The complaints about GPs are not always entirely justified. Some GPs seem to their patients to have an unsympathetic manner when in fact they are performing their primary care role perfectly well. On the other hand, some GPs appear sympathetic and reassuring while at the same time making poor choices about medication and referral. It takes all sorts.

The article, What would an ideal mental health service for primary care look like? (PDF) looks forward to the near future when GPs will be much more involved in commissioning community and hospital treatment (secondary care) services in the NHS.

When the article was written, the organizations that are planned to commission NHS secondary care were to be called “GP commissioning consortia” but the name has since been changed to Clinical Commissioning Groups (CCGs) to reflect the involvement of other professionals in addition to GPs.

One of the article’s key messages — the only message, really — is that:

In order to commission an ideal mental health service for primary care, GP commissioners should challenge accepted distinctions and divisions.

I think that’s putting it a little too strongly. Certainly, the point of creating CCGs is that clinicians are very likely to do things differently from, and better than, the NHS bureaucrats who are in charge of commissioning secondary care at present, but it’s not clear to me that challenging accepted distinctions is really part of the commissioning role, and the article doesn’t elaborate the point.

Ten distinctions

Anyway, the ten distinctions and divisions that allegedly should be challenged do make interesting reading. The divisions are between:

• mental health clinics and the GP surgery
• short GP consultations and extended mental health ones
• mental and physical illness
• severe and enduring mental illness and other difficulties
• the individual and the family
• the mental, social and economic domains
• all the different mental health disciplines and ideologies
• neighbouring localities or boroughs
• offering a diagnosis and treatment, and having a therapeutic conversation
• the patient’s voice and the doctor’s decision making

The end. The article doesn’t suggest any new distinctions and divisions to replace the ones in the list. That makes it a bit obvious that the whole idea is utter nonsense. If there were to be no distinctions at all between all these things, then the whole field of mental health would become a huge pile of mush, impossible to manage or even to discuss intelligently.

Looking at one of the ten in more detail, the division between severe and enduring mental illness and other difficulties, the article makes a blatant factual error:

There may not be DSM-IV labels for people struggling with complex social and family problems, existential crises, longterm loss of confidence, permanent lack of direction or intractable self-absorption…

In DSM-IV, Axis IV covers external psychosocial stressors, although the axis is admittedly rarely used, and other symptoms like self-absorbtion are certainly covered by axes I and II. (Axis III, by the way covers physical conditions that have a psychological effect, another of the ten distinctions.)

Regardless of this error, the final assertion is just silly:

An ideal mental health service would recognise the scale of difficulties experienced by people without a severe and enduring diagnosis and would make adequate provision for them.

Trying to treat all of life’s difficulties as mental health problems would just clog the system with people who have difficulties, i.e. absolutely everyone. People with specific, curable, mental illnesses would easily be forgotten in the crush.

Indeed, this has happened to some extent in the NHS’s IAPT services, which have encouraged people to seek treatment for perfectly normal mild, short-term feelings of depression and anxiety, and as a result find it hard to deliver successful treatment to patients with more severe disorders.

Grains of truth

There are some grains of truth, though, in the proposals. For example, the ground-breaking Open Dialogue approach to psychotherapy that I described almost exactly a year ago in Grass does to some extent challenge the distinction between the individual and the family.

And the distinction between the patient’s voice and the doctor’s decision making has been breaking down for a long time, challenged by NICE guidelines and the NHS Constitution:

Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment.

So, while the idea as a whole is nonsense, the article nevertheless makes an interesting read because of the way it juxtaposes sound ideas with drivel. The author certainly knows how to tell a good story.

The author

The author, John Launer, originally graduated in English before training in medicine. He is now a big noise in the training of doctors, and a prolific writer. His writings help make the case that doctors should have a scientific background, it seems to me.

One of his favourite notions, mentioned a couple of times in the article, is the importance of narrative in medicine. A 1999 paper of his in the BMJ (British Medical Journal) describes the approach in mental health, using three brief case studies: A narrative approach to mental health in general practice (PDF)

Again, the overall gist of the article is nonsense:

The success of “talking cures” depends on their ability to give coherence to the client’s experience of physical or mental illness and to enable the construction of a narrative of healing or coping

That’s like saying the success of flying in aeroplanes depends on your ability to describe how aeroplanes fly. It’s just not true. The passengers don’t need to know how the wings work. Even the pilot doesn’t really need to know how the wings work. And, like the more recent article, this one didn’t elaborate the point.

Talking cures may sometimes provide a coherent narrative, just as some passengers may know how the wings work, but it is neither necessary nor sufficient. Far from supporting narrative, the three case studies actually undermine it.

Case studies

In the first, Helen’s story, an elderly woman regularly talks to her GP about her difficulties over the last ten years. The narrative we are offered is that the GP’s role is to make sense of the story of Helen’s life:

…not just as listening to Helen, nor just as formulating diagnoses, but to see it as asking questions which explore a better story…

However, another narrative might be that the GP is creating dependency here, getting a vulnerable patient hooked on pointless exploration of her past. Helen’s psychological problems are no more than a competent counsellor should have been able to help her deal with in a matter of weeks, and at only 70 Helen could have moved on and built a new life for herself.

In Rustem’s story, the GP imagines that Rustem might be suicidal because of his many problems of social isolation, physical health and addiction. Yet there is no evidence whatsoever that Rustem really is suicidal. It’s just a story the GP made up.

In addition to all his other problems, Rustem now has a GP whose actions are guided as much by the GP’s own imaginary fears as by the tragic reality of Rustem’s life. It’s hard to see how that can possibly help, and the article doesn’t elaborate the point.

Sheryl’s story, finally, is of a child whose behaviour causes problems. The child’s mother would like a referral to a specialist who might be able to help her child, but the GP imposes a narrative in which the idea that a specialist might be able to help is no more than the mother’s “impulsive optimism” and he only reluctantly agrees.

Distinctions and divisions

GPs like this, who blur the accepted distinctions and divisions between the reality of a patient’s difficulties and the GP’s own imaginary narrative can be a menace. They’re the ones who won’t order the right tests, who resist making referrals, and who refuse to prescribe what consultants recommend for their patients.

As a teller of stories, John Launer has had a successful career. But some of his stories are tall tales, full of superstition and imagination. They’re great to read, but you’d be very silly to believe in them. Among the GPs who do believe in them are the ones patients and bloggers complain about, the ones who seem to be on a different planet, unable to align their thinking with what mental illness is about because in their heads they are telling themselves a different story.

Later, it got me thinking. A similar graph appears on page 8 of How to Deal with Stress by Stephen Palmer and Cary Cooper. Here’s a simplified adaptation of it:

The points it is illustrating are that:

• Stress is not the same as pressure.
• When there is too much external pressure, it causes the subjective experience and symptoms of stress.
• When there is too little external pressure, it causes a subjective experience and symptoms like depression.
• There is an optimum amount of external pressure that maximises one’s ability to cope, balancing stress against apathy.

And a further point made in the accompanying text, but not illustrated in the graph, is that:

• The optimum is different for different people.

Some people thrive on a lot of pressure, while others thrive when there’s very little pressure on them. (This can be important for team-building in business, because different people will come into their own at different phases of a project cycle.)

