Evolution not revolution: My thoughts on the DCP’s call for a paradigm shift

For those that don’t know, there has been a long standing debate in mental health.  At its simplist, it is an argument about whether biological or social factors are the predominant cause of mental health problems, including those difficulties at the most severe end of the spectrum, including schizophrenia, bi-polar, severe depression and personality disorders.  Debates that follow from this, orientate around the extent to which commentators and researchers endorse or dispute the ‘medicalisation’ of mental health.  Debates such as whether diagnostic categories are a useful way of understanding mental health problems, whether psychiatric medication is over prescribed, whether the social influences on human suffering are overlooked in favour of biological, medical explanations.  Recently the Division of Clinical Psychology (DCP) released a position statement, basically arguing for a ‘paradigm shift’, away from psychiatric diagnoses, in favour of a ‘formulation’, and context specific understanding of mental ill health.

 

I am an avid follower of this debate. I always, since the start of my career in psychology, have been. It has, as different stages, fascinated me (“I can’t believe there are such different ways of understanding the same thing”), filled me with professional confidence (“I am sure my way of understanding these issues is the most helpful for clients”), filled me with uncertainty (“I really thought my way was the ‘best’, and now I’m not so sure”), and most recently, left me feeling perpetually conflicted, and at times, markedly irritated.

 

That’s why, when I found out Lucy Johnstone, one of the most outspoken advocates of the hotly debated ‘paradigm shift’ in mental health, was speaking at the Manchester University’s Clinical Psychology Annual Review, I jumped at the chance to attend.

 

As a Twitter follower of Dr Johnstone’s, I had a good idea of what her position would be, but the chance to hear her elaborate on some of her ideas was genuinely exciting to me.

 

I find myself in an almost constant state of conflicted ambivalence about this debate, most likely attributable to the unpleasant and unhelpful polarisation that has taken place within the field in recent years (this being at its most distilled and distasteful on social media).  Would the talk by Lucy Johnstone in Manchester help me with my own search for a greater sense of certainty and understanding? Would it help me feel more aligned to my professional bodies’ recent position statement. Or, conversely, would I have greater confidence in challenging some of the assumptions on which it is based? The answer…..none of the above. What it did do is spur me on to write this blog, to express in writing some of the thoughts and ideas that I find myself pondering on a near daily basis.

The Caricatured Professional

One of the main concerns I have had with this debate is the polarisation that has taken place. The ‘us’ versus ‘them’ positioning I have seen emerge between many psychologists and psychiatrists involved.  This happens on both sides of course. At Johnstone’s talk there was an undeniable caricaturing of psychiatrists. I say it was undeniable, but Johnstone did indeed deny this when it was suggested by the chair of the event. To paraphrase, according to Johnstone, a typical psychiatrist is likely to list a client’s historical adversities and conclude by suggesting something along the lines of “and on top of all this you have gone on to develop ‘x’ mental illness”, as though the historic traumas have nothing to do with the client’s current psychological difficulties. This simply does not tally up with my experience of working with many psychiatrists. Maybe it’s because I’ve spent most of my career in CAMHS, maybe I have just been lucky, but I am not convinced that the majority of psychiatrists view historical adversity and trauma as unrelated to adulthood psychological problems.

 

The caricaturing goes both ways. I often hear complaints that Clinical Psychologists are motivated simply by power; they are resentful of the dominant position psychiatrists have in mental health services and want to overthrow the hegemony for their own professional gains. I have worked very closely with many psychologists staunchly critical of psychiatry, and I can honestly say their motivation and drive is centred around the welfare of clients, and by their belief that changing the system will honestly improve outcomes for those they work with.

 

Maybe it’s a lack of vision on my behalf, but I can’t envisage a mental health system that does not involve medication and forced hospitalisation for clients at their most confused and distressed.  On the other hand, I find it peculiar that medics are the default clinical leads for services in a field where psychological and social factors are so central. Similarly, why do medics hold ultimate clinical responsibility for mental health clients they work with?  Senior psychologists and social workers should be able to take these positions, and even better, some kind of multidisciplinary panel should share clinical responsibility for the most complex clients, rather than one professional with one professional (at present medical) perspective.

