowers).

But there is calling into question and there is discouraging ruling out. The problem with an official language (the DSM is a dictionary rather than the "bible" it is often claimed to be) is that it sets up a seemingly "correct" and an "incorrect" way of talking. In some cases this is necessary (the much scorned "political correctness" is an appropriate effort to rule out ways of talking which offend minority groups in society), but there is always a trade off. The downside of being "PC" is that it can make people less considerate about their linguistic choices, while leaving them feeling righteous nonetheless. Think of the character Gareth in The Office, bemoaning the fact that his dad says "darkies, instead of coloureds"

This is one way in which the new BPS guidelines look to me like a misstep. Moving from "mental illness" to "mental distress" is superficial in itself. Language surely interacts with habits of thought, but a guideline like this just replaces one jargon with another.

The Turn Against Pluralism:

If this were my only complaint then I would lump it. We should be careful about language, and sometimes guidelines are the only way to do that. But the language of mental health is different from the language of race. There are racial terms so bound up with hate that officially discarding them is the only sensible choice. The same is not true of "illness", "OCD" and "Anxiety Disorder". 

We don't yet have the definitive account of who is and and who is not ill (defining illness turns out to be a dreadful philosophical tangle) so for all practical purposes there is no fact of the matter. One way of dealing with this uncertainty is to adopt a form of pluralism which allows for multiple frameworks for understanding. 

Some people see themselves as ill, others don't. Some people think of themselves as ill because they feel themselves to be ill. While not unproblematic, pluralism puts a person's experience at centre stage, affirming their chosen framework as a way to make sense of them. This is a principle I thought I saw affirmed in the "Understanding Psychosis" document released last November:

Plenty of first person accounts attest to the value of "illness-talk" (some of them in Understanding Psychosis itself), but the BPS has just discounted those experiences in a stroke. The approach adopted in the new guidelines is a solution that DSM-detractors have been descrying for decades. Rather than expand the repertoire of explanatory terms, this document shrinks it. Some language is good, some bad; some frameworks more correct than others. This works for people who are served by the new official language (those for whom "mental distress" is personal preference), but it alienates anyone who falls outside the charmed circle. Given how strongly the BPS has opposed the regulating languages of official psychiatry, I am astonished they have chosen this route. 

Election 2015: Those Pathetically Vague Mental Health Pledges in Full

I'm working on a longer post about the manifesto pledges that have been made on mental health. Manifestos are supposed to help people decide which party to vote for on the basis of concrete promises for which they could later be held to account. As I read through the different parties' mental health pledges I noticed that many of them were so vague as to amount to no promise at all. In this post I bring you the crappest and most hopeless mental health election pledges of 2015.

Conservative:

How's this for conjuring an empty promise out of thin air and giving it the veneer of credibility despite the total absence of any concrete objective? The Tories seem to suggest that there are not already therapists in "every part of the country", but this seems like a hard claim to defend. Do they mean in every town, in every borough, in every post code? Exactly which parts of the country have no therapists, and when can this promise be judged to have been fulfilled? The Tories here acknowledge that there could be more therapists, but without saying what they are committing themselves to precisely zero action on changing the status quo. Crafty!

Green

Perhaps because they have the least to lose (no-one anticipates a Green led government after May, sorry!) the Greens actually have the most concrete list of promises on offer. However, this one stood out. Which party is not going to "invest in dementia services", and in what sense will the Greens' offerings be different than anyone else's in terms of "support"?

Labour:

Let's get this clear, you're going to "encourage" social and emotional skills. How will you "encourage" them exactly? Billboards? A daily radio broadcast? This is a sentence comprised almost entirely of rather zeitgeisty hot-air with "mindfulness"crowbarred in as a very tokenistic buzzword.

Liberal Democrat:

The Liberal Democrats are going to get kudos for developing probably the most detailed plans on mental health (though it's a close race between them and the Greens), but this bullet point struck me as a little weird. First there is this idea of a "clear approach" which, in the absence of detail is actually anything but. Second, there is the notion of the well being equivalent of the "Five a Day" campaign. I have no idea what it is that one should do to improve mental resilience that is "the equivalent" of eating five pieces of fruit or veg. The Liberal Democrats clearly don't either. 

Another strikingly vague promise from the Lib Dems here. I can't argue with the sentiment , but neither can I tell you what it really means

UKIP:

UKIP win the competition for the greatest number of half arsed bullshit empty pledges.

What would the mental health world do without UKIP? In these two promises they affirm that people should be directed to mental health professionals "when appropriate" (begging the more interesting question of when UKIP feel it actually is appropriate) and that there is "often a link" between addiction and mental illness. Excuse me while I completely reconfigure everything I thought I knew about psychiatry! Why offer a specific policy formulation when you can have the half-baked wittering of some bloke in a pub?

