A little while ago, an email appeared in my inbox about a trauma conference that is soon to occur. The conference is being conducted by the International Society for Ethical Psychology and Psychiatry and is titled “Understanding Trauma: Responding beyond the medical model.” Having just facilitated a workshop at the Psychology of Trauma conference in Darwin (Northern Territory, Australia), I was very interested in this forthcoming conference. It has a great line up of speakers and looks like it will be a really exciting and productive event.
In the information provided for the conference, the following question was asked: What would happen if the mental health system stopped asking, “What’s wrong with you?” and instead asked, “What happened to you?.” I guess in some ways the author of the question has posed it rhetorically with the assumption being that if we stopped asking “What’s wrong with you?” and instead asked “What happened to you?” then we would begin to see changes in the understanding and treatment of mental health problems. Given the title of the conference it is probably safe to assume that the person who posed the question is of the opinion that if we asked “What happened to you?” rather than “What’s wrong with you?” then we would begin to develop responses that are beyond the medical model.
I’m going to suggest, perhaps contentiously, that if we ask “What happened to you?” instead of “What’s wrong with you?” we wouldn’t see much of a change at all. Those people who are inclined to think of mental health problems as illnesses, as something “wrong,” would be able to explain that what happened to you was the cause of the illness; it produced what is wrong with you.
To be clear, I am a very strong advocate for moves away from the medical model towards a different understanding of the manifestation and amelioration of psychological distress. Part of my lack of engagement with the idea behind this particular question-switching strategy is because I don’t think it moves us very far away from the medical model, if at all. I think people will be able to retain their medical model understanding while asking the new question.
I suppose, in some ways, it’s a bit of a hypothetical point. We don’t know what would happen if we asked “What happened to you?” rather than “What’s wrong with you?” Maybe I’m wrong and others are right. Perhaps we would see a radical overhaul of our mental health systems. I would be surprised, however, if at least some of the proponents of the medical model wouldn’t object and argue that they already ask “What happened to you?” They might consider that they do this every time they take someone’s history.
I’d like to propose that it’s actually not the question being asked that is the problem. Any question is posed from a particular perspective or point of view. People can ask different questions to achieve the same goal and the same question to achieve different goals. I could ask the questions “What’s your favourite movie?” and “Where do you see your career going?” both with the goal of getting to know you better. On the other hand, I could ask “What are you doing this weekend?” because I have the goal of asking you out or because I have the goal of asking your friend out and I want to make sure you’ll be otherwise engaged. Trying to change the question being asked without changing the point of view that’s generating the question is a classic case of the tail wagging the dog.
It’s the understanding of mental health problems that needs fixing. The research in recent decades pointing to the importance of adverse childhood events has been wonderful in helping people reorient to more social and psychological explanations of psychological distress and torment. There is a danger though that the “adverse childhood event” explanation will just replace the “chemical imbalance” explanation while maintaining a linear, causative model as the understanding of mental illness and dysfunction.
It is very clear that many people who experience severe psychological distress report instances of adverse childhood events. It is just as clear, however, that there are other people who experience adverse childhood events and don’t go on to experience frightening and debilitating psychological distress in later life. The differential impact of adverse childhood events is something we need to learn from if we are to arrive at a different understanding of psychological distress and more effective and efficient treatments. The fact that some people are distressingly immobilised by their past while others are not, teaches us that it is not the historical event that is the problem. The problem lies in the way the event is remembered, re-experienced, and reconstructed right now in the hustle and bustle of daily life.
From any event that occurs people take certain meanings and may develop goals, expectations, beliefs, and values about the world and their place in it. Those internal specifications about the way they experience the world can persist long after the actual event has ended. The specifications persist in the neural organisation that makes people the individuals they are.
Often, as a result of troubling occurrences from the past, people may find they have conflicting views about themselves, their relationships, and the life they are living. They might oscillate between believing they are worthless and then thinking they are a decent person who deserves better. Perhaps they tell themselves that their abuser loved them while also knowing at some level that they were not treated in a loving way. Maybe they have the confusing experience of wanting to be far away and wanting to be close to their abuser at the same time.