 

I digress though; what I am saying is that this caricaturing is bad, and often inaccurate. Like the one about critical psychologists holding their views in the absence of front-line work.  It goes something like this, “if those psychologists saw how disturbed these patients were when they come in to hospital, they wouldn’t be denouncing the use medication, or terms such as mental illness”. Codswallop. Some of the most critical psychologists I have known, work in acute, inpatient mental health settings and are well aware of the severity of inpatients’ difficulties.

 

Why is caricaturing bad? Well I have personally seen colleagues on both ‘sides’ become more entrenched and polarised in their positions.  They see and hear the over simplified arguments, and inaccurate representations of their profession and move away from the middle ground.

What is the Alternative?

I think I would find the whole ‘paradigm shift’ agenda far less difficult to consider if a clear alternative was set out.  An alternative to how services are structured and research organised (if not according to diagnostic groupings).

 

Sticking to research for the moment, Johnstone was explicit in her opinion that research based on diagnostic categories had offered us absolutely nothing in furthering our understanding of mental health.  Really?!? Do we not now know much more about which therapies are better for which problems.  For example, DBT for people diagnosed with Borderline Personality Disorder1, IPT for Depression2 (but certainly not panic3), and most recently, Mindfulness based interventions for depression (but at present not anxiety disorders)4.  Does research not tell us something about relapse rates and patterns for certain categories of distress5?  Has research not told us the significantly increased likelihood of developing a diagnosable mental health problem if exposed to early life trauma6?  In fact, aren’t most of the recommendations for psychiatric and psychological interventions for mental health problems set out by the National Institute for Clinical Excellence (NICE) based on research into diagnostic categories?

 

There will hopefully be improvements to research outcomes as refinements are made to how we group participants’ problems together. Like considering how people diagnosed with depression may have different information processing styles or different attachment styles7. But these changes would represent an improvement in the sensitivity of a categorical system, rather than the wholesale rejection of it.

 

Johnstone cited NIMH’s announcement that the research they funded would no longer be based on diagnostic categories, and instead they would look to other, trans-diagnostic processes and experiences on which to base research questions. Fair enough. I think a symptom/experience based focus could further our understanding of certain presentations, particularly when we remember that a proportion of people satisfying the criteria for a diagnostic category will not represent the archetype, and will sometimes have quite divergent experiences from one another. But, firstly, NIMH’s emphasis on trans-diagnostic processes seem, at the moment, to favour underlying biological processes; hardly a good example of how the mental health establishment is turning its back on a medical understanding of mental health.  Secondly, any symptom/experience based approach to research would have to include some system for organising participants into meaningful groups. Some people who hear voices will do so in the context of substance misuse, some following a bereavement, some is the context of a brief emotional crisis, and some in the context of a much longer-standing course of psychological dysfunction. Some will have overt experiences of childhood trauma, many will not.  Lumping all of these people together could be problematic for conducting reliable research, but separating them up is, essentially, just another way of categorising people.

 

Johnstone revealed that she was, along with some other high profile Clinical Psychologists, working on an alternative system for organising people with mental health problems, for the purposes of research and intervention.  She admitted that this was proving difficult, and at present any details are sketchy at best. She indicated that their focus was on the identification of underlying psychological processes, such as, for example, guilt cognitions.  She denied that this would operate anything like a categorical or clustering system, and that there would be no concept of co-morbidity in the system, as people could be identified as having any number of experiences without this being understood as representing multiple conditions.

 

Unclear? Me too. I just can’t conceptualise how one might start to meaningfully organise clients’ difficulties without using categories or groups. By the way, Psychologists are as partial to categorical systems as the next Mental Health professional (think attachment styles or personality types).

 

In saying all of this, DSM 5 was an omni-shambles and there is surely a more scientifically sound way of organising the presenting problems of service-users. I am all for developing new, more robust systems, but calling for a wholesale ‘paradigm shift’, when a workable alternative has not yet been developed, never mind validated, is a bit of a misstep in my opinion.

