Brief Interpersonal Dynamic Therapy

 

Though working in IAPT, a CBT-dominant mental health service, if you have read any of my posts before you’ll know that my temperament aligns far more naturally with the dynamic, interpersonal and exploratory therapeutic modalities. This means I often find myself in unpleasant moral dilemmas where I worry that I am short-changing my clients by sticking faithfully to the ‘Behavioural Activation Protocol’, but have zero other training that could better guide me with my clients.

So, I’ve started to read the textbooks of other psychotherapies, for some pointers of what kind of approach I have a better fit with, and to inspire ideas as to where my career path goes next…

The first book I’ve finished is Alessandra Lemma, Mary Target & Peter Fonagy’s Brief Dynamic Interpersonal Therapy: A Clinician’s Guide (2011), and it felt like balm to my CBT-crushed soul. The book is a treatment manual for practicing clinicians to deliver short-term, focussed, psychodynamic therapy for complex cases of depression and anxiety. (And they define short-term as 16 sessions! What would they call my 6 thirty-minute IAPT sessions I wonder?).

This is an interesting concept, because psychodynamic clinicians are usually allergic to manuals and time-constraints, seeing the complexity and variety of human nature as bound to doom any standardised approach to failure.

There are three key points about this kind of therapy that make it far more appealing to me than CBT.

Firstly, the importance given to interpersonal processes, both past and present. DIT structures itself around an Interpersonal-Affective Focus (IPAF), which it does by identifying one dominant and recurring unconscious interpersonal pattern. For example, an individual might find that, for whatever reason, they tend to see themselves as ‘a flawed woman’ and significant others as ‘critical and superior’, which, played out enough times in various relationships, would quite naturally lead to depressive symptoms. The logic behind this is the idea that because we are social animals that depend so strongly on others, most forms of psychological distress will likely be caused by, and then maintained, in some disrupted interpersonal functioning. Maybe we experience some form of interpersonal trauma, which then makes us fearful of getting emotionally close to someone, so we withdraw, but then feel lonely and depressed. From my limited clinical experience thus far, it does seem like the vast majority of psychological distress is usually due to, or resulting in, problems in relationships. Because of this focus, a key DIT technique involves working within the transference relationship, as this is a ‘live’ relationship in which those patterns are likely to surface, and hence can be a useful place to begin exploring those patterns in a safe and non-judgemental space.

Second, the attention to affect. To most fruitfully use the transference and countertransference processes that occur within the therapeutic relationship, DIT takes a far more detailed and exploratory approach to the individual’s affect on a moment-by-moment basis during the sessions, as these affects are likely to give important clues about their interpersonal patterns. The thought here is that the better able we are at identifying our affects, the more control we will have over them in future, as we might be able to shift the perspective and not get so wrapped up in the more automatic/unconscious affective patterns that might otherwise control us.

And third, the move away from symptoms and towards a more holistic view of what makes a life worth living. (The absence of symptoms does not a meaningful life make!) DIT understands symptoms as existing further along the line from where the problem started. Symptoms, such as anxiety or panic, might be manifestations of faulty interpersonal/affective patterns as they are enacted in situations that are not well suited to them, so are more like the tip of the iceberg. CBT approaches tend to treat panic symptoms as if that were the only thing going on in that person’s internal world (they might well be), whereas psychodynamic approaches are more interested in why and how that symptom started. They attend more to an individual’s underlying personality structure, which typically might not even bring a person into therapy in the first place (most of us take our personality as a given). The idea here is that by working at the deeper levels of human psychology, the therapeutic benefits will hopefully be more long-lasting, as the anxiety or panic won’t just pop up later on in another form. I think this narrow attention of CBT on presenting symptoms only, especially the low-intensity CBT in IAPT, might explain the 50% relapse rates (within a year) of the clients who ‘recover’. And we must not forget that those clients who ‘recover’ are only ~50% of those ‘completing’ treatment.

I’ll finish this post with a quote from the book summarising the main aims of DIT, being to:

  • ‘Identify what he/she feels, encouraging the patient to stay with a current feeling as it emerges in the session.
  • Communicate what he/she feels more effectively.
  • Build greater facility in connecting his/her feelings, thoughts, and actions, and how these relate to others’ internal states and behaviour.

The therapist thus strives to help the patient to identify the way in which his/her feelings are guided by the particular self and other representation that is activated in a given relationship. The patient’s conscious affect, though important given that this is what the patient feel’s troubled by … may yet conceal latent affect that may be even more disturbing to the patient.’ (pg. 158).

Avoiding Advice

Something I’ve been struggling with in my Psychological Wellbeing Practitioner training and clinical work so far is that we are told that the ‘therapy is in the materials’ rather than in ourselves as clinicians. Our role is to guide our clients through self-help material that is appropriate to their psychological distress, and help them to problem-solve any difficulties that they might have along the way. Rightfully, due to our lack of training in delivering any kind of therapy proper, we are told to concentrate on the CBT-based tools and techniques that we are supposed to be imparting to our clients. It is (also rightfully) emphasised to us that the focus should be on ‘collaboration’ rather than any kind of didacticism in our delivery.

