Response to the Power, Threat Meaning paper recently published by the division of clinical psychology at the British Psychological Society.

There is so much I can agree with in this paper – it is an insightful piece of work but whether it warrants either the accolades that seem to be expected by some of its authors or the brickbats that have been thrown at it already is, in my opinion, doubtful.
I think the paper will be helpful in a public health kind of way, guiding policy makers in putting together a more coherent approach to some aspects of the development of more effective mental health services but whether it will help therapists and clients in the room to work better together for the benefit of the distressed individual is another matter.
First of all, it is yet another static model firing at a moving target. It is an improvement on the fixed single barrel sniper rifle of psychiatry whose diagnoses are inevitably going to label the individual, though those labels can be helpful in this current climate of categorisation, litigation and limitation, but the PTMF is little better than the “duck foot” gun favoured by security guards in the C18th that sprayed a limited but wider area with several bullets in the hope of hitting a number of targets.
I want to make a few observations about the development of the concept of trauma and why I think that this new framework is little more than a yet another particular feature in the view seen from the railway carriage of human development racing through the countryside of social evolution.
Human beings as a species have been experiencing trauma throughout their existence. That human beings could experience psychological damage related to traumatic experiences was not recognised in any meaningful way until the beginning of the 20th century. Since then trauma, in the form of the diagnoses of post-traumatic stress disorder, adjustment disorder, et cetera has been increasingly recognised as phenomena experienced by individuals in response to events that are frightening and out of the ordinary. It is necessary to ask the question as to how these behaviours became abnormal and the medicalisation of behaviours in response to trauma occurred.
During the 20th century vast social changes took place and particularly after the Second World War the world became a much safer place (Pinker 2011, Harari 2015). For the first time in our lives the majority of human beings could expect to live out their lifespan in relative comfort and safety. As a consequence of this improvement in security and safety, particularly in the West, unpleasant experiences such as war, violence and natural disaster became much less common and when they did occur far fewer people were injured or killed. Furthermore, many forms of trauma and abuse were being exposed, and still are, and thus the commonality of violence and abuse against the vulnerable became less common. It is also increasingly becoming a subject awareness for the population and increasingly disapproved of. Many forms of abuse that have been previously acceptable are now treated as crimes, for example the abuse of women in one form or another for sexual pleasure by men.
That more people are now traumatised by abnormal and horrific experiences is not so much a tribute to professionals recognising these events but that they are brought into profile by a much more benign environment that causes them to stand out. There are also the traumas of everyday life such as road traffic collisions, injury at work and other personal injuries that in themselves have become much more apparent due to the increase in regulation of activities that might be considered dangerous but were part of everyday life previously. One only needs to look at the nature of health and safety on building sites, in industrial settings and even in office settings to see how much more physically benign these environments now are. Road traffic collisions are a particular example as the number of deaths has declined consistently over the last 30 years, though there may be a number of reasons for this, for example, the improved safety features of cars and restrictive driving regulations play a large part.
That these events now stand out in our lives as worthy of attention by medical and psychological professionals is a tribute to how society and its lawmakers have contributed to making this aspect of the environment much safer. However, it does not mean that these behavioural responses by people who have experienced unusual and traumatic events are now the remit of the medical profession in the form of a disorder. These responses remain a normal and when thought about carefully, a logical response to an unpleasant experience. Allen Frances makes the observation:
“Our brains and our social structures are adapted to deal with the toughest of circumstances-we are fully capable of finding solutions to most of life’s troubles without medical meddling, which often muddles the situation and makes it worse. As we drift evermore toward the wholesale medicalisation of normality, we lose touch with our strong self healing capacities-forgetting that most problems are not sickness…” (Frances 2013)
Unfortunately, like most theories of human psychology this power threat meaning framework remains threatminded and backward looking. Assessment and formulation are subjective, capricious and based upon the ability of the practitioner to ask the right (and sufficient) questions about a person’s history and the trauma.
Assessment and formulation is also based upon the accurate memory and honesty of the client. I for one would never disclose my darkest secrets and thoughts to a relative stranger, nor is my memory sufficiently good to remember the details of what happened to me. Furthermore, my memories are coloured by my own emotions and experiences since that time. So, any description of those events is clearly questionable, which is why uncorroborated evidence is not admissible in legal situations. For example, notes of medical and psychological interventions have to be written as soon as reasonably possible after the event (within 24 hours) Loftus’ work for example gives us plenty of examples. A short trawl of Twitter researching the experiences of people who have suffered trauma and are in the mental health system very quickly throws up plenty of examples of thoughtless, unhelpful assessments and history takes.
The framework itself is complex and open to misinterpretation, as has already happened in the discussions I have seen on social media. How a therapist is supposed to hold all that framework and theory in their head while working in the room is beyond me. Furthermore, if it were to become a taught model it is going to be open to the interpretation of the tutors with their own innate bias and preferences. Again, something we have seen time and again expressed in the classroom and upon social media.

