There is a different way……

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Critique of Wampold’s “How important are the common factors in psychotherapy? An update” part 2

Critique of Wampold’s “How important are the common factors in psychotherapy? An update”
part 2
Towards the end of his paper Wampold makes the observation that, “effective therapists are able to form stronger alliances across a range of patients, have a greater level of facilitative interpersonal skills, express more professional self-doubt, and engaging more time outside of the actual therapy practising various therapy skills”. It is interesting that despite being the most significant common factor, the one related to goalsetting, Wampold ignores almost entirely. Also, I note that agreement on outcome has had relatively little research done upon its significance according to his bar graph. I find it remarkable that such an important aspect of psychotherapy is almost entirely ignored.

Like so many others, Wampold chooses to focus upon process rather than upon outcome.
He also makes the observation that sometimes it is worthwhile dismantling a particular therapy and removing a specific ingredient to determine whether that ingredient is significant or not. However, this particular approach also troubles me as one cannot improve a particular ingredient without impacting upon the interaction as a whole. Psychotherapy is not amenable to a placebo type approach and Martin Seligman many years ago made the observation that random control trials are not the way to explore psychotherapeutic interventions.

In his penultimate section Wampold considers adherence and competence and he makes some very interesting points which I would like to make more explicit. He makes the point that in clinical trials adherence to a protocol is vital and competence in delivery of a treatment is rated by other experts in the same specific treatment. This immediately suggests to me that this is not about competence with respect to outcome, but competence with respect to process.

In my experience people that I work with are more interested in me helping their lives to become more the way they want them to be rather than my maintaining fidelity to a particular treatment protocol. I would also make the observation that few people would fit any treatment protocol that could be devised and any person wishing to be helped by a language based intervention would expect that intervention to fit their needs rather than those of the professional they are working with.

In his conclusions. Wampold makes the observation that, “although the common factors have been discussed for almost a century, the focus of psychotherapy is typically on the development and dissemination of treatment models… The evidence, however, strongly suggests that the common factors must be considered therapeutic and attention must be given to them, in terms of theory, research and practice.” Again, this statement gives me great cause for concern as implicit in it is the assumption that we know what the common factors are.

It seems to me that the most common factor of all has not even been mentioned in his paper, despite the fact that thousands of papers and hundreds of books have been written on the matter. That common factor is language. Wampold has fallen into the trap that of assuming that the way we use language is not particularly significant. As I pointed out in part one, Wampold uses the language of medicine throughout the paper, yet the reality of any language based intervention does not match the clear interventions of medicine. The suggestion that he seems to be making is that we can apply a treatment through a talking therapy and it will have the same impact as a medication or the surgeon’s knife.

This is clearly not the case and any experienced and competent therapist will understand that what is said and the way it is said, has a significant impact upon the likely outcome of the work that therapist and client do together. To give a simple example, a medication impacts upon our bodies in, by and large, a predictable way. The person swallowing the medication cannot affect the impact that that medication has upon them. In the case of an antibiotic that impact will hopefully be to destroy an infection. However, that same medication can also destroy all the flora in the gut and produce some very unwanted side-effects. The side-effects are tolerated in the short-term as the long-term destruction of the infection is immensely beneficial. However, even in these situations unforeseen effects cannot be predicted and some people are dangerously intolerant of some antibiotics.

The case for psychotherapy is rather different. When a dialogue begins neither party can be sure what their words mean to the other. As the dialogue progresses greater understanding is achieved if that dialogue is successful. If there are misunderstandings or misinterpretations then that dialogue is likely to be discontinued. As Wampold points out, “more patients prematurely terminate from therapy after the first session than at any other point.” While Wampold seems to think that it is the expectations of the client with regard to culture, prior expectations and recommendations and, as observed in part one, the initial appraisal by the client of the therapist. I consider it to be much more likely that it is not only the presentation of the therapist toward the client, but also based fundamentally in the nature of the language that the therapist uses in those initial minutes

There are a number of issues that I wish to address here:
1) the use of technical language in order to provide a veneer of science by the therapist to the intervention
2) the reinterpretation of the words of the client by the therapist into the language of the therapist
3) the assumption that the therapist understands the language and thinking of the client sufficiently well to be able to reinterpret it.
There has long been an assumption that psychotherapy comes under the rubric of medicine. I consider this to be an erroneous assumption, as all psychotherapeutic processes are socially constructed. The distress that people feel is now widely recognised as a product of their environment and their response to events in their lives rather than some inherent internal weakness. Yet the medical model largely determines illness of any sort as a failure of individual bodily systems. While a physical illness may well be a response to a toxic environment, that environment has made physical changes to the individual’s bodily functions and capacity to be well, that can be corrected by very specific physically based interventions.

When it comes to psychological distress of any kind there is currently no certain substrate that can be pinpointed as being a failure within the individual’s brain or psychological systems. This does not mean that medications cannot work, it simply means that currently that we do not know why they work, or even sometimes what their action is upon an individual brain.

The idea that a talking therapy can target a particular aspect of a person’s distress in a particular way, in the same manner, in multiple persons, time after time is, in my opinion, a very dangerous assumption. As Wampold points out, “the various meta-analyses for psychotherapies in general and specific disorders, if they do find difference amongst the various types of treatment, typically find at most differences of approximately d=0.20.” An effect size that is generally seen as small but it also needs to be borne in mind that is based upon only the studies that were published and publication bias against unsuccessful studies or studies that do not replicate previous findings is a significant issue in all research papers let alone psychologically based research.

With those caveats in mind, is the use of technical and medical language actually helpful for most people? First of all, people come to see a therapist because they are distressed, their judgement and ability to think clearly may be compromised. How useful will it be to insist that they learn a new language in order to be able to make progress in their own lives? All of us who went through some kind of training to become psychological therapists had to learn a whole new academic language in order to be able to make progress with our tutors and peer group. A time of distress is not a time to be attempting to take on new terminology. The use of technical language is much more about the needs of the therapist than it is of the client.

My next point is about the reinterpretation of the client’s language by means of reflection. Reflecting is a very common activity in psychotherapy, therapists use it to show that they have understood and are in tune with their client. Yet one of the first things that tends to happen is that the reflection from the therapist is based upon the culture and modality of the therapist. Some modalities would reflect the words without any change whatsoever. In the first instance, the therapist is likely to be changing the meaning of the words that the client spoke, even in subtle ways, which has the potential to cast doubt for the client upon what they have said. The power of the therapist to direct the dialogue through subtle changes in language is immense, particularly if the intervention is a protocol driven process that leaves the client two alternatives, either to comply or to withdraw. Neither of these options could be considered empathic. In the second instance reflecting the client’s words back exactly does not engage the client in a new thought, but may fixate them upon what they have said. I want to make the point here that reflection of a client’s words is nowhere near as straightforward as many therapists seem to think.

This brings me to the third point that therapists seem to consider that they have a sufficiently well-developed theory of mind to be able to understand what is going on in the mind of their client. Theory of Mind, in my opinion, has no place in the therapy room.

Theory of mind is a process of assumptions. Theory of mind is the divination of another’s state of mind and thoughts that are not directly observable but are intimated or interpreted from the language that is used or the behaviour that is displayed. That divination is entirely based upon the experience and understanding of the person interpreting those behaviours and language. It seems to me that there has been an assumption in psychotherapy, that the skill of the therapist is sufficient to enable the therapist to make this divination accurately. However, while that may be true for some therapists and not true for others, theory of mind is neither observable nor measurable in any meaningful way. Therefore, these assumptions about knowledge of the mind of another is neither certain nor scientific.

