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.

Tuesday, 18 July 2017

Being Difficult

When my son was born, a simple administrative error on the part of the insurance company (they temporarily gave him the "wrong" gender) meant that the hospital did not get immediately reimbursed for the costs of the birth. American healthcare companies are expert at extracting money from patients. Even when the error had been resolved and the insurance company was in the process of paying, we received a quick succession of increasingly threatening letters for a sum that would have been ruinous to almost anyone, let alone two graduate students. When the letters started to include indicatinons that they were from a debt collection agency, I called the hospital billing department. I didn't intend to be particularly pushy, but the conversation took a turn toward the perverse. I was told that they had not forwarded the claim to a debt collection agency, and that I shouldn't worry. I felt like I was being gaslighted. I was holding a letter that said, in caps, that it was sent by a debt collection agency. I pointed this out. Again the agent asserted that the case had not been forwarded. Someone's vision of reality was under threat, and I wasn't about to relinquish mine. I got...shirty. I raised my voice, I told the agent that I felt like I was in Alice in Wonderland.

I don't feel proud of telephone rudeness, but I don't feel ashamed either. This is unusual; I am a person who is prone to deep bouts of shame. I think everyone needs to be difficult sometimes. When dealing with large organizations it is often unavoidable. We are under pressure, faced with an unsympathetic or belligerent representative, or just with a good old fashioned jobsworth. A bit of assertion greases the wheels. A but too much assertion can really get the job done. 

So being difficult is something we tolerate. It feels like an allowance to be spent under certain conditions. But in mental healthcare the allowance is far smaller. Recently I have had several experiences in which patients have spending some of this allowance, and it has come back to bite them. It's not
 my place to share the details, but suffice it to say that they include more or less reasonable assertiveness, some fragile professional egos, and a healthcare system that is far less used to regular pushback from users. They have made me think. If I had been a psychiatric patient my pushiness around the billing might have been more readily shrugged off.

In mental health care, the users of services tend to get pushed around a lot more than in other systems. They are typically more likely to be used to being treated this way by professionals. If they aren't, then learned passivity is one adaptive response. It is rare for a mental health professional to have to explain themselves in plain English, or to give reasons for a decision. Their word so usually goes, and when it is questioned they are tempted to describe someone as being oppositional, even Borderline.We should be energetically resisting this tendency for all we are worth.

Yes there are people who need more effective ways to problem solve.If difficult is all you can ever be, you soon find out that it stops working for you. Something useful for a sympathetic outsider to do is to flag such tendencies in a way that you can recognize, and even help look for alternatives. This might be one of the best uses of psychotherapy. 

But often the soul-searching is on the professional. We don't ask often enough why our decisions have resulted in anger or distress. Sometimes the reasons are subtle and complex. It is reasonable not to have realized, but we really should learn. Sometimes the answer is more obvious and our failure is staggering. At their best healthcare systems can be infuriatingly counterintuitive. At their worst they are absuive. Staff have a duty to acknowledge this and to not be part of the problem.



Thursday, 6 July 2017

History of psychiatry. History as psychiatry.

Somewhere between symptoms and intentional actions lie behaviors that are both deliberate and compulsive, owned and alien. Such behaviors are troubling, either to the people who so behave or (more commonly) to those around them. How do we make sense of actions which can't be fully explained even by their actors? Psychiatry has tended to ascribe meanings at the personal or sub-personal level. But such explanations break down when behaviours interact with broader social patterns, messily assimilating, communicating and discharging. Psychiatry needs a wider angle lens; psychiatry needs history.



This truth is brought into relief by Sarah Chaney's book Psyche on the Skin, a wonderful new history of self harm. That such an important and enjoyable read could have arisen from someone's PhD thesis seems almost a little unfair. 

Chaney's subject threatens to pull apart any coherent historical account. The history of self-harm strains in almost as many different directions as there are acts and actors. This is not a limitation of the project, it is part of its point. In its prehistory (Chaney demarcates as "prehistory" those forms of self-harm that preceded psychiatry and thus escaped its codification), self harm could signify religious piety, self-cure, or sexuality among other things. Individual motivations may have involved some all or none of these and to different degrees. At different times, a cultural framework made specific forms of self-harm intelligible. Religious flagellants acted under a description which accounted for their behaviour. When particular expressions of religious zeal came to be less widely shared, they looked more and more pathological. When medicine stopped endorsing so widely the practice of bleeding, the impulse to purge in this way looked less like a cure and more like an illness. Psychiatry's arrival signalling a shift to a new over-arching lens. Self harm became the sign of a simple psycho-biological "morbidity", an inwardly directed aggression, or an attention-seeking malingering, depending on which psychiatric epoch you lived through. 

