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The Big Match

1/4/2016

 
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Who do you support?

​Team Body—or Team Mind?

The former adopts the “medical model” approach to psychological distress: the root causes are largely found within the biology of the unwitting individual and the best treatment is medication.
Sample narrative: “I am stressed and can't cope. The chemical levels in my brain are slightly off—I need medication to restore the balance.”
 
The Mind team, by contrast, regards symptoms as manifestations of underlying, unresolved inner conflict which needs to be explored, processed and resolved through talking therapy.
Sample narrative: “I am stressed and can't cope. I am such a workaholic and brutally hard on myself—I now see this as some kind of loyalty to my very strict and punitive. parents.”

Longstanding debate 
In his article “The 'drugs v talking' debate doesn't help us understand mental health," in The Guardian on Wednesday, Simon Wessely, chair of psychological medicine at King's College London and president of the Royal College of Psychiatrists, attempts to build a bridge across the yawning divide.
The longstanding debate, he writes, often “has been caricatured as ‘psychiatry v psychology’, or equally unhelpfully ‘drugs v talking’, or ‘brain v mind’. But these are false distinctions, which don’t help in understanding mental disorders, don’t help mental health professionals, and most of all don’t help patients.”
Wessely argues instead for a pluralistic approach: “As there is incontrovertible evidence that physical, psychological and social factors contribute to the development of mental health problems – in different degrees and mixtures according to the type of illness and the particular individual – it follows that treatments that psychiatrists use can be physically, psychologically or socially based, either singly or more often in combination.”
And, according to Wessely, a pluralistic, multidisciplinary approach is precisely what patients get: “The truth is that up and down the land psychiatrists, psychologists, social workers and other mental health professionals work together in multi-disciplinary teams for the benefits of patients.”
 
All that is missing from the picture he paints is a rose-tinted sky filled with smiling cherubs.
 
Three points:
• Wessely doesn’t address the economic and political forces that have a vested interest in promoting a biologically reductionist, medical model of mental health which, despite his claims to the contrary, remains the default setting in the NHS.
There is much commerce in pathologising aspects of the human experience that are deemed problematic, itemising them according to their symptoms, then prescribing drugs which promise to reduce or eradicate them.
Facilitated by enormous amounts of sponsored “research” and marketing, one in 10 people here and in America now have a prescription for an antidepressant. You are shy? OK, you need to take a pill for that. The diagnosis of “bipolar” has risen by 4,000 percent since the mid-1990s when, not entirely coincidentally, the patents for the best-selling antidepressant drugs began to run out.

• Psychiatrists of course vary in their outlook, but some—perhaps most—have limited tolerance for non-biological explanations of psychological distress, and non-pharmacological treatments. In some settings, blank stares will greet any mention of psychotherapy, or suggestions that a patient’s symptoms might have some meaning or purpose, or point to some deeper underlying, unresolved conflict, or are borne of dire socioeconomic circumstances (yes there's another team—they believe that mental illness is not from mind or from body but from the psychologically toxic waters we swim in; a sane response to an insane, unfair, oppressive world).
I have listened to consultant psychiatrists debate a patient’s treatment—the conversation is generally about meds, along the lines of: “How about a little bit more of this one, a little bit less of that one?”
This is modernist, one-person psychology: the expert hands down the objective truth of the condition to the grateful patient. In “The Wounded Storyteller,” Arthur Frank describes how as patients we must surrender our own narrative of our dis-ease and submit to the narrative provided by the expert. Some proverbial “men in white coats” seem to have very little interest in what a patient might have to say about the condition that belongs to them.

• When talking therapy is offered, in most cases that means CBT. There will likely be a waiting list, then a handful of sessions devoted to cleaning up your thoughts and actions. There is a great debate about the wisdom and effectiveness of this. Other approaches get squeezed out. Unless you go private, you’ll be hard-pressed to experience care at greater depth, such as psychoanalysis, which attempts to uncover unconscious processes, or integrative, humanistic therapies that depend on building a healing, accepting relationship with an emotionally available therapist.
 
