Spurred by Masuma Rahim's thoughtful piece about the issue, I have been thinking about psychiatric assisted suicide. She points out that this is an issue it is "very difficult to have a settled opinion about". I don't yet have one, but it seems important to understand some of what is at stake. This is a list of thoughts. The topic may be triggering, and this post should be approached with that in mind.
1. Any debate about psychiatric assisted suicide concerns the question of whether there are ever circumstances in which people with mental health problems should be allowed to receive help to die.
2. If healthcare professionals are to have any role in this process, part of it must be in trying to provide the best possible assessment of whether a person can reasonably expect their life to improve.
3. Unless we think assisted suicide is always unconscionable, we have to accept that there exist reasons that bear on those cases in which it is not. Clarifying those reasons will help us think more clearly about the issue in general.
4. Whether or not mental health problems are "illnesses" is of no relevance to the question of whether psychiatric assisted suicide is morally palatable. The desire to die seems driven by the intensity, and particular quality, of individual suffering. It is not clear that this suffering is more real in cases where an illness exists. Whether or not a person wants to die is likely to be a function of whether they think their misery will persist.
5. A domain specific prohibition on assisted dying in psychiatry would appear to suggest that it is not possible for mental health service users to make reasoned choices about whether they can end their lives.
6. Psychiatry has a long history of "great and desperate cures", driven by desire to avoid feelings of hopelessness on the part of the doctor. How would we know psychiatric assisted dying isn't just the latest chapter of this ignoble tradition?
7. I have, in the past, walked on to a psychiatric ward and felt a chill at the idea that I could end up locked in a place that is organised almost entirely around the idea that I should be denied, at any cost, the freedom of killing myself.
8. To characterise this debate in terms of one group of people declaring another group "better off dead" is to fail to engage with the experiences of those who have advocated for their own right to psychiatric assisted suicide, or pursued it for themselves.
9. There is a particularly difficult balance to be struck between emotion and reason in this debate. We need to think calmly and clearly about psychiatric assisted suicide, but it is hopeless to try and avoid appeals to emotion. No-one can hope to understand what is at stake unless they take time to imagine what it is like to spend many years very seriously wanting to die. Equally no-one can hope to understand what is at stake unless they take time to imagine what it is like to lose someone to suicide.
10. We might wonder whether a policy like this would have a positive impact on the suicide rate. If people are aware that it is possible for them to die under medical supervision, that may reduce the intensity of some people's despair and desperation, making them less likely to kill themselves. Hope, even the paradoxical hope for death, might help people feel better.
11. Alternatively, a policy like this might increase the social visibility of suicide and diminish the taboo that surrounds it. This might lead to an increase in thoughts of death and more completed suicides, even in a sort of contagion as the idea occurs to more people. Legal protection would put suicide into the "pool" of acceptable solutions.
Saturday, 21 May 2016
Thursday, 5 May 2016
Genetic Disavowalism is the Denial of Privilege
Here are two recent strands of thinking about genetics in clinical psychology: 1. Oliver James's (and others) bold position, that genetics play little or even no role in human psychology. Marcus Munafo has called this "genetic denialism" 2. The diffuse suggestion (one recent example here) that to pursue genetic research into mental health problems is related in some way to a eugenic agenda; to wit, that (i.e.) a genome wide association study looking at the diagnosis of schizophrenia may encourage us to think in quasi-fascistic ways. There are some good responses to the first of these strands, in Munafo's article (linked above), and in this piece by Kevin Mitchell at Wiring The Brain. Here, I want to address the second strand, which I will call genetic disavowalism.
The purpose of genetic disavowalism is pretty clear; to encourage us to think of genetic research and theories of genetic risk as inherently negatively morally valenced. This argument (to the extent that there is an argument; it is seldom made explicitly) is a little under-cooked to say the least. It is of course perfectly possible to acknowledge a genetic contribution to human behaviours and mental states without commencing some inexorable slide toward Nazi-ism. Does the genetic aetiology of Down Syndrome commit society to a re-run of the Nazi Aktion T4 programme? Clearly not. For one thing, a eugenic policy is a choice a government makes rather than a necessary consequence of a given set of scientific knowledge. For another, there is nothing to stop any government undertaking such a programme targetting people on the basis of behavioural or cognitive traits it doesn't like, but which are not genetically determined. Even if genetic theories about human behaviours and tendencies do incline some sorts of person towards ideas about eradicating those behaviours and tendencies (by "breeding them out" or what have you), there is no logical entailment, and we carry on with genetically inclined research because we wonder if there might be benefits to be derived from the knowledge.
Apart from all that, I think that genetic disavowalism has itself a moral problem to contend with; the denial of genetic privilege.
We are accustomed to thinking about privilege in terms of race, gender or social class. As a white man, for example, I have the privilege of not being looked on with suspicion in certain neighbourhoods, and I have the privilege of not feeling tense when groups of NYPD officers walk past me. It has come to be seen as crass and offensive to fail to acknowledge our privilege, especially when discussing race (see Peggy McIngtosh's essay on the invisble knapsack here), but the notion of privilege has been linked to mental health as well, by Martin Robbins here, and by me here.