Here's another half arsed thought:

Gee...thanks guys. UKIP seem to have heard of stigma but, unclear exactly what it means, they offer some vague handwaving around the issue, assuming apparently that it mainly has to do with not having a job. Feeble.

Book Review: A Prescription For Psychiatry

This month I have a review of Peter Kinderman's "A Prescription for Psychiatry" in the BJP. This post is a more extended version of the text published there.

      "Is the problem you're allergic

       To a well familiar name?
       Do you have a problem with this one
       If the results are the same?"

           -The White Stripes:

Girl You Have No Faith in Medicine

Battle-fatigued psychiatrists could be forgiven for wanting to steer clear of what looks like another attack on their profession. More waggish readers may wonder about responding with their own “formulation for clinical psychology”, and then there is the combative note. Does not the title seem to indicate a barely concealed desire to give psychiatrists a taste of their "own medicine"?

However, such aversion would be a tremendous shame, for while there is some familiar ground trodden here, there is also much that is new, positive, and well worth some serious thought. There is also an idea that is more audacious and direct than usually be found in books about psychiatry.

The book is made up of nine chapters, the first three of which occupy just over half the space. In this first half, more than in the second, there is a focus on criticism. The “disease model”, the use of diagnosis, and the role of medication are all subjected to scrutiny. Some of this ground is wearyingly familiar. On the subject of illness as opposed to “psychosocial problem”, we must ask whether Kinderman is giving full due to all the available evidence. The roles of trauma and of life events in schizophrenia are offered to raise our credence that this problem is best considered a psychological reaction. A major alternative theory, that some manifestations of this behavioural presentation may best be considered a developmental disorder, (after all, not everyone who meets the DSM criteria will have been abused or suffered other traumas) is not even mentioned, let alone appraised.

On diagnosis: It is quite right that psychiatry should face the shameful aspects of its history. The tremendous psychic damage wrought by pathologising homosexuality for decades, and the odious debacle of draetopmania are not to be lightly dismissed. However, given the intentions of the present book, Kinderman might have done more to explain why these despicable examples have a substantive bearing on the question of modern diagnostic practice in general. The DSM is a problematic and contested document, but while we should feel queasy about its politics and many of its categories (“Oppositional Defiant Disorder” gets a justified grilling), even the most sceptical clinician cannot shy away from asking whether we can as easily dissolve those two major categories “Schizophrenia” and “Bipolar Disorder”.

A superficially appealing argument raised here is that "abnormal psychology" is an unreasonable field of study; after all, we don't speak of "abnormal physics". There is an important idea here with which I find myself aligned. Using the word "abnormal" is indeed a needlessly unpleasant way of speaking about people, but the physics analogy doesn't fly. All physical phenomena are subject to the same basic laws (as far as we know), but that hasn't prevented the fruitful subdivision of their study into solid state physics, condensed matter physics, and so forth. When people have experiences of psychological distress, these tend to manifest in a propensity toward particular states of mind. Is it really so unreasonable to study these states in their specificity, cautiously categorising them until some better framework is offered?

Kinderman favours a dimensional approach to mental distress, and a recent international survey of psychiatric attitudes (Reed et al, 2011) suggest that close to half of psychiatrists could feel the same way. A more significant question is whether this is really inconsistent with a system of classification; unless mental health problems could somehow be incorporated on the same single dimension (as opposed to a psychotic spectrum, an affective spectrum etc.), there is no reason it should be.

The book is, in my relatively ill-informed view, sensibly skeptical on medication, suggesting (via Joanna Moncrieff) the adoption of a “drug centred” model, with prescription based on anticipated effects of a compound rather than the anticipated imbalances caused by a disease. Such caution seems laudatory, though there is an interesting debate about how to judge the risks and benefits of specific medications, and Kinderman prefers to leave this in the hands of others.

Those readers who get beyond the first half will find themselves on more interesting territory. Books that criticise psychiatry are common enough, but a considered and viable set of suggestions for improvement of the mental health system is much harder to come by. A number of the issues Kinderman raises are very important, and the book is good on linking its own position to the debates that are taking place within the profession of psychiatry itself. What is more, many of the suggestions made in the last six chapters are not dependent on his having won over the reader in the first three. Alzheimer’s is a brain disease, but that shouldn't rule out the provision of psychosocially oriented residential care for sufferers. Down’s Syndrome is a genetic disorder, but it would be extremely myopic not to provide care and support of an imaginative and holistic nature for this population.