However, it feels that by focusing so much on the content and tools that we are providing our clients with, I too easily slip into ‘offering advice’, which I think is usually so antithetical to any kind of meaningful therapeutic intervention! I really do try not to do it, but find myself on occasion saying, ‘What about trying this…’, when discussing how to change a sleep routine, for example. (I feel no temptation to offer any more significant life advice, thank god). One way around this that our supervisors have recommended is to ask questions based on the materials/information you’ve given your client, for example, ‘Why do you think I asked you to read that Booklet?’, ‘Can you explain to me the rationale behind Behavioural Activation?’. But I think those questions can be useful to check or consolidate learning, rather than genuinely encouraging the client to arrive at their own conclusions and answers…

I think this is related to my major qualm with CBT-based approaches in general, the fact that though they profess themselves to be less hierarchical than psychoanalytic or psychodynamic approaches are seen to be (in that old-fashioned idea of psychoanalyst having all the answers but remaining silent), they can end up being more unequal in power dynamics. In the psychoanalytic approach, regardless of whether the analyst thinks she has all the answers, she at least gives the patient space to think things through in their own way, following their own patterns of thought, rather than shoving tips and tricks down their throat in a limited number of sessions. The CBT clinician can end up asking patronising questions (like those above, ‘Can you confirm that you’ve understood all the information I have imparted to you today?’), rather than genuinely engaging with the client’s way of understanding the world, and taking it on its own terms. The CBT clinician is Wise Teacher, who benevolently takes on board the patient’s particular life circumstances to adapt the techniques to them, but nevertheless remains the one with all the information the client needs to live a better life. I guess these power dynamics risk becoming problematic in all kinds of therapies, because essentially, the client is coming to a trained ‘expert’ for help. But I think it’s important that we remind ourselves of the pitfalls of this kind of imbalance as often as possible, and do everything we can to stop offering advice. I’m mainly speaking to myself here.

Book Review: ‘Man’s Search for Meaning’ by Viktor Frankl

This book is divided into two parts. The first part is an autobiographical account of Viktor Frankl’s time in concentration camps during the second World War, and the second part is a more academic exposition of the type of psychotherapy that he created, Logotherapy.

He begins the book with an admission that ‘This book does not claim to be an account of the facts’, which is an interesting start, given that I think most people opening a book about the Holocaust are going into it prepared to be smacked in the face with some cold hard truths, and (hopefully) a willingness to take the survivors’ at their word. My comment isn’t to suggest that Frankl is painting a fictional picture, but he is reminding us that even factual accounts of events, especially those involving immense suffering, will always be shot through with the strong emotions colouring a first-person account. Which makes it then all the more surprising, and initially disorienting, to find in the pages that follow an absence of emotion, to the point where it can feel quite like watching a scientist observing the facts. This is soon explained however, when Frankl writes that: ‘Cold curiosity predominated in even in Auschwitz, somehow detaching the mind from its surroundings, which came to be regarded with a kind of objectivity’ (29). He describes this as a self-preservation mechanism, and we come closer to understanding just what happens at the limit of human cruelty and suffering experienced in concentration camps all over the world.

What the book goes on to teach us, is that positive transformation can be achieved even through the most horrendous experiences of suffering. This is a hard idea to take. Our immediate reaction might be to reject that kind of inhumane suffering forthright as an absolute evil (which it is), but what Frankl pushes us to confront is the possibility that so long as someone is still alive, there is still hope. Something can be made of the situation, even if it is only a kind of ‘spiritual’ and inner transformation. And what he wants us to take from that fact, those of us so far from having any comparable kind of experience of hardship, is that our experiences of difficulty can also be transformed into something meaningful and positive. This is another surprising move of the book – as we might feel uncomfortable trying to place the two different kinds of suffering side by side in this way – especially when ours might feel trivial in comparison.

But that is exactly what he asks us to do, to use his experience as something we can learn from to live our lives in more meaningful ways. And this is how we arrive at Part 2, on Logotherapy, which is a therapy designed to help the individual discover, and live by, the unique meaning that they can create for their lives. Frankl explains that there are three different ways we can discover meaning: ‘(1) by creating a work or doing a deed; (2) by experiencing something or encountering someone; and (3) by the attitude we take toward unavoidable suffering’ (155). (Note the importance of the word ‘unavoidable’ to qualify suffering here, Frankl is adamant that self-inflicted suffering is masochism, without the potential for self-actualization). Where logotherapy differs from Freudian psychoanalysis is that according to Logotherapy, ‘man’s search for meaning is the primary motivation in his life and not a “secondary rationalisation” of instinctual drives’ (105), and this has close links with Nietzsche’s idea of the will to power – but Frankl edits the phrase to will to meaning.

