Thanks for your further thoughts Don. Of course, you’re perfectly entitled to disagree. I disagree with your disagreement :-)!
It’s great that you’re interested in things like consciousness and the mind. I’ve actually just finished writing a book chapter about consciousness from a PCT perspective. It’s due to be published in May next year.
PCT is a first person perspective theory. That is, it explains behaviour and the process of living from the inside looking out not from an observer’s perspective. As such it is entirely compatible with, and accommodates, trauma-informed work and listening-based approaches. The Method of Levels is almost entirely “listening-based” and trauma-informed work is an important aspect of working effectively with Aboriginal and Torres Strait Islander Australians.
PCT and MOL are definitely not everyone’s cup of tea. I’d love it if they were, but they’re not. That’s OK.
Thanks Don. It’s a great question and, I agree, that paragraph probably did stand out a bit from the others. All of my work is based on the premise that we are designed as living control systems as described by Perceptual Control Theory (www.pctweb.org; http://www.iapct.org). I’ve developed a transdiagnostic cognitive therapy based on these ideas (Method of Levels; http://www.methodoflevels.com.au). Being controlled by other people is so damaging because we’re designed to control the things that matter to us ourselves. No-one else can do that for us because no-one else knows how it is to be another individual or what the life is that that individual would like to carve out for themselves.
Thanks Rebel. I think it would be great if people would listen to themselves a little more. Understanding who I am as an individual and what I need to move in the direction I want to go in is surely one of the most important things I can do. I wonder if the first step in solving some of the conflicts of the world is first resolving our own internal conflicts.
Thanks for your perspective Jordanfallis. Yes, there could be many explanations for why people are feeling the way they are feeling. Unfortunately, when we label something as “depression” we think that’s an explanation and stop looking for other reasons.
By the way, I also really go along with your idea stopping the dividing up we do and focus more on our individual uniqueness. I think it’s possible to recognise that we all share some common fundamental features as being part of the same species but, within it that, we are all marvellously unique.
If we recognised that and celebrated it a little more we might be in a different place.
Yes, the invention of the DSM (I’ve suggested elsewhere that this might stand for “Damn Smoke n Mirrors”) categories is a big part of the problem. The importance of things like current relationships and past trauma is ever so slowly being recognised but there’s a mountain to move when it comes to industry of diagnosing and medicating.
It’s great to have a forum like this where we can communicate our ideas and perspectives on these issues and help to keep the ground swell swelling 🙂
Little Women was a favourite in our family when I was a child too!
I agree that anger can be a big problem for both individuals and social relationships. Ironically, in the work I do, self-control is considered to be a form of internal conflict. The reason people experience this sense of needing to control themselves is because they want to do something (maybe yell at someone) but they also don’t want to do it (they want to treat people respectfully) at the same time. When people are unconflicted and pursuing important life goals it doesn’t feel like self-control. It doesn’t feel like anything really it’s just kind of going with the flow.
Maybe the reason that counting to 10 can be so effective is that it gives people a chance to step back (in their own minds), see the bigger picture, and remind themselves of the things that are really important to them.
Thanks for the reference to Little Women … that was a delightful trip down memory lane :-)!
I really like the way you’ve expressed this. The mutually interdependent, bidirectional nature of influences is really important isn’t it? All of my work is based on the idea of circular, rather than lineal, causality which very much speaks to these ideas as well. At the same time that we are influencing we are also influenced. It’s a very cool concept!
Yes, I did suggest that neither of us were going to get much mileage out of continuing this conversation. We just operate in different worlds. My understanding is that blood and urine tests detect metabolites of neurotransmitters which do not have a straightforward relationship with levels of neurotransmitters in the brain.
But these are all just details. The bottom line is that you’re happy believing that the chemical imbalance myth is not a myth and I’m firmly convinced that it is.
I’m not sure I made a relative comparison in terms of saying that Santa Claus “is as mythical” as the chemical imbalance. Whether one is more mythical than the other isn’t important from my perspective. They’re both mythical. That’s the point I was wanting to make.
That’s the way I see it too. There’s definitely more that unites us than separates us. If we could harness that we’d be all the more powerful and influential.
Thanks for the extra information. We just have a very different perspective on all this. I’ve never heard of dopamine and serotonin levels charts and I have no idea how they would possibly even have established them. Even if those charts were accurate at a population level they still wouldn’t be meaningful for an individual. Think about height and weight charts. What is “normal” height? Should we give growth supplements or bone grafts to people whose height is normal (whatever that is)?
Also, I don’t place too much (read “any”) faith in commercials about drugs or neurotransmitters. I’m sceptical of all advertisements. I think we generally accept and acknowledge that advertisements about things like shampoo and cars are probably exaggerating their claims and distorting the information somewhat to portray a glowing image. That is magnified exponentially when the topic is psychotropic medication.
As I said in my article, 80% to 90% of the bodies’ serotonin lies _outside_ the brain. I wonder how their tests cope with that. In doing research for this article I contacted a couple of expert researchers who are involved in this area and they weren’t aware of “precise” neurotransmitter tests that were available.
We just have different views, that’s all. I get the sense that you’re pretty happy with where you’re at. Me too 🙂
Thanks loads Alex. I’m really glad you’ve got something out of this. Me too! I’ll have a look at your youtube site. I feel the same way about posting person details here. I can be contacted through the MOL website.
Each time I read your posts Alex, I find myself smiling by the end of them. This is so similar to what I do. I call what I do “psychotherapy” or “therapy” or “psychological treatment” but it’s really facilitating the other person having a conversation with themselves about difficult issues. Nothing happens unless they want it to. Even not having “therapy” is OK. The whole focus of MOL is on present time, in fact it’s about the “right now” of what’s happening for the person as they’re talking about all this difficult stuff.
And yes, even in the face of all the hard stuff, there’s often humour and almost a “playfulness”. I’ve also found that most people only need a small number of sessions. I think about 4 or 5 is the average people seem to come a long to see me for.
Thanks Alex. Yep, interference is the key. It’s the problem with medications (or psych drugs or whatever you want to call them) too – they interfere with the bodies’ own processes. And lots of times the mental health professionals don’t even know they are interfering so they take resistance, not as a sign of how functional the person is, but how they “lack insight” so the mental health person does more of what they were doing, hence more interference, the person being “treated” tries to do more to protect themselves, and so it spirals!
At least while we’re talking like this and bringing these issues into the light there’s a chance to change them. Those new perspectives we’ve both been talking about!
Thanks Alex. I’ll check out the films. They sound really interesting.
Yes, the way you’re using the term “control” is the way I understand it. A few years ago I came across an entire field devoted to the study of control as it occurs in living things. From this perspective, control is a process that is essential to life. In fact, control is life. In order to keep living, we need to be able to control things like our body temperature, the amount of oxygen in our blood, and so on. At another level we also need to be able to control things like the amount of trust and openness in our relationships, the extent to which we think well about ourselves etc.
From this perspective, problems occur when this natural control process is disrupted or interfered with. It’s a big reason for me as to why mental health services fail so spectacularly most of the time. Because of the extent to which they go to control “patients”, they actually interfere with that person’s own control and set up a recipe for disaster!
The point about therapy impacting on the therapist as well as the “therapee” is a really important point too. It’s a really humbling experience for me to be a therapist. To be entrusted with someone else’s stories is an enormous privilege. And you’re right, there’s definitely a learning and growing for therapist … if they’re open to it :-)!
I’m really enjoying reading about your journey. There is so much overlap with the work that I do, it’s uncanny. We’re using different words but I get the sense that we’re talking about the same kind of thing. The therapy I use is called the Method of Levels (MOL; http://www.methodoflevels.com.au) which is based on Perceptual Control Theory (PCT, http://www.pctweb.org). MOL is all about having people listen to their own talk so that they can become conscious of their problems in different ways and reorganise neuronally (this is the neuroplasticity bit) to arrive at new perspectives, new insights so control (you might call that balance) is restored.
I also share the big “IF” that you describe. None of this can happen unless the person wants it to. And even when they want it to, it still can be gruelling, emotionally draining work. An important part of my work has been what I’ve called “patient-led treatment” so the person who is accessing the service is the one who makes the appointments and the one who decides how many they will have and how often they will have them. I’ve also started to develop an idea lately called “patient-perspective care” which in the services I’ve worked in would be much more helpful than “patient-centred care”. In my experience, “patients” can be at the centre of a clinicians deliberations while decisions are still made about them and for them and on them. That might be a lot harder to do if it was the perspective of the person accessing the service that had to be used to guide decision making.
Thanks Stephen. I appreciate you taking the time to explain your position.
I completely agree that the psychotropic drugs that are used as medication in the mental health industry do not treat illnesses and don’t “cure” anything. Your point about having a particular preference for the word you would choose to use is well taken.
To be honest, I wasn’t even aware I had a preference until posting this article. I’m still not sure that I do. I think the words I use depend very much on the context. I’ve been really surprised that the focus of this article for some people has been on a particular word or term.
To put it in context, the article has 1902 words. Of those, the word “medication” is used 5 times. Twice when it is used it is used as “psychotropic medication” and on the the other three occasions it is used it is being discussed in the context of what mental health service providers frequently try to do from the perspective of the chemical imbalance nonsense.
I’m sorry that the use of the term “medication” seems to have offended some people but I’m probably even more disappointed that the focus on that term seems to have distracted a lot of discussions from the main point of the article. I think it would be very hard, based on the content of the article, to justify the idea that I support the notion of mental health disorders as “illnesses” or that I’m an advocate for the biomedical model of conceptualising and treating psychological distress.
Thanks loads for sharing this. What a profound and moving story. It’s a great comment on the strength and resilience of the human spirit. Your point about the chaotic environment really resonated with me. You say towards the end “If my chemicals had been out of whack” … it’s a big “if” :-)!! My interpretation would be you reacting very normally to a very abnormal environment!
The problem lies in this sentence “A person can have a dopamine level that is higher than normal (schizophrenia) or they can have dopamine levels that are lower than normal (ADHD).” We have absolutely no idea what “normal” dopamine levels are. Then to try and assume a particular amount of dopamine is “causing” a particular problem called “schizophrenia” or “ADHD” is a massive leap in flawed logic. “Schizophrenia” and “ADHD” are made up categories. They’re not illnesses or dysfunctions in the same way that breast cancer, Parkinson’s Disease, malaria, and diabetes are. So even if we knew what “normal” dopamine levels were (which we don’t) we still wouldn’t have solved the problem of the diagnostic categories.
I definitely believe that “We humans say and do things because we derive some benefit from that activity”. From my perspective, that’s called a process of control. Problems then, arise when people aren’t able to derive the benefit they would wish for from the activities they prefer.
Thanks AA. I definitely think psychiatric medications are at the top of the list in terms of wildly exaggerated benefits and grossly minimised harms but it’s a really important point you make. I really like Peter Gotzsche’s work in this area. He makes the point that all drugs can cause harm. In fact, according to him, prescription drugs are the third leading cause of death in Europe and the US behind heart disease and cancer. It’s a staggering statistic.
I guess we all have our big ticket items. For me quotation marks aren’t one of them despite how useful they can be.
I appreciate you posting this information but, from my perspective, there’s nothing here to address. Identify people as having a particular “disorder” and then looking for things they might have in common that help to explain the disorder is exactly the reverse of the logic that is needed. Demonstrating that people experience some benefits when they take various medications does not provide any support for the chemical imbalance idea. If that were the case then headaches would be caused by a panadol deficiency and the people who report benefits from taking lithium would be experiencing a lithium deficiency.
Like I said in my article, the chemical deficiency is created after the medications are ingested. So, in a way, you’re very correct. It is because of a chemical imbalance that Big Pharma is making billions of dollars. It’s an iatrogenic chemical imbalance caused by the chemicals.
I think approaches that attempt to “regain control of the child” are actually part of the problem. My perspective is that people need to control the things that are important to them not be controlled by others. When children are behaving chaotically it’s often because, from their perspective, they’re in the middle of a chaotic environment.
There are certainly lots of things to address and the longevity of the chemical imbalance fallacy is one of them.
It would be nice if we had more common ground but, on this issue, we see things very differently.
I’m jumping in here to clarify one last point here. I was waiting until the previous comments had been restored but that doesn’t look like happening soon. In one of my last posts I wished you all the best with your revolution and you replied saying it was “dripping” with arrogance (or some other similar term. I can’t remember exactly which one it was). Here again in this post you refer to my arrogance. I wanted to post this just to emphasise that, when I sent that comment, I had no intent other than wishing you the best for you in terms of where you’d like to head. There was no arrogance “dripping” from the words when I clicked on “Post Comment”. All you got were words on a screen Richard so if there was arrogance dripping from the message that was your interpretation. But it is our inability to even agree on simple matters like that that reveals the huge gulf there is between us in how we communicate and what we communicate about. Again, that’s not written from a position of arrogance or superiority. It’s just an observation of the pattern of communication with this article. It’s for that reason that I can’t see any purpose in us continuing our conversation. That doesn’t mean I think you’re bad or inferior or unworthy it just means I think we have different priorities. I genuinely hope you’re able to bring about the change you’d like to see. I genuinely hope I’ll be able to do that as well.
I can’t type it any more clearly than that. That’s where I’m coming from.
Thanks Alex. There’s not much more I can add to your comments except to say “Nice one!”. It would appear you and I see things pretty similarly. Recognizing that each of us has a part and that telling other people what to do and how to do it is rarely effective will be a very significant leap forward!
Tim
From my perspective our conversation has been characterised by misinterpreting each other’s email. I can’t see a way to correct that so my solution is to leave things alone.
In the most recent exchange, for example, I wrote “If there are things that are useful in this discussion you then that’s terrific. It’s gone way past being productive or useful for me.”
To which you replied “And then you have to throw in the zinger at the end that you have better use for your time then to engage in dialogue with the likes of someone like me.”
So my idea of respectfully allowing us both to do what we’d like to do is an insult to you with the implication that I don’t want “to engage in dialogue with the likes of someone like me.”
I think it’s worth remembering that this whole discussion has arisen because my use of the terms “mental health”, “mental illness”, and “medication” didn’t match the way you thought I should be using those terms. Because I didn’t use quotation marks in the way that you thought I should there have been statements like “This is about unscientific and harmful language that is part of the very foundation upon which Biological Psychiatry was constructed and now reinforces and justifies all the harm carried out in its oppressive “mental health” System.”; “making comments that I believe denigrate my reputation”; “totally clueless”; “you have have found it necessary to concede Biological Psychiatry certain key aspects (use of the terms “medications,” “mental health,” and “mental illness”) within the other two thirds of their dangerous and mythical narrative”; “Every single argument you make in the above statement could also apply to the continued use of “medication,” and the use of “mental health” and “mental illness” without quotations. The overall harm done by these above terms is essentially NO LESS than the harm done by excepting and propagating the “chemical imbalance” theory for which you have correctly dissected.” and; “The maturity of our current scientific and political understanding on the use of the terms “medication” vs “psychiatric drug” (and “mental illness” and “mental health”) is such that there is absolutely no longer (if there ever was) any rational reason to make harmful CONCESSIONS in our writings by accepting the continued use of these unscientific and politically backward terms. WE DENIGRATE, AND RENDER LESS PROFOUND, OUR ANALYSES BY CONTINUING TO MAKE THESE CONCESSIONS IN OUR USE OF TERMINOLOGY. THIS DAMAGE BEING DONE WILL NOT STOP HAPPENING UNTIL WE MAKE IT STOP HAPPENING!”
This is clearly a topic you feel very strongly about. I don’t feel as strongly about the use of quotation marks in this manner. I think you should be able to conduct the revolution in the way that you think it will be most effective and I think I should be able to do the same thing. We just have different views on this that’s all. I don’t think your view is wrong, it’s just different. From everything you’ve written I think it’s safe to conclude that you think my view (with regard to the use of quotation marks) is wrong. I don’t think there’s anything I can do about that. That’s why I’m bowing out of the conversation.
I really do hope you get the revolution you’re after.
I couldn’t agree more. Cohesion within diversity is a powerful attitude to strive for. I think keeping the bigger picture in mind and recognising that, very often, there is not one right way to get to the destination might be a helpful perspective.
Thanks for getting back to me. I find this whole discussion a bit mind-boggling really. This whole thing has arisen because I didn’t put quotations marks around three terms. I clearly just don’t see this as the priority that other people do. I think if you have a look at other articles I’ve posted on this blog you would get a sense of where I’m coming from. I think I do my fair share of questioning and criticising the disease model and, perhaps I’m kidding myself, but I don’t feel trapped in a disease model narrative. Like you, I think the BPS has made some great strides forward. I worked in the NHS in Scotland for 5 years and really liked a lot of what went on over there. I’m still a member of the BPS.
Thanks Borut. I agree, we do need a much wider focus. Most of my work is focussed on the phenomenon of control as the basic process of living. From this perspective, psychological distress is considered to occur when control is prevented or disrupted.
Is this really how you want to be spending your time? It’s not the way I want to be spending mine. Perhaps I’m being defensive again! 🙂 So be it. I have other things that I’d rather prefer to turn my attention to.
I’ll have to bow out of this one. If there are things that are useful in this discussion you then that’s terrific. It’s gone way past being productive or useful for me.
I think it’s pretty obvious that we’re just not going to agree on this issue and I can’t see us bunkering down into our sides of the argument as being very useful for anything. I have lots of positive and productive things to turn my attention to as I’m sure you do too.
