Psychotherapies and the space between us

Public domain image from pixabay. Click for source.There’s an in-depth article at The Guardian revisiting an old debate about cognitive behavioural therapy (CBT) versus psychoanalysis that falls into the trap of asking some rather clichéd questions.

For those not familiar with the world of psychotherapy, CBT is a time-limited treatment based on understanding how interpretations, behaviour and emotions become unhelpfully connected to maintain psychological problems while psychoanalysis is a Freudian psychotherapy based on the exploration and interpretation of unhelpful processes in the unconscious mind that remain from unresolved conflicts in earlier life.

I won’t go into the comparisons the article makes about the evidence for CBT vs psychoanalysis except to say that in comparing the impact of treatments, both the amount and quality of evidence are key. Like when comparing teams using football matches, pointing to individual ‘wins’ will tell us little. In terms of randomised controlled trials or RCTs, psychoanalysis has simply played far fewer matches at the highest level of competition.

But the treatments are often compared due to them aiming to treat some of the same problems. However, the comparison is usually unhelpfully shallow.

Here’s how the cliché goes: CBT is evidence-based but superficial, the scientific method applied for a quick fix that promises happiness but brings only light relief. The flip-side of this cliché says that psychoanalysis is based on apprenticeship and practice, handed down through generations. It lacks a scientific seal of approval but examines the root of life’s struggles through a form of deep artisanal self-examination.

Pitching these two clichés against each other, and suggesting the ‘old style craftsmanship is now being recognised as superior’ is one of the great tropes in mental health – and, as it happens, 21st Century consumerism – and there is more than a touch of marketing about this debate.

Which do you think is portrayed as commercial, mass produced, and popular, and which is expensive, individually tailored, and only available to an exclusive clientèle? Even mental health has its luxury goods.

But more widely discussed (or perhaps, admitted to) are the differing models of the mind that each therapy is based on. But even here simple comparisons fall flat because many of the concepts don’t easily translate.

One of the central tropes is that psychoanalysis deals with the ‘root’ of the psychological problem while CBT only deals with its surface effects. The problem with this contrast is that psychoanalysis can only be seen to deal with the ‘root of the problem’ if you buy into to the psychoanalytic view of where problems are rooted.

Is your social anxiety caused by the projection of unacceptable feelings of hatred based in unresolved conflicts from your earliest childhood relationships – as psychoanalysis might claim? Or is your social anxiety caused by the continuation of a normal fear response to a difficult situation that has been maintained due to maladaptive coping – as CBT might posit?

These views of the internal world, are, in many ways, the non-overlapping magisteria of psychology.

Another common claim is that psychoanalysis assumes an unconscious whereas CBT does not. This assertion collapses on simple examination but the models of the unconscious are so radically different that it is hard to see how they easily translate.

Psychoanalysis suggests that the unconscious can be understood in terms of objects, drives, conflicts and defence mechanisms that, despite being masked in symbolism, can ultimately be understood at the level of personal meaning. In contrast, CBT draws on its endowment from cognitive psychology and claims that the unconscious can often only be understood at the sub-personal level because meaning as we would understand it consciously is unevenly distributed across actions, reactions and interpretations rather than being embedded within them.

But despite this, there are also some areas of shared common ground that most critics miss. CBT equally cites deep structures of meaning acquired through early experience that lie below the surface to influence conscious experience – but calls them core beliefs or schemas – rather than complexes.

Perhaps the most annoying aspect of the CBT vs psychoanalysis debate is it tends to ask ‘which is best’ in a general and over-vague manner rather than examining the strengths and weaknesses of each approach for specific problems.

For example, one of the central areas that psychoanalysis excels at is in conceptualising the therapeutic relationship as being a dynamic interplay between the perception and emotions of therapist and patient – something that can be a source of insight and change in itself.

Notably, this is the core aspect that’s maintained in its less purist and, quite frankly, more sensible version, psychodynamic psychotherapy.

CBT’s approach to the therapeutic relationship is essentially ‘be friendly and aim for cooperation’ – the civil service model of psychotherapy if you will – which works wonderfully except for people whose central problem is itself cooperation and the management of personal interactions.