Cops

All this stuff is pretty well known, though people often need to be reminded. For example, the generally fascinating (but sometimes annoyingly large print) Police Mental Health blog by Jeff Shannon in San Francisco, in the recent post Bureaucracy v.s. The Guy who First Starting Playing this Game, lists some of the stressors (pressures) on police officers:

Critical incidents.
Public scrutiny.
The administration.
Shift work.
Bureaucracy.
…
Lack of leadership.

He points out that fighting the bureaucracy can make cops give up their initial idealism about the job. They redefine themselves and just “spin their wheels” so as to reduce the pressure, but, he reminds them:

Like you, I didn’t become a cop to spin my wheels. I became a cop to have an exciting, challenging career and to MAKE A DIFFERENCE. How does an officer who has lost this desire to make a difference get it back?

He has four pieces of advice about what to do:

1. Have at least two support people on your “team.” These are workmates who really get it and who will allow you to scream, “This place is sooooo fucked up!!” Use your teammates liberally…

2. Challenge. This is where you make it a game. You want to win the game, right? …

3. Control. Related to challenge, control is when you don’t give the bureaucracy a chance to ding you…

4. Commitment. Keep your eye on the ball… Remind yourself about the reasons you got into police work.

So, again, this is not about making the pressure go away. For the kind of cop who wants to be challenged and to make a difference, reducing the pressure to none at all — just spinning the wheels — is not the answer.

DSM-5

One of the controversial aspects of the draft version 5 of the American diagnostic manual, DSM-5 is the way that in some contexts it rejects this concept of an optimum that’s different for different individuals. Instead, in some places, it proposes diagnostic scales that don’t match most people’s normal everyday experience.

For example, the draft DSM-5 description of personality functioning is intended for use in the diagnosis of personality disorders. It has five levels, numbered from 0 to 4, with 0 representing “healthy functioning” and 5 representing “extreme impairment”.

The problem with it is that descriptions of dysfunctional states appear at level 0 as “healthy functioning”, while descriptions of normal functioning appear at other levels as “impairment”.

For example, we find this description of “healthy functioning”:

Ongoing awareness of a unique self; maintains role-appropriate boundaries.

So if you ever “lose yourself” while dancing or playing football, or if you’ve ever broken down in tears, you’ve failed and you’re on a spectrum of personality disorder, according to this daft draft.

Another description of “healthy functioning” is:

Strives for cooperation and mutual benefit and flexibly responds to a range of others’ ideas, emotions and behaviors.

So if you’re a charismatic leader, or a leading academic and original thinker, you’ve failed too and you’re also on this crazy spectrum of personality disorder.

Among the descriptions of “impairment” we find:

Inconsistent i[n] awareness of effect of own behavior on others.

Thus, if you sometimes know what effect you are having on other people, but you sometimes don’t realize, you’re supposed to think you have a level 1 disorder.

And again, this time at level 2:

Excessive dependence on others for identity definition, with compromised boundary delineation.

Can any normal person define their identity except by reference to others? And does any normal person not feel some shared experience and sympathy with other people?

At level 4, the most “extreme impairment”:

Social interactions can be confusing and disorienting.

And at level 3, perhaps most significantly:

Difficulty establishing and/or achieving personal goals.

These two descriptions are aimed at pathologizing people who set themselves challenges and who sometimes, or perhaps often, fail at them. They idealize people whose relationships and personal goals are safe and bland.

Although I have picked out the worst examples, there is a pervasive sense that people who challenge themselves in life, whose relationships and other ventures only sometimes work out well, are being classified as mentally ill. This is exactly the fallacy that the graph in the stress management book was designed to refute.

Optimum coping occurs when people constantly challenge themselves and sometimes fail, with the right level of challenge and failure being different for each individual. The DSM-5 draft describes a strange fantasy world in which everything can be cozy and nice and challenge-free.

In all twelve descriptions of DSM-5′s level 0, “healthy functioning”, there is no mention of challenge, risk, adversity, creativity, experiment, or resilience in the face of failure in any of them. DSM-5′s idealized personality is completely rusted out, just spinning the wheels.

DSM-5′s descriptions of personality disorder specifically target traditional American heroes: the immigrant, the pioneer, the frontiersman, the entrepreneur, the go-getter, the risk taker. It’s like a manifesto for settling down and giving up.

ibn Khaldun

The same idea crops up in an article by Chief Rabbi Jonathan Sacks on the subject of Western civilization: How to Reverse the West’s Decline

Drawing on the writings of Tunisian historian ibn Khaldun from six centuries ago, he outlines an alternative narrative of the Soviet Union’s collapse and the difficulties America now faces.

Ibn Khaldun’s theory was that every urban civilisation becomes vulnerable when it grows decadent from within. People live in towns and get used to luxuries. The rich grow indolent, the poor resentful. There is a loss of asabiyah, a keyword for Khaldun. Nowadays we would probably translate it as “social cohesion”. People no longer think in terms of the common good. They are no longer willing to make sacrifices for one another. Essentially they lose the will to defend themselves. They then become easy prey for the desert dwellers, the people used to fighting to stay alive.

Sacks advocates people taking things into their own hands and creating a renewal of values, noting that this is what happened nearly two centuries ago:

There is, to my mind, only one sane alternative. That is to do what England and America did in the 1820s. Those two societies, deeply secularised after the rationalist 18th century, scarred and fractured by the problems of industrialisation, calmly set about remoralising themselves, thereby renewing themselves.

The three decades, 1820-1850, saw an unprecedented proliferation of groups dedicated to social, political and educational reform-building schools, YMCAs, orphanages, starting temperance groups, charities, friendly societies, campaigning for the abolition of slavery, corporal punishment and inhumane working conditions, and working for the extension of voting rights…

People did not leave it to government or the market. They did it themselves in communities, congregations, groups of every shape and size.

Ibn Khaldun, in Muqaddimah, as translated by Yale Professor of Semitic Languages Franz Rosenthal, contrasted “sedentary” people with the desert-dwellers:

The sedentary person cannot take care of his needs personally. He may be too weak, because of the tranquility he enjoys. Or he may be too proud, because he was brought up in prosperity and luxury. Both things are blameworthy. He also is not able to repel harmful things, because he has no courage as the result of (his life in) luxury and his upbringing under the (tyrannical) impact of education and instruction. He thus becomes dependent upon a protective force to defend him.

These concepts — being sedentary, spinning the wheels, DSM-5′s level 0 — they all seem to describe a kind of rust that corrodes people’s ability to function and makes them dependent.

Its primary difficulty is very limited relevance. At its core, UKCP is a federation of training providers, “laundered” as it were through member organizations and concealed behind individual subscriptions. The primary driver for its continued existence is that it helps guarantee revenue for the training industry by insisting on more and more training for professionals who are already over-trained.

And the professionals who pay for all this training also pay for the UKCP. And pay for their member organizations too.

It’s uncomfortable for members to be reminded of this reality, though. So they go to enormous lengths to avoid making eye contact with it.

The result is an obsession with every conceivable side issue, quibble and fantasy. Tom Warnecke’s feature article, Paper — Scissors — Stone, is based on the fantasy that psychotherapy has an underlying set of values that could save the UKCP if only someone could find out what they are.