The paper is repetitive, and this seems to me to be largely to ensure that as many of the great and good get a referenced mention in the document, after all we have to keep as many powerful and influential academics onside as possible, don’t we?
The paper criticises psychiatry for its logical positivism and then goes on to use the same approach to showcase its own ideas.
The paper remains problem focused in much the same way that psychiatry is; it just does away with the labels. There have been many people have criticised the increasing medicalisation of human emotion and experience in an attempt to check the onward march of psychiatry into normality as Frances’ quote above illustrates. Focusing upon problems merely emphasises problems.
My immediate response to power threat meaning is that clinical psychologists have not attempted to check that march on normality but simply to attempt to impose a new paradigm upon that onward march.
Professionals having a narrow view is a criticism aimed at medical diagnosis, yet surely the same criticism can be made of this theoretical framework as well? Certainly, the social media discussions illustrate a very clear, “you are either for us or against us!”
There is a further fundamental problematic assumption in this document. There seems to be a sense of what is normal and what is not normal. An arbitrary line drawn between acceptable behaviours and responses and those that are traumatic. As I have pointed out in the past and this has been illustrated shockingly in the last few weeks in relation to what is acceptable in the way that women are treated. Acceptable behaviour by human beings one to another is constantly evolving and what was acceptable 300, 200, 100 even 10 years ago is not acceptable today. Therefore, what may have been considered acceptable 50 years ago for example is no longer acceptable today and thus now becomes traumatic. This is a complex area. I have already seen examples in the press of people questioning this evolution or even perception of abuse to be shot down immediately by proponents of power threat meaning without discussion or apparently much thought.
While there is a nod in the document to individual strengths, most of the attention is focused on problems and trauma. There seems to be very little attention to the things that people are coping with that are helping them survive. Where the paper does allude to this I get the sense that it is unnecessarily complicated and the need for professional “expert interpretation” seems to override client experience. My own experience is that these interpretations often get in the way; these tend to be assumptions that are accepted by the client on the basis that the expert knows best. This attribute to the professionals is carried throughout the document with the idea that the professional can empower the client. This is at best a dubious idea and at its worst illustrates the need for the professional’s sense of control and power which is one of the things the framework is trying to deal with and dissing the psychiatric profession for.
The writings within the document seem to suggest that there are patterns but is constantly recognising that these are not consistent patterns and “The implication is that ‘comorbidity’ is not a nosological problem to be solved, but a reflection of the fact that people can use multiple ways to respond to adversity and threat.” I don’t understand; if people respond in multiple ways to what may appear to be the similar stimuli then how can a pattern be imposed upon it?
One of the most interesting statements in the whole document is:
“The evidence cited in the main publication supports the contention that humans are social beings whose core needs include: To experience a sense of justice and fairness within their wider community.
The Power Threat Meaning Framework states explicitly the following core needs:
To have a sense of security and belonging in a family and social group.
To be safe, valued, accepted and loved in their earliest relationships with caregivers.
To meet basic physical and material needs for themselves and their dependants.
To form intimate relationships and partnerships.
To feel valued and effective within family and social roles.
To experience and manage a range of emotions.
To be able to contribute, achieve and meet goals.
To be able to exercise agency and control in their lives.
To have a sense of hope, belief, meaning and purpose in their lives.
…all of which will provide the conditions for them to be able to offer their children…
Secure and loving early relationships as a basis for optimum physical, emotional and social development and the capacity to meet their own core needs.”
While they are all very laudable and clearly we would all want them in our own ways, these are political aspirations for a society and not usually the remit of theoreticians and therapists. They are a very middle-class, professionally based set of aspirations and criteria. These are WEIRD criteria! They are also based upon current Western thinking. Another aspect that the paper claims to be aware of yet seemed rather confused in its thinking about it.
While I may be at appear to be at odds with the paper, I do agree with much of what it says particularly with respect to the statements above. It is high time that psychologists stepped away from the almost entirely individualistic approach to matters psychological and began to look at the wider aspects of the impact that communities, security and a sense of future will have upon any population anywhere in the world. It is time for psychologists to become overtly political, begin to study and research in detail what it is that actually impact upon our well-being and how that might be better derived. Following a neoliberal and individualistic pathway is not going to change levels of well-being in this country or globally. It is time to stop thinking about threat and to begin to build opportunity, security and a sustainable future.
So, in conclusion while I can agree with many of the aspirations of the paper, I find it confusing, repetitive and unclear about what it wants to be and even how it intends to achieve it. It is far too academic and technical, it is based upon an understanding from the viewpoint of the ivory tower and seems to take little into consideration of the common person stood at the base of the tower who may be either “waving or drowning”.
I’m quite sure that most people will never read it properly, many will never understand it and I doubt very much whether it will ever be taken up seriously as a challenge to psychiatry.
Frances, A. (2013) Saving Normal, Harper Collins, London.
Harari, Y. (2105) Homo Deus, A Brief History of Tomorrow, Penguin, London.
Pinker, S. (2011) The Better Angels of Our Nature: Why Violence Has Declined, Penguin Books, London.

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Executive travel, online mental health apps and profit.

There is yet another big player coming from America to the United Kingdom selling an online APP aimed at providing people with common mental health problems digital CBT.