The actual meaning of the event is likely to be represented in different ways by different people. The important point, though, is that it is being represented now. It is the way the remembering of the event is affecting the person right now in their daily life that is of utmost importance. Rather than asking “What happened to you?” it is much more crucial to understand “What is happening for you now?” If people are to be helped to change their current situation, the focus needs to shine a light on how the person understands things at the present time: how they are currently organised in terms of the active goals, expectations, desires, values, beliefs, and attitudes that are defining the life they are currently living.
From this perspective, what is happening to the person at the present time becomes the focus rather than spending time seeking to understand the dynamics of past events. If an event from the past is troubling now, it is vital to explore what the now trouble is. What is it about the events from long ago that continue to trouble the person? What specifically is the trouble? What is the experience of being troubled at the moment?
The Method of Levels
The Method of Levels (MOL) is an approach to psychotherapy and psychological treatment that emphasises the present time being of the person. It is based on the principles of Perceptual Control Theory (PCT) which proposes that the neural network is organised as a myriad of control systems arranged hierarchically and in parallel. From this perspective, control is understood to be the fundamental phenomenon in people’s lives. With this understanding, the central task in MOL is one of exploring the areas in people’s lives in which control is interrupted and compromised and enabling their own reorganising processes to resolve any conflicts that exist so that control can be restored.
It was Heraclitus who said: “No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.” If we follow the logic of this idea it becomes obvious that it doesn’t make a lot of sense to ask about the river a person stepped in last year or last week or even yesterday. It is crucial to understand, however, who the person standing in front of you is right now. The past river stepping activity undoubtedly contributes to who the person is at this point in time but it is the inability to achieve things in the present moment that is paramount.
We are only ever a present moment. This sentiment is epitomised in MOL in which each session is seen as a discrete problem solving journey of exploration. Typically, an MOL therapist does not even enquire about the time between this meeting and the last one but just encourages people to begin talking about and exploring the current botherations they are grappling with.
Because of the backing of PCT, MOL is an unfailingly optimistic therapy which fully accepts that people will be able to restore meaning and purpose to their lives if they are assisted to spend time exploring important areas in sufficient detail. Past events, therefore, can be discussed in MOL but the emphasis is always on the impact of the event right now with questions such as: How is the event being remembered?; Which bits are remembered?; What happens when these experiences are replayed?; and so on.
The reorganisation model of change from PCT helps explain why people take different amounts of time to arrive at the solution that is right for them. It also explains that the best solution doesn’t necessarily come along first and that, sometimes, things can even get worse before they get better.
In a sense, from an MOL stance, it doesn’t matter how people get to be the way they are. It’s the way they are at this very moment, and how they feel about the way they are, that is of most interest. In MOL sessions people spend time explaining the way they are and how they feel about this particular state of being. As they explain this to their therapist in ever more detail they are explaining it to themselves as well. From these indepth explanations and explorations come new insights and perspectives that the people generate as they make connections and realisations they had not previously contemplated.
The questions we ask are important but they are not as important as why we are asking them. It is our conceptualisation of how people are organised and how they conduct themselves on a daily basis that needs a radical remodelling. Once a more accurate and precise blueprint is commonly understood, the questions we ask and the treatments we offer will have a much better chance of being meaningful, respectful, and effective.
I find this article rather unclear and unconvincing. The way the author uses semantics is at times unclear and confusing. So I’m going to play the devil’s advocate and argue against some of its points:
1) “Those people who are inclined to think of mental health problems as illnesses, as something “wrong,” would be able to explain that what happened to you was the cause of the illness; it produced what is wrong with you.” –
My viewpoint would be that viewing abuse, neglect, and trauma as producing “what is wrong with you”, would be a step in the right direction, i.e. the direction of viewing environmental stress as the primary factor in the generation of “symptoms” like hallucinations, feeling of depression, paranoia, mania, etc. The author doesn’t appear to consider that the shift could be gradual and along a spectrum; that some people, via considering more about what happened to people, might have their medical model thinking weakened before being finally eliminated. Of course there will be some hard-core medical model nuts who won’t get it no matter how its framed.
2) “I would be surprised, however, if at least some of the proponents of the medical model wouldn’t object and argue that they already ask “What happened to you?” They might consider that they do this every time they take someone’s history.”