Thesis-Antithesis-Synthesis
If the medical model—a strictly biological/genetic/chemical approach to psychological distress—is dangerously one-sided, equally preposterous is the converse, the kind of guilt-gave-you-cancer psychological determinism peddled by the likes of Louise Hay (see The worst self-help book ever).
Wessely is right when he says that mind and body cannot be separated. Such “Cartesian dualism” is to be rejected; we ignore the complex, mysterious interaction between them at our peril. I like the enigmatic Zen perspective of Shunryu Suzuki: “Our body and mind are not two, and not one. If you think your body and mind are two, that is wrong; if you think that they are one, that is also wrong. Our body and mind are both two and one.”
Of course, for all illness, medications have a vital role to play. Many of us are incredibly grateful for a daily dose of pills that allow us to function better. But for mental health care, increasingly the old paradigm is crumbling, to be replaced by a new, postmodern outlook, one that offers a broad array of different therapies to match the broad array of human struggles; that honours qualitative research as well as quantitative; and that listens to the person in distress rather than talks at them.

One example: Anyone who told a doctor in the past that they hear voices would have been labelled schizophrenic and prescribed major tranquilisers to make the voices—and much else besides—go away. Now, however, thanks to initiatives like the 
Hearing Voices Network, we don’t automatically sedate. We listen.
Writes Frank: “Postmodern times are when the capacity for telling one’s own story is reclaimed.”

This trend towards a synthesis of body and mind also reunites psychology with its philosophical history, following a century of trying on the ill-fitting, positivist clothes of science. When it comes to the infinitely complex, fluid and diverse experience of being human, there are no objective certainties. We are not just machines—there are ghosts in the machine, too.

Psychology is not a hard science. It is so much more than that.

An interpretation of Freud

22/1/2016

 
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​Long considered a sexist dinosaur with a cocaine habit and some bizarre ideas—does anyone believe that little boys literally fear castration, want to kill their fathers and have sex with their mothers?—Sigmund Freud is enjoying something of a renaissance.

As Oliver Burkeman recently outlined, the therapy Freud invented, psychoanalysis, is at last gaining some much-needed empirical support, while at the same time the default treatment on offer in the U.K., quick fix, symptom-focussed cognitive-behavioural therapy (CBT), is increasingly looking like some sort of snake oil.

CBT appeals to our common sense. But common sense isn't as common as we'd like to believe.

Freud’s revelation was that we are not necessarily always logical, rational beings making optimal choices as we navigate through life’s vagaries, that we are in fact to a large extent strangers to ourselves.

A few years ago, a relative had a terrible holiday in Italy. On returning home, in retaliation, she boycotted her favourite local Italian restaurant and has not been back since. This marvelously illogical yet so very human protest is typical of how inventive and fluid our psychology can be.

Unlike my relative’s very deliberate restaurant boycott, however, Freud argued that much of what we do operates “under the hood,” out of awareness. Our conscious, stated desires can be different from or even completely opposed to our unconscious ones. We might say we want to give up smoking, or find a partner, or start (or finish) a big project, or do something bold and courageous, but somehow we find ways to ensure it doesn’t happen. We make mistakes, and we vow never to be so foolish again, but then we find ourselves doing the exact same thing. Over and over. Freud called this “repetition compulsion.” Britney Spears called it “
Oops, I did it again.”

According to Freud, our unconscious motivations generally can be traced back to our formative years. We learned how to be in the world as children, and decades later this blueprint remains. Sometimes it’s as if we were insisting on still using a crutch long after our broken leg has healed. The blueprint includes an imperative to repress disturbing ideas, thoughts, emotions, events, memories and conflicts from long ago. But they are not so easily silenced—they retain some kind of energetic charge which can find all manner of expressions, sublimations, projections and other creative outlets.

One of Freud’s patients, five-year-old “Little Hans,” had an intense fear of horses—Freud said they represented his father. “Rat Man” had an obsessive, intrusive fear of torture involving rats and bottoms which Freud linked to early experiences of discipline and sexuality. “Dora” had a suicidal breakdown after being propositioned by a family friend because, claimed Freud, she was repressing a lesbian attraction for the man’s wife. Freud’s most notorious cases are summarized here.

Freud argued that neurotic symptoms, when unmasked, usually make some kind of sense. They have an intent, a meaning; they exist to resolve something or defend us from pain, guilt or shame. Merely removing the symptom without addressing the cause—the CBT approach—might just lead to another symptom.

And anyway, a symptom is not so easily removed. Since it serves a purpose, writes Freud, a patient will “make the most of it, and when it comes to taking it away from them they will defend it like a lioness her young.”
​

Freud defined his invention of psychoanalysis as “the science of unconscious mental processes.” The power of the unconscious is his greatest legacy.

