Wednesday, 22 June 2022

Some barriers to sense making about ECT

The longstanding debate about ECT has been in the news again. A report about the treatment was discussed in an article in The Independent. There was also an strikingly rancorous debate on Women's Hour (starting here at about 34.20). The context for all this is the finding that women receive ECT at a higher rate than men. The Independent article seems to present this as if it were a bad thing.  That is only the case if ECT's benefits are outweighed by is disbenefits. Some people claim as much, but if they are wrong, then it might be good that more women than men receive ECT. Women are more likely then men to experience depression.

I have never got to grips with the details of ECT's efficacy. As a psychologist I feel I should have an opinion. This post is an attempt to engage honestly with the topic and form a view. Unfortunately there are several barriers to doing this. Here are three that I see:

1. Polarisation:

There exists one group of mental health professionals who administer ECT and profess that they would be happy to have it performed on them, and another group who oppose it to the extent that they call for a moratorium on its use. The way these groups interact on Twitter, in blogs, and in the scholarly literature suggests that there is a degree of ill feeling between these camps. 

The most striking fact about these two groups to me seems to be their different characterisation of the nature of depression. For psychologists this perhaps evokes a milder picture: someone who feels low or sad, with self-denigrating thoughts and perhaps feelings of hopelessness, but ultimately ambulatory and potentially responsive to psychological therapy. For psychiatrists, depression also includes those individuals so severely impaired that they are at risk of severe neglect or death by suicide. 

The temptation to "join" one side or the other is strong. Such "joining" is likely to increase bias and rationalisation. 

2. Florid rhetoric:

Rhetoric is a significant barrier to sense making in the ECT debate. For sure it is an intervention that makes me think of “great and desperate cures." ECT is – there’s no escaping it – a pretty extraordinary way of proceeding. Its origin story is startling: its founder was inspired by witnessing the sedating electrocution of pigs at a slaughterhouse. But a startling origin story can be rhetorically inflamed and overdone. Stated baldly, many of the facts of medical practice would whip up frenzy in a newspaper headline (try redescribing a bilateral mastectomy without medical euphemism). Those who oppose ECT tend to be guilty of describing it in terms that make it seem prima facie abhorrent. Those who defend it tend towards excessively sanitising language that elides its negative effects. 

3. Incomplete consideration of the stakes

ECT's opponents tend to discount the risks of no treatment. In the context of our conception of medical responsibility, failure to treat is also an intervention.

When people make the case against ECT, cognitive side effects are a central part of the argument. Sure enough the only person I have ever spoken to about their ECT suffered autobiographical memory loss that they regretted bitterly. These effects are often cited as evidence that the treatment causes brain damage (incidentally those who see ECT's cognitive side effects as a sign of brain damage also tend to argue against the framing of psychiatric disorders as brain diseases, even though it is widely established that depression, schizophrenia and bipolar disorder are all associated with sometimes very severe cognitive impairment). Considered in isolation, these cognitive effects seem so obviously undesirable that only a barbarian would consider risking them. 

However, working in a major trauma centre, primarily with people with acquired brain injury, the physical and cognitive aftermath of uncompleted suicide is a salient part of my professional life. At any time we usually have one or two people known to our service who were admitted for this reason. When psychiatrists make decisions about treatment of depression, this kind of aftermath is part of the stakes they have to weigh. It is in the nature of risk that the worst case scenario will not always be actualised. This doesn't mean it can be entirely discounted. We often choose a course of action with a more likely but less severe payoff so that we can avoid a less likely but more severe payoff. This is the structure of buying insurance. Considered this way, I think ECT becomes a far more reasonable proposition. Given a choice between the cognitive side effects of ECT, and the cognitive effects of a severe traumatic brain injury sustained by walking under a lorry or jumping of a bridge, I would most certainly choose the former. 

Extant evidence: 

Forming a view comes down to making sense of the efficacy literature. This is hampered by many of the barriers discussed here. 