So where does this leave us? Wampold seems to be saying that the “Dodo verdict” is true across therapy modalities, other researchers seem to be saying the same thing (Asarnow & Ougrin 2017). So, it is not the specific techniques or protocols that make a difference to the successful outcome of a particular therapy or therapist. Furthermore, there are an increasing number of studies that now suggest that trainee psychotherapists, psychologists and even lightly trained lay professionals are as effective as seasoned, highly experienced therapists, for example see (Patel et al 2016, Richards et al 2016) and there has been a long running study in the USA and Canada that suggests that volunteers are at least as effective as professionals in suicide prevention (Mishara et al 2016). So, it isn’t necessarily the ability of the therapist either. Wampold seems to assume that it is the relationship that is key; he also seems to assume that it is the therapist who has the power and ability to create the necessary conditions for a “therapeutic relationship.”

True to the medical model Wampold seems to see the client as an almost passive recipient of a treatment that is being delivered by the therapist.
I feel that this approach is fundamentally flawed and inevitably doomed to failure as the person who is capable of making the changes is not the therapist but the client. It is the client who ultimately chooses whether or not to internalise the content of the interaction between themselves and the therapist and act upon it. While therapists may well be able to coerce, direct, challenge irrational thinking and be directive about behavioural change. It is only the client that can ultimately make those changes. The only tool that the therapist has to aid them in the process of helping is language. The way that we say things, the things that we say and the way we present ourselves to the client are the agents of change. That process puts language firmly at the centre of the interaction.

As you can tell from the arguments I am laying out, I consider language to be the fundamental building block of any effective psychological intervention and I want to illustrate that with a couple of examples from literature.

Telling Is Listening: Ursula K. Le Guin on the Magic of Real Human Conversation
“Words are events, they do things, change things. They transform both speaker and hearer; they feed energy back and forth and amplify it. They feed understanding or emotion back and forth and amplify it.”

And Maria Popova in the same article:
“Every act of communication is an act of tremendous courage in which we give ourselves over to two parallel possibilities: the possibility of planting into another mind a seed sprouted in ours and watching it blossom into a breath-taking flower of mutual understanding; and the possibility of being wholly misunderstood, reduced to a withering weed. Candor and clarity go a long way in fertilizing the soil, but in the end there is always a degree of unpredictability in the climate of communication — even the warmest intention can be met with frost. Yet something impels us to hold these possibilities in both hands and go on surrendering to the beauty and terror of conversation, that ancient and abiding human gift. And the most magical thing, the most sacred thing, is that whichever the outcome, we end up having transformed one another in this vulnerable-making process of speaking and listening.”

Words are powerful, transforming and vulnerable making! When we talk, we expose ourselves. This is especially true in a conversation between someone who is distressed and someone who considers themselves to be an expert therapist and thinks that they understand that distress. The power balance in that interaction is by definition, uneven. It is therefore essential that the one who holds the power is particularly sensitive as to how it is to be used. The therapist inevitably holds the power, they have a choice in how they can use that power and one would hope that they would be intentionally using it for the benefit of the person with whom they are working.

Words are magic! Both Freud and De Shazer, who might be considered to be at opposite ends of the psychotherapy continuum considered that, “Words were originally magic and to this day words have retained much of their ancient magical power…. Thus we shall not depreciate the use of words in psychotherapy”.

Ever since the dawning of humankind communication has been fundamental to our intellectual and physical evolution. Language transformed our ability to communicate abstract ideas and concepts. Language continues to evolve. (Kane, A. 2017). As Holtgrave (2014) observes, “…conversations are joint accomplishments requiring the coordination of all involved parties. In short, talk, both its production and interpretation, cannot really be understood apart from the social context in which it is produced and understood.” Let me give you an example, suppose for a moment there is a therapist and the client sitting talking in a session. The therapist is predominantly working in a modality that is based upon the medical model their language involves a considerable number of technical words, including treatment, diagnosis, symptoms, etc. This language is an integral part of the professional environment and culture from which the therapist comes.

The client on the other hand, sometimes has not had the good fortune of a higher education, lives in a world where vocabulary is significantly more limited and often involves street language. Their knowledge and understanding of the words used by the therapist is limited by conversations they may have had with others in their social context, some understanding of which may be erroneous and incorrect. In this situation, the therapist may well be categorising that person, providing them with a label (which may or may not be helpful) by giving them a diagnosis, e.g. clinical depression, and then proceeding to offer them a series of evidence based interventions that have been shown to help with this particular disorder.

The client, on the other hand, has come from a social environment in which they find it difficult to express themselves, an environment which is toxic due to lack of security, risk of abuse (intentional or otherwise) by others and what they are seeking is an opportunity to explore their distress in a way that has meaning that has context in their environment.

Both are using forms of language that are entirely valid in their own social environments and yet have dubious validity in the context of the other. The reason I make this observation is because most therapists have undergone a significant amount of academic training (that tends to lead to an elitist viewpoint in my experience), that leads them away from the world of the person who is sitting in front of them. Their linguistic vocabulary is often vastly greater and has a significant array of technical words that are now only beginning to enter the common lexicon. Even when these words are in common parlance, they are not often not well understood and the technical nuances have not been explained. For a person in distress, the interpretation of the language of the therapist is much more likely to be a negative interpretation than a positive one as I suggest below by describing error management theory.

Work that has been done by people such as Haselton, Nettle & Murray (2014) on error management theory (EMT) clearly shows that the way we manage threat is such that “within this framework, many ostensible faults in human judgment and evaluation may reflect the operation of mechanisms designed to make inexpensive, frequent errors rather than occasional disastrous ones.” For example, missing something good or pleasurable may make one feel sad or disappointed; missing something life-threatening has far more dramatic consequences! This focus of attention for all human beings has been upon noticing threats, communicating threats and sometimes offering threat. For most of our evolution if we did not see threat then our future was probably nasty, brutish and short.

The way we think, the way we perceive the world is primarily threat based. The bias of our thinking and observing is always towards that of the negative. Those historical threats were, by and large, physical. In today’s world, though it may not feel like it, we are safer than we ever have been (Pinker 2007) and our bias towards noticing threats is far less useful than it was even prior to the Second World War. Most threats that most of us encounter in today’s world are intellectual not physical. They come in the form of economic, social or professional intellectual challenges. These challenges are based in language. Though, in the past few years, austerity has caused physical insecurity for a significant proportion of the population to become reality once more.

Therefore, our natural evolutionary bias is towards noticing problems, preferably avoiding them, or when necessary solving them. This bias is apparent in psychotherapy, particularly in the medical model orientated modalities by the use of the “history take,” which rarely takes into account person’s achievements, but focuses almost exclusively upon their failures. The subsequent formulation or diagnosis is a reiteration of those failures and how they might be resolved using new techniques provided by the therapist, this also emphasises the power disparity in the relationship, as the step forward will be provided by the therapist rather than the client. There is little exploration of how the person has coped with these difficulties in the past, how they have managed to survive despite all the difficulties that they have been presented with.

