Working towards What?

Do you know what your goals are? And if so, are you certain that if you achieved them you would be happier, or more satisfied, than you are now?

I think many of us might answer negatively to at least one of those questions, and I’m surprised that CBT thinks that most of us know what our goals are, but that we just have difficulty working towards them.

I’m closer to thinking that most of us would be able to work towards goals that we have identified that are meaningful to us (they would be inherently aligned with us and therefore more likely to be motivating), but our difficulty is more often rather in identifying what is important to us.

So while CBT sounds like it’s a therapy that believes in the agency of the individual, I think more exploratory approaches like psychoanalysis or psychodynamic approaches have more faith in the individual’s agency to achieve their goals.
CBT assumes that we know what our goals are, just need help achieving them with a boost of willpower.
Psychoanalysis assumes that we are pretty good at going after what we want, but we often need help clarifying and unearthing those ‘truer’ or more authentic values and goals.

What sparked this thought was a guilty feeling, because I have recently started twice-weekly psychoanalysis, whilst clinician-me delivers six 30-minute sessions of Low Intensity CBT to clients suffering from similar (if not far more debilitating) mental health difficulties than patient-me. I know that if I switched roles, if I approached myself as PWP, and was told by PWP me to identify ‘Goals’ to work towards across 6 weeks in ‘therapy’, I’d be stumped. It would be totally meaningless, and potentially even distressing. What I am beginning to identify – slowly, tentatively – in psychoanalysis, is that sometimes seeking and going after goals is a blind race towards, or perhaps more accurately away from, something else as-yet-unidentified. And we don’t necessarily know what we should be striving towards or moving away from until we have stopped for a moment to reflect, and I don’t mean for a matter of moments or even days, but a stretched-out kind of reflection that happens best in the presence of a non-judgemental other. I think I am learning that healing (sometimes) can come from a moment of pause, or stillness, where for a couple of times a week you don’t need to press forward towards an unending improvement.

Admittedly, this will not apply to everyone. Despite my belief to the contrary, many of my clients say that they have found our sessions helpful and they even seem to ‘recover’ as according to the PHQ-9 and GAD-7. So, clearly, the approach taken by psychoanalysis as opposite to CBT is not for everyone, sometimes we do just need that boost of motivation, or a few handy techniques for stopping worrying so much. But maybe it’s a question then of time of life, sometimes we need CBT goal-oriented help, and at other times we need just a space to think and speak.

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.

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…

Louis Sass on Wittgenstein and Freud

[This blog captures my initial thoughts while reading Louis Sass’s chapter in Wittgenstein, Theory and the Arts (eds. R. Allen & M. Turvey), titled: ‘Wittgenstein, Freud, and the Nature of Psychoanalytic Explanation’. The bracketed page numbers are from that book.]

Louis Sass begins by acknowledging the complex relationship Wittgenstein seemed to have with Freud and the Psychoanalytic method. Wittgenstein valued the profundity of Freud’s discoveries about the human unconscious, but disagreed with Freud’s attempt to transform this theory into a scientific, deterministic, enterprise: ‘What Wittgenstein criticises, then, is not the adopting of such frameworks but only the tendency – which he discerns in Freud and various philosophers – to mistake the frameworks themselves for something in the nature of empirical assertions or discoveries.’ (260).

While theorising explanations of human action, Wittgenstein distinguishes between causes and reasons, claiming that both partake of entirely different ‘language games’. Causes establish empirical correlations, while reasons are used to rationalize or see the point of our own or others actions, and can therefore take only an ad hoc form.  

Sass writes that Freud generally portrayed himself as a scientist pursuing causes for phenomena. ‘But Wittgenstein suggests that Freud’s actual methods are, in fact, more akin to those of an aesthetic investigator who puts things side by side or strives to give a good simile, as when a critic of literature or art seeks agreements to the aptness of certain comparisons or tries to sum up a complex artistic work or effect in a succinct expression.’ (261).