A high profile 2010 review by Read and Bentall concluded: "placebo controlled studies show minimal support for effectiveness with either depression or ‘schizophrenia’ during the course of treatment (i.e. only for some patients, on some measures, sometimes perceived only by psychiatrists but not by other raters), and no evidence, for either diagnostic group, of any benefits beyond the treatment period." They discount these minimal benefits as outweighed by "strong evidence ... of persistent and, for some, permanent brain dysfunction." As discussed above, this discounting may be unwarranted.
Meechan and colleagues recently published a literature summary that meta-analysed the ECT vs placebo trials that Read and Bentall had reviewed. Their analysis favoured ECT:

A  response to that analysis by John Read (who opposes ECT) counters some criticisms made by Meechan and colleagues, but does not (as far as I can see) give grounds to  discount the results themselves. 

What are some things that seem reasonable to say about ECT?
  • ECT has cognitive side effects that can be long lasting, primarily a loss of autobiographical memory
  • The state of the evidence is fairly poor: there are only 11 placebo controlled RCTs that examine the issue. These RCTs tend to support ECT's efficacy in improving depression - the effect size is greater than those observed for medications and psychotherapy.  
  • Any positive effects of ECT are likely to be short term: i.e. long enough to get someone out of a very severe depression, but not sufficient to maintain them in that state. 
  • More ECT efficacy research is needed.

In a blog for the "Council for Evidence Based Psychiatry" (CEP) Richard Bentall (a psychologist skeptical about ECT) articulated a position that I found surprisingly sympathetic:

"I have been challenged to explain what I would do if faced with a patient suffering from life threatening depression (to which the answer is: try other therapies but, if there really was no alternative and death was imminent, I would probably try ECT in desperation despite the questionable evidence of its effectiveness)."

I wonder how many psychiatrists - themselves worried about the limited research on ECT, but aware of the possibility it can be helpful - proceed in precisely this way? 

Thursday, 15 July 2021

Challenging behaviour

Psychologists are accustomed to thinking about "challenging behaviour" in terms of the mechanisms of reinforcement that contribute to sustaining it. I associate this view with the work of Eric Emerson - who wrote an excellent book on the topic. 

The Emersonian view is a perspective that focuses on the contingencies that reinforce behaviour. It gives rise to mechanistic interventions that adjust those contingencies: removal of the rewards that sustain a behaviour, easier routes to the outcome being sought, differential reinforcement of other behaviour (DRO). This sort of approach has been effective especially in Learning Disability settings, where people typically spend long periods of time living, and where staff are primarily concerned with supporting behaviour. There are also case reports of successful interventions in long term psychiatric hospitals. These are the sorts of settings where the consistency and commitment required to adjust environmental contingencies are in more plentiful supply. 

Recently I have been involved in delivering "challenging behaviour" training in the context of an acute general hospital. I use scare quotes because the whole concept of challenging behaviour (a concept clinical psychologists are fond of) begins to fray a bit around the edges when examined more closely. For one thing, some have pointed out that the terminology itself is likely to stigmatise and mislead; framing behaviours as inherent to the people who exhibit them. This kind of critique seems right to me: behaviours are of course a function of person and the situation they are in.  Too much terminological pendantry can seem to miss the point. I have heard it suggested that "challenging behaviour" should be replaced by "behaviour that challenges," as though the two terms weren't in fact extremely similar. The sort of flexibility that would help us think productively about behaviour is likely best served by a similar flexibility in our approach to terminology.

More significantly, professional approaches to challenging behaviour are substantially impacted by the role the professional occupies, and the sorts of permissions they feel they have. Even before you get into adjusting reinforcement contingencies and so on, there is a significant difficulty about helping people feel permitted to do the basics. That sounds a bit strange - what am I talking about? 

When a person in a hospital becomes upset and behaves in a way that is experienced as challenging, the optimal response is for the staff around them to make sense of the behaviour (as a communication of distress and so on) and to respond in a way that the distress is mitigated. So a person shouts and punches in fear. They aren't restrained, but instead are met with reassurance. They feel calmer and they shout and hit less. This sequence seems so obvious that I sometimes feel embarrassed to deliver the slides about it. People usually nod enthusiastically along. But its obviousness or otherwise isn't really at issue. For the most part - I increasingly feel - it's not that staff don't know how to behave, it's that they lack a subjective sense of permission to behave in this way.