This resonates really strongly with my own approach. I base my work on a theory of control called Perceptual Control Theory (www.iapct.org; http://www.pctweb.org) and I’ve developed a therapy called the Method of Levels (www.methodoflevels.com.au) which helps people regain control of their own process. I think lack of control is at the heart of psychological distress. It is really hard to know what to believe but finding our own voice, and allowing others to have theirs, is, I think, a bit part of the solution.
Really? In the context of a discussion about the language we use, you would call me “totally clueless” because I don’t share Richard’s opinion for the way terms are used. I note, also, that you didn’t put quotation marks around “totally clueless” so I’m assuming you literally mean “totally” as in “wholly, completely, entirely” and “clueless” as in “ignorant, uninformed, unaware”. So, I’m entirely uninformed and “engaging in hate speech” simply because I didn’t put quotation marks around the word “medication”. And because of this you make the assumption that “Jack Daniels is medication to you”.
Amazing.
Tim
Actually Richard, this is ALL about preferences. You have a particular recipe for advancing the revolution, I have a different one. So you will not grant me the right to pursue the revolution in the way I think it should pursued. Hmmm. That seems a lot like a mental health professional not letting a patient determine the way they would like to be treated.
Thanks for this. I don’t know a lot about the Maori approaches but there seems to be a lot of really positive things to the work they do. There are a small number of places in Australia where traditional healers work in health clinics alongside other health professionals.
I couldn’t agree more Frank. We need a world where people are a little more accepting of differences. It will be a great time when people can achieve the things that are important to them without preventing other people from doing the same thing.
I would suggest you’re not victimized by a term. You might have been victimized by health professionals in mental health services but very few of them are even called “mental health somethings”. There are certainly mental health nurses, psychologists, psychiatrists, and so on. Are you of the opinion that if they weren’t called “mental health services” then you wouldn’t have been victimized?
That’s a great point. A lot of what passes for science in the mental health field is not very scientific. I completely agree that genuine reform will take time and will take many people working together. It will also take acceptance of the fact that there is not probably any one right way to proceed and criticising each other when individual approaches differ is likely to be counterproductive.
We each have our own ideas about what will help to progress things. Are you saying that if I don’t come around to your way of thinking then I’m not “truly open minded” and not using my “critical thinking skills”? Hmmm. Doesn’t that seem like the very dogmatic medical attitude that we’re trying to change? I’m not sure that we’re going to change the situation by taking the same single-minded, authoritarian approach that seems to be so pervasive at the moment in mental health services.
Thanks for taking the time to reply. I’m sure there are lots of other myths that we have – sometimes without even being aware of it. An area I’ve done a lot of work in has to do with how much psychological therapy people need. There are lots of myths here about people needing 10 sessions to get better, or 12, or some other arbitrary number. The evidence is that most people only need a small number of sessions to get to where they want to be and a small number of people need many more. My approach has been to let patients tell me how many sessions they need rather than me telling them. It’s not a common approach though and one that is regarded unfavourably by some clinicians.
That’s a great question Karma! The supply and demand perspective is an interesting angle because some psychotropic medications can be taken as a remedy for one type of distress while at the same time creating other sorts of problems that other drugs are needed for so the kind of have supply and demand all wrapped up in one neat little pill!
It’s a good point Karma. I think we could all do a whole lot better with the language that we use. It’s also an area where we will all have difference standards about what is acceptable and appropriate. “Mental health”, for example, probably isn’t the greatest term in the world but I don’t find it hugely offensive. “Mental illness”, however, is a term I almost never use except if I’m referring to a specific context where that term is used. Aboriginal and Torres Strait Islander Australians prefer to use the term “social and emotional wellbeing” and that sits pretty comfortably with me.
For me, even having a forum where these sorts of ideas can be discussed is progress!
It’s disappointing that you don’t find my article excellent because I didn’t put quotation marks around the terms “mental health”, “mental illness”, and “medication”. I didn’t do that because that the language that is used at the moment. I don’t ordinarily put quotation marks around all made up things I discuss like mermaids, unicorns, Major Depressive Disorder, Schizophrenia, lovesickness, heartbreak, and so on. I think I used the term “mental illness” twice in the article. Once it was actually used in quotation marks and on the second occasion I used it in this context “medical explanations of mental illness”. I didn’t use quotes here because, regardless of how erroneous we think it is, that’s what medical explanations are explanations of.
I also didn’t put quotation marks around “medication” because psychotropic medication is medication. It might be highly problematic medication but it’s still medication. I’m actually not anti-medication. I’m anti mis-information. I think the big problem is that many people are misinformed about the benefits and harms of psychotropic medication. I like to keep in mind, however, that some people take psychotropic medication and experience benefits from it and are happy to keep taking it. In my zeal to inform people about the mis-information surrounding psychotropic medication I don’t want to be disrespectful to these people who have just as much right to take psychotropic medication as other people should have not to take it.
When I’m discussing my own perspective on mental health problems I refer to them as “psychological distress” but when I’m referring to the context in which services are delivered I generally use the term “mental health problems”.
We’re definitely on the same page with wanting to raise the bar in terms of our scientific and political standards. In pursuit of these higher standards I do find it curious that you would withhold this otherwise “excellent” article because it doesn’t have as many quotation marks as you would prefer.
It’s these kinds of differences that make life so interesting.
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. 😉
HI Travailler-vous,
You’re right, there are many questions that RCTs are not designed to answer and, of course, the other point you raise is that RCTs won’t help you identify the someone who is allergic to the mediction because RCTs aren’t interested in ‘someones’, they’re only interested in group averages. At best, an allergic reaction might get included in a count of adverse events but that would require that it was identified in the study and judged to be an effect of the medication. And, as you finish your comment with, there’s always the question of why a particular individual decides to take a particular drug. RCTs are silent on this matter as well.
Tim
Hi Trvailler-vous,
Thanks for highlighting this. Yes, I think psychological distress is quite different from a physical cut or a broken bone. Most of our current emphasis seems to be on understanding and treating particular symptom patterns which are considered to be analogous to various physical maladies such as diabetes. My focus, however, is on the distress associated with any particular set of symptoms rather than the symptoms themselves. For any particular symptom or symptom pattern there are almost always people in the general population that experience similar things but are not bothered by them at all. From my perspective, it’s the botheration or distress that is the defining feature of what we now call mental health disorders and it’s this distress – closely associated with a person’s agency – that should be the focus of our research and treatment efforts.
Tim
Hi Rick,
Thanks for coming in on this – you’re spot on with your comments. Even when RCTs are very good the direction of inference is from the sample to the population but, of course, this is exactly the opposite direction from the direction clinicians are interested in. Clinicians want to know who they can use the results of studies to inform their work with individuals. Unfortunately, statistical inference is currently silent on that topic although conducting studies like the ones you suggest would be a start. Of course, that still wouldn’t answer the questions that are relevant in routine clinical practice such as what’s happening for clients when they are on a gallimaufry of different drugs in different combinations.
Statistics are fantastic resources when they’re used appropriately but very blunt instruments when they’re being used for purposes for which they were not designed.
Tim
Hi Jens,
Thanks for your comments. Alternatives are definitely needed. One of my favourite books was published way back in 1991. It’s called Casting Nets and Testing Specimens. It’s written by Phil Runkel. Phil puts forward the idea that our current reliance on statistics to answer basically all questions from a quantitative perspective is a problem. The “Casting Nets” part of the title refers to statistical approaches and Phil argues that, in order to understand how people function we need to complement statistical approaches with a “Testing Specimens” attitude as well. From this perspective, a model building approach is adopted based on understanding individuals and building up common principles from the establishment of functional, rigorous models. This is the approach used by Perceptual Control Theory (www.pctweb.org). One of the interesting results from conducting research this way is the discovery that we need a different model of causality when we consider living thngs. The independent variable – dependent variable (IV-DV) methodology is a limited way of understanding behaviour. Much like the holistic paradigm you suggest, we need a model of circular rather than linear causality in order to understand accurately how living things function.
Tim
Hi 9,
The question you started with is brilliant!? That’s exactly the point isn’t it? Thanks for your insights.
Part of the problem with sleep disorders is that the term “sleep disorder” can cover a wide range of problems. Just like a cough can indicate very different underlying problems I expect the same thing is going on with sleep disorders. As you illustrate so clearly, it’s important to understand each person and the nature of their particular problem rather than making assumptions based on inaccurate theories.
Tim
Hi Steve,
Yep, great point. Robert Whitaker has done a great job of highlighting these problems. As has David Healy. Not only do we focus almost exclusively on symptoms but we also investigate these symptoms using, mostly, self-report questionnaires.
We need a much greater focus on the effects our treatments have on the person’s life from the person’s perspective. Are they able to socialise more, or hold down a job, or build lasting relationships, and so on. Unfortunately, these things are hard to pin down and not necessarily changeable over the few months that most RCTs last.
Tim
Hi bpdtransformation,
Yes, exactly. That’s just the sort of thing I wanted my article to highlight. There are moves to change our reliance on the 0.05 benchmark but it’s a hard tradition to change.
Tim
Hi Rhonda_B17,
Thanks for taking the time to comment. Experiences like the ones you describe are just the kinds of things I had in mind while I was writing the article.
I’m not sure whether there are some people who aren’t able to take the ‘clean’ option but, for me, the more important issue is how people come to be living the life they’re living. I think why people are taking drugs is perhaps more important than what they’re taking. If they’re informed and are voluntarily using some form of medication because they find it helpful then that seems pretty ideal. It’s a different scenario though when people are not fully informed and have inaccurate and incorrect information about the drugs and their effects or when they’re coerced into taking the medication.
Unfortunately there are still too many situations like the ones you’ve described.
Tim
Hi Travailler,
Yes, I’d but Niall in that category. I’ve never worked with him but was fortunate enough to meet him once and we’ve exchanged emails a few times.
Tim
Hi Slaying,
Psychotropic medications can be dangerous and toxic and their harms have been explained by some brilliant authors. Robert Whitaker’s book is sensational. Some of my other favourite authors are David Healy, Joanna Moncrieff, Ben Goldacre, Peter Gotzsche, and, of course, Peter Breggin.
In my reply to Barrab I was picking up on the use of the word “really”. How do we “really” know? I’m not sure we do but I don’t think that means we can dismiss it either. I don’t really know that people are being helped by the conversations I have with them but I’m prepared to believe them when they tell me that they find them helpful or when they complete a questionnaire a particular way or when they tell me they’re socialising more or they’ve cut down on their cigarettes or they’re not as angry as they used to be.
Perhaps I’m naive but, by and large, I tend to believe what people tell me. I may be misreading things but from the words that you’ve typed it seems as though you’re implying that people can think they feel better but they’re not really feeling better. I’m not sure I understand that distinction. Sometimes, after a hectic day at work, I have a glass or two of wine at night at home and I feel a whole lot better. Now do I just think I feel better or do I actually feel better. I don’t know and I don’t really care! When I get a headache and I take a headache tablet I think I feel better and that’s good enough for me.
I guess the point of my article was just to say that it can be really tough to sort through problems psychologically and some people choose other ways of dealing with things. I think it’s their right to do so. People have to find their own way through the troubles that plague them. Sometimes I can help with that and sometimes other things are what they need at that time.
Tim
Hi Slaying,
Yep, I agree. Individual situations and circumstances related to psychological distress are unique and they need to be explored and examined not categorised according to a diagnostic system. There’s a great paper by E. I. Fried and R. M. Nesse (2015) called “Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study” published in the Journal of Affective Disorders. They analysed the symptom profiles of 3703 people who met the diagnostic criteria for Major Depressive Disorder. Overall, they identified 1030 unique symptom profiles so even with something as well known as depression we can’t assume what we know is going on for someone.
I think you’re right too in that sometimes people can become more distressed as a result of treatment. It’s one of the reasons I think it’s important to let the person receiving the treatment be the best judge of how much treatment they need and how often they need it.
Tim
Hi Slaying,
There’s good and bad in every profession I guess. I’m fortunate to have known and worked with some really great psychiatrists and some of the biggest critics of biomedical psychiatry are, in fact, psychiatrists. There’s a lot clinical psychology could do to tidy up its own backyard but, as you say, psychology is more benign than psychiatry so, even when we get it wrong, it probably doesn’t have the devastating consequences that it can have when psychiatry gets it wrong.
Tim
Hi Slaying,
The love sickness metaphor isn’t central for me but it is a good way of emphasising the idea that psychological distress is fundamentally different to a physical illness. Sometimes the two can co-occur but they don’t have to. People can be physical unwell and not psychologically distressed and it can happen the other way around too.
I definitely take your point that what is offered as help is not always experienced that way by the “helpee”. One of my fundamental principles is that help can only be defined by the helpee and not the helper. If what I’m offering isn’t experienced as help by you then it isn’t help regardless of how good my intentions are. It’s not a very common idea but one that I think is hugely important. I’m glad you raised it.
Tim
Hi Travailler-vous,
Yes, people do often confuse themselves in the conversations we have and the confusion can lead to new and helpful insights and perspectives.
I certainly take your point about how far we have yet to go on a societal level regarding our understanding of drugs and how the brain works. I get the sense that the tide is turning – and websites like Mad in America are a big part of that – but it’s a slow process at the moment and many people still experience the full brunt of a medical approach to psychological distress.
Tim
Ah, OK. Got it. Thanks! Yep, I agree – assuming we know what someone is experiencing or what’s wrong with them is a sure-fire way of shutting down the exploration of how they’re travelling. Of course, it’s fine to assume when you get it right but many times we don’t get it right and the people you describe are good examples of that.
This is yet another problem with the area of psychiatric labels. As you point out, once someone has one of those labels, a lot of their experiences are interpreted from that perspective. I don’t subscribe to the DSM way of thinking about people’s problems so my approach is to listen and question without assuming. As people explain their situation in detail to me they’re explaining it to themselves as well and something very useful seems to happen when people say out loud the things that are bothering them and listen to what they’re describing.
Thanks for commenting and highlighting the point about the problems with assuming – it’s one of the big barriers to effective (and therapeutic) communication I think.
Tim
Hi AA,
Where I work in remote Australia we are very limited in being able to refer on to specialists.
I guess we just have different perspectives on how to work with people experiencing psychological distress. The people I see are all accessing the public mental health service. When they come to see me I ask them questions about the things that are bothering them. Invariably, there are things that are bothering them of a psychological nature: they don’t know who they are; they were abused in their childhood; they can’t decide where their relationship is going; and so on. These are the things we focus on.
I guess if someone came in and wasn’t bothered or distressed about any psychological conflict or dilemma but had some unexplained pain or sleep problem we might explore options for how that could be investigated but, in my experience, people are pretty good at deciding for themselves what they need and who the best person is to see if they’re given the opportunity to express that. Where I am mental health problems still carry a lot of stigma so coming to see a psychologist isn’t something someone does lightly. I’m sure some people would much rather go to a sleep specialist and have their sleep sorted out than come to a psychologist to sort out their mind.
This is an important conversation and probably a good indication that we still have a long way to go before we can accurately pin down the nature of someone’s difficulties.
Tim
Thanks heaps Alex. The healing journey you describe is very much what MOL tries to help people create. Getting to those meta levels seems to be a key in reorganizing all those problems that are being experienced. As you say, it’s hard work to get there but the benefits are worth the effort. Thanks for sharing your experience.
Tim
Hi Alex,
You raise a really important point. Words can be used very differently depending on the intent of the person using the word. I agree, “resistance” could be used neutrally, however, I have often seen it used in a pejorative sense in that the client was somehow rejecting the help that was offered. For me, it all gets back to considering the perspective of the person we’re working with.
Tim
Hi Steve,
No trouble at all. I read a great quote once (can’t remember the source) that said something like “there’s no such thing as a resistant client, just an inflexible therapist”. That’s always stuck with me.
Tim
Hi Steve,
Thanks for your comments. Yes, I definitely agree that physiological problems should be ruled out first. I’m not medically trained though so I rely on my medical colleagues to do that and I assume that if they’re referring a person to me it’s because the physiological aspects have been sorted. Definitely scope of practice can be a real barrier to progress for both the practitioner (from an ethical point of view) and the person accessing the service.
Tim
Hi again Travailler-vous,
The reason I mention “parts” is because that is how many people I work with describe their experiences … “one part of me wants to move on but another part of me wants to sort it out with him” … one part of me has a thirst for life but another part of me has a desire for oblivion … and so on.
Tim
Hi Duane,
I wouldn’t be so grand as to represent my profession here. These are just my thoughts I’m expressing. Nevertheless, I think you raise a great point that some medical conditions do have psychological effects associated with them. I’m fortunate in where I work that I get referrals mainly from psychiatrists so I assume that physical anomalies have already been checked out.
I really take your point about the dangers of assuming. The therapy I use (Method of Levels; http://www.methodoflevels.com.au) is based on the idea of assuming as little as possible and building a therapy around the cornerstone of “curious questioning”.
Tim
Hi Alex,
I’m really glad the article resonated with you. I love the term “radically self-responsible”. How amazing would the world be if radical self-responsibility was the norm?! I think the ideas of cause and effect are important to keep in mind. The particular story of behavior that I like (Perceptual Control Theory; http://www.pctweb.org) talks about the concept of circular causality rather than linear causality being more appropriate for living things. It’s a very cool idea.
Tim
Hi Ron,
Thanks loads for your comments. Yes, I’m sure my doctor could give me something (probably two of them) to help me cope! 😉 Have you seen the Despondex ad on youtube (https://www.youtube.com/watch?v=jd4tugPM83c)? The headline is “FDA Approves Depressant Drug for the Annoyingly Cheerful”. It’s terrific.