The first way we discover meaning, ‘creating a work or doing a deed’, is fairly self-explanatory and well-established, so Frankl doesn’t dwell on it. The second, ‘experiencing something or encountering someone’, Frankl explains by delving into the meaning of love: ‘Love is the only way to grasp another human being in the innermost core of his personality … by his love, the loving person enables the beloved person to actualise these potentialities’ (116). I think it is still an open question as to whether this kind of ‘therapeutic’ love can exist within a psychotherapeutic relationship (my inclination is towards the negative), but that’s something I’ll write about in a future post. It sounds like Frankl is talking predominantly about real-world love experiences here, so maybe he’d agree with me. The third way to find meaning, ‘through suffering,’ is what Part 1 had described for us, as he was somehow able to transform his experience of suffering into something with meaning. However, I would like to tentatively suggest that perhaps point 1 (‘creating a work or doing a deed’) also has a role to play in what enabled Frankl to find meaning through suffering (point 3). From what we learn in the autobiographical part of his book, it seems as though Frankl’s role as a doctor towards the end of his time in the camps was at least partially what helped him survive, both physically and psychologically. At one point, given the chance to escape, Frankl decides to stay in the camp hospital and tend to his dying patients.

I like the idea of life as guided by those three ways of creating meaning: Works and deeds, experiences and relationships, and the strength to try to step back from our suffering to see what good can come of it, even if that might only be an increased ability to empathise.

I’ll finish by sharing some of my favourite quotes from the book:

‘Yes, a man can get used to anything, but do not ask us how.’ (30)

‘An abnormal reaction to an abnormal situation is normal behaviour.’ (32)

‘A thought transfixed me: for the first time in my life I saw the truth as it is set into song by so many poets, proclaimed as the final wisdom by so many thinkers. The truth – that love is the ultimate and highest goal to which man can aspire.’ (49)

‘This intensification of inner life helped the prisoner find a refuge from the emptiness, desolation and spiritual poverty of his experience, by letting him escape into the past.’ (50)

‘Humour was another of the soul’s weapons in the fight for self-preservation. It is well known that humour, more than anything else in the human make-up, can afford an aloofness and an ability to rise above any situation, even if only for a few seconds.’ (54)

‘Suffering completely fills the human soul and conscious mind, no matter whether the suffering is great or little. Therefore the “size” of human suffering is absolutely relative. It also follows that a very trifling thing can cause the greatest of joys.’ (55)

‘No man should judge unless he asks himself in absolute honesty whether in a similar situation he might not have done the same.’ (58)

‘The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity – even under the most difficult circumstances – to add deeper meaning to his life.’ (76)

‘It is a peculiarity of man that he can only live by looking to the future – sub specie aeternitatis.’ (81)

‘Thus it can seem that mental health is based on a certain degree of tension, the tension between what one has already achieved and what one still ought to accomplish […] What man actually needs is not a tensionless state but rather the striving and struggling for a worthwhile goal, a freely chosen task. What he needs is not the discharge or tension at any cost but the call of a potential meaning waiting to be fulfilled by him.’ (110)

Book Review: ‘The Adolescent Psyche’ by Richard Frankel

This book is filled with wisdom, and I think it would be helpful for any mental health professional working with adolescents (regardless of their preferred brand of therapeutic approach) so I’ll attempt to summarise its main points:

The Freudian psychoanalysts were wrong to treat adolescence as primarily a return to infantile id drives/impulses (only with different conflicts against a more strongly developed superego), and instead it should be seen on its own terms, as a distinct developmental period. We should take the transformations of puberty and the tumultuousness of the experience as meaningful in itself, and with its own progressive functions (telos), rather than as some kind of a backward step. And to do this we should use a phenomenological approach, staying close to the actual experiences of adolescents, rather than theoretically hypothesising what we think is happening…

The best starting point for understanding adolescence is seeing it as time of paradox and conflict – the adolescent is pulled in both ways at once: back towards its childhood, but also towards adulthood and the wider social world (beyond the family unit). This paradoxical position, or point of tension, defines what it is like to be an adolescent. Adolescents are both a child and an adult at once, and they are constantly negotiating between the archetypes representing these: the puer (youth) and the senex (older adult). What I think Frankel takes from Donald Winnicott is also the idea that the boldness and bravery of adolescence is something society needs as a creative and refreshing force; we should appreciate their ‘fierce and stubborn morality’ and their way of refusing ‘false solutions’. Winnicott wrote somewhere that ‘Infinite potential is youth’s precious and fleeting possession’. What typically society tends to dislike about adolescence is something that we should rather appreciate and value in itself – ‘Could we imagine that the instinctual turmoil of adolescence creates a special sensitivity and receptivity to the world and that this can manifest in the pleasure with which ideas are entertained, engaged and undertaken?’ (98)

Adolescents in our era have a particularly difficult time also because there are no, or few, community-organised initiatory rites designed to mark the transition period. Primitive societies usually did have some kind of ritual/initiation designed to mark the young person’s entry into the adult world, which meant that it could be a fairly quick and organised process. Frankel quotes Michael Ventura here: ‘Tribal adults didn’t run from this moment in their children as we do; they celebrated it. They would assault their adolescents with, quite literally, holy terror: rituals that had been kept secret from the young till that moment – rituals that focused upon the young all the light and darkness of their tribe’s collective psyche, all its sense of mystery, all its questions, and all the stories told both to contain and answer those questions’ (69). Because these initiatory rites are an ‘archetypal human need’, our adolescents can’t just skip them, but rather must invent a kind of replacement for these community-organised ones on their own, and evidence of their attempts can be seen in youth gang culture, self-mutilation, substance-abuse, and impulsive/risky sexual behaviour.