The language of psychotherapy is naturally biased towards focusing the person upon their problems, their inadequacies and their failure. This attentional bias reduces the ability of the individual to focus upon their successes, their abilities and their own natural strengths.

Let me give you an example of the very subtle changes that therapists need to make in order to move from a problem focus approach to a forward or solution focus approach. Elliott Connie (2017) has recently recorded a video about empathy that illustrates this particularly well. In the video. He describes a conversation with a client in which he illustrates a moment when he can make a choice about how he responds to the client. His first response goes like this, “Gosh, that sounds very tough” and, “so how do you deal with things now?” Both sound very reasonable responses to the client’s situation but both mire the client in the problem itself; the focus of the interaction, the emphasis, is upon the problem and reinforces the client’s current knowledge about their situation.
Connie goes on to illustrate what he would rather say in the situation as, “And what would you notice going forward to let you know that those things are no longer a part of your life?” This change of emphasis does not deny the existence of the problem, indeed, in the video he is at pains to make it clear that he is not problem phobic; what the change of emphasis does is to enable the client to think about what their life would be like if the problem was not there and engages the client’s imagination in the event that the problem had either gone away or been resolved. This change of emphasis enables the client to think about what is wanted, rather than what is not wanted and fundamentally changes the focus of perspective.

This little vignette also rather beautifully illustrates the difference between emotional empathy, e.g. the first two phrases, “gosh, that sounds very tough” and, “so how do you deal with things now?” And cognitive empathy, which engages the imagination in the form of, “and what would you notice going forward to let you know that those things are no longer a part of your life?”

This simple example illustrates the subtleties and complexities of how the use of language can radically change both the level of engagement and direction of travel in therapeutic conversations.

There has been a great deal of work already carried out upon the microanalysis of language and the impact of the way words are used in order to help people progress in their lives. For example, Bavelas, Gerwing and Healing (2014) discuss in some detail the connection between language and hand gestures and how tightly they are linked in our attempts to communicate. I would recommend anyone who is seriously contemplating therapeutic conversations with another to explore in far more depth the consequences of particular forms of language upon their interactions and the outcomes of those conversations.

In conclusion, I would like to reiterate my point that I made in the first part of this critique that I am not convinced that we have even begun to seriously unpick the real factors that bring about change in therapeutic conversations. I consider that while the medical model continues to hold sway the effectiveness of therapeutic conversations will be limited. The creation of protocols to enable the measurement of the process and the fidelity to the process will significantly hamper our ability to increase the level of success of outcomes.

Until we begin to focus upon the one common factor in all therapeutic conversations, that of language, and determine what the most effective use of language is, recognise our own biases, both as human beings and as therapists in the way that we use language, we are not going to significantly improve our performance as therapists or as human beings.

References
Asarnow, J. Ougrin, D (2017) From efficacy to pragmatic trials: does the dodo bird verdict apply? http://www.thelancet.com/psychiatry Vol 4 February
Bavelas, J, Gerwing, J. Healing, S. (2014) hand and facial gestures in conversational interaction, found in the Oxford Handbook of Language and Social Psychology, Oxford University Press.
Connie, E. (2017) http://elliottconnie.com/presence-empathy-sfbt/
Haselton. M, Nettle, D. Murray, D. (2014) The Evolution of Cognitive Bias, in Buss D. M. The Evolutionary Psychology Handbook, 2nd Edition, Wiley
Holtgrave, T. (Editor) (2014) The Oxford Handbook of Language and Social Psychology, Oxford University Press. Page 2.
Kane, A. (2017) http://www.omniglot.com/language/articles/englishevolution.htm
Mishara, Brian L. Phd, Marc Daigle, Phd, Cecile Bardon, Phd, Francois Chagnon, Phd, Bogdan Balan, Md, Phd, Sylvaine Raymond, Ma, And Julie Campbell, MA (2016), Comparison of the Effects of Telephone Suicide Prevention Help by Volunteers and Professional Paid Staff: Results from Studies in the USA and Quebec, Canada, Suicide and Life-Threatening Behavior 46 (5) October 2016 577. DOI: 10.1111/sltb.12238
Patel, V., Weobong, B., Weiss, H. A., Anand, A., Bhat, B., Katti, B. . . . Fairburn, C. G. (2016). The Healthy Activity Program (HAP), a lay counsellor-delivered brief psychological treatment for severe depression, in primary care in India: A randomised controlled trial. The Lancet, doi: http://dx.doi.org/10.1016/S0140-6736(16)31589-6 (Abstract)
Pinker, S. (2007) https://www.ted.com/talks/steven_pinker_on_the_myth_of_violence
Popova, M. https://www.brainpickings.org/2015/10/21/telling-is-listening-ursula-k-le-guin-communication/
Richards. David A, David Ekers, Dean McMillan, Rod S Taylor, Sarah Byford, Fiona C Warren, Barbara Barrett, Paul A Farrand, Simon Gilbody, Willem Kuyken, Heather O’Mahen, Ed R Watkins, Kim A Wright, Steven D Hollon, Nigel Reed, Shelley Rhodes, Emily Fletcher, Katie Finning (2016) Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Published Online July 22, 2016, ttp://dx.doi.org/10.1016/S0140-6736(16)31140-0

 

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Critique of Wampold’s “How important are the common factors in psychotherapy? An update” part 1.

Reading through casually and quickly this document looks like it is based in science and the foundations of psychology and psychotherapy. Yet a more careful reading brings to light a series of assumptions that the paper and its science is based upon.
I propose to attempt to bring to light those assumptions and suggest that the bedrock of psychotherapy has not even been detected yet in the mainstream literature let alone tested for its security as a foundation. My object is not to destroy the article or the work Wampold has done over the years (and he has done a great deal) to further the discovery of the active ingredients of psychotherapy; rather it is to try to ask more questions about how we might find the foundations of what makes good and effective psychological interventions that can help people as quickly as possible, in a minimally intrusive way and that has long lasting benefits to the individual. There may be many paths – let us not assume that there is a holy grail – but also let us not assume that we have already found the basic ingredients.
There are several assumptions slipped in neatly under the description of the “contextual model” where Wampold outlines the “three pathways of the contextual model: a) the real relationship, b) the creation of expectations through explanation of the disorder and the treatment involved, and c) the enactment of health promoting action.” Let’s take these one by one. “The real relationship”. While he goes on to explain what this means under “pathway 1” he uses lots of generalities that apply to most human relationships, his one exception is that he states the therapist will not terminate the relationship. Certainly, in England at this time, it is axiomatic that most therapy interventions are based upon a limited number of sessions and that relationship will be brought to an end by the therapist due to the needs of the service providing it. Furthermore, he makes the picture even more confusing by his last sentence in this section where he states that, “psychotherapy provides the patient (note the word patient – I will return to this later) a human connection with an empathic and caring individual, which should be health promoting, especially for patients who have impoverished or chaotic social relations”.
Let us begin with the word empathy. What is empathy? There are many definitions but I like Paul Bloom’s (Bloom 2016) the best,
“Empathy is a spotlight focusing on certain people in the here and now. This makes us care more about them, but it leaves us insensitive to the long-term consequences of our acts and blind as well to the suffering of those we do not or cannot empathize with. Empathy is biased, pushing us in the direction of parochialism and racism. It is shortsighted, motivating actions that might make things better in the short term but lead to tragic results in the future. It is innumerate, favoring the one over the many. It can spark violence; our empathy for those close to us is a powerful force for war and atrocity toward others. It is corrosive in personal relationships; it exhausts the spirit and can diminish the force of kindness and love.”