Tim
Hi barrab,
How do I “really” know that medication helps some people some of the time. I guess I don’t “really” know that. I only know what the people with whom I work tell me and some of those people tell me that the medication has helped them. You can’t see any point in taking an antidepressant and, from my perspective, I feel the same way. Some people, however, do see a point and some people say that it helps them. It’s not the course of action I would choose but I think I need to respect that as a therapist. That’s all I was trying to communicate.
Tim
Hi Someone Else,
Just picking up on your last point … I’m not sure “schizophrenia” is a “thing” that is caused by child abuse or any other event or happening. Once we start moving beyond the label of “schizophrenia” we might get close to understanding how people arrive in the severely distressed states they end up in .
Tim
Hi Travailler-vous,
Yes, you’re absolutely right. My inspiration for the love-sickness metaphor was indeed Thomas Szasz from The Myth of Mental Illness. And, yep, I pretty much agree with the other things you’ve pointed out … I didn’t mean to communicate that it was OK to label and deceive people about the benefits of medication and I agree that medical problems can start after, rather than before, the person has taken the psychotropic medication.
Tim
Hi Slaying,
Wow! Out of my whole article you chose to focus on the love sickness metaphor. That must have really meant alot to you. I used the word “relief” rather than “spell binding” because that’s how some of the people I work with describe it. I’m sure people experiencing psychological distress didn’t come up with the “mental illness” term themselves but I’ve never heard them come up with the “spell binding” term either!
I really didn’t mean love-sickness to be a central part of the article but I do think the agency that you mention is fundamental to living lives of value (valued from an individual perspective that is!).
Tim
Hi Jonathon,
Yes, I agree. Feeling better is often the key. And the paradox of that is that medication can help people feel better initially (well, after the two to three weeks that they start to have some effect) whereas psychological therapies can be unsettling initially. People I see can have quite a torrid time in sessions but end up feeling better afterwards. That’s where I think the trade-off between long term and short term feeling better can be important.
Tim
I think you’re really ‘on the money’ with these comments. Conflict goes by different names – ‘dissonance’ is one of them, ‘ambivalence’ might be another. Even concepts such as ‘willpower’ and ‘self-control’ are really issues of conflict I think. I’ve written about self-control as conflict in my Psychology Today blog. You can read it here: http://www.psychologytoday.com/blog/in-control/201412/the-difficulty-self-control-is-conflict
One of the things I like about the ‘distress as conflict’ idea is that it doesn’t mean anyone is sick or broken or disordered. They’re just chronically conflicted. Conflict is very common. Essentially, every choice situation is a conflict so, clearly, we’re ordinarily very good at resolving internal conflicts. As you say, sometimes people don’t even resolve conflicted ideas; they just keep them in mind and focus on one rather than the other.
At times, however, conflict can become chronic and distressing. Helping people explore and understand conflict can be very useful in enabling people to function as they would like in a world that is, often, as you put it, “in-understandable”.
You’ve highlighted the slipperiness of the slope upon which “involuntary treatment” sits. Part of my motivation in writing this article was to encourage a shift away from an “I know what’s best for you” attitude and towards an understanding of people as active, purposeful creatures who have their own ideas, dreams, and hopes about the sort of life they’d like to live.
If we thought of “treatment” as a resource people could use to make their lives be more like the way they want them to be, then, from this perspective, it would be very hard to even construe what “involuntary treatment” might be.
I’ve had a terrific Christmas and New Year. I hope yours has been to your liking!
Thanks for adding to the discussion. I’m really glad you liked the article.
I think the safety of people is important. Personally, I like the idea of living in a society where those individuals who want to hurt people are humanely and compassionately prevented from doing so. I also think, however, that it would be useful to distinguish between measures taken to prevent people causing harm and “treatment”. It seems to me that there would be fairly widespread agreement in averting harm to people but what should happen to the harmer once the harm has been averted is less than straightforward. In the spirit of the article that started this discussion, even when people seem like they might cause harm I still think it is important to seek to appreciate their perspective and world view when deciding what to do next.
It’s puzzling to me that we’re continuing to discuss and deliver involuntary treatment in the 21st century. I’m not even sure that involuntary treatment is possible with psychological and social treatments. We can force people to turn up to therapy but we can’t make them engage or process the information. In this sense “involuntary treatment” is something of an oxymoron. Some years back I ran an anger management program and a substance abuse program in a prison where the prisoners received favourable reports for attending and participating in the groups. My strong feeling at the time was that the prisoners got very little out of the group in terms of helping them to think differently about their lives – even though they ended up with a positive report at the end of the group.
The situation with psychiatric and medical treatments is a little different because people can be administered treatments like medication and ECT against their will. Even though it is possible to provide treatments this way, I’m not aware of any compelling rationale or convincing evidence for actually providing treatments in this way. In fact, given that the harms of medication are often minimised and the benefits exaggerated, I think there are some very good reasons to argue against involuntary treatment even when it is possible.
There are broader issues as well to consider such as what it is that we are treating when we provide treatment involuntarily.
If safety is threatened then I think the threat to safety should be addressed but, once safety has been restored, any treatment that follows should be guided by the perspective of the patient.
Do these ideas speak to some of the things you were wondering about?
Thanks for taking the time to let me know how this landed for you. I’m really glad it struck a chord with you. I think we really underestimate just how pervasive internal conflict is and how distressing it can be.
I hope you find the information helpful. For me, learning from and about PCT has been a revelation. PCT shifts the focus away from behavior as it is observed by external onlookers to behavior as it is experienced by the behaving entity. It really does offer a new perspective on many things and suggests some possible reasons for why we are not making the progress we could be making.
I found that it does take some effort and more than a little grappling with concepts to really understand PCT but the effort has been well and truly worth it in both my professional and personal life.
I think it would help to talk alot more about the importance of our perceptions in our ongoing daily conduct. It’s one of the reasons that I’m so interested in Perceptual Control Theory (www.pctweb.org) – it places perceptions as central in understanding behaviour.
I think we could learn a lot from the people experiencing the problems but that would first mean having to accept that we don’t know what they’re going through.
So you prefer “patient liberation” and I prefer “patient-perspective”. Seems like a great example of why considering the point of view of the individual is so important 🙂
Thanks for taking the time to post your thoughts. I agree that, in many ways, things are as bad as ever with the possible exception that there are now forums like this to give a voice to people who would otherwise be silent (or should that be “silenced”) as well as a venue for interesting and lively discussion.
I think there are probably a few reasons for the patient-perspective approach not taking off more widely. One is the view expressed so eloquently (and incorrectly) by my colleague who didn’t think depressed and anxious people were able to make choices. We have all sorts of “legitimate” ways of disregarding the patient’s perspective – lack of insight is one of them. I’ve often wondered why it is always the patient who lacks insight when the patient and the clinician disagree over an interpretation of the patient’s problem. Could it not also be the case that the clinician lacks insight into the patient’s problem? That possibility never seems to be on the table for consideration.
A second reason for resistance to the idea is that, if the patient’s perspective was adopted, then patients would not always make the decisions that the clinicians think they should make. I think many clinicians have some idea of the “right” sort of life the patient should be living and, if the patient’s views were taken as the guide, the patient might not go down the path the clinician thinks they should go down.
In many cases it seems that clinicians judge patients to be “getting better” the more that they agree with the clinician and the more that they behave as the clinician thinks they should behave.
In terms of where the patient-perspective would apply, I guess I haven’t thought of applying it in particular areas, I’ve thought of replacing the current system with it. You’re right, it certainly wouldn’t apply to forced psychiatry. In fact, it’s the antithesis of forced psychiatry. We would have to figure out a different way of dealing with risk in a patient-perspective approach. From the little bit I know of the Open Dialogue approach in Finland it seems to be very much aligned with a patient-perspective approach.
Cost is certainly a consideration in overhauling any system but some of my work indicates that it may actually cost less than the current system. When we moved to a patient-led appointment booking system, for example, we increased service capacity and reduced waiting times with no additional staff or extra resources. The only change we made was the way appointments were booked for treatment.
There would no doubt be problems with the system but I don’t think there’d be any problems that were insurmountable or that are as bad as some of the problems with the current system. I’ve also found that there are many benefits. I have the feeling that there are lots more benefits that haven’t even been realised yet.
I think the clinician-perspective approach has had a decent run – I’d like us to give the patient-perspective approach for a while to see where that takes us.
I’m not sure I follow your logic about being able to tell whether people are making a choice or being forced but I guess from a patient-perspective stance that’s not such a big problem. For me the crucial issue is “from whose perspective is treatment being devised and delivered?”. Alot of problems would be taken care of if the patient’s perspective was the bottom line in mental health service delivery.
I definitely agree that there are many ways to resist oppression and your post provides a nice example of the importance of the patient-perspective. The fact that you agree with Frank should be noted as well as the fact that there will be people who prefer a different path. Suggesting that there is one right way to resist or one right way to get out of hospital is a bit like mental health professionals suggesting there is one right way to think about and treat psychological distress.
We need to find ways (in my opinion) of understanding, acknowledging, and accommodating different preferences and opinions without attempting to persuade people to come around to our way of thinking.
Even with my passion for the patient-perspective approach I’m very aware that this won’t be everyone’s cup of tea. I’ll do what I can to explain the approach as best I can and I really enjoy discussing it with people who are interested but I’m not inclined to spend time persuading people that they should subscribe to this way of thinking. People need to, and will, find their own way.
Yes, that seems to be the way it plays out doesn’t it? People in positions of authority often seem to be more concerned with preserving the status quo than questioning it.
Unfortunately, I don’t know Chief Bromden either! Clearly my reading isn’t as broad as it could be. The point from the patient-perspective approach though is that the idea that “you do whatever you can to get out of hospital” can only be individually determined. One person’s preferred means of getting out of hospital will be different from another’s. Even the desire to get out of hospital will be different for different people.
The lesson that resistance gets you more rather than less severe treatment will, similarly, have different meanings for different people. Some people are prepared to go to extraordinary lengths to preserve their sense of autonomy. That’s a decision that can only be made by individuals. At least, that’s the idea from the patient-perspective approach.
Yes, I think a one-sided establishment and imposition of rules is bound to invite resistance and push-back from the people who the rules are supposed to contain.
I don’t know about McMurphy or Branson but I think you provide a really useful insight into the importance of the patient-perspective approach. To you, resistance is fool-hard and you found another way to navigate through the mental hospital system. To others, however, resistance is important. The patient-perspective approach accommodates both points of view.
I think there are often very good reasons for a person’s oppositional stance. I think it was why I liked working as a behaviour management teacher so much. Many of the kids I worked with had drive and energy and a different way of seeing things that could be really useful. The questioned the status quo and weren’t prepared to go along with things “just because”. Those sort of people can be really helpful in any organisation.
In relation to my countercontrol thesis, I’m not sure how to go about linking to my thesis but I had three papers published from the work that I did:
1. Carey, T. A., & Bourbon, W. T. (2004). Countercontrol: A new look at some old problems. Intervention in School and Clinic, 40(1), 3-9.
2. Carey, T. A., & Bourbon, W. T. (2005). Countercontrol: What do the children say? School Psychology International, 26(5), 595-615.
3. Carey, T. A., & Bourbon, W. T. (2006). Is countercontrol the key to understanding chronic behaviour problems? Intervention in School and Clinic, 42(1), 5-13.
Also, my book “Control in the Classroom: An adventure in learning and achievement” explores the idea of students as controllers and how this can be facilitated and supported in the classroom.
Thanks B. Yes, regardless of the rationale that’s offered it would be extremely difficult to support the idea that the patient was being helped if a “patient-perspective” view of help was adopted. As you say, other people might be helped but not the person experiencing the help. Or, if they are, it’s a lucky coincidence and says more about their resilience, resolve, and ingenuity than it does about the treatment forced upon them.
Yes, “patronising” was one of the words I thought of when this view was expressed to me. This was from an experienced psychologist in a senior position. It blew me away.
Yes, you make a good point. I’m not sure how far the comparisons between schools and mental health units can be stretched. There may be some countercontrol going on in mental health but there are likely to be some important and serious overriding factors as well such as the coercive and arbitrary conditions that can exist in mental health units.
I would be very surprised if patients weren’t frustrated in the conditions you describe. I think anyone would be frustrated under those circumstances. I’m a fan of fewer rather than more rules and I think the rules need to make sense, be applied consistently, and have some general function of enhancing the activity of whatever context they’re being applied to. Unfortunately, alot of rules seem to be invented sporadically and spontaneously for the convenience of the rule maker. And, as you say, often the creation of a rule can lead to other problems.
Perhaps some clarity around rules would arrive with the adoption of a patient-perspective approach. If we were to constantly ask ourselves “What does this person need, from their perspective, to live the life they want to live?” and to act on that we might actually need far fewer rules.
I”m glad you like the idea!! It’s a favourite one of mine too. Ironically, the topic was first mentioned by B.F. Skinner in his book Science and Human Behavior published in 1953. When I first learned about it I was a behaviour management teacher and, despite all the training I had been to about behaviour management techniques no-one had ever mentioned that countercontrol might be one of the consequences.
I did have a few papers I published from my thesis. How should I get them to you?
I think potentially, this is a really important area. If countercontrol is going on at all, then for those kids who countercontrol, most school interventions simply give them more opportunities to countercontrol rather than helping them learn different ways of interacting.
I definitely think it has important implications for many of the students we currently label with DSM diagnoses such as ADHD, Conduct Disorder, Oppositional Defiant Disorder, and so on.
All of my work centres around the idea of individuals – kids included – being intentional, goal-directed creatures. My book “Control in the Classroom” actually takes up this idea and looks at curriculum delivery from the perspective of students have goals, intentions, desires, and so on.
Yes, countercontrol was (is?) fascinating. Like you, I’m one of those people who would not take the option of handing over control to their GP. I remember having an intriguing conversation with some friends in Scotland while I was living over there. We were talking generally about health care, visiting GPs and so on, and something came up about responsibility for health care. I asked who they saw as being responsible for their own personal health care and they said “my GP”. I was stunned. Then they asked me “Who do you think is responsible for your health care?” and I said “Me of course!”. I’d never thought about the idea that someone else could be responsible for my personal health care so the idea fascinated me. These people were health care professionals as well so it was a really amazing conversation.
The countercontrol study I did involved going into schools and asking 10 to 12 year olds what they did when their teachers asked them or told them to do things. In the main study I surveyed about 830 students and their teachers. I went into different schools – big schools, little schools, city schools, country schools, co-ed schools, and single sex schools. Across all the classes about 10% of students in each class reported countercontrolling frequently. I asked students what they did and how they did it. Students said they could make their teachers yell, scream, get mad, run out of the room, and so on. And they said they did this by walking around, calling out, not doing what they were asked.
One student said they could get their teacher to “give me one more chance” and they did that by using “my sweet innocent voice”! It was really amazing stuff. The results fitted so well with what teachers thought was going on but it was the first time this had been investigated systematically.
Interestingly there was some prosocial stuff as well – students said they could get their teachers to give them free time or help them with their work by doing things like putting their hand up, asking questions, and so on.
I’m not sure of the extent to which countercontrol might apply in the mental health field. Where it’s possible to just leave I guess there might not be a need for countercontrol but it might be part of the dynamics in situations where psychiatrists won’t let the patient leave.
I’m not really sure how you come to the conclusion that “patient-perspective care” is a shambolic term because we currently have the situation where some clients in some situations can’t “pull the plug”. It’s precisely because situations like clients not being able to control their own access to treatment exists that I’m advocating for patient-perspective care.
I’m also not sure what “common sense” is or how its helpful to people and I don’t see my role as the dispenser of common sense. I think, again, perspective is very important when things like “common sense” are being discussed. What is common sense to one is not common sense to all.
I’m also not sure what would motivate you to wish me luck in “helping people “reach their potential”” although I agree with you that that statement has a ring of arrogance about it. Perhaps you got that idea from this statement that I made in a reply to another post: “People have the right not to live up to their potential just as much as they have the right to push themselves and find out what their potential might be.” You’ll notice here that I don’t say that I consider my role to be helping people live up to their potential. I was using this as an example because it’s a common way of speaking about the way people live their lives. It’s not something I base my practices on. In fact it’s not something I even think about. People’s “potential” – whatever that is – is very much their own business from my point of view.
Thanks for giving me the opportunity to further clarify some of my thinking in this area.
No need for “I told you so” in this conversation … the dynamics around the patient and clinician relationship are fascinating and the nuances to the control in these situations can also be intriguing.
My PhD research was on a topic called countercontrol which refers to what people who are being controlled might do to the controllers. I haven’t ever investigated it in the mental health field but I’d be surprised if it wasn’t occurring.
For me I think we could do a lot better at clarifying what our role as a mental health clinician should be. My idea is that I’m a resource people can use to explore ways of making their lives be more like they want them to be in much the same way that a mechanic is a resource people can access when they want their car to run more like they want it to.
Sometimes harsh situations call for harsh statements! I agree that the system isn’t conducive to client control and in situations where the client can cease seeking the services then the harm may be minimised. There are some situations, though, where ceasing to access the services is problematic and people can be involuntarily detained if they try.
If clinicians were approaching service delivery from a patient-perspective then that might even help with the “clinically relevant” material that is being documented since what is clinically relevant would be judged in terms of the patient’s perspective as well.
People see clinical psychologists and other psychologists for all sorts of different reasons in Australia. The people I see in my clinical practice in Alice Springs come along for different reasons but, if I was to sum it up, I’d say people come along to see me because their life isn’t going the way they want it to.
I didn’t intend to draw a distinction here between psychiatry and clinical psychology. In fact, in the article I wrote above, where I referred to colleagues who opposed the patient-led style of appointment scheduling, they were clinical psychologists. On the other hand, psychiatrists who refer to my service at the moment in the public mental health service in Alice Springs are supportive of it.