Frankel offers Jung’s insights as more helpful and relevant to working with adolescents than Freud’s, primarily because Jung sees the self as a ‘self-regulating system’ (5), in contrast to Freud’s Id which is always in need of externally-imposed prohibitory forces. If parents and clinicians of adolescents remember that the best way to stop someone – particularly an adolescent – doing something unhelpful is to speak to with their own ‘inhibitory’ sense, and get them to arrive at the desire not to do it themselves (rather than simply acting as that external prohibitory force), then they’ll be better able to help them.

Final point that I want to share is Frankel’s suggestion that art and cultural artefacts should have a much larger role to play in clinical work with adolescents. In connection to the idea that inhibitory forces must be engaged with adolescents having a particularly difficult time, Frankel writes that: ‘The inhibition of action produces imagination. Experiencing an inhibition is feeling into the imaginative pattern that contains the impulse towards action. Engaging an instinctual impulse imaginally, feeling where it is rooted in the body, may reduce the need literally to take action. Thus imagination is one of the most effective tools we have in working with adolescents who are prone to impulsive behaviour.’ (169) In order to connect meaningfully with adolescents, we must be prepared to meet them on their own level, which might not necessarily be the ‘literal’ adult world. We must instead stay empathetically attuned to the deeper meanings in their narratives – and art might provide that fruitful meeting-ground.

Book Review: ‘Re-Visioning Psychology’ by James Hillman

If a book had the power to redeem 2020 for me, this one would be it. It’s so refreshing to read a book that manages to change your mindset or show you old things in a new and surprising way, and this one succeeds at both. At the same time, the book gave form and substance to ideas that had been floating around my mind since my disillusionment with psychology (as it is typically taught) during my undergraduate degree and beyond. It reminded me of one of my favourite quotes of Montaigne: ‘We are all patchwork, and so shapeless and diverse in composition that each bit, each moment, plays its own game.’ 

James Hillman was a psychologist and Jungian psychotherapist who founded the movement of ‘archetypal psychology’. The approach is an invigorating blend of philosophy, religion, myth, art, history, classicism, literature, depth psychology, rhetoric, and more…  

The general idea of the book – if it could be summarised easily, which it cannot – is that we humans are both myth-makers and made-by-myths. There is not one ‘I’ within us that directs and controls us, nor something so coherent as an ‘ego’ à la Freud. Hillman complains that ‘diversification of personality, and its differentiation and vivification have been suppressed. “Integration of personality” has become the moral task of psychotherapeutics.’ (2) Instead, we are better thought of as a composite of various mythical archetypes or Gods that have been carried through culture down the ages, and at times we are led by some more than others. Some situations call for certain Gods rather than others, as all are characters each with their own strengths and weaknesses, and a distinct way-of-being. Before I go further, it is worth noting that none of this should be taken literally – literalism is one of the most insidious culprits that Hillman identifies as holding too much power in our era, and that is why he relies on the Ancient Greek mythical personas as the ‘archetypes’ that govern our soul. Hillman defines archetypes in a helpful way for those of us unfamiliar with Jung’s work, as ‘the deepest patterns of psychic functioning, the roots of the soul governing the perspectives we have of ourselves and the world.’ (xix). 

For psychology to return to ‘the soul’, we must remain cognizant of the power each of these various Gods holds within ourselves and allow each space to exist freely, and in relation with the others. That is the benefit of both dreams and pathologies, both give voice to the characters that typically we may suppress when we aim for an integrated (but false) ‘wholeness’ under the ego or subjective ‘I’. I found this idea hugely liberating, and therapeutic in itself somehow. Thinking of our psychopathologies as means through which our internal ‘Gods’ are communicating with us to alert us to some kind of mis-alignment either within ourselves, or between ourselves and our environment, felt novel and comforting. The idea lets us both try to cure or resolve the conflict while allowing us to accept it on its own terms. His own words capturing the role our psychopathologies play are more bombastic, which makes for far more exciting reading: ‘do not forgive me the means by which the divine powers connect and become real: my complexes, which are my sacrifices to these powers … Forgiveness of the confusions in which I am submerged, the wounds that give me eyes to see with, the errant and renegade in my behaviour, blots out the Gods’ main route of access.’ (186) 

Hillman’s approach in general also aligned with my feeling that psychology as a discipline had lost some of the creativity that is necessary to capture the immense complexity and richness that each of us hold within us. That was precisely why I turned to studying literature at postgraduate level after my undergraduate degree in psychology – and I was unsurprised to find that Hillman too had an academic background in literature. But literature and the arts are by no means the only disciplines that can enrich psychology, psychology can only gain by incorporating concepts and approaches from other disciplines, if only because humans (with other interests) are its subject.  

