Tuesday, 25 July 2017

The Pool of Explanations

I'm loathe to return to this subject. Sensible Twitter voices have lamented the repetitive diagnosis debate, and it fuels ugly disagreement. But it is an issue I care about, and one that really matters, so here goes.

A couple of years ago I wrote a post in response to DCP guidelines on psychologists' language in mental health. This week a sharper, wittier writer has made similar points. It brings up all the same arguments, which have played out on Twitter in a remarkably similar way. 

For the avoidance of bad feeling, I would like to address this post directly to people who would normally disagree with me. I want to make a short, good faith argument and try to persuade you of the merits of what I said then. But I want to do it in a way that brings you with me. I plead for your good humour and open mindedness. Despite the siloing that happens in social networks, virtually everyone who engages in this debate is on the same page in one major respect. Everyone wants better mental health care. 

Why does such a goal lead to concern about the DCP guidelines? It has to do with the pool of explanations. The pool of explanations is the set of viable theories a person has available to them to make sense of their psychological suffering.

The great liberating component of opposition to diagnosis has been in the push to a wider range of explanations for people to use in making sense of their experiences. We want to move beyond limiting and dominant accounts like simplistic versions of the chemical imbalance theory, or over attachment to DSM categories. However, the mind is so mysterious that very a relatively small proportion of historical theories (see e.g. the "schizophrenogenic mother") can really be conclusively junked. For the time bring,  more is better. Frameworks that emphasize the importance of trauma, of relational and interactional factors, and of intrapsychic processes have pulled back successive layers of mire from our vision of the field, and have liberated many people. Frameworks that talk in terms of illness and diagnosis continue have real meaning for others. This isn't controversial.

Until a new epoch of more comprehensive mental health theory, it is absolutely incumbent on us to continue to grow the pool of explanations rather than shrink it. Shrinking the pool pushes people out. Enlarging it means more imagination, more discovery, and more choice. This is not a call for a slide into relativism. We need a range of ways of getting at the single inarticulate truth. We need a cacophony of voices in order to approach understanding.

The DCP language guidelines were not an expansionist project. They sought to shrink the pool of available explanations. This was for noble reasons, but with unintended effects. They alienated people who do relate to diagnostic/illness language, and they policed the language of professionals who already prize reflectiveness and theoretical pluralism. As someone who works with the confounding complexity of mental health every day I value explanatory pluralism. You can refine language to avoid harm, but you cannot make reality more tractable by dispensing with whole swathes of lived experience. This is not an ill tempered intellectual game we are playing. It is real people and their real sense of self. It matters.

Tuesday, 18 July 2017

Being Difficult

When my son was born, a simple administrative error on the part of the insurance company (they temporarily gave him the "wrong" gender) meant that the hospital did not get immediately reimbursed for the costs of the birth. American healthcare companies are expert at extracting money from patients. Even when the error had been resolved and the insurance company was in the process of paying, we received a quick succession of increasingly threatening letters for a sum that would have been ruinous to almost anyone, let alone two graduate students. When the letters started to include indicatinons that they were from a debt collection agency, I called the hospital billing department. I didn't intend to be particularly pushy, but the conversation took a turn toward the perverse. I was told that they had not forwarded the claim to a debt collection agency, and that I shouldn't worry. I felt like I was being gaslighted. I was holding a letter that said, in caps, that it was sent by a debt collection agency. I pointed this out. Again the agent asserted that the case had not been forwarded. Someone's vision of reality was under threat, and I wasn't about to relinquish mine. I got...shirty. I raised my voice, I told the agent that I felt like I was in Alice in Wonderland.

I don't feel proud of telephone rudeness, but I don't feel ashamed either. This is unusual; I am a person who is prone to deep bouts of shame. I think everyone needs to be difficult sometimes. When dealing with large organizations it is often unavoidable. We are under pressure, faced with an unsympathetic or belligerent representative, or just with a good old fashioned jobsworth. A bit of assertion greases the wheels. A but too much assertion can really get the job done. 

So being difficult is something we tolerate. It feels like an allowance to be spent under certain conditions. But in mental healthcare the allowance is far smaller. Recently I have had several experiences in which patients have spending some of this allowance, and it has come back to bite them. It's not
 my place to share the details, but suffice it to say that they include more or less reasonable assertiveness, some fragile professional egos, and a healthcare system that is far less used to regular pushback from users. They have made me think. If I had been a psychiatric patient my pushiness around the billing might have been more readily shrugged off.

In mental health care, the users of services tend to get pushed around a lot more than in other systems. They are typically more likely to be used to being treated this way by professionals. If they aren't, then learned passivity is one adaptive response. It is rare for a mental health professional to have to explain themselves in plain English, or to give reasons for a decision. Their word so usually goes, and when it is questioned they are tempted to describe someone as being oppositional, even Borderline.We should be energetically resisting this tendency for all we are worth.