I’m not sure what your experience of psychologists has been but I work very hard not to pressure people to do anything. I’m fairly sure most people I see don’t feel that I’m treating them like trash and, because my clinic is in the public mental health service people don’t pay for appointments. I’ll also don’t use diagnostic labels with people. I’m not saying people don’t come to me with labels but I focus on helping them with their problems of living. My work is outlined in quite a bit of detail in my books about the Method of Levels.
I’m sorry you’ve had such an unpleasant experience.
Thanks for your insights Someone Else. I’d very much like to see forced psychiatry changed. It’s a bit of a sad comment that a conversation such as this is still so relevant and important in the 21st Century but, like you, I think we often use the word “care” in a very strange way in mental health.
I would argue that the recipient of the intervention is the only person who can judge whether or not what they’re receiving is “care”.
In Daniel Mackler’s documentary “Coming off Psych Drugs: A meeting of the minds” (https://www.youtube.com/watch?v=Q5EpnVdLvkU) one of the participants made the point that we should do away with the concept of “shared decision making” between patient and therapist and should instead be promoting “supported decision making” of the patient by the therapist. That’s very much in line with how I imagine a patient-perspective mental health field would be operating.
Thanks for your support. I love your example of the mechanic. That’s exactly the way I feel about it. Just as the mechanic can advise you what’s possible but the final decision about what you get done to your car is up to you, I think mental health professionals can advise people about what they think might be possible but the final decision of the path to be taken must be left up to the patient.
People have the right not to live up to their potential just as much as they have the right to push themselves and find out what their potential might be.
I also agree that patient-perspective care is impossible in a context of forced psychiatry.
Thanks for your perspective. I agree. I think forced anything is likely to be counterproductive. I think sometimes, though, forced psychiatry is justified by claiming to be in the patient’s “best interests”. I don’t go along with that rationale but I thought if we adopted a stance of “patient perspective care” then what was or wasn’t in the patient’s best interests might be a lot clearer.
Thanks for your article. It’s really useful to have the history of the DSM reliability drama described like this. I’m a big fan of the work of Kirk and Kutchins.
Unfortunately, I think it’s easy to get beguiled by all of the reliability statistics and the judgements about whether they are “good”, “acceptable”, or some other term denoting an apparent standard. I’m not meaning to imply that you have been beguiled – the clarity of your writing would certainly argue against that – I think, for me, there is a broader conceptual issue that is fundamental to the reliability issue. I’ve written about this on another website (http://dxsummit.org/archives/608) where I talk about the “red herring of reliability”.
Even if the developers of the DSM could achieve perfect reliability for all of their diagnostic categories it would still be the wrong way to understand psychological distress and problems of living. In fact, in some respects, it’s trivially simple to achieve good reliability. With nothing than a date of birth and a few minutes of training, “diagnosers” could routinely achieve perfect reliability in assigning people to various star signs (Sagittarius, Gemini, and so on). The impressive reliability in this case does not add legitimacy to the system of horoscopes as a way of understanding human functioning.
While in principle I agree with your statement that “The basic idea behind reliability tests is that the diagnosis that a patient receives should depend on their symptoms, rather than on who does the diagnosing.” this doesn’t apply to diagnosis in psychiatry. Because there is no independent means for determining if someone has “really” “got” Borderline Personality Disorder or Generalised Anxiety Disorder the only thing that DSM reliability tells us is how much two people agree on the presence of certain symptom categories. What we learn from DSM reliability is the extent to which two independent raters can see the same disorder in a set of symptoms – and, apparently, the extent is “not great”! What DSM reliability does not tell us is whether or not a DSM disorder is “really” present. DSM reliability can’t tell us that because DSM disorders are never “really” present or absent – they are just assigned and either believed or refuted.
The DSM system is simply the wrong way to understand psychological problems of human functioning and no amount of attention to Kappas or field trials will correct that. We need to be devoting our best scientific efforts to something other than the improvement of DSM reliability.
Thanks for this post. Like you, I’m a very optimistic therapist who never loses faith in the abilities of people to make important and sometimes dramatic changes in their lives. I trained in NLP in the ’90s and while it’s not an explicit part of the transdiagnostic cognitive therapy (Method of Levels; see https://www.youtube.com/watch?v=LQLnOHoko7U) I have developed, many of the questioning techniques have their basis in the NLP methods of investigating thought patterns and processes.
Again, like you, I don’t see any reason why people can’t make lasting changes quickly. I’ve found in my clinical practice that people just take different amounts of time to change – some people change quickly and some people take more time. There’s no reason to believe, however, that quick changes are somehow inferior or more superficial than slower change. Often debilitating psychological distress can arise very quickly, sometimes after just one unfortunate event, so I don’t see any reason why it can’t disappear just as quickly.
For me, being able to provide therapy is a tremendous privilege and I’m constantly in awe of people’s capacity to make new sense for themselves from a position sometimes of great distress.
Thanks for your article. It’s great to read about someone who seems to have similar experiences to me with regard to therapy.
Thanks enormously for posting this article. I find historical perspectives to be extremely valuable in understanding where and why we are today and so I appreciate your contribution in that regard. I’ve read some of Kurt Danziger’s books about the historical development of concepts in psychology and they were just as illuminating as your article.
Your ideas were so interesting I read some paragraphs a few times just to let your suggestions roll around in my mind. I’ve been a fan of Szasz’s for a long time so I really appreciate the perspective you’re offering in your post. I was intrigued that Epicurean philosophy could accommodate the idea of a spirit but not as a God-given entity. I’ll need to mull that one over for a while. It’s counter-intuitive but appealing and provocative all at the same time.
Your article has helped me think about my own work and the work of the movement generally that is working towards a different understanding of mental health and its treatment and the extent to which it’s important to think about how messages are received by others. I can understand why the idea of personal responsibility might not be a tune that all would want to hum along to but it’s there nevertheless.
Hi B,
I wish it was different but, unfortunately, there seem to be a lot of psychologists who are just as wedded to the medical model of mental health as psychiatrists. Interestingly some of the strongest opposition I’ve had to my patient-led model of treatment delivery has come from psychologists and yet some of the psychiatrists I currently work with a supportive of it. We also have some strong champions for mental health reform as demonstrated by Peter Kinderman’s recent post but we could definitely do better.
Hi Oldhead,
I’m not sure what you mean by “class analysis” and I’m not sure specifically which insights you’re referring to. If you’re asking whether I think social class is important in understanding individuals then the answer is “yes”. Some of the other comments in which I mentioned the importance of context and individual’s perspectives speak to this point.
Yes definitely. A person who has been both a mental health professional and a person accessing mental health services will have a very different perspective. It will probably be different too if they became a mental health professional after they had accessed mental health services or if they accessed mental health services while they were a mental health professional. People’s perspectives based on their individual experiences will always be different. For me, that’s why it’s so important to make the perspective of the individual seeking assistance the perspective to be guided by. If I could change one thing about the mental health field that would be it. That’s why I called my approach to organising services “patient-led treatment”. I think mental health services might be both more effective and more efficient if the people accessing the service rather than the people providing it did more of the leading. Yep, hope is important. In many ways there’s not a lot of it out there but there is a little bit and that’s a start.
Hi Uprising,
You’re right – I probably didn’t need to insert the word “inappropriate” in that sentence. I also agree that a mental health professional’s perspective is bound to be different from the perspective of a mental health patient although it would be a mistake to assume that a mental health professional has never been a mental health patient and so can’t have both perspectives. I’m aware that there have been lots of injustices and acts of inhumanity perpetrated by psychiatry and that definitely requires changing. Only very recently, however, I was working with a person with a long history of contact with the mental health service and very serious problems who was telling me how good his psychiatrist was. According to this person the psychiatrist listened to him, took his concerns seriously, and was working with him to taper him off some of his medication. This is only one small case but it provides me with a glimmer of encouragement that things are changing. Sometimes mental health professionals need hope just as much as other people. 🙂
Hi B,
Yes, I think psychiatry as a field is at a disadvantage because of the whole “mental illness just like a medical illness” charade. Mind you, I know some psychologists who have just as much allegiance to the DSM as do many psychiatrists. Training in this model must make it ultra hard to take that step back in order to consider things in a different light. Some do however. Admittedly the numbers of psychiatrists who consider things other than medical explanations are probably small but there’s definitely a change in the air and some psychiatrists are making that change happen.
I think the ability to live life according to your own, rather than someone else’s, design is important regardless of which country you’re living in or which culture you’ve been raised in. I’d go so far as to say that we’re designed to be autonomous, self-regulating creatures. That’s the reason I think having our autonomy restricted can be so painful.
That’s a shame. That hasn’t been my experience. I’ve worked in both the UK and Australia and have found that in psychiatry, just like in any other profession, there are highly effective practitioners and others who are not so effective. Some of the loudest voices advocating for mental health reform are, in fact, psychiatrists. Perhaps it’s because of the power the psychiatry profession is afforded that the effects on people’s lives can be so devastating when psychiatrists are ineffective. Other mental health professionals who don’t listen to the people with whom they’re working, who don’t attempt to consider the situation from the other person’s perspective, and who make assumptions about what would be best for the other person can also cause harm. Many other mental health professionals, however, can’t detain people against their will, can’t prescribe medication or ECT, and can’t force people to be treated involuntarily. When these things are used inappropriately by psychiatrists the harm is likely to be much greater.
I’m not sure why the pastors would have said that. In any profession there are those who are effective and those who are not so effective. I’m fortunate to work with some excellent psychiatrists.
I had a read through your “communication breakdown” forum Boans. It sounds like you’ve had a really rough time of it. I hope things are picking up for you now. I know there are potential problems with any system but I can’t help thinking that our current allegiance to an “illness” model of psychological distress is a big stumbling block in the path of progress.
Part of the problem for me is the “lens” of mental illness that we often have before us in the mental health field when we’re considering the conduct of another person. To step away from that lens and to seek to understand the person, their aspirations, and the environmental contexts they are operating within would move us a long way towards helping people live the sort of lives they would want for themselves.
Context for me is always crucial. Understanding behaviour requires understanding the environmental context in which the behaviour occurs. Different behaviours can be used to achieve the same goal and the same behaviours can be used to achieve different goals depending on the environmental circumstances.
G’day!
The problem of behaviour as we currently understand it is most definitely dependent on the eye of the beholder. My preferred way of thinking about behaviour is based on Perceptual Control Theory which explains behaviour from an inside looking out perspective.
There can be some consistency across therapists with regard to diagnoses depending on different facts such as the particular diagnosis being considered. As you point out, the environmental context will also be important. For me, though, consistency is not such an important issue. It’s quite easy to get consistency or agreement between people about various things. Based on nothing more than a date of birth, for example, it would be easy to get quite robust consistency across people with regard to the particular star sign that various people should assigned. It would also be possible to have people consistently identify Santa Claus, the Tooth Fairy, and Mickey Mouse from a line up. Consistency is useful in some context but it’s a red herring when it comes to establishing the legitimacy of a construct. The degree to which a particular mental health disorder diagnostic label is consistently identified should not be taken as evidence that the disorder either does or does not “really” exist.
Anonymity can be an important part of the therapeutic process. Sometimes internet resources can provide this but it’s also possible to achieve in a face-to-face session. Some of the people I work with, for example, tell me that they like the fact they can say anything to me because I’m not in “their world”.
I think you’re right that there are many good and useful parts to both sorts of relationships and keeping a balance is likely to be a key factor. And what is balanced for one person might not be so balanced for another.
This is a good example of why options are so important. Different things are useful for different people and different things are even useful for the same people at different times. And for me some of the most important options are informational: learning that there are ways to think about problems of living other than “mental health disorders” and learning that there are ways of helping other than chemical.
Thanks Ted. It’s an important question. There’s certainly a growing number of articles and authors pointing out different problems and different perspectives about the current state of play in the mental health arena. I kind of think that’s a good thing. Lots of different ways of saying similar things has the potential to be helpful to lots of different people. I’d like to think articles such as these help inform people of options so that they are in a better position to make decisions. I also think that the more articles that are produced by a range of people of varying backgrounds, educations, and experiences will help to demonstrate that the tide really is changing with regard to the way we conceptualise and treat mental health problems. It’s changing slowly but it’s definitely changing. A few years ago there wouldn’t have been a forum to even discuss ideas like this. That MIA and other sites like it exist is a very good thing.
So how does publishing articles like these help to end some of the less desirable practices of psychiatry. I’m not sure. I work with people who think they’ve “got” one or more of the DSM disorders among other things. If articles like these can help them question what they’re being told and maybe seek a different story I think we might begin to see the end you’re asking about.
Thanks for your perspective. It’s true that a lack of community can exist in the world of interactions as well as the world of e-interactions. The web is a wonderful resource and I wouldn’t like to be without it. At times, though, the possibilities on the web (such as online therapies) are offered as alternatives to talking therapy rather than as additional resources and I think that’s a shame. it shouldn’t be a case of “either/or” but “this and that” depending on the person, the problem, and the circumstances.
Hi B,
I agree – it’s very important for people to know what to expect. I don’t know what the situation is like in the US but in Australia one of the standards of the Code of Ethics for psychologists is informed consent. The Code specifies that psychologists should inform people about what to expect including things like how appointments can be made, how long treatment will last, and even that they have the right to withdraw from treatment. I think it’s important to routinely check in with people I’m working with about how they’re experiencing the service. I use the Session Rating Scale at the end of every session which provides people with an opportunity to give me feedback about the session and it enables us to have a conversation about how they think things are going.
You’re right too that finishing therapy after a long period of time can be problematic. That’s why I like what I call the “patient-led” approach so much. From the very beginning the person accessing the service is the one who controls how many sessions they have and how often they have them so they get to regulate their own exit from the service.
I agree too that it works for some people but it’s not for everyone and it’s certainly the case that, at times, when used poorly or misapplied, it can cause harm. The potential to exacerbate problems rather than alleviate them is something that should always be taken seriously.
Thanks for your perspective.
Tim
Hi there,
You’re right that talking therapies are not for everyone but many people do find tremendous value in talking to someone outside their usual relationships. Ironically, some people I work with tell me that it’s precisely because they don’t know me that they can visit and talk about those dark places that they are reluctant to share with people they are close to. Again, that’s not the case for everyone but it’s certainly some people’s experience. My job description does not require that I do not care about people but it’s a different kind of caring to the way a parent, or friend, or spouse might care. Well, maybe it’s not so different but it’s expressed differently. For me, being able to work as a psychologist is an incredible privileged. I’m constantly humbled by the worlds that people share with me and I never ceased to be amazed at their abilities to make sense where there seemed to be none before.
Thanks for your views – it’s important for me to have the opportunity to reflect on things like what it means to care.
Tim
Thanks for taking the time to post a reply.
Unfortunately, as in most professions there are great counselors and counselors who are not so great.
Being informed is definitely a great strategy for navigating your way through the mental health field.
Tim
Thanks for your further thoughts Don. Of course, you’re perfectly entitled to disagree. I disagree with your disagreement :-)!
It’s great that you’re interested in things like consciousness and the mind. I’ve actually just finished writing a book chapter about consciousness from a PCT perspective. It’s due to be published in May next year.
PCT is a first person perspective theory. That is, it explains behaviour and the process of living from the inside looking out not from an observer’s perspective. As such it is entirely compatible with, and accommodates, trauma-informed work and listening-based approaches. The Method of Levels is almost entirely “listening-based” and trauma-informed work is an important aspect of working effectively with Aboriginal and Torres Strait Islander Australians.
PCT and MOL are definitely not everyone’s cup of tea. I’d love it if they were, but they’re not. That’s OK.
Tim
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Thanks Don. It’s a great question and, I agree, that paragraph probably did stand out a bit from the others. All of my work is based on the premise that we are designed as living control systems as described by Perceptual Control Theory (www.pctweb.org; http://www.iapct.org). I’ve developed a transdiagnostic cognitive therapy based on these ideas (Method of Levels; http://www.methodoflevels.com.au). Being controlled by other people is so damaging because we’re designed to control the things that matter to us ourselves. No-one else can do that for us because no-one else knows how it is to be another individual or what the life is that that individual would like to carve out for themselves.
Does that help?
Tim
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Thanks Rebel. I think it would be great if people would listen to themselves a little more. Understanding who I am as an individual and what I need to move in the direction I want to go in is surely one of the most important things I can do. I wonder if the first step in solving some of the conflicts of the world is first resolving our own internal conflicts.
Tim
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Thanks for your perspective Jordanfallis. Yes, there could be many explanations for why people are feeling the way they are feeling. Unfortunately, when we label something as “depression” we think that’s an explanation and stop looking for other reasons.
Tim
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It’s one of those timeless classics isn’t it?
By the way, I also really go along with your idea stopping the dividing up we do and focus more on our individual uniqueness. I think it’s possible to recognise that we all share some common fundamental features as being part of the same species but, within it that, we are all marvellously unique.
If we recognised that and celebrated it a little more we might be in a different place.
Tim
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Hi Bradford,
Yes, the invention of the DSM (I’ve suggested elsewhere that this might stand for “Damn Smoke n Mirrors”) categories is a big part of the problem. The importance of things like current relationships and past trauma is ever so slowly being recognised but there’s a mountain to move when it comes to industry of diagnosing and medicating.
It’s great to have a forum like this where we can communicate our ideas and perspectives on these issues and help to keep the ground swell swelling 🙂
Tim
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Hi Rebel,
Little Women was a favourite in our family when I was a child too!
