Friday, 23 March 2018

Boundaries

The psychologist's interest in boundaries is the source of much well deserved mockery. Apart from the jargonistic deployment of "boundaries" as a justification for various therapeutic prohibitions (second only, perhaps, to the use of "inappropriate"), the enforcement of a boundary often looks like an effective way of keeping a genuine relationship at bay.

Of course there is a certain necessity to boundaries. Apart from the fact that a professional relationship has to begin and end somewhere (you really don't want your therapist following you home), the moments when a boundary is pushed can provide a useful source of discussion. Take the example of a clear start time for psychotherapy sessions. If someone is repeatedly 15 minutes late for therapy, that is something to be interested in. Sometimes life gets in the way and people are late. No one should be getting too hung up on lateness - we're all adults. But if someone is repeatedly late then something might be going on. A polite person, reluctant to hurt a therapist's feelings, might be having reservations about the sessions. Noticing the lateness and discussing it is a way of drawing attention to something that might be important.

But boundaries can definitely be a fetish for psychologists. There is a deliciously daft example of this in Allan Young's "Harmony of Illusions," a history and anthropology of PTSD and its treatment. Young spent some time conducting fieldwork in a VA hospital during the 1980s. As part of this work he sat in on trauma focused psychotherapy groups where Vietnam veterans were encouraged to broach the atrocities they had witnessed or participated in. Because the therapeutic model put a high value on disclosure, the group members were expected to stay with the difficult content of the sessions and not engage in avoidance. Young describes how the group entered a crisis when it seemed to the psychologists that one of the members was going to the bathroom rather a lot during the discussions.

Because these frequent bathroom trips looked (to the psychologists) a lot like avoidance, the psychologists felt they had to address them. A rule was put in place - no bathroom trips during the group sessions. If that sounds unreasonable to you then you can imagine the reactions of group members. There was something of a revolt and, stuck between the need to stand their ground (notice the power struggle that has immediately snuck in) and the need to be reasonable  the facilitators had to find a solution. The apparently face saving solution elected was for group members to urinate into wastepaper bins in the group room. This met the ordinary human need to urinate without sacrificing the psychologists' insistence on staying in the room to engage with trauma narratives.

Of course, urinating into a bin in a group therapy room is not only undignified, it is patently absurd. It is hard to imagine that the vets in this group weren't aware of this, and Young describes how they availed themselves of the opportunity to relieve themselves with what became an unsustainable frequency. There is a kind of check-mate that has happened here. The staff's desire to focus so heavily on rules over good sense allows the veterans to adhere to the letter of the law while ignoring its spirit. If the facilitators felt any horror at their proximity to increasingly full buckets of pee, they had only themselves to blame.

Versions of this kind of struggle are the bread and butter of inpatient mental health care. It is par for the course that protocols will be set and violated, and that this kind of thing will be grist for discussion. But the descent into naked power struggle is far too frequent. When this happens the staff have the double advantage to setting rules (however unreasonable) and then blaming patients for their violation. If you must leave the room to pee then it has to be your avoidance/aggression/personality disorder that is to blame. This is getting things all wrong. Yes, boundary transgressions (and isn't the language of boundaries so accusatory!) should be discussed. But if some sort of staff/patient power struggle emerges, it is the job of the staff to see this unfolding and to sidestep it. This may have to involve a climb-down and a dose of good old fashioned humility. Of course people go to the bathroom as a form of avoidance (at least, I know I do). If that starts happening then discussion is a better way out than ad hoc rule creation. Any sensible polity can only implement laws that don't burden its participants unreasonably.

Tuesday, 6 March 2018

Eight signs you might be a clinical psychologist

The following criteria for the newly proposed disorder "being a clinical psychologist" have been leaked from the early planning discussions for the DSM-6. They are subject to revision and the committee in charge is apparently still taking suggestions:

DIAGNOSTIC CRITERIA:

A. On hearing an acronym like VAT you assume that someone has devised a new form of therapy.

B. When someone is referred to as "dynamic" you expect them to wear tweed and smoke a pipe.

C. You are extremely concerned about issues of power in healthcare, but you couldn't wait to get "doctor" into your social media profile.

D. The worst public denunciation you can imagine giving of something is to say that it is "very concerning."

E. You own (and have read) at least three books from list 1. and you own (but have not read) at least one book from list 2.