To his great credit, he does give reality some furtive sideways glances. On the benefits of psychotherapy:

There is no evidence that the three most developed markets for psychotherapy, namely the USA, Brazil and Germany, are functioning any better as a result of their population’s psychotherapy experience than other, less psychotherapy-privileged societies.

And on the culture of the UKCP:

We may also need to live down the image of UKCP as a cabal of trainings driven by vesed self-interest.

Ideals

The idea that UKCP should somehow embody, articulate and stand up for a set of ideals is a popular one among contributors to the journal. It’s as impractical as it is popular, however, because no one can agree on which ideals they should be.

It’s easy to see how so many UKCP therapists, dominated by variants of psychodynamic theory that encourage emotional dependency, yearn for an all-powerful parental body to validate their professional existence. The work itself is insidiously invalidating. Being validated by completing training doesn’t feel enough. Being validated by membership, and by registration, and by paying the annual subscription, still doesn’t feel enough. There’s always a feeling of something missing.

“Integral-relational body therapist” Carmen Joanne Ablack, in her feature article, yearns for a magical transformation of the many factions in UKCP to make it feel safe for her:

We have a web to build together that can weather the storms and that we can learn to repair as needed.

Family systems therapist Judith Lask, in her detailed and specific feature article, deplores UKCP’s pervasive infighting. She catalogues several of the things that have gone wrong, and that have made her feel UKCP is like “a rather scary family”:

Dissent could often be met by personal attack. This felt like bullying at times and such unpleasantness was left to run, it seemed. It was like a family that did not have an effective parental subsystem.

Other articles continue along similar lines. Someone wants UKCP to acknowledge the harmful effects of market-led economies. Someone wants UKCP to promote more research. “Validate me!” “Validate me!”

Strategy

Those who run things have settled on five strategic themes to guide UKCP’s development over the next three years. Characteristically, each of the themes carefully evades the difficult issues.

One theme is to establish the core values of psychotherapy:

…a safe place in which personal exploration and reflection can take place, respect for the autonomy and safety of the client/patient, and recognition that the personal qualities of the therapist are as important as any specific technique or method.

The difficult issue of personal qualities, techniques and methods that are inherently unsafe for the client/patient is not mentioned.

Another theme is improving access to psychotherapy, partly by providing low-cost and free psychotherapy. The extent to which this will amount to handing out tasters in order to get people hooked on forms of therapy that will eventually damage them is not mentioned.

Another is engaging members, where none of the problems Judith Lask catalogued are mentioned.

Another is maintaining excellence and professionalism, and the last is recognition of psychotherapy:

The general public is currently, for the most part, denied excellence in favour of a quick fix.

The quick fix being referred to is, of course, CBT. For these two themes measurement of outcomes is the difficult issue. No realistic view of excellence and professionalism can exclude what actually happens to the people subjected to therapy, and the public will increasingly want to understand the outcomes, too.

The NHS piloted comprehensive outcome measurement in its Improving Access to Psychological Therapies (IAPT) programme (though the outcomes have turned out to range from not great to terrible), and it has well-publicized plans to extend outcome measurement to the whole of medical practice. UKCP doesn’t stand a chance in the medical world unless it understands this and gets on board.

Outlook

The outlook for UKCP is not good. It has been trying hard recently, under the leadership of Jungian psychotherapist Andrew Samuels, but he has announced that he will soon stand down.

Huge issues not only remain unresolved, but remain without any intention to resolve them: UKCP’s position in relation to CBT, its propensity for savage in-fighting, its avoidant reaction to consideration of outcomes, its continued blind allegiance to the training paradigm.

Underlying all these failures of intention is UKCP’s inability to grasp its role as surrogate parent to those therapists who have made a profession of dependency and insecurity.

It looks like the time is almost right for some of the more grown-up organizations to jump ship in the way BABCP did.

NICE (the National Institute for Health and Clinical Excellence) is consulting on a draft guideline on Improving the experience of care for people using adult NHS mental health services. Much of the guideline is based on other guidelines for specific conditions. The consultation is not public even though the documents are — only registered stakeholders can submit comments.

The 200-page draft pursues a customer satisfaction questionnaire approach, although of course instead of ‘customer’ it uses the term ‘service user’. It includes the wonderful finding that (p. 166):

…a study that evaluated the presence or absence of a window and the affect on service users’ experiences in hospital suggest that satisfaction is generally achieved when window area occupies 20-30% of the window wall

Discharge

A telling feature of the draft is that discharge and transfer of care are considered together (Chapter 10). It’s clear that the authors are thinking only of discharge from hospital to subsequent community care, or discharge from community care to some other form of care.

There is little or no mention of discharge from the system altogether. Even the small section on discharge from community care (10.3) emphasizes continuing support and the availability of top-up appointments and re-referral.

It’s as if the entire mental health system has become an asylum in the community, a grim institution that no one ever really leaves, with the hospital ward taking on the role of padded cell for those patients who become too troublesome. This ties in with the widespread belief, a false belief, that mental illness indicates a fundamental weakness in you as a person from which you will never recover, and that the best you can ever hope for is life-long struggle in the care of others.

Online sources

An encouraging feature of the draft is its use of online sources. However, the source mentioned most frequently is healthtalkonline.org.

If you go there you will not find much of interest. There is a mental health group with 17 members and six topics, only four of which have replies. There is a blogs page with 36 posts, some of which are spam. The site’s main claim to fame seems to be that some TV celebrities have been involved in publicizing it.

Online resources that cater specifically for people with mental health problems tend to over-represent those whose treatment has been ineffective, because those people stay ill for longer and identify themselves more closely with mental illness. People who fall ill, get treatment, and recover are less likely to become members because they see the illness as something unfortunate that happened to them, not as part of who they are.

So the online sources used by NICE are likely to have reinforced the false belief that mental illness is always permanent. Also, it is not clear whether the source material obtained was all spontaneous material from patients, or whether some of it might have been material selected by the sites’ owners to publicize their various causes.

Accessing care

The draft does acknowledge many common problems. For example (p. 41):

Service users expressed wanting to have more time to speak about their problems which were often complex, and not be given pills and sent home.

and (p. 44):

…a barrier to accessing services was due to the prolonged waiting times when being referred to services and the limited resources available…

Waiting times and apparently limited resources are a side-effect of ineffective treatments, of course, because untreated patients get worse and clog the system for years.

Assessment

There were problems with assessment, too. For example, here’s a description that many people will recognize (p. 58):

O.K. The first interview was just “so tell us what happened” and he wrote it up and said “um hm, um hm” and wrote notes and he didn’t look at me but he was nodding and looking at the other guy. And they looked at each other and exchanged nods. It was very factual like “So what did you take?” and “What happened at the house?” Um, you know I felt like saying “I can understand English, doctor”. It was just very factual. They filled out their little form and that was it.

and (p. 62):

The qualitative evidence and survey both suggest that many service users are not getting sufficient information about the assessment process, about their diagnosis, and about their care plan.

The tick-box approach, which NICE encourages with guidelines like this, is the beginning of treatment failure for many patients finding themselves in a system that does not really treat them as troubled human beings.