 

Regarding mental health services, this is an area of even greater personal conflict for me. I have worked on inpatient units, most recently with adolescents.  I was concerned about the sheer quantity of PRN medication being used, and the essentially uni-professional (medical) running of the ward.  The care of the young people I worked with could, and should be improved.  But would the abolishment of a diagnostic system facilitate this? I think not.  What the service did need was more funding, better training for staff of all levels, a team approach to understanding and working with very high levels of distress, and a truly multi-disciplinary approach to decision making and clinical responsibility.  Do these changes require a less medically dominated system? Yes. Do they necessitate a revolution in mental health, and the abolishment of the very concept of diagnosis and categorical systems? I, personally, think not.  What we do need is more money to train more staff, to spend more time with clients, to provide more evidence-based alternatives to PRN medication.

 

Similarly, I agree with Johnstone’s calls for mental health services to have, at their heart, a psychosocial perspective, with intervention driven by a formulation-based approach.  Can this only exist in the absence of a diagnostic system? I don’t think so.  I really don’t see why the two approaches must be mutually exclusive.  One of the therapy models I practice is Interpersonal Psychotherapy (IPT).  It takes the approach that depression is an illness. It emphasises the utility of making a diagnosis of depression, and also welcomes the use of anti-depressant medication if therapy is not progressing as expected, and the client is inclined to use meds based on an understanding of the evidence base around medication usage.  At the same time, this illness is understood to have been brought about by problematic relationship experiences, life changes or loss.   It is completely formulation driven. It focuses immediately on the life changes required to increase the chances of a positive outcome from therapy.  It focuses thereafter on supporting the client to reflect on and adapt how they relate to others, and how they work through and come to terms with major life changes or bereavement. Calling depression an illness, and making a diagnosis simply has not, in my experience, undermined the therapy, and may well have optimised it.

 

Similarly, Dialectical Behaviour Therapy (DBT), another intervention I use regularly, emphasises the biological and social underpinnings of emotional dysregulation or, for adults, Borderline Personality Disorder (BPD).  Personally I despise the name BPD, but, at the same time, certainly see the value in having a group or category that captures the kind of difficulties often experienced by this group of clients.   Again, as psychologists I think we use categories all the time. We might prefer to describe BPD as an ‘emotional dysregulation difficulty’ or a ‘complex trauma reaction’. Were these concepts formalised, they would have their own value and drawbacks, but would constitute categories none the less.

 

A phrase I have written a few times throughout this blog is ‘at the same time’.  Whilst I share some of my colleagues’ concerns regarding the relative dominance of a medical model for understanding human suffering, I think both can exist together, at the same time.  The balance of influence should be re-dressed, but I fear that the recent calls for a wholesale abandonment of diagnosis, and a general denial of the value of psychiatric input is both unnecessary and unhelpful. I would call for evolution rather than revolution. A combination of perspectives is always favourable, surely?

 

References

1. Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling.
Kliem, Sören; Kröger, Christoph; Kosfelder, Joachim
Journal of Consulting and Clinical Psychology, Vol 78(6), Dec 2010, 936-951

2. Interpersonal Psychotherapy for Depression: A Meta-Analysis
Pim Cuijpers, Ph.D.; Anna S. Geraedts, M.A.; Patricia van Oppen, Ph.D.; Gerhard Andersson, Ph.D.; John C. Markowitz, M.D.; Annemieke van Straten, Ph.D.
Am J Psychiatry, 2011, 168:581-592.

3. A randomized clinical trial of cognitive behavioral therapy and interpersonal psychotherapy for panic disorder with agoraphobia
Vosa, S.P.F, Huibers, M. J. H., Dielsa, L., Arntza, A
Psychological Medicine, Volume 42, Issue 12, 2012, pp 2661-2672

4. Mindfulness-Based Interventions for People Diagnosed with a Current Episode of an Anxiety or Depressive Disorder: A Meta-Analysis of Randomised Controlled Trials.Strauss C, Cavanagh K, Oliver A, Pettman D
PLoS ONE, 2014, 9(4)

5. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders 1
Jan Scott, Francesc Colom, Eduard Vieta
Int J Neuropsychopharmacol, 2007, 10(1):123-9

6. The link between childhood trauma and depression: Insights from HPA axis studies in humans Christine Heim, D. Jeffrey Newport, Tanja Mletzko, Andrew H. Miller, Charles B. Nemeroff
Psychoneuroendocrinology, 2008, 33 (6), 69 – 710

7. Attachment Theory, Psychopathology, and Psychotherapy:
The Dynamic-Maturational Approach
Crittenden, P. M.
Teoria dell’attaccamento, psicopatologia e psicoterapia: L’approccio
dinamico maturativo. Psicoterapia, 2005, 30, 171-182.