When I first blogged about sane privilege, I was thinking in terms of the social position people have when they are viewed as less rational in virtue of their psychiatric status. When a person is considered deluded, their utterances become generally more suspect in the eyes of people around them They lose certain testimonial privileges (some of their statements about reality are taken less seriously). But privileges are also conferred on us by our genetic predispositions. This is most obviously the case in the way that skin colour or primary and secondary sexual characteristics are genetically determined facts about our appearance, but it presumably has cognitive implications too.
To the extent that IQ is genetically influenced, my course mates or colleagues with IQs two standard deviations above the mean have an advantage relative to me (with my quite middling IQ) in performance on exams or the production of research and logically sound clinical arguments. Equally, to the extent that my genetics plays a role in my tendency to not have debilitating emotional "highs" or feel my relationship with reality become terrifyingly fragmented, I have a sort of privilege conferred on me relative to people who are prone to such experiences. It is no good arguing that actually a tendency toward certain mental states is actually perfectly desirable, and should itself be considered a privilege. That may so for some people, but unless we want to deny that mental health problems are frequently extremely difficult to live with (and unless we want to throw out even the apparently politically neutral term "distress" to refer to such experiences), we have to acknowledge that is not the case for all.
Acknowledging cognitive genetic privilege need not entail acceptance of an illness account of mental health problems. Peter Kinderman has movingly written about his risk for a psychotic experience, given a possible personal high genetic loading for such an occurrence. At the same time, he resists the implication that this means he has a disorder or "attenuated syndrome". Even if you feel more inclined than Kinderman to describe such a genetic loading as predisposition toward illness, his is a perfectly consistent intellectual position.
Genetic influences on psychology have always been a controversial topic, and there is an easy tendency to accuse genetic researchers or thinkers of secretly holding eugenic aspirations. Perhaps some strains of genetic reasoning are infused with a negative moral valence (think of the pub bore who argues that women are genetically inferior), but to the best of our knowledge, genes make certain aspects of our lives more or less easy for us. They confer varying degrees of privilege. To ignore this is not only unrealistic, it is insensitive.
The purpose of genetic disavowalism is pretty clear; to encourage us to think of genetic research and theories of genetic risk as inherently negatively morally valenced. This argument (to the extent that there is an argument; it is seldom made explicitly) is a little under-cooked to say the least. It is of course perfectly possible to acknowledge a genetic contribution to human behaviours and mental states without commencing some inexorable slide toward Nazi-ism. Does the genetic aetiology of Down Syndrome commit society to a re-run of the Nazi Aktion T4 programme? Clearly not. For one thing, a eugenic policy is a choice a government makes rather than a necessary consequence of a given set of scientific knowledge. For another, there is nothing to stop any government undertaking such a programme targetting people on the basis of behavioural or cognitive traits it doesn't like, but which are not genetically determined. Even if genetic theories about human behaviours and tendencies do incline some sorts of person towards ideas about eradicating those behaviours and tendencies (by "breeding them out" or what have you), there is no logical entailment, and we carry on with genetically inclined research because we wonder if there might be benefits to be derived from the knowledge.
Apart from all that, I think that genetic disavowalism has itself a moral problem to contend with; the denial of genetic privilege.
We are accustomed to thinking about privilege in terms of race, gender or social class. As a white man, for example, I have the privilege of not being looked on with suspicion in certain neighbourhoods, and I have the privilege of not feeling tense when groups of NYPD officers walk past me. It has come to be seen as crass and offensive to fail to acknowledge our privilege, especially when discussing race (see Peggy McIngtosh's essay on the invisble knapsack here), but the notion of privilege has been linked to mental health as well, by Martin Robbins here, and by me here.
When I first blogged about sane privilege, I was thinking in terms of the social position people have when they are viewed as less rational in virtue of their psychiatric status. When a person is considered deluded, their utterances become generally more suspect in the eyes of people around them They lose certain testimonial privileges (some of their statements about reality are taken less seriously). But privileges are also conferred on us by our genetic predispositions. This is most obviously the case in the way that skin colour or primary and secondary sexual characteristics are genetically determined facts about our appearance, but it presumably has cognitive implications too.
To the extent that IQ is genetically influenced, my course mates or colleagues with IQs two standard deviations above the mean have an advantage relative to me (with my quite middling IQ) in performance on exams or the production of research and logically sound clinical arguments. Equally, to the extent that my genetics plays a role in my tendency to not have debilitating emotional "highs" or feel my relationship with reality become terrifyingly fragmented, I have a sort of privilege conferred on me relative to people who are prone to such experiences. It is no good arguing that actually a tendency toward certain mental states is actually perfectly desirable, and should itself be considered a privilege. That may so for some people, but unless we want to deny that mental health problems are frequently extremely difficult to live with (and unless we want to throw out even the apparently politically neutral term "distress" to refer to such experiences), we have to acknowledge that is not the case for all.