‘For Wittgenstein, a key difference between causes and reasons seems to be that, whereas causal explanation operates in the third-person realm of objective or objectifiable reality, there is something more first-person about the nature of reasons, some way in which reasons are intimately connected with the point of view of the person whose action is being accounted for.’ (262)

I wonder whether this ‘something more first-person about the nature of reasons’ can be elucidated using Polanyi’s conception of tacit knowledge (which he says underlies all forms of knowing), or whether they are incompatible positions? Polanyi writes that: ‘Our body is the ultimate instrument of all our external knowledge, whether intellectual or practical. In all our waking moments we are relying on our awareness of contacts of our body with things outside for attending to these things.’ (Loc. 322 in Kindle book ‘The Tacit Dimension’). Sounding much like a phenomenologist, he is saying that because we are bodily beings, all of our reasons (and much else) will have this ‘first-person nature’. Polanyi interestingly qualifies that this does not necessarily make them ‘subjective,’ but that is a topic for another post.

(As a side note: There seems to be ongoing debate as to whether this tacit element has much explanatory value, and might not be worth being scrapped, sticking instead with the anti-private language approach that Wittgenstein puts forward. See Tim Thornton’s chapter in The Oxford Handbook to the Philosophy of Psychiatry which compares Wittgenstein and Polanyi and concludes that Polanyi’s tacit knowledge is better conceptualised as ‘context-dependent knowing’, leaving out much of the tacit bit.)

Back to Sass – The biggest difficulty for bringing together Wittgenstein and psychoanalysis is Wittgenstein’s emphasis that self-ascriptions are sufficient and do not require any grounding, or private, introspective access to ‘inner’ mental states; whereas psychoanalysis is of course all about those private inner mental states… (Polanyi would presumably be on the side of the psychoanalysts here).

Sass emphasises that even if Wittgenstein is suggesting that no causes can be given for motives, we shouldn’t take this in a postmodernist, sceptical or relativistic fashion. To make this point he enlists the help of a philosopher personally acquainted with Wittgenstein, Freidrich Waismann, who, in his essay ‘Will and Motive’ describes a way we can understand motives as something between a ’cause’ and a ‘reason’. This treats motives as a ‘family-resemblance’ concept that has no clear boundaries (276), and is able to encompass two extremes: the cause (lawlike) and the purpose (constituted within).

Waismann acknowledges the inherent difficulty in disciplines such as psychology (and philosophy) because of the fact that ‘our ordinary concepts are too rigid’ (qtd in Sass 277), ‘we need something looser, more indefinite … In order to describe the mental we need a language that is just as flexible; which, of course, runs counter to our usual way of thinking.’

And it is here that Sass neatly brings back mention of aesthetics: ‘The project of understanding motivation – one’s own or that of another – also has much in common with that of artistic representation or appreciation, for it is something that demands active, imaginative interpretation or an attitude of subtle, connoisseur-like discernment toward the world.’ (278) Understanding motives is like understanding aesthetic patterns but this does not lead us to subjectivism in a postmodernist way, nor to pure behaviourism. (Here Sass also references Merleau-Ponty on ‘reciprocal expression’ which I have made a note to follow up in future reading).

(Earlier in the chapter Sass mentioned Wittgenstein’s notion of ‘Seeing-as’ or ‘Aspect-seeing’, which is when we can see something in a new way, while knowing that it itself has not changed (274). I always think of art’s ability to provoke this in us…)

I love the quote from Waismann that follows so I will quote it at length: ‘There really is something like digging down to deeper layers, becoming more truthful, struggling passionately, while things become clearer and clearer. There is undoubtedly such a process of plumbing the depths in which one penetrates to one’s innermost motives. So things are not entirely subjective; there is truth after all. And yet! When we want to put our finger on it, it will not stand up; when we look more closely at it, it looks different again. It is an interpretation and yet something more than an interpretation, knowledge and yet not quite knowledge: what are we dealing with? […] We require a composite concept that combines “knowing, acknowledging and interpreting. For fathoming a motive touches on all three”.’ (279, and 136 in Waismann.)

Sass concludes by summarising his two main points. What Wittgenstein and Freud have remarkably in common is their shared ideal of clarity. Wittgenstein says so much by explicitly comparing his method to psychoanalysis: ‘It is a principal function of philosophy to warn against false analogies. To warn against the false analogies which lie embedded in our forms of expression without our being fully conscious of them. I believe our method here resembles psychoanalysis which also makes conscious the unconscious and thereby renders it harmless, and I believe that this resemblance is not purely superficial. (Wittgenstein manuscript 109, 174)’ (Sass 280). (But couldn’t you say that surely most philosophers share this ideal? I imagine that even a rouge philosopher wanting to deliberately complicate our understanding of the world would be doing so in order to make that complexity clearer in some way?)