Consider this story:

A young girl sits in the middle of a room in a psychiatric ward. She has removed all of her clothes and is rocking back and forth.

The hospital staff has invited a visiting doctor to look in on the patient. They talk about the girl, who was diagnosed with schizophrenia: for a long time now, she has done nothing but rock, and she has not spoken since being admitted many months ago. They ask the visitor’s opinion.

His response is wordless: he takes off all his clothes and steps into her room.

He sits down next to the girl and begins to rock in sync with her, two naked figures side by side.

This goes on for a while. This goes on for 5, 10, 15, 20 minutes.

And then she speaks to him. Her first words in nearly 200 days.

Later, the visitor will ask the staff, “Did it never occur to you to do that?

The visiting doctor in that story was RD Laing, and its hard to read it without entertaining the hope that you too would have the clinical nous to do something similarly dramatically empathic. Laing comes off as heroically insightful, drawing his colleague's attention to their failure to do the obvious.

But such an approach is far from obvious. Assuming this really happened as reported, Laing's colleagues must have had doubts about what he was doing. The same is true - I want to suggest - even for responses with much lower stakes. Who wants to risk spending time listening when you don't feel qualified to deal with a person's tears? Who wants to try and reason with an angry shouting patient when you worry it might be done better by a more senior member of staff?

To connect with someone emotionally in hospital - even in a less dramatic way than Laing - involves a degree of risk. There is the risk of becoming emotionally impacted, the risk of feeling engulfed, and there is the risk of doing something wrong or foolish. Laing was free of this latter risk. He was Laing - a great psychiatric guru. Even if the encounter hadn't gone so well (the patient might not have talked - might even have baulked at the idea of being approached by a naked doctor) he would still have been lauded as a psychiatric genius taking an empathic risk. In other words, Laing was permitted by the whole set up to do something that was actually very difficult, even if he said it was obvious.

When we teach about responding to "challenging behaviour" in terms of a technical approach to reinforcement or distress reduction, we risk overlooking systemic factors that have to do with the granting of permission to respond empathically. My impression is that people want to respond empathically and know in theory what that looks like. A difficulty arises in any given stressful situation when people think that they are not the right person for that job, that someone more senior or more qualified ought to be drawn on. We could improve institutional approaches to "challenging behaviour" by finding ways to grant this permission as extensively as possible. 

Monday, 6 July 2020

The imposter's guide to imposter syndrome

Imposter syndrome is a concept that is having its time in the sun. Although first christened almost forty years ago in a professional article, it seems positively de-rigeur. Diagnostic concepts come and go but the extent to which they take root in the popular imagination is an indication of how far they speak to broader social phenomena. This one co-exists with increasing awareness of gendered discrimination in the work place. The article linked above is about women's experience specifically, and a recent book (Valerie Young's The secret thoughts of successful women) has expanded on the theme. Perhaps imposter syndrome might be recast as a description of the way that women have been made to feel by male dominated professional spaces.

Its widespread acknowledgment means there are some self-help interventions out there for chronic self doubters, with a dedicated website (, the companion to Young's book) leading the way. These interventions tend to focus on a version of cognitive re-structuring, with a large helping of positive self talk. We are encouraged to "learn to think like non-impostors" by engaging in self directed pep talks. Techniques like saying out loud that we are awesome, or making a list of "at least 10 things that show you are just as qualified as anyone else for the role you are seeking." This kind of approach involves entering into an argument with yourself about the reality of whether you are or are not in fact an imposter.

Having been through that self-argumentative cycle myself multiple times, it seems to me that the big problem with debating yourself out of imposter syndrome is the corrosive skeptical worry that you might be wrong. This doesn't need to feel plausible, only possible. On self examination I can easily find areas of relevant knowledge I feel I don't have, and evidence of times I failed to meet a relevant personal standard. "OK" I tell myself, "but everyone has limitations and failures." "Yes" I snap back, "but yours are worse!"