The surprising fact at the heart of this book is the diversity of forms self-harm has taken, even in its recent history. The diversity of the associative networks it has occupied. Each era finds new ways to physically manifest misery. These have fluctuated through the ages. It is tempting to frame this in terms of a trend, but something else also played a role. Chaney presents evidence that the prominence of a phenomenon in the medical literature did not accurately represent its prevalence in reality. In the last two decades of the 19th Century, around 25% of publications on self mutilation focused on castration, but this was seen only around 2% of self-harm cases admitted to the Maudsley. For less headline grabbing phenomena (picking and "knocks") the statistics were approximately reversed. British alienists developed a penchant for the sensational, and this of course shaped their view of what they were studying. 

The running theme here is not the search for some over-arching cultural true meaning that can be bestowed on self harm. Rather it is psychiatry's engagement with the phenomenon that is under scrutiny. Each chapter unfolds like a historical case study, but the objects of the case study are the doctors who have tried to bring order. Self-harming persons are not absent by any means, but Chaney declines to speak on their behalf. Instead they appear in simply elaborated descriptions or images, silently looking out at us like Robert H, photographed in the Maudsley hospital at the end of the 19th Century. 

Chaney's treatment of these individuals reminds me of Ian Hacking's approach to fuguers in "Mad Travelers." She doesn't pretend she can account for the behaviour of someone who rubs at their head until their hair has worn away, or inserted needles into her skin, she simply presents facts. We are left with a respectful outline, of people doing perhaps what they had to, or felt they had to do under the circumstances. My reading of the book dovetailed with the broadcast of Hilary Mantels' Reith Lectures, which proved apt. Mantel reflects on the impossibility of a fully psychologically informed history. History for Mantel is
...the multiplication of the evidence of fallible and biased witnesses, combined with incomplete accounts of actions not fully understood by the people who performed them. It’s no more than the best we can do, and often it falls short of that. (page 4)
So in providing an honest history, Chaney offers a subtle contrast to the confident and totalizing narratives of many of her psychiatrist and psychologist subjects. She doesn't overdo it (her book is not a polemic), but the desperate need to explain and domesticate self-harm is a thread that binds a diversity of medical encounters across time. Confident pronouncements abound, particularly during the psychoanalytic heydey of the US in the 1950s. Psyche on the Skin expands the historical horizon, and in turn shrinks the parochial theoretical perspectives of its medical and custodial protagonists. There is a clear lesson here for modern practitioners; resist too strong an attachment to your theory of choice, otherwise anachronism awaits.

There is a personal note to this book too. Chaney has her own experiences of self harm. In her conclusion she says "The history of medicine has been a solution for me in the way medicine itself never was." There is a warning in there for those of us who would too readily organize our own lives around the particular brand of sense-making that is mental health care.

Saturday, 20 May 2017

The first modern survivor advocate?

I could not but respect the mind that had laid out so comprehensive and devilishly ingenious and, at times, artistic a Third Degree as I was called upon to bear. And an innate modesty (more or less fugitive since these peculiar experiences) does not forbid my mentioning that I still respect that mind. 
A Mind That Found Itself-p.31
Clifford Beers seemed to have everything going for him. A young and talented graduate of Yale, he started work at the New Haven tax office in 1897 anticipating a better job in New York. Months later his dream was realised and Beers took up a job for an insurance company near Wall Street, staying until 1900. But all was not well and Beers increasingly succumbed to what he later described as depression and depletion of his vitality. Beers moved home to his parents in New Haven, rapidly descending into fantasies of suicide. Unable to tolerate his "terrific nervous strain" any longer, Beers threw himself from the fourth floor of the townhouse in which his parents lived.

Beers' darkest moment was the start of one of the most extraordinary stories in psychiatric history. To become a psychiatric patient in America at the start of the 20th Century was to fall mercy to entrepreneurial hacks or sprawling and anonymous state asylums. Beers experienced both of these, but would later go on to be one of the most important survivor advocates in history. It started with his memoir A Mind That Found Itself (a title I love for its mind boggling implications) in which he writes of his experiences of what then passed for mental health care.