It’s no accident that most extensions of CBT (schema therapy, DBT and so on) add value by paying additional attention to the therapeutic relationship as a tool for change for people with complex interpersonal difficulties.

Because each therapy assumes a slightly different model of the mind, it’s easy to think that they are somehow battling over the ‘what it means to be human’ and this is where the dramatic tension from most of these debates comes from.

Mostly though, models of the mind are just maps that help us get places. All are necessarily stylised in some way to accentuate different aspects of human nature. As long as they sufficiently reflect the territory, this highlighting helps us focus on what we most need to change.

Alzheimer’s from the inside

There’s an excellent short-film, featuring journalist Greg O’Brien, who describes the experience of Alzheimer’s disease as it affects him.

It’s both moving and brilliantly made, skilfully combining the neuroscience of Alzheimer’s with the raw experience of experiencing dementia.

I found it in this Nautilus article, also by O’Brien, who has taken the rare step of writing a book about the experience of Alzheimer’s disease before it affected his ability to write.
 

Link to short film Inside Alzheimer’s on vimeo.
Link to Nautilus article.

The real history of the ‘safe space’

There’s much debate in the media about a culture of demanding ‘safe spaces’ at university campuses in the US, a culture which has been accused of restricting free speech by defining contrary opinions as harmful.

The history of safe spaces is an interesting one and a recent article in Fusion cited the concept as originating in the feminist and gay liberation movements of the 1960s.

But the concept of the ‘safe space’ didn’t start with these movements, it started in a much more unlikely place – corporate America – largely thanks to the work of psychologist Kurt Lewin.

Like so many great psychologists of the early 20th Century, Lewin was a Jewish academic who left Europe after the rise of Nazism and moved to the United States.

Although originally a behaviourist, he became deeply involved in social psychology at the level of small group interactions and eventually became director of the Center for Group Dynamics at MIT.

Lewin’s work was massively influential and lots of our everyday phrases come from his ideas. The fact we talk about ‘social dynamics’ at all, is due to him, and the fact we give ‘feedback’ to our colleagues is because Lewin took the term from engineering and applied it to social situations.

In the late 1940s, Lewin was asked to help develop leadership training for corporate bosses and out of this work came the foundation of the National Training Laboratories and the invention of sensitivity training which was a form of group discussion where members could give honest feedback to each other to allow people to become aware of their unhelpful assumptions, implicit biases, and behaviours that were holding them back as effective leaders.

Lewin drew on ideas from group psychotherapy that had been around for years but formalised them into a specific and brief focused group activity.

One of the ideas behind sensitivity training, was that honesty and change would only occur if people could be frank and challenge others in an environment of psychological safety. In other words, without judgement.

Practically, this means that there is an explicit rule that everyone agrees to at the start of the group. A ‘safe space’ is created, confidential and free of judgement but precisely to allow people to mention concerns without fear of being condemned for them, on the understanding that they’re hoping to change.

It could be anything related to being an effective leader, but if we’re thinking about race, participants might discuss how, even though they try to be non-racist, they tend to feel fearful when they see a group of black youths, or that they often think white people are stuck up, and other group members, perhaps those affected by these fears, could give alternative angles.

The use of sensitivity groups began to gain currency in corporate America and the idea was taken up by psychologists such as the humanistic therapist Carl Rogers who, by the 1960s, developed the idea into encounter groups which were more aimed at self-actualisation and social change, in line with the spirit of the times, but based on the same ‘safe space’ environment. As you can imagine, they were popular in California.

It’s worth saying that although the ideal was non-judgement, the reality could be a fairly rocky emotional experience, as described by a famous 1971 study on ‘encounter group casualties’.

From here, the idea of safe space was taken up by feminist and gay liberation groups, but with a slightly different slant, in that sexist or homophobic behaviour was banned by mutual agreement but individuals could be pulled up if it occurred, with the understanding that people would make an honest attempt to recognise it and change.

And finally we get to the recent campus movements, where the safe space has become a public political act. Rather than individuals opting in, it is championed or imposed (depending on which side you take) as something that should define acceptable public behaviour.