At this point it has helped me to notice what I am up to. I suspect a degree of characterological inclination toward self-sabotage; an overly aggressive super-ego. Here the ruminations on imposter syndrome become a self indulgent cocoon. A "poor me" reclusiveness, a way to hide in an endless cycle of self-abuse and avoid hard work. I have also noticed a decidedly unattractive inclination toward self deprecation in conversations - picking up on my own defects. The result is often reassurance from others, which is presumably the point.

In fact the whole concept of imposter syndrome sets up a specific question ("am I an imposter?") and invites arguments about how to best reach an answer. The dysthymic self attends to evidence that affirms the proposition ("I definitely fouled up in that meeting; "I don't know half of what I need to in order to be competent"; "I can account for all my achievement in terms of luck rather than merit"). The positive therapeutic self is supposed to weigh evidence more favourably. But this is an effortful process, and runs the risk that (without the support of an external voice) you conclude that you are an imposter after all.

I have found it more helpful to engage a gestalt shift in attention that leaves aside the question of whether I really am an imposter. It even leaves room for the possibility that I am. The focus moves instead to the facts of any given professional situation, and to considerations of what ought to be done. Instead of looking in at the person, look out at the parameters of the task, regardless of who is undertaking it.

Viewed this way, the "imposter" question evaporates. It can even be viewed as a convenient evasion.

For the real issue in most professional scenarios is not so much you as the task you confront. The question is not "do I belong?" but "what has to happen?" In work situations you have already been selected for a job. Perhaps there was someone else on the interview shortlist who would have been better at it in some sense. Too bad. It is unlikely that person (or anyone else) can replace you imminently. The ethical thing to do is to work hard and keep your end up in the now. That will probably involve hard work. You certainly cannot save the situation by appeals to the idea you "belong" after all.

Are you going to direct your attention to the job in hand, or are you going to expend energy fretting about whether you really ought to be there? Unless you're in imminent danger of harming people (say, you somehow wound up convincing people to let you perform a surgery or fly a plane without the relevant qualifications), you most likely owe it to those around you to do your job as well as you can.

I realise this approach lacks the positive validating tenor of typical imposter syndrome self help. This is not a comment on the general validity of positive-validating approaches. It is a letter to myself, and so reflects instead my personal preferences. Deliberating over whether I am an imposter has resulted in some half hearted self-praise. But seeing the ways in which that whole game is a distraction has been altogether transformative.

Monday, 6 January 2020


Let me not be mad - A.K. Benjamin.
Bodley Head - 2019.
212 pages.

Into the abyss - Anthony David
Oneworld - 2020.
189 pages.

By the time Oliver Sacks died in 2015 he had become something of an untouchable. Not exactly a "national treasure" - but whatever the transatlantic equivalent of that might be. It seems strange to remember that, although he had attained sage-like status at his death (see Vaughan Bell's obituary post for a lovely example of the justified affection Sacks' inspired), he attracted controversy earlier in his career. The ethical worry about Sacks was that he was "the man who mistook his patients for a literary career;" writing for the "voyeuristic cognoscenti."

Whatever other legacies Sacks may have left, he arguably created more or less an entirely new literary genre ("neurolit" perhaps?), and every publisher of popular neurological case studies since has been keen to get "Oliver Sacks" onto the cover in some form, to provide the requisite signal to browsers.

I could read Sacks endlessly. After he died I ploughed through many of the ones I hadn't yet got to. I also worked through some of the expanding shelf of his literary progeny: Paul Broks, Suzanne O Sullivan, Jules Montague, the list goes on. As a psychologist this is all work related, but it is also a guilty pleasure - like detective fiction or spy thrillers.

Two recent books in the Sacks tradition have revealed some of the different things it can offer. A.K. Benjamin is the pseudonym for a mysterious clinical neuropsychologist who writes in the idiom of a world weary psychoanalyst. Anthony David is an academic psychiatrist and giant of his field whose first foray into popular writing is a spare but immaculate primer on psychiatry.

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Benjamin's book comes with something of a "twist," for we learn by the end that some of the clinical vignettes within pertain to his own mental health problems. This device is personally revealing, but the use of pseudonym necessarily takes some of the edge off. In the end it is far from the most interesting part of the book.

