The Headclutcher Strikes Again

In May I posted this about the peculiar tendency for newspapers to run a "headclutcher" image with any story about mental health issues. Silly though these pictures are, their use raises some interesting questions. How do we see people with mental health problems? Who are the acceptable faces of mental health in the mainstream media? What representations of distress are we prepared to look at when we scroll through the news? These questions are linked to the issue addressed in this pertinent New Statesmen article by Glosswitch, that not everyone with mental health problems will fit into a comforting "normal" image.

Today there has been a brief flurry of activity around the headclutcher below, which was originally used to accompany this article about voice-hearing by Charles Fernyhough and Eleanor Longden. Though still certainly a headclutcher, this lady has a more aggressive, scary presentation than usual. She is trying to block her ears in a flamboyant over the top way and appears to be shouting in anger or distress. We may note that the Guardian chose a red-head, perhaps seeking to bring to mind the lazy associations people have about their being tempestuous or hot tempered. 

Fernyhough immediately expressed discomfort with the Guardian's choice of image on Twitter, and he and Longden appear to have had words with the article's editor. The piece is now garnered with a tasteful screengrab from Longden's recent TED Talk.

Though they may sometimes seem a mere distraction from the main event, the media's use of illustrative pictures is important in the public consumption of mental health stories. Stigma is a huge problem and recent experiences with Asda's "mental health patient" halloween costume and Thorpe Park's "Asylum" have shown that it takes sensitive and thoughtful people to notice the implicit messages that are finding their way through to us. Headclutchers are not stigmatising in the same way as tasteless Halloween products but they are embarrassing and lazy; a form of journalism that is subtly derogating its subject. It's time the media thought a little harder about what images they used to accompany such important stories. 

The Scientist and the Practitioner: Some thoughts on A Vexed Relationship

The first thing I ever knew about clinical psychology was that it was based on the "scientist-practitioner" model. This paradigm, dating from a conference in Boulder Colorado in the 1940s (just as clinical psychology was taking off after the second world war), has largley defined the profession on both sides of the Atlantic ever since.

However, despite the fact that the science of psychology has expanded wildly since 1949, the scientist practitioner model seems ever less central to the profession. There are instances of outright disregard for the "scientist" part evident in many quarters and I find myself in interesting debates with psychologists and other therapists, trying to figure out how to define the role of "evidence" in that cumbersome phrase "evidence based practice". For many I detect a current of hostility to thinking in data and a general preference for using common sense and seeing the person with whom you are working. Data, by some accounts, is the kind of thing upon which we can become "hung up". Perhaps people are wary of becoming cold hearted Spocks:

"I'm Listening"

Although I have previously been scornful of the woollier arguments used against evidence in psychology, I have sympathy for some of what people are (I think) trying to express in these reservations. This post is an attempt to persuade them there is less disagreement than they fear.

Basic Problems:

Let's put our hands up right away and get a few things straight about the science of therapy. First, what gets called "evidence based practice" is not necessarily always (or even most of the time) living up to the lofty ideal of the name. For some institutional bodies, the existence of plausible seeming figures in some journal is good enough to plough ahead and recommend a therapy. I have even seen people make quite important decisions on the basis of a single pie chart (of unknown provenance) in a promotional brochure:

Even Data Can be Meaningless

Equally, much research is compromised by financial interest and driven by large pharmaceutical companies. Furthermore, the terms under which research is conducted are largely defined by political considerations of what is in vogue or popular. CBT gets more attention than any other modality, especially ones that don't sound snazzy or mysterious (like ordinary "befriending" or "supportive therapy").

Empathy and Therapeutic Skill:

There are definite limits for the role of science in the practice of therapy. The skills and considerations of an effective therapist can probably be determined by data, but perhaps their cultivation is a separate thing. I am sure there is no contradiction between being an empathic, kind and effective therapist and being statistically competent to assess efficacy, but I am aware of no reason to believe that proficiency in one automatically helps with the other. Whatever it is we do to cultivate kindness and empathy (an empirical question), it seems pretty clear we should do it.

The Role of Values and Outcomes:

The question of what kind of society we wish to have cannot always be answered empirically. A neat example of this is in a debate I recently had with a friend. In New York, unlike London, people have to pay to get into museums. In a basic way this doesn't feel right to me and I was trying to articulate why. "Societies just seem better when their art and culture is accessible to anyone" I argued. "Can you prove that?" asked the friend, and of course I couldn't. There may exist some quantitative indications that free cultural activities are good for people, but I doubt they are very robust, and in any case I am not interested in them. Even if you couldn't show conclusively that free access to culture improved people's lives, I would still maintain it was a social good. This is because it is not a question of tangible effects, but of what kind of society I want to live in.

