On psychology getting its priorities right

Well, it’s been a year since I last blogged, and frankly that’s probably a good thing. I had anticipated a reduction in productivity and so it came to pass. 2017 turned out to be a year in which I changed job several times, moved house and watched two people die, so it’s fair to say it was eventful. Oh and I got a kitten, who is sweet and funny and of whom I am very fond, despite the fact that she constantly gets in the way and that I now get absolutely no peace in my own house. So all in all, keeping my head down – relatively speaking – was probably necessary.

I write this as I journey to Cardiff. My only blog of 2017 was written shortly after a trip to Liverpool, technically because I was speaking at the UK’s main clinical psychology conference, but mainly because I and some friends had organised our own (not exactly rival but not exactly not rival) events: a fringe festival bringing mental health and the arts together, and then a one-day conference looking at psychology going ‘beyond therapy’. Cardiff is the venue for this year’s events, both the main conference, which I’m not going to, and the fringe events, which I am proud to be a small part of.

I think it’s important to be proud of your contribution to your profession. Not in the way that many of us are – considering ourselves experts; getting caught up in the arrogance that can pervade; judging people based upon their academic output – but of the important stuff. Of going to work and doing what needs to be done to help people. Of using the knowledge and skills you have to try to bring psychological ideas to new audiences. Of doing it all in a way that tries make things better. The small things that are really the big things. Often unsung, but vitally important.

I am privileged to do what I do for a living, and I am privileged to know so many people who go above and beyond to try to fly the flag for better health and social care services, and who critique the policies that cause so much damage. Almost all of these people do huge amounts of work – usually for no money and very little in the way of glory – to do these things. Our profession is stronger for them, and lucky to have them.

So I am very dedicated to the profession of clinical psychology. But sometimes I have real concerns about other psychologists. And this past week has brought that to the fore.

A week ago a new document was launched looking at an alternative to psychiatric diagnosis. This blog is not a review of that document, because it’s 400 pages long and I haven’t had a chance to read it properly yet. The principle tenets of this framework are as follows:

And when I’ve finally read it I might write something on it, but there are plenty of people cleverer and better-read than me who will likely do a better job. And 400 pages is no small task. It was actually my planned train reading but I only got to page 18.

I have no major problem with the framework, though I don’t believe diagnosis is going to fall overnight, and I don’t know how health, social care or welfare systems would operate if it did, so I’m not getting too excited just yet. And it does strike me as interesting that a team of white professionals has written a 400-page document talking about power – and, whilst there was a consultancy group, consultancy is not the same as authorship and as a brown Muslim woman I absolutely own my response to that defence – but in the main I’m interested in seeing what impact this framework has on policy, because that’s where it needs to take root.

I do have a problem with the reaction of my fellow professionals to the same document. People who dislike or disagree with the framework have pulled it to pieces and questioned why it was ever written. Now, sure, pull it apart – we need to critique ourselves and our practice – but to denounce it as heresy is unhelpful, particularly if you don’t have the courage to write your own alternative framework. Being catty on Twitter is undignified. It does all of us a disservice. We should be better than that. It’s not that I can’t see why people might be sceptical – when my patients need the be signed off work their employer needs a diagnosis. So does their insurer. If they have OCD or a specific phobia it’s probably helpful to be able to give it a name, because talking about intrusive thoughts and compulsions is all a bit psych-speak for most of us. Labels and names and categories have their uses and we can’t lose sight of that. But there are diagnoses which are very harmful – I speak here of ‘personality disorder’ – and we do need to think very carefully about how we move away from decades of iatrogenic harm based upon a label that tells you that you are defective to the very core. Perhaps, then, trying to look at the whole spectrum of human distress within one framework – even one that’s 400 pages long – isn’t the ideal place to start. But there are ways of saying it, and a substantial number of people haven’t demonstrated much understanding of that.

People I would consider to be quite eminent – by which I mean long in the tooth – have been hostile to the point of vitriol. The authors have been attacked in a most unpleasant way. Clinical psychologists (thankfully very few of them, though) have used Twitter as a platform to call those who disagree with them – including people who use mental health services – stupid or unenlightened. The word ‘stupid’ has actually been used. It’s gone so far that I and some similarly perturbed colleagues had a look at the social media guidance provided by our professional and regulatory bodies. Someone else has grumbled about it being our new professional ‘policy’. It’s nothing of the sort. It’s a model; a construct; not an ultimate truth. You’d think people trained as social scientists would understand that notion. Instead, we’ve had people saying things like ‘Not in my name!’, as though the the document was tantamount to the dodgy dossier which led to the Iraq invasion. It’s ridiculous, and its unprofessional, and it makes me ashamed.

Psychologists – particularly of the clinical variety, it seems – have really got to up their game. We lord about declaring ourselves to be reflective and able to consider a range of perspectives and then we act like this. It’s a disgrace. But it’s also the wrong battle to be fighting.