Community care

Care in the community is criticized too (p. 70):

Service users said they were not able to play an active role in treatment. Some felt treatments were forced upon them and were not listened to when they expressed that certain treatments were not helpful for them. Service users want more responsibility to manage their care

and (p. 76):

Professionals were also viewed as barriers to effective treatment when they did not demonstrate understanding for the service user?s experience and when they forced uninvited ideas upon an individual

For example, here’s a quote from a patient (p. 77):

I would get very frustrated with what I felt was incompetence and ineptitude by my doctors. I did not feel that they were listening to me nor were they willing to make medication changes when my current mix of medications did not seem to be stopping my cycling. I had three doctors within that year, until I found my current doctor, who I am finally comfortable with.

And I liked this quote (p. 78):

I felt my psychiatrist was a very … oh … wet individual. Again, I think because I’d been quite a numerate, factual, organised person, to have someone…talking about feelings and what about this and what about that? And it was…nothing could ever be pin-pointed or…I just found it annoying.

This kind of thing is typical of professionals who are trained for years to interact with books, and then find themselves in a job where they have to deal with people.

Crisis

The chapter on crisis is surprisingly brief, perhaps because many of the problems that affect people in crisis had already been covered in previous chapters. A theme that will be familiar to many patients is acknowledged here (p. 94):

One study found that service users questioned the legitimacy of the diagnosis of personality disorder as they suffered from other primary, co-morbid problems. However, one participant in another study found it to accurately describe his condition…

…some service users received many diagnoses in the past and were therefore sceptical about the diagnosis and others were unsure whether they were ill or just a troublemaker

The 2009 NICE guideline on borderline personality disorder seems to have made little difference to the general accuracy of this diagnosis, except perhaps to introduce the bogus diagnosis of “borderline traits” in some places — a scam that is not mentioned anywhere in the draft document.

Common emotional disorders like depression and anxiety can get worse if left untreated. The symptoms multiply, and the sufferers become desperate. Anyone who was once diagnosed with a common disorder but received no effective treatment for it at the time is probably right to question the legitimacy of later changes in their diagnosis.

Hospital

The state of affairs on acute mental health wards makes it an urgent clinical, social and economic problem…most of all it is recognised by service users, many of whom find acute wards untherapeutic and unsafe.

That is the strongest statement I saw in the entire draft (p. 101). A detailed list of contributing factors follows, for example (p. 103):

A key problem noted in hospital care was the characteristics of the professional. Service users felt that there was a lack of rapport with some professionals and felt in some cases that they needed to act in exaggerated ways to get the attention of professionals

and (p. 106):

Some service users felt they were merely being watched while in care rather than receiving any therapy for self-harm

A patient writes (p. 106):

In eight weeks, I very quickly became institutionalised myself. I was scared to come out because I was in this enclosed world where I knew what was going to happen. There were routines, mealtimes, getting up times, medication times, OT [occupational therapy] times. There were routines and I had no responsibilities…I was in a place where I didn’t have to think about anything, and nobody could touch me.

Recommendations

I have just skimmed through some parts of this huge document. As well as the barriers to good care I have quoted, it also lists things that facilitate good care.

It’s recommendations, though, are checklists that don’t mention the cockroaches. Mental health trusts will be able to tick boxes and give themselves high scores, while their patients remain ill, clogging the system.

Lest anyone despair at the bureaucratic numbskullery of the NHS, it should be said that this NICE consultation is hopefully one of the last to get away with a tick-box approach that sidesteps the question of whether people are actually getting better.

Although it may take years to arrive, hopeful new thinking is on the way — the thinking that the outcomes people experience are more important than the NHS’s internal procedures. NICE might have to change or be abolished to make way for the new thinking, but whatever it takes there is at last hope.

If you’re a patient, how much effort does your therapist make to understand what it’s like to be you?

In an excellent description of how an effective therapist’s mind works, David Kronemyer reveals some of his own thought processes when engaging with a withdrawn and suicidal 17-year-old for the first time: Clinical Impression – A Smart but Acutely Suicidal Adolescent Girl

I was exhausted at the end, fully depleted by the experience. I felt as though I had summoned all of my inner resources and powers…I stepped outside for a few minutes to get some fresh air, tears welling up in my eyes.

It’s well worth reading the whole piece.

(By the way, “5585″ is a section of the California Mental Health Act, under which someone who is not yet 18 years old can be held for 72 hours against their will for psychiatric assessment and treatment.)

The analogy that Stanford professor  Elliot Krane draws in this short talk is that it’s like stroking your arm with a feather:

But the sensation is as if it’s a blowtorch:

A specialist in working with children who suffer chronic pain, he says (1:55):

Imagine I were to stroke your child’s arm with this feather, and their brain were telling them that they were feeling this hot torch.

Case study

He tells the story of a 16-year old dance student who sprained her wrist, but instead of the wrist recovering in the usual way, chronic pain of this kind crippled her whole arm. After treatment at a specialist pain clinic she recovered completely, and she is now continuing with her dance studies.

The talk briefly describes how this can happen. It’s thought that cells in the spinal cord malfunction and create a feedback loop that generates false pain signals, affecting the brain’s perception of pain and also affecting the arm itself.

Emotion

It struck me while watching the talk that the experience it describes is not a million miles away from the emotional pain that cripples the lives of many people with mental illnesses. There’s an initial event, or maybe a sequence of them, and the pain of that event somehow causes a malfunction — a feedback loop that constantly turns mild everyday sensations into intense pain.

Of course, emotional pain of this kind is unlikely to be caused by a malfunction in the spine.

Treatment

The treatment he describes includes painkillers and local anaesthetics, but its main focus is on (6:30):

…therapy to retrain the nerves in the nervous system to respond normally to the activities and the sensory experiences that are part of everyday life.

In addition:

…we support all of that with [an] intensive psychotherapy programme to address the despondency, despair and depression that always accompanies severe chronic pain.

In broad outline, the treatment is remarkably similar to therapy for emotional pain. The goal in both cases is not to destroy all feeling, but to break the feedback loop and restore normal feeling.

While chronic physical pain requires physiotherapy to retrain the nerves, chronic emotional pain requires psychotherapy to retrain the mind.

Here’s the whole talk:

First, to the islands of the Hebrides, where I will show you that none of them is Timbuctoo. Then to the Welsh valleys, none of which hides Timbuctoo either. Crossing the Channel to France and then the Pyrenees to Spain, we establish that there is no such city in those countries. Therefore it can only be in China!

This kind of persuasive logic is used by the writer Julian Baggini in his latest book, The Ego Trick, which I had the opportunity to read recently. His supposition is that the self, your sense of being a person, is not real, and that you are instead just a bundle of parts.

To convince his readers, he writes about a voyage of discovery, and a fascinating voyage it is too. He has interviewed many interesting people, and he has read books about many others.

There are men who have decided to become women, former professors, the 17th Century French philosopher, Déscartes, the blogger, prostitute and research scientist who became famous as Belle de Jour, and many others.

Each time, we find no definition of the self. Therefore the self must not be real!

Perhaps the most interesting interview he reports was with Oxford theologian Richard Swinburne, who argues for the existence of the soul. It’s interesting partly because Baggini returns to the topic of the soul in the book’s final chapter, and also because he singles Swinburne out for personal attack (page 69):

Swinburne’s commitment to the truth seems to be genuine, whatever his ability to arrive at it.