There are thousands of various different sorts of apps on the market some are very good, some are ridiculously bad. I rather suspect that those that are particularly bad will fall by the wayside as the word goes round. Those that are good and have some benefit will remain in the marketplace. However, is not that that I wish to discuss today but a rather different aspect of this whole debate about online therapy.
There are an increasing number of studies that suggest that online therapy is as effective as face-to-face therapy. Indeed there are two companies in this country who are competing hard for NHS contracts on that basis. What I am curious about is why when the senior executives and managers of these organisations need to meet customers, need to have discussions about policy and need to enter new markets they always choose face-to-face consultations. If their online strategies are so good for people in distress why do they need to meet face-to-face in order to be able to promote their products?
It is very rare for senior executives to hold important business meetings without being face-to-face, particularly if these meetings have considerable financial consequences. There is a vast amount of training advertised online as to how to get the best out of these face-to-face meetings. Executives fly thousands of miles business class to meet with their peer group in order to discuss important issues.
Yet when it comes to our mental health and well-being the research is produced suggests that online is as effective as face-to-face. I therefore put the challenge to these companies who spend tens and possibly hundreds of thousands of pounds to fly their executives to different parts of the world for face-to-face meetings to do two things:
1) justify the expense in the light of the damage that such mobility does to the environment
2) justify why they need to be face-to-face for their far less important financial deals when somebody in distress is  apparently perfectly capable of dealing with the complexities digital technology, indeed if they have the technology, and can be effectively “treated” in this one step removed manner.
It is time that people started to think more carefully about these issues; it is time we started to call out these people who provide one service for themselves and another for those whom they are exploiting for profit.
Mental well-being has become big business, thousands are trying to get on the bandwagon, not to improve the well-being of the population but to improve the well-being of their pocket. These organisations and the people running them will make vast sums of money while the well-being of the population globally will continue to fall and increasing numbers of people will experience more and more psychological distress at the expense of the elite.
There are so many ideas about improving mental health by using online tools, yet we already know that the world on the Internet and in social media can have devastating consequences for young and old alike.
Human beings evolved to be social creatures to observe and interact with each other face-to-face. The New World of virtual reality has had a massive impact upon our well-being and, judging by the figures (one in four suffering some kind of mental health problem), not a good one. Perhaps it’s time that those of us who believe in community and creating well-being through security raised our heads and started pointing out the potential consequences of living our lives through, amongst other things, a touch sensitive screen.

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Turf wars, Status quo and the same old thinking!