More kindly definitions come from a range of sources including the Merriam-Webster dictionary include,
1) the imaginative projection of a subjective state into an object so that the object appears to be infused with it
2) the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner;

A small digression: there is a difference between empathy and compassion that needs to be elucidated here. Empathy seems to be more of a feeling – identification with another’s emotions while compassion is a sense of feeling combined with an action or actions. This digression however, begs the question of whether therapists should be feeling empathy (apparently a relatively passive state) or more properly, as Wampold uses medical terminology constantly, compassion where an action is part of the procedures he describes.

Let us return to the main argument, the definition of empathy I have illustrated makes it clear that empathy is an assumed state “without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner”. Surely, if psychotherapy is to enter into a state of science we need to leave these assumptions behind and be clear about what it is we are doing?

Empathy by its very definition is unscientific, difficult to describe and almost impossible to be sure that it is occurring between two people in a manner that is clear, understood and common to both. I hear the cries of, “We know it when we see it”. My simple answer to that is, “Do we?” Anyone who thinks that they know it when they see it should read Paul Bloom’s rather challenging book “Against Empathy”, it provides a more complex and nuanced view of how empathy can do damage rather than be the healing stance that it is connected to on so many occasions.

Wampold also discusses the nature of “empathy” at some length further into the article but makes the point that, “experimental manipulation of empathy in psychotherapy studies is not possible for design and ethical reasons.” This nicely avoids the possibly of having to describe or test empathy in a psychotherapeutic setting. I think he is wrong, empathy could be tested easily in strictly controlled ways using a variety of methods and experimental interventions without either abusing the client or reducing the efficacy of the intervention.

“The real relationship” – I do not understand what this is supposed to mean? Any relationship is real! Only those who have no connection with others do not have relationships. Even the most abusive relationships are real, especially to those who are being abused. Wampold seems to differentiate between the alliance and the “real” relationship. In the context of a psychotherapeutic relationship we run into trouble immediately as I am now confused about what the “therapeutic alliance” is. If it is not a “real” relationship then it is an incongruent activity that is sure to be detected by the client – our radar for incongruency is 100,000’s of years old and plays a big part in Roger’s theory of counselling (Hergenhahn 1996). If it is a real relationship then it is dependent upon the congruency of at least one party and one would expect that to be the therapist.

If we define it in the vague way that Wampold does as a connection which should be health promoting then we run into all sorts of problems around the definition of “health promoting” and the cultural issues that are immediately raised as a result. Wampold makes it worse by then suggesting that it is especially important for those “who have impoverished or chaotic social relations”.

To illustrate the difficulties with this I want to quote an article from a guardian article. Elf Lyons (Lyons 2017) calls herself a poyamorist. Her definition is:
“Friends before defined me as a “friendly philanderer”. I love to kiss people. Friends usually, or women who wear polo-necks. Polyamory is consensual non- monogamy. It’s a philosophy. Rather than the active pursuing of multiple partners in a lascivious way, it’s the embracing and understanding that it’s possible to fall in love, and have relationships, with more than one person at the same time.”

Now clearly Ms Lyons in not in chaotic or impoverished social relations but she clearly falls outside what are the “norms” of society and indeed challenges many aspects of western society. So, the point I want to make is that the definition of “impoverished and chaotic relationships” lies with the client not with the therapist. Wampold has already made the step of assuming that he, as therapist, knows what impoverished and chaotic relationships are. Wampold also suggests that the therapy should be health promoting – what and who decides what is health promoting? What are healthy psychological relationships? Again, my fear is that Wampold has been sucked into the idea that therapists have the holy grail of a healthy relationship and this homogeneous model should be applied to all. Wampold goes on to compound this error in the same section.
Wampold uses the words “patients,” “disorder” “treatment” and “therapy” throughout the article. These are medical terms that are predicated upon the assumption that there is illness involved in the person’s presentation. This is an assumption and there are numerous problems related to this. I have already pointed to one in the comment on polyamory above. In order to describe an illness one must have a set of “normal” health parameters that the person falls outside of. While there are many diagnoses relating to psychological and psychiatric disorders these are predicated upon arbitrary determinants laid out by a range of medical professionals who are embedded in a social and cultural fabric that determines their thinking and opinions. Wampold does make this point in a roundabout way as I note in his quote below. However, that adds to the confusion of the article as I will observe in a moment. I am not going rehearse the many arguments against biological psychiatry and clinical psychology here but suffice to say that I fail to understand how a diagnosis can be made in a medical sense when there is no cause or foundation upon which the structure of diagnosis can be built. Those diagnoses are based upon the dominant cultural and social norms of the society they were borne out of.

Therefore, if a therapist is using a diagnostic category to determine what treatment is to be implemented in a given situation they are imposing a categorical structure upon the person they are working with. That may not be empathic. It may still be helpful and compassionate but it may not be empathetic. For if the therapist were being empathic they would be asking questions to ascertain what would be helpful to the person rather than assuming what they are offering is going to be an effective treatment. So many “treatments” are now based upon a manual, yet Wampold (2017) points out further in his article that,
“patients come to therapy with an explanation of their distress, formed from their own psychological beliefs, which is sometimes called folk psychology. These beliefs, which are influenced by cultural conceptualisations of mental disorder but also are idiosyncratic are typically not adaptive, in the sense that they do not allow for solutions.”
So, on that basis either Wampold has to accept the client’s version of what is troubling them and what they have brought to work on, which may not be within the experience or understanding of the therapist and therefore empathy becomes dangerous and ill advised. Alternatively, a diagnostic label is applied which may or may not be acceptable to the person upon which it is imposed and that will definitely not be empathic. So even if I were to accept the concept of empathy in the benign description above it is potentially dangerous and misleading for both parties.

The next assumption that I struggle with is the statement that clients come with their problems and need explanations for them before they can begin to solve them. Outside of medicine, only in psychotherapy do we spend time exploring the problem to determine its history and the antecedents of their situation. In every other aspect of our lives we proceed to resolving difficulties as soon as we have determined that an aspect of our lives is no longer working properly any more. We do not spend vast amounts of time exploring every detail of the journey to our current point rather, we immediately begin to consider what life would look like if we had moved on and consider activity that would help us move in the desired direction.

It is the medical model that has imposed the “history take, assessment, formulation/diagnosis and treatment” protocol upon psychotherapy. It is not a “god given” law that must be adhered to but rather a ritual that provides a semblance of scientific endeavour to a human process. And like most rituals it needs to be questioned, particularly with regard to who would most benefit from its enactment.

Furthermore, the explanations that Wampold suggests are necessary are based in the knowledge of the therapist and their particular school of psychotherapeutic thought, whatever that is (and there are over three hundred). So, the client is already being socialised to a particular view of how human psychology works via the model used – of course each therapist has high allegiance to their model so it will be the correct one. He makes the observation that:
“a strong alliance indicates that the patient accepts the treatment and is working together with the therapist, creating confidence in the patient that the therapy will be successful”

This is yet another assumption about the client accepting the terms of the therapy. If there has been no opportunity for choice (and there is the whole thorny issue of how the client can make an informed choice about what is best for them) does the client have a meaningful choice about what is being provided (certainly there is little real choice in English services) but engages with what is provided on the basis that that is what is on offer. I would also anticipate that very few therapists would turn a client away on the basis that they could not provide the right and helpful therapy for that client.