Where Wittgenstein and Freud most drastically differ, though, relates to Wittgenstein’s second ideal of ‘awe or wonder’. Freud’s method towards greater understanding of the the human psyche was driven by the desire for scientific objectivism. This was anathema to Wittgenstein, who repeatedly argued that we should remain aware of the limits of scientific knowledge, and not try to cross those lines. Wittgenstein wanted us to avoid rationalising things into generalisations or too-clear pictures. Sass quotes Wittgenstein earlier in the chapter: ‘And may we not advance any kind of theory … We must do away with all explanation, and description alone must take its place.’ (273) And of course his most famous quote encapsulates this sentiment: “Whereof one cannot speak, thereof one must be silent.” (Tractatus)

It’s somewhat ironic now that Freud is treated more seriously in humanities/arts disciplines than the sciences, and Wittgenstein’s (lay) reputation remembers predominantly his dry and methodological treatment of how we use ordinary language rather than his mysticism; but I think that is precisely the richness and value of both thinkers – both occupy an ambiguous space between two extreme camps, and can’t easily settle into either, as they themselves well knew.

Final thought – I think this is also why I am so interested in Michael Polanyi’s work at the moment, because he seems to have tried to build a comprehensive theory explaining why sciences and the humanities aren’t diametrically opposed projects at all, an idea he also lived by.

Michael Polanyi on the Arts

I have recently become interested in how the scientist-turned-philosopher Michael Polanyi’s understanding of the arts can help us theorize how creating or appreciating the arts has a role to play in clinical psychology, in particular psychoanalytic or psychodynamic approaches.

In his 1958 book Personal Knowledge, as he leads up to a discussion of ‘indwelling’, Polanyi sets forth a theory of the arts. He compares the abstract arts (music, abstract painting), to pure mathematics, describing both as ‘appreciated for the beauty of a set of complex relations embodied in them.’ Like mathematics, music ‘articulates a vast range of relationships for the mere pleasure of understanding them’ (193).

He continues: ‘Laments for the dead and songs of love are likewise formulations of earlier shapeless emotions, which are refashioned and amplified into something new by words and music.’ (194). If the arts give words to ‘shapeless emotions’ which are then ‘refashioned and amplified into something new’, is this not what psychoanalysis is trying to do within the psychoanalytic encounter?

How the arts differ from mathematics or science is that they do not try to map precisely what those underlying formulations are. The scientist is trying to construct a framework which will handle experience on our behalf, while the artist is content to allow that framework to remain such that allows us a ‘contemplative experience’ of those shapeless emotions. At the other extreme is mystic experience, which attempts to ‘dissolve the screen [which separates us from experience], stop our movement through experience […] we cease to handle things and become immersed in them.’ (197). Appreciating artistic works, we are able to contemplate those ‘shapeless emotions’ in a position that is at once immersive and detached:

‘Music, poetry, painting: the arts – whether abstract or representative – are a dwelling in and a breaking out which lie somewhere between science and worship […] Owing to its sensuous content a work of art can affect us far more comprehensively than a mathematical theorem […] Art, like mysticism, breaks through the screen of objectivity and draws on our pre-conceptual capacities of contemplative vision.’ (199).

This intermediate position of the arts reminds me of psychoanalysis as a discipline caught somewhere between a science (as holding universal ‘truths’) and an art (as always coloured by our ‘personal’ or  ‘tacit’ knowledge, that lies beyond the grasp of scientific propositions). And so, if the two share this liminal position, might they both have interesting things to teach each other?

A Common Criticism of CBT

Some critics of Cognitive Behavioural Therapy (CBT) have focussed their attack on its underlying theoretical assumption that our ‘beliefs’ cause mental distress. That’s a pretty easy target, though, once you look at the correlations between factors like poverty, abuse, systemic oppression; and mental distress – in those cases, would you really call their thinking ‘faulty’ when it reacts against these conditions? It seems more mistaken not to be distressed in those cases. So naturally, CBT theorists adjusted and now recognise that external factors play a significant role in contributing to mental distress.

In practice, that meant that CBT moved away from the ‘C’ and towards the ‘B’ (Behaviour): instead of telling the individual to change their thoughts, the idea now was to get them to change their behaviour, which would hopefully go some way towards fixing their unhelpful environment. For example, if poverty is making you depressed, why not get a job? If your husband’s drunken violence is causing you anxiety, why not go to a friend’s house next time this happens?