Darwin told us about ourselves as members of the animal kingdom. Marx told us about ourselves as members of society. Freud told us about ourselves as individuals.
​The battle within
A cornerstone of Freudian psychology is his 1923 structural model of the human psyche. The idea—which wasn't original: Plato proposed the same thing two millennia earlier—is that we have three parts to our interior system of government, which Freud called the id, ego and super-ego. The selfish, erogenous, childlike id seeks gratification. The autocratic finger-wagging super-ego by contrast is a sanctimonious, guilt-inducing presence, forever hectoring you about what you should be doing. Mediating in between is the harried, democratic ego, trying to keep everyone happy. It’s like having Caligula, the Pope and Bill Clinton sitting around the negotiating table. On different days, some voices are louder than others. Freud likened the internal conflict between the three constituents to a legendary 5th century battle between Attila and the Romans and the Visigoths.

The battle is as old as the hills and most people—and families, cultures, countries—generally have a default setting, either on the side of the super-ego, favouring restraint, prudence, safety and being “good,” or on the side of the id, living their lives with more freedom, spontaneity, creativity, passion and throwing caution to the wind. Many clients belong in the former category, paralysed by a brutally harsh inner self-critic. The more you try to please the super-ego by doing the “right” thing, the more demanding and punitive it can become. The super-ego usually has its origin with parents, but also can come from teachers, bosses, governments and religions. Freud writes that it “rages against the ego with merciless violence.” That violence can be the cause of much psychological and somatic distress.

Therapy is about shining a light on these and other haunted caverns of the unconscious, understanding them, accepting them—making the unconscious conscious or, as Freud put it, “where id was, there ego shall be.” To be enlightened is perhaps to have no fears, illusions or deceptions about one’s propensity for darkness.
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Case vignettes*
• After a lifetime of short-term relationships with troubled men, Karen is lonely and desperately wants to settle down. She has a social life, she does various evening classes, she has joined a dating site. “But there are no good men out there,” she complains. Her checklist of criteria that must be fulfilled is so long that she has effectively ensured it will never happen. She is thus spared the pain of rejection. In therapy we learn that Karen’s father left the family when she was 10 and was barely spoken of again.

• Dave lives under a blanket of depression. He collects evidence everywhere for his worthlessness. Every chance remark, askance glance or unsuccessful outcome is added to the rap sheet and presented as evidence that there’s no point. He is thus relieved of having to take responsibility for his life and the possibility of real failure is averted. Dave initially dismisses the fact the he was born into an acrimonious divorce—which he feels was his fault—as irrelevant “ancient history.”

• Jessica is a workaholic with no time for relationships. She has risen to the top of two professions and is considering starting a third. She has a history of unexplained physical complaints and finally sought out therapy when one morning, on her way to work, she inexplicably burst into tears. She came to realize how as a teenager, after her father had died, she had become “the man of the house,” helping her depressed, bereaved mother, looking after her younger siblings, getting a part-time job to make ends meet. She held the family together; now she lives alone.

​

*These are fictionalized, representative stories; names and details have been changed

PictureFreud's facial expressions run the gamut from utter foreboding to grim disdain.
Therapy today
Freud’s influence was far-reaching and profound. But he was a flawed character. You get the feeling he started to believe in his own myth. Patients often had to fit into his theories rather than the other way round. Any dissent might be met by indignant harrumphing or an ended friendship. He was capable of exploiting his position as a white male authority figure for personal ends. His work was sometimes more to do with furthering the legend of Sigmund Freud than with healing.

Some of his ideas and speculative musings have great metaphorical and symbolic value, yet he invited ridicule by insisting on speaking in absolutes and the rigid certainties of hard science. He was somewhat obsessional, detached, and ironically perhaps not so much of a people person, once writing, “I have found little that is ‘good’ about human beings on the whole. In my experience, most of them are trash.” The best they could hope for was “common unhappiness.” In photographs, his facial expressions run the gamut from utter foreboding to grim disdain.

Freud claimed psychoanalysis worked. He would identify unconscious motivations and unhelpful patterns, explain them to the grateful patient and, thus fortified, the patient would make better choices going forward. Except that very often they didn’t.

Today’s therapists who work at any depth will, like Freud, want to uncover your blueprint, your patterns, your unconscious processes. They might explore your childhood, interpret significant memories, analyse your dreams, which for Freud were the “royal road” to the unconscious. But they know that, while self-knowledge is helpful, it only takes a client so far. Lasting change and healing comes from the heart as well as the head, through acceptance, support and love. Research shows it is the therapeutic relationship itself which heals.