1.
Oliver Sacks - The Man Who Mistook His Wife For a Hat
Irving Yalom - Love's Executioner
Victor Frankl - Man's Search For Meaning
Kay Redfield Jamison - An Unquiet Mind
Norman Doidge - The Brain that Changes Itself
Anything by Jon Kabat-Zinn

2.
Judith Beck - Cognitive Behaviour Therapy: Basics and Beyond
Muriel Lezak - Neuropsychological Assessment
RD Laing - The Divided Self
Carl Rogers - On Becoming a Person
Anything by Sigmund Freud

F. You long to be referred to by someone else as a "geek."

G. You have an unusually intimate knowledge of the surface of raisins.

H. You use the following words or phrases with approximately 46 times their average frequency in ordinary human speech: "narrative"; "coping"; "psychoeducation"; "third wave"

Thursday, 11 January 2018

Of paradigm shifts and professional rifts

It's been nearly five years since the BPS Division of Clinical Psychology (DCP) published a position paper advocating a "paradigm shift" in thinking about mental health. That document might be regarded as a promissory note, with the much-trailed Power Threat Meaning Framework (due to be unveiled within hours of me writing this) representing a more ambitious attempt to make the shift happen. The moment of the PTMF's arrival seems a good time to reflect on some conceptual ambiguity in the paradigm shift idea.

At its most straightforward, a paradigm shift may just mean something like a change of perspective or change of emphasis. This is a good idea. Concerns about the validity of many DSM categories, the inappropriateness of an illness framework for many mental health problems, and the general theoretical paucity of chalking mood difficulties up to chemical imbalance all make a shift of emphasis seem important. Such a shift might mean an increased focus on socio-economic context, historic life events and psychological mechanisms. For sure some have argued (see this post by Paul Salkovskis) that such a change of emphasis is not needed in clinical psychology, and that the DCP is out of touch with how psychologists are trained. But given the overwhelming dominance of the DSM model in mental health in general, a focus on psychosocial factors seems desirable.

However "paradigm shift" also connotes a more specific conceptual frame of reference: Thomas Kuhn's Structure of Scientific Revolutions. Kuhn's argument offered a historically and sociologically inflected re-writing of scientific progress. Science - under this view - doesn't proceed in increments, rather there are periods of tidy problem solving (normal science) punctuated by large shifts in understanding that usher in a new framework and render the old one redundant.

I have seen periodic hints that the Kuhnian sense of paradigm shift is what the DCP document is promoting. The clearest example is the closing passage from this paper, co-authored by contributors to the DCP position statement:


In the history of science, Kuhnian shifts have occurred where a radical development in knowledge made it impossible to think about things in terms of an old theory. Phlogsiton theorists and oxygen theorists were battling over the same territory, engaged in a scientific zero sum game. Once you are in possession of the theory of oxygen, the theory of phlogiston cannot also be true. Similarly with the Copernican revolution. Once you accept that the evidence suggests the earth rotates around the sun, it cannot also be true that the sun revolves around the earth. In short: if one group was right the other had to be wrong.

The current situation in mental health doesn’t resemble anything like this. Yes there is a difference between the idea of a predominantly genetic or biological illness vulnerability that is triggered at some point, and a normative trauma response that makes sense primarily in psychodynamic terms. These are no doubt radically different ways of viewing one sort of problem. But the sprawling field of mental health is not centered on just one sort of problem, it contains multitudes. Different problems will be more or less well understood under different frameworks.

Unlike Phlogiston vs. Oxygen, it is not the case that one form of explanation makes the other unthinkable or impossible (i.e. “because people have psychological reactions to trauma and to ongoing relational/political experience of poverty if follows that no one has a mental illness”), but rather that a range of different types of psycho-social-physiological phenomena exists and no one can quite agree on how much explanatory weight to place where. What we see in mental health is not a steady march towards the new integrative paradigm, but a slow iterative process of deciding that such and such a thing is more disease-like or more socially-determined.

Why is this important? The idea of the Kuhnian paradigm shift creates a worldview on which you are either with progress or against it. Conceive of your experiences as illness? Too bad for you, the historical bandwagon ain't stopping. Your particular psychosis results from an as-yet poorly understood neurological problem? Get with the programme! This attitude can be exclusionary. For all that many are liberated by discarding individualising ideas like personality disorder, there are others whose problems cannot be understood by appeal to life events or social circumstance. 