There are obvious problems with this – most glaringly that the focus is still on the individual (rather than the structural or societal), however, I do understand that psychologists are limited in the areas that they can help with – they aren’t politicians or social workers, after all.

Another way that the CBT theorists tried to update the underlying philosophy of CBT was to think in a less linear (‘x causes y’) fashion, replacing this with a cyclical framework of our thoughts, behaviours, emotions and physical feelings as all interrelated and mutually reinforcing.

CBT formulation - 80ss Anxiety - POINT-1

This served to disperse the blame, so now we can’t ever quite say for certain which came first: the faulty thoughts or faulty environment… Do we pick poor husbands because we think badly of ourselves, or do we think badly of ourselves because of our abusive partners?

The 5 Areas Model we are taught appears comprehensive, but I still get the feeling that the CBT-based approach is missing out on some vital aspects of human life. Predominantly, I begrudge the lack of a detailed discussion on affects and moods as non-propositional, and the importance of intersubjectivity. CBT seems to be based on some unhelpful and out-dated conceptions of how we exist in the world. The underlying theory describes the human being in a mechanistic, representational manner – someone that understands the world in propositions (or mental images) and then acts accordingly.

I am not breaking new ground by arguing that CBT feels impoverished in these respects – Anthony Ryle’s psychoanalytic alternative to CBT, CAT (replacing ‘Behavioural’ to ‘Analytic’), attempts to redress this individualistic approach by creating a space for ‘Reciprocal Roles’ formed in our early relationships with caregivers. I have not yet read as much about CAT as I would like to (I’ve only just started reading Introducing Cognitive Analytic Therapy [Ryle & Kerr 2020] – and am very much enjoying it so far), but I think there’s a chance that it also remains too firmly representational, and doesn’t fully conceptualise things like affects and moods that couldn’t easily be formulated into propositions. From what I know so far, and as suggested by its name, CAT takes a similarly computational approach to the human psyche, only it has broadened the roots of these cognitions to include our early relationships, instead of keeping the focus on the individual as a separate being. It sees cognitions as arising within intersubjective relationships and from the roles we assume within those relationships. I like this expanded concept, and perhaps I’ll find that it is a good enough update to the theory, but I will save that conclusion until I’ve finished the book. From where I stand now, however, I don’t think that we should limit ourselves to cognitions that can easily be translated into propositions or even mental images.

I’ve developed this view through my reading of phenomenological approaches to psychology, starting with Maurice Merleau-Ponty who argued that perception is direct (and hence against the subject-object distinction), similar arguments put forward by the ‘Ecological’ psychologist James Gibson, the philosopher of psychiatry Thomas Fuchs who writes of affects and moods as existing in the ‘backdrop of an experiential field’, and Enactivist philosophers of mind (Varela, Thompson, De Jaegher) who stress the ‘embodied, embedded and extensive nature of mentality’…  

Perhaps it’s a matter of temperament, but these thinkers seem to capture something that fits more with my experience as a human being. I can’t convince myself that ‘representations’ or mental images play as large a role in our thoughts, feelings and behaviour as cognitive scientists seem to believe. Maybe I have a distinctly empty inner world, but I hardly ever seem to be thinking of any clear representations of things, or even thoughts in words. From his case studies it sounded like Beck’s clients had similar difficulty in formulating what they were thinking. Of course, if I were to be asked, as they were, ‘what thought went through your mind when you last felt sad?’ I could probably think of something (as they did) but I have a feeling that I’d be creatively guessing rather than faithfully reporting what was going on my mind. Usually when I feel low it is due to a more vague sense of wrongness, more like a mood that colours my entire environment, rather than a clear ‘negative thought’; and might be due to some kind of interpersonal shift in atmosphere that I will have picked up from my partner, for example. These are distorted once they are forced into the form of a clear proposition – ‘my boyfriend doesn’t like me’ – would be the forced answer I’d give to Beck, but that wasn’t really what I thought, so if he started listing reasons as to why that might not be the case I’d find it a waste of time, or if he did a bad job and didn’t persuade me, insulting.

At the same time, I don’t believe that we need to make this an either/or dilemma – I don’t want to say that cognitive representations do not exist full stop – they may well do when we are more explicitly remembering or imagining. I just don’t think that ‘internal representations’ are all that we have – more often it feels as though we are behaving in a more automatic-pilot way – perceiving and responding to the world as it happens, and as we move through it. And I think that our moods and feelings are born and played out within interpersonal relationships and situations, rather than our inner mind observing and formulating its own little images.