This brings me to another point, the truthfulness of the client. Significant research is going on to determine just whether or not clients tell all the truth in session with psychotherapists. For example, Baumann and Hill (2016) show from their research that, “about half of the participants (53%) reported that they were concealing a secret from their therapist, a statistic that is somewhat higher than those found in other studies”.

In a rather more contentious study Blanchard and Farber (2016) make the following assertions:
“Ninety-three percent of respondents reported having lied to their therapist, and 72.6% reported lying about at least one therapy-related topic. Common therapy-related lies included clients’ pretending to like their therapist’s comments, dissembling about why they were late or missed sessions, and pretending to find therapy effective. Most extreme in their extent of dishonesty were lies regarding romantic or sexual feelings about one’s therapist, and not admitting to wanting to end therapy. Typical motives for therapy-related lies included, “I wanted to be polite,” “I wanted to avoid upsetting my therapist,” and “this topic was uncomfortable for me.”

This research puts the ability of the therapist firmly in the spotlight with regard to their certainty about a) the reliability of the “real therapeutic relationship” and b) their ability to “empathise” with the client when these issues are not disclosed. It also brings into question the validity of any diagnosis or formulation based upon a history given by the client.

To continue in this vein, I need to return to a topic of research that Wampold alluded to at the beginning of the article that is also germane to the topic of the relationship. He makes the statement that,
“The formation of the initial bond is a combination of bottom up and top down processing. Humans make a very rapid determination (within 100ms), based upon viewing the face of another human, of whether that person is trustworthy or not, suggesting that patients make very rapid judgements about whether they can trust the therapist or not.”

He suggests, “more than likely”, that these judgements are made upon various extraneous objects such as dress and décor. This is clearly an assumption. However, if true, it would mean that therapists would have to be context specific to meet this initial appraisal or then have to overcome a prejudice that they themselves have created by decorating, behaving, and dressing in a particular way that is part of their culture. He goes on to point out that more patients terminate therapy prematurely after the first session than at any other time. He makes the point that it is this moment that is critical to the future success of the therapeutic relationship. This seems to me to fly in the face of what is said later about building a therapeutic alliance, as the foundation is created in those first few milliseconds and therefore everything subsequently is about the therapist not messing it up!
I am posting at this point and will return in further parts to continue the critique and then to consider how we as helpers might be more effective.

References
Ellen C. Baumann & Clara E. Hill (2016) Client concealment and disclosure of secrets in outpatient psychotherapy, Counselling Psychology Quarterly, 29:1, 53-75, DOI: 10.1080/09515070.2015.1023698
Matt Blanchard & Barry A. Farber (2016) Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship, Counselling Psychology Quarterly, 29:1, 90-112, DOI: 10.1080/09515070.2015.1085365
Bloom, Paul (2016). Against Empathy: The Case for Rational Compassion (p. 9). Random House. Kindle Edition.
Empathy: https://www.merriam-webster.com/dictionary/empathy
Hergenhahn, B. (1996) an introduction to the history of psychology, Wadsworth, California. Page 517.
https://amp.theguardian.com/lifeandstyle/2017/jul/23/polyamory-new-way-to-love-men-women-sex-relationships-elf-lyons

Wampold, B. (2015), how important are the common factors in psychotherapy? an update. world psychiatry, 14:270-277.

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Stress and mental health!

Increasingly people are writing and blogging about psychological distress in relation to stress and medication. Let’s try to put a few things straight!

Stress is not an illness, any more than a headache, a cut, an ache, etc. is an illness. It is a response to a situation, to an environment and to a perception by the person experiencing it. I do not wish to trivialise stress but there is no physical malfunction in the medical sense. Medicalising stress is a very dangerous path to go down. Let’s face it, medicine hasn’t even got to grips with what depression or anxiety are yet! The diagnoses of depression and anxiety cover a multitude of sins (mostly of interpretation and disagreement among medics) as to what constitutes these conditions. When it comes to psychological distress diagnosis does not do the job! Why not? Quite simply because diagnosis requires a source, signs and symptoms. For the vast majority of psychiatric diagnoses there are no sources and no signs. Therefore the criteria for a true diagnosis cannot be met.

Mental health (political correctness) conditions are largely the consequences of stress. Stress is the response to environmental situation; it is not the consequence of a weakness of the individual (though there is some evidence of possible genetic predispositions.  Although it almost certainly has a biological basis we do not know what that basis is.

Stress is the consequence of a myriad of neurochemical and neuro-electrical processes going on in our brains that are a response to our external environment. To try to breakdown those neurological processes and suggest that any particular one is responsible for depression or stress or even behaviours is akin to dismantling a pen molecule by molecule to discover what it does. It is the combination of constituent parts that make us behave as we do in response to stress not a particular neurochemical level or neuron firing at a particular time. Furthermore, whether that response is mediated by our own thoughts and beliefs (the rational self as Jonathan Haidt would have it, or system 2 as Kahneman would have it, or as a direct survival based response (The emotional self as Haidt would have it or system one as Kahneman would have it) is incredibly important to determine, not separating out those different types of response through thoughtful questioning can only lead to failure of the therapy, but even the best neuroscientists in the world cannot identify, even in a general sense, what the specific processes are that underlie our responses to stimuli, internal or external. Furthermore, we mostly respond in a multitude of ways; behavioural, emotional and cognitively.

GPs are very quick to prescribe antidepressants for these conditions on the basis that they have little else to offer as their surgery structures do not allow for significant periods of time to discuss the issues that may be producing distress. Those same pills (antidepressants) have been sold on the basis that they alter the necessary neurochemicals in the brain to adjust us back to some kind of normality. This sales pitch is disingenuous and simplistic. However, the evidence suggests that these medications make a difference when used sensibly and thoughtfully. They are as effective by treating some of the symptoms as aspirin is in treating a headache. However, if the person continues to bang their head against the wall eventually the aspirin will become ineffective as the source of the headache has not been removed. And so it is with stress, depression and anxiety. Medication may well remove the symptoms for a period of time but if the source (which is an external environmental stimulation) remains the medication will be ineffective in the longer term (as the research shows).

To me the real difficulty comes because we have changed our environment in the last 70 years to such an extent that we are no longer able to cope with it.

We have underlying primitive systems that respond to threat (see my earlier blog – “what is anxiety”? for further information on this. Many people are suggesting that we ignore this system (for example “beating the chimp inside”), this is a ridiculous response. These primitive systems are far older and far more powerful than our intellectual systems. The only people who are capable of ignoring this system are those who have serious neurological developmental problems. Many writers have described this system in different ways, for example Daniel Kahneman talks about slow and fast thinking and Jonathon Haidt describes the elephant and rider. I prefer to use a rider and horse analogy as this describes the counter intuitive process  of how we can manage the conflicts between the primitive very old (at least 270 million years) survival system  and the brand new (only about 140,000-70,000 years old) “rational”, self-aware and purely human system. Why is it counterintuitive?