To transpose this onto the field of mental health and social care; at least some proportion of what is at stake in the debates cannot be settled by data. Walking onto a mental health ward for the first time, I was struck by a sense of how cold and cruel it seemed. Apparently abandoned residents walked about in distress and staff members callously (so it seemed to me) bossed and condescended to them. Leaving the place behind felt like a palpable relief. Who knows how you would begin to quantify what it is like to live in such places; what kind of impact it would have on your sense of self. This is not to say that we shouldn't try, nor that we can ignore good quality data, but we can't depend on quantitative data to know everything we feel to be worth knowing. Sometimes the feelings that philosophers call "intuitions" are worth listening to. Debates outside of science, about what we should value are worth having too.

Rapprochement:

However, none of these readily acknowledged limitations is straightforwardly an argument against the centrality of the scientist practitioner position. I see a definite tendency to martial the limitations of science-based practice and attempt to assemble them into a case against data, but that way danger lies. One line of attack is to identify a scientific persuasion as a kind of arrogance. The logic apparently being that the scientifically oriented are vulnerable to using data to somehow over-ride the immediate experience of the service user, perhaps by steadfastly maintaining that they continue to do something (take a pill, undergo a form of therapy) when it is not working for the individual. This is indeed a risk of following evidence-based recommendations blindly, but it would in fact be a deeply unscientific thing to do. Reasoning from samples to individuals is probabilistic, and even if an intervention worked for 95% of cases, there are still 5% for whom it won't. The rational scientist-practitioner treats every case as a new instance of reality and pays attention to what is and is not working. This is what Jacqueline Persons (here) calls "Treatment as Experiment".  People who say that therapy is an "art" or that clinicians need to "be confident enough not to need to know all the answers" can, I hope, see a direct parallel with what they are proposing. 

Therapy, like most complex human behaviour, can probably be described as an art, but that doesn't mean it can ignore science. Is architecture an art? Plausibly yes, but if architects ignore the principles of engineering and physics, their buildings will kill people.

No the DSM is not like Astrology

I am genuinely ambivalent about the broad line of arguments we can call "the case against the DSM". I don't mean ambivalent in the modern sense ("a bit confused and unsure what to think"), I mean ambivalent in the classic psychoanalytic sense; harbouring strong feelings in both directions. On the one hand there is the interesting and essential level of critique which brings to our attention the experience of feeling labelled and the unsettling bureaucratisation of medical terminology. This line of argument I feel very positive about and engaged with. On the other there is the ever resounding echo chamber of over-confident assertions about the malign intentions of the APA and the total unusability of the DSM for research or clinical purposes. One recurring theme in the latter category is the quip that the DSM is no better than astrology. It appears in this (otherwise excellent) piece by Edward Shorter, in this interview with Richard Bentall, and in many other places besides.

DSM diagnoses would be just like the signs of the zodiac 

if  it weren't for the fact they're very different in many ways.

In the Bentall profile, the New Scientist interviewer opens by asking if comparing the DSM with astrology isn't "a bit strong". "No" says Bentall. I happen to agree with him, but not with the reasons he gives. Comparing the DSM with astrology isn't "a bit strong" (criticism of something you dislike should be strong) it's wildly off the mark. Why? Well although you can derive some superficial comparison between the categories of the DSM and the signs of the zodiac (both describe classes of people; both aspire to some degree of reliable prediction) there are also clear differences.

The most obvious and important difference is the way the way the categories are derived and assigned. The signs of the zodiac are assigned to people on the basis of their date of birth and based upon the idea that these dates are linked to personality characteristics in a meaningful way. Meanwhile DSM diagnoses are applied on the basis of set of criteria describing patterns of behaviour. Someone designated as having, say, OCD, can be expected to resemble a particular broad set of clearly defined features. However a Libra is not just someone who is "on an even keel" (which may way not be an unreasonable classification in itself) but someone who was born between the 22nd September and 23rd October and is regarded as "on an even keel" in virtue of this fact. In short, astrology makes a needless jump--the linking of birth dates and personality traits--that the DSM doesn't.

