Friday, December 9, 2022

Comments by Nick Drury

Showing 25 of 26 comments. Show all.

  • An ironic thing is that if we took to heart Smail & Epstein’s criticism of psychotherapy; that is, it is just a reflection of “heroic individualism” posing as a science, we would abandon it, and leave people to their own devices. In a word we would support heroic individualism.

    Some of us are acutely aware that psychotherapy and its cousin, psychiatry, are not sciences, and indeed are more pseudosciences; but the question of whether they are sometimes helpful or not is not answered by pointing out they are not scientific. Talking with one’s pastor is sometimes helpful even though there is no scientific evidence for much of what’s talked about. And in a world where psychiatry is constantly shooting itself in the foot, many grassroot helping services are springing up. Are they more helpful or less?

    I would say some attempt to measure outcome is better than none. The problem with “deliberate practice” is the demand characteristic of the measure – I think there is a real risk of people filling in the forms wanting to appease the therapist/grassroot helper. But don’t give them up, rather find supporting evidence. Two major ones – are they in full-time work or study now? Are they on medication now? These are sociological indictors; and by all means criticise these, but suggest alternatives.

  • One “new” paradigm that is making inroads is radical enactivism in cognitive science. When it comes to helping others a proposal is to strip “therapy” (if you want to call it that) down to the minimum – and that appears to be not more than asking “what is you preferred future” (or a similar question), and “what help do you need to get there” (or some variation of that). All other questions are “ornamentations” which may dress up your help-giving a little but are not essential. Existing “therapies” maybe compared – eg the nurtured heart approach comes close but biomedical psychiatry doesn’t.

  • Yes its not science, its pseudoscience. 70 years ago Wittgenstein wrote that the barrenness of psychology is not to be explained by suggesting it is a young science (like physics was when it started), but due to basic conceptual confusions. It uses the empirical method, but the method is useless whilst these conceptual confusions remain. Before embarking on a scientific endeavour you have to sort out your concepts – the confusions in philosophy disappear when everyone agrees – they literally dissolve. We say, “now I can go on”.

  • Marie, can I suggest a broader reading base for you – Perhaps Spengler’s Decline of the West with regard to the decay of Western culture, then some Foucault and about the individuating (isolating) processes that have occurred over the past 200 years, especially the speeding up of alienation under neoliberalism. Then perhaps ‘The Dawn of everything: a new history of humanity’ by Graeber and Wengrow, which is about the last 17,000 years, and how we have sought (and achieved for long periods) egalitarianism. It appears to be something which we NATURALLY gravitate towards; a journey which is disrupted by natural disasters and “disturbed” neighbours that make us lose our reason (sanity) for a while. Hopefully this will lead to a dream of living in the eastern State of Ch’i during the Han dynasty between 201BC and 193BC – when a prosperous egalitarianism existed….

  • Yes Steve – you are right – so-called “mental health” cannot be measured in the same way that physical health can. I agree the whole idea of treating “mental health” as a disease is wrongheaded and destructive. But to have no outcome measurement at all allows the status quo to go on; it allows the widespread and largely invisible (to most prescribing psychiatrists) to remain invisible. I think a more sociological measure(s), rather than a medical-like measure is the way to go. If you were living in a country where your taxes paid 90% of the health bill, would you be happy with the status quo?

  • I don’t think it is only the cavalier use of diagnosis – solution focused therapists demonstrate daily that you don’t need to diagnose to have successful outcomes. Look at that study that was done in Australia with ADHD – those receiving diagnosis fared poorly compared to those that didn’t. Same symptoms in both cases. That study is not alone. Diagnoses are ornamentations to good therapy – you can do therapy without them. A study of Wittgenstein’s philosophy first addresses what are necessary ingredients before it does the science of therapy. I suggest that the only reason you want them Michael is for your outcome measures – and that is a case of the tail wagging the dog.