It can seem that would be paradigm-shifters want to have their theoretical cake and eat it. One the one hand the argument relies substantially on the (to my mind essentially correct) point that DSM-categories lump together disparate phenomena and are thus “invalid” as descriptions of “real” entities. On the other, the assertion is then made that these things (meaning these problems that we used to call schizophrenia, depression, bipolar disorder or what have you) are not illnesses at all, but normative reactions to circumstance. The first hand bestows a sort of complex pluralism (not everything that gets called “schizophrenia” is actually a brain disease) but the second takes it away.

Wednesday, 25 October 2017

The ethical dilemma of transformative psychotherapy

Psychotherapies - it is often said - are unlike other medical interventions. Where most medical procedures are targeted at bodies and their sub-personal mechanisms, psychotherapies happen to people. We can get up a debate about how consistently this is true. Some psychotherapists target only specific behaviors, and many medical interventions have profound rippling effects on persons, but there is something to the distinction. After some experiences of therapy people make all sorts of unpredictable changes. Relationships are ended, jobs are left, and entire patterns of living might shift. The hope is that these changes will be positive but that is not always the case. There is an emergent literature (example here) on the negative side effects of therapy. Additionally some (this letter being an example) have questioned the shift in role that takes place in the creation of psychotherapy patients, making them "psychologically dependent on their therapists and their therapists [...] financially dependent on them." Psychotherapy changes us in all sorts of ways - some of them dramatic.

The philosopher L.A. Paul raises an interesting problem for what she calls Transformative Experiences. In a nutshell the problem is this: when you make decisions about your life, you are choosing for a future version of your self whose preferences you can broadly anticipate. I decide to book a holiday in the mountains because I know myself well enough to know that I will enjoy the scenery, the walking and so on. But this is not true, Paul argues, for all the decisions we make. Some experiences are transformative, meaning that our entire preference structure is altered when we have them. This makes some decisions radically different in type. Among other examples Paul raises the experience of having a baby. When you decide to become a parent you make a decision that may make you into a version of yourself you could not have anticipated. You don't just have to reckon with the question "what will it be like?" but also "what will I be like, and will the future me be happy?"

If psychotherapy ever fits the bill as an example of one of Paul's transformative experiences, then there is a special problem in the vicinity, because it is a process that is subject (in some jurisdictions) to the provision of informed consent. Informed consent is an important way of respecting the autonomy of people who enter into psychotherapy. a person cannot meaningfully agree to something they haven't had the chance to understand. The Wiley Encyclopedia of Clinical Psychology (linked to a few sentences ago) sets out part of the obligation thus: "psychologists should inform clients at the earliest possible point in time about numerous aspects of the treatment, including its nature and  expected course." Expected course? What should you say to someone embarking on a process that could change not only their lives but also their self? The person entering therapy might welcome the changes, but will that also be true of the person left over when the changes have been made?

Psychotherapy presents many of the same ethical worries as more straightforwardly medical interventions. It's outcomes will never be completely predictable, and it can do harm as well as good. But it is unusual among clinical activities in that its aims sometimes include changes to whole personalities. L.A. Paul's work on Transformative Experiences illustrates the way that psychotherapy presents both a personal dilemma ("should I embark on psychotherapy given I can't predict my preferences once it has finished?") and a professional one ("should a clinician recommend psychotherapy given the limits on the possibility of informed consent?")

Wednesday, 27 September 2017

The psychiatric diagnosis debate does not exist

As someone who has a slightly excessive relationship to aspects of the psychiatric diagnosis debate, I was relieved to see Vaughan Bell's excellent post on the topic. It gave me a sense of an emerging clarity as a number of shibboleths were put to rest. But my equilibrium didn't last for long. In the comments section there soon appeared counter arguments that not only pushed back against the original post, but seemed to resist its entire intellectual framework. As ever some were really nasty.