I agree that anger can be a big problem for both individuals and social relationships. Ironically, in the work I do, self-control is considered to be a form of internal conflict. The reason people experience this sense of needing to control themselves is because they want to do something (maybe yell at someone) but they also don’t want to do it (they want to treat people respectfully) at the same time. When people are unconflicted and pursuing important life goals it doesn’t feel like self-control. It doesn’t feel like anything really it’s just kind of going with the flow.
Maybe the reason that counting to 10 can be so effective is that it gives people a chance to step back (in their own minds), see the bigger picture, and remind themselves of the things that are really important to them.
Thanks for the reference to Little Women … that was a delightful trip down memory lane :-)!
Tim
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Hi Bradford,
I really like the way you’ve expressed this. The mutually interdependent, bidirectional nature of influences is really important isn’t it? All of my work is based on the idea of circular, rather than lineal, causality which very much speaks to these ideas as well. At the same time that we are influencing we are also influenced. It’s a very cool concept!
Tim
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Hi Ceebee1,
Yes, I did suggest that neither of us were going to get much mileage out of continuing this conversation. We just operate in different worlds. My understanding is that blood and urine tests detect metabolites of neurotransmitters which do not have a straightforward relationship with levels of neurotransmitters in the brain.
But these are all just details. The bottom line is that you’re happy believing that the chemical imbalance myth is not a myth and I’m firmly convinced that it is.
There’s not a lot of room for discussion there 🙂
Tim
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Oh OK. I didn’t know that. Thanks for clarifying the point.
Tim
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Thanks for sharing your perspective Rebel. I agree with both your points about the pervasiveness of the myth and the damage that it does.
Tim
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Hi there RJGrigaitis,
Actually, the modern day Santa Claus is the combination of a few different historical figures: https://en.wikipedia.org/wiki/Santa_Claus
I’m not sure I made a relative comparison in terms of saying that Santa Claus “is as mythical” as the chemical imbalance. Whether one is more mythical than the other isn’t important from my perspective. They’re both mythical. That’s the point I was wanting to make.
Tim
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Hi again Stephen,
That’s the way I see it too. There’s definitely more that unites us than separates us. If we could harness that we’d be all the more powerful and influential.
Tim
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It was great to see your comments too humanbeing. “Follow the money” is a terrific line!
Tim
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Hi Chet,
Thanks for the extra information. We just have a very different perspective on all this. I’ve never heard of dopamine and serotonin levels charts and I have no idea how they would possibly even have established them. Even if those charts were accurate at a population level they still wouldn’t be meaningful for an individual. Think about height and weight charts. What is “normal” height? Should we give growth supplements or bone grafts to people whose height is normal (whatever that is)?
Also, I don’t place too much (read “any”) faith in commercials about drugs or neurotransmitters. I’m sceptical of all advertisements. I think we generally accept and acknowledge that advertisements about things like shampoo and cars are probably exaggerating their claims and distorting the information somewhat to portray a glowing image. That is magnified exponentially when the topic is psychotropic medication.
As I said in my article, 80% to 90% of the bodies’ serotonin lies _outside_ the brain. I wonder how their tests cope with that. In doing research for this article I contacted a couple of expert researchers who are involved in this area and they weren’t aware of “precise” neurotransmitter tests that were available.
We just have different views, that’s all. I get the sense that you’re pretty happy with where you’re at. Me too 🙂
Tim
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Thanks loads Alex. I’m really glad you’ve got something out of this. Me too! I’ll have a look at your youtube site. I feel the same way about posting person details here. I can be contacted through the MOL website.
More soon.
Tim
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Each time I read your posts Alex, I find myself smiling by the end of them. This is so similar to what I do. I call what I do “psychotherapy” or “therapy” or “psychological treatment” but it’s really facilitating the other person having a conversation with themselves about difficult issues. Nothing happens unless they want it to. Even not having “therapy” is OK. The whole focus of MOL is on present time, in fact it’s about the “right now” of what’s happening for the person as they’re talking about all this difficult stuff.
And yes, even in the face of all the hard stuff, there’s often humour and almost a “playfulness”. I’ve also found that most people only need a small number of sessions. I think about 4 or 5 is the average people seem to come a long to see me for.
Tim
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Thanks Alex. Yep, interference is the key. It’s the problem with medications (or psych drugs or whatever you want to call them) too – they interfere with the bodies’ own processes. And lots of times the mental health professionals don’t even know they are interfering so they take resistance, not as a sign of how functional the person is, but how they “lack insight” so the mental health person does more of what they were doing, hence more interference, the person being “treated” tries to do more to protect themselves, and so it spirals!
At least while we’re talking like this and bringing these issues into the light there’s a chance to change them. Those new perspectives we’ve both been talking about!
Tim
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Thanks Alex. I’ll check out the films. They sound really interesting.
Yes, the way you’re using the term “control” is the way I understand it. A few years ago I came across an entire field devoted to the study of control as it occurs in living things. From this perspective, control is a process that is essential to life. In fact, control is life. In order to keep living, we need to be able to control things like our body temperature, the amount of oxygen in our blood, and so on. At another level we also need to be able to control things like the amount of trust and openness in our relationships, the extent to which we think well about ourselves etc.
From this perspective, problems occur when this natural control process is disrupted or interfered with. It’s a big reason for me as to why mental health services fail so spectacularly most of the time. Because of the extent to which they go to control “patients”, they actually interfere with that person’s own control and set up a recipe for disaster!
The point about therapy impacting on the therapist as well as the “therapee” is a really important point too. It’s a really humbling experience for me to be a therapist. To be entrusted with someone else’s stories is an enormous privilege. And you’re right, there’s definitely a learning and growing for therapist … if they’re open to it :-)!
Tim
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Hi Alex,
I’m really enjoying reading about your journey. There is so much overlap with the work that I do, it’s uncanny. We’re using different words but I get the sense that we’re talking about the same kind of thing. The therapy I use is called the Method of Levels (MOL; http://www.methodoflevels.com.au) which is based on Perceptual Control Theory (PCT, http://www.pctweb.org). MOL is all about having people listen to their own talk so that they can become conscious of their problems in different ways and reorganise neuronally (this is the neuroplasticity bit) to arrive at new perspectives, new insights so control (you might call that balance) is restored.
I also share the big “IF” that you describe. None of this can happen unless the person wants it to. And even when they want it to, it still can be gruelling, emotionally draining work. An important part of my work has been what I’ve called “patient-led treatment” so the person who is accessing the service is the one who makes the appointments and the one who decides how many they will have and how often they will have them. I’ve also started to develop an idea lately called “patient-perspective care” which in the services I’ve worked in would be much more helpful than “patient-centred care”. In my experience, “patients” can be at the centre of a clinicians deliberations while decisions are still made about them and for them and on them. That might be a lot harder to do if it was the perspective of the person accessing the service that had to be used to guide decision making.
Tim
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Thanks Stephen. I appreciate you taking the time to explain your position.
I completely agree that the psychotropic drugs that are used as medication in the mental health industry do not treat illnesses and don’t “cure” anything. Your point about having a particular preference for the word you would choose to use is well taken.
To be honest, I wasn’t even aware I had a preference until posting this article. I’m still not sure that I do. I think the words I use depend very much on the context. I’ve been really surprised that the focus of this article for some people has been on a particular word or term.
To put it in context, the article has 1902 words. Of those, the word “medication” is used 5 times. Twice when it is used it is used as “psychotropic medication” and on the the other three occasions it is used it is being discussed in the context of what mental health service providers frequently try to do from the perspective of the chemical imbalance nonsense.
I’m sorry that the use of the term “medication” seems to have offended some people but I’m probably even more disappointed that the focus on that term seems to have distracted a lot of discussions from the main point of the article. I think it would be very hard, based on the content of the article, to justify the idea that I support the notion of mental health disorders as “illnesses” or that I’m an advocate for the biomedical model of conceptualising and treating psychological distress.
Tim
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Hi Alex,
Thanks loads for sharing this. What a profound and moving story. It’s a great comment on the strength and resilience of the human spirit. Your point about the chaotic environment really resonated with me. You say towards the end “If my chemicals had been out of whack” … it’s a big “if” :-)!! My interpretation would be you reacting very normally to a very abnormal environment!
Thanks again.
Tim
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Hi Chet,
The problem lies in this sentence “A person can have a dopamine level that is higher than normal (schizophrenia) or they can have dopamine levels that are lower than normal (ADHD).” We have absolutely no idea what “normal” dopamine levels are. Then to try and assume a particular amount of dopamine is “causing” a particular problem called “schizophrenia” or “ADHD” is a massive leap in flawed logic. “Schizophrenia” and “ADHD” are made up categories. They’re not illnesses or dysfunctions in the same way that breast cancer, Parkinson’s Disease, malaria, and diabetes are. So even if we knew what “normal” dopamine levels were (which we don’t) we still wouldn’t have solved the problem of the diagnostic categories.
I definitely believe that “We humans say and do things because we derive some benefit from that activity”. From my perspective, that’s called a process of control. Problems then, arise when people aren’t able to derive the benefit they would wish for from the activities they prefer.
Tim
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Thanks AA. I definitely think psychiatric medications are at the top of the list in terms of wildly exaggerated benefits and grossly minimised harms but it’s a really important point you make. I really like Peter Gotzsche’s work in this area. He makes the point that all drugs can cause harm. In fact, according to him, prescription drugs are the third leading cause of death in Europe and the US behind heart disease and cancer. It’s a staggering statistic.
I guess we all have our big ticket items. For me quotation marks aren’t one of them despite how useful they can be.
Tim
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Hi Chet,
I appreciate you posting this information but, from my perspective, there’s nothing here to address. Identify people as having a particular “disorder” and then looking for things they might have in common that help to explain the disorder is exactly the reverse of the logic that is needed. Demonstrating that people experience some benefits when they take various medications does not provide any support for the chemical imbalance idea. If that were the case then headaches would be caused by a panadol deficiency and the people who report benefits from taking lithium would be experiencing a lithium deficiency.
Like I said in my article, the chemical deficiency is created after the medications are ingested. So, in a way, you’re very correct. It is because of a chemical imbalance that Big Pharma is making billions of dollars. It’s an iatrogenic chemical imbalance caused by the chemicals.
I think approaches that attempt to “regain control of the child” are actually part of the problem. My perspective is that people need to control the things that are important to them not be controlled by others. When children are behaving chaotically it’s often because, from their perspective, they’re in the middle of a chaotic environment.
There are certainly lots of things to address and the longevity of the chemical imbalance fallacy is one of them.
It would be nice if we had more common ground but, on this issue, we see things very differently.
Tim
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Hi Richard,
I’m jumping in here to clarify one last point here. I was waiting until the previous comments had been restored but that doesn’t look like happening soon. In one of my last posts I wished you all the best with your revolution and you replied saying it was “dripping” with arrogance (or some other similar term. I can’t remember exactly which one it was). Here again in this post you refer to my arrogance. I wanted to post this just to emphasise that, when I sent that comment, I had no intent other than wishing you the best for you in terms of where you’d like to head. There was no arrogance “dripping” from the words when I clicked on “Post Comment”. All you got were words on a screen Richard so if there was arrogance dripping from the message that was your interpretation. But it is our inability to even agree on simple matters like that that reveals the huge gulf there is between us in how we communicate and what we communicate about. Again, that’s not written from a position of arrogance or superiority. It’s just an observation of the pattern of communication with this article. It’s for that reason that I can’t see any purpose in us continuing our conversation. That doesn’t mean I think you’re bad or inferior or unworthy it just means I think we have different priorities. I genuinely hope you’re able to bring about the change you’d like to see. I genuinely hope I’ll be able to do that as well.
I can’t type it any more clearly than that. That’s where I’m coming from.
Over and out.
Tim
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Thanks heaps for taking the time to post this comment Peridot. I’m delighted you liked it.
Tim
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Thanks Kram. I’m really glad you found it helpful.
Tim
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Thanks Alex. I have a sense of completion too. It’s nice to know you’re out there!
Tim
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Thanks Alex. There’s not much more I can add to your comments except to say “Nice one!”. It would appear you and I see things pretty similarly. Recognizing that each of us has a part and that telling other people what to do and how to do it is rarely effective will be a very significant leap forward!
Tim
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Hi Richard,
From my perspective our conversation has been characterised by misinterpreting each other’s email. I can’t see a way to correct that so my solution is to leave things alone.
In the most recent exchange, for example, I wrote “If there are things that are useful in this discussion you then that’s terrific. It’s gone way past being productive or useful for me.”
To which you replied “And then you have to throw in the zinger at the end that you have better use for your time then to engage in dialogue with the likes of someone like me.”
So my idea of respectfully allowing us both to do what we’d like to do is an insult to you with the implication that I don’t want “to engage in dialogue with the likes of someone like me.”
I think it’s worth remembering that this whole discussion has arisen because my use of the terms “mental health”, “mental illness”, and “medication” didn’t match the way you thought I should be using those terms. Because I didn’t use quotation marks in the way that you thought I should there have been statements like “This is about unscientific and harmful language that is part of the very foundation upon which Biological Psychiatry was constructed and now reinforces and justifies all the harm carried out in its oppressive “mental health” System.”; “making comments that I believe denigrate my reputation”; “totally clueless”; “you have have found it necessary to concede Biological Psychiatry certain key aspects (use of the terms “medications,” “mental health,” and “mental illness”) within the other two thirds of their dangerous and mythical narrative”; “Every single argument you make in the above statement could also apply to the continued use of “medication,” and the use of “mental health” and “mental illness” without quotations. The overall harm done by these above terms is essentially NO LESS than the harm done by excepting and propagating the “chemical imbalance” theory for which you have correctly dissected.” and; “The maturity of our current scientific and political understanding on the use of the terms “medication” vs “psychiatric drug” (and “mental illness” and “mental health”) is such that there is absolutely no longer (if there ever was) any rational reason to make harmful CONCESSIONS in our writings by accepting the continued use of these unscientific and politically backward terms. WE DENIGRATE, AND RENDER LESS PROFOUND, OUR ANALYSES BY CONTINUING TO MAKE THESE CONCESSIONS IN OUR USE OF TERMINOLOGY. THIS DAMAGE BEING DONE WILL NOT STOP HAPPENING UNTIL WE MAKE IT STOP HAPPENING!”
This is clearly a topic you feel very strongly about. I don’t feel as strongly about the use of quotation marks in this manner. I think you should be able to conduct the revolution in the way that you think it will be most effective and I think I should be able to do the same thing. We just have different views on this that’s all. I don’t think your view is wrong, it’s just different. From everything you’ve written I think it’s safe to conclude that you think my view (with regard to the use of quotation marks) is wrong. I don’t think there’s anything I can do about that. That’s why I’m bowing out of the conversation.
I really do hope you get the revolution you’re after.
Tim
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Hi Alex,
I couldn’t agree more. Cohesion within diversity is a powerful attitude to strive for. I think keeping the bigger picture in mind and recognising that, very often, there is not one right way to get to the destination might be a helpful perspective.
Tim
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Thanks Nick!
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Hi Gerard,
Thanks for getting back to me. I find this whole discussion a bit mind-boggling really. This whole thing has arisen because I didn’t put quotations marks around three terms. I clearly just don’t see this as the priority that other people do. I think if you have a look at other articles I’ve posted on this blog you would get a sense of where I’m coming from. I think I do my fair share of questioning and criticising the disease model and, perhaps I’m kidding myself, but I don’t feel trapped in a disease model narrative. Like you, I think the BPS has made some great strides forward. I worked in the NHS in Scotland for 5 years and really liked a lot of what went on over there. I’m still a member of the BPS.
Tim
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Thanks again for your thoughts Alex. Diversity is certainly important.
Tim
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Thanks Borut. I agree, we do need a much wider focus. Most of my work is focussed on the phenomenon of control as the basic process of living. From this perspective, psychological distress is considered to occur when control is prevented or disrupted.
Tim
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Hi Oldhead,
Is this really how you want to be spending your time? It’s not the way I want to be spending mine. Perhaps I’m being defensive again! 🙂 So be it. I have other things that I’d rather prefer to turn my attention to.
Tim
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Hi Richard and Oldhead,
I’ll have to bow out of this one. If there are things that are useful in this discussion you then that’s terrific. It’s gone way past being productive or useful for me.
Tim
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Hi there Oldhead,
That would be the Revolution Richard mentioned in his post.
Tim
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Hi oldhead,
Hmmm. Doesn’t it take two to carry on an argument ;-)? This one will be carrying on no longer.
Tim
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Hi there Richard,
I think it’s pretty obvious that we’re just not going to agree on this issue and I can’t see us bunkering down into our sides of the argument as being very useful for anything. I have lots of positive and productive things to turn my attention to as I’m sure you do too.
All the best.
Tim
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Thanks Alex. I definitely think our lack of connection is part of the problem.
Tim
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Hi Alex,
This resonates really strongly with my own approach. I base my work on a theory of control called Perceptual Control Theory (www.iapct.org; http://www.pctweb.org) and I’ve developed a therapy called the Method of Levels (www.methodoflevels.com.au) which helps people regain control of their own process. I think lack of control is at the heart of psychological distress. It is really hard to know what to believe but finding our own voice, and allowing others to have theirs, is, I think, a bit part of the solution.
Tim
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Really? In the context of a discussion about the language we use, you would call me “totally clueless” because I don’t share Richard’s opinion for the way terms are used. I note, also, that you didn’t put quotation marks around “totally clueless” so I’m assuming you literally mean “totally” as in “wholly, completely, entirely” and “clueless” as in “ignorant, uninformed, unaware”. So, I’m entirely uninformed and “engaging in hate speech” simply because I didn’t put quotation marks around the word “medication”. And because of this you make the assumption that “Jack Daniels is medication to you”.