Why does this matter? It's not as though it puts the DSM above criticism after all. My answer is that the debate about mental health and diagnosis is very important, but if we want a serious discussion about DSM's flaws we need to accord some respect to considerations of plausibility. You can hate the very guts of the manual and its creators and still martial the strongest possible case against it. If you spin off into crowd-pleasing claims and ignore reality people will stop listening.

Aberrant Salience and a New Meaning of "Lynchian"

Fans of the director David Lynch have a clear sense of what it means for something to be "Lynchian", but if we are pushed to put into words what this adjective captures we confront an extremely difficult task. Urban Dictionary gives us this: "having the same balance between the macabre and the mundane found in the works of filmmaker David Lynch." but that definition seems almost circular. Lynch isn't the only person to balance the macabre and the mundane (see also the ubiquitous slasher films of the late 70s and 80s) and we are left with a sense that the word just means "Lynch-like". David Foster Wallace had a go at a definition in the essay here, but was still forced to admit that it is "ultimately definable only ostensively – i.e., we know it when we see it."

There is something that unites all Lynch films for me, and that is the sense that one is being invited to take as significant and sinister various encounters in the plot which turn out to have no ultimate explanation or meaning. I have been struck how this reminds me of the Aberrant Salience account of psychosis. The aberrant salience theory arose out of a brilliant review by Shitij Kapur positing that the mesolimbic dopamine system regulates the salience of elements of our environment, and that it is this process which becomes dysregulated in psychosis and gives rise to phenomena like delusions. When faced with a feeling that something is inexplicably salient or significant humans, story telling creatures that we are, cook up a story to account for the feeling. Part of the beauty of the theory is the way it offers a means for thinking about the interaction between the biological and the psychological. Kapur's language also makes the idea wonderfully intuitive:

By Kapur's account, a dysregulated dopamine system is "the wind of the psychotic fire" and helps us to understand how people can get wrapped up in terrifying implausible stories, but what does any of this have to do with David Lynch? 

Lynch's films, by my account, do a similar thing with our tendency to tell ourselves explanatory stories. Lynch can't dysregulate your dopamine system for you (that's a bit too "This is Your Brain on Cinema" for me), but what he can do is obey nearly all of the conventions of straightforward story telling while artfully ignoring others. Thus we have a series of wonderfully opaque and seemingly significant moments throughout Lynch's oeuvre. Each one seems to add something highly meaningful to the plot, but we can't be sure what. Who is the Cowboy who appears to Adam Kesher (Justin Theroux) in Mulholland Drive to tell him how to cast his film? We don't know, but the exchange has all the hallmarks of a plot-changing moment and we wait eagerly to find out what sinister forces lie behind this sinister man's authority: 

Mulholland Drive's Cowboy: A Vagueness we Are Forced to Explain

What we are doing here, filling in a story in the absence of being let in on its details, bears a striking similarity to what Kapur describes in the formation of a delusion. Something salient has happened and our minds go into overdrive to impose meaning on it. Something similar takes place when Betty and Rita visit Club Silencio and are moved to uncontrollable sobbing as they watch the singer's rendition of Llorando:

Club Silencio

The sense of significance is reinforced by the appearance in Betty's hands of a locked blue box, which appears to be a key clue for understanding the entire film. Unfortunately, no clear resolution exists, and we are left with a plurality of efforts to untangle the multi-layered plot. Film critics have tried but can't agree, and the Internet is home to an endless quantity of logorrheic accounts cooked up by obsessive fans. 

Mulholland Drive is just one example of the way an entire Lynch plot can feel like it hangs on a meaningless symbol. Apparent clues abound in nearly everything Lynch makes. In Twin Peaks, agent Dale Cooper solves the mystery of the death of Laura Palmer after a dream in which he is told "that gum you like is going to come back in style":

The Red Room

Has he solved the crime, or is he just subject to the feeling that something highly significant has happened? What about the severed ear on the lawn which opens Blue Velvet? To the viewer here is a moment that seems so macabre that it must explain something. Whose ear is it? Why was it cut off and by whom? The human tendency to paranoia goes into overdrive and is never resolved.

Blue Velvet's Ear on a lawn: The Macabre and the Banal in spades

Lynch's last film, Inland Empire, consisted almost entirely of such floating signifiers; bedside lamps and bizarre unconnected characters; extended sequences with rabbits talking gibberish. As Laura Dern navigates this confusing world she finds herself outside Room 47, which seems (from the horrified look on her face and the lingering camera work) like it must be a scene of some highly significant event. 