The counterargument could be made, however, that maybe the CBT ‘philosophy’ doesn’t quite capture it all, but this isn’t important because the therapy works. My tutors on the Psychological Wellbeing Practitioner course are always drilling it into us not to think too much about our client’s past experiences or even their thoughts – because it’s their behaviour that we need to change, as this will have the biggest benefits. How would I go about shifting someone’s mood anyway, if it really is that nebulous thing that I have described? Beck wanted to make a practitioner’s science, not a philosophy of mind. But the low intensity CBT approach in IAPT is getting only 50% recovery rates at the moment, so I don’t think anything’s decided yet, and we should probably keep thinking and revising…

Coaches or Clinicians?

I’ve recently started training to become a Psychological Wellbeing Practitioner in an IAPT (Improving Access to Psychological Therapies) service, and what that means is that I will soon be able to deliver Low Intensity Cognitive Behavioural Therapy to ‘clients’ with mild to moderate common mental health problems such as depression and anxiety.

The training is delivered 2 days per week by lectures and seminars from University College London, and the remaining 3 days per week I spend working at my IAPT service doing assessments and low-intensity treatments.

One thing in particular that we learnt in the first week threw myself and my fellow Trainees: the fact that we should not think of ourselves as therapists or clinicians, but as coaches. We didn’t do so big-headedly, but in our previous role (when we were doing Triage Assessments and offering people Step 2 Guided Self-Help, or Low Intensity CBT), we always thought that Step 2 was a sort of CBT-lite, and so the Step 2 clinician was therefore a sort of therapist-lite.

Also, when I was learning about IAPT as an outsider, I was wrongly led to believe that the program is training ‘therapists’ not coaches. David Clark says so himself in his ‘IAPT at 10: Achievements and Challenges’ post, he writes (under the dramatic title ‘A revolution in mental health’), that to overcome the shortage of psychological therapy available to people suffering from common mental health problems, ‘the NHS has trained over 10,500 therapists and deployed them in new psychological therapy services’ (emphasis added). This is misleading, and I often find evidence of IAPT’s main advocates (usually people with a stake in the game), claiming more for the service than it deserves. I think Clark and others should be more cautious in over-selling IAPT, because it will eventually lead to disappointment when people’s expectations aren’t managed.

Thanks to that misinformation, when I used to allocate people whom I had triaged to Step 2 treatments, I always sold it as a ‘guided cognitive behavioural therapy over 6 weeks, for 30 minute sessions’. But now that we are training to be those Step 2 ‘clinicians’, we find that we are not that at all, and what we offer isn’t Cognitive Behavioural Therapy, but rather a life-coaching session.

But – I agree with this. We shouldn’t think of ourselves as clinicians or therapists because we don’t have those skills – we aren’t taught about what happens within the therapeutic relationship, and how to more supportively guide our clients through more long-lasting psychic change. I think it also serves to prevent us from feeling also like counsellors, whose role is to sit and listen to the client as they talk about whatever they feel like getting off their chest. By reminding us that we are there to encourage behaviour change (and that’s essentially it), it makes a lot of sense to call us coaches.

Having said that, however, it’s now clearer to me just how difficult I’m going to find this year in how it jars with my fundamental values and assumptions as to how psychological therapy should be. It’s odd, and I must try to check it, but I have an almost instinctual aversion to CBT and the phrase ‘evidence-based treatment’. Aaron Beck (the founder of CBT), gives me an uncomfortable feeling, I can’t help but think he’s getting something terribly wrong, or turning something complex into something robotically simple (to its detriment). I don’t have enough learning or experience to quite put into words what exactly I distrust about Beck’s cognitive approach, and I know that it has changed and improved a lot since his day so I’m probably being hugely unfair to modern practitioners of CBT, but I have read a couple of things recently that have started to confirm my uncomfortable feeling about it…

The first was a blog post by philosopher and clinical psychologist Richard Gipps, on how Beck’s turn away from psychoanalytic psychotherapy was caused by his own misunderstanding of the theory, rather than with any fundamental flaw in the approach itself.

And the second was a journal article by Michael McEachrane on the flawed assumptions that Cognitive Therapy is based on to do with what it really means to ‘think that p‘.