And (page 72):

Put simply, [the majority of serious thinkers] recognise bad arguments when they see them, and Swinburne’s are often very bad indeed…

The other interesting character in the book is Derek Parfit, who appears to be Baggini’s only hero, but whom he did not actually interview (page 234):

Of course, the person I most wanted to ask about the liberating effects of embracing a bundle theory was Derek Parfit, to whose work in this are my PHD was really just a series of footnotes.

The pearl

I described Timbuctoo as an “opulent city of legend, it’s shaded squares alight with the vivid yellow blossom of a thousand Jacaranda trees”. Is Timbuctoo really like that? Armed only with that description, if you did pass through Timbuctoo somewhere on our journey, would you even recognize it?

As a straw man, a false argument that is easy to knock down, Baggini uses the idea of the self as a pearl. This metaphor conflates several falsehoods, guaranteeing that the reader who falls for the ruse will not recognize the self along the journey.

A real pearl is an inanimate physical object, but no one thinks of himself or herself as an inanimate physical object. A pearl represents something rare and valuable, whereas everyone has a self, making selves commonplace. A real pearl is small and unchanging, whereas oneself is everything that one is, and always changing.

On Baggini’s journey, the reader is misdirected to seek a pearl. Although the description of the pearl changes, the pearl is never found. Therefore the self must not be real!

The science

From Gibraltar we look towards Africa. There’s no point, I explain, in going there because the African language does not contain the letter T. It follows that Timbuctoo cannot possibly be in Africa.

Baggini’s writing is engaging when he reports his encounters with all the various people he interviewed and when he reviews the books he read. As a journalist, he is very readable. When he attempts reasoned argument, though, it tends to fall apart spectacularly.

As an example, take his argument that no region of the brain could possibly represent the unity of the self (page 28):

The unity of the self is not to be explained in terms of a single, unified brain region, which acts as the master controller.

He attempts to use the example of vision to explain how the brain works (page 29):

Armed with an elementary knowledge of how the eye works, it is tempting to think that light shines on the retina and then the brain creates from this a single, three-dimensional image. But who sees this image? The temptation is to think (or perhaps more usually assume) that there is a kind of mind’s eye which inspects the image in the brain. But then how does this ‘mind’s eye’ see this image? It cannot be that there is a little person — a homunculus — in our brains which watches mental images. If that were the case, we’d have to ask what was going on inside the head of that homunculus. Would there be another mental image, and if so, what would be seeing that? An even smaller homunculus? If we continued to explain each stage in the same way, we’d end up with an infinite number of even smaller homunculi, each packed Russian-doll-like into our brains. Such an infinite regress could never explain how any seeing actually went on at all.

You can see clearly that this is a straw man argument. He describes it only to knock it down at the end of the paragraph. The flaw in his argument is elementary: in the mind, it is perfectly possible to have an infinite regress.

Indeed, there must have been an infinite regress in Baggini’s mind when he wrote those sentences. He must have imagined a ‘mind’s eye’, and inside that another ‘mind’s eye’, and inside that another, and so on, in order to have been able to describe it to us. And anyone who reads it also gets to imagine the same infinite regress.

Suppose Baggini had applied this argument to mirrors instead of brains. A mirror, he might say, could be placed behind you and another one in front of you. Looking in the mirror before you, you would see the one behind you, and in that the one in front of you, and so on — an infinite regress. Therefore mirrors are impossible!

This is the elementary mistake he made. It is indeed impossible for a mirror to contain another mirror, or for a brain to contain another brain, but it is certainly possible for a reflection to reflect another reflection, or for a mind to imagine another mind.

Representation

In the book, the argument drifts off topic after that, but Baggini has missed something important about how brains process and represent information. It is entirely possible for the representation of an abstract property like the unity of the self to be represented in a single place.

As an example, suppose this web page you are reading were coded to do some computation with dates. Every web browser contains an abstract representation of dates, called a prototype.

The prototype is not an actual date. It is a representation of all the things that dates have in common. For example, every date must be in some month, and this ‘monthiness’ of dates is represented in the prototype in your browser.

If this web page wanted to work with an actual date, known as an instance of a date in programming jargon, then it would have to specify an actual day, month and year. If you visit many web pages that perform computations with many dates, those dates would all have separate days, months and years, but the monthiness of all those instances of dates, the requirement that every date must be in some month, exists in only one place — in the single Date prototype that is shared by all the instances.

Therefore it is perfectly possible for the representation of an abstract property to exist in a single place even though it is a property that belongs to many separate things. This makes it seem entirely possible that the brain could store an abstract property like ‘unity over time’ in a single place and apply it to the many things that have that property — the self, other people, rivers, trees, and so forth.

What’s more, the way vision has been found to work in the brain suggests that something like the prototype model really is what’s going on. For example, it has been found that when you look at a scene, certain brain cells respond to abstract properties of the image.

For example, certain brain cells respond only to vertical lines. If you gaze out to sea at the horizon, those brain cells go quiet. If you look at anything with a vertical line, they become active. It is suggestive of a single prototype that represents verticalness.

This is not to say that ‘unity over time’ really is represented in a single place in the brain, only that it could be. Systems of representation of that kind are as common as web browsers, and they have already been identified in the activity of brain cells.

By contrast, Baggini’s argument against this kind of representation of the unity of self is trivial and foolish.

The answer

The book’s conclusion is in the middle, where Baggini informs his readers of what he considers to be the correct answer. The answer is supported by four claims, but each of them is shaky (page 114, original emphasis).

First, there is no thing or part of you which contains your essence…

This claim is shaky for the reason I outlined above. The essence of your identity might well be a single part of your mind that represents not just your identity but the identity of other people and things.

Second, you have no immaterial soul…

Weirdly, Baggini himself tears this claim down later in the book when he considers in more detail what various theologians mean by the word soul. For example, depending on who you ask, your soul might be your unique combination of mind, body and personality — that unique combination not being a material object, while at the same time certainly being something that exists.

Third… If there is no single thing which makes you the person you are, then you must be the result of several parts or things working together.

This is so obvious that it does not need saying, but it tells you nothing about your sense of being a unified self. One of those parts, a part of your mind, might be your sense that you are yourself. Or it might not. This third claim is a statement that contains no information.

Fourth, the unity which enables you to think of yourself as the same person over time is in some ways fragile, and in others robust…

This claim assumes you do have a unity after all, but further than that it says nothing useful. What is there, after all, that is not in some ways fragile, and in others robust?

After some faffing around, and after crediting philosopher Derek Parfit with finding the correct answer, Baggini gets to the point (page 120):

There is no single thing which comprises the self, but we need to function as though there were.

The bundle

It turns out that Parfit’s theory of the self is only one of many theories that see the self as a bundle of parts. The remainder of the book refers to bundle theories in the plural, and it mentions some of the individual bundle theories, amongst other things, by way of trampling the straw man pearl theory that was put forward at the start. It is not just that the self is a bundle, but bundle theories of the self are themselves bundled into the second half of the book.

The book ends by explaining what it was really all about — it was not about the nature of the self at all. The last chapter, Living without a soul opens by quoting Derek Parfit (page 218):

My life seemed like a glass tunnel, through which I was moving faster every year, and at the end of which there was darkness. When I changed my view, the walls of my glass tunnel disappeared. I now live in the open air.