Inland Empire: One Long Paranoid Detour

But like the rest of the film, there is little in the way straightforward resolution to this encounter. Something profoundly creepy happens right afterwards (I'll let you find the clip on YouTube if you're curious) but with no explanation as to why. In many ways Inland Empire was the logical end point of Lynchian cinema. Over the last few films he had eroded the coherence of his plots and emphasised the apparent meaningfulness of moments, symbols and exchanges. The two most recent films especially look like an exercise in discovering how much you can ask the viewer to fill in for themselves. Because of the reliable beauty of Lynch's imagery, and his mastery with creating salient episodes, we go along with him. The resulting experience is an exquisite paranoia, more chilling and rich than almost any other thriller. 

Useful Guides Which Limit our Thinking

This quote is a follow on from this previous post. I came across it while reading Heinz Kohut and Ernest Wolf on Self Psychology. Like the earlier Freud quote, it has relevance to the modern debate on psychiatric diagnosis:

"The best efforts of the past [...] are no exception to the rule that the simplified correlation of specific patterns of manifest behaviour with universally present psychological conditions which of necessity forms part of any such typology will, in the long run, impede scientific progress. Why then, do we persist in the attempt to devise characterologies? The answer is that such classifications, even though we must be aware of the fact that they may eventually limit our thinking and stand in our way, can for a while be valuable guides in psychological territory in which we feel not yet at home."

 Kohut, H., Wolf, E.S. (1978). The Disorders of the Self and their Treatment: An Outline. Int. J. Psycho-Anal., 59:413-425.

6 Effective Ways to Avoid Engaging With Quantitative Data in Mental Health

1. Imply that Quantitative Data is Inherently Flawed:

One of the most effective ways to undermine anyone trying to appeal to principles of empirical research is to remind them and everyone else that the whole project of obtaining supposedly "objective" data is doomed to begin with. We all know that all research in psychiatry is hopelessly biased by its connections to Big Pharma, so be sure to muddy the waters and block further discussion by asking profound sounding rhetorical questions like "what research? conducted by whom?" Ignore the fact that questions about prospective bias, methodology and misuse of statistics are already central to the effective interpretation of any research and that some of the most effective ways to guard against them are statistical procedures.

If you don't feel that accusations of an inevitable and pervasive bias are a strong enough slur against the principle of empirical data collection, be sure to make bold assertions to the effect that the whole principle of obtaining quantitative data on people is an act of "violence" on the holistic truth about humanity.

2. Remember that a Focus on Subjective Experience is the Only Worthwhile source of Knowledge:

Researchers are supposed to be interested in experience right? So why are they all faffing around with experiments and longitudinal surveys? There are plenty of people around who have actually had experiences and their testimonies should be entirely sufficient. Be sure to remind researchers of this whenever they suggest the spurious use of numbers to try and figure things out.  You are more than just a number!

3. Remind People that You Aren't Interested in the Entity Being Studied:

"Not everything that counts can be counted, and not everything that can be counted counts" Einstein said that didn't he? Or was it Eleanor Roosevelt, or Winston Churchill? It doesn't matter, the principle is sound. Maybe researchers want to pigeonhole people into entirely irrelevant categories and measure things about them, but why should the rest of us give a stuff? They say that they are interested in learning about groups of people who meet a set of agreed upon characteristics, but it is pretty clear this is just a front for the propagation of a sinister medical model. Further proof of this can be seen in the fact that almost no researchers ever mention a strict biological conception of mental illness; they're keeping it under wraps!

4. Accuse Anyone Deploying Empirical Reasoning Of "Scientism":

This one is particularly effective because very few people actually know what it means. Sciencey people all hate religion don't they; so if you accuse them of an irrational faith in the power of science you can win any debate while simultaneously getting on their nerves. Ignore the fact that a belief in the use of the best available empirical evidence is not even close to being scientism proper, anyone who dabbles in science is unlikely to have retained their common sense and will almost certainly be out of touch with reality. If someone has used "Schizophrenia" or "Bipolar Disorder" in their work then they plainly believe these entities to be illnesses just like Hepatitis or diabetes and certainly don't have any curiosity regarding their ontological status. They are no better than mystics or astrologers, and anything they say can be dismissed.

5. Remind People of the Nazis:

Scientists always drift back towards biology and genetics, they can't help themselves. Even if they are only suggesting that genetics and constitutional physiology account for a relatively small proportion of variance in any given problem, there is no telling how long it will take before they drift towards a policy of eugenics and ethnic cleansing. You are only ever doing anyone a favour by reminding them of phrenology, eugenics and--ideally--the Nazis before they walk foolishly out onto this slippery slope.