Acknowledging cognitive genetic privilege need not entail acceptance of an illness account of mental health problems. Peter Kinderman has movingly written about his risk for a psychotic experience, given a possible personal high genetic loading for such an occurrence. At the same time, he resists the implication that this means he has a disorder or "attenuated syndrome". Even if you feel more inclined than Kinderman to describe such a genetic loading as predisposition toward illness, his is a perfectly consistent intellectual position.
Genetic influences on psychology have always been a controversial topic, and there is an easy tendency to accuse genetic researchers or thinkers of secretly holding eugenic aspirations. Perhaps some strains of genetic reasoning are infused with a negative moral valence (think of the pub bore who argues that women are genetically inferior), but to the best of our knowledge, genes make certain aspects of our lives more or less easy for us. They confer varying degrees of privilege. To ignore this is not only unrealistic, it is insensitive.
Tuesday, 29 March 2016
"Difference Makers" and "Background Conditions"
A group of clinical psychologists has made the case that the UK's Medical Research Council should spend more money funding research into the social rather than biological causes of mental health problems. Note the headline of the article reporting the story: "Mental illness mostly caused by life events not genetics, argue psychologists". The argument is clear; mental health problems are set off by life events, not by some underlying biological vulnerability.
This sort of claim about causality has consistently proved controversial. Oliver James recently ignited firm criticism from behaviour geneticists when he baldly denied the role of genetics in mental health problems. I am with the behaviour geneticists in that dispute; James' dogmatic environmentalism rests on a wilful misunderstanding of scientific findings, and on some very shaky arguments.
Environmentally inclined clinical psychologists often want to push back against a view that says most of the cause of mental health problems lies in our genes. There is a fact of the matter about this, and it does suggests a powerful role for pre-disposition. If we want to find someone who meets criteria for schizophrenia our best bet is to find someone who has an identical twin with the disorder. Nothing else raises the risk so far (from its baseline of around 1% to 28%*). Because of this, many researchers now hold that bio-genetic vulnerabilities do the bulk of the causal work in psychosis (leading some psychologists to complain that environmental factors are marginalised by being reduced to the status of "trigger").
But even so, the claim that we underplay the environment's role as a cause may be warranted. Causality is complex and we assign different weights to different causal stories depending on what we intend to use them for. A criminal court, for example, may apply a "but for" test, asking whether the events under examination would have happened but for the actions of a defendant. This doesn't necessarily show us the full causal picture as it doesn't answer questions about why the defendant behaved as they did (indeed liberally inclined thinkers tend to feel that the criminal justice system focuses too much on individual responsibility and not enough on societal causal factors when punishing people), but it works tolerably well for assigning a certain sort of criminal responsibility.
Bringing environmental factors further into the foreground may serve a valuable purpose in the mental health debate. Consider this passage from Peter Zachar's book A Metaphysics of Psychopathology:
Most relevant to what? To the interventions we can make to help people. Perhaps the enormous bulk of research that investigates the genetic and biological underpinnings of mental health problems takes a particular view about what can be seen as "background" and what can be seen as a "difference maker". If your aim is to develop medicines and genetic tests, then it makes sense to focus on neurotransmitters and SNPs, as these are the things you hope to change. They start to loom into focus as "difference makers". But it is also possible (especially in most mental health settings, where it feels like gene therapies or radically improved medications are a very long way off) to see these ingredients as part of the background. This makes sense in the light of a burgeoning "neurodiversity" movement, which re-frames genetic variation as normal, and thus undermines the notion that this or that genetic predisposition (to schizophrenia say) is itself a relevant pathological "difference maker".
What motivates psychologists who see trauma and "life events" as significant in causing mental distress is a refusal to see various forms of adversity as a "background condition". Sure, genetics plays an important role, these researchers suggest, but the public health implications of that fact are not immediately clear. Meanwhile, the public health implications of an aetiological role for traumatic life events are obvious; we should aim to stop people being exposed to them. As Peter Kinderman says in the article I linked to at the top, "when unemployment rates go up in a particular locality you get a measurable number of suicides".
If asked, I am sure Kinderman would deny that a change in economic circumstances is the whole causal story in any given suicide. Likely a host of factors (personality variables, social support network and so forth) combine to create something like more or less "resilience" in people. But unless you can intervene to improve that resilience, it makes sense to push it some way into the background and focus on things you feel you can change. If you do this, life circumstances and political events start to look more like "difference makers", even if we can still have a debate about what constitutes a cause.