Well, when we ride a horse when we want it to speed up we grip tighter on its flanks and the horse gets the message to go faster. When we want it to slow down we relax our grip, which is great if you are riding a horse. However, if you are trying to control your emotions (the horse) the more you try to control (grip on) the faster and more out of control they become (unless you are a psychopath who doesn’t feel the normal emotional range in the first place). Our natural response to our emotions (and much of our western cultural training promotes this) is to “get a grip”. But as in the analogy of the horse, the tighter we grip the faster we go.

Ironically, the more out of control we feel the tighter we grip. Learning to control emotions effectively is about learning to let go (mindfulness, for example; it is also about noticing what is actually happening rather than what we think is happening so “beating the chimp” doesn’t make sense. On the other hand, being mindful of the moment, allowing yourself to be upset and caring for yourself at these times (being self compassionate as Paul Gilbert makes so clear in his book The Compassionate Mind) as you would another and letting go instead of gripping on will ease the arousal and lower the desire to “do something, anything” at times of stress.

So much is being said about mental health currently. Government spokesmen are talking about parity for “mental health” with physical illness. There is no comparison between mental and physical health and as I pointed out earlier the basis is not the same either. Trying to increase the medicalisation of psychological distress will merely be a “gripping on” response.

To clarify this with some statistics:

According to the National Psychiatric Morbidity Survey about 6.1 million people have a “diagnosable” mental condition in the UK, or about 10% of the population. The prevalence (or awareness) of mental health issues has risen steadily since the end of the Second World War across the western world until the present day where we now have a figure that is about 10% of population and still rising.

Attempts to deal with this epidemic medically is futile. It is about as effective as dealing with the obesity problem with bariatric surgery. The service “Improving Access to Psychological Therapy” will fail simply because the solution to the problem does not lie with fishing people out of the river after they have fallen in but in mending the bridge they keep falling off. (In three years IAPT has seen about 1million people, by their own admission only 47% of those who need attention have been “effectively treated” [which is a whole other story of statistics and spin] which means that it would take fifteen years to treat those who are already suffering let alone those who will begin to suffer in the future and remember the numbers are increasing.)

We are creating an increasingly toxic environment in which to live. An environment that is no longer full of the physical threats that we evolved to cope with through the “survival mechanism” but full of intellectual threats that we haven’t even begun to manage with our modern “rational system”.  We have not evolved to deal with non-physical threats produced by our imaginations or the imaginations of others. Intellectual threats such as money, job security, retirement, debt, the list is endless, none of which can be managed by the primitive system which just wants to beat the hell out of the problem or run away from it. Our intellectual rider has a very imperfect control of the horse but we are constantly loading ourselves up with more and more worry through the very nature of  the focus of our society and this results in our emotional selves becoming more and more difficult to control and more prone to stress, depression, anxiety and panic.

The human mind is evolving at an ever faster pace as we evolve our technologies. Can we assume that our minds are the same now as they were in the past. There is evidence of evolution in the human intellect in the last 3000 years – for example, the shift from first person narratives in the Greek tales to third person narrators in modern novels, from reading out loud up till the 11th century (Bishop Ambrose is the first recorded person to read silently). The increasing sophistication of the written word, verbal communication and social media belies this evolution of purely human psychological skills.  Even psychotherapy in the last century has gone through many transformations from Freud and psychoanalysis to behaviourism to Rogerian counselling to Beck’s CBT as the current darling of therapists with Seligman’s positive psychology lurking in the background as the next “expert driven” therapy. All of which assume that the professional is the expert in the life of the person; that the professional interprets and provides ideas and exercises for the correction of irrational thoughts and behaviours and guidance on what would be more effective for each person based upon a manualised or protocol driven, expert led process.

But is treating the problem in the same way as we have in the past going to be adequate or do we have to accept that evolution of human psychology is ongoing and work with it. Perhaps the days of traditional psychotherapy with an “expert” has passed. Perhaps it is time to recognise we are all experts in our own lives and know what we want but haven’t been able to draw on our own resources effectively to achieve it, whatever we choose to do with our lives.

If this change is taking place and is ongoing then perhaps it is time to place the “therapy” in the hands of everyone and begin to share what are some very simple skills (that are not easy to use effectively but can be learned) and enable everyone to be their own therapist?

So, we have to start thinking about other ways to deal with our situation.

On that basis, these are the questions I would like to ask:

Is treating a natural but individual human response to environmental pressure as though it is an illness going to be an effective solution? (This is the equivalent of treating a toxic chemical leak in a town by giving each person a stern talking to and sending them back into the polluted area.)

How does medicalising the problem assist us in a situation that requires a social solution?

How have we dealt with so many other social problems? Do we hide them or do we educate?

Is trying to provide all those who are “not coping” with some form of expert therapy going to solve this continually increasing level of psychological distress (bearing in mind more and more children are reporting psychological distress)?

Is trying to match the number of “experts” to the increasing numbers of “mentally ill” people ever going to work? Can we control for the level of expertise, can we prevent abuse of the vulnerable by “experts”.

Instead, should we be creating a highly trained carefully selected group of professionals to work with those who are clearly seriously psychologically ill and are clearly unable to resolve their situation themselves or through environmental change?

Then how about formalising educating for the rest of us in more effective 21st century ways of thinking that provides each of us with more effective psychological tools to manage our own psychology?

It’s our call!

Copyright Steve Flatt 30/1/14

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To be or not to be: Clinical psychology

I have been following the “future of clinical psychology” debate with some interest. I can’t help making a comparison with the current debate over Brexit. It seems to me that clinical psychologists wanting to set up their own professional organisation and separate themselves from the rest of mental health professionals is a similar stance to that of the UK separating itself from Europe. It is also about as practical and logical.

It seems to me, despite multiple denials from clinical psychologists on social media, that this whole issue is largely about professional turf. Currently the whole of the professional sector working in mental health is fighting to regain some kind of identity due to the obvious lack of any scientific basis for the interventions currently being provided and by this I mean diagnosis or formulation as a starting point, though the number of reviews and disputes currently going on seems to suggest the science of psychological interventions is finally in question and under some scrutiny.

It is also very apparent that the rest of the world is moving on from this unscientific and simplistic approach, for example, Danius Puras (2017) made the observation in his report to the United Nations:
“The modern understanding of mental health is shaped by paradigm shifts often
marked by a combination of improvements and failures in evidence-based and ethical care. This began 200 years ago with the desire to unchain the “mad” in prison dungeons and moved to the introduction of psychotherapies, shock treatments, and psychotropic
medications in the 20th century. The pendulum of how individual pathology is explained
has swung between the extremes of a “brainless mind” and a “mindless brain”. Recently, through the disability framework, the limitations of focusing on individual pathology alone have been acknowledged, locating disability and well-being in the broader terrain of personal, social, political, and economic lives.”

It is apparent from this statement that the idea that psychological distress is of a purely clinical nature and internal to the person suffering cannot stand up. This is a purely ideological stance which is of benefit to professionals rather than to people who are struggling with psychological distress howsoever it may be caused.

It is clear that clinical psychology as a whole has become frightened of losing its identity. As a result, it is now doing what psychoanalysis did 60 years ago and turn in upon itself rather than embrace a new reality.

Let us be clear about this, clinical psychology is not a homogenous profession. It has more branches and ideologies than the sons of Abraham. Discussions and disputes continue furiously about the founding features of clinical psychology. Whilst this temporary focus on creating a new body to protect and develop the interests of clinical psychologists remains there will be a temporary, though surface, unity of purpose. However, when the internal focus returns and the fear of the “other” has subsided due to the new silo that has been created by separating the profession from other mental health professionals, the disputes about what the correct way forward for clinical psychology is will resurface.