In other words, creating a safe space is considered to be a social responsibility and you can opt out, but only by leaving.

What do children know of their own mortality?

CC Licensed Image by Flickr user DAVID MELCHOR DIAZ. Click for source.We are born immortal, as far as we know at the time, and slowly we learn that we are going to die. For most children, death is not fully understood until after the first decade of life – a remarkable amount of time to comprehend the most basic truth of our existence.

There are poetic ways of making sense of this difficulty: perhaps an understanding of our limited time on Earth is too difficult for the fragile infant mind to handle, maybe it’s evolution’s way of instilling us with hope; but these seductive theories tend to forget that death is more complex than we often assume.

To completely understand the significance of death, researchers – mortality psychologists if you will – have identified four primary concepts we need to grasp: universality (all living things die), irreversibility (once dead, dead forever), nonfunctionality (all functions of the body stop) and causality (what causes death).

In a recent review of studies on children’s understanding of death, medics Alan Bates and Julia Kearney describe how:

Partial understanding of universality, irreversibility, and nonfunctionality usually develops between the ages of 5 and 7 years, but a more complete understanding of death concepts, including causality, is not generally seen until around age 10. Prior to understanding nonfunctionality, children may have concrete questions such as how a dead person is going to breathe underground. Less frequently studied is the concept of personal mortality, which most children have some under standing of by age 6 with more complete understanding around age 8–11.

But this is a general guide, rather than a life plan. We know that children vary a great deal in their understanding of death and they tend to acquire these concepts at different times.

Although interesting from a developmental perspective these studies also have clear, practical implications.

Most children will know someone who dies and helping children deal with these situations often involves explaining death and dying in a way they can understand while addressing any frightening misconceptions they might have. No, your grandparent hasn’t abandoned you. Don’t worry, they won’t get lonely.

But there is a starker situation which brings the emerging ability to understand mortality into very sharp relief. Children who are themselves dying.

The understanding of death by terminally ill children has been studied by a small but dedicated research community, largely motivated by the needs of child cancer services.

One of the most remarkable studies, and perhaps, one of the most remarkable studies in the whole of palliative care, was completed by the anthropologist Myra Bluebond-Langner and was published as the book The Private Worlds of Dying Children.

Bluebond-Langner spent the mid 1970’s in an American child cancer ward and began to look at what the children knew about their own terminal prognosis, how this knowledge affected social interactions, and how social interactions were conducted to manage public awareness of this knowledge.

Her findings were nothing short of stunning: although adults, parents, and medical professionals, regularly talked in a way to deliberately obscure knowledge of the child’s forthcoming death, children often knew they were dying. But despite knowing they were dying, children often talked in a way to avoid revealing their awareness of this fact to the adults around them.

Bluebond-Langner describes how this mutual pretence allowed everyone to support each other through their typical roles and interactions despite knowing that they were redundant. Adults could ask children what they wanted for Christmas, knowing that they would never see it. Children could discuss what they wanted to be when they grew up, knowing that they would never get the chance. Those same conversations, through which compassion flows in everyday life, could continue.

This form of emotional support was built on fragile foundations, however, as it depended on actively ignoring the inevitable. When cracks sometimes appeared during social situations they had to be quickly and painfully papered over.

When children’s hospices first began to appear, one of their innovations was to provide a space where emotional support did not depend on mutual pretence.

Instead, dying can be discussed with children, alongside their families, in a way that makes sense to them. Studying what children understand about death is a way of helping this take place. It is knowledge in the service of compassion.

A social vanishing

CC Licensed Photo by Flickr user Jonathan Jordan. Click for source,A fantastic eight-part podcast series called Missing has just concluded and it’s a brilliant look at the psychology and forensic science of missing people.

It’s been put together by the novelist Tim Weaver who is renowned for his crime thrillers that feature missing persons investigator David Raker.

He uses the series to investigate the phenomenon of missing people and the result is a wonderfully engrossing, diverse documentary series that talks to everyone from forensic psychiatrists, to homicide investigators, to commercial companies that help you disappear without trace.

Missing people, by their absence, turn out to reveal a lot about the tension between social structures and individual behaviour in modern society. Highly recommended.
 