I wasn't taking notes as I read Let me not be made, but so vivid and honest is the writing that much of it has implanted itself in my mind. Healthcare often involves an element of facade; of adopting a confident professional position and sticking by decisions despite the knowledge they could be wrong. Benjamin sees and - you sense - detests this facade.

In an extraordinary passage he writes of the emotional work that patients (sometimes) do to protect clinicians from the worst of their experiences. Our patients do us a service, Benjamin points out, by dying well. Most of us want a social encounter to feel comfortable and will collude with people, including clinicians to make it so. This is a form of protection, but it is coursing in the wrong direction. The person receiving the salary ought to the be the one doing the protecting. Benjamin invites us to recognise that it is often the other way round. That this is so brings into relief the importance of discomfort. If someone can make you feel uncomfortable, and you can sit with that discomfort and bear it, you might really be doing something for them.

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The title of David's book seems to conjure something rather vague and mystical, but it in fact denotes a precise idea. Karl Jaspers once posited an "abyss" between the mechanistic and hermeneutic forms of understanding people. David sees the psychiatrist's task as bridging this abyss, to provide a working understanding of people that draws on both. Much has been made in mental health of the biopsychosocial model. David points out that in offering an apparent theory of everything, this idea threatens to explain nothing. Here he is on the way psychiatrists ought to related to the three strands, bio, psycho and social: "Every time we meet a new patient, we must decide which of the three, if any, is most important." (p.2) This is a punchy and pragmatic version of sense making that I recognise in the referral questions to a neuropsychology department, and it seems potentially at odds with my own profession's sometimes broadly inclusive formulations.

Each case study here seems carefully sculpted to reveal something important about the discipline of psychiatry - there is a patient with Capgras and Cotard's, who allows David to illustrate the meaning of the two-factor theory of delusions; another who illustrates the paradoxical neuropharmacological connection between psychosis and parkinsonism. Unusually for neurolit - David also includes a case that illuminates the issue of race and psychosis - allowing him to weave in some reflections on Frantz Fanon.

My own route into neuropsychology has felt weird to me - like many I was inspired by the intrigue of astonishing neurological phenomena and a desire to understand them. But I came into the field via an interest in psychoanalysis, phenomenology and mental health. What is the appeal of these books to this jobbing clinician? As a psychologist, working in neuropsychology, I realise I read them as something like a form of supervision. Academic texts give you statistical generalities, but there is nothing like a vivid account of the minutiae of clinical work and some startling clinical advice (at one point he abruptly announces to a family affected by head injury that they "will never be the same again") to help you really learn something.

A book like Abyss then is something like a series of lessons - archetypal illustrations of how people can be distressed. It expands ones clinical repertoire, opening up new possibilities for formulating complex situations. This is more or less what you would expect from a prominent expert in psychiatry. The cases are well worked through and served up with aplomb. But they are also like events from a distant past. As a clinician I envied David the unruffled clarity he brings to bear on each situation. A patient appears to recover from a crippling depressive guilt, only to throw himself under a lorry within moments of being discharged. David is unsettled, but seeks solace in Durkeim's writing on anomic suicide and emerges a wiser clinician with what reads like relative ease.

Benjamin's book offers something more emotional, and counterintuitively more reassuring. Here is an author who portrays the startling and graphic events that bring people into contact and inevitable emotional entanglement with neuropsychologists. He is vividly impacted by his patients and has gone searching in some unusual places (tibet, his own dreams; psychoanalytic theory) to try and make sense of them. But as he shows in a remarkably drawn scene of an NHS team meeting ("the decision is made, the knife is readied, and nobody who was there can quite say what just happened" - p.67), there is never really anything like a complete sense to be made. The best we can hope for is to figure things out a little better and a little more usefully. The note of horror, the terrible senseless randomness in the world that lets brains grow tumours and collide with skulls at high velocity, haunts the pages relentlessly.

Friday, 3 May 2019

Therapy for therapists?