Clearly, this describes a spiritual conversion of some kind. The change of view that it refers to was (according to Baggini) when Parfit adopted a bundle theory and abandoned any clear sense of self. It is not clear whether Baggini is aware of the irony of quoting that under the chapter heading Living without a soul.

What Baggini seems to be proposing, and perhaps Parfit too, is that self-as-bundle is a kind of artificial do-it-yourself soul. The point of believing in a soul is to express the idea that your existence as a person has a higher meaning, so that if there are parts of you that seem to make no sense to you, it is OK because at some higher level they do make sense.

The point of believing in a bundle theory is exactly the same. If there are parts of you that seem to make no sense, it is OK because you are just a bundle and the parts do not need to make sense.

Belief in the soul and bundle theories therefore share the same function of making it OK for there to be parts of you that cannot be made to fit with the rest of you. How attractive this seems probably depends on the kind of person you are.

If you are a person whose sense of self seems to encompass your whole self, then you don’t need to believe that you have a soul or that you are a bundle. It does nothing for you.

If, though, you are a person who feels oppressed by irreconcilable elements within yourself, then belief either in a soul or in a bundle theory is no doubt liberating. There will no longer be any need to reconcile those elements. This seems to be Baggini’s conclusion — that believing in a bundle theory sets you free.

It is tempting to speculate that when interviewed, Swinburne detected a need in Baggini to be reconciled with himself in some way, and that was what led to the personal attack, while Parfit’s theories offered Baggini a way out of something oppressive in his life without actually having to face it. As to what that oppressive something might be, the book does contain clues, but I won’t spoil the whole plot.

Jacarandas

The real Timbuktu in West Africa, should you ever find it, will not live up to the expectations that its legend and I may have created. There, at the edge of the Sahara, it is too dry for jacaranda trees to flourish. Go four thousand miles south to Pretoria in October for the profusion of their vivid blue blossom to take your breath away.

Just as I would not venture into Africa, Baggini did not venture into psychotherapy to discover what the self means. Psychotherapists help people to reconcile the apparently irreconcilable within themselves every day, making it OK to be who you are. There is no need for complicated theories about either souls or bundles in order to make it OK. It’s just OK all by itself.

The 2005 paper Chimerical Colors (PDF) describes a standard model of how humans perceive colours, the Hurvich–Jameson opponent-process network. The model is convincing. It provides a good explanation of colour perception, explaining the observed fasts about how people see colours.

But the model goes further, predicting that we ought to have the ability to see colours that do not exist in nature. And the paper goes even further, including actual examples of experiments you can perform on yourself to see colours that don’t exist.

Fatigue

The general principle is that when you gaze at a strong colour for a while, it fatigues the part of your brain that responds to that colour. When you transfer your gaze somewhere else, you see a negative after-image of the colour you were gazing at.

For example, gaze steadily at the white + sign in the middle of this blue square, close up for about 20 seconds or until you start to see ghosting around the edges. Then transfer your gaze to the + sign in the pale blue square. You see a white after-image where your ability to perceive blue was fatigued. The fatigue gradually wears off.

Chimeric colours

There’s nothing chimeric about white, but when you do the same with this pair the red fatigue you create makes you see a blue-green after-image on the black background. In the real world black cannot have a hue. There is almost no blue or green light reaching your eyes from the black area. So this blue-green yet black colour is chimeric — impossible in nature but visible to humans.

The paper is technical but it explains the model very clearly. For more examples of chimeric colours, scroll down to the diagrams starting with Figure 11 on page 22 of the PDF.

Emotion

The way these after-images work is broadly similar to the CBT model of emotional disorders.

Some circumstance produces a cognitive bias in your perception of the world, so that your emotional response to the world no longer represents the way the world really is. Your emotional response might even represent a world that’s impossible.

Normally, the cognitive bias would be temporary, and as it wears off your emotions return to normal. That is, they return to representing the world accurately. But in mental illness the cognitive bias gets stuck. You continue to have a biased emotional response. This is like continuing to see the blue-green after-image for months after you gazed at the red square.

The discovery that made CBT possible was that the emotions are not a direct perception of the world in the same way that colour is. Emotions are an indirect perception mediated by thoughts.

So CBT works by identifying the particular bias that you have somehow got stuck with, and then using thoughts to undo the bias. The end result is that you can once again experience a full range of emotions without bias.

For example, we might say that suffering from depression is like seeing a blue after-image everywhere. The aim of treatment is not that you should never see the colour blue again, making your whole world yellow. The aim is that you should only see the colour blue when the thing you are looking at really is blue.

Or in other words, after treatment you should be able to become as depressed as the next person when something depressing happens to you. CBT only removes the after-image of that past circumstance, so that it no longer colours everything.

The term counselling covers such a wide range of things that it can be very confusing. At one end of the range, it is fairly close to advice. At the other, it is indistinguishable from psychotherapy.

The documentary film, The Trouble with Love and Sex, uses the voices of real clients and counsellors in an animated film that weaves together three stories. The animation is well done, but we do not know how much of what we see is based on reality, nor indeed whether some of what we hear was recorded specially for the film.

Guidance

Guidance counselling is an old-fashioned but useful term for counselling-as-advice. You go to a guidance counsellor to benefit from their knowledge about good solutions to the problems of ordinary everyday life. This is the kind of counselling shown in the documentary.

The advice you get from a guidance counsellor is somewhat personalized, in the sense that the counsellor has to understand your situation a little in order to choose from a selection of prefabricated solutions. However, the counsellor’s role is mainly to elicit information from you, categorize it, and inform you about the solution they think fits your situation best.

In the film, people sought guidance about relationships at the charity Relate. Counsellors interviewed them, advised them about the kind of things that are known to work in relationships, and encouraged them to adopt those solutions.

Facing problems can make people emotional. Guidance counsellors know to expect some shouting, and some tears. On a couple of occasions the film focussed on the box of tissues on the counselling room’s coffee table.

But in guidance counselling emotion is not central to the plot. Guidance counsellors, like other advisors, keep their distance from it. In the film this was portrayed as physical distance between the chairs in the counselling rooms, which faced each other directly — confrontationally.

Emotion

When emotion is central to the plot, it changes the nature of the counselling. This is the kind of counselling that you can expect (well, OK, not expect, but you might get it if you are lucky) from the NHS, and from many private counselling practices.

Counselling of this kind deals with normal emotions. That is, the emotions relate to something that you can identify, but the emotions themselves disrupt your life to some extent.

To engage with an emotional problem, you and the counsellor have to get close. The chairs are probably not that far apart, they are probably on the same side of the coffee table, and they are probably angled instead of confronting each other.

Emotional counselling mostly relies on activating your own ability to recover. Having a counsellor who is close to you makes it easier and quicker. The counsellor might throw in a little guidance for good measure — advice on good ways to solve life’s everyday problems.

Illness

When you have emotions that disrupt your life severely, when this goes on for a long time, and when you cannot identify any good reason for the emotions, that’s an illness — an emotional disorder. Treating an emotional disorder goes beyond counselling into psychotherapy.

A psychotherapist also has to get close to you, just like a counsellor dealing with normal emotions. Psychotherapy introduces you to ways that you can recover that go beyond your own abilities and strengths, and beyond prefabricated solutions.