I am fascinated by the current spat going on between psychiatry and psychology and psychology and psychology. There seems to be many ways in which all three camps can fire salvos at the others. There is the dispute over diagnosis and formulation, there is the argument about the art and science there are arguments over the differing philosophies yet really these disputes boil down to two things: power and money.
All of these disputes are really about professional importance, they are about turf as many of the combatants have observed. But I’ve always been minded of Douglas Adams story in one of the “Hitchhiker’s guide to the Galaxy” books in which a messenger is sent to the people in the lowlands to explain why the people from the forests and the people from the hills have to fight on the lands of the people in the lowlands. And when the messenger has spread the message to the people of the lowlands it seems terribly logical that the war has to take place on their land until they sit down and begin to ask the question all over again, “why do they have to fight over us?”
It seems to me that this current battle is largely over who is delivering the correct service, who is doing the better science when in reality neither side are particularly successful, but it doesn’t stop them fighting at the cost of those people they are meant to be serving.
I notice that Phil Hickey ( ) has taken a pretty strong view about the way psychiatrists are attempting to rebrand psychiatry and makes the observation that psychiatrists are using exactly the same tools as the advertising industry to create fear and anxiety in order to sell their brand. I could argue that psychologists are attempting to do exactly the same thing but have neither the cohesion nor the money to achieve what psychiatry is achieving.
The reality is that the very thing that psychiatry and psychology are supposed to be helping people with, their knowledge and expertise, is being used to create anxiety and fear. All this suggests to me is that the same kind of thinking is being applied to the problem as the thinking that created it in the first place.
If those who want to help people suffering psychological distress, mental health problems, psychiatric disorders or whatever the current buzz term, is are going to be effective then they are going to have to change their own thinking in order to be effective. No longer is it sufficient to take a history, produce a diagnosis or formulation and, on the basis of that, determine a treatment program. The population has moved beyond this process, by large people want to understand what is happening to them; this is why they are turning in increasing numbers to Dr Google (which is often even worse) for an explanation. The professionals talk of collaboration, they talk of co-production, some even talk of co-creation but how can any of these things come to pass when one part already has a fixed idea of what needs to be done and which is then imposed upon the other part?
As I have said on many occasions we are living in a world in which the human psyche is fast changing, not only by education and understanding but by changing environments and circumstances that are moving far faster than any of the theories and “science” of either psychology or psychiatry. It is time to step back and think that perhaps instead of trying to provide answers and solve problems as has been the way for the last hundred years that instead we should be beginning to trust our clients, ask questions that would be helpful for them and not assume that as experts we have the answers to their difficulties, environments and situations, but that they have the capacity and the power to discover explanations and resolutions by applying their own skills and strengths in discovering that in some small way they can change and make better their own environments. This is an essential change if we are really going to be able to make a difference to the lives of those people we work with.
I also consider that at the other end of the scale those professionals who come into contact with distressed members of the public should be feeding back up the chain to the policymakers just how their policies are negatively impacting upon the population and creating many of the problems that psychiatry and psychology are being asked to “cure”. The sad thing is that many of those professionals collude with the policymakers in order to strengthen their own positions and maintain a status quo that is entirely beneficial to the professions rather than the population. This continuing need to be “the expert” is preventing progress from being made in the field of human psychology and psychiatry. I will leave you with the story of the Zen master to ponder upon.
The Zen Master
A university professor went to visit a famous Zen master. While the master quietly served tea, the professor talked about Zen. The master poured the visitor’s cup to the brim, and then kept pouring. The professor watched the overflowing cup until he could no longer restrain himself. “It’s full! No more will go in!” the professor blurted. “This is you,” the master replied, “How can I show you Zen unless you first empty your cup?”
There have been many different reactions to this story, but I want to tell you mine because I think it will help to highlight the problem I have with the whole “expert” debate.
First of all, how many of you think that the story portrays the professor as someone a bit clever?
How many of you think the Zen Master is being wise?
(BTW please notice that I am already guiding your thinking by the way I ask the question.)
So, let’s think about this for a moment. The professor is talking about Zen – the Zen master has the advantage of us here as we don’t know what is being said. However, the Zen master is clearly implying that the professor is:
1) Trying to show off his knowledge (by talking about Zen)
2) Already has too much knowledge (by talking about Zen)
3) Has to empty his mind before he can learn Zen (by a direct observation –“unless you empty your cup”) and that what the ZEN master knows is more important than the professor’s knowledge.
4) That the Zen master already knows the professor well (the observation that his mind is already full of other stuff)
So, what is the motivation of the professor? He has attended an appointment with a Zen master to learn about Zen. He is talking about Zen; he could be anxious but seems eager to learn. What else do we know? That he doesn’t like the tea ceremony being spoiled by the act of over filling the cup.
What do we know about the Zen master?
1) He is prone to making assumptions! What assumptions? “This is you”. What a huge assumption that is in the few minutes of the tea ceremony. That he could so swiftly come to a decision about the nature of the professor’s mind. There is a parallel to this; there has been a lot of study relating to the diagnosis making speed of GPs after a patient walks into their surgery (about 20 seconds before training, about 22 seconds after training to be more aware of their prejudices)!
2) He clearly feels that through mild humiliation that the professor will learn something – we all know that the most effective and open learning comes through positive responses and achievement. Aversive environments and punishment encourage avoidance and defensiveness.
So, within a couple of minutes the story of the Zen master and the professor has unravelled and a rather different perspective has come to light.
Which version is correct? Who knows? I don’t! The point I want to make is about meanings! What means one thing to one person may mean something entirely different to another. It seems to me that the need to be in control and an expert in the psyche of another is more about the insecurity and neediness of the expert than it is about the mind of the person they are supposed to be working with.

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The same old thinking!!

Nafeez Ahmed has just published a piece on the Medium website ( ) that very insightfully begins to unpick many of the problematic aspects of our current relationship with our planet and each other. In it he quotes Dr Otto Scharmer, senior lecturer at MIT’s Sloan School of Management and co-founder of MIT’s Presencing Institute, “Scharmer rightly recognizes that there is a fundamental lack of joined up thinking in the approach to the multiple crises facing the planet. He calls for a more integrated response, and sets out his diagnosis of the problem in the destruction wrought by early phases of capitalism.”
This statement caught my eye for a number of reasons. First of all, he made it clear that he agrees with Scharma about the lack of joined up thinking in terms of the multiple crises facing the planet. I couldn’t agree more! The lack of vision in terms of thinking about what is needed and what would work for the longer term is almost entirely missing from the lips of most politicians. If we are going to survive as a species we have to begin to think much more clearly and carefully about what a sustainable planet, a sustainable society and a sustainable use of energy would look like. While there are many people addressing many different aspects of pollution, power use, sustainable ecology, war, communication and just generally trying to solve problems many of these often nearsighted solutions are pulling in opposite directions.
A classic example of this is the current British government’s approach to employment and automation. The government is carrying out a Draconian program of reducing support for the unemployed, the sick and distressed in an attempt to get more people into work. While at the same time they are spending vast sums of money encouraging driverless cars and automated processes and yet they don’t even seem to realise the irony of what they are doing.
Solutions that are being provided to “resolve” our problems are short-term and usually benefit those who own the means of production and are an opportunity to make more profits for the already very rich. He cites in particular Google who are currently using carbon offsets to maintain their green credentials while at the same time are actually increasing their carbon production. There is little in current neoliberal thought to suggest that this kind of behaviour is going to change anytime soon.
The second item that caught my eye in this short quote was the phrase, “sets out his diagnosis of the problem in the destruction wrought by early phases of capitalism”. This statement, though short, is full of profound culturally laden thinking.
First of all it shows just how deeply the medical profession and its way of thinking has infiltrated not only academia but the population as a whole. The idea of diagnosing the problem by looking at its history which is exactly what Scharma is saying has come from the medical model. This would be fine if there was a static and consistent set of symptoms that led up to the diagnosis of the problem. However, the world is neither static nor consistent and Ahmed goes on to make this point further in his article when he talks about Scharma’s proposed solution – corporate brainwashing.
There is a profound assumption that diagnosing the problem will lead to some kind of solution. We are in a new world. Every day we wake up we are in a new world. The awareness of the global population is changing and increasing every day, both of themselves and of the world. Looking back and identifying the root causes of a problem in a dynamic population is inevitably going to result in a solution that is based in existing thinking rather than in creativity and novel sustainable solutions to ever evolving situations.
The medical model does not provide the space for creative thinking, indeed it channels the person who uses this kind of thinking into thinking in a particular way and actively prevents novel thought processes. I am not criticising the medical profession for this process because by and large with the physical body of human beings this is an entirely appropriate and sound method for diagnosing and resolving illness. The physical body has not evolved significantly in the last 10,000 years. In terms of the body’s response to threats this has remained largely the same throughout all of human history. When it comes to human thinking our capacity for knowledge and understanding has changed dramatically in the last hundred years let alone the last 10,000 and it has probably changed more globally in the last 30 years that it has in the last 300,000 years.
No, the solution does not lie in diagnosing the problem and, as Einstein said, “we can’t solve problems by using the same kind of thinking we used when we created them.” We need radical new forms of thinking, thinking that begins to create images of where we need to get to, what it would look like when we have got there and what difference that would make to all of the population.
We cannot go on thinking like dinosaurs, diagnosing, problem solving and applying a patch whether it is to a piece of software, a wound or an ecological disaster. We have to start considering what the planet would look like if we as human beings were actually behaving in a way that enabled the planet to remain sustainable for our own lifeform let alone that of all the other animals on the planet.