We see periodic flare ups - among psychologists and psychotherapists - of a debate about the importance of personal therapy for therapists. If you want to work in this business providing it to others, the central question goes, is it imperative that you undergo your own? The debate usually gets hot headed, perhaps because it is actually a form of culture clash between very different types of professional psychology. Across the spectrum of the "psy professions," the requirements vary. Many (most?) psychotherapy training courses mandate it. Others don't. It is constitutive of what it means to a psychoanalyst that you are someone who has been psychoanalysed. Meanwhile, most courses in clinical psychology will not insist that their trainees receive any sort of therapy.

It seems easy to argue that personal therapy has value for several rather banal reasons: the experience of being in the “hot seat” (being encouraged to divulge personal details, opening up about your insecurities) can give you a sense of what you are asking people to do. The opportunity to discuss feelings about the ways your work affects you personally is also a way to ward off professional fatigue and "burn out." The privacy of the whole situation (it's hard to see what a therapy session is like without actually sitting in one) also makes personal therapy seem an attractive introduction to how the process ought to look - a sort of apprenticeship. 

There are also arguments that the case in favour of personal therapy is overdone. It is a very resource intensive requirement, hitching entry to the profession to a large financial outlay that some more "hard headed" clinicians argue is simply unnecessary. I sought therapy when I was training to be a therapist, but whatever value it had for me as a person, it was not the only (and maybe even not the best) source of insight about the intersection of my personal and professional development. Intensive supervision on the other hand was profoundly helpful. I had the fortune to meet with supervisors who took a granular interest in the blow to blow of the sessions, and who were not afraid to tell me when they thought I was avoiding material from my own anxieties, or getting wrapped up in a response that was more aimed at gratifying me than helping the person I was meeting. 

Looking at my colleagues I hesitate to suggest personal therapy is essential. Some of them were the most gifted and emotionally insightful people I have met, but I suspect this was principally a result of their temperament, interests and life experiences. Many psychologists seem conscientious and rather neurotic, making them good candidates for extensive self-examination in or out of therapy. Others I have met seem somewhat emotionally unaware despite years of personal therapy. Hardly a convincing advert. 

It may be that this is a case (one of many in my view) in which the psychoanalysts have made an accurate diagnosis of a problem (therapists without personal insight are a bad thing!), but don’t have a monopoly on the remedy. Much as “mindfulness” is actually a description of a wide ranging mental state, which can be facilitated in many ways other than those that have been made popular since the advent of professional meditation training, so "emotional insight" does not only need to arise from a particular form of two way conversation that became popular in the 20th Century. The flip side of this is that therapy is not a precise science and has no guaranteed outcomes anyway. It would seem weird therefore to put too much store by it as some sort of royal road to clinical wisdom. 

How could we settle the question? Apart from examining the efficacy of therapist therapy on outcomes (those who worry about the value of personal therapy for trainees often ask to see the evidence that it "works"), the most interesting way of looking at the problem would be a straightforward “taste test”. You could (for instance) take a panel of senior psychotherapy teachers who run therapy courses mandating personal therapy and have them interview a sample of psychotherapy trainees, some of whom have had at least a year of therapy and some of whom have had none. Would the trainers be able to discern the “analysed” from the “unanalysed” cases? If the trainers’ judgments about who had had therapy were no better than chance then that would seem a significant challenge to the dogma that personal therapy is doing something clinically relevant.

Ultimately the dispute is so intractable because what is at stake is two conflicting visions of the ways that it is possible for us to deceive ourselves. For the cognitively minded, a salient sort of self deception might arise from the various self-justifying biases that are tied up with the insistence upon personal therapy: that it may seduce you into thinking that you’ve got (that it is possible to get) your own psychological house in order; that it bestows an unchallengable authority on the figure of the "well analysed" therapist ("I have the requisite sort of insight - you do not"), and that it is an arrangement principally suited to keeping psychotherapists in business through a steady flow of trainees who need to sit on the couch.

For the psychoanalytically inclined, the relevant self deception is tied up in the hubris of embarking on "the work" without sufficient knowledge of what lurks in your own unconscious. Enter the room as a psychoanalytic naïf and you will be hit by a storm of transferential and counter-transferential responses that you can’t make sense of. You will likely be pulled into a range of potentially harmful enactments with the people you’re trying to help. You'll be lucky to avoid causing harm to the client and to yourself, let alone providing help. I find this way of thinking fairly compelling. The rampant abuse of patients by mental-healthcare professionals (who didn’t – I assume – enter their field as aspirant sadists) looks like striking evidence of how harmful and surprising our unconscious motivations can be. Personal therapy - under the psychodynamic conception - is a way to start looking at the darkness that lies within you so you can stop it from wreaking havoc on those you work with.