On the contrary, most proponents of the medical model I’ve heard are caught up in the delusional fantasy of claiming that “poor parenting” and “family environment” do not cause psychosis, depression, or other problems. Looking at what happened could weaken this delusion on their part; why not try it? Furthermore, many, many psychiatrists ask only about immediate symptoms and never ask what happened to a person at all
3) “Trying to change the question being asked without changing the point of view that’s generating the question is a classic case of the tail wagging the dog.”
No, changing the question being asked can effect a change in point of view. It doesn’t always, but it is not fair to generalize that this is (always) a case of the tail wagging the dog.
4) “The fact that some people are distressingly immobilised by their past while others are not, teaches us that it is not the historical event that is the problem. The problem lies in the way the event is remembered, re-experienced, and reconstructed right now in the hustle and bustle of daily life.”
This is another huge generalization. Who would tell a rape victim, “The rape that happened to you is not the problem. The problem likes in the way you are handling this experience in your mind now in the hustle and bustle of your daily life.” Hopefully, the victim would tell you to screw yourself. Traumatic events are in and of themselves major stresses. Some people do overcome them immediately, and we don’t know why that is – perhaps they are more resilient or have more auxiliary supports or luck than others. And yes, how the person experiences trauma and what they do with the memory of that experience is a second important factor. It’s not either/or…. this idea about the historical event not being the problem by the author is all or nothing.
5) “From this perspective, what is happening to the person at the present time becomes the focus rather than spending time seeking to understand the dynamics of past events. If an event from the past is troubling now, it is vital to explore what the now trouble is.”
Yes, but, understanding the past is also important as well as the present. Transference (the way people relate to present others as if they were people from the pastm by projecting feelings about the past onto the present) is real and important. Resolving transference distortions can often be accomplished by discussing and understanding the past, which can result in better functioning in the present. What is happening now is important too. Again, there is no need for this all or nothing position…
6) “If we follow the logic of this idea it becomes obvious that it doesn’t make a lot of sense to ask about the river a person stepped in last year or last week or even yesterday.” What? This is so illogical! Without the river of last week, the river of today wouldn’t be here, nor would it be in its present shape/version. Both past and present matter, and asking about the past can be helpful, although that doesn’t mean getting stuck or overfocusing on the past.
The end of this article meandered off into a seeming promotion of this author’s brand of therapy. My thought is that research by Barry Duncan and his coauthors (e.g. The Heart and Soul of Change) pretty clearly indicates that the specific “brand” of therapy a therapist uses is not the biggest factor for outcome, far from it. What’s most important is the quality of relationship between therapist and client, especially as experienced by the client. Furthermore, external life factors outside the therapy, i.e. what the client brings to therapy, are far more important in effecting change than the brand or type of therapy itself.
So, to reframe the title of this article, The Questions Can Indeed Be A Problem, and Changing Those Questions Can, But Does Not Always, Effect Change 🙂
Hi bpdtransformation,
Thanks for the detailed comment you’ve provided. It’s disappointing that the ideas I presented weren’t more engaging for you but the points you’ve raised present an opportunity to clarify some of what I outlined in the paper:
bpdtransformation:
My viewpoint would be that viewing abuse, neglect, and trauma as producing “what is wrong with you”, would be a step in the right direction, i.e. the direction of viewing environmental stress as the primary factor in the generation of “symptoms” like hallucinations, feeling of depression, paranoia, mania, etc. The author doesn’t appear to consider that the shift could be gradual and along a spectrum; that some people, via considering more about what happened to people, might have their medical model thinking weakened before being finally eliminated. Of course there will be some hard-core medical model nuts who won’t get it no matter how its framed.
Tim:
OK, so you see that changing questions would be a step in the right direction. Fair enough. I think changing questions could be a step in the right direction but is not a guarantee of a shift in any direction. I can see that my writing has been unclear for you because I wasn’t really discussing how the change would occur. I was responding to the question that was posed in an email I received recently. What would happen if we started asking a different question? I’m suggesting probably nothing.
bpdtransformation:
On the contrary, most proponents of the medical model I’ve heard are caught up in the delusional fantasy of claiming that “poor parenting” and “family environment” do not cause psychosis, depression, or other problems. Looking at what happened could weaken this delusion on their part; why not try it? Furthermore, many, many psychiatrists ask only about immediate symptoms and never ask what happened to a person at all
Tim:
I guess we’ve been listening to different proponents of the medical model. Your point, however, kind of illustrates what I was trying to emphasise in this article. I think we need to move away from notions of things like “psychosis” and “depression” being caused by anything at all. Psychosis and depression are not the same as malaria and tuberculosis. They need different explanations that step away from a simple, linear cause-effect model.
bpdtransformation:
No, changing the question being asked can effect a change in point of view. It doesn’t always, but it is not fair to generalize that this is (always) a case of the tail wagging the dog.