Today some data was published showing that in poorer parts of the UK life expectancy is decreasing for the first time since 1945. This appears closely linked to cuts to health and social care, as well as welfare changes. The decrease has only been observed since 2011. It’s not hard to make the link. But has there been a social media furore from my colleagues over this? Was it mentioned once in any presentation today? Was it ‘eck. But this is what we need to be talking about. These are the battles we need to fight. Not squawking about changes that might or might not affect policy over the next decade; shouting and stamping about the people who are dying now.

I simply don’t understand why more of my colleagues aren’t beating the same drum. Sure, my perspective is heavily coloured by my demographics and the experiences that have come with them, but surely even the most privileged person must understand that the basics of food and shelter and dignity keep people level. Not entirely level, but they make a good start.

Really what I’m saying is that I have been profoundly disappointed by some of my colleagues recently. And if I’ve been disappointed goodness knows what the public has made of it. And we have got to change. Not just for the sake of clinical psychology but for the rest of society. If we don’t wake up to that we’re going to perish. And that really would be a shame.

The language of psychiatric disorder: How useful is it?

The field of mental health is often presented as dichotomous in its thinking. There is a common presumptions that we focus on symptoms and declare you ‘ill’ if you meet a certain (usually arbitrary) number of criteria. Like many presumptions, it’s not strictly true.

I came across this recently, in which an America soldier declares that PTSD is ‘not a disorder’. For the uninitiated, PTSD is post-traumatic stress disorder, characterised by exposure to some kind of significant trauma during which the person was (perceived risk of death, injury or sexual violence. It needs to cause some kind of uncontrollable response – nightmares, perhaps, or flashbacks. It must manifest itself in heightened awareness to perceived threat and there must be a marked effect on mood or thinking style, such as blaming yourself for the event. It is, unsurprisingly, common in those who engage in military combat and there is much research into the (often profoundly negative) effect of combat on veterans’ mental health and their level of substance misuse. So for a soldier to say that PTSD is not a disorder is unusual, but his reasoning is perfectly sensible: if you have seen active combat and witnessed death and destruction, if you have been involved in scenarios in which you thought you might die, why wouldn’t you expect to experience some adverse consequences?

It doesn’t just apply to PTSD. If you’ve lost your job, you’re about to evicted from your home and your relationship is breaking down from the stress of it all, why wouldn’t you experience a dip in mood? If you were mugged and seriously assaulted to the extent that you avoided going out I wouldn’t think it bizarre if you developed agoraphobia. If you’ve had a bout of terrible physical health and the doctors couldn’t work out what was wrong it might be entirely expected that you would become anxious about your health. For most people, psychological difficulties arise in a context which means that the person is finding it difficult to cope, in some way. It doesn’t make them weak, it makes the human. If you push your body too much it will start to break down and the mind is not so different. But there is real debate about the language of disorder.

It’s a difficult one. It is generally accepted that well-being and distress exist on a continuum and to some extent, our diagnoses are arbitrary. We might have six criteria and say to have to meet three. We might say you have to experiences the symptoms for at least three months or two weeks. Why do we say this? Because we feel the symptoms need to be problematic for a certain length of time and that we should be past the point at which they resolve themselves. So there is a logic to it all, but it is fundamentally arbitrary. And because of the history of psychology, the language is one of ‘disorder’, of ‘illness’, of ‘deficit’. ┬áThat’s really difficult to reconcile with a belief that sometimes we all find life tough and that that is human. Physical health is not usually defined as ‘disorder’ or ‘deficit’, and if it is it is generally localised (‘your pancreas is not producing insulin and this means that you are diabetic and we need to give you injections’). We can;t say for sure that psychological problems ‘exist’ in any particular part of the brain – we know that the frontal lobe is responsible for empathy, but we don’t know that ‘depression’ lives in any part of the brain. And when we suggest that poor emotional well-being is ‘mental illness’ we are pathologising you and your sense of self and that means a lot more than pathologising your thyroid.

Personally, I don’t find diagnostic labels all that useful because they’re no more than a label. What matters to the person is not what a group of psychiatrists think they have, what matters to them is why they are feeling the way they are feeling and how to stop feeling that way. We refer to it as ‘formulation’, which is simply a personalised explanation, put together with the person who is accessing mental health services and built up over time, of what is causing the problem, what keeps it going and how we might be able to do something about it. But we exist in a system which does apply diagnostic labels and which does treat you as ‘ill’ if you meet our criteria (and they are ‘our’ criteria; they’re not fail-safe, like the criteria for coronary heart disease, for example). It’s a real struggle – how do we make people feel that they are not the only ones who feel the way they fail whilst also helping them understand that the fact they are seeing mental health professionals does not make them deficient? There are strong voices on both sides of the debate (strong enough to warrant a blog post of their own), but for most us , who spend our time trying to reduce people’s distress, it’s less about the ethics of diagnosis and labelling and more about the meaning these concepts have to the people we see. I don’t talk to the people who are referred to me about diagnostic criteria. I talk to them about what isn’t going as well as they would like to and how I might be able to help. I worry about the language we use and I try to adapt mine accordingly. I wonder, though, if I worry about it more than the person I see, who often, simply wants life to be good again.