Good therapists are not inflated with their own importance, nor blinded by their own certainties. They treat clients ethically, not just because there are codes of ethics to abide by, but because ethical therapy is inherently good therapy. Above all, they are fully engaged with the client, noticing what is happening between them, and always working in partnership with them, in their best interests, rather than lording over them as they lie on the couch, prostrate and exposed (whether as a client or a therapist, I prefer to sit chair to chair and eye to eye). A good therapist cares.

It’s not enough to know and be known. To thrive in this life it helps, too, to love and be loved.

The great CBT debate

18/11/2014

 
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If you’ve received any psychological care from the NHS, the likelihood is that it would have involved cognitive behavioural therapy (CBT).
     Since 2006, CBT has been the fuel that drives the government’s mental health initiative, the “Improving Access to Psychological Therapies” scheme: 6,000 new CBT therapists have been trained since then, and in 2012, the government spent £213 million delivering CBT through the NHS. CBT is the default non-pharmaceutical service offered by the NHS for most common forms of mental distress. Other kinds of therapy get squeezed out.
     CBT has faced heavy criticism over the years. Now author and psychologist Oliver James is leading the charge, calling on the government to take a more holistic approach that embraces other talking treatments such as psychodynamic therapy. Why? Because, says James, CBT simply doesn’t work.
     He writes: “A quarter of us suffer from a mental illness at any one time, mostly anxiety or depression. The cost to our economy is enormous—£105 billion a year, never mind the personal anguish—and for too long the only treatment was pills. What a tragedy, then, that the first attempt to provide talking therapy to patients nationwide is using the wrong kind: cognitive behavioural therapy.”

What is CBT?
In the 1950s, Aaron Beck became disillusioned with the-then prevailing approaches to psychological treatment. On offer was either psychoanalysis, which suggested clients were at the mercy of their unconscious processes, or behaviourism, which suggested they were at the mercy of their external environments. Beck felt little consideration was given to people’s power as conscious beings able to make good choices. In working with clients with depression, he came to understand their condition as arising from unhelpful thinking or “cognitive distortions”—negative thoughts which are fed by underlying beliefs or assumptions or “rules for living.” CBT was an unlikely marriage in the 1970s between this cognitive approach and more traditional behavioural ideas.
      These days, CBT takes a broader approach, considering emotions and the body, too. All four “elements of life” interact with each other, often in a negative spiral. So while a person’s thought and behaviour patterns are the focus of CBT—considered the twin engines in creating and curing psychological distress—practical, skills-based steps to improving emotional and physical wellbeing are also encouraged, such as exercise, sleep, meditation, yoga and nutrition. CBT has evolved and expanded and branched off, too, incorporating other ideas and practices. Some of the new “third wave” forms are mindfulness-based CBT, Dialectic Behaviour Therapy; compassion-focused CBT, Schema therapy.
     In a course of standard CBT treatment, typically anything from 2 to 12 weekly, 50-minute sessions, you and your therapist will break down your problems into their separate parts using worksheets such as Padesky’s “hot cross bun.” Unrealistic or unhelpful thought and behaviour patterns will be identified, and together you will come up with better alternatives. These will be practised during sessions and also between sessions with “homework” assignments such as keeping a thought record or carrying out behavioural experiments where you try to expose yourself to feared situations. Says the NHS: “The eventual aim of therapy is to teach you to apply the skills you have learnt during treatment to your daily life. This should help you manage your problems and stop them having a negative impact on your life—even after your course of treatment finishes.”

The case for CBT
• It offers a common sense, structured, systematic approach with a focus on problem solving in the here-and-now. No need to spend years (and fortunes) in analysis, lying on a couch ruminating about your childhood. CBT is a practical, non-threatening approach, especially for clients experiencing psychological treatment for the first time.
• It’s easy to grasp, and offers clients some certainty, clarity and an action plan. In the midst of the storm of a crisis, that can be very comforting.
• It’s short-term, and can therefore be delivered economically.
• It’s an evidence-based treatment. Since the days of Beck, it has been subject to extensive testing, especially in the form of randomized control trials. This research claims CBT is an effective treatment for anxiety, depression, panic disorder, personality disorders and many other forms of psychological illness, including some psychoses.
     According to the National Institute for Health and Clinical Excellence: “CBT’s evidence base, short-term nature and economical use of resources have made it attractive to clients, practitioners and service purchasers."