Link to Missing podcast series with iTunes / direct download links.

From school shootings to everyday counter-terrorism

CC Licensed Image from Secretive Ireland. Click for source.Mother Jones has a fascinating article on how America is attempting to stop school shootings by using community detection and behavioural intervention programmes for people identified as potential killers – before a crime has ever been committed.

It is a gripping read in itself but it is also interesting because it describes an approach that is now been rolled out to millions as part of community counter-terrorism strategies across the world, which puts a psychological model of mass-violence perpetration at its core.

The Mother Jones article describes a threat assessment model for school shootings that sits at an evolutionary mid-point: first developed to protect the US President, then to preventing school shootings, and now as mass deployment domestic counter-terrorism programmes.

You can see exactly this in the UK Government’s Prevent programme (part of the wider CONTEST counter-terrorism strategy). Many people will recognise this in the UK because if you work for a public body, like a school or the health service, you will have been trained in it.

The idea behind Prevent is that workers are trained to be alert to signs of radicalisation and extremism and can pass on potential cases to a multi-disciplinary panel, made up of social workers, mental health specialists, staff members and the police, who analyse the case in more detail and get more information as it’s needed.

If they decide the person is vulnerable to becoming dangerously radicalised or violent, they refer the case on the Channel programme, which aims to manage the risk by a combination of support from social services and heightened monitoring by security services.

A central concept is that the person may be made vulnerable to extremism due to unmet needs (poor mental health, housing, lack of opportunity, poor social support, spiritual emptiness, social conflict) which may convert into real world violence when mixed with certain ideologies or beliefs about the world that they are recruited into, or persuaded by, and so violence prevention includes both a needs-based and a threat-based approach.

This approach came from work by the US Secret Service in the 1990s, who were mainly concerned with protecting key government officials, and it was a radical departure from the idea that threat management was about physical security.

They began to try and understand why people might want to attempt to kill important officials and worked on figuring out how to identify risks and intervene before violence was ever used.

The Mother Jones article also mentions the LAPD Threat Management Unit (LAPDTMU) which was formed to deal with cases of violent stalking of celebrities, and the FBI had been developing a data-driven approach since the National Center for the Analysis of Violent Crime (NCAVC) launched in 1985.

By the time the Secret Service founded the National Threat Assessment Center in 1998, the approach was well established. When the Columbine massacre occurred the following year, the same thinking was applied to school shootings.

After Columbine, reports were produced by both the FBI (pdf) and the Secret Service (pdf) which outline some of the evolution of this approach and how it applies to preventing school shootings. The Mother Jones article illustrates what this looks like, more than 15 years later, as shootings are now more common and often directly inspired by Columbine or other more recent attacks.

It’s harder to find anything written on the formal design of the UK Goverment’s Prevent and Channel programmes but the approach is clearly taken from the work in the United States.

The difference is that it has been deployed on a mass scale. Literally, millions of public workers have been trained in Prevent, and Channel programmes exist all over the country to receive and evaluate referrals.

It may be one of the largest psychological interventions ever deployed.
 

Link to Mother Jones article on preventing the next mass shooting.

The Quiet Room

This month’s British Journal of Psychiatry has a brief but fascinating article about a 1979 Marvel comic featuring and written by rock legend Alice Cooper which depicts his real-life admission to a psychiatric ward.

The comic was timed to coincide with the release of his concept album From The Inside which describes his experiences as a psychiatric patient being treated for severe alcoholism and depression.

He was there for 3 months and in the comic he depicts the patients, doctors and nurses he met during his admission. Alice has often commented in interviews that treatment in hospital and recovering from his substance misuse saved his life, when many similar artists at that time, such as Jim Morrison and Janis Joplin, were not as fortunate, succumbing to their addictions. The lead single from the album was ‘How You Gonna See Me Now’, a song describing the anxiety the singer felt coming back home to his wife after his stay in hospital and facing the stigma of being treated for his mental illness. It went on to become a well-known successful ballad. The comic can still be found in comic shops or through online auction sites.

 

Link to brief British Journal of Psychiatry article.