The nastiness results - in part - from the fact is that the debate in question is not really one debate, it is a cluster of related debates, which subdivide further into a whole series of difficult questions. Those questions are distinct, but are nonetheless bound together in a tightly woven network such that it is hard to start to answer one of them without first taking a view on the questions in nearby nodes. Pick up one node and the others nearby come with it. So when you adopt one position it can seem to are endorsing others too. Nonetheless it might be possible for any given individual in the discussion to hold a view that answers this constellation of questions in a way that is entirely idiosyncratic.

No wonder it is so hard for anyone to agree. No wonder this has occupied people for so long. Unfortunately the unpleasantness doesn't make the debates any less important, just harder to have. One way to ease up on the twin vices of tribalism and triumphalism is to back away from the temptation to have more answers than questions. A switch to the interrogative brings forth a cascade of loosely grouped considerations:

The DSM debate:

Is the DSM any use?
Does it do more harm than good?
Are its categories ever reliable?
Are they ever valid?
If a diagnosis is invalid, does an expert in, say, Bipolar Disorder still have expertise?
What is the nature of that expertise?
How important is it that DSM diagnoses are formed by committee?
Is matching to criteria better or worse than prototype matching?
Is the DSM really atheoretical?
Should it be?
Were we better or worse off before the DSM? 
How seriously would one have to take the DSM in order to find some uses for it?
Is the DSM a primarily cynical enterprise?
Should it be replaced?
With what?

The diagnosis debate:

Does diagnosis have sufficient merit to be used for mental health problems?
What is a diagnosis?
Does it need to consist of more than purely descriptive terms?
Does a diagnosis necessarily efface a person's suffering/identity/personal understanding of their experience?
Is diagnosis a good thing?
Is diagnosis a bad thing?
How bad?
Is it as bad as punching someone?
As apartheid?
As Nazism?
Is diagnosis consistent with a formulation?
Is a formulation closer to the dictionary definition of "diagnosis" than most diagnoses manage to be?

The illness debate:

What makes something an illness?
Is it defined by biological marker?
Do people who experience chronic fatigue have an illness?
What about people who become depressed?
Or develop psychoses?
Or become manic?
Or tic?
Or rage?
Who decides whether someone is ill?
Them?
You?
Someone who wrote a clever technical definition of illness?
Do we need to be consistent about it?
If some people who meet criteria for a diagnosis regard themselves as having an illness while others don't, what do we do about that?
Over what aspects of your behaviour do you retain responsibility when you are ill?
How could we come to agree about where the answers could come from? 

The aetiology debate:

Why do people come to develop anxiety/depression/psychosis?
Is it ever sensible to give a diagnostic label to experiences that result from trauma?
What would it mean for something to be genetic?
What would it mean for something to be environmental?
Is it eugenics to implicate genetics in mental illness?

The meta debate:

Why do we all get so het up about this?
Are we really debating what we think we are debating?
Is it worth it?
Is it better to take a strong, unequivocal view on these issues and stick with it?
Is it a guild dispute?
A turf war?
Is anyone helped?
Is it indecent to enjoy it?
Is it negligent to ignore it?

Wednesday, 16 August 2017

Sovereign Citizens: A Psychiatric Edge Case

Between clear cut cases of delusion and ordinary beliefs lies an interesting no man's land. It's difficult (arguably impossible: 12) to clearly define a delusion, so the border between ideas that are and are not of psychiatric concern is uneasily guarded. One strand of this pragmatic policing involves considerations about how widely shared a candidate belief is. If lots of people believe something - even if that something is manifestly false or at odds with other culturally mainstream ideas - it is less likely to be judged a delusion.

This issue comes up infrequently in regular mental health work. Most clinically significant ideas are personal and are causing people terror. An individual who believes they are being injected with AIDS every night is almost certainly not in possession of a shared belief. Such a belief is first personal, not belonging to a broader cultural web.  But in forensic psychiatry, where people often endorse unusual beliefs that get them into trouble, determining whether a belief represents a delusion can sometimes be more complex. It also has significant ethical and legal implications. Reasonably widespread but relatively obscure belief systems can fall into the psychopathological no man's land.