______________________________
* UPDATE: I originally cited the figure 48% here, reflecting the commonly quoted probandwise concordance rate for schizophrenia in identical twins. 28% reflects a lower estimate of concordance, based on a pairwise concordance rate. There is some controversy over which rate to cite, and as this post was an argument for greater focus on environmental factors, I did not want to lay myself open to the charge of minimizing the genetic contribution. However, it was suggested to me that the probandwise rate is an inflation of the true concordance rate, and for the time being I'm inclined to agree. Nonetheless, there are good arguments for using the probandwise concordance rate, and when I have better understood the issue, I will try to write a post outlining them.
This sort of claim about causality has consistently proved controversial. Oliver James recently ignited firm criticism from behaviour geneticists when he baldly denied the role of genetics in mental health problems. I am with the behaviour geneticists in that dispute; James' dogmatic environmentalism rests on a wilful misunderstanding of scientific findings, and on some very shaky arguments.
Environmentally inclined clinical psychologists often want to push back against a view that says most of the cause of mental health problems lies in our genes. There is a fact of the matter about this, and it does suggests a powerful role for pre-disposition. If we want to find someone who meets criteria for schizophrenia our best bet is to find someone who has an identical twin with the disorder. Nothing else raises the risk so far (from its baseline of around 1% to 28%*). Because of this, many researchers now hold that bio-genetic vulnerabilities do the bulk of the causal work in psychosis (leading some psychologists to complain that environmental factors are marginalised by being reduced to the status of "trigger").
But even so, the claim that we underplay the environment's role as a cause may be warranted. Causality is complex and we assign different weights to different causal stories depending on what we intend to use them for. A criminal court, for example, may apply a "but for" test, asking whether the events under examination would have happened but for the actions of a defendant. This doesn't necessarily show us the full causal picture as it doesn't answer questions about why the defendant behaved as they did (indeed liberally inclined thinkers tend to feel that the criminal justice system focuses too much on individual responsibility and not enough on societal causal factors when punishing people), but it works tolerably well for assigning a certain sort of criminal responsibility.
Bringing environmental factors further into the foreground may serve a valuable purpose in the mental health debate. Consider this passage from Peter Zachar's book A Metaphysics of Psychopathology:
Zachar brings out the element of choice we have in identifying causes. Exactly what we choose to call a cause depends in part on what aspects of the whole situation we consider "background conditions". He does not imply that the choice is limitless (he is not a relativist about causes), but he does suggest that where you turn your investigative attention may legitimately be a function of your interests; a function of what aspects of the total situation you feel to be most relevant.
What motivates psychologists who see trauma and "life events" as significant in causing mental distress is a refusal to see various forms of adversity as a "background condition". Sure, genetics plays an important role, these researchers suggest, but the public health implications of that fact are not immediately clear. Meanwhile, the public health implications of an aetiological role for traumatic life events are obvious; we should aim to stop people being exposed to them. As Peter Kinderman says in the article I linked to at the top, "when unemployment rates go up in a particular locality you get a measurable number of suicides".
If asked, I am sure Kinderman would deny that a change in economic circumstances is the whole causal story in any given suicide. Likely a host of factors (personality variables, social support network and so forth) combine to create something like more or less "resilience" in people. But unless you can intervene to improve that resilience, it makes sense to push it some way into the background and focus on things you feel you can change. If you do this, life circumstances and political events start to look more like "difference makers", even if we can still have a debate about what constitutes a cause.
______________________________
* UPDATE: I originally cited the figure 48% here, reflecting the commonly quoted probandwise concordance rate for schizophrenia in identical twins. 28% reflects a lower estimate of concordance, based on a pairwise concordance rate. There is some controversy over which rate to cite, and as this post was an argument for greater focus on environmental factors, I did not want to lay myself open to the charge of minimizing the genetic contribution. However, it was suggested to me that the probandwise rate is an inflation of the true concordance rate, and for the time being I'm inclined to agree. Nonetheless, there are good arguments for using the probandwise concordance rate, and when I have better understood the issue, I will try to write a post outlining them.
Friday, 25 March 2016
Mental Health Conferences and Service User Inclusion
I'm just back from a fantastic conference laid on by the History and Philosophy section of the BPS, and the Critical Psychiatry Network (thanks to Alison Torn at Leeds Trinity University for putting together such a great programme).
Beyond the content of the papers, I was struck by the way that the event recapitulated an ongoing tension evident around the inclusion in academic spaces of "experts by experience". Conferences like this are increasingly attended by people who have experience of using mental health services (a fact which seems essential if "critical" aspirations are ever going to bear serious fruit), but are they always included effectively?
One attendee noticed a bunching together of service user talks into a single session:
Did this encourage the use of kid gloves with service-user researchers? Or set up an implicit distinction between more and less "professional" research? Rather than dividing presenters up by identity (into service users and professionals, or experts by training and experts by experience), a useful distinction might be between people who are attending a conference with the purpose of presenting research and those who are giving testimony.
There is nothing about service user produced research that makes me feel inclined to judge it differently than that produced by non-service users. It will be a very good thing for everyone if more research is conducted by people on whom it has a direct bearing, but it is subject to the same scrutiny as research conducted by anyone else.