Amazing.
Tim
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Actually Richard, this is ALL about preferences. You have a particular recipe for advancing the revolution, I have a different one. So you will not grant me the right to pursue the revolution in the way I think it should pursued. Hmmm. That seems a lot like a mental health professional not letting a patient determine the way they would like to be treated.
Difference doesn’t necessarily mean wrong.
Tim
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Hi Nick,
Thanks for this. I don’t know a lot about the Maori approaches but there seems to be a lot of really positive things to the work they do. There are a small number of places in Australia where traditional healers work in health clinics alongside other health professionals.
Tim
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I couldn’t agree more Frank. We need a world where people are a little more accepting of differences. It will be a great time when people can achieve the things that are important to them without preventing other people from doing the same thing.
Tim
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I would suggest you’re not victimized by a term. You might have been victimized by health professionals in mental health services but very few of them are even called “mental health somethings”. There are certainly mental health nurses, psychologists, psychiatrists, and so on. Are you of the opinion that if they weren’t called “mental health services” then you wouldn’t have been victimized?
Tim
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Hi Nick,
That’s a great point. A lot of what passes for science in the mental health field is not very scientific. I completely agree that genuine reform will take time and will take many people working together. It will also take acceptance of the fact that there is not probably any one right way to proceed and criticising each other when individual approaches differ is likely to be counterproductive.
Tim
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Hi Richard,
We each have our own ideas about what will help to progress things. Are you saying that if I don’t come around to your way of thinking then I’m not “truly open minded” and not using my “critical thinking skills”? Hmmm. Doesn’t that seem like the very dogmatic medical attitude that we’re trying to change? I’m not sure that we’re going to change the situation by taking the same single-minded, authoritarian approach that seems to be so pervasive at the moment in mental health services.
Tim
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Thanks for sharing your story Elaine99. That’s a great example of what the possibilities are.
Tim
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Hi Alex,
Thanks for taking the time to reply. I’m sure there are lots of other myths that we have – sometimes without even being aware of it. An area I’ve done a lot of work in has to do with how much psychological therapy people need. There are lots of myths here about people needing 10 sessions to get better, or 12, or some other arbitrary number. The evidence is that most people only need a small number of sessions to get to where they want to be and a small number of people need many more. My approach has been to let patients tell me how many sessions they need rather than me telling them. It’s not a common approach though and one that is regarded unfavourably by some clinicians.
Tim
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That’s a great question Karma! The supply and demand perspective is an interesting angle because some psychotropic medications can be taken as a remedy for one type of distress while at the same time creating other sorts of problems that other drugs are needed for so the kind of have supply and demand all wrapped up in one neat little pill!
Tim
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It’s a good point Karma. I think we could all do a whole lot better with the language that we use. It’s also an area where we will all have difference standards about what is acceptable and appropriate. “Mental health”, for example, probably isn’t the greatest term in the world but I don’t find it hugely offensive. “Mental illness”, however, is a term I almost never use except if I’m referring to a specific context where that term is used. Aboriginal and Torres Strait Islander Australians prefer to use the term “social and emotional wellbeing” and that sits pretty comfortably with me.
For me, even having a forum where these sorts of ideas can be discussed is progress!
Tim
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Hi Richard,
It’s disappointing that you don’t find my article excellent because I didn’t put quotation marks around the terms “mental health”, “mental illness”, and “medication”. I didn’t do that because that the language that is used at the moment. I don’t ordinarily put quotation marks around all made up things I discuss like mermaids, unicorns, Major Depressive Disorder, Schizophrenia, lovesickness, heartbreak, and so on. I think I used the term “mental illness” twice in the article. Once it was actually used in quotation marks and on the second occasion I used it in this context “medical explanations of mental illness”. I didn’t use quotes here because, regardless of how erroneous we think it is, that’s what medical explanations are explanations of.
I also didn’t put quotation marks around “medication” because psychotropic medication is medication. It might be highly problematic medication but it’s still medication. I’m actually not anti-medication. I’m anti mis-information. I think the big problem is that many people are misinformed about the benefits and harms of psychotropic medication. I like to keep in mind, however, that some people take psychotropic medication and experience benefits from it and are happy to keep taking it. In my zeal to inform people about the mis-information surrounding psychotropic medication I don’t want to be disrespectful to these people who have just as much right to take psychotropic medication as other people should have not to take it.
When I’m discussing my own perspective on mental health problems I refer to them as “psychological distress” but when I’m referring to the context in which services are delivered I generally use the term “mental health problems”.
We’re definitely on the same page with wanting to raise the bar in terms of our scientific and political standards. In pursuit of these higher standards I do find it curious that you would withhold this otherwise “excellent” article because it doesn’t have as many quotation marks as you would prefer.
It’s these kinds of differences that make life so interesting.
Tim
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Thanks Nick. I’m really glad you liked the article. Yes, the whole area of the DSM and diagnostic categories is another hugely problematic area.
Tim
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Yes Boans, the consequences of believing in the chemical imbalance fable are much more serious and damaging than believing in Santa Claus.
Tim
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Hi Fiachra,
I agree. I think it’s very much the case that different approaches can help different people.
Thanks for your comment.
Tim
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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
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Hi Travailler-vous,
Thanks for explaining where you’re coming from.
Tim
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HI Travailler-vous,
You’re right, there are many questions that RCTs are not designed to answer and, of course, the other point you raise is that RCTs won’t help you identify the someone who is allergic to the mediction because RCTs aren’t interested in ‘someones’, they’re only interested in group averages. At best, an allergic reaction might get included in a count of adverse events but that would require that it was identified in the study and judged to be an effect of the medication. And, as you finish your comment with, there’s always the question of why a particular individual decides to take a particular drug. RCTs are silent on this matter as well.
Tim
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Hi Trvailler-vous,
Thanks for highlighting this. Yes, I think psychological distress is quite different from a physical cut or a broken bone. Most of our current emphasis seems to be on understanding and treating particular symptom patterns which are considered to be analogous to various physical maladies such as diabetes. My focus, however, is on the distress associated with any particular set of symptoms rather than the symptoms themselves. For any particular symptom or symptom pattern there are almost always people in the general population that experience similar things but are not bothered by them at all. From my perspective, it’s the botheration or distress that is the defining feature of what we now call mental health disorders and it’s this distress – closely associated with a person’s agency – that should be the focus of our research and treatment efforts.
Tim
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Hi Rick,
Thanks for coming in on this – you’re spot on with your comments. Even when RCTs are very good the direction of inference is from the sample to the population but, of course, this is exactly the opposite direction from the direction clinicians are interested in. Clinicians want to know who they can use the results of studies to inform their work with individuals. Unfortunately, statistical inference is currently silent on that topic although conducting studies like the ones you suggest would be a start. Of course, that still wouldn’t answer the questions that are relevant in routine clinical practice such as what’s happening for clients when they are on a gallimaufry of different drugs in different combinations.
Statistics are fantastic resources when they’re used appropriately but very blunt instruments when they’re being used for purposes for which they were not designed.
Tim
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Thanks Carina! I’m really glad you liked it.
Tim
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Thanks loads!
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Hi Jens,
Thanks for your comments. Alternatives are definitely needed. One of my favourite books was published way back in 1991. It’s called Casting Nets and Testing Specimens. It’s written by Phil Runkel. Phil puts forward the idea that our current reliance on statistics to answer basically all questions from a quantitative perspective is a problem. The “Casting Nets” part of the title refers to statistical approaches and Phil argues that, in order to understand how people function we need to complement statistical approaches with a “Testing Specimens” attitude as well. From this perspective, a model building approach is adopted based on understanding individuals and building up common principles from the establishment of functional, rigorous models. This is the approach used by Perceptual Control Theory (www.pctweb.org). One of the interesting results from conducting research this way is the discovery that we need a different model of causality when we consider living thngs. The independent variable – dependent variable (IV-DV) methodology is a limited way of understanding behaviour. Much like the holistic paradigm you suggest, we need a model of circular rather than linear causality in order to understand accurately how living things function.
Tim
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Hi 9,
The question you started with is brilliant!? That’s exactly the point isn’t it? Thanks for your insights.
Part of the problem with sleep disorders is that the term “sleep disorder” can cover a wide range of problems. Just like a cough can indicate very different underlying problems I expect the same thing is going on with sleep disorders. As you illustrate so clearly, it’s important to understand each person and the nature of their particular problem rather than making assumptions based on inaccurate theories.
Tim
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Thanks travailler-vous – I’m glad you liked the way it ended up.
Tim
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Hi Steve,
Yep, great point. Robert Whitaker has done a great job of highlighting these problems. As has David Healy. Not only do we focus almost exclusively on symptoms but we also investigate these symptoms using, mostly, self-report questionnaires.
We need a much greater focus on the effects our treatments have on the person’s life from the person’s perspective. Are they able to socialise more, or hold down a job, or build lasting relationships, and so on. Unfortunately, these things are hard to pin down and not necessarily changeable over the few months that most RCTs last.
Tim
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Thanks B. I’m really glad you liked it.
Tim
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Hi bpdtransformation,
Yes, exactly. That’s just the sort of thing I wanted my article to highlight. There are moves to change our reliance on the 0.05 benchmark but it’s a hard tradition to change.
Tim
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Hi Rhonda_B17,
Thanks for taking the time to comment. Experiences like the ones you describe are just the kinds of things I had in mind while I was writing the article.
I’m not sure whether there are some people who aren’t able to take the ‘clean’ option but, for me, the more important issue is how people come to be living the life they’re living. I think why people are taking drugs is perhaps more important than what they’re taking. If they’re informed and are voluntarily using some form of medication because they find it helpful then that seems pretty ideal. It’s a different scenario though when people are not fully informed and have inaccurate and incorrect information about the drugs and their effects or when they’re coerced into taking the medication.
Unfortunately there are still too many situations like the ones you’ve described.
Tim
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Hi Travailler,
Yes, I’d but Niall in that category. I’ve never worked with him but was fortunate enough to meet him once and we’ve exchanged emails a few times.
Tim
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Thanks for sharing that – what a bizarre story! I’m not sure why he thinks that would be an effective sales pitch!
Tim
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Hi Slaying,
Psychotropic medications can be dangerous and toxic and their harms have been explained by some brilliant authors. Robert Whitaker’s book is sensational. Some of my other favourite authors are David Healy, Joanna Moncrieff, Ben Goldacre, Peter Gotzsche, and, of course, Peter Breggin.
In my reply to Barrab I was picking up on the use of the word “really”. How do we “really” know? I’m not sure we do but I don’t think that means we can dismiss it either. I don’t really know that people are being helped by the conversations I have with them but I’m prepared to believe them when they tell me that they find them helpful or when they complete a questionnaire a particular way or when they tell me they’re socialising more or they’ve cut down on their cigarettes or they’re not as angry as they used to be.
Perhaps I’m naive but, by and large, I tend to believe what people tell me. I may be misreading things but from the words that you’ve typed it seems as though you’re implying that people can think they feel better but they’re not really feeling better. I’m not sure I understand that distinction. Sometimes, after a hectic day at work, I have a glass or two of wine at night at home and I feel a whole lot better. Now do I just think I feel better or do I actually feel better. I don’t know and I don’t really care! When I get a headache and I take a headache tablet I think I feel better and that’s good enough for me.
I guess the point of my article was just to say that it can be really tough to sort through problems psychologically and some people choose other ways of dealing with things. I think it’s their right to do so. People have to find their own way through the troubles that plague them. Sometimes I can help with that and sometimes other things are what they need at that time.
Tim
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Hi Slaying,
Yep, I agree. Individual situations and circumstances related to psychological distress are unique and they need to be explored and examined not categorised according to a diagnostic system. There’s a great paper by E. I. Fried and R. M. Nesse (2015) called “Depression is not a consistent syndrome: An investigation of unique symptom patterns in the STAR*D study” published in the Journal of Affective Disorders. They analysed the symptom profiles of 3703 people who met the diagnostic criteria for Major Depressive Disorder. Overall, they identified 1030 unique symptom profiles so even with something as well known as depression we can’t assume what we know is going on for someone.
I think you’re right too in that sometimes people can become more distressed as a result of treatment. It’s one of the reasons I think it’s important to let the person receiving the treatment be the best judge of how much treatment they need and how often they need it.
Tim
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Hi Slaying,
There’s good and bad in every profession I guess. I’m fortunate to have known and worked with some really great psychiatrists and some of the biggest critics of biomedical psychiatry are, in fact, psychiatrists. There’s a lot clinical psychology could do to tidy up its own backyard but, as you say, psychology is more benign than psychiatry so, even when we get it wrong, it probably doesn’t have the devastating consequences that it can have when psychiatry gets it wrong.
Tim
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Hi Slaying,
The love sickness metaphor isn’t central for me but it is a good way of emphasising the idea that psychological distress is fundamentally different to a physical illness. Sometimes the two can co-occur but they don’t have to. People can be physical unwell and not psychologically distressed and it can happen the other way around too.
I definitely take your point that what is offered as help is not always experienced that way by the “helpee”. One of my fundamental principles is that help can only be defined by the helpee and not the helper. If what I’m offering isn’t experienced as help by you then it isn’t help regardless of how good my intentions are. It’s not a very common idea but one that I think is hugely important. I’m glad you raised it.
Tim
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Hi Travailler-vous,
Yes, people do often confuse themselves in the conversations we have and the confusion can lead to new and helpful insights and perspectives.
I certainly take your point about how far we have yet to go on a societal level regarding our understanding of drugs and how the brain works. I get the sense that the tide is turning – and websites like Mad in America are a big part of that – but it’s a slow process at the moment and many people still experience the full brunt of a medical approach to psychological distress.
Tim
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Ah, OK. Got it. Thanks! Yep, I agree – assuming we know what someone is experiencing or what’s wrong with them is a sure-fire way of shutting down the exploration of how they’re travelling. Of course, it’s fine to assume when you get it right but many times we don’t get it right and the people you describe are good examples of that.
This is yet another problem with the area of psychiatric labels. As you point out, once someone has one of those labels, a lot of their experiences are interpreted from that perspective. I don’t subscribe to the DSM way of thinking about people’s problems so my approach is to listen and question without assuming. As people explain their situation in detail to me they’re explaining it to themselves as well and something very useful seems to happen when people say out loud the things that are bothering them and listen to what they’re describing.
Thanks for commenting and highlighting the point about the problems with assuming – it’s one of the big barriers to effective (and therapeutic) communication I think.
Tim
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Thanks Duane.
Tim
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Hi AA,
Where I work in remote Australia we are very limited in being able to refer on to specialists.
I guess we just have different perspectives on how to work with people experiencing psychological distress. The people I see are all accessing the public mental health service. When they come to see me I ask them questions about the things that are bothering them. Invariably, there are things that are bothering them of a psychological nature: they don’t know who they are; they were abused in their childhood; they can’t decide where their relationship is going; and so on. These are the things we focus on.
I guess if someone came in and wasn’t bothered or distressed about any psychological conflict or dilemma but had some unexplained pain or sleep problem we might explore options for how that could be investigated but, in my experience, people are pretty good at deciding for themselves what they need and who the best person is to see if they’re given the opportunity to express that. Where I am mental health problems still carry a lot of stigma so coming to see a psychologist isn’t something someone does lightly. I’m sure some people would much rather go to a sleep specialist and have their sleep sorted out than come to a psychologist to sort out their mind.
This is an important conversation and probably a good indication that we still have a long way to go before we can accurately pin down the nature of someone’s difficulties.
Tim
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Thanks heaps Alex. The healing journey you describe is very much what MOL tries to help people create. Getting to those meta levels seems to be a key in reorganizing all those problems that are being experienced. As you say, it’s hard work to get there but the benefits are worth the effort. Thanks for sharing your experience.
Tim
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Hi Alex,
You raise a really important point. Words can be used very differently depending on the intent of the person using the word. I agree, “resistance” could be used neutrally, however, I have often seen it used in a pejorative sense in that the client was somehow rejecting the help that was offered. For me, it all gets back to considering the perspective of the person we’re working with.
Tim
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Hi Steve,
No trouble at all. I read a great quote once (can’t remember the source) that said something like “there’s no such thing as a resistant client, just an inflexible therapist”. That’s always stuck with me.
Tim
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Hi Steve,
Thanks for your comments. Yes, I definitely agree that physiological problems should be ruled out first. I’m not medically trained though so I rely on my medical colleagues to do that and I assume that if they’re referring a person to me it’s because the physiological aspects have been sorted. Definitely scope of practice can be a real barrier to progress for both the practitioner (from an ethical point of view) and the person accessing the service.
Tim
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Hi again Travailler-vous,
The reason I mention “parts” is because that is how many people I work with describe their experiences … “one part of me wants to move on but another part of me wants to sort it out with him” … one part of me has a thirst for life but another part of me has a desire for oblivion … and so on.
Tim
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Thanks Duane. It’s interesting reading. I’m not exactly sure of the relevance to my article but it was engaging to read about just the same.
Tim
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Hi Duane,
I wouldn’t be so grand as to represent my profession here. These are just my thoughts I’m expressing. Nevertheless, I think you raise a great point that some medical conditions do have psychological effects associated with them. I’m fortunate in where I work that I get referrals mainly from psychiatrists so I assume that physical anomalies have already been checked out.
I really take your point about the dangers of assuming. The therapy I use (Method of Levels; http://www.methodoflevels.com.au) is based on the idea of assuming as little as possible and building a therapy around the cornerstone of “curious questioning”.