The point of raising these two types of consideration is not to try and arbitrate between them, but to diagnose the whole problem with the debate as it is currently constituted. Both sorts of concern seem valid to me. I am convinced of the fact that therapists bring things into therapy that will impact on the work in potentially profound ways. I am also convinced that therapists are motivated to preserve their professional identity by appeal to the special significance of their hard-won clinical insight, and that this can often be overblown. If different sides can retreat from their favoured assumptions, a new way of asking the question might emerge.  

Thursday, 31 January 2019

Psychoanalysis' unlikely innovator

There is a popular narrative about the history of psychoanalysis and schizophrenia; that it involved little more than the invocation of schizophrenogenic parents and equated to victim blaming. This version of history is sometimes raised to engender doubts about any psychological theorizing in this area and shut it down.  It’s intellectually healthy to raise such doubts. Contemporary psychoanalysts - worried about repeating historical mistakes - have grappled with them too. Here is an excellent essay, by a psychoanalyst warning his colleagues to heed the "cautionary tale" of the schizophrenogenic mother theory.  

But historical reality is more nuanced than the narrative that runs "psychoanalytic theory bad; biomedical revolution good": Frieda Fromm-Reichmann’s “schizophrenogenic mother” idea has come to symbolise the theoretical chauvinism of the age, but her legacy is more complex. She didn’t focus on aetiology as much as on therapy. Her heroic efforts are documented in Gail Hornstein’s fantastic biography.

More overtly anti-mother was the work of Theodore Lidz, who devoted a large part of his career to studying the dynamics of families of those diagnosed with schizophrenia. His descriptions of two schizophrenia-creating family patterns (skewed families locate all of the power in one parent while schismatic families split it between them in a perplexing civil war) contain toe-curlingly misogynistic descriptions of mothers. These ideas stuck around a long time. As late as 1994 the notion of schizophrenogenic parenting was still doggedly advocated by some authors, with no attention to the idea’s serious evidential shortcomings.

But there was a more subtle and integrative idea at large during the psychoanalytic heydey of American Psychiatry. Sandor Rado was a peculiar figure in American psychoanalysis. Although an elder statesman of the field (he had known Freud well and was selected by him to edit two early psychoanalytic journals), he was cast out from the orthodox New York Psychoanalytic Society for his belief that psychoanalytic knowledge could not be separated from a sound understanding of neurology and genetics. “I believe that the influence of genetics, especially biochemical genetics, is going to be so enormous that it would be bootless to try to outline it.” Rado once said (see page 141 in this)

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Rado coined a term that has become ubiquitous in modern academic psychiatry: schizotype. This portmanteau (a collapsing of “schizophrenic genotype”) was used to designate an individual genetically vulnerable to a psychotic decompensation. For Rado (who outlined his ideas in a 1953 paper) a psychotic breakdown represented a combination of this genetic predisposition and the very human process of adapting to the world in light of that predisposition. Although highly speculative and somewhat vaguely couched, Rado’s paper on schizotypy is notable for its almost Laingian level of phenomenological detail. His ideas about the relationship between the constitutional factor (an “integrative pleasure deficit”) and the dynamic contents of the mind were supposed to be the start of a serious mind-body theory of psychosis. But it wasn’t to be.

Although some theorists took note (Paul Meehl brought the concept to academic clinical psychology where it slowly began to gain traction), American psychoanalysis at the time - which is virtually to say American psychiatry at the time - entirely ignored Rado’s idea. In fact “ignored” might be too suggestive of indifference.Some have gone so far as to suggest that Rado’s influence on psychiatry was repressed: “Rado and his collaborators were shunted out of the mainstream psychoanalytic journals and largely vanished from even their references and citations” (p.975 here). Instead American psychoanalysis became committed to ever more dogmatic assertions of the role of parenting in the development of schizophrenia. It's tantalizing to imagine how different it could have been.