6. ...Continue to draw on Data when it Suits You:

None of this should leave you feeling that you can't preface your own views with comments to the effect that "it has been shown..." or "data proves..." In fact, now that you have an arsenal of tools to discount any research that doesn't back up your own case, you are free to deploy research of any quality; it cannot be countered by anyone else's!

At the Limits of Meaning

Here's a neat irony: so often is it said that psychiatric problems are"meaningful" that the statement itself is starting to sound rather meaningless. Used as a rallying cry to focus attention on the content of people's experience rather than viewing its form as a kind of pathology, the "distress is meaningful" idea has become diluted and distorted through careless use. This is a shame as, like most ideas in "critical" psychology and psychiatry, it has a worthwhile core which it is worth staying in contact with.

"Man's Search For Meaning":

Pareidolia: Making Meaning Where None Exists

To say "distress has meaning" can mean the tendency we have to imbue our health problems, like anything we experience, with special significance and form associations to them. In this sense even the most random or the most biologically determined forms of health-problem have "meaning". It is very meaningful to me that I am starting to notice the slow and inevtiable movement of my hairline towards my crown, but this doesn't mean I can halt it by "making sense" of it. More seriously, it is extremely meaningful when people with Alzheimer's start to lose their memory as a result of cortical atrophy, but this is because our grasp on our minds is very significant; it does not mean they are, say, trying to repress something.

The existence of this general sort of meaning making about our lives is uncontroversial and only a rather perverse and callous person would deny it. There is, however, another sense in which distress has been taken to "mean" something, and its conflation with the weaker form above has generated some confusion.

Symptoms as Messages:

Freud was prompted to develop the technique of Psychoanalysis when it began to seem to him that the symptoms of his patients weren't just manifestations of some physical problem ("degeneracy") but were a sort of communication about the contents of their minds.

Conversion Hysteria: Meaning's Search for Expression

Freud and Breuer had noticed that when they encouraged their patients to speak freely--and without the sorts of prohibitions that teenage Viennese girls were normally subject to--their symptoms cleared up (we'll leave for now the question of whether this really took place, and for the reasons they claimed). This led them to conclude that, in some circumstances, the body itself became a channel for communicating the sorts of emotions we normally communicate in speech. Although initially of interest in the case of "conversion hysteria" (a category which has fallen into relative disuse) Freud extended the principle to obsessional behaviour (where obsessions divert the energy created by resisting expressions of desire) and hallucinations (which acted to fulfill a resisted desire).

One result of the Freudian meaning of "meaningful" was that by the middle of the 20th Century, and especially in America, psychoanalysts came to be seen as a cabal of expert decoders, essential to tell us the real underlying meaning of our actions. With the decline of the dominance of this framework there has arisen a new skepticism about what our bodies and minds can ever be said to be telling us about our lives.

Nonetheless this meaning of "meaningful" has its modern counterpart in claims that (for instance) the voices heard in psychosis are expressions of emotions which the hearer has not yet dealt with; that bouts of intense paranoia reflect a feeling of danger which has its root in early experiences. I don't want to deny or defend these claims here, they appear to have their use in some situations and not necessarily in others. Instead, I want to draw attention to the fact that they form a stronger assertion than the more banal observation that everything means something to someone, and that these two can come to be thoughtlessly merged.

Psychoanalysts: The great decoders 

Why does this matter? The weak claim (that everyone's experiences come to have meaning) and the strong claim (that the meanings are central to the phenomena, which can be healed by the right kind of understanding) have different implications for treatment, but to carelessly fudge them allows us to overlook this. If you assert the weak form then you are simply saying we should pay attention to the meaning of people's distress and try to engage with the reasons for it. If you assert the strong form then you are claiming that the right sort of interpretation can essentially dissolve certain forms of distress. This belief can be expected to lead to an anti-medication ethic as people come to see the effects of medication as a violent denial of meaning. Such a belief (which virtually amounts to a superstition) should be kept separate from the very real problem of people being unnecessarily over-medicated and it should also be kept separate from the obvious fact that talking to people about what things mean to them is a kind and helpful thing to do.

Unless we are a bit more rigourous about this separation, it is unclear whether we are saying healthcare professionals should engage with the meaning of people's suffering or whether we are saying that healthcare professionals have a special access to its interpretation. The latter is a rather arrogant claim, promoting dependency on special interpreters with defintive answers, but it can be smuggled in alongside the more benevolent position if we don't look out.