Service users who deliver testimonials however are doing something very different. Their words are personal and a degree of emotional risk is involved when you disclose intense experiences and give voice to anger. We don't subject this sort of testimony to the same degree of quarrel, nor pore over it in quite the same "academic" manner as we do a theoretical exposition or literature review.
Making a research/testimonial distinction might create greater clarity about what we want service user inclusion to do for conferences (and for service users), because at least two distinct goals seem to be in play. One is that service users be included in mental health research in a way that expands our epistemological horizons and rejects a hierarchy that privileges some researchers over others. The other is for people to be able to speak at such conferences when they may not have the means or the interest to develop research per se, but nonetheless have something important to say.
Thursday, 21 January 2016
Something's Missing: What Psychotherapy Research Leaves Out
It is common to hear, in discussions about the value of psychotherapy research, that nomothetic outcomes leave out some indiscernible inter-personal human "magic". That there is something missing from psychotherapy research, which renders its findings essentially moot. So often do I hear this point in discussions, that I want to take it on and suggest that it presents less of a problem than is generally supposed.
When the "something missing" argument is wielded in a debate about research, two consequences usually seem to be implied:
1. That psychotherapy research cannot tell you very much about what psychotherapy is really like, and so should not be trusted in appraising whether it is helpful.
2. That psychotherapy research does a sort of crass violence to the psychotherapy relationship itself, and that psychotherapy researchers are naive to think they can capture something so delicate.
When the "something missing" argument is wielded in a debate about research, two consequences usually seem to be implied:
1. That psychotherapy research cannot tell you very much about what psychotherapy is really like, and so should not be trusted in appraising whether it is helpful.
2. That psychotherapy research does a sort of crass violence to the psychotherapy relationship itself, and that psychotherapy researchers are naive to think they can capture something so delicate.
The "something's missing" argument is often stated as though it were a knock-out blow to the value of outcomes research. It isn't. That something should be left out whenever we attempt to measure or represent something else is a banal truism. It simply presents no problem to the project of learning about reality. I am sure I have quoted Paul Meehl on this question before. In his book on statistical prediction, he refutes those who claim that any aspect of human behaviour is too complex to be in principle predictable from regression models, because humans are "more than" the models in question:
"A cannon ball falling through the air is “more than” the equation S=½g, but this has not prevented the development of a rather satisfactory science of mechanics".
The same goes for all of science (the full reality of a Large Hadron collider is more than the sum of the research produced by the physicists who work with it, but the research they produce does not lack veracity or utility in virtue of that fact) and the humanities too (no quantity of historical books on the American Civil War will ever completely reconstruct the experience of someone who fought in it). In fact, it is inherent to representing a state of affairs in any form other than the original.
So yes, psychotherapy research has "something missing", but that is trivial and we have to either accept the limitation or offer solutions to it (which is to say, become methodologists rather than critics). The choice we have is not between trite, uninformative quantitative research and rich-full-blooded qualitative information, it is between some combination of those two approaches and sheer guesswork.
Quantitative research does not just forget the magic of the interpersonal encounter, it factors it out in a bid to discover a separate numerical truth: how many people show some sort of measurable improvement (and how much of one)? This can look clumsy, but it is actually necessarily revealing to escape the persuasion of interpersonal charm and the therapeutic relationship. Think of a doctor like John Bodkins Adams, who appears to have been very successful interpersonally. He was sufficiently charming that he received money from many of his patients in their wills and became a extremely successful GP. Only something as crass as a body-count (Bodkin-Adams may have killed as many as 160 of his patients) revealed that something untoward was going on.
We should think of psychotherapy outcome research as analogous to the body count. Without it, we are too apt to be misled by the charisma and good intentions of the therapy industry.
Monday, 4 January 2016
Unpacking the "illnessy intuition"
Last summer I wrote a post examining why, in the face of fairly wide dissatisfaction, the concept of schizophrenia seems to show such tenacity. As part of that argument I invoked the idea of an intuition that people have about schizophrenia; namely that it seems there is often something "illnessy" there:
At the time, someone rightly pointed out that this is a weak point in the inferential chain.
"There is a way in which the diagnosis is very convincing; on the face of it many people who meet criteria for schizophrenia seem to be seriously unwell and many of them will testify to that fact.
...even with skepticism about the DSM construct [of schizophrenia], many people's intuitions are that there is something illnessy about the experiences which commonly attract the diagnosis."
At the time, someone rightly pointed out that this is a weak point in the inferential chain.
Interesting argument. Not sure about the scientific validity of the "something illnessy" intuition, though. :-)
http://t.co/FPSP8JdGd5
— Jane E.M. Callaghan (@JaneEMCallaghan) July 25, 2015
To some extent this does not matter, as my post was not an attempt to justify the continued "success" of the schizophrenia concept, but rather to explain it. Thus, I do not need to show that the "illnessy intuition" is scientifically valid, only that it has a hold on people's imaginations. However, if you detected a note of endorsement in my post, that is because it was there. I do not really believe in the notion of schizophrenia as illness, but unlike some critics, I do not think it is warranted to conclude that no-one who meets the diagnostic criteria is ill. In some cases the illnessy intuition is valid. Here's how.