One distinctively North American example is the Sovereign Citizen movement, brought to my attention by a forensic clinical supervisor who has evaluated some adherents for their competency to stand trial. This is a terrain in which Sovereign Citizens are assessed with some frequency, as their beliefs bring them into direct conflict with the US legal system. There is no single coherent belief system (check out this link to the Southern Poverty Law Center,and the papers linked below for more information), but adherents believe a diverse mix of things about their relationship to the state. Broadly - as implied by the name - Sovereign Citizens take themselves to be technically legally independent of the government. For at least one strand of believers this is because they think that they were put up as collateral for US government debt when the dollar came off the gold standard in the 1930s. By cashing themselves in against this in some way Sovereign Citizens seem to hold that they can opt out of the country's laws.

As a result these individuals are not very cooperative participants in legal interactions. They present police with fake government documents to evade basic traffic regulations. They commit violent crimes but refuse to enter pleas. Their lack of cooperation sometimes extends to levels of disruption that require their ejection from court. It may be that their anti-government beliefs elevate the risk that they will break the law. They are frequently violent, and are regarded as a domestic terrorist threat in the US. For the seriously interested, there is a Reddit thread devoted to collecting (and mocking) their antics. 

But what do mental health professionals make of these individuals? They certainly have idiosyncratic and over-valued ideas. Their behavior is sometimes described as "bizarre." When they put forward their ideas they talk in a strange pseudo-legal language that sounds idiosyncratic and grandiose, resembling what Silvano Arieti called "talking on stilts." But the limited available literature suggests a wariness to include them under the umbrella of the mentally disordered. Sovereign Citizens share their beliefs with other people; they are typically able (if not always willing) to converse with professionals, and they don't necessarily meet other criteria for mental health problems. A good case series can be found in this article by a US psychiatrist, and their spread into Canada is evidenced in this article by two University of Toronto psychologists. The case of Sovereign Citizens provides a fascinating example of a distinctively American extreme belief system somewhere between the religious and the legal. It also speaks against the worry that the country's mental health care is nothing more than a way of regulating political and social deviance. 

Tuesday, 1 August 2017

The Pool of Explanations

I'm loathe to return to this subject. Sensible Twitter voices have lamented the repetitive diagnosis debate, and it fuels ugly disagreement. But it is an issue I care about, and one that really matters, so here goes.

A couple of years ago I wrote a post in response to DCP guidelines on psychologists' language in mental health. This week a sharper, wittier writer has made similar points. It brings up all the same arguments, which have played out on Twitter in a remarkably similar way. 

For the avoidance of bad feeling, I would like to address this post directly to people who would normally disagree with me. I want to make a short, good faith argument and try to persuade you of the merits of what I said then. But I want to do it in a way that brings you with me. I plead for your good humour and open mindedness. Despite the siloing that happens in social networks, virtually everyone who engages in this debate is on the same page in one major respect. Everyone wants better mental health care. 

Why does such a goal lead to concern about the DCP guidelines? It has to do with the pool of explanations. The pool of explanations is the set of viable theories a person has available to them to make sense of their psychological suffering.

The great liberating component of opposition to diagnosis has been in the push to a wider range of explanations for people to use in making sense of their experiences. We want to move beyond limiting and dominant accounts like simplistic versions of the chemical imbalance theory, or over attachment to DSM categories. However, the mind is so mysterious that very a relatively small proportion of historical theories (see e.g. the "schizophrenogenic mother") can really be conclusively junked. For the time bring,  more is better. Frameworks that emphasize the importance of trauma, of relational and interactional factors, and of intrapsychic processes have pulled back successive layers of mire from our vision of the field, and have liberated many people. Frameworks that talk in terms of illness and diagnosis continue have real meaning for others. This isn't controversial.

Until a new epoch of more comprehensive mental health theory, it is absolutely incumbent on us to continue to grow the pool of explanations rather than shrink it. Shrinking the pool pushes people out. Enlarging it means more imagination, more discovery, and more choice. This is not a call for a slide into relativism. We need a range of ways of getting at the single inarticulate truth. We need a cacophony of voices in order to approach understanding.

The DCP language guidelines were not an expansionist project. They sought to shrink the pool of available explanations. This was for noble reasons, but with unintended effects. They alienated people who do relate to diagnostic/illness language, and they policed the language of professionals who already prize reflectiveness and theoretical pluralism. As someone who works with the confounding complexity of mental health every day I value explanatory pluralism. You can refine language to avoid harm, but you cannot make reality more tractable by dispensing with whole swathes of lived experience. This is not an ill tempered intellectual game we are playing. It is real people and their real sense of self. It matters.