Nafeez Ahmed

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Spare rooms can’t solve the bed crisis in the NHS

The headline may well be accurate but the hysterical response to this idea is simply a knee jerk response to the concept of change.
The world is changing faster now than it has ever done in the whole of human history. The idea that the NHS or indeed any statutory organisation can manage all the needs of a population effectively is just ridiculous. There is also a further fear underpinning the responses to the article the idea that anyone who is not employed by the NHS is going to rip off the public purse or abuse the people who need the service.

The arrogance and snobbery of public some public sector workers illustrates more about their need to feel in control and powerful than it does about their desire to serve the public.

I note that the one wholehearted response to the idea came from an architect who made the observation that, “Effective safeguarding provisions will be needed, but a mutual review system, similar to that used by Airbnb, could flush out rogue hosts and impossible patients alike.” The hysterical assumptions made by the respondent from the Tavistock belies the paternalistic Freudian roots in which their philosophy is rooted.

Let me make some observations about the potential benefits of a programme of this nature:

1) One of the key planks of government and NHS policy has been to attempt to expand care in the community. I consider that the methods employed are profoundly flawed and are based upon the paternalistic attitude alluded to above. There is an assumption that no one can provide the kind of service necessary other than the NHS. The reality of it is that if a few minutes were spent thinking about how this process can be regulated; the kind of people that could be licensed to undertake it; the nature of the buildings in which this kind of care would occur it would become very apparent that it could indeed be an effective, though far from complete solution to one of the biggest problems the NHS currently has.

2) But there is a further advantage to this; this country has lost its connection with community, people want to help other people and don’t know how to do it. This project could be a wonderful opportunity, conducted properly, to rebuild in a small way some of those community connections. People want to be with people, the production line process that the medical profession has developed within hospitals reduces those kind of connections. Government cuts and “efficiency” creating structures have ruined something fundamental about the way we interact with each other. One only needs to read Fred Lee’s books and articles to know that “efficiency” is not the same as effectiveness, nor as satisfying for all those involved.

3) Problem-solving approaches do not look to the future, they only look at present. Real solutions are created through imaging what it is that is wanted and would work and moving towards that rather than simply attempting to solve problems which is short-sighted and often unachievable.

This idea is truly imaginative, could be world changing but is likely to be destroyed by the vested interests of those who are more interested in preserving the status quo than building on human desires for connection and security. This project could not only be effective in terms of helping people return to their own homes in a timely manner but also in a manner in which they actively feel cared for, supported and have a human connection rather than feeling they are on a conveyor belt.


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“Working Conversations” : What would an effective Mental Health Service Look like?

University of Liverpool Management School (ULMS)

Epigenetic The Big E
by Peter Ogunsiji
2 July 2017

Epigenetic’s what the bleep is that I hear you say.
But it could be the word that changes your life today.

What one eats Neuroscientists now understand,
can have a dramatic effect on one’s DNA sequencing strand

You are what you eat, is a saying from times gone by
But we now know taking care of what one eats will enhance your life if you try.

Did you know that Sugar is more addictive than cocaine,
And that both of them can have a detrimental affect on one’s brain.

Our Grandparents and parents were right in their understanding of cuisines,
How many time have you been told that you must eat your greens.

So now we know it not just our own lives that we must take in to consideration.
For what we eat today can have a profound effect on the DNA sequencing of the next generation.