Defining illness is slippery, and I am not going to get into philosophical debates here about how to arrive at a definition. For my purposes I don't need to. Some phenomena are so widely agreed to be illnesses that to describe them in any other way seems redundant. I could argue, for example, that leukemia is not an illness, but generally we accept it is because that framework has remained the most useful game in town.
The same appears to be true of some of the phenomena which can give rise to a diagnosis of schizophrenia. It has recently been suggested that some proportion of individuals with "schizophrenia" may actually have a form of NMDA-receptor encephalitis, a brain disorder which is treatable. If these people are not considered ill then two harms arise; they are denied effective medical treatment, and they are denied an adequate narrative account of their distress.
It is this fact that gives rise to the "illnessy intuition" in the case of schizophrenia, and for two reasons. The first is that some unknown (and possibly quite high) percentage of cases clearly arises from biological states of affairs which it will prove useful to describe as illnesses. Think not only of NMDA receptor encephalitis, but also of the conditions, and pharmacological treatments, which are yet to be discovered. The second is a sort of reasoning by analogy. If the set of symptoms associated with schizophrenia can be produced by an illness then it stands to reason that even cases which are not produced by the same phenomena might reasonably be construed as illness, pending a fuller explanation.
None of this speaks against the project of providing alternative non-medical narratives for understanding the suffering associated with psychosis. As I said in the original post, we don't yet know how (or if) all cases of schizophrenia will wind up being explained.
Defining illness is slippery, and I am not going to get into philosophical debates here about how to arrive at a definition. For my purposes I don't need to. Some phenomena are so widely agreed to be illnesses that to describe them in any other way seems redundant. I could argue, for example, that leukemia is not an illness, but generally we accept it is because that framework has remained the most useful game in town.
The same appears to be true of some of the phenomena which can give rise to a diagnosis of schizophrenia. It has recently been suggested that some proportion of individuals with "schizophrenia" may actually have a form of NMDA-receptor encephalitis, a brain disorder which is treatable. If these people are not considered ill then two harms arise; they are denied effective medical treatment, and they are denied an adequate narrative account of their distress.
It is this fact that gives rise to the "illnessy intuition" in the case of schizophrenia, and for two reasons. The first is that some unknown (and possibly quite high) percentage of cases clearly arises from biological states of affairs which it will prove useful to describe as illnesses. Think not only of NMDA receptor encephalitis, but also of the conditions, and pharmacological treatments, which are yet to be discovered. The second is a sort of reasoning by analogy. If the set of symptoms associated with schizophrenia can be produced by an illness then it stands to reason that even cases which are not produced by the same phenomena might reasonably be construed as illness, pending a fuller explanation.
None of this speaks against the project of providing alternative non-medical narratives for understanding the suffering associated with psychosis. As I said in the original post, we don't yet know how (or if) all cases of schizophrenia will wind up being explained.
Wednesday, 9 December 2015
Psychoanalysis and Schizophrenia?
I've just finished reading Christopher Bollas' newest book When the Sun Bursts, about his work providing psychoanalysis to people going through psychosis. I realised I feel very mixed about it, and I suspect this tells me about my ambivalence about psychoanalysis more generally.
Psychoanalysis and schizophrenia fell out with one another in the 1980s, when the idea that the latter was a brain based disorder began to usurp the notion (mainstream in the 1950s, 60s and 70s US) that it was a psychological reaction originating in family dynamics. Many things contributed to the therapeutic divorce. The overall background was the rise of biological psychiatry and the renewed interest in using the DSM as a systematic tool for empirical research, but several historical events also conspired to paint psychoanalysis in a particularly unfavourable light. One major blow was the Chestnut Lodge Follow Up Study, conducted by Thomas McGlashan, a psychiatrist with sympathies to psychoanalysis who became curious about how effective it was. He examined the long term outcomes of patients at Chestnut Lodge (pretty much the world center of psychoanalytic treatment for schizophrenia) and concluded they were not being helped by their treatment. Another was the Osheroff Case, in which a physician with severe depression was treated psychodynamically and tried to sue Chestnut Lodge for not deploying the most effective treatment.
The Osheroff case did not actually concern an individual with a diagnosis of schizophrenia, but the principle at stake (whether psychoanalysis was an effective treatment for a severe and enduring psychological difficulty) was highly relevant to that diagnosis. Furthermore the case concerned treatment at, again, Chestnut Lodge. Many histories of psychiatry cite these events as key factors in the decline of psychoanalysis as a treatment for schizophrenia. One such (Edward Dolnick's Madness on The Couch) reads as a stern polemic, taking psychoanalysis to task for victim blaming. Another, Jeff Lieberman's Shrinks (review by me here), is a good example of how contemptuous many psychiatrists are about Freudian therapies and ideas.