There is far more in the book than I can adequately capture in one post, so I do really urge you to find a copy of this book and read it for yourselves.  

Which book has been your favourite of 2020? 

Book Review – ‘Madness and Modernism’ by Louis Sass (2017 Ed.)

This ground-breaking work revises traditional understandings of schizophrenia as ‘a form of encroaching dementia, regression, or dominance by instinct and the irrational’ and instead views it as ‘involving unusual forms of self-consciousness together with associated alienation and withdrawal – not only from the surrounding world and other human beings, but also from one’s own thoughts, feelings, and bodily presence.’ (Preface).

It is a work of ‘comparative phenomenology,’ which uses modernist art and literature as a tool to help us better understand schizophrenia. By placing both next to each other, Sass draws out some striking similarities to illuminate a potential logic that might underpin them both.

Sass argues that both modernist art and schizophrenia can be understood as evidencing ‘hyperreflexivity’ and a concomitant ‘alienation’. The range of material that he covers, and the detailed analyses of case studies of individuals with schizophrenia, make this book a brilliant attempt at better understanding a mental disorder that has, since its conception, baffled psychiatrists and researchers.  

My own academic background is in both psychology and literature, so I was extremely excited to see the disciplines used productively together to help us understand, phenomenologically, madness – and, by bringing its opposite into relief, sanity as well. Sass doesn’t try to explain the aetiology of schizophrenia, other than gesturing towards the likely conclusion that it will involve several primary and secondary factors, in unpredictable combinations, and this is a good thing. His aim is to understand, rather than explain, and this book does a fantastic job in making sense of symptoms and behaviours that have typically been distinctive by their complete incomprehensibility. I thoroughly recommend this book to anyone interested in phenomenological psychopathology and/or modernist art.

I’d be very interested to know whether any other scholar has attempted a study of contemporary, 21st century art and thought, in its relation to another form of madness? It seems that Sass is right in identifying the parallels between 20th century modernist art and schizophrenia, but times have changed, and I wonder what the contemporary parallel could be? The present day has moved interestingly away from the ‘modernist/postmodernist’ zeitgeist that Sass studied, into new territory, and I think one deserving the same kind of scrutiny that Sass gave the 20th century!

Quotes from Freud (Standard Edition, Complete Works, Vol. XXI)

The Future of an Illusion (1927)

‘There are two widespread human characteristics which are responsible for the fact that the regulations of civilization can only be maintained by a certain degree of coercion – namely, that men are not spontaneously fond of work and that arguments are of no avail against their passions.’ (8)

I don’t agree with the above quote, I would counter that human beings are spontaneously fond of meaningful work, and that there are countless examples of men forgoing passion for legitimate reasons.

‘So long as a person’s early years are influenced not only be a sexual inhibition of thought but also by a religious inhibition and by a loyal inhibition derived from this, we cannot really tell what in fact he is like.’ (48)

Civilization and its Discontents (1930)

‘If we want to represent historical sequence in spatial terms we can only do it by juxtaposition in space: the same space cannot have two different contents. Our attempt seems to be an idle game. It has only one justification. It shows us how far we are from mastering the characteristics of mental life by representing them in pictorial terms.’ (71)

^ This quote felt relevant as an argument against the reductionist drive to explain everything in terms of neuroscience! But I’m probably stretching it a little...

‘Happiness, in the reduced sense in which we recognise it at possible, is a problem of the economics of the libido. There is no golden rule which applies to everyone: every man must find out for himself in what particular fashion he can be saved.’ (83)

‘In this respect civilization behaves towards sexuality as a people or a stratum of its population does which has subjected another one to its exploitation.’ (104)

The following two pessimistic quotes I am sorry to say that I think he’s right:

‘In abolishing private property we deprive the human love of aggression of one of its instruments, certainly a strong one, though certainly not the strongest; but we have in no way altered the differences in power and influence which are misused by aggressiveness, nor have we altered anything in its nature. Aggressiveness was not created by property.’ (113).

‘It is always possible to bind together a considerable number of people in love, so long as there are other people left over to receive the manifestations of their aggressiveness.’ (114)

‘And now, I think, the meaning of the evolution of civilization is no longer obscure to us. It must present the struggle between Eros and Death, between the instinct of life and the instinct of destruction, as it works itself out in the human species. This struggle is what all life essentially consists of, and the evolution of civilization may therefore be simply described as the struggle for life of the human species. And it is this battle of the giants that our nurse-maids try to appease with their lullaby about Heaven.’ (122)

‘Just as a planet revolves around a central body as well as rotating on its own axis, so the human individual takes part in the course of development of mankind at the same time as he pursues his own path in life.’ (141)

Mysterious Pain

‘Just try – in a real case – to doubt someone else’s fear or pain!’
(303. Ludwig Wittgenstein, Philosophical Investigations)

Recently I’ve been bothered by a few mysterious and troublesome physical health problems, which has meant lots of doctor’s calls and appointments, but with little clarification. Luckily, my problem is minor, and its main annoyance is the fact that I don’t know what it is. But it did have one big benefit, which was that it sparked an interest in (actual) chronic pain conditions or Medically Unexplained Symptoms (MUS), and what psychological support is offered in those cases.