Tim
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Hi Alex,
I’m really glad the article resonated with you. I love the term “radically self-responsible”. How amazing would the world be if radical self-responsibility was the norm?! I think the ideas of cause and effect are important to keep in mind. The particular story of behavior that I like (Perceptual Control Theory; http://www.pctweb.org) talks about the concept of circular causality rather than linear causality being more appropriate for living things. It’s a very cool idea.
Tim
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Hi Ron,
Thanks loads for your comments. Yes, I’m sure my doctor could give me something (probably two of them) to help me cope! 😉 Have you seen the Despondex ad on youtube (https://www.youtube.com/watch?v=jd4tugPM83c)? The headline is “FDA Approves Depressant Drug for the Annoyingly Cheerful”. It’s terrific.
Tim
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Hi barrab,
How do I “really” know that medication helps some people some of the time. I guess I don’t “really” know that. I only know what the people with whom I work tell me and some of those people tell me that the medication has helped them. You can’t see any point in taking an antidepressant and, from my perspective, I feel the same way. Some people, however, do see a point and some people say that it helps them. It’s not the course of action I would choose but I think I need to respect that as a therapist. That’s all I was trying to communicate.
Tim
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Hi Someone Else,
Just picking up on your last point … I’m not sure “schizophrenia” is a “thing” that is caused by child abuse or any other event or happening. Once we start moving beyond the label of “schizophrenia” we might get close to understanding how people arrive in the severely distressed states they end up in .
Tim
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Hi Travailler-vous,
Yes, you’re absolutely right. My inspiration for the love-sickness metaphor was indeed Thomas Szasz from The Myth of Mental Illness. And, yep, I pretty much agree with the other things you’ve pointed out … I didn’t mean to communicate that it was OK to label and deceive people about the benefits of medication and I agree that medical problems can start after, rather than before, the person has taken the psychotropic medication.
Tim
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Hmmm. I’m not sure that calling clinical psychology a pseudo science is a “fact” but, nevertheless, I wasn’t offended.
Tim
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Hi Slaying,
Wow! Out of my whole article you chose to focus on the love sickness metaphor. That must have really meant alot to you. I used the word “relief” rather than “spell binding” because that’s how some of the people I work with describe it. I’m sure people experiencing psychological distress didn’t come up with the “mental illness” term themselves but I’ve never heard them come up with the “spell binding” term either!
I really didn’t mean love-sickness to be a central part of the article but I do think the agency that you mention is fundamental to living lives of value (valued from an individual perspective that is!).
Tim
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Thanks Sa. I’m really glad it hit the mark for you. I think carers and family members often have the toughest job of all!
Tim
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Hi Jonathon,
Yes, I agree. Feeling better is often the key. And the paradox of that is that medication can help people feel better initially (well, after the two to three weeks that they start to have some effect) whereas psychological therapies can be unsettling initially. People I see can have quite a torrid time in sessions but end up feeling better afterwards. That’s where I think the trade-off between long term and short term feeling better can be important.
Tim
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Hi B,
I think you’re really ‘on the money’ with these comments. Conflict goes by different names – ‘dissonance’ is one of them, ‘ambivalence’ might be another. Even concepts such as ‘willpower’ and ‘self-control’ are really issues of conflict I think. I’ve written about self-control as conflict in my Psychology Today blog. You can read it here: http://www.psychologytoday.com/blog/in-control/201412/the-difficulty-self-control-is-conflict
One of the things I like about the ‘distress as conflict’ idea is that it doesn’t mean anyone is sick or broken or disordered. They’re just chronically conflicted. Conflict is very common. Essentially, every choice situation is a conflict so, clearly, we’re ordinarily very good at resolving internal conflicts. As you say, sometimes people don’t even resolve conflicted ideas; they just keep them in mind and focus on one rather than the other.
At times, however, conflict can become chronic and distressing. Helping people explore and understand conflict can be very useful in enabling people to function as they would like in a world that is, often, as you put it, “in-understandable”.
Warm regards,
Tim
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Hi Boans,
You’ve highlighted the slipperiness of the slope upon which “involuntary treatment” sits. Part of my motivation in writing this article was to encourage a shift away from an “I know what’s best for you” attitude and towards an understanding of people as active, purposeful creatures who have their own ideas, dreams, and hopes about the sort of life they’d like to live.
If we thought of “treatment” as a resource people could use to make their lives be more like the way they want them to be, then, from this perspective, it would be very hard to even construe what “involuntary treatment” might be.
I’ve had a terrific Christmas and New Year. I hope yours has been to your liking!
Tim
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Hi Daniel,
Thanks for adding to the discussion. I’m really glad you liked the article.
I think the safety of people is important. Personally, I like the idea of living in a society where those individuals who want to hurt people are humanely and compassionately prevented from doing so. I also think, however, that it would be useful to distinguish between measures taken to prevent people causing harm and “treatment”. It seems to me that there would be fairly widespread agreement in averting harm to people but what should happen to the harmer once the harm has been averted is less than straightforward. In the spirit of the article that started this discussion, even when people seem like they might cause harm I still think it is important to seek to appreciate their perspective and world view when deciding what to do next.
It’s puzzling to me that we’re continuing to discuss and deliver involuntary treatment in the 21st century. I’m not even sure that involuntary treatment is possible with psychological and social treatments. We can force people to turn up to therapy but we can’t make them engage or process the information. In this sense “involuntary treatment” is something of an oxymoron. Some years back I ran an anger management program and a substance abuse program in a prison where the prisoners received favourable reports for attending and participating in the groups. My strong feeling at the time was that the prisoners got very little out of the group in terms of helping them to think differently about their lives – even though they ended up with a positive report at the end of the group.
The situation with psychiatric and medical treatments is a little different because people can be administered treatments like medication and ECT against their will. Even though it is possible to provide treatments this way, I’m not aware of any compelling rationale or convincing evidence for actually providing treatments in this way. In fact, given that the harms of medication are often minimised and the benefits exaggerated, I think there are some very good reasons to argue against involuntary treatment even when it is possible.
There are broader issues as well to consider such as what it is that we are treating when we provide treatment involuntarily.
If safety is threatened then I think the threat to safety should be addressed but, once safety has been restored, any treatment that follows should be guided by the perspective of the patient.
Do these ideas speak to some of the things you were wondering about?
Tim
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Hi madincanada,
Thanks for taking the time to let me know how this landed for you. I’m really glad it struck a chord with you. I think we really underestimate just how pervasive internal conflict is and how distressing it can be.
Tim
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Hi Boans,
Thanks for your comments. It’s amazing how the internet works isn’t it?
Yes, I’m a big fan of Joanna Moncrieff’s work. Her book, The Myth of the Chemical Cure, is terrific.
I very much subscribe to her reasoning including the way in which she thinks psychiatric drugs should be used in clinical practice.
Tim
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Hi Travailler-vous,
I hope you find the information helpful. For me, learning from and about PCT has been a revelation. PCT shifts the focus away from behavior as it is observed by external onlookers to behavior as it is experienced by the behaving entity. It really does offer a new perspective on many things and suggests some possible reasons for why we are not making the progress we could be making.
I found that it does take some effort and more than a little grappling with concepts to really understand PCT but the effort has been well and truly worth it in both my professional and personal life.
Tim
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Hi again Travailler-Vous,
I think it would help to talk alot more about the importance of our perceptions in our ongoing daily conduct. It’s one of the reasons that I’m so interested in Perceptual Control Theory (www.pctweb.org) – it places perceptions as central in understanding behaviour.
I think we could learn a lot from the people experiencing the problems but that would first mean having to accept that we don’t know what they’re going through.
Tim
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Hi Frank,
So you prefer “patient liberation” and I prefer “patient-perspective”. Seems like a great example of why considering the point of view of the individual is so important 🙂
Tim
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Hi Travailler-Vous,
Thanks for taking the time to post your thoughts. I agree that, in many ways, things are as bad as ever with the possible exception that there are now forums like this to give a voice to people who would otherwise be silent (or should that be “silenced”) as well as a venue for interesting and lively discussion.
Tim
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Thanks Duane. It’s an amazing group and a privilege to be a part of it.
Tim
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thanks B!
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Hi Boans,
I think there are probably a few reasons for the patient-perspective approach not taking off more widely. One is the view expressed so eloquently (and incorrectly) by my colleague who didn’t think depressed and anxious people were able to make choices. We have all sorts of “legitimate” ways of disregarding the patient’s perspective – lack of insight is one of them. I’ve often wondered why it is always the patient who lacks insight when the patient and the clinician disagree over an interpretation of the patient’s problem. Could it not also be the case that the clinician lacks insight into the patient’s problem? That possibility never seems to be on the table for consideration.
A second reason for resistance to the idea is that, if the patient’s perspective was adopted, then patients would not always make the decisions that the clinicians think they should make. I think many clinicians have some idea of the “right” sort of life the patient should be living and, if the patient’s views were taken as the guide, the patient might not go down the path the clinician thinks they should go down.
In many cases it seems that clinicians judge patients to be “getting better” the more that they agree with the clinician and the more that they behave as the clinician thinks they should behave.
In terms of where the patient-perspective would apply, I guess I haven’t thought of applying it in particular areas, I’ve thought of replacing the current system with it. You’re right, it certainly wouldn’t apply to forced psychiatry. In fact, it’s the antithesis of forced psychiatry. We would have to figure out a different way of dealing with risk in a patient-perspective approach. From the little bit I know of the Open Dialogue approach in Finland it seems to be very much aligned with a patient-perspective approach.
Cost is certainly a consideration in overhauling any system but some of my work indicates that it may actually cost less than the current system. When we moved to a patient-led appointment booking system, for example, we increased service capacity and reduced waiting times with no additional staff or extra resources. The only change we made was the way appointments were booked for treatment.
There would no doubt be problems with the system but I don’t think there’d be any problems that were insurmountable or that are as bad as some of the problems with the current system. I’ve also found that there are many benefits. I have the feeling that there are lots more benefits that haven’t even been realised yet.
I think the clinician-perspective approach has had a decent run – I’d like us to give the patient-perspective approach for a while to see where that takes us.
Tim
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Hi Boans,
I’m not sure I follow your logic about being able to tell whether people are making a choice or being forced but I guess from a patient-perspective stance that’s not such a big problem. For me the crucial issue is “from whose perspective is treatment being devised and delivered?”. Alot of problems would be taken care of if the patient’s perspective was the bottom line in mental health service delivery.
Tim
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Hi Boans,
I definitely agree that there are many ways to resist oppression and your post provides a nice example of the importance of the patient-perspective. The fact that you agree with Frank should be noted as well as the fact that there will be people who prefer a different path. Suggesting that there is one right way to resist or one right way to get out of hospital is a bit like mental health professionals suggesting there is one right way to think about and treat psychological distress.
We need to find ways (in my opinion) of understanding, acknowledging, and accommodating different preferences and opinions without attempting to persuade people to come around to our way of thinking.
Even with my passion for the patient-perspective approach I’m very aware that this won’t be everyone’s cup of tea. I’ll do what I can to explain the approach as best I can and I really enjoy discussing it with people who are interested but I’m not inclined to spend time persuading people that they should subscribe to this way of thinking. People need to, and will, find their own way.
Tim
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Yes, that seems to be the way it plays out doesn’t it? People in positions of authority often seem to be more concerned with preserving the status quo than questioning it.
Tim
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Hi Frank,
Unfortunately, I don’t know Chief Bromden either! Clearly my reading isn’t as broad as it could be. The point from the patient-perspective approach though is that the idea that “you do whatever you can to get out of hospital” can only be individually determined. One person’s preferred means of getting out of hospital will be different from another’s. Even the desire to get out of hospital will be different for different people.
The lesson that resistance gets you more rather than less severe treatment will, similarly, have different meanings for different people. Some people are prepared to go to extraordinary lengths to preserve their sense of autonomy. That’s a decision that can only be made by individuals. At least, that’s the idea from the patient-perspective approach.
Tim
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Hi B,
Yes, I think a one-sided establishment and imposition of rules is bound to invite resistance and push-back from the people who the rules are supposed to contain.
Tim
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Hi Frank,
I don’t know about McMurphy or Branson but I think you provide a really useful insight into the importance of the patient-perspective approach. To you, resistance is fool-hard and you found another way to navigate through the mental hospital system. To others, however, resistance is important. The patient-perspective approach accommodates both points of view.
Tim
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Hi B,
I think there are often very good reasons for a person’s oppositional stance. I think it was why I liked working as a behaviour management teacher so much. Many of the kids I worked with had drive and energy and a different way of seeing things that could be really useful. The questioned the status quo and weren’t prepared to go along with things “just because”. Those sort of people can be really helpful in any organisation.
Tim
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Yes B, something fundamental is wrong with a system when a child has to receive a psychiatric label in order to access support.
Tim
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Hi B,
In relation to my countercontrol thesis, I’m not sure how to go about linking to my thesis but I had three papers published from the work that I did:
1. Carey, T. A., & Bourbon, W. T. (2004). Countercontrol: A new look at some old problems. Intervention in School and Clinic, 40(1), 3-9.
2. Carey, T. A., & Bourbon, W. T. (2005). Countercontrol: What do the children say? School Psychology International, 26(5), 595-615.
3. Carey, T. A., & Bourbon, W. T. (2006). Is countercontrol the key to understanding chronic behaviour problems? Intervention in School and Clinic, 42(1), 5-13.
Also, my book “Control in the Classroom: An adventure in learning and achievement” explores the idea of students as controllers and how this can be facilitated and supported in the classroom.
Tim
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Thanks B. Yes, regardless of the rationale that’s offered it would be extremely difficult to support the idea that the patient was being helped if a “patient-perspective” view of help was adopted. As you say, other people might be helped but not the person experiencing the help. Or, if they are, it’s a lucky coincidence and says more about their resilience, resolve, and ingenuity than it does about the treatment forced upon them.
Tim
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Hi B,
Yes, “patronising” was one of the words I thought of when this view was expressed to me. This was from an experienced psychologist in a senior position. It blew me away.
Tim
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Hi Boans,
Yes, you make a good point. I’m not sure how far the comparisons between schools and mental health units can be stretched. There may be some countercontrol going on in mental health but there are likely to be some important and serious overriding factors as well such as the coercive and arbitrary conditions that can exist in mental health units.
I would be very surprised if patients weren’t frustrated in the conditions you describe. I think anyone would be frustrated under those circumstances. I’m a fan of fewer rather than more rules and I think the rules need to make sense, be applied consistently, and have some general function of enhancing the activity of whatever context they’re being applied to. Unfortunately, alot of rules seem to be invented sporadically and spontaneously for the convenience of the rule maker. And, as you say, often the creation of a rule can lead to other problems.
Perhaps some clarity around rules would arrive with the adoption of a patient-perspective approach. If we were to constantly ask ourselves “What does this person need, from their perspective, to live the life they want to live?” and to act on that we might actually need far fewer rules.
Tim
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Hi Steve,
I”m glad you like the idea!! It’s a favourite one of mine too. Ironically, the topic was first mentioned by B.F. Skinner in his book Science and Human Behavior published in 1953. When I first learned about it I was a behaviour management teacher and, despite all the training I had been to about behaviour management techniques no-one had ever mentioned that countercontrol might be one of the consequences.
I did have a few papers I published from my thesis. How should I get them to you?
I think potentially, this is a really important area. If countercontrol is going on at all, then for those kids who countercontrol, most school interventions simply give them more opportunities to countercontrol rather than helping them learn different ways of interacting.
I definitely think it has important implications for many of the students we currently label with DSM diagnoses such as ADHD, Conduct Disorder, Oppositional Defiant Disorder, and so on.
All of my work centres around the idea of individuals – kids included – being intentional, goal-directed creatures. My book “Control in the Classroom” actually takes up this idea and looks at curriculum delivery from the perspective of students have goals, intentions, desires, and so on.
Thanks for making contact.
Tim
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In reply to Boans …
Hi Boans,
Yes, countercontrol was (is?) fascinating. Like you, I’m one of those people who would not take the option of handing over control to their GP. I remember having an intriguing conversation with some friends in Scotland while I was living over there. We were talking generally about health care, visiting GPs and so on, and something came up about responsibility for health care. I asked who they saw as being responsible for their own personal health care and they said “my GP”. I was stunned. Then they asked me “Who do you think is responsible for your health care?” and I said “Me of course!”. I’d never thought about the idea that someone else could be responsible for my personal health care so the idea fascinated me. These people were health care professionals as well so it was a really amazing conversation.
The countercontrol study I did involved going into schools and asking 10 to 12 year olds what they did when their teachers asked them or told them to do things. In the main study I surveyed about 830 students and their teachers. I went into different schools – big schools, little schools, city schools, country schools, co-ed schools, and single sex schools. Across all the classes about 10% of students in each class reported countercontrolling frequently. I asked students what they did and how they did it. Students said they could make their teachers yell, scream, get mad, run out of the room, and so on. And they said they did this by walking around, calling out, not doing what they were asked.
One student said they could get their teacher to “give me one more chance” and they did that by using “my sweet innocent voice”! It was really amazing stuff. The results fitted so well with what teachers thought was going on but it was the first time this had been investigated systematically.
Interestingly there was some prosocial stuff as well – students said they could get their teachers to give them free time or help them with their work by doing things like putting their hand up, asking questions, and so on.
I’m not sure of the extent to which countercontrol might apply in the mental health field. Where it’s possible to just leave I guess there might not be a need for countercontrol but it might be part of the dynamics in situations where psychiatrists won’t let the patient leave.
Tim
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Hi Barrab,
I’m not really sure how you come to the conclusion that “patient-perspective care” is a shambolic term because we currently have the situation where some clients in some situations can’t “pull the plug”. It’s precisely because situations like clients not being able to control their own access to treatment exists that I’m advocating for patient-perspective care.