  • Yes but the bureaucrats want this objectified. That is insurance companies in health insurance countries, or govt departments in tax paying for health countries. Some kind of objective measure is needed so results can be compared. The status quo exists because psychiatry doesn’t have an agreed upon measure of outcomes – which was the main point of Michael’s article. Psychiatry goes on serving up poisons, premature deaths, crippled people, etc, with impunity because there is no measure of outcome. Many don’t care; but those that do are struggling to find a way of comparing results.

  • Steve – yes the client is a viable source, but how exactly you obtain this information from her or him is not so straightforward. In my part of planet mental health a group of noisy “consumers” insisted they represented all “consumers”, and could develop and design an outcome measure. So the Ministry of Silly Walks (aka The Ministry of Health) gave them a few million dollars of tax-payer money, and flew them round the country to meet over a 2 year period. They then launched their “outcome measure” which consisted of over 35 items and took the best part of an hour to 2 hours to administer; and there were many launch meetings up and down the country (in which they served lovely cream cakes). Needless to say the measures were never used as they were impractical – how many people want to take another hour or two filling in a form to say how they did (let alone validity and reliability tests to see if the measure was actually scientific). However it did provide some employment for a group of “consumers” for 2 years. This was 20 years ago.
    Next cab off the ranks was some indigenous academics who designed an outcome measure for the local indigenous folk. 2 years in the making, various mtgs around the country, and a 30 item 1 hour to complete outcome measure was complete. To the best of my knowledge it has never been used – again because its impractical. I pissed these academics off a little as I designed, researched, and launched a brief 4 item (that took less than a minute to administer) measure before they launched theirs.
    But as Michael comments, these type of measures although of some use, have demand characteristics (who wants to score your therapist badly if you like him or her), that counts against them. But Michael’s solution is diagnoses – and we know (or there is empirical evidence demonstrating) that diagnoses can be harmful – the Dark Side Manual is, I believe, evil.
    Simple and broad measures of outcome that reflect what would occur naturally in a small community where word of mouth would put bad practitioners out of business.

  • I am so against diagnostic interviews – they are not necessary for good therapy. I was very attracted to outcome measures that are meaningful to people I’m endeavouring to help – (I went Chicago to study Scott Miller’s system 20 years ago; I have designed outcome measures for indigenous people, etc), – but they have an unfortunate effect of the tail wagging the dog – somebody wrote psychiatry is heading towards a Stepford Wives scenario (on another thread this morning/evening). Simple and broad I think is best with regards to outcome – are they working or in full time study, are they taking meds, a random sample at 2 years post treatment and/or 5 years, random sample quality of life, etc. Too tightly defined and it becomes counter-therapeutic – you maybe happy to do diagnostic interviews, but I find them a recipe for “stuck-ness”.

  • At the end of my comment I suggested a wider reading basis maybe helpful for you Michael to address this subject. The philosopher Wittgenstein ended his Philosophical Investigations by saying the barrenness of psychology is not due to it being a young science (as William James suggested), but because there are conceptual confusions. “The existence of experimental methods or science makes us think we have the means of solving problems which trouble us, although the problem and method pass one another by”. Confusions are clarified (ie the problem “dissolved” in Witt.) by philosophy although most psychologists don’t bother with philosophy.

    Being a little solution focused I ask what’s working now. A successful marker for Seikkula is people in full-time work or study post-intervention; another is are they medication free; that ADHD study in Australia that found diagnoses makes for problems, used quality of life (Q-O-L) measures. Those of us who live in small communities see the results amongst those who remain. I would further suggest that another, broader outcome, is a particular community would not be making as many referrals to MH services, as the community knows how to look after each other (which is a long term effect of Open Dialogue as veterans of previous OD meetings attend – which means the community is learning how to manage “alienation”). [Suggested further reading – “relational responsibility”]
    Michael wrote “There is a need to more carefully define, what it is that is being measured”. This is the rhetoric of science but not everything can be or needs to be tightly defined – “stand over there somewhere ‘cos the light is right for photographing you” – you say to a friend – that doesn’t have to be exact to be “good enough”. Yes self-report measures are limited, but only when they are the only measure. But they are a good start.