During one doctor’s appointment, after he did lots of tests and all of them came back normal, I gave a breathless spiel documenting every possible symptom that’s occurred recently hoping that one of them might be some kind of a magic clue. The doctor let me finish, then very gently asked if I might be an anxious person. This threw me a little, because I don’t think I am anxious normally, but of course I probably did sound a little anxious to him and have been more so recently with all these unknowns around my body. I said no and he seemed to believe me.

Leaving that appointment, with not much more information or help than when I went in, I noticed that I did nevertheless feel slightly better, or at least calmer. He was a caring doctor with a nice, patient manner, and it felt comforting to have someone thinking with me about what might be the issue. It felt less lonely. It also felt good to be proactive about the situation – the previous month I had been monitoring symptoms and hoping they’d go away soon, which only increased my anxiety when they didn’t appear to do so. This reminded me of research finding that people’s mental distress sometimes decreases once they know they are about to begin therapy or treatment, even if they haven’t started yet. Simply anticipating support often gives us a little boost of optimism. (I can no longer find where I read this finding but if anyone else remembers it please share!) I also realised that someone merely validating your discomfort often makes it a little more bearable. ‘A problem shared is a problem halved,’ as the saying goes. But most of all, I was grateful for the fact that the doctor seemed to believe me and my description of my symptoms, as I know that this is not always the case, and especially not so for ethnic minorities and/or women.

Last week at work, I triaged a Somalian lady, who told me about the traumatic experiences she had during the pregnancy of her third child. Six months into her pregnancy, she felt severe pains in her womb, but all the medical professionals she told dismissed it and told her not to worry. Eventually she persuaded her husband to take her to a different hospital, and luckily there someone listened to her and the necessary procedures and adjustments were made, but her son did have some complications because of the time initially wasted. I don’t want to make any assumptions as to why this particular lady wasn’t believed in this case, as I have no information about anyone involved, but at the same time, I am all too aware that the fact that I am middle-class, white, and speak with an accent that marks me as ‘educated’, gives me huge advantages whenever I speak to all kinds of professionals. My concerns are often believed and taken seriously, while others who perhaps fit less smoothly into the conservative British system will no doubt have a far more difficult time navigating it, and sometimes with disastrous consequences.

Research has investigated these disparities. A study in the US found that differential treatment of pain for Black vs. White Americans (with Black Americans being systematically undertreated for pain) was related to racial biases about biological understandings of pain experiences in medical professionals and lay people. Horrifyingly, ‘half of white medical trainees believe such myths as black people have thicker skin or less sensitive nerve endings than white people’ (reference). It’s likely that a similar situation exists in the UK as well.

These biases also exist when it comes to gender, with women’s pain often being treated less seriously than men’s. A study found that women presenting at A&E with acute abdominal pain were less likely to be given opioid pain killers than men presenting with the same issue. A review of the evidence around pain treatment and gender biases identified many studies revealing that woman with chronic pain are assigned psychological rather than somatic causes for their symptoms, and often given anti-anxiety medication instead of painkillers.

The fact that it’s treated less seriously might also have to do with the huge gender disparities in reporting pain, with women far more likely to report pain than men, augmenting (or a result of?) the traditional conception of men as ‘stoic’ and women as ‘hysterical’. Women are also far more likely to experience chronic pain conditions such as fibromyalgia, IBS, interstitial cystitis, and temporomandibular disorders (reference). Since Christianity at least, women have had a complicated relationship with pain (Genesis 3:16 ‘To the woman, God said: “I will greatly multiply your pain in child bearing; in pain you shall bring forth children…”.’).

‘Art Must Be Beautiful’ (1975) Marina Abramović

Biological explanations have been offered for why women seem to experience more pain than men, but there is increasing attention on the psychosocial explanations that might be contributing towards these gender differences. This is important to acknowledge and research further, but it might also be a double-edged sword. What may happen is that when patients come to the doctors with ‘unexplainable’ symptoms (which do not respond to treatment and there appears to be no identifiable cause), doctors start looking towards psychological/social factors. They find that people with conditions such as Interstitial Cystitis (IC), for example, are far more likely to also suffer from mood disorders than healthy controls. One such study concluded that: ‘IC/BPS patients frequently exhibit several mental health disorders and negative personality traits [like hypochondriasis]. Therefore, in addition to targeting the bladder pathological condition, psychological intervention focusing on personality traits and anxiety mood status should be provided to improve quality of life of IC/BPS patients.’. The same study also found that ‘the duration of the symptoms is longer in depressive IC/BPS patients,’ so they seem to be implicitly suggesting that perhaps the depressive symptoms are somehow prolonging the physical pain symptoms, which is why they are recommending treating the depressive symptoms at the same time – in order to ‘attack’ the problem from another angle.