Unfortunately, those who have decided that a new professional body is required in order to protect the interests of clinical psychology have not understood the paradigm shift that is taking place with regard to mental well-being and helping those who are likely to permanently struggle with their well-being. While I have no doubt that many clinical psychologists will argue with my analysis above, there is little doubt that the future of well does not lie in the individualist diagnosis or formulation approach to helping people in distress. Nor does it lie in outdated processes such as assessment, diagnosis, formulation or, worst of all, treatment!

The future lies in a very different place where the client is seen as expert in themselves and their situation; a future in which the environment in which the person is embedded is as significant as any internal or psychical phenomena; a future in which asking questions that will be useful to the person will be more important than providing answers that even the most skilled practitioners cannot be really sure about; a future in which education in clear and unequivocal terms is provided that demystifies the distress the person feels; a future in which distress is placed in the context of a person’s life and their ability (or inability) to cope with all that has happened to them; a future in which the client determines the outcome or future that they wish for.

Currently ideology demands that symptom reduction, return to work or some other form of conformity with current needs of the society in which they are embedded are required rather than an honest and truthful exploration of what might be useful to the client and which they can engage with.

For too long the “expert” has imposed their need upon the mental health of others, whether it be therapists or clients, to meet the needs of government or indeed just the powerful and often ignorant who set policy around this all pervading aspect of being human.

If clinical psychologists really believe that they can maintain some kind of homogeneity and significance in respect of the future of mental health policy in this country then it is time for them to recognise that they will neither have the answers nor the power to affect the discussion unless they climb down off their current bandwagon and join a debate that is moving faster than practically anyone anticipated.

But, as I have observed in the past, the human psyche is changing faster than at any other time in history and that is due to a fast changing environment and speed of learning of populations, not the influence of professionals who are most definitely not “the guardians of the human psyche”.

Reference:
Puras, D. Human Rights Council, Thirty-fifth session, 6-23 June 2017, Agenda item 3
Promotion and protection of all human rights, civil, political, economic, social and cultural rights,
including the right to development

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Young people, New world, Old models, outdated dinosaur thinking!

 

The more I read, the more I observe of the world today, the more I  begin to realise just how true Max Planck’s famous statement was:

 

“A new scientific approach does not triumph by convincing its opponents and making them see the light, but rather because its opponents die and a new generation grows up that is familiar with it”.    (Planck cited in Kuhn, T. [1970])    

 

So many academics, politicians, economists, psychologists and sociologists, amongst others, are wedded to what are now obviously outdated and outmoded theories and protocols. Despite the obvious bankruptcy of the systems that are currently being applied throughout the world, dogmatic and ideological fervour maintains a Skinner like persistence in pulling the same levers and pushing the same buttons time and time again in the expectation, it seems, that a different result will come up.

 

I have just read Kate Raworth’s book, doughnut economics: seven ways to think like a 21st-century economist, in it she makes a scholarly argument for the uselessness of current economic models. The really interesting thing about the book is that she uses a very simple model to describe a more effective way of thinking about economics. This model applies across the whole of human activity and is one that should be thought seriously about in every aspect of our lives. The doughnut that she describes is just such a logical step, yet so radical that it will almost certainly be rejected by the vast majority of national and global politicians simply because it requires a redrawing of all the rules related to wielding power.

 

In the current climate where fewer and fewer people are determined to concentrate more and more power and wealth into their own hands at the expense of the overwhelming majority of the population of the planet, the redistribution that she describes is unlikely to happen until such times, as the ingenious twentieth-century inventor Buckminster Fuller once said, ‘You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.’

 

Nowhere is this more true than in the field of psychology. The dogged resistance of psychologists to let go of their rigid and unresponsive models of human behaviour and recognise that the human brain and the human mind are so incredibly flexible, change themselves constantly and adapt to changing environments is preventing any real opportunity for the population as a whole to understand what is happening to them.

 

So many people have shouted that education is the key! Some people have even talked about educating children about mental illness. Yet all of these cries in relation to our psychology have been related to avoiding illness or use a medical model to describe what should be done. This is ridiculous, as all it does is re-stigmatise the process of what it is to be a human being with our fears and doubts and uncertainties. it is time to begin, as Roger Bacon intended universities to be, a place to teach young people how to think.  We need to learn to think clearly and consistently about what is wanted rather than what is not wanted and we need our children to do it too.

 

If we are really going to be serious about improving our mental well-being, then, rather than looking at each individual and attempting to create “resilience”, which in itself, if you think about it clearly, is ridiculous, we should be looking at environment. Resilience is all about creating an ability to cope with a poor or toxic environment. Raworth makes an excellent economic case for creating a sustainable environment for the planet and its global population of human beings and other organisms. The argument she makes is just as applicable to our mental health as it is to our economic health.

 

The irony of all of this is that we are attempting to “fix” people of their mental health problems and throwing them back into an increasingly difficult and toxic environment. An environment that is known to be unsustainable, unhelpful for the majority, and sometimes deadly for those who are less fortunate in terms of their health, both mental and physical.

 

The metaphor:

 

Suppose a chemical plant had a leak of a toxic substance, and some of the workers were injured through skin damage or inhalation of the toxic material, the initial process would be to clear the area, plug the leak, clear the toxic material away safely, hold an enquiry to determine the reason for the leak, consider the options for improving safety and lessening risk. New safety measures would be implemented. The injured workers would be treated and possibly counselled (I do this work regularly for a wide range of industries) and eventually returned to work or pensioned off if too badly injured to return. Many industries use this model every time there is a serious incident, as do most industrial processes – some more enthusiastically than others.

 

The Health and Safety Executive would monitor the process to ensure that remedial work was carried out correctly and subsequently make regular checks of the plant to ensure it doesn’t happen again.

 

The view that I see of current policies with regard to mental health is rather different from the above process. What is currently happening in mental health services across the world is that people are patched up, provided with “tools of resilience”, and sent back into the same toxic environment. Many people are living in conditions that require them to fight for even the most basic needs such as food and warmth. They have to choose between eating and keeping warm. The environment in which they exist does not provide them with even the basic requirements for security.

 

I am so glad that academics are beginning to step out of their silos, even just a little bit, and observe what is going on in the real world. If we really want to make a difference, then we are going to have to start thinking about how we can learn to consider what the future will look like, not based on what we need now, or even on models from the past, but what a sustainable future would look like.

The next-generation of young adults is already on to this, they are worried about the damage that the current generation is doing to their future, both physically and psychologically. We have created a world in which more young people are suffering from mental health problems than ever before. I for one, cannot go to my grave without the least attempting to do something to put right the mess that my generation has created. We need to assume less, listen more with a constructive ear and not constantly reapply outdated and outmoded models to a world in which they no longer apply because the world has moved on and our generation hasn’t noticed.

References:

Planck cited in Kuhn, T. (1970) The structure of scientific revolutions, 2nd edition Chicago, University of Chicago Press.

Raworth, Kate (2017). Doughnut Economics: Seven Ways to Think Like a 21st-Century Economist. Random House. Kindle Edition.

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How toxic does our society need to be?

The more I think about English mental health services, the more I begin to think about the analogy of a chemical plant.