    Michael, I fear that psychologists who see themselves as scientists and not philosophers will foster upon all practitioners some requirement such as the diagnostic interview, in a similar vein to NICE (and utilise licensing bodies), claiming that it is more “scientific”; and trying to scare us all with horror stories of the widespread incompetence amongst us; but with end result of making a rod for our backs. Spare me from such bureaucrats.

  • Hi Michael
    What did you make of the previous article in todays MiA newsletter that kids who receive an ADHD diagnosis had worse quality of life and were more likely to self-harm when compared to kids with the same symptoms, but no diagnosis? Are you open to the possibility that diagnoses are harmful in most mental health care? Did you see the interview with Seikkula last week, where he said, “not focusing on symptom interventions seems to remove the ‘symptoms’ most effectively, as we have repeatedly seen in several studies.” If you had your way you would make as a foundation the diagnoses interview, which would in effect outlaw Solution Focused Brief Therapy.
    I suggest you engage in a wider reading base – and ask questions as to whether this field (MH) is similar to (or so dissimilar from) medicine and it doesn’t lend itself to measuring in this way..

  • Many thanks James for engaging Jaakko in this dialogue. A few years ago Jaakko wrote a paper, published in The Australian & NZ Journal of Family Therapy, subtitled ‘Psychotherapy or a way of life?’, which goes some way to an understanding of the difference between Open Dialogue and psychotherapy as it is taught and practiced throughout the world. Psychotherapy, as traditionally taught is a form of social engineering; an endeavour to apply an Archimedean lever to psychological problems. There are estimated to be about 500 psychotherapy schools, or what I’d call levers, that social engineers can learn at graduate schools. (Archimedean levers was appropriated by Descartes, and led to the success/(failure by way of destruction) of the engineering of nature since). The fulcrum point of much of psychotherapy appears to be the relationship; once established then you can apply leverage. However Jaakko is reluctant to call OD a “method”; he preferred “approach” for a while; but in the paper above he says it is a “way of life”. A “way of life” is another word for “philosophy”, and I read Jaakko as saying here that we need to take a step back from seeing psychotherapy as a “science” in the traditional sense, but more of a philosophy as that word was used, say pre-19th century. Not only is he teaching this “way of life” to mental health practitioners, but he is also teaching it to communities. As OD has been going on around the district of Keropudas hospital for over 30 years, they are finding these days numerous veterans of previous OD meetings in attendance. So they are putting themselves out of business as the community learn a way of acceptance, a non-focus on symptoms (which “seems to remove the ‘symptoms’ most effectively”), and greater relational response-ability; in a word “a way of life”. Once the community learn this they can go out of business.

    The only other form of psychotherapy that I glimpse this potential in is Solution Focused Therapy. But they seem hell-bent on find a scientific rationale or theory ….

  • What makes you say that a “cultural disorder” is by definition not medical? I suspect this belief is limiting your thinking. We are alike in agreeing that psychiatry is bankrupt and its diagnostic categories, such as ADHD, are meaningless. I think, like me, you are looking for new way of thinking about the problem of social “illness”. Ditention was once likened by Burrow as being like the mexican walking fish (axoltle) which has an arm, every now and then takes on a quite independent, reflex action departing from the holistic action of the total organism. This partial action remains quite discrete and brief, and so long as it doesn’t get organised, does not from a union, as it were, it doesn’t threaten the natural capital of the central salamander. But this part function has taken over in (Western) humans, resulting in a loss of grace of movement. It results in a measurable (by eeg) chronic tension; experienced as being in the head. McGilchrist has described this as “the master and his emissary” (book title), without mentioning Burrow – but as Burrow was first to describe the condition, I think he should get credit. Burrow was communicating with DH Lawrence and John Dewey and influencing them. One of Burrow’s arguments was that malaria was not seen as a disease by some countries and shrugged off as cultural disorder by the locals – it took some educative efforts by the world health professionals to convince them otherwise. I make the bold claim that I think you will find as you read the literature on the ameliorative course of treatment for ditention you will have a way of dissolving most “mental health” problems.