It obviously makes more sense, however, to understand this correlation as resulting from the fact that you’re more likely to feel depressed or anxious if you’ve been suffering from medically unexplained painful symptoms for a prolonged period of time.

Having said that, it may not always be so simple. Research is finding evidence of Adverse Childhood Experiences (ACEs) as potentially playing an active role in contributing towards chronic pain conditions: ‘specific ACEs (e.g., verbal and sexual abuse, parental psychopathology, and early parental loss) were associated with the painful medical conditions’. And when people are researching ACEs they are particularly thinking of the ‘psychological’ damage that results, rather than looking into long-term physical consequences. But it looks like the distinction between the psychological and the physical is (rightfully) becoming ever-more blurred. The title of the just-quoted paper is: ‘When Emotional Pain Becomes Physical’, and I hope that a lot more research goes into this murky area of the overlap between the psychological and the physical – as many are starting to agree, it’s time we moved past Descartes.

Another shocking finding that I came across was that among women who had been through severe or chronic abuse, there was a 79% increased risk of being diagnosed with endometriosis, compared to women who hadn’t been abused. This is necessary research into a hugely debilitating condition that affects around 10% of women of reproductive age world-wide.

At the same time, we must also remain cautious that we do not too easily equate chronic pain conditions with past histories of trauma or psychological ‘disorders’. Even if it is acknowledged to be somehow a consequence of trauma, that sometimes puts too much ‘responsibility’ or ‘blame’ onto the patient experiencing the symptoms, and away from the medical community. Medicine was a discipline created by men, so naturally the conditions that affect primarily women are often the ones still under-researched and poorly understood. And then it’s too easy for doctors to assume that, if medicine hasn’t explained it yet, it must be beyond their remit and in the domain of ‘the mind’ instead. (Funny also that these doctors who start leaning on psychological explanations for what they cannot biologically understand are also the ones that may also subscribe to a reductionist physicalist explanation for other mental health conditions!).

We have no idea what direction things happen in – whether it’s a biological problem that causes comorbid mental health problems, or MH problems which drive mysterious physical symptoms, or even emotional abuse that leads to depression which then manifests in physical symptoms. More likely, it makes no sense to think even of causal directions or separate domains influencing each other in turn. We are bodies with minds embedded in worlds so all those strands will be inextricably related and influencing each other all at once, in a non-linear and mutually reinforcing way.

I haven’t reached any neat conclusion in this post, but just wanted to share some interesting findings that I’ve come across. All I can say is that I hope research continues to examine the links and threads that are found in complicated conditions like those still misunderstood or chronic conditions. I also want to start thinking about what psychological support can be offered to people who suffer from these conditions which explicitly doesn’t imply that their suffering is in any simple sense ‘psychologically’ caused. How can we make people feel better when their own body becomes a mystery both to them, and the medical community? At the moment, it appears that the most beneficial support for people with chronic conditions comes from support groups with other sufferers, suggesting that so far, the most helpful psychological support is simply knowing that others are going through something similar. So, validation offers some, though perhaps minimal, respite. CBT also seems to help, but presumably mainly when it doesn’t imply that it’s your ‘negative beliefs’ that are causing the pain in the first place, and instead offers tools for focusing your attention on other things.

This is only an initial foray into studies on chronic pain conditions and psychological distress, but I hope to continue to read and learn more.

Are We Fudging IAPT Data?

In my PWP training today we were taught how we are supposed to record our targets and recovery rate data, and I think I’ve just realised one way that IAPT services might potentially be overestimating their success rates…

We were told that if, by the end of the 6 Low Intensity CBT sessions we offer (outcome measures for depression and anxiety are taken at each session), the client’s scores on the two main measures have gone to ‘recovery’ (meaning below caseness, so scoring below 9 for the PHQ-9 or below 7 for the GAD-7) then we mark the final session as a ‘treatment session’, the system will count that client as ‘recovered’ – which makes sense, and that’s all fine and well.
But if we arrange a ‘follow up session’ with them in a few weeks time, and find that their scores have risen to now above caseness, then we are told to mark that session as a ‘follow up session’, and it will not count towards our recovery rates. So, we would have learnt that the person has not in fact really benefitted from the sessions that we have given them, or at least not in any lasting way, but on the system that rise in scores will essentially be ‘invisible’, so ours, and our companies recovery targets, will be unaffected. It will look like IAPT did its job and was successful in ‘curing’ the individual, even though the benefits of our treatment have actually not had too much of a lasting impact, and so weren’t so good after all.