Beers spent time in three different institutions, two private sanatoriums before being moved to the state asylum in Middletown. His description of what he encountered is a disarming mix of the tragic, the enraging, and the comic. Beers is repeatedly beaten and restrained, including in a "muff," something I hadn't learned about before reading his book. A picture of one (courtesy of MissCreepers) helps us to understand how it would work:

He also describes acutely the petty and largely invisible cruelty experienced at the hands of staff unable to recognise and constrain their own punitive impulses. A Mind That Found Itself is a catalogue of small but poisonous interactions which escalate to physical violence. Beers does not profess complete innocence in all this and does not shy away from candid reflections on his own sometimes provovative conduct. Indeed when he had completed his manuscript he sent a copy to William James. James wrote back:
You were doubtless a pretty intolerable character when the maniacal condition came on and you were bossing the universe.
But as a man who was viewed by his treaters as "insane," the onus was not on Beers to maintain the highest standards of conduct. The repeated failure of his custodians to avoid reflexive and punitive reactions to unusual behavior is a problem that still runs shamefully through mental health treatment today. Bringing it to light will stand as one of Beers' greatest legacies. He is at his most heartbreaking when describing the treatment of others:
Of all the patients known to me, the one who was assaulted with the greatest frequency was an incoherent and irresponsible man of sixty years. This patient was restless and forever talking or shouting, as any man might if oppressed by such delusions as his. He was profoundly convinced that one of the patients had stolen his stomach—an idea inspired perhaps by the remarkable corpulency of the person he accused. His loss he would woefully voice even while eating. Of course, argument to the contrary had no effect; and his monotonous recital of his imaginary troubles made him unpopular with those whose business it was to care for him. They showed him no mercy. Each day—including the hours of the night, when the night watch took a hand—he was belabored with fists, broom handles, and frequently with the heavy bunch of keys which attendants usually carry on a long chain. He was also kicked and choked, and his suffering was aggravated by his almost continuous confinement in the Bull Pen. An exception to the general rule (for such continued abuse often causes death), this man lived a long time—five years, as I learned later. 
A Mind That Found Itself-p.139

A Mind That Found Itself is also fascinating psychologically, for its reflections on the thinking and reasoning involved in what we might now describe as an affective psychosis:
They thought I was stubborn. In the strict sense of the word there is no such thing as a stubborn insane person. The truly stubborn men and women in the world are sane; and the fortunate prevalence of sanity may be approximately estimated by the preponderance of stubbornness in society at large. When one possessed of the power of recognizing his own errors continues to hold an unreasonable belief—that is stubbornness. But for a man bereft of reason to adhere to an idea which to him seems absolutely correct and true because he has been deprived of the means of detecting his error—that is not stubbornness. It is a symptom of his disease, and merits the indulgence of forbearance, if not genuine sympathy. Certainly the afflicted one deserves no punishment. As well punish with a blow the cheek that is disfigured by the mumps. 
A Mind That Found Itself-p.42

And this, along with Beers' experience of a Capgras-style delusion, may be part of why William James found the book so compelling. He wrote to Beers:
The most striking thing in it to my mind is the sudden conversion of you from a delusional subject to a maniacal one—how the whole delusional system disintegrated the moment one pin was drawn out by your proving your brother to be genuine. I never heard of so rapid a change in a mental system.
When he was discharged from the state asylum, Beers became an energetic advocate for the rights of people receiving psychiatric treatment. Among other things, Beers went on to found an outpatient clinic in New Haven, which just happens to be at the bottom of the road I currently live on:



But not everyone was impressed with Beers' book. Shortly after its publication, the superintendent of the Connecticut state asylum, Alfred Noble, felt moved to write a defensive response in one of his regular reports. Irritably and awkwardly, Dr. Noble blames the victim, saying "insane people do not always manifest the angelic temperament which some would have us believe," before going on to indulge some egregious character assassination:


(I am indebted to a librarian at the Connecticut Valley Hospital library for making this available)

But Beers has the last laugh. The grounds of the old asylum house the campus of what is now called Connecticut Valley Hospital. Dotted around the grounds are buildings named for various esteemed former superintendents. Noble Hall stands in abandoned disrepair, but at the crest of the hill overlooking the eponymous valley stands a building still in use. Its name? Beers Hall.

______________________________________________________________

You can read more about Beers' reform work here
A Mind That Found Itself is available online in its entirety courtesy of Project Gutenberg

Thursday, 6 April 2017

The ethics of fascination

Much as I can get fed up with the glibness and superficiality of Twitter, it occasionally throws up some sustaining gems. Thankyou to Neassa Conneally (@neasaconneally) for posting this gut-punching extract from the Oxford Handbook of Clinical Medicine:


It somehow chimed with a remarkable piece I read recently by Kate Davies, who reflects on reading books about the brain while she prepares her own personal work about a stroke she suffered. Davies is somewhat critical of the genre, and takes to task in particular one widely respected author:
I know that [Oliver] Sacks is much beloved as a sort of avuncular figure in the field of popular science, and that many of you find his writing humane and amusing and insightful. Perhaps I too might once have felt that way, but from the perspective of a person who has experienced brain injury he really is “the doctor who mistook his patients for a literary career” in the memorable words of one reviewer. He may be a fantastically able writer with an undeniable facility of communicating the way that brain deficits might hold a key to the mysterious operations of our grey matter to a general audience, but his early work is so deeply exploitative of his patients, their complex conditions, their lives and their experiences, that I find myself unable to reconcile myself to anything of potential worth in his output. 
That section hit me in particular because I am probably one of those who have lionised Sacks. Davies' post made me think about a more general tendency alive in psychology and neuropsychology, and probably in all caring professions; the tendency toward fascination with people and their problems.