One’s phenotype’s characteristics exhibiting their epigenetic gestation
Genome influenced by our environment, diet, life style and habitual inclination
We must grasp this new epigenetic understanding as a disruption for our good,
For now we have the knowledge to change not only one’s own life but that of the next generation once understood.

It is truly a case of nurture, not nature, we are what we practice, actions can speak louder than words,


About the author:
Peter is a talking book storyteller with a life time of experience, knowledge, and skills, including being artistic and creative. He provides talks and workshops and works from the perspective and under the title of Thinking outside the box before one is placed in it. He is interested in research linked to education, social enterprise, health & wellbeing, technology in its broadest terms, and so on and so forth.


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Language, meanings, practitioner and Client.

According to the Merriam-Webster dictionary Psychotherapy is the “Treatment of psychological, emotional, or behaviour disorders through interpersonal communications between the patient and a trained counsellor or therapist.”
“Interpersonal communications”. What an interesting phrase! I guess that broadly speaking what the definition is referring to is language.
According to Burke (1966) humans are symbol using animals whose most important symbols are words. While symbols are useful in organising and giving meaning to people’s experiences, they are also sources for dilemmas, paradoxes and counterproductive ideologies.
Vocabularies emerge within the context of particular interactions, neither the practitioner nor the person they are trying to help can know in advance what words they are going to use to describe a life, a situation, an interpersonal communication.
The meaning and practical implication of an interaction will vary from one situation to another. It cannot be predicted! (Point one: science requires prediction to be science)
Let me illustrate this with a story:
A university professor went to visit a famous Zen master. While the master quietly served tea, the professor talked about Zen. The master poured the visitor’s cup to the brim, and then kept pouring. The professor watched the overflowing cup until he could no longer restrain himself. “It’s full! No more will go in!” the professor blurted. “This is you,” the master replied, “How can I show you Zen unless you first empty your cup?”
There have been many different reactions to this story but I want to tell you mine because I think it will help to highlight the problem I have with the Scientist/practitioner debate.
First of all how many of you think that the professor is being portrayed as someone a bit clever by the story?
How many of you think the Zen Master is being wise?
So let’s think about this for a moment. The professor is talking about Zen – the Zen master has the advantage of us here as we don’t know what is being said. However, the Zen master is clearly implying that the professor is:
1) Trying to show off his knowledge (by talking about Zen)
2) Already has too much knowledge (by talking about Zen)
3) Has to empty his mind before he can learn Zen (by a direct observation –“unless you empty your cup”) and that what the ZEN master knows is more important than the professor’s knowledge.
4) That the Zen master already knows the professor well (the observation that his mind is already full of other stuff)
So what is the motivation of the professor? He has attended an appointment with a Zen master to learn about Zen. He is talking about Zen; he could be anxious and thus gabbling (a temptation of mine in front of my august colleagues) but seems eager to learn. What else do we know? That he doesn’t like the tea ceremony being spoiled by the act of over filling the cup.
What do we know about the Zen master?
1) He is prone to making assumptions! What assumptions? “This is you”. What a huge assumption that is in the few minutes of the tea ceremony. That he could so swiftly come to a decision about the nature of the professor’s mind. There is a parallel to this; there has been a lot of study relating to the diagnosis making speed of GPs after a patient walks into their surgery (about 20 seconds before training, about 22 seconds after training to be more aware of their prejudices)!
2) He clearly feels that through mild humiliation that the professor will learn something – we all know that the most effective and open learning comes through positive responses and achievement. (No doubt our colleagues would acknowledge that too; members of CAF sig would bend your ear for hours about this). Aversive environments and punishment encourage avoidance and defensiveness. Two minutes ago you were telling me how wise you thought the Zen Master was! What do you think now?
So, within a couple of minutes the story of the Zen master and the professor has unravelled and a rather different perspective has come to light.
Which version is correct? Who knows? Any of you know? I don’t!
The point I want to make is about meanings! What means one thing to one person may mean something entirely different to another.
Which brings me to another quote from a rather more famous master: Richard Feynman.
How many of you have heard of him? He was a physicist and probably one of the most famous physicists ever. He has said many things but one of them is this:
“The scientist has a lot of experience with ignorance and doubt and uncertainty, and this experience is of very great importance, I think. When a scientist doesn’t know the answer to a problem, he is ignorant. When he has a hunch as to what the result is, he is uncertain. And when he is pretty darn sure of what the result is going to be, he is in some doubt. We have found it of paramount importance that in order to progress we must recognize the ignorance and leave room for doubt. Scientific knowledge is a body of statements of varying degrees of certainty– some most unsure, some nearly sure, none absolutely certain.”
The great failing of the Zen Master in the story was that he left no room for doubt and uncertainty. He clearly did not feel he was ignorant but “master” of the situation. This is a great failing in science.
John Ionnadis, a very eminent statistician, wrote a paper in 2005 in which he stated:
“Most research questions are addressed by many teams, and it is misleading to emphasize the statistically significant findings of any single team. What matters is the totality of the evidence. Diminishing bias through enhanced research standards and curtailing of prejudices may also help. However, this may require a change in scientific mentality that might be difficult to achieve.”
Richard Smith, editor of the BMJ when speaking of Ioannadis’ work put it rather more succinctly:
“Most scientific studies are wrong, and they are wrong because scientists are interested in funding and careers rather than truth.”
Along the same lines, Max Planck, another famous scientist once said:
“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”.
More recently, in the Lancet, the following observation was made after the recent retraction scandals, “All institutions—not just those reacting to a case of misconduct—need to critically look at the environment in which research is done. Transparency, positive and open support, and true scientific enquiry rather than a race to innovation that cuts corners are the key to trust in research.”
I don’t intend to go further down this route for the time being as I have no wish to insult anyone – merely to get you to think about science and scientists. If we are to earn the name of scientist we have to doubt, be uncertain, be aware of our biases and tell a version of the truth that is as close as we can get to it. That means following the data, the outcomes and not trying to prove our hypotheses.
So much for the moniker of scientist, what about that of the practitioner?