So in one sense, Bollas' book looks like an anachronism. Few now expect psychoanalysis to ameliorate psychosis anymore, and Bollas is aware of the of how widespread is this view. He skirts the issue:
But goes on to makes a claim (a few pages later) which is quite definitie in nature and would require just the sort of outcome study that Bollas has recently repudiated:
This sort of sophism is irritating; does Bollas want to claim his approach is effective, or does he not? It's tempting to dismiss him altogether at this point, but does reading someone like Bollas have anything to teach us? I think it might.
It is not totally outlandish to suggest that R.D. Laing wrote one of the 20th century's best books about psychosis. The Divided Self is an unparalleled masterpiece of phenomenology (read it if you haven't already). Yet at the same time, there is also something approaching consensus (from what I have read) that his major therapeutic innovation, the Philadelphia Association, was something of a failure. Sure you can read Mary Barnes and Joe Berke's favourable account of a "Journey Through Madness", but when it comes to a more overarching view of the project (as found in Daniel Burston's very respectful biography of Laing), it doesn't look like the majority of people were helped any more than they would have been without the Scottish guru.
What Laing offered the study of psychosis then was not a viable alternative therapeutics (ultimately it's not clear that his notion of psychosis, as a revelatory journey one must past through, offered the sort of safety and serenity that might be optimal in a residential setting) but a powerful vision of how we can approach highly disorganized and disoriented people as people, with a degree of empathy and openness to listening to their experiences. Whatever packaged and marketed therapies are regarded as appropriately evidenced and offered in healthcare services, this sort of humane engagement is not only highly desirable, it is unavoidable. Whether you are discussing a person's medication, their experiences or their occupational aspirations, you need some way of taking them seriously and understanding what it might be like to live in their head. Laing's description of ontological insecurity, followed by the development and ultimate collapse of a protective "false self" system allowed clinicians to at least imagine what might lead to behavior which is so confusing as to be routinely described as "mad".
It is this kind of imaginative material that Bollas offers, and it is what makes his new book worthwhile for clinicians, even if they don't follow him all (or even most of) the way. Bollas and many other analysts (and not just analysts) may eschew the value of evidence in psychotherapy, but that doesn't invalidate everything they have to say. Whatever you think of the benefits of psychoanalysis as a therapy, it still has potential as a mode of observation and phenomenological hypothesis forming. None other than Paul Meehl once wrote a very effective argument to the effect that the un-testability of many psychoanalytic assertions does not itself render them untrue or worthless. If you take empathetic and highly attentive individuals (psychoanalytic clinicians) and put them in a situation in which they observe people's verbal behaviour over long periods of time, it seems highly implausible that they wouldn't derive any very insightful and useful ideas about how minds work.
Bollas' book has many such ideas. He suggests that the symptom of hearing voices is the result of "despositing" unwanted parts of the self in the environment such that they start to talk back to you, representing aspects of your past in ways that demand to be listened to. He describes the experience of the separation of the "I" from the "me", such that people with psychosis may split their self and behave in remarkable ways once they have done so . He suggests that people in the grips of a psychosis may be so frightened by their thoughts that they take an (often bizarre seeming) action to prevent having them. This sort of deep meditation gives rise to some remarkably empathetic moments:
Such intuitive accounts may be "wrong" (in the sense that they don't really get at what individuals experience) but they strike me as preferable to a defensive dismissal of people's "crazy" experiences. Many mental health services for psychosis currently isolate patients and ignore their experiences, alienating rather than engaging them. If social isolation is an exacerbating factor in the deterioration of people's mental health, we need to find ways of spending time with such individuals, even at their most disorganized and frightening. At least Bollas (and he is in a long line of psychoanalytic clinicians on this score) is trying his damnedest to connect.
Some of his ideas I found intuitive and quite striking, others (the obscure theory of "Metasexuality") I found maddeningly arcane. As Meehl (and many others) have pointed out, there may be no decent way to adjudicate between them, but unless you subscribe to a sort of rigid Vienna-Circle logical positivism in which statements about the self can only ever be empty "metaphysics", they don't seem entirely worthless. Are we only interested in ideas that are testable scientifically? Surely not; many highly speculative and unverifiable ideas (the dialectic movement of history) are valuable, so long as you have a clear distinction in your mind between them and some notion of "truth". We value novelists and poets who can illuminate their inner worlds through their vivid writing, why not try and find some similar worth in the imagination of psychoanalysts?