To be a psychologist of any stripe is to be fascinated by people, almost by definition. The field is crowded with a canon of human intrigue. A considerable amount of what we know about our minds has come from famous case studies of people whose lives were disrupted by events of violence and tragedy (a not insignificant number of which were aggressive surgeries by optimistic doctors). That tragedy fades into the background when we focus on a striking loss of ability, change in personality, or new double dissociation. When neuropsychological case studies are presented as education or literature, the dominant response is generally meant to be "Wow, how interesting!" rather than a reflection on the depths of a tragedy.

What are the ethics of this fading? Let's put aside ethical issues about what and whether to publish about patients. That question has its own well trodden terrain. What are the ethics of simply being fascinated in the clinical encounter? Of regarding people's minds not just in terms of their private sorrow, but as phenomena that engage interest? How often do clinicians remark to their colleagues that someone they are working with is fascinating? What do they do to that person when they say such things?

On the positive side of the ledger, I have always been impressed by Sacks' evident enthusiasm for the subjectivity of his patients. His pursuit of their experiences doesn't just deepen the reader's theoretical understanding, it presumably intensified the quality of the care Sacks gave as a doctor. His books are always full of ingenious rehabilitative strategies that could only come from an intimate understanding of the what it's like-ness of neuology. In this sense then, fascination is an engine for the good. Think of Jimmy, The Last Hippie in An Anthropologist on Mars. Sacks' curiosity about the nature and extent of Jimmy's dense amnesia prompts him to organize an outing to Madison Square Garden to see The Grateful Dead.

But does this process of deep scrutiny itself have a clinical downside? If some patients problems are fascinating enough to be worked up into bestsellers, what of the more mundane cases whose neurological losses are patchy and banal? Might they be implicitly shunted further down the pecking order of intrigue? Such a hierarchy is disquieting enough in itself. What if it led to those less interesting patients being afforded less attention?

Fascination might also be a distraction or manic defense. The extract I started with draws our attention to an aspect of illness that it can be easy to avoid thinking about; the loneliness and despair it so often entails. These are the things that patients might be expected to care about. But professionals have the luxury of keeping their focus on what is intriguing. What does it mean for patient care when the novelty or peculiarity of a symptom comes to dominate the picture? More attention perhaps, but more attention to a symptom, which would seem to entail distraction from the humdrum daily struggle of being unwell. Even without tangible effects on the well-being of the patient, such distraction seems somehow inherently perverse.

I'll finish with a quote from the psychiatrist Elvin Semrad, drawn from a book of his aphorisms:
I don't have any more interest in hallucinations and delusions that I would in a fever. I don't care about the fever, but what's going on to cause it. Don't get me wrong, fever is interesting for people interested in research on fever. But what are you going to do with this guy, help him or make him an academic study? -p.164.

Monday, 20 February 2017

Agency in Madness

I have a piece in the March edition of The Psychologist on the history of thinking about agency in psychosis. It is meant to be a brief whisk through of some of the literature (fictional and psychiatric) on the issue.

However, there is an intriguing conundrum nearby that I don't really get into: the question of whether it is actually possible to think yourself into a psychosis. If, like me, you are tempted to answer "no," then it is worth wondering why. Two obvious thoughts: 1. Psychosis seems, at least in part, to be a matter of predisposition. 2. Most people experience psychosis as something that happens to them. But these are not knock down arguments

First, a predisposition needn't entail something's being entirely passive. Many talents are probably (partly) a matter of predisposition, but you can't express a talent without agency. Does it ever make sense to say that someone has a talent for psychosis? Second, experiencing something as though it were passive is not the same as its actually being so. We can be mistaken about mental agency, as psychologists well know.

Part of why this question is interesting is that the non-standard answer (the one that violates our traditional intuitions) would seem to vindicate some peoples' experiences. I once asked someone in the recent aftermath of a psychosis how they had found their antipsychotic medications. Did their thinking feel clearer? It certainly seemed (from the outside) as though it was. They agreed their thoughts were clearer, but disavowed a role for the medicine, saying they had done it themselves.