  • It is a pity that I could not persuade you to do some reading on this. Clifford Geertz, the anthropologist, noted that the idea of a ‘self’ as the centre of one’s being, “…however incorrigible it may seem to us, [is] a rather peculiar idea within the context of world cultures”. Similarly Joseph Henrich has written a book entitled “The weirdest people in the world: How the west became psychologically peculiar and particularly prosperous”. Did you understood what a phylogenetic disorder is? It is more of a cultural disorder. Yes we know causes ditention. I think Burrow would have been pleased with Foucault’s panopticism as the generator. Foucault described a prison designed by the 18th century architect and politician Jeremy Betham, where the guards could see into the cells but the prisoners could not tell when they were looking and when not. The prisoners develop an attitude of being under constant surveillance. Bentham then encouraged this as a metaphor for politics – and we have entered a world of constant surveillance. Rather than have a small subgroup of people who actually do have something wrong with them, Burrow identified a very large group who have a measurable something wrong with them. I could say more, but I hope I’ve led some of you to read more on this.

  • Yes ditention is not a DSM diagnosis – I never said it was, just as Bruce didn’t limit his article to DSM diagnoses. Some would say that is the point – Burrow took a very different direction from mainstream psychiatry. I’m suggesting there is another avenue to explore here. Ditention isn’t distinguished from “normalcy” in Western culture – that is why Burrow labelled it as phylogenetic disorder. Some non-western people are not so ditentive, just as small children are not so ditentive. As you can measure it by EEG, you have a way of distinguishing it objectively, unlike DSM diagnoses. I suggest some reading is in order…..

  • Hi Bruce – your assertion that there is no neurobiological evidence for any psychiatric disorder is not quite accurate. Trigant Burrow published evidence in Nature, in 1938, by way of EEG studies (then called kymographic), that showed a disorder, which he claimed was widespread and was in fact a phylogenetic disorder, in attention. He named this disorder “ditention” – divided attention – most people in the western world were going through life constantly looking in the rear view mirror. He contrasted this with “cotention” – where a person is giving their full attention to what they are doing (and not trying to watch themselves as they performed). Although a founding father of the American Psychoanalytic Society, he had earlier been kicked out for disagreeing with Freud – for Burrow, mother was not the love object (as she was with Freud) but the love subject; we retain a primary identity with “mother” and objectify ourselves.

    I suspect we may also find a biological marker for autism.

  • I don’t think the problem is staying within the realm of biology; it is to reunite biology and mind, which enactivism does. Descartes is largely responsible for splitting the two apart, and set the wheels in motion for the subsequent development of separate disciplines, which find a pseudo-unity in psychiatry. Gregory Bateson brought the two together again with his ‘Mind & Nature: A necessary unity’. Enactivism takes us further in this reunification.

    Practically what does it portend for the future. Seikkula refers to his approach (Open Dialogue – which has been so successful with psychosis) as not really a method but a “way of life” – it’s an applied philosophy more than it sits in the traditional “psy” disciplines. As a way of life, or philosophy, suggests that being with people is more important than doing something to them. Milton Erickson, the great hypnotist and healer, remarked toward the end of his career that it took him a long time to learn not to direct “patients”; instead “…let things develop and make use of things as they develop… You let the subject grow”. [The language is pretty dated but we can forgive Erickson for this.] I think that enactivism makes for a “relational self”, and as this develops it has an influence on other people.