I’m also not sure what “common sense” is or how its helpful to people and I don’t see my role as the dispenser of common sense. I think, again, perspective is very important when things like “common sense” are being discussed. What is common sense to one is not common sense to all.
I’m also not sure what would motivate you to wish me luck in “helping people “reach their potential”” although I agree with you that that statement has a ring of arrogance about it. Perhaps you got that idea from this statement that I made in a reply to another post: “People have the right not to live up to their potential just as much as they have the right to push themselves and find out what their potential might be.” You’ll notice here that I don’t say that I consider my role to be helping people live up to their potential. I was using this as an example because it’s a common way of speaking about the way people live their lives. It’s not something I base my practices on. In fact it’s not something I even think about. People’s “potential” – whatever that is – is very much their own business from my point of view.
Thanks for giving me the opportunity to further clarify some of my thinking in this area.
Tim
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Hi Boans,
No need for “I told you so” in this conversation … the dynamics around the patient and clinician relationship are fascinating and the nuances to the control in these situations can also be intriguing.
My PhD research was on a topic called countercontrol which refers to what people who are being controlled might do to the controllers. I haven’t ever investigated it in the mental health field but I’d be surprised if it wasn’t occurring.
For me I think we could do a lot better at clarifying what our role as a mental health clinician should be. My idea is that I’m a resource people can use to explore ways of making their lives be more like they want them to be in much the same way that a mechanic is a resource people can access when they want their car to run more like they want it to.
Thanks again for your thoughts.
Tim
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Hi Barrab,
Sometimes harsh situations call for harsh statements! I agree that the system isn’t conducive to client control and in situations where the client can cease seeking the services then the harm may be minimised. There are some situations, though, where ceasing to access the services is problematic and people can be involuntarily detained if they try.
If clinicians were approaching service delivery from a patient-perspective then that might even help with the “clinically relevant” material that is being documented since what is clinically relevant would be judged in terms of the patient’s perspective as well.
Thanks for your further comments.
Tim
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Hi Barrab,
People see clinical psychologists and other psychologists for all sorts of different reasons in Australia. The people I see in my clinical practice in Alice Springs come along for different reasons but, if I was to sum it up, I’d say people come along to see me because their life isn’t going the way they want it to.
I didn’t intend to draw a distinction here between psychiatry and clinical psychology. In fact, in the article I wrote above, where I referred to colleagues who opposed the patient-led style of appointment scheduling, they were clinical psychologists. On the other hand, psychiatrists who refer to my service at the moment in the public mental health service in Alice Springs are supportive of it.
I’m not sure what your experience of psychologists has been but I work very hard not to pressure people to do anything. I’m fairly sure most people I see don’t feel that I’m treating them like trash and, because my clinic is in the public mental health service people don’t pay for appointments. I’ll also don’t use diagnostic labels with people. I’m not saying people don’t come to me with labels but I focus on helping them with their problems of living. My work is outlined in quite a bit of detail in my books about the Method of Levels.
I’m sorry you’ve had such an unpleasant experience.
Tim
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Thanks for your insights Someone Else. I’d very much like to see forced psychiatry changed. It’s a bit of a sad comment that a conversation such as this is still so relevant and important in the 21st Century but, like you, I think we often use the word “care” in a very strange way in mental health.
I would argue that the recipient of the intervention is the only person who can judge whether or not what they’re receiving is “care”.
In Daniel Mackler’s documentary “Coming off Psych Drugs: A meeting of the minds” (https://www.youtube.com/watch?v=Q5EpnVdLvkU) one of the participants made the point that we should do away with the concept of “shared decision making” between patient and therapist and should instead be promoting “supported decision making” of the patient by the therapist. That’s very much in line with how I imagine a patient-perspective mental health field would be operating.
Tim
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Hi Boans,
Thanks for your support. I love your example of the mechanic. That’s exactly the way I feel about it. Just as the mechanic can advise you what’s possible but the final decision about what you get done to your car is up to you, I think mental health professionals can advise people about what they think might be possible but the final decision of the path to be taken must be left up to the patient.
People have the right not to live up to their potential just as much as they have the right to push themselves and find out what their potential might be.
I also agree that patient-perspective care is impossible in a context of forced psychiatry.
Tim
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Hi Jan,
Thanks for your perspective. I agree. I think forced anything is likely to be counterproductive. I think sometimes, though, forced psychiatry is justified by claiming to be in the patient’s “best interests”. I don’t go along with that rationale but I thought if we adopted a stance of “patient perspective care” then what was or wasn’t in the patient’s best interests might be a lot clearer.
Tim
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Hi Rachel,
Thanks for your article. It’s really useful to have the history of the DSM reliability drama described like this. I’m a big fan of the work of Kirk and Kutchins.
Unfortunately, I think it’s easy to get beguiled by all of the reliability statistics and the judgements about whether they are “good”, “acceptable”, or some other term denoting an apparent standard. I’m not meaning to imply that you have been beguiled – the clarity of your writing would certainly argue against that – I think, for me, there is a broader conceptual issue that is fundamental to the reliability issue. I’ve written about this on another website (http://dxsummit.org/archives/608) where I talk about the “red herring of reliability”.
Even if the developers of the DSM could achieve perfect reliability for all of their diagnostic categories it would still be the wrong way to understand psychological distress and problems of living. In fact, in some respects, it’s trivially simple to achieve good reliability. With nothing than a date of birth and a few minutes of training, “diagnosers” could routinely achieve perfect reliability in assigning people to various star signs (Sagittarius, Gemini, and so on). The impressive reliability in this case does not add legitimacy to the system of horoscopes as a way of understanding human functioning.
While in principle I agree with your statement that “The basic idea behind reliability tests is that the diagnosis that a patient receives should depend on their symptoms, rather than on who does the diagnosing.” this doesn’t apply to diagnosis in psychiatry. Because there is no independent means for determining if someone has “really” “got” Borderline Personality Disorder or Generalised Anxiety Disorder the only thing that DSM reliability tells us is how much two people agree on the presence of certain symptom categories. What we learn from DSM reliability is the extent to which two independent raters can see the same disorder in a set of symptoms – and, apparently, the extent is “not great”! What DSM reliability does not tell us is whether or not a DSM disorder is “really” present. DSM reliability can’t tell us that because DSM disorders are never “really” present or absent – they are just assigned and either believed or refuted.
The DSM system is simply the wrong way to understand psychological problems of human functioning and no amount of attention to Kappas or field trials will correct that. We need to be devoting our best scientific efforts to something other than the improvement of DSM reliability.
Tim
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Hi Kjetil,
Thanks for this post. Like you, I’m a very optimistic therapist who never loses faith in the abilities of people to make important and sometimes dramatic changes in their lives. I trained in NLP in the ’90s and while it’s not an explicit part of the transdiagnostic cognitive therapy (Method of Levels; see https://www.youtube.com/watch?v=LQLnOHoko7U) I have developed, many of the questioning techniques have their basis in the NLP methods of investigating thought patterns and processes.
Again, like you, I don’t see any reason why people can’t make lasting changes quickly. I’ve found in my clinical practice that people just take different amounts of time to change – some people change quickly and some people take more time. There’s no reason to believe, however, that quick changes are somehow inferior or more superficial than slower change. Often debilitating psychological distress can arise very quickly, sometimes after just one unfortunate event, so I don’t see any reason why it can’t disappear just as quickly.
For me, being able to provide therapy is a tremendous privilege and I’m constantly in awe of people’s capacity to make new sense for themselves from a position sometimes of great distress.
Thanks for your article. It’s great to read about someone who seems to have similar experiences to me with regard to therapy.
Tim
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Hi Michael,
Thanks enormously for posting this article. I find historical perspectives to be extremely valuable in understanding where and why we are today and so I appreciate your contribution in that regard. I’ve read some of Kurt Danziger’s books about the historical development of concepts in psychology and they were just as illuminating as your article.
Your ideas were so interesting I read some paragraphs a few times just to let your suggestions roll around in my mind. I’ve been a fan of Szasz’s for a long time so I really appreciate the perspective you’re offering in your post. I was intrigued that Epicurean philosophy could accommodate the idea of a spirit but not as a God-given entity. I’ll need to mull that one over for a while. It’s counter-intuitive but appealing and provocative all at the same time.
Your article has helped me think about my own work and the work of the movement generally that is working towards a different understanding of mental health and its treatment and the extent to which it’s important to think about how messages are received by others. I can understand why the idea of personal responsibility might not be a tune that all would want to hum along to but it’s there nevertheless.
Thanks again,
Tim
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Hi B,
I wish it was different but, unfortunately, there seem to be a lot of psychologists who are just as wedded to the medical model of mental health as psychiatrists. Interestingly some of the strongest opposition I’ve had to my patient-led model of treatment delivery has come from psychologists and yet some of the psychiatrists I currently work with a supportive of it. We also have some strong champions for mental health reform as demonstrated by Peter Kinderman’s recent post but we could definitely do better.
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Hi Oldhead,
I’m not sure what you mean by “class analysis” and I’m not sure specifically which insights you’re referring to. If you’re asking whether I think social class is important in understanding individuals then the answer is “yes”. Some of the other comments in which I mentioned the importance of context and individual’s perspectives speak to this point.
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Yes definitely. A person who has been both a mental health professional and a person accessing mental health services will have a very different perspective. It will probably be different too if they became a mental health professional after they had accessed mental health services or if they accessed mental health services while they were a mental health professional. People’s perspectives based on their individual experiences will always be different. For me, that’s why it’s so important to make the perspective of the individual seeking assistance the perspective to be guided by. If I could change one thing about the mental health field that would be it. That’s why I called my approach to organising services “patient-led treatment”. I think mental health services might be both more effective and more efficient if the people accessing the service rather than the people providing it did more of the leading. Yep, hope is important. In many ways there’s not a lot of it out there but there is a little bit and that’s a start.
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Hi Uprising,
You’re right – I probably didn’t need to insert the word “inappropriate” in that sentence. I also agree that a mental health professional’s perspective is bound to be different from the perspective of a mental health patient although it would be a mistake to assume that a mental health professional has never been a mental health patient and so can’t have both perspectives. I’m aware that there have been lots of injustices and acts of inhumanity perpetrated by psychiatry and that definitely requires changing. Only very recently, however, I was working with a person with a long history of contact with the mental health service and very serious problems who was telling me how good his psychiatrist was. According to this person the psychiatrist listened to him, took his concerns seriously, and was working with him to taper him off some of his medication. This is only one small case but it provides me with a glimmer of encouragement that things are changing. Sometimes mental health professionals need hope just as much as other people. 🙂
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Hi B,
Yes, I think psychiatry as a field is at a disadvantage because of the whole “mental illness just like a medical illness” charade. Mind you, I know some psychologists who have just as much allegiance to the DSM as do many psychiatrists. Training in this model must make it ultra hard to take that step back in order to consider things in a different light. Some do however. Admittedly the numbers of psychiatrists who consider things other than medical explanations are probably small but there’s definitely a change in the air and some psychiatrists are making that change happen.
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I think the ability to live life according to your own, rather than someone else’s, design is important regardless of which country you’re living in or which culture you’ve been raised in. I’d go so far as to say that we’re designed to be autonomous, self-regulating creatures. That’s the reason I think having our autonomy restricted can be so painful.
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That’s a shame. That hasn’t been my experience. I’ve worked in both the UK and Australia and have found that in psychiatry, just like in any other profession, there are highly effective practitioners and others who are not so effective. Some of the loudest voices advocating for mental health reform are, in fact, psychiatrists. Perhaps it’s because of the power the psychiatry profession is afforded that the effects on people’s lives can be so devastating when psychiatrists are ineffective. Other mental health professionals who don’t listen to the people with whom they’re working, who don’t attempt to consider the situation from the other person’s perspective, and who make assumptions about what would be best for the other person can also cause harm. Many other mental health professionals, however, can’t detain people against their will, can’t prescribe medication or ECT, and can’t force people to be treated involuntarily. When these things are used inappropriately by psychiatrists the harm is likely to be much greater.
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I’m not sure why the pastors would have said that. In any profession there are those who are effective and those who are not so effective. I’m fortunate to work with some excellent psychiatrists.
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I had a read through your “communication breakdown” forum Boans. It sounds like you’ve had a really rough time of it. I hope things are picking up for you now. I know there are potential problems with any system but I can’t help thinking that our current allegiance to an “illness” model of psychological distress is a big stumbling block in the path of progress.
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Part of the problem for me is the “lens” of mental illness that we often have before us in the mental health field when we’re considering the conduct of another person. To step away from that lens and to seek to understand the person, their aspirations, and the environmental contexts they are operating within would move us a long way towards helping people live the sort of lives they would want for themselves.
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Context for me is always crucial. Understanding behaviour requires understanding the environmental context in which the behaviour occurs. Different behaviours can be used to achieve the same goal and the same behaviours can be used to achieve different goals depending on the environmental circumstances.
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G’day!
The problem of behaviour as we currently understand it is most definitely dependent on the eye of the beholder. My preferred way of thinking about behaviour is based on Perceptual Control Theory which explains behaviour from an inside looking out perspective.
There can be some consistency across therapists with regard to diagnoses depending on different facts such as the particular diagnosis being considered. As you point out, the environmental context will also be important. For me, though, consistency is not such an important issue. It’s quite easy to get consistency or agreement between people about various things. Based on nothing more than a date of birth, for example, it would be easy to get quite robust consistency across people with regard to the particular star sign that various people should assigned. It would also be possible to have people consistently identify Santa Claus, the Tooth Fairy, and Mickey Mouse from a line up. Consistency is useful in some context but it’s a red herring when it comes to establishing the legitimacy of a construct. The degree to which a particular mental health disorder diagnostic label is consistently identified should not be taken as evidence that the disorder either does or does not “really” exist.
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Anonymity can be an important part of the therapeutic process. Sometimes internet resources can provide this but it’s also possible to achieve in a face-to-face session. Some of the people I work with, for example, tell me that they like the fact they can say anything to me because I’m not in “their world”.
I think you’re right that there are many good and useful parts to both sorts of relationships and keeping a balance is likely to be a key factor. And what is balanced for one person might not be so balanced for another.
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This is a good example of why options are so important. Different things are useful for different people and different things are even useful for the same people at different times. And for me some of the most important options are informational: learning that there are ways to think about problems of living other than “mental health disorders” and learning that there are ways of helping other than chemical.
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Thanks Ted. It’s an important question. There’s certainly a growing number of articles and authors pointing out different problems and different perspectives about the current state of play in the mental health arena. I kind of think that’s a good thing. Lots of different ways of saying similar things has the potential to be helpful to lots of different people. I’d like to think articles such as these help inform people of options so that they are in a better position to make decisions. I also think that the more articles that are produced by a range of people of varying backgrounds, educations, and experiences will help to demonstrate that the tide really is changing with regard to the way we conceptualise and treat mental health problems. It’s changing slowly but it’s definitely changing. A few years ago there wouldn’t have been a forum to even discuss ideas like this. That MIA and other sites like it exist is a very good thing.
So how does publishing articles like these help to end some of the less desirable practices of psychiatry. I’m not sure. I work with people who think they’ve “got” one or more of the DSM disorders among other things. If articles like these can help them question what they’re being told and maybe seek a different story I think we might begin to see the end you’re asking about.
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Thanks for your perspective. It’s true that a lack of community can exist in the world of interactions as well as the world of e-interactions. The web is a wonderful resource and I wouldn’t like to be without it. At times, though, the possibilities on the web (such as online therapies) are offered as alternatives to talking therapy rather than as additional resources and I think that’s a shame. it shouldn’t be a case of “either/or” but “this and that” depending on the person, the problem, and the circumstances.
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Hi B,
I agree – it’s very important for people to know what to expect. I don’t know what the situation is like in the US but in Australia one of the standards of the Code of Ethics for psychologists is informed consent. The Code specifies that psychologists should inform people about what to expect including things like how appointments can be made, how long treatment will last, and even that they have the right to withdraw from treatment. I think it’s important to routinely check in with people I’m working with about how they’re experiencing the service. I use the Session Rating Scale at the end of every session which provides people with an opportunity to give me feedback about the session and it enables us to have a conversation about how they think things are going.
You’re right too that finishing therapy after a long period of time can be problematic. That’s why I like what I call the “patient-led” approach so much. From the very beginning the person accessing the service is the one who controls how many sessions they have and how often they have them so they get to regulate their own exit from the service.
I agree too that it works for some people but it’s not for everyone and it’s certainly the case that, at times, when used poorly or misapplied, it can cause harm. The potential to exacerbate problems rather than alleviate them is something that should always be taken seriously.
Thanks for your perspective.
Tim
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Hi there,
You’re right that talking therapies are not for everyone but many people do find tremendous value in talking to someone outside their usual relationships. Ironically, some people I work with tell me that it’s precisely because they don’t know me that they can visit and talk about those dark places that they are reluctant to share with people they are close to. Again, that’s not the case for everyone but it’s certainly some people’s experience. My job description does not require that I do not care about people but it’s a different kind of caring to the way a parent, or friend, or spouse might care. Well, maybe it’s not so different but it’s expressed differently. For me, being able to work as a psychologist is an incredible privileged. I’m constantly humbled by the worlds that people share with me and I never ceased to be amazed at their abilities to make sense where there seemed to be none before.
Thanks for your views – it’s important for me to have the opportunity to reflect on things like what it means to care.
Tim
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Thanks for taking the time to post a reply.
Unfortunately, as in most professions there are great counselors and counselors who are not so great.
Being informed is definitely a great strategy for navigating your way through the mental health field.
Tim
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