For example, if the psychotherapy is CBT you and your therapist might explore how certain of your thoughts interact too strongly with your emotions. It’s hard work for the therapist, who has to understand you as an individual well enough to help you work out what’s going on.

Ian and Mandy

One of the cases in the film illustrates guidance counselling very well. Mandy feels that she and her husband, Ian, have drifted far apart emotionally.

Their guidance counsellor suggests that they don’t talk to each other very much. So they talk to each other more and the difficulties go away. Toward the end of the film we see them in the bath together drinking champagne cocktails, and then telling each other that they love each other.

“Talk to each other more” is a prefabricated solution often used in relationship counselling. The fact that a counsellor is telling you to do it probably makes it easier to do. There’s an element of parenting about it, an element of coercion, an element of consulting tribal elders who tell you how life should be lived.

Dave

In another case, Dave, a single man, feels strongly attracted to a woman he knows at work, but he finds it difficult to approach her. When he talks to a guidance counsellor, he soon finds himself describing the way his father often beat him and even tried to kill him on one occasion when he was a boy, his subsequent thoughts of suicide, his tendency to drink too much, and the large collection of pills he has saved up.

The counsellor in this case is an odd bloke, considerably odder than the client. The film makers portray the counsellor as a stock Hollywood psychoanalyst type, dressed over-precisely, with a pointed beard that he sometimes strokes, peering over rimless glasses. He says “Hmmmmmm” a lot. One feels that if they had not had to use the original voice they would surely have given him a creepy Austrian accent (14:18):

Dave: I actually thought about finishing myself off, actually.

Counsellor: Suicide.

Dave: Yeah.

Counsellor: Hmmmm.

Whenever the counsellor finds himself at the edge of his comfort zone, he stops dead. Some of his behaviour suggests he might have Asperger Syndrome, although we do not know how much of what we see in the film was invented by the animators — we can only rely on what we hear.

Anyway, a good example is when the first session has ended but Dave wants to say something else. The counsellor is suddenly out of his depth. He becomes agitated and inflexible, ignoring the client’s feelings and using a visual metaphor (the line in the carpet at the door of the room) to communicate the boundary of the session:

Another example is when Dave describes the time his father tried to kill him in his bedroom. His father apparently changed his mind, and Dave ran away down the stairs. The counsellor is completely emotionless, and without the slightest pause he changes the subject to ask about the other children at Dave’s school.

In an early session Dave speaks of a time when he felt there might be “dark forces” in his life (14:48):

Dave: I’m always sort of subconsciously worried about dark forces, or something going to happen, something nasty’s going to happen…

Soon afterwards, the counsellor starts to speak of “voices” even though he understood the word “forces” when it was originally spoken (15:28):

Counsellor: Part of you is saying “Go take the tablets.” Another part of you is saying, “No.”

In a later session, the counsellor refers again to these voices, forgetting that it was he, the counsellor, who introduced them (43:56):

Counsellor: I’ve been very struck by your talking, through our sessions, of these voices.

The guidance that Dave receives is that his father’s violence left him with a dark side. He should say goodbye to his dark side, practice restraint in his drinking, throw away his collection of pills, and forget about approaching the woman at work because he’s better off on his own.

The counsellor writes a goodbye letter to Dave’s dark side. (It’s a standard letter — this is a prefabricated solution.) Dave signs the letter, takes all the other advice and lives happily ever after. Maybe.

The upshot is that when Dave left counselling he was still unable to approach the woman he fancies, but he had solved a different problem he didn’t know he had until the counsellor gave it to him.

Susan and Iain

The third case in the film (but the one the film begins with) is different again. A couple who have been married for a long time feel their relationship is coming to an end. They argue a lot about sex (lack of). Susan has a tendency to be tearful, while Iain has a tendency to retreat within himself.

As the story develops, it turns out that their difficulties go back almost to the start of their relationship, when her parents rejected him as being unsuitable for their daughter. She once had an affair. He is unemployed. The guidance counsellor struggles to find a prefabricated solution to this complex situation.

“Talk to each other more” helps a little. They become more tolerant and more affectionate, but it’s not enough. Although the film ends with them holding hands, we learn later that they continued the counselling.

Both Susan’s tearfulness and Iain’s withdrawal suggest emotional states that there is no apparent explanation for. So this would indicate that they both have mild emotional disorders that could easily be treated with psychotherapy. However, that’s not what happens. The guidance counsellor just struggles on, even though it isn’t working.

After the end of the film we learn that Iain had died suddenly of a heart attack. I won’t write what I’m thinking.

Appropriateness

It can be difficult to work out what kind of help to seek when such a wide range of services are all covered by the same word, ‘counselling’.

If an overwhelming feeling is central to the problem, you have had this feeling for a long time, it disrupts your life, and you cannot make sense of why you feel this way, then psychotherapy is indicated. Of the various psychotherapies around, CBT usually works quickest, going to the root cause of the problem and resolving it permanently.

If you do know the reason for the feeling, and you have not suffered from it for very long, or it is not particularly disruptive, then counselling is indicated. Of the various types of counselling around, humanistic counselling makes best use of your own ability to recover.

If the problem is an everyday situation, not a feeling, then guidance counselling or advice is indicated. This applies even when you have strong feelings about the problem, as long as the feelings themselves are not the problem. The type of advice or guidance you seek depends on the nature of the problem.

The film illustrates that people can have all kinds of misery in their lives and yet be mentally well. Even being mistreated as a child and having thoughts of suicide as an adult does not in itself mean you are ill.

Beware

Beware, however, psychotherapists and counsellors whose behaviour is not appropriate to the kind of help you need.

For example, if you go along for some advice about your mortgage but the advisor tries to get into an emotional relationship with you, leave immediately. That advisor is trying to mess with your head.

Equally, if you go along for psychotherapy but the therapist sits on the other side of the room facing you directly and cannot engage with you emotionally, leave immediately. All you’ll get from that therapist is prefabricated advice.

Some people choose to become counsellors or psychotherapists because they have problems of their own. That’s not in itself a reason to reject their help. As in the film, if all you need is some sound advice, then someone who knows a lot but has difficulties with personal interaction might do very well.

But if your counsellor’s or psychotherapist’s own problems get in the way of helping you, leave immediately. That could happen, for example, if you need mortgage advice but you end up being asked to invest in the advisor’s own company, or if you need help with your emotions but you end up being asked to deal with your counsellor’s emotions.

Perhaps the worst case is when you go for help with a problem, but the counsellor cannot solve your problem, so the counsellor invents another problem that he can solve (because he invented it).

Or perhaps the worst case is when you go for help with a problem that the counsellor cannot solve, but the counsellor keeps trying anyway, preventing you from getting proper help.

Three New Zealanders, none of them accredited CBT therapists in the UK, have nevertheless had an article published in one of the BABCP’s two research journals, Behavioural and Cognitive Psychotherapy. In line with most other academic research, this journal is not freely available to the public, allowing academics to spend other people’s money for almost no practical or theoretical benefit in almost total secrecy.