Saturday, 24 November 2018

Matthew Parris misses the point

Matthew Paris has written an essay in The Times arguing against increased mental health funding. This issue is a sacred cow for politicians and the media so I have some respect for Parris for going against the grain. Mental health is too important to be untouchable. Unfortunately the article is based on a series of misconceptions that undermine its argument.

Here is how the substantive line of reasoning gets going. Treatment should be based on science, Parris is going to say, and psychiatry isn't scientific:

This is a ludicrously limited understanding of science. There is virtually no area of medicine where patients behave like the billiard balls of Parris' schoolboy physics. Medical science is generally probabilistic; surgeries tend to have a particular outcome, babies tend to emerge in particular ways. Psychiatry is more probabilistic than most, dealing as it does with cognitions and affects rather than hearts and livers, but the empirical principles are the same. To try and reign in the uncertainty, patients are grouped together by diagnoses and provided with treatments. What works best is what gets recommended for the NHS. That formula doesn't always get implemented properly, and we can argue about ways to change it, but it's misleading to ignore the fact that it exists as an ideal.

To bolster his case about the unscientific foundations of therapy, Parris makes reference to psychoanalysis:

Parris is talking here about psychoanalytic therapists (the majority of whom are paid privately) as a way of arguing for reduced NHS spending. It's a spurious connection. We can get up a whole separate debate about the merits of Freud, Adler and Jung, but in this context they are a distraction. 

When he does turn to the dominant mode of NHS therapy, Parris' ignorance is astounding. First he paints a picture on which the only sort of research conducted into therapy's effectiveness is from the most casual inquiry on the part of the therapist:

Then, with the sort of comic assuredness that can only come from profound ignorance of the literature, he cooks up a scheme for how such research might be better conducted:

These passages suggest that Parris cannot have read -- nor read about -- a single randomly controlled trial of psychotherapy in preparation for his essay on psychotherapy. Only someone in such a state of epistemic innocence could suggest with a straight face that, hey, psychiatrists might like to conduct a systematic test of their treatments one of these days. The problem he thinks he as identified was foundational for the project of psychotherapy research, well over 50 years ago. The broad consensus of that literature is that psychotherapy is helpful. Parris could take issue with those results but instead he doesn't acknowledge they exist. 

There follow some rather waffly personal reflections on the ascendancy of therapy as a culturally available means of dealing with distress, and the vagaries of psychopharmacology. With regard to the first Parris says that he was averse to seeking therapy on the two occasions it was offered to him. This tells us little about the value of therapy per se and only about Parris' attitude toward it. Fair enough - psychotherapy should always be an informed choice. 

On the latter issue he makes some concerned noises, but may as well have pasted in the shrug emoji:

There follow some half baked worries about Ritalin use in schools and the rising demand for antidepressants, but without any solid idea of what impact these things are having Parris just sounds like Robert Whitaker without the conviction or the reference list.

All of this is building up to what amounts to a tepid call for hesitation about funding:
This is infuriatingly facile. It's just the old Cameron idea of the Big Society, warmed over. Moreover, however shaky the ground he has trodden to get to this conclusion, the things he has left out are even more damning. Everyone can surely agree that kindness is essential in mental health. What is so frequently missing, and what drives people to campaign for increased funding in the sector, is the means to implement that kindness.

Parris tries (unconvincingly) to debunk therapy and medication, but he doesn't even touch on the most important parts of mental health. Put aside therapy, put aside medications, a huge amount of mental health care consists of things that are far more basic and important and done by people who aren't particularly interested in Freud, CBT or Ritalin. It can be found in practical support with daily tasks, in messy intervention at times of crisis, in advocacy, in needs and risk assessments, and in simple human contact.

The contemporary mental health crisis emerges not in the consulting room, but in A&E departments, job centres and community mental health teams. It arises because people in intense distress are showing up in all sorts of places that have neither time nor resources to help them. The political push for more mental health funding is not some rarefied thing that can be separated from the kindly pastoral figures that inhabit the conservative imagination. There can be no kindness where there are no people available to offer it.