Looking forward to the Good Ol’ Days

Tim Carey, PhD
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One of the most remarkable aspects of Robert Whitaker’s (2010) outstanding book Anatomy of an Epidemic was his comparative data that contrasted outcomes for mental disorders prior to the introduction of pharmacological treatments with outcomes for mental disorders after pharmacological treatments became the main, and often only, course of action. I have asked people in workshops to estimate who might be better off – someone diagnosed with what we now call bipolar disorder prior to the introduction of lithium or someone diagnosed after lithium became a standard treatment. Almost without exception workshoppers estimate that the people diagnosed before lithium was available do much worse. Whitaker’s data indicate exactly the opposite. It’s a staggering finding.

The data about depression are perhaps even more mind-boggling. Healy (2004; Healy et al., 2001) maintains that the frequency of depression has increased a thousandfold since the introduction of antidepressants. Would this be acceptable anywhere else in medicine? Imagine disseminating a treatment for tuberculosis and then discovering after the treatment had been in widespread use that the prevalence of tuberculosis had increased by a factor of 1000.

The field of mental health today could be characterized by expanding diagnostic categories that include more and more people who are subjected to treatments that do not cure and, in many cases, do not even enhance recovery. This situation is troubling enough on its own but it perhaps also indicates a more fundamental problem. We seem to be developing a social environment in which difference is not tolerated. Any quirk or eccentricity is now suspiciously considered a sign of a lurking “mental illness” and a mythical state of eternal happiness is relentlessly promoted and pursued at any cost. Life is no longer viewed as a journey of ups and downs but a high-speed, multi-lane highway that travels over the countryside rather than meandering through it. In all of the gains we have made in modern times, have we also lost some of our humanity?

In many ways we are living in a glorious age. There are certainly still important and serious problems to overcome but many people enjoy a quality of life that would have been unimaginable a century ago. We have developed technology that allows us to maintain an unprecedented level of contact with the world around us yet, in some respects, as individuals we may be more disconnected now than ever before. Many friendships and social relationships are maintained in the mysterious and nebulous e-world where, to a very large extent, people can present whatever image they desire. Texting people or communicating with them on facebook is different in important ways from sitting across the table from them in a café. Blogging, as I am doing, would not be possible without the incredible advances we have made in e-communication and there is much to be gained from utilizing forums such as this one to disseminate and share ideas. Blogging sites have given a voice to many who previously would have been silent and so in that sense they are invaluable. We all have an opportunity to learn in environments such as these.

There is much that is good about the modern world and a return to the past would not necessarily be desirable even if it were possible. There are some aspects of today, however, that are not advantageous when compared to yesterday. As already mentioned, many more people are being diagnosed with psychiatric problems than before but we are not developing treatments of increasing effectiveness. While this is certainly true for pharmacological treatments it also seems to be true for psychological treatments. Although we have hundreds of “brands” of psychotherapy available today, it is not clear that the treatments on offer are more effective than previous treatment options. For example, over a span of more than three decades, a meta-analysis of psychotherapy for depression indicates that effect sizes declined until about 1995 at which point they stabilized somewhat (Collins, 2010).

In my book Hold that Thought? Two steps to effective counselling and psychotherapy with the Method of Levels I make the point that each therapy has different techniques and different models for psychological problems that arise. Suppose that three different people went to three different therapists and received three different treatments for depression and they all improved similarly. Could it really be the case that three people just happened to access the specific treatment that matched their particular types of depression? It is much more likely that there is something common going on whenever any therapy is effective.

An important aspect of that “something common going on” involves making a connection with a therapist. It is well known that the therapeutic relationship make a substantial contribution to treatment outcome in psychotherapy. It is less well known why. Qualities such as hope and trust are often discussed but even these are not entirely satisfactory in terms of explaining what the essential element might be. Perhaps the connection that is established allows people to look at those aspects of themselves that they would ordinarily avoid (Carey, Kelly, Mansell, & Tai, 2012) which promotes a fundamental learning and re-learning of who they are and who they want to be within their social context. Maybe if we focussed on promoting this aspect of therapy rather than the elements that make each therapy distinct we might achieve major leaps forward in terms of effectiveness.

The notion of “individuals in context” should not be underestimated. We are inherently social beings and while we can vary on what the “right” amount of socialising is for each of us, the social context is universally an important consideration. Even hermits and others who shun social living are making decisions within the context of their place in a social world. Increasingly we find ourselves in a disconnected social world.

Perceptual control theory (PCT; Powers, 2005) highlights the importance of context by describing a precise relationship between our behavior and the environment. PCT explains how different behavior can be used to achieve the same goal and the same behavior can be used to achieve different goals depending on the context. Booking a table at a restaurant and washing a car can both be ways of communicating affection. Standing on the curb and waving one’s hand could be to hail a cab or to catch a police officer’s attention or to say goodbye to a dear friend.