Thus, regardless of his audience’s prior commitments on the nature of mental health problems, Kinderman is going to find much more agreement on the broad thrust of chapters 4 to 9. Many of these questions go well beyond a simple question of which profession is dominant and which intervention is the “correct” one. He is quite right to advocate a holistic approach to wellbeing, and his proposal for comfortable, decent residential care (“a place of safety”) over psychiatric hospital wards should be a public health priority. These latter can be traumatising and chaotic (not to mention expensive) places, and the “medical” context can place unnecessary limits on the nature of the care that is provided. Under Kinderman’s model, a new generation of local authority funded homes would provide safe, calm places for “respite” rather than “cure”. A suggestion that mental health nurses be renamed “psychosocial therapists” (on the grounds that “nurse” is overly medical) seems, to my mind, unnecessary given that the verb to nurse has thoroughly humanistic connotations.

Hanging over all this is the audacious idea referred to above. In "Our Necessary Shadow", Tom Burns doubted psychiatry would even exist without Schizophrenia and Bipolar Disorder. Kinderman's most radical conclusion pushes that logic to it's ultimate conclusion. In a chapter on promoting health, he suggests that psychiatrists add little value to mental health beyond a general medical consulting role. In his breathless (and well thought out) penultimate chapter he even insinuates that we could save considerable expenditure if our mental health system did without them altogether.

While it has often occurred to me that other professionals could perform many of the legal and leadership roles currently undertaken by psychiatrists, to argue they are entirely redundant relies on the acceptance of a conclusion that Kinderman has already taken for granted. Namely, that the field currently denoted by those two headline diagnoses is one devoid of anything resembling an illness or disorder. I am considerably more agnostic than Kinderman on this score, so while I have to credit him for such an invigorating interrogation of the “value added” of psychiatrists, I don’t think the argument has been won. Further, even if you do accept such a premise, the expertise required to distinguish "organic" psychiatric presentations from "functional" ones (yes this is something like a dualism, but it's really just a loose way of talking: think of the distinction between a drug induced psychosis and a psychosis whose causal factors are more diffuse) is not something psychologists are trained to develop.

This is a rip-roaring book; readable and broadly constructive. Like the broader debate of which it is a part, it succeeds where it is most surprising and lets down where it is most predictable. 

23 Contentions

Keeping an argumentative blog has the strange effect of "placing" you within the broader debates your writings touch. In the context of discussion, supporting or denying any claim raises questions about which other related claims you also might also endorse or contest. This gets tricky. In virtue of a position I have taken, other parties to a debate have often assumed they know my views on similar but different points. Frustratingly it can be mistakenly suggested that a claim I support entails another which I do not. Of course for my part I've frequently made precisely the same mistake in return. This experience has made me wonder what general statements about mental health I do feel broadly committed to. In turning over this question over the last months I have collected a rag-bag list of claims and suggestions that I think I would stand by, but which don't necessarily warrant more developed blog-posts in their own right. The only thing uniting them thematically is that writing this blog has brought me into contact with all the issues here at various times. Some of my contentions will seem trivial and others more challenging depending on your starting point, but I have included them for three reasons. The first is that many of them go too often unsaid, which is a shame. The second is that some of them may trigger interesting discussion with people who don't agree about them. The third is that I am curious to see which of them will stand the test of time and which I might end up being persuaded to abandon.

1. Individual case studies are significantly less informative than large scale controlled trials when it comes to determining the efficacy of a treatment. That said, the label "anecdote" can seem to be needlessly dismissive of people's experience.
2. Case studies and testimonials are extremely valuable in virtue of their potential to improve services and highlight malpractice. However, they also have much value in their own right.
3. Empirical research in psychology and psychiatry has historically been deployed toward both progressive emancipatory political ends and restrictive conservative political ends, but generally facts are a powerful corrective to bias, bigotry and oppression. 
4. Given the ways in which mental function is rooted in brain function, it would be extraordinary if a moderate amount of what we call "psychological distress" was not determined principally by biological factors.
5. An apparent thematic similarity between early life experiences (i.e. being bullied) and later symptoms (i.e. being paranoid) can easily mislead us into overestimating the extent of any causal link.
6. Childhood Sexual Abuse would be just as abhorrent if it played no role at all in psychosis.
7. Whatever the disadvantages of psychiatric diagnosis, it has validated the experiences of millions of people who have felt themselves to be suffering from serious illnesses.
8. Whatever the advantages of psychiatric diagnosis, it has saddled millions of people with labels they find inaccurate and invalidating.
9. The DSM project has almost certainly led to a huge rise in the diagnosis of certain mental disorders that is probably not commensurate with a change in anything other than diagnostic practices around those categories.
10. "Personality Disorder" is no way to talk about people.
11. There is no satisfactory way of cleanly distinguishing "mental disorder" from "mental health". This does not in itself invalidate these categories or render talk about them nonsensical.
12. The fact that gay people were "cured overnight" by the removal of homosexuality from the DSM does not provide a good analogy for other DSM diagnoses. If the DSM were scrapped, people currently diagnosed with many of its disorders would continue to suffer from their experiences. This would be in virtue of facts about those experiences that have little to do with how they are described.
13. That being said, the way we choose to describe people's experiences has real and substantial impact on the people who have them. People's lives can be improved dramatically by changing the way their experiences are constructed.
14. The statement " schizophrenia exists" may capture reality in important ways, but it cannot be regarded as straightforwardly true.
15. It can be overly general and dismissive to make statements of the form "Schizophrenia does not exist", even though the considerations that often motivate such statements are rooted in fact.
16. The claim that CBTp is not effective does not amount to a claim that people with psychosis should not be offered psychosocial support. It is claim about the relative efficacy of a specific treatment.
17. To promote CBTp is to privilege, over other approaches, a particular technical and hierarchical way of talking to people. In virtue of this it is more in line with a "medical model" than many of its advocates generally emphasise.
18. The provision, by health services, of CBTp stands to benefit the profession of clinical psychology in ways that are analogous to (though different in scale from) gains that have accrued to psychiatry through the provision of drug treatments.
19. It seems to be the case that different parties in the broad conversation about mental health want for it to be true that mental health problems are "mainly biological" or "mainly environmental". This is a decidedly strange fact and should stimulate our curiosity.
20. In the broad conversation about mental health, we all show a tendency to align into loose (but real) groups. Once in these groups we are more forgiving of the rhetorical excesses, rudeness and inaccuracy perpetuated by those with whom we are aligned.
21. On balance, "antipsychiatry" and "critical" psychiatry and psychology have been extremely valuable contributions to the discussion on mental health.
22. Sometimes asking questions can be an effective rhetorical strategy for avoiding the existence of people's efforts to provide answers whose implications we would benefit from talking about.
23. Mental disorders would not need to be geographically or temporally invariant to be considered real in a meaningful sense.