We were also taught another way that might overestimate IAPT’s success rate. If, at the end of the 6 sessions the client’s scores have not lessened enough for them to count as ‘recovered’, but at the follow up session a few weeks later we find that their scores have dropped to below caseness, we are told to mark that extra session as a ‘treatment session’ (not a ‘follow up session’ as in the situation that I’ve described above) so that on the system it will count as thanks to our treatment, and so count towards our recovery rate. If we’re feeling generous to IAPT, we may say that our sessions and support just ended up having a bit of a delayed effect – maybe they were a bit slow to apply all the ‘tools’ we gave them and so we do deserve to pat ourselves on the back. But, you could just as well argue that maybe their life just improved slightly (nothing to do with us), or it was a purely natural recovery (generally consistent low mood does tend to improve over time even with no treatment). So basically we’re allowing natural recovery to count as IAPT-caused, when there is no true measure as to whether this was actually the case.

Neither of these situations are explicitly fiddling with the data – we are still trusting and taking at face value someone’s scores (this is to say nothing of the problems that may inhere in using the outcome measures that IAPT services do, for more on this see Levis et al. 2020), but it’s easy to see how they might lead to a slight bias towards favouring IAPT Guided Self-Help treatments which may not reflect their actual efficacy…

Would be very interested to hear people’s thoughts on this!

‘Epistemic Injustice’ in Therapy?

Most of the time I spend scrolling through Twitter is probably time I won’t ever get back, but the other day I ‘overheard’ an interesting conversation between two academics on what one said was psychological therapy’s primary aim: constructing a sense of dignity, and the other academic voicing the opinion that in fact, therapy often risks having the opposite effect. It also introduced me to the work of philosopher José Medina on ‘epistemic injustice’ – which I will write about in another blogpost.

I will quote Nev Jones’s Twitter thread before adding my thoughts:
“I fear I’m still not great at this in Tweet form but let me try. Again very important to my argument is that these are risks, not inevitabilities. (1) when, to quote José Medina, “the epistemic agency of an informant qua informant is…subordinated to that of the inquirer’s” Or, as he continues “at the service of the inquirer’s questions, assessments and interpretations” — in which case there can be no full & equal “epistemic cooperation”. [Here one might discuss at length how this does/doesn’t play out in eg in CBTp-style ‘reality testing’]. Then there is the issue of communicative “reversibility” and “reciprocity” which JM frames as central to equal epistemic exchanges. Reciprocity seems more fundamentally absent from the traditional therapeutic relationship but again a point one could debate at length…JM then underscores the interactional relationship between hermeneutic & testimonial injustices, viz “interpretive gaps are formed & maintained [when] those who are struggling to make sense are persistently not heard & their inchoate attempts at generating new meaning… unanswered”. To continue “because of difficulties in hearing and interpreting certain things — because of hermeneutical I sensitivities — people’s credibility gets undermined. Testimonial and hermeneutical insensitivities [thus] converge and feed each other.” “[Once] hermeneutical gaps are formed…they handicap our communicative lives and are hard to eradicate.” I will stop there and say that said gaps of course emerge at multiple levels of discourse—dyadic exchanges and also the more macro levels of clinical knowledge generation.” (bold font added by me)

I’ve recently started my own therapy, and this was something I felt almost immediately – the quite unsettling one-sidedness of the therapeutic relationship. Nev Jones and José Medina raise the possibility that this inequality might be more damaging than beneficial, if it perpetuates the sense that the patient is ‘at the service of the inquirer’s questions, assessments and interpretations.’

I can think of two things that might reduce the risk of this happening:
1) The therapist should undergo their own in-depth therapy so that they truly understand how it feels to be on the other side of the power structure. Only then can they properly empathise with how their patient might be feeling during this organised, and often expensive, form of self-disclosure.
2) We can think of Jessica Benjamin’s psychoanalytic Recognition Theory (also see her book ‘Beyond Doer and Done To‘) which describes how analyst and analysand can meet and speak as equals joined by the ‘Third’. Benjamin’s work centres around achieving that ‘reciprocity’ that may or may not be present in the therapeutic encounter.

To expand on Benjamin’s theory – she argues that the therapeutic encounter should be understood as dynamic, and with a two-way directionality, both analyst affecting the analysand, and vice versa. One way the analyst could highlight this ‘two-wayness’ would be by telling the analysand how what they are hearing is making them feel. Only when the analysand starts to see themselves as a being who makes an impact on other people’s subjective experiences can they regain the sense of agency that will help them recover. The risk this runs is that the analyst must make sure that they don’t then steer the conversation too much onto their own thoughts and feelings – it should always be based in the intersubjective encounter.

This is related to what I think might be the fundamental hurdle and balancing act implicated in the therapeutic encounter – the therapist must somehow help the patient regain a sense of agency, while at the same time not ‘blame’ them for the problem they came in with in the first place. The therapist needs to communicate: that what happened to you wasn’t your fault, but now you must find the strength and agency towards repairing that ‘damage’. It aligns with an interesting and complex picture of free will and responsibility, that I am yet to understand fully…