The article purports to be about case conceptualization, the process of working out the specific cause of an individual patient’s illness so that it can be treated. In line with most other academic research, there are no useful conclusions. No actual conceptualizations of actual cases were involved at any stage of the research. The whole thing is entirely conjecture: Improving the Quality of Cognitive Behaviour Therapy Case Conceptualization: The Role of Self-Practice/Self-Reflection

However, doing research into case conceptualization without conceptualizing any cases poses an interesting problem. What do you do instead? The choice of what to do instead reveals what the researchers and participants really think CBT is all about.

Self-practice

At the heart of this research is the idea of self-practice. Sixteen qualified therapists were encouraged to perform a kind of fantasy CBT on themselves using a specially designed workbook.

Of course, such a thing is clearly nonsense. Psychotherapy is designed to be used to treat mental illness. In the absence of any mental illness, there can be no psychotherapy.

And psychotherapy is designed to rely on an observer’s perspective of the patient’s mental state. In the absence of any observer perspective, when someone merely reflects on their own mental state, there can be no psychotherapy.

Generalizations

While real life case conceptualization results in a very specific treatment plan, the fantasy self-practice that participants indulged in resulted only in generalizations. The therapists were encouraged to reflect by answering questions [sic] like (page 327):

Comment on how it felt to process your thoughts in this way?

Mary, for example, is said to have reflected as follows, neither she, the researchers nor the journal’s editors attempting to make grammatical sense of her ramblings (page 328):

I don’t learn from similar experiences all that well. That I tend to act like this without thinking and then reflect on how I should have responded afterwards.

And Angela (page 329, original emphasis):

Enlightening completing the schema questionnaires and I enjoyed this part of the study the most as it gives me a sense of where I can challenge myself. Fits well with unrelenting standards.

Veronica, who had been so depressed two years previously that she could not go to work, apparently learned to understand her core beliefs (page 330):

I am glad they are fully exposed now (core beliefs) I don’t have to try so hard as to stress myself up to do my work and be a little more caring of myself.

Veronica’s example is the most revealing, because we never learn what these core beliefs are, or why their being “exposed” makes her glad. Neither she nor the researchers seem to have any interest in taking these generalizations further and getting anywhere close to what might reasonably be called conceptualization.

Empathy

After this, the paper loses its way entirely and gives up any attempt to address case conceptualization. There is a confused section on empathy. Here’s Veronica again (page 330):

I can relate to the difficulty and pain of people who have depression and anxiety disorders, low self esteem etc…

And Helen (page 330):

It reminded me of the bravery and difficulty in examining one’s beliefs.

This is not empathy, of course. It’s sympathy. That is, these feelings that Veronica and Helen describe are not real feelings they have in relation to any particular person. They are not a genuine mirroring of another human being’s emotional state. They are are just narcissistic fantasies based on their own emotional states.

Childhood

A section on memories of childhood is similar. Mary found it difficult to remember specific things about her childhood, but she was able to conclude (page 333):

It has made me more sensitive to the connections between childhood experiences, the schema.

No actual connections are mentioned, and as she found it difficult to remember anything, it is hard to believe that she was able to make any connections, never mind identify schemas.

Personal conceptualization

A section with no heading appears to deal with making a personal case conceptualization. It is not clear what this means, because no example is given, and none of the quotes refers to this personal case conceptualization.

However, this section contains some disturbing statements made by participants about the way they behave towards their patients. For example, Jennifer (page 333):

I have tended to avoid case conceptualization in the past or at least avoided sharing them with clients as they seemed a bit harsh, whereas in reality clients might enjoy/be interested in/relieved etc to understand themselves in this way.

And an unnamed participant wrote (page 334):

It reinforced the importance of providing not just a lip service of CBT. Mental health service demands e.g. waiting lists and pressure to treat and discharge clients, can I believe “short change” some clients of full treatment.

Criticism

One participant, Joan, criticized the fantasy CBT self-practice exercises (page 335):

…I am not sure that I know or can make any conclusions about the results that are meaningful or have currency for me.

The researchers retaliated by criticizing Joan (page 335):

…there may be some cause for concern regarding the way in which she would process client’s [sic] emotions[.]

Then they took a swipe at her again on a later page, referring to (page 337):

…Joan, who “got lost”…

Piggybacking

To improve its position in the search rankings, as it were, the paper includes the names Kuyken, Padesky and Dudley in the abstract, attempting to piggyback on the success of the book, Collaborative Case Conceptualization, which I reviewed in Reliability. The connections between the book and the research can only be described as shallow at best.

For example, one of the book’s most memorable features is its use of boxes captioned “INSIDE THE THERAPIST’S HEAD“, which show over and over again that a therapist’s own thought processes are distinct from (though closely related to) the therapist’s interaction with the patient. It is difficult to believe that anyone who reads the book could possibly miss this. Yet these researchers created self-reflection exercises in which there is no such distinction.

And again, while the book does mention reflective learning, it does so in relation to clinical practice (page 256):

Reflective learning describes what goes on when therapists stand back from their clinical practice and observe what has happened in order to improve knowledge, skills and therapeutic behavior.

In the book’s example of this, Theresa is a therapist treating Joe. She reflects on her sessions with Joe to understand why they make her feel fatigued. Her reflections are specific and detailed (page 277):

Theresa noticed that Joe’s vocal tone and patterns of complaint evoked images of her older brother, Pete.

Yet these researchers devised a form of reflection that is unrelated to observing what has happened in clinical practice, focusing instead on therapists’ feelings about themselves. And instead of being specific and detailed, the reflections in the research are vague and general.

From its very first page, and throughout every chapter, the book warns against unquestioning belief in pre-existing models. For example, (page 69):

…it is important that the therapist be equally attentive and curious regarding client observations that fit and do not fit the model. Otherwise, expressed curiosity is a thinly veiled method for convincing the client of a therapist’s belief…

Yet in the research study Joan’s findings that the pre-existing model in the workbook did not fit her caused a backlash from the researchers.

Implications

There is nothing very significant about the conclusions of this almost meaningless research paper, but it illustrates how an idea like case conceptualization can be digested and excreted in an unrecognizable form by academics.

Case conceptualization is intended to be a well-defined process for determining the nature of individual cases of mental illness. It is intended to lead to a treatment plan. The treatment plan is intended to lead to recovery. The whole idea of it is that the mental illness ends. It’s therapy.

Alas, for some therapists and academics that is apparently too challenging. It would be nicer, they seem to feel, if the words “case conceptualization” meant something different. Something softer. Something that doesn’t require any particular clinical outcome.

In this paper we can clearly see the softening process in action. The term case conceptualization is applied to contrived exercises in which no one is mentally ill, and where there is no therapeutic alliance, no treatment and no outcome.

It is worrying that all the therapists who took part in this charade, with the exception of Joan, went along with it. It says little for the quality of their training and supervision that so many of them were complacent and compliant in the face what of was, in several essential respects, little more than a hoax.

The propaganda claims being made in this research paper are that it’s OK not to treat mental illness, and that its OK deal in generalizations about everyday life instead of in particular treatments for particular patients. Exercises of this kind encourage the idea that fantasy therapy and lifestyle CBT are a good enough substitute for the real thing.

Therapists who are serious about psychotherapy, and patients who are serious about getting well, should be very wary of approaches like this that evade the uncomfortable details of illness by retreating into navel-gazing.