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.

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 Validity of Formulation:

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.

"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:

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.

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:

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.

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.

Five Halloween Costumes to REALLY be Scared of

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

1. The Pharmaceutical Sales Rep:

Aaaarrrggghhh!!!!

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

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

2. The Healthcare Administrator:

Nooooooo!!!!!!

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

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

3. The Public Relations Expert:

UUUuuuUUuuUuurGHhhhhh!!!!

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

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

4. The Arms Dealer:

Urryhhhhlllghhllgg!!

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

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

5. David Cameron:

AaaAAAAAARRRRGGGGHHH!!!!!

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

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

From "Diagnosis" to "Characterisation"

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

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

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

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

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

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

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

How to Critique the DSM

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Numbskulls: Thoughts as Instructions

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

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

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

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

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

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

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

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

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

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

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

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

Cycle-diagnosticator

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

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

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

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

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

Sunrise, Waterloo Bridge, October, 2010

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

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

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

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

Sunset, Woolwich, 2010

Houses rise from a winter morning mist, Woolwich 2010

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

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

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

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

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

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

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

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

Williamsburg Bridge on the Lower East Side. June 2014

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

When is a Parachute Just a Parachute?

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

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

Coldplay's Parachutes: Not Evidence Based,

Not Effective, just Dismal.

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

What is a Parachute?

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

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

Excerpt from How The Dead Live. More available here.

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

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

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

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

When is a Parachute Not a Parachute?

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

Sometimes a Parachute is not a Parachute.

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

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

Notes on the Sociology of Evidence in Clinical Psychology

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

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

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

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

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

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

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

On a Certain Queasiness Regarding the Word "Diagnosis".

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

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

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

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

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

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

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

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

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

Not that kind of selfi-ness

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

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

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

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

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

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