Who Owns "Critical"?

This post is about "critical psychology". Or rather (as i don't think there is one cohrent movement under this heading) it is about the fact that some people call themselves "critical psychologists".

I like the idea of a "critical" psychology. Being critical is something I aspire to in this blog and in my research and clinical work, though I don't know how often I manage it. But what do I mean by critical? Something like thinking as hard and as intelligently as possible about what I do and say. I think that when some people talk of being "critical psychologists" they are using the word in a more complicated way.

Partly this is because the word "critical" does not refer only to acuity of judgement, but also denotes a specific historical/philosophical intellectual project. To identify as "critical" is to invoke "critical theory", an approach to culture and knowledge which stresses the importance of analysing communication intensely for hidden assumptions. This project is specifically engaged in liberation from oppression by implicit historical structures supported by texts. It is interested in the ways that power gets played out in the deployment of knowledge. As such, critical theorists are open to ways of talking that move outside the "traditional discourses" of any given subject. It's also a project I with which I feel aligned.

Critical theory has been very fruitfully used by critical mental health professionals. The notion of clinical practice as the exercise of power has found particular traction in UK Clinical Psychology, and this is a good thing. You can find it in the work of David Smail, Dorothy Rowe, and in Joanna Moncrieff's critique of diagnosis as a political tool.

But there is a difference between doing critical psychology, and saying you're a critical psychologist. Identifying oneself as "critical" is more than just a description, is an action, which different people undertake to different ends. Many people may want to signal that they are amenable to thinking in particular ways (often in psychology it signifies a willingness to consider the relevance of non-quantitative evidence). "Critical" here is a shorthand for an interest in the use of political and social theory as well as psychological.

Critical or "Critical"?

Being "Critical" often also marks people out as holding particular views. For some it has explicitly provided a way to get distance from. "antipsychiatry" (a term which at least has the virtue of accuracy). Thus many psychologists are "Critical" in virtue less of an approach than an entire system of beliefs, and this is where things get tricky. Calling oneself "critical" might be intended to signal a particular perspective, but it also (in virtue of the word's broader meaning) serves as the subtle assertion of superior judgement.

Often in reality "Critical" simply serves to flag that you take for granted that certain things about mental health are true; that some treatments are necessarily "good", others "bad"; some ways of describing mental health problems as inherently morally superior. That is not what Foucault had in mind when he wrote "Madness and Civilisation". Saying you are "critical" under these circumstances is both a distraction and an untruth.

If calling oneself "critical" is no guarantee that a person will always be critical, nor is it a necessary condition for being so. There is much uncritical, partisan nonsense written under the banner of Critical Psychology, and many sharp critical voices outside it.

You Don't Own Critical:

When we consider the power of our blind-spots and personal biases, it seems unreasonable that any person can say accurately or in good faith that they are more critical than anyone else. Certainly no-one can be critical all the time. If there is a viable "critical psychology" project, it is probably the sort of thing we should do without feeling the need to draw attention to ourselves in the process. If you want to be critical you are better off showing people than telling them. 

Mental Illness and the Case of Phlogiston

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.

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.