Described in dictionaries as “someone who practises an art”. Is that all you front line therapists are? “Someone who practises an art”. What is daily your activity about? Can anyone describe it in simple terms? Want to try?
Well here’s my take on it after about 4,500 clients over the last 15 years (in no particular order):
Timer keeper, communicator, lawyer, behaviour therapist, cognitive therapist, keeper of the peace, scribe, teacher, student, whipping post, the human face of the NHS or the insurance industry, the buffer for the manager, the reason the research doesn’t work, a human being, a shoulder to cry on, the butt of jokes, carer, ethicist and moralist, keeper of the numbers but above all the listener.
Why the listener? Surely if we apply the manual firmly enough the client will get sufficient doseage to recover. Then we don’t need to listen.
Are we really empty vessels through which the definitive scientific work passes to the client? Are we unchanged by the processes? Do we not react in a very human way to our environment in the same way the client does? Do we robotically adhere to a set of instructions?
How many of you agree with that? Hmmm, even the scientists aren’t putting their hands up.
Foucalt illustrates this canard beautifully by saying: “men and women have become objects of information, never subjects in communication” (Foucault 1995).
By the way if any of you think I am stepping over the mark, there is an IAPT manual out there with the words, “show empathy here” written in the margin of the instructions.
Let’s return for a moment to my opening statements, “symbols are useful in organising and giving meaning to people’s experiences, they are also sources for dilemmas, paradoxes and counterproductive ideologies”
There is a great deal of evidence to suggest the nature of the relationship is as important, if not more so, than the modality that is being delivered. For example:
“Research is increasingly showing that the success of therapy depends not on the theoretical orientation of the therapist, but on key therapeutic processes that cross theoretical boundaries. Two such processes are ‘problem activation’ – helping the client to face up to their problems, and ‘resource activation’ – reminding the client of their strengths, abilities and available support. In a new study, Daniel Gassmann and the late Klaus Grawe have shown that for therapy to be successful, simply using these mechanisms is not enough; rather, success depends on how and when the mechanisms are brought into play.”
This clearly illustrates that a very high level of knowledge on the part of the practitioner is necessary to engage, in an idiographic manner with the person they are working with to resolve dilemmas, paradoxes and counterproductive ideologies. Idiographic manner meaning that it is dependent entirely upon the person they are working with, the material and the emotional temperature in the room at the time.
No manual can ever identify, let alone predict the nature of that intervention, the relevant information or the moment. Creating engagement, enabling belief, providing motivation are skills that depend upon the ability of the practitioner to read the situation correctly not upon some predetermined process.
That is the art of the practitioner and far too little attention is paid to it. There is a vast amount of work going on in other areas around the nature of interaction, for example, micro-analysis (Bavelas et al). Yet surprisingly little attention is paid to this in CBT at this time. The nuances of language in the therapy room is the domain of the therapist, the decision about what words to use, when to use them, how to use them. These are the tools of the therapist.
Appropriate language, timing, active listening and, dare I say it, interpretation of the words of the client are the main tools of the therapist. Listening for those opportunities to ask the right question, offer a specific phrase are what successful therapeutic interventions are built upon, getting the person engaged and believing in the activity is crucial.
None of those things can be written in a manual and they can’t be anticipated in the classroom. I have read transcriptions, seen videos where practitioners have said the right words, used the correct interactions for a CBT session yet missed the point completely because their words were completely irrelevant to the needs of the person in front of them. The Practitioner didn’t listen but applied a scientifically based and perfectly acceptable intervention – at the wrong time!!
Let’s have a service user (how I dislike that phrase) have the last word in this section:
“What is important is how we build the most connection between people. Talking about experiences in non-clinical, everyday talk provides a bridge between people that is otherwise drowned by psychiatric jargon. I cannot relate to someone who is having a symptom of schizophrenia called paranoia, but I can relate to someone who is really scared. And if I can relate, maybe I can align, be real, and open up with my own learned wisdom instead of parroting prescriptive treatment modalities.” (Morgan 2012)
This brings me to my main point about the scientist/practitioner. Many of you have been taught “Socratic Questioning”. A skill that might arguably be called “bringing your client round to your way of thinking”. Socrates was a man who claimed he knew nothing. Yet in making this claim he was being disingenuous as he clearly knew a great deal and used that knowledge to harangue people in the market place until he trapped them in their own inconsistencies (no wonder the Greeks developed agoraphobia).
Yet he didn’t recognise his own inconsistency. He was not interested in what the world was like for the person he was haranguing – he wished to impose his “rational” world upon the “irrational” world of his victim. He didn’t listen, except to find weakness – he did not seek to support but to dominate.
To return for a moment to the scientist/practitioner model: The scientist practitioner model has been around since the last few years of the 19th Century. Lightener Witmer (a clinical psychologist) established a view of clinical psychology that would be closely aligned with scientific or experimental psychology and used the results and theories produced by those disciplines to inform the treatment of disturbed individuals. His model expected that the scientist and the clinical practitioner would often be the same individual (Hergenhahn 1992). These people were often philanthropists who could indulge their curiosity – like Charles Darwin for example.
In 1949 this tradition was reinforced by the ‘Boulder conference’ that meant that clinicians had to obtain a Ph.D. that included training in research methods like all other psychologists. (Hergenhahn 1992). In the time following Boulder there was increasing dissention amongst psychologists about whether there was a need for the two aspects, many thought that clinical and research psychology go hand in hand (Peterson 2000).
However, this was brought to a head at the Vail Conference in 1973 where the link between scientist and practitioner was broken and schools were subsequently sanctioned to offer clinical doctorates on much the same lines as a doctor of medicine. Despite these controversial decisions the model of scientist/practitioner was maintained and reconfirmed at Salt Lake City in 1987. (Hergenhahn 1992)
There are a number of issues here for me:
1) The role of scientist practitioner was aimed at clin psychs, not therapists.
2) The link between the two was formally broken at a conference in 1973 and then ignored.
3) The scientist and practitioner roles are polar opposites and thus inconsistent; for example:
Scientist Practitioner
Nature of laws Generalising laws idiosyncratic
Academic style Third person First person
process reductive creative
Thought pattern Categorical thinkers Dynamic thinkers
Data processing Large numbers Individuals or small numbers