Medication in this instance looked like the most plausible proximal cause, but if psychosis is more likely to emerge under certain cognitive conditions, might it be that medications provide the conditions, and that the patient does the rest? Outcomes in psychosis are very variable. Could agency be an overlooked piece of the puzzle?

Sunday, 29 January 2017

Diagnosing Donald

(note: more than is usually the case, credit must go to my wife for formulating many of the substantive ideas in this post)

Since he lurched into the Republican primaries last year, There seem to have been more published diagnostic impressions of Donald Trump than for any public figure. Perhaps someone with interests in both mental health and politics can't avoid seeing such pieces doing the rounds, but I suspect it is not just me.

We should all know better. The Guardian's Hannah Jane Parkinson wrote a well thought out piece about the issue back in November, when the Donald's combination of prominence and unpleasantness had reached its latest peak. Distance diagnosis, she reminded us, can be inaccurate, undermine confidentiality, and perpetuate stigma. It didn't seem to change very much. 

Sometimes I see what purport to be knock down arguments against diagnosing Trump. He doesn't have a mental disorder, he's just a bad person. He doesn't have a mental disorder, he has a flawed character. But however small the overlap might be on the Venn diagram of "bad people" and "diagnosable people," it is not non-existent. These arguments don't hold water and are a red herring. There are other more pressing reasons not to diagnose Trump.

If diagnosis is to have any place at all in mental health care (and I have argued frequently that it inevitably does and will), it can only be as a beneficent way of re-conceiving the difficulties that bring people to mental health services. Even if you oppose diagnoses and resolutely refuse to use them in practice, a referral to a particular EST, the use of particular therapeutic style, or medication all indicate a particular diagnostic formulation; the use of categories as a reference class to guide decision making. Users of mental health services are not stupid; people can infer diagnoses, ask for information about them, or even explicitly ask for one to be given. Professionals have to make peace with how they use that information and how they frame it.

Let's focus on personality disorder diagnoses, as this is type that most frequently gets applied to Trump. I don't like "personality disorder" as a way of talking, and am inclined to see that cluster of problems as having to do with what David Shapiro called "styles." Life is a weird and difficult thing, and we all have styles that help us get through it. My own style, for example, might be framed as a sort of cautious, ruminating introversion. My temperament and my lifetime's reinforcement schedule have helped pushed me into acting in a particular way. Sometimes it works well, and sometimes less so.

Sometimes our styles get us into trouble. When that trouble is of a particular sort, our styles can get called personality disorders. If you want to help people examine and adapt their style, you have to first create a situation in which you aren't just some hostile outsider telling them they're doing things wrong. You have to try to understand what the style feels like to inhabit, what it is helping someone to achieve, and how it might look different. Help for someone with a diagnosis like "borderline personality disorder" can only come with honest communication about what such a term is supposed to denote.

Herein lies the problem with diagnosing Trump. It's not that he is in principle un-diagnosable, but that the people diagnosing him are doing it for all the wrong reasons. Opponents of diagnosis sometimes say they are insults, and that they perpetuate an uncomfortable power imbalance between clinician and service user. Is that not exactly what we see in the bandying around of "narcissism" as a word to describe Trump? 

When Deborah Orr called Trump "King Narcissist," she deployed the formal sounding acronym "NPD," but went on to frankly insult him in less clinical terms:
"In the world beyond psychiatric jargon, narcissists are usually known by the more colloquial terms of “bully” or “abuser.”
And when journalists, psychologists and psychiatrists wade in and offer diagnoses, are they not trying (rather desperately) to pull back some power from the man who now arguably holds more of it than any single other person? Trump is a whirl of aggression, authoritarianism and petty nativism. Like all politicians, he is a human with a mind. It is appropriate, even imperative, to wonder about his reasons and emotions. One day (if we survive) someone will probably write a fascinating biography that explores why Trump came to be the sort of president he's turning out to be. But unless he elects to see a mental health professional, or falls so far foul of the law that he can't avoid it, diagnosing him serves no purpose.

A mental health diagnosis can only have value if it takes place in a formal compact, usually between two people who want to work on a problem. We know that diagnoses can be stigmatising and insulting. We know that they map uncomfortably onto what can be a pernicious power dynamic. We know that many people find they make matters worse. Trump's would be analysts seem to believe they are casting light on his behaviour, and helping to predict his presidency, but they are engaged only in power play and sophisticated insult throwing. If you're the kind of clinician who thinks they can help anyone by diagnosing a public figure from arm's length, you're mistaken.