PictureAt its worst, CBT has a flavour of Bob Newhart's "stop it!" comedy sketch.
The case against CBT
• CBT is an absurdly simplistic, quick-fix approach. It’s just common sense—thinking and behavioural hygiene—dressed up as something grander. At its worst it offers little more than Bob Newhart’s comic “Stop it!” therapy. The idea that a person’s complex distress will be resolved after a few sessions of having their thoughts and actions challenged is laughable—like putting a tiny sticking plaster on a deep, long-standing and festering wound.
• CBT only targets symptoms rather than underlying causes. There are deep unconscious processes at play, often forged in childhood, and unless these are explored, brought to light and processed—this is the domain of psychodynamic therapy—nothing will ever really change.
• It’s a manualised, one-size-fits-all method that is imposed “top-down” on the client, rather than starting with the client and their experience and working together in a “bottom-up” way. Unlike physical diseases, psychological distress does not so easily lend itself to being pigeon-holed into different, neat and tidy “diagnoses”—one person and their “anxiety” for instance, might be very different from another, and they might benefit from very different approaches.
• It’s patronizing and disrespectful to the client to imply they should have “recovered” after a few sessions of CBT, which blithely attempts to whitewash over difficult childhoods, traumas, hardship, and the very real consequences of the oppression resulting from a deeply unequal, divided society. The “blame-the-victim” ethos that’s inherent to CBT—all your problems are the result of your faulty thinking and behaviour—only makes people feel even worse when the treatment inevitably fails to make a difference.
• CBT comes from a narrow, ethnocentric world view, making assumptions for instance that all individuals are rational, autonomous, in charge of their own destiny, disregarding for instance those who might be more collectively-minded, or generally less amenable to logic, homework, psycho-education and the cognitive model.
• The “evidence” for CBT is highly questionable. Any positive effects of CBT in research tend to be very small. The few long-term studies show little or no lasting benefit. And some favourable research is biased, bogus and politicized—often it’s a somewhat rigged, circular process in which CBT looks for and finds results that portray itself in a favourable light, like a schoolboy left to mark his own homework. It is doubtful that CBT is at all effective in the long term in the real world of clinical practice, especially for chronic, complex, or long-term conditions. Writes James: “After two years, those given CBT have no better mental health than ones who have been untreated.”
     Concludes psychiatrist and writer Jeremy Holmes: “It is hard to escape the suspicion that cognitive behavior therapy seems so far ahead of the field in part because of its research and marketing strategy rather than because it is intrinsically superior to other therapies.”

The case for integration
There is something to be said for CBT. It has a place. It’s a good starting place for a lot of clients; a way in. The benefit of symptom reduction can’t be underestimated. I have incorporated some CBT into my work as a counsellor, particularly some CBT ideas around assessment, formulation, psycho-education, self-monitoring and reality testing. Considering each client through a CBT lens is a worthwhile exercise and should be a part of any therapist’s toolkit.
     But overall I tend to agree with James. CBT is rather too superficial, pedantic, and highly directive, sometimes oppressively so. Rather than imposing fixed goals and tasks on the client, I prefer a more open-ended, collaborative way of working, one which allows the encounter to unfold organically, with a sense of exploration. “Being with” is better than “doing unto”; allowing a therapeutic relationship to emerge is preferable to attempting to batter away a client’s symptoms with a CBT bludgeon.
     Human dis-ease is as varied as humans are, and clients rarely come seeking goal-oriented solutions to tangible, well-defined problems. And symptoms often exist for very good reasons. They serve a psychological purpose—and so we defend our neurosis, as Freud said: “like a lioness defends her young.” Untangling unconscious and conscious motivations, intrapsychic and interpersonal conflicts, and environmental constraints and challenges—it’s a tricky business. Better to go with an integrative, flexible, and reflective therapist who has had plenty of therapy of their own than an insensitive, dogmatic CBT evangelist who demands that you get with the program. Better for the government to offer a flexible, pluralistic, comprehensive therapy service than only a simplistic, dogmatic, ineffective one.

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    John Barton is a counsellor, psychotherapist, blogger and writer with a private practice in Marylebone, Central London. To contact, click here.

DR JOHN BARTON IS A PSYCHOTHERAPIST, BLOGGER AND WRITER WITH A PRIVATE PRACTICE IN MARYLEBONE, CENTRAL LONDON
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