  • Jeremy Bentham was an 18th century architect and politician who, amongst his many achievements, is famous for designing a prison where the guards could see the prisoners, but the prisoners could not see the guards. It was called the “panopticon” – and as a politician he modelled society on it. (He’s also famous for having his body on display at the student centre of the University of London). Foucault cites panopticism as the turning point when we went from “sovereign power” to “disciplinary power” – [In the former the source of power is highly visible and the subjects of power highly invisible. In the latter the source of power is highly invisible and the subjects of power highly visible.]

    Yes today we can see “panopticism” operating in Zuckerberg’s Facebook – where everyone is encouraged to compare themselves with others – knowing what will make you popular – and where you can be, as you say, “cancelled”.

    A “relational self” is not overly concerned about being cancelled, and in fact feels a little sorry for the guards. This is because Bentham had the guards monitored by prison visitors, the only problem for the guards was they didn’t know who amongst the many visitors, who was there to audit them. So the guards too became subjects in this diabolical scheme (Foucault called it diabolical)..

  • Thank you Erica for warning us about Angermayer and ATAI Life Sciences. Set and Setting are the 2 guiding principles of psychedelic use as we learnt from Leary in the 1960s; and I remind people that Leary’s “Psychedelic Prayers” begins with a guide for the guide. It would appear (from what you have written) that Angermayer has not been well guided.
    You have taken an interesting ameliorative to neoliberalism – a culturally mandated initiation. Various attempts to offer “boot camps” to troubled youth, have not generally worked well.

    I agree with you that neoliberalism is the problem, as much as for any reason because, it intensifies the disciplining society that Foucault identified. Since about 1800 people in western culture have been looking in the panopticon mirror – the panopticon was a prison designed by Jeremy Bentham in which the guards could see into the cells, but the prisoners could not see the guards. After a while the prisoners developed a habit of assuming the guards were watching. This became the political metaphor that guides Western society – we are all looking in the mirror of “normalising judgements” and developing “fabricated selves” as we try to adjust to what society considers “normal”. Foucault said that under neoliberalism this has grown more intense – everyone having an isolated (and fabricated) self that is economically considered as an entrepreneur. As you correctly point out it makes for selfish narcissistic individuals.

    I also think you are correct in saying that the ameliorative to neoliberalism is the development of a conscience. I am sceptical that the likes of a “boot camp” would do this. I favour the development of a “relational self” along the lines suggested by the radical enactivists. A “relational self” develops with the growing awareness that “no man is an island” until a point is reached where you recognise that Dostoevsky’s “Father Zossima” is correct when he said “Everyone of us is responsible for everyone else in every way, and I most of all”. A well-guided psychedelic trip may facilitate this.

  • Yes, the conclusion to the article is wrong; the error is thinking the brain is the source of mind – these guys give cognitive science a bad name. The majority of cognitive scientists have long discarded the reductionist fallacy of equating mind with brain. There’s even a word for this – the mereological fallacy. Dan Hutto, the guru of radical enactivism, once wittingly said that enactivists are no longer the barbarians at the gates of cognitive science, but now occupy its cafes and wine bars. Read Alva Noë’s ‘Out of our heads: Why you are not your brain, and other lessons from the biology of consciousness’ for an introduction to this way of thinking, if you are unfamiliar with it.