If you are still queasy about such unscientific shenanigans, it's worth remembering that a phenomenological account is not inconsistent with an informed empirical one. I'll end with a quote from one of Paul Meehl's best papers:
The Osheroff case did not actually concern an individual with a diagnosis of schizophrenia, but the principle at stake (whether psychoanalysis was an effective treatment for a severe and enduring psychological difficulty) was highly relevant to that diagnosis. Furthermore the case concerned treatment at, again, Chestnut Lodge. Many histories of psychiatry cite these events as key factors in the decline of psychoanalysis as a treatment for schizophrenia. One such (Edward Dolnick's Madness on The Couch) reads as a stern polemic, taking psychoanalysis to task for victim blaming. Another, Jeff Lieberman's Shrinks (review by me here), is a good example of how contemptuous many psychiatrists are about Freudian therapies and ideas.
So in one sense, Bollas' book looks like an anachronism. Few now expect psychoanalysis to ameliorate psychosis anymore, and Bollas is aware of the of how widespread is this view. He skirts the issue:
But goes on to makes a claim (a few pages later) which is quite definitie in nature and would require just the sort of outcome study that Bollas has recently repudiated:
It is not totally outlandish to suggest that R.D. Laing wrote one of the 20th century's best books about psychosis. The Divided Self is an unparalleled masterpiece of phenomenology (read it if you haven't already). Yet at the same time, there is also something approaching consensus (from what I have read) that his major therapeutic innovation, the Philadelphia Association, was something of a failure. Sure you can read Mary Barnes and Joe Berke's favourable account of a "Journey Through Madness", but when it comes to a more overarching view of the project (as found in Daniel Burston's very respectful biography of Laing), it doesn't look like the majority of people were helped any more than they would have been without the Scottish guru.
What Laing offered the study of psychosis then was not a viable alternative therapeutics (ultimately it's not clear that his notion of psychosis, as a revelatory journey one must past through, offered the sort of safety and serenity that might be optimal in a residential setting) but a powerful vision of how we can approach highly disorganized and disoriented people as people, with a degree of empathy and openness to listening to their experiences. Whatever packaged and marketed therapies are regarded as appropriately evidenced and offered in healthcare services, this sort of humane engagement is not only highly desirable, it is unavoidable. Whether you are discussing a person's medication, their experiences or their occupational aspirations, you need some way of taking them seriously and understanding what it might be like to live in their head. Laing's description of ontological insecurity, followed by the development and ultimate collapse of a protective "false self" system allowed clinicians to at least imagine what might lead to behavior which is so confusing as to be routinely described as "mad".
It is this kind of imaginative material that Bollas offers, and it is what makes his new book worthwhile for clinicians, even if they don't follow him all (or even most of) the way. Bollas and many other analysts (and not just analysts) may eschew the value of evidence in psychotherapy, but that doesn't invalidate everything they have to say. Whatever you think of the benefits of psychoanalysis as a therapy, it still has potential as a mode of observation and phenomenological hypothesis forming. None other than Paul Meehl once wrote a very effective argument to the effect that the un-testability of many psychoanalytic assertions does not itself render them untrue or worthless. If you take empathetic and highly attentive individuals (psychoanalytic clinicians) and put them in a situation in which they observe people's verbal behaviour over long periods of time, it seems highly implausible that they wouldn't derive any very insightful and useful ideas about how minds work.
Bollas' book has many such ideas. He suggests that the symptom of hearing voices is the result of "despositing" unwanted parts of the self in the environment such that they start to talk back to you, representing aspects of your past in ways that demand to be listened to. He describes the experience of the separation of the "I" from the "me", such that people with psychosis may split their self and behave in remarkable ways once they have done so . He suggests that people in the grips of a psychosis may be so frightened by their thoughts that they take an (often bizarre seeming) action to prevent having them. This sort of deep meditation gives rise to some remarkably empathetic moments:
Such intuitive accounts may be "wrong" (in the sense that they don't really get at what individuals experience) but they strike me as preferable to a defensive dismissal of people's "crazy" experiences. Many mental health services for psychosis currently isolate patients and ignore their experiences, alienating rather than engaging them. If social isolation is an exacerbating factor in the deterioration of people's mental health, we need to find ways of spending time with such individuals, even at their most disorganized and frightening. At least Bollas (and he is in a long line of psychoanalytic clinicians on this score) is trying his damnedest to connect.
Some of his ideas I found intuitive and quite striking, others (the obscure theory of "Metasexuality") I found maddeningly arcane. As Meehl (and many others) have pointed out, there may be no decent way to adjudicate between them, but unless you subscribe to a sort of rigid Vienna-Circle logical positivism in which statements about the self can only ever be empty "metaphysics", they don't seem entirely worthless. Are we only interested in ideas that are testable scientifically? Surely not; many highly speculative and unverifiable ideas (the dialectic movement of history) are valuable, so long as you have a clear distinction in your mind between them and some notion of "truth". We value novelists and poets who can illuminate their inner worlds through their vivid writing, why not try and find some similar worth in the imagination of psychoanalysts?
If you are still queasy about such unscientific shenanigans, it's worth remembering that a phenomenological account is not inconsistent with an informed empirical one. I'll end with a quote from one of Paul Meehl's best papers:
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