Yes there are people who need more effective ways to problem solve.If difficult is all you can ever be, you soon find out that it stops working for you. Something useful for a sympathetic outsider to do is to flag such tendencies in a way that you can recognize, and even help look for alternatives. This might be one of the best uses of psychotherapy. 

But often the soul-searching is on the professional. We don't ask often enough why our decisions have resulted in anger or distress. Sometimes the reasons are subtle and complex. It is reasonable not to have realized, but we really should learn. Sometimes the answer is more obvious and our failure is staggering. At their best healthcare systems can be infuriatingly counterintuitive. At their worst they are absuive. Staff have a duty to acknowledge this and to not be part of the problem.

Thursday, 6 July 2017

History of psychiatry. History as psychiatry.

Somewhere between symptoms and intentional actions lie behaviors that are both deliberate and compulsive, owned and alien. Such behaviors are troubling, either to the people who so behave or (more commonly) to those around them. How do we make sense of actions which can't be fully explained even by their actors? Psychiatry has tended to ascribe meanings at the personal or sub-personal level. But such explanations break down when behaviours interact with broader social patterns, messily assimilating, communicating and discharging. Psychiatry needs a wider angle lens; psychiatry needs history.

This truth is brought into relief by Sarah Chaney's book Psyche on the Skin, a wonderful new history of self harm. That such an important and enjoyable read could have arisen from someone's PhD thesis seems almost a little unfair. 

Chaney's subject threatens to pull apart any coherent historical account. The history of self-harm strains in almost as many different directions as there are acts and actors. This is not a limitation of the project, it is part of its point. In its prehistory (Chaney demarcates as "prehistory" those forms of self-harm that preceded psychiatry and thus escaped its codification), self harm could signify religious piety, self-cure, or sexuality among other things. Individual motivations may have involved some all or none of these and to different degrees. At different times, a cultural framework made specific forms of self-harm intelligible. Religious flagellants acted under a description which accounted for their behaviour. When particular expressions of religious zeal came to be less widely shared, they looked more and more pathological. When medicine stopped endorsing so widely the practice of bleeding, the impulse to purge in this way looked less like a cure and more like an illness. Psychiatry's arrival signalling a shift to a new over-arching lens. Self harm became the sign of a simple psycho-biological "morbidity", an inwardly directed aggression, or an attention-seeking malingering, depending on which psychiatric epoch you lived through. 

The surprising fact at the heart of this book is the diversity of forms self-harm has taken, even in its recent history. The diversity of the associative networks it has occupied. Each era finds new ways to physically manifest misery. These have fluctuated through the ages. It is tempting to frame this in terms of a trend, but something else also played a role. Chaney presents evidence that the prominence of a phenomenon in the medical literature did not accurately represent its prevalence in reality. In the last two decades of the 19th Century, around 25% of publications on self mutilation focused on castration, but this was seen only around 2% of self-harm cases admitted to the Maudsley. For less headline grabbing phenomena (picking and "knocks") the statistics were approximately reversed. British alienists developed a penchant for the sensational, and this of course shaped their view of what they were studying. 

The running theme here is not the search for some over-arching cultural true meaning that can be bestowed on self harm. Rather it is psychiatry's engagement with the phenomenon that is under scrutiny. Each chapter unfolds like a historical case study, but the objects of the case study are the doctors who have tried to bring order. Self-harming persons are not absent by any means, but Chaney declines to speak on their behalf. Instead they appear in simply elaborated descriptions or images, silently looking out at us like Robert H, photographed in the Maudsley hospital at the end of the 19th Century. 

Chaney's treatment of these individuals reminds me of Ian Hacking's approach to fuguers in "Mad Travelers." She doesn't pretend she can account for the behaviour of someone who rubs at their head until their hair has worn away, or inserted needles into her skin, she simply presents facts. We are left with a respectful outline, of people doing perhaps what they had to, or felt they had to do under the circumstances. My reading of the book dovetailed with the broadcast of Hilary Mantels' Reith Lectures, which proved apt. Mantel reflects on the impossibility of a fully psychologically informed history. History for Mantel is
...the multiplication of the evidence of fallible and biased witnesses, combined with incomplete accounts of actions not fully understood by the people who performed them. It’s no more than the best we can do, and often it falls short of that. (page 4)
So in providing an honest history, Chaney offers a subtle contrast to the confident and totalizing narratives of many of her psychiatrist and psychologist subjects. She doesn't overdo it (her book is not a polemic), but the desperate need to explain and domesticate self-harm is a thread that binds a diversity of medical encounters across time. Confident pronouncements abound, particularly during the psychoanalytic heydey of the US in the 1950s. Psyche on the Skin expands the historical horizon, and in turn shrinks the parochial theoretical perspectives of its medical and custodial protagonists. There is a clear lesson here for modern practitioners; resist too strong an attachment to your theory of choice, otherwise anachronism awaits.

There is a personal note to this book too. Chaney has her own experiences of self harm. In her conclusion she says "The history of medicine has been a solution for me in the way medicine itself never was." There is a warning in there for those of us who would too readily organize our own lives around the particular brand of sense-making that is mental health care.