The crucial point here is that, in order to understand people’s behavior accurately, we need also to consider the environment in which they are functioning at any point in time. So-called “crazy” behavior may indicate that the person is responding to what he perceives to be a crazy environment. Chaotic behavior may, similarly, mean that the individual is experiencing her environment as chaotic.

This principle illuminated for me the common finding that children at school can be experienced differently by the teacher than they are by their parents. I remember as a preschool teacher having parents complain about the behavior of their children yet I found their kids to be complete delights in class. Similarly, some children who seemed to struggle at school had parents who reported no problems at home. These occurrences are completely understandable when the demands and requirements of different environmental contexts are considered.

It is interesting to me that the array of childhood diagnostic labels is primarily social-relational in nature. Labels such as “Asperger’s Disorder”, “Oppositional Defiant Disorder”, “Attention Deficit Disorder”, and “Conduct Disorder” all have something to do with a perceived rupture between the child and the child’s environment. Regrettably, labelling a child with a disorder serves the function of diverting attention away from whatever difficulties there might be in the behavior-environment relationship and places full responsibility for the problem with the child.

Given the social nature of many of the problems children can be labelled with, should we wonder about the developing child’s understanding of social relationships given the long hours many children spend in day-care situations? Sometimes, from before they are 12 months old, youngsters are looked after by day-care centre staff. Regardless of the quality of the staff, or the necessity of this arrangement, we need to consider what children might be learning from a very early age about social relationships and how they are formed and maintained. What connections are they forming and what are they learning from and about these connections? What expectations are they developing with regard to their social interactions with others?

Perhaps we are still in a state of transition. We have developed a new world of e-toys and we are still learning how to play nicely with them. For some people it seems as though the e-world has become a replacement rather than a resource for the social world. Also, e-technology has the capacity to make an enormous contribution to health services in rural and remote locations but, even here, their use needs to be carefully thought through. Where they are used to augment and enhance face-to-face services they are likely to be extremely effective, however, if they are used instead of face-to-face to services they may not be as beneficial as they otherwise might be.

There is still much we can learn from the past when people were, arguably, more interpersonally connected than we are today. Perhaps the quantity of social connections was smaller but the quality might have been much greater. Emailing people is terrific, eyeballing them is better.

Despite all the advances we have made, the best things people can do to look after themselves remain remarkably stable over time: eat a balanced diet, exercise, get enough sleep, maintain friendships and other social relationships, and so on. Life seems faster now that it was “back then” but we don’t seem to be getting anywhere more quickly than we did before. Reclaiming time and taking more of it is perhaps the best thing we can do to get to know ourselves and each other more closely. Family meal times do not only provide nutritional sustenance they provide relational nourishment as well. Sitting around the dinner table talking, laughing, even squabbling as a family, provides an old fashioned remedy to many of the daily strains and stresses of modern life.

We are very much living in a “data age” where people count anything from the number of calories they consume to the number of steps they take on a given day. Perhaps we should also count the number of quality connections we make each day. How many people did I laugh with today? How many eyes did I look into?  In the midst of our superb modernity we need to stay in touch with what’s important. Recognising our place in the social sphere, taking time to connect, and getting to know better both ourselves and those we are close to will help us build lives of meaning and value at a time when the quality and importance of our connections threatens to be eroded.

 

References

Carey, T. A. (2008). Hold that thought! Two steps to effective counseling and psychotherapy with the Method of Levels. Chapel Hill, NC: newview Publications.

Carey, T. A., Kelly, R. E., Mansell, W., & Tai, S. J. (2012). What’s therapeutic about the therapeutic relationship? A hypothesis for practice informed by Perceptual Control Theory. The Cognitive Behaviour Therapist, 5(2-3), 47-59. doi:10.1017/S1754470X12000037

Collins, M. (2010). Identification of real and artefactual moderators of effect size in the treatment of depression. Unpublished Master of Clinical Psychology Thesis. Canberra, ACT: University of Canberra.

Healy, D. (2004). Let them eat Prozac: The unhealthy relationship between the pharmaceutical industry and depression. New York: New York University Press.

Healy, D., Savage, M., Michael, P., Harris, M., Hirst, D., Carter, M., Cattell, D., McMonagle, T., Sohler, N., & Susser, E. (2001). Psychiatric bed utilization: 1896 and 1996 compared. Psychological Medicine, 31,779-790.

Powers, W. T. (2005). Behavior: The control of perception. New Canaan, CT: Benchmark.

Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Broadway Paperbacks.

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33 COMMENTS

  1. Without the web, I might have been completely subsumed by psychiatry and one of the medications I’ve taken for MS. It’s the biggest library ever and it’s ever expanding.