I’m tempted to share these two articles with the other Trainees on my course to see what they think, but I don’t want to be the bad, critical one in the bunch.

And, I do understand why IAPT uses the CBT model so religiously. The aim of IAPT is to ‘democratise psychological therapy’ – it wants to make it accessible on the NHS, and this I fervently agree with. Unfortunately, however, CBT is the only kind of therapy that can be made ‘efficient’ and ‘wide-spread’ in this way, because it’s less about the relationship that the client has with their therapist, and more about the ‘tools’ that they learn from them. So, the therapists can be quickly and inexpensively trained, because it’s not really about them and their skills.

Research has shown that this can be effective (with about a 50% recovery rate; not bad, not good?), but the jury’s out as to how long those benefits last for, and I have a feeling that the main function of having Step 2 low-intensity treatments available on the NHS isn’t so much for the good they do, but as a sifting mechanism for finding out who are the really serious cases on the waiting list who need longer-term therapy. Without Step 2, we would have one big, long waiting list for CBT Proper (Step 3), and that wouldn’t be good for anybody.

First Day as a Mental Health Support Worker

Yesterday I had my first shift as a Support Worker at a Recovery House; it was both exhausting and fascinating.

I arrived for 8am, which was when the night staff give us the hand-over on each individual staying at the house, how their night went, etc. so that we know how everyone is feeling in the morning. Then myself and a colleague went around each room at 9am to say hello to everyone, even if that’s just a sleepy grunt, and give some people their morning medication. The rest of the day was spent checking various inconsistencies (one lady had much less medication left than we would have expected given how much she is supposed to take), or issues (to do with housing, mis-remembered doctors appointments…). We also keep regularly checking-in on everyone, and take notes throughout of everything that happens so that we can then hand over that info to the night staff that will follow us when we leave at 9pm.

One of the most interesting parts of the day for me was shadowing a 1-on-1 chat between my colleague and a service user who had only recently come to the house, and listening to how we first get a sense of the individual joining us – what they are struggling with, what they hope to achieve, what particularly distresses them, and general background information…To be totally honest, the conversation was heartbreaking. What seemed to be the major problem for the service user, apart from her mental health difficulties (which were being relieved somewhat by medication, I think), was her lack of social networks. She said that she had no friend or family member who was there for her outside of the house. The only person ‘in her life’ was her Care Co-Ordinator. That must be so frightfully painfully lonely and horrible. I don’t think many of us can even imagine what it must be like to have literally no one that we could turn to if we were ever in a difficult situation (aunts, friends from school, neighbours…). And, in a cruel turn of fate, it is as if having that support network there is even enough to prevent us from actually needing them. I think that the very fact that we know that they are there, is enough to comfort us and stop us slipping into a spiral wherein we really need to rely on them.

In talking to this woman I suddenly realised how powerful those invisible support networks (and, of course, the less invisible ones that we get joy and love from on a regular basis) are to our mental health and stability. Her affect felt completely hopeless, and I really felt and shared her suffering as I listened to it.

Since the ‘social networks’ box that my colleague ticked seemed to be the major problem, (I must add that I really didn’t like the very obviously ‘structured’ interview style that we were doing, I understand that it is useful to quickly measure and compare over time, but it felt inhumane and insensitive when discussing such intimate difficulties.) – she tried to suggest ‘ways to improve’, such as to hang out in the lounge or kitchen more, and get to know other service users, or join one of the activities that the house runs like yoga or a film night.
These are all great ideas, but, to me it almost felt too soon to ask this lady to ‘get out a bit more’. I would have wanted to talk to her a bit more personally first, try to understand what kinds of things she as an individual could imagine enjoying doing, get a little bit more of a sense of herself first, so that she wouldn’t feel overwhelmed and incompetent while trying to socialise. I say this because she really struggled to even look either of us in the eye during the conversation. Though, actually, trying to socialise could probably only help, and maybe she would be pleasantly surprised by the ease with which everyone seems to get along in the house. So, both efforts could be used at once, I think. And of course my own presence probably didn’t help the conversation, as I was just awkwardly sitting there watching. A genuinely 1-on-1 conversation would have been easier for everyone involved.

So, those were my first day thoughts! I am very very much looking forward to getting comfortable with all the admin-stuff of the house, the millions of forms to fill, and which keys open which doors, etc., so that I can concentrate fully on providing the best possible service to the residents. Will keep you updated.