So much for the two terms. Are they compatible – I don’t think so!
So what are the objectives of this symposium?
We are discussing whether or not the title of Scientist /Practitioner makes sense in the 21st Century.
To me it never made sense. The point I was trying to make at the beginning of my exposition is that the subtly of human interaction between individuals is not predictable and thus fails at the first fence of scientific enquiry.
To ask a person to go into a room with another and hold two dichotomous positions in their head while trying to understand the symbols provided to them by the person they are with would be impossible.
Either you are a scientist, in which case you would be dispassionate, objectively observing (but Ioannidis makes it clear that science isn’t like that anyway) and providing pre-scripted interventions (which may or may not be relevant) or you are engaged and listening carefully to the descriptions of life provided by the person opposite and seeking to find ways of interacting with that person in a way that has meaning for them and will help them make progress in their lives – toward their preferred future.
The real expert in the room on the client is the client. That human being who has hopes and fears for themselves and their loved ones, ambitions, a history we can only guess at most of the time, much that they will never share with us, especially those bits they are ashamed of.
Surely it is far better to know that we don’t know and seek to help the person discover what they want, their strengths, their skills, their hopes for the future than to pretend we are all knowing, certain and impose our reality upon that person, expecting them to accept a vision that is almost certainly a poor fit to their reality. Surely our use of language and symbols is the key to helping those less fortunate than ourselves? If we are to have any title then it could be that of linguist and listener while we are in the room….. and when we are outside the room, that of investigator or explorer in order to increase our insight.
If we are scientists at any time then it ought to be related to the study of the language, the interaction and the relationship between ourselves and our clients. While the study of general patterns of behaviour of populations, psychological distress in populations and how to manage those phenomena are of overwhelming interest to me, the current
“scientist/medical” approach doesn’t cut it at all for me. But that is a discussion for another place and time.
Scientists, practitioners know stuff but they know little about the individual in front of them. They can never know very much about that person. Both titles have now been so devalued both in the press and in the room that it is time we began to consider what symbols we can legitimately apply to ourselves and what we do. Perhaps Scientist/practitioner has had its day. Perhaps psychotherapist has had its day.
Me? I’m called Steve in the room and “that annoying pain in the bum” outside it. I’m happy with both.
Thank you for listening!

Burke, K, (1966) Language of symbolic action, Berkeley, University of California press.

Feynman, R. (2007), The Pleasure of Finding Things Out, Penguin, New York.

Foucault, Michel (1977). “Discipline and Punish, Panopticism.” In Discipline & Punish: The Birth of the Prison, edited by Alan Sheridan, 195-228. New York: Vintage Books, 1977.

Gassman, D. & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology and Psychotherapy, 13, 1-11.

Ioannidis, J. (2005) Why Most Published Research Findings Are False DOI:

Retractions: the lessons for research institutions, The Lancet, The Lancet – 12 July 2014 ( Vol. 384, Issue 9938, Page 104 ), DOI: 10.1016/S0140-6736(14)61145-4

Morgan, S. (2012),

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

ZenMaster story,

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