    It’s true that the social world on the web is truncated and very limited, but that is to some degree true in the face-to-face world as well. Our lack of community and the degree to which our behaviors and values are forced into the molds of capitalism and business school management protocols leaves us without community.

    • I think the interactions and relationships one forms in real world as opposed to internet are simply different. They are not replacements, they are completing. The interactions you form in real world are more often based on chance, on where you happen to live, what interactions your family has, what school you go to etc. They are influenced by how you look, what sex you are, how much money you have etc. In the internet if you don’t want to you don’t even have to provide any of that data – it offers you freedom from these restrictions and the only thing that guides your relationships are your interests, your intellect and ability to express yourself.
      My relationships and connections in the real world are sometimes very different from my interactions on the web and I like it so. I think internet brings me to people I would have never be able to meet and talk so it expands my horizons but it also shows me that there are more people who think like me and share my views – this is very validating though it does create a bubble of sorts.
      I think it’s just important to keep the balance and take what’s best from both worlds.

  2. I have no problem with this article. Nothing to argue about. There are many such articles on MIA now, but I am really not understanding where MIA is going. There are many outlets for articles like this. There is almost no outlet for talking about how to actually change what is being done to people trapped in the “mental health” system.

    People are being abused and damaged by psychiatry in huge numbers. How does publishing articles about the fine points of therapy help to end those atrocities?

  3. I was drugged for concerns my child had been abused. But the medical evidence proves, in fact, he likely was. And I’ve been told by subsequent pastors that the function of the psychiatric industry is to cover up sexual abuse of children for the religions. Is that actually appropriate? I don’t believe it is.

  4. “This principle illuminated for me the common finding that children at school can be experienced differently by the teacher than they are by their parents. I remember as a preschool teacher having parents complain about the behavior of their children yet I found their kids to be complete delights in class. Similarly, some children who seemed to struggle at school had parents who reported no problems at home. These occurrences are completely understandable when the demands and requirements of different environmental contexts are considered.”

    Gday Tim,

    I can’t help but wonder if your conflating the subjective interpretation of the observer and the environmental context here.

    For example you describe a situation where a three people go to three therapists. I was having a discussion with someone and explaining that if I go to three doctors in different parts of town with a skin cancer, tests will be done and one would expect that all three doctors would give a diagnosis of skin cancer and recommend treatment paths.

    However, if I were to go to three psychiatrists, I would quite possibly get three separate diagnoses, and recommended various medications for these ‘illnesses’. So whilst the environmental context is most certainly important, the subjective interpretation of each individual therapist is always going to effect how that environment is understood.

    Minus any truly objective test, the problem of ‘behaviour’ is always going to be dependent on the eye of the beholder. This of course is Art, not Science.

    Do you see consistency across therapists with regards diagnoses?

    • That should read “how that environment/behaviour is understood”.

      I find this issue of environmental context of particular interest. The Mental Health Act in Western Australia states that an Authorised Mental Health Professional “who suspects on reasonable grounds that a person should be an involuntary patient” can detain that person. When I contested the “reasonable grounds” of a referral with our Chief Psychiatrist he reworded that particular section of the Act to read “The referrer has only to ‘suspect’ on grounds they believe to be reasonable” that a person should be involuntarily detained.

      I don’t know if you can see the substantive change in this, but it takes what is an objective legal standard (suspect on reasonable grounds) and turns it into a subjective interpretation that can not be tested (‘suspect’ on grounds they believe to be reasonable). This of course provides AMHPs with carte blanche to detain anyone they wish without any accountability.

      I am at a loss to understand why the Chief Psychiatrist whose primary responsibility is to protect the rights of consumers, carers and the community doesn’t know what those protections are.

      What was actually done by the AMHP was to omit significant environmental factors, and it made what were perfectly rational behaviours , appear irrational, and thus created the “reasonable grounds” required to detain. So the protections of the Act are easily subverted by the omission of environmental context, and if one makes a complaint to the person responsible for protecting the community, one finds that he is unaware of those protections.

      It then becomes a matter of ones creative writing skills, and has absolutely nothing to do with objective facts as to which ‘illness’ a person has.

      • “There can be some consistency across therapists with regard to diagnoses depending on different facts such as the particular diagnosis being considered.”

        This was particularly problematic for me. The AMHP started with the intention of making me look mentally ill in order to create the reasonable grounds for detention. He did really well, as anyone who examines his Form would suggest that I was a violent, psychotic, drug abusing, wife beater.

        Of course when I was examined by the psychiatrist and the context of family conflict was included, I was the victim of domestic abuse, with no illness, and my decision to leave my home was perfectly reasonable.

        This type of inconsistency across mental health professionals that results in the trauma of being deprived of ones liberty quite possibly causes more damage than the actual illness a person may be suffering from. I know it was a “major contributing factor” in my attempted suicide.