  • Hi Steve – this is becoming a bit drawn out for me. Although Wittgenstein thought Freud’s psychoanalysis a “foul practice” that’s done “no end of harm”, he was in agreement that it’s a person’s will that gets in the way of understanding – not intellectual argument. Many sciences don’t have experiments – astronomy, anthropology, etc – they are straight descriptive sciences, and every now and then someone comes up with a “fertile new point of view” (Wittgenstein). You and l.e. Cox consider “mind” as a noun; in the new paradigm “mind” is used more as a verb.
    You’ve no doubt heard of “fast” and “slow” thinking – animal intuitions and human social language based thinking. Most of our thinking turns out to be the fast animal kind. Especially relevant is social thinking – we are excellent “mind readers” – we mostly understand each other instantly – there is no interpretation involved in this – think of an obvious example – a friend in pain – Now the Cartesian paradigm gave rise to various ‘Theories of Mind’ – everyone was an imaginary psychologist or anthropologist and understood others by putting their expressions through your theory of mind and your ‘biocomputer’ chugged out “Oh they are hurting”. Now Dreyfus and Dreyfus had a chess grandmaster playing fast chess and at the same time adding numbers delivered at 1 a second. The grandmaster computing ability was taken up with adding – but they still won the majority of games against skilled players – so this shows that you rely on the fast animal intuitions – think of driving, you daydream or have an intense conversation with your passenger. Haidt calls the animal part “the elephant” and the slow social reasoning “the rider”. You can, for example, show the rider an argument for this new paradigm but if the elephant doesn’t want to go there – you’re pissing in the wind.
    Seikkula says he prefers to call open dialogue “a way of life” in preference to calling it a psychotherapy (The Australian & NZ Journal of Family Therapy, 32, 3: 179-193). This fits with this new paradigm – and is where I came in – saying that the relationship (ie ethics) comes first ontology a distant second. [Notice our discussions have focused on questions of ontology rather than ethics].
    I must leave it there – but I will post on other topics on MiA in the future. Thanks for the conversation.

  • Steve – we are somewhat apart on this. Radical enactivism originated in philosophy – (Moyal-Sharrock 2016 – “Wittgenstein today”, the quote “father of enactivism”) – but now it is answering empirical questions. Philosophy comes first in any endeavour that later develops an empiricism. You agree, hopefully, that there is a discipline called ‘Cognitive Science’ that employs thousands of academics in universities around the world, hold conferences, write papers etc etc. Now when a revolution occurs in a science it generally also shakes up some philosophical foundations. For example, it was thought for a long time that just as a bell struck in a vacuum makes no sound, so light must also need a medium to travel through. So the luminous aether was postulated to exist. Then Einstein showed that light waves are different from sound waves in that they don’t need a medium to travel thru. So the luminous aether was dropped from science – a philosophical assumption we found we could do without.
    Cognitive science is currently gripped by papers wrestling with this new paradigm. If you google “4E Cognition” you will find your way to many papers that explain this paradigm far better than I.

  • Hi Steve

    I try to keep my comments very brief. So my bad if I’ve made it appear very shallow. This was a description of radical enactivism – which is all the rage in cognitive science since 2000. It goes way beyond the Cartesian dualism – mind is no longer in the head – but firmly centred in the body. In a way it is the body. People are usually so entrenched in a form of Cartesian dualism that it takes quite a bit to get your head around (ha ha – given that mind is not in the head) this new paradigm. I would suggest some Hutto – although he is a little obtuse at first. I hope to have an article out shortly explaining it for the armchair philosophers.

  • Medicine has made numerous advances since adopting a particular ontological approach since 1800 – see Foucault’s ‘Birth of the Clinic’. Except in psychiatry. Here an ethics first approach is more important. Dethroning ontology is all important. Numerous philosophers have said this (e.g. Wittgenstein, Levinas, even Husserl). For those who don’t understand these terms – I’m saying the relationship comes first in psychiatry – and what a thing (such as the likes of what we call “depression”, “schizophrenia”, “obsessive-compulsive”, etc) is is unimportant. There is ample evidence that when we get the relationship right the ontological problem disappears (or dissipates, or “dissolves like sugar in water” – Wittgenstein).

    For Daiphanous Weeping, you must have a good reason for writing such long replies, but I couldn’t help noticing that you claimed science doesn’t know what emotions are. Yes they do. The enactive cognition approach, which sees “mind” as located in the body, describes emotions as subtle neurological-muscular movements often exhibited as we anticipate events.