Tim:
As you quoted, I said “Trying to change the question being asked without changing the point of view that’s generating the question is a classic case of the tail wagging the dog.” so, when it’s read this way, I still maintain that it is fair to generalise that it’s a case of the tail wagging the dog. Notice, too, that this makes no comment on the effectiveness of otherwise of the strategy. A dog can be wagged if it’s tail moves vigorously enough. I find it hard to understand the scenario where asking a question would effect a change in viewpoint. Why would the person be asking the question in the first place if their point of view was contrary to that?
bpdtransformation:
This is another huge generalization. Who would tell a rape victim, “The rape that happened to you is not the problem. The problem likes in the way you are handling this experience in your mind now in the hustle and bustle of your daily life.” Hopefully, the victim would tell you to screw yourself. Traumatic events are in and of themselves major stresses. Some people do overcome them immediately, and we don’t know why that is – perhaps they are more resilient or have more auxiliary supports or luck than others. And yes, how the person experiences trauma and what they do with the memory of that experience is a second important factor. It’s not either/or…. this idea about the historical event not being the problem by the author is all or nothing.
Tim:
It’s a bit hard to know how to respond to these comments. Suffice to say that when I work with people (including people who have been raped or experienced traumatic childhood events) from the perspective that it is their re-experiencing of the traumatic event in their day to day living that is the problem they don’t tell me to go screw myself. Generally, they seem to find it pretty helpful.
bpdtransformation:
Yes, but, understanding the past is also important as well as the present. Transference (the way people relate to present others as if they were people from the pastm by projecting feelings about the past onto the present) is real and important. Resolving transference distortions can often be accomplished by discussing and understanding the past, which can result in better functioning in the present. What is happening now is important too. Again, there is no need for this all or nothing position…
Tim:
I’m not sure what it is about the past that needs to be understood in order to assist someone in the present. I’m also not clear on how this is related to transference.
bpdtransformation:
What? This is so illogical! Without the river of last week, the river of today wouldn’t be here, nor would it be in its present shape/version. Both past and present matter, and asking about the past can be helpful, although that doesn’t mean getting stuck or overfocusing on the past.
Tim:
Definitely. That’s why I wrote things like “The past river stepping activity undoubtedly contributes to who the person is at this point in time but it is the inability to achieve things in the present moment that is paramount.” and “Past events, therefore, can be discussed in MOL but the emphasis is always on the impact of the event right now with questions such as: How is the event being remembered?; Which bits are remembered?; What happens when these experiences are replayed?; and so on.”
bpdtransformation:
So, to reframe the title of this article, The Questions Can Indeed Be A Problem, and Changing Those Questions Can, But Does Not Always, Effect Change 🙂
Tim:
Even after reading all your comments a few times, I’m happy to keep the title as is. 😉
Tim
I think different approaches can help different people. My recovery was straightforward – looking at problems and figuring out a way to deal with them, one of my main problems was anxiety (and I found good ways to deal with this). I needed an emergency sticking plaster but this worked for me in the longterm as well.
I’d be insulting if I were to suggest that practical anxiety techniques would ‘work’ for everyone.
I think it’s different for different people. And I think many if not most are not really looking for a change in themselves – they’re looking for a change in their circumstances. That’s my biggest beef with psychiatry and psychology in general. You can’t talk someone out of poverty, disease or ongoing abuse. I like the idea of concentrating on the present but I don’t think talking about it is going to help. I sometimes think there are to many therapists and too few social workers who help people with day to day struggle.
Hi B
My main thing in adulthood has been to stay out of a mental hospital.
But to be truthful I’ve never had a hungry day in my life.
Hi Fiachra,
I agree. I think it’s very much the case that different approaches can help different people.
Thanks for your comment.
Tim
“From this perspective, what is happening to the person at the present time becomes the focus rather than spending time seeking to understand the dynamics of past events. If an event from the past is troubling now, it is vital to explore what the now trouble is.”
Yes, exactly.