Suppose a chemical plant had a leak of a toxic substance, and some of the workers were injured through skin damage or inhalation of the toxic material, the initial process would be to clear the area, plug the leak, clear the toxic material away safely, hold an enquiry to determine the reason for the leak, consider the options for improving safety and lessening risk. New safety measures would be implemented. The injured workers would be treated and possibly counselled (I do this work regularly for a wide range of industries) and eventually returned to work or pensioned off if too badly injured to return. Many industries use this model every time there is a serious incident, as do most industrial processes – some more enthusiastically than others.

The Health and Safety Executive would monitor the process to ensure that remedial work was carried out correctly and subsequently make regular checks of the plant.

The view that I see of current government policy with regard to mental health is rather different from the above process. What is currently happening in English mental health services(IAPT) is that people are patched up, provided with “tools of resilience”, and sent back into the same toxic environment. Many people are living in conditions that require them to fight for even the most basic needs such as food and warmth. They have to choose between eating and keeping warm. The environment in which they exist does not provide them with even the basic requirements for security. In the sixth richest country in the world this cannot be right.

The analogy of the chemical plant is as follows:

People are out of work, unable to work, in work that is demeaning or meaningless, sick or miserable. They are struggling with what amounts to a toxic environment at work including bullying (and I have many examples of this including the NHS), domestic abuse, insufficient money to pay bills despite working many hours per week because wages are now lagging behind inflation (that is an interesting study in itself as the way it is calculated includes the increases of the highest earners and thus hides the losses of the lowest earners – the headline figures are misleading) and become increasingly insecure and desperate. This is the toxic environment I allude to in the chemical plant analogy.

However, when the person begins to fail they are referred for CBT via their GP, or provided with an antidepressant and told clearly that work is good for them and that they should return as soon as possible to the environment in which their misery began. They have been “treated” with “resilience tools” or chemicals which are the equivalent of a poorly fitting gas mask and returned to the toxic environment which remains the same as it is not considered as part of the problem (or solution).

As a side issue the government has over the years eased the restrictions on employers to address these matters and taken away the rights of workers to access justice. Again, in my own work I am increasingly seeing people who have legitimate claims against their employer or other third party unable to fight for their rights because their access to professional support is denied due to the removal of funding and support while employers have the funds to employ all the necessary expertise to fight their corner. It is increasingly hard to succeed at a tribunal if you are a worker on a low income despite having a good case and the restrictions on who might attend a hearing is severely limited for the plaintiff while the defence can employ as many “experts” who are accredited to the court as they wish because they can afford them. Again, this is the toxic environment I describe above.

When the person fails to cope with the ongoing toxic nature of their situation despite having had Cognitive Behaviour Therapy, some other psychological intervention or chemical hit that was supposed to help them, they are then sacked, evicted, or blamed for their inadequacies and replaced by another worker until such time as the cycle is repeated.

There is no investigation into the environment. For example, this has been very apparent in the NHS when evidence on the burnout of NHS mental health service staff was raised by a number of organisations and individuals the request for an enquiry was ignored.

When someone suffers misery as a result of work related stress, environmental issues, professional incompetence (the toxic environment) and they come to me for some help, as well as providing care in one form or another I used to write to the relevant authority about my concerns, in a polite and constructive way, generally to receive a response (usually verbal, though I do have a few letters and emails) that boil down to “keep your nose out, or the employee will be fired (for causing trouble) and you won’t get any more work from us”.

There is rarely an enquiry into what happened, why it happened or how it might be prevented in the future. The law of the land and policies enacted under its umbrella are now creating an increasingly toxic environment, none of the leaks are being fixed, the safety equipment is not fit for purpose and the plant is getting less and less maintenance.

However, significant sums of money are being spent ensuring that the board room and senior manager’s offices are sealed against the toxic fallout from the leaky plant. This situation will continue until such times as the plant fails altogether, there are no more workers or the workers revolt and wreck the plant as they have little left to lose.

Policy makers (plant managers) are at a crossroads, they can continue in the same vein as they are currently and eventually grind to a standstill or worse; or they can improve the working conditions (community and national environments); the sense of security for their workforce (the population) and share more evenly the profits of the efforts of all of us (and I don’t mean communism – I am an entrepreneur) so that improvements are made enabling opportunity, security of tenure and a future that is assured both at an individual level for most, if not all, people and at a community and national level, enabling opportunity for all to contribute in a meaningful way to the wellbeing of our society. To many are contributing at considerable cost for the benefit of the few. Furthermore, the many who fail (25% of the population who are suffering common mental health problems) are being blamed for their own responses to the toxic environment and treated as though it is their fault.

Below is an extract from the words of a depressed person posted on line that sums it up:

“Rather we struggle in a system where the ‘long fix’ is inaccessible, and often inappropriate in its focus (because hey, psychological models are often pretty individualising too!).  We struggle in a system where time is money, and where every minute of our time is scheduled. The time to do the work of therapy is something many of us simply don’t have. The support to cope with its fallout is also often not there.

The ‘quick fix’ isn’t my laziness, its a feature of my oppression. It is itself a feature of socioeconomic and psychosocial processes that position me to endlessly care, but rarely be cared for, to work without rest, to keep on keeping on regardless of what life throws at me, because the alternative is to sink, and there is no help for us when we sink anymore. Austerity cuts and neoliberal economic practices have seen to that.” https://janeemcallaghan.wordpress.com/2017/01/24/teaching-critical-approaches-to-depression-and-anxiety-an-insider-perspective/

 

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The efficacy of Mental health Services in England – not!

On world mental health day the following was posted by the United Nations:“A balanced approach to mental health is needed, including population-based services as well as care and support for individuals, so that we can forge better interventions in the community and strengthen protection for rights holders seeking or using healthcare services,”
Mr. Pūras. “I call on States to shift their mental health investments from focusing on ‘chemical imbalances’ to tackling ‘power imbalances’ and inequalities,” the expert says.  “We all need to talk about depression and policy makers need to talk about what has gone wrong with addressing the mental health both of individuals and societies, and about the changes we need. It may be a difficult conversation but it is important that we have it now.”
It is a clear steer toward changing the individualised form of intervention to community style interventions that enable groups and communities to manage their mental well being and determine what is best for them. The current approach of one person at time is inevitably going to fail and so far has made no demonstrable difference to the overall level of well being in the country. Indeed a World Psychiatry journal article indicates that:
“ALL FOUR COUNTRIES HAVE HAD INCREASES IN RATES OF TREATMENT FOR THESE DISORDERS (common mental health problems) SINCE THE 1990S… DESPITE THESE CHANGES, NONE OF THE FOUR COUNTRIES HAD ANY EVIDENCE FOR A REDUCTION IN PREVALENCE OF DISORDERS OR SYMPTOMS OVER THE PERIOD. IF ANYTHING, THERE WERE INDICATIONS OF CHANGES IN THE OPPOSITE DIRECTION IN AUSTRALIA, ENGLAND AND THE US,” Jorm, A. F., Patten, S. B., Brugha, T. S., & Mojtabai, R. (2017). Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry, 16(1), 90-99.
The approach to the issue of mental well being in England is ill thought out, ill advised and ineffective. it is driven by an ideological stance that is not based in science or evidence and is determined to blame the individual for the failure of government to address the environmental and systemic failure of its policies in this regard.

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