Mindfulness Meditation – Not just a hippy thing!

I wanted to write about mindfulness meditation as my next blog topic as it is an approach I am increasingly using with therapy clients, and in my own life, to help with sleep and relaxation.

Mindfulness is a branch of meditation rooted in eastern philosophy and religion, but is increasingly used across a number of health settings, and is accumulating a very impressive research base, suggesting significant health benefits – but I will come to the evidence later.

What exactly it is?

Just think for a moment how much of our mental time and energy is spent thinking about past events, or predicting the future, and how little of the time is spent experiencing the present moment.  Mindfulness is all about experiencing the present moment, fully, without judgment, without distraction.

People lucky enough to have passions in which they can immerse themselves, talk of ‘getting lost in it’, ‘switching off from everything else’, ‘being in the zone’. Artists, sportsmen, mathematicians all describe this quality of experience.  Doing something that grounds them in that present moment, without the pull of distractions, either from outside or within.

Those of us without such passions can experience this too.  But it can be hard to begin with.  For example, just take 60 seconds right now to look at your own hand.  Look at it.  Scrutinise, non-judgmentally, every detail.  Describe it to yourself.  The contours, lines, textures.

How did you do?  My bet is that you got distracted within seconds of this task starting.  That you probably didn’t even realize you had got distracted for several seconds.  That you were quick to make judgments about your hands (‘I didn’t realize my thumb was so fat’. ‘I hate my nails’. ‘I’ve got great hands’.)  That you were quick to make judgments about this task (‘This is too hard’.  ‘This is pointless’.  ‘Jamie’s taking the piss’.)

When I asked my wife to do this for the first time, she reported that within milliseconds of starting she had planned out the next three Friday night family dinners, decided who was coming and what we were all eating!  Our minds are like untrained puppies.  They’re all over the place and don’t do what we want most of the time.  Mindfulness exercises are a great way to start training our mind, so that when we need it to be, it will be more under our control.

What’s so good about a trained mind?

Ever had a restless night when your mind is racing and you can’t sleep?  Ever struggled to listen to a friend or colleague because you can’t stop thinking about something else?  Ever struggled to watch a film or read a book because you were distracted by thoughts about what happened earlier in the day.  Of course you have!  What’s more, many of us are prone to worry thoughts.  Negative thinking that results in increased anxiety and stress levels.  Thoughts about the past (‘why did I say that, what an idiot!’), thoughts about the future (‘It’s going to be a nightmare, I don’t know how I’ll cope’), judgments about the present (‘I can’t cope with these thoughts, I’m never going to fall asleep’).  Being more ‘mindful’, that is, getting better at controlling your attention, and experiencing the present moment without judgment, has been scientifically proven to help with all of these difficulties, and can be learnt through regular practice.  Just like going to the gym, it can feel hard to begin with, but with enough effort progress is easily attained.

Go on then, how do I do it?

The great thing about Mindfulness is that you can do it in any situation.  Anything you do can be done more mindfully.  Brushing your teeth, eating a meal, taking a bath, listening to music, walking to the bus stop, even breathing can be done be mindfully.  Choose something to do mindfully everyday, dedicate five minutes to it and follow these simple instructions:

  • Bring all of your attention to that activity
  • Allow yourself to experience it fully
  • Notice when you get distracted (this will happen numerous times)
  • Do not judge yourself for getting distracted – it is normal and part of the process
  • Bring you mind back on to the task at hand

Breathing is a good one because you always do it.  We never really notice our breathing and yet it can be such a powerful anchor, grounding us in the present moment.  Notice your breath, the sensation of it passing through your nose and mouth.  The feeling of your chest and stomach expanding.  The sound your breath makes as it passes up and down your narrow nasal passage.  These principles can be pretty much applied to any activity.

Some people ask me what the point is.  Do I really need to know the sound of my own breath?  No you don’t.  But getting better at grounding yourself in the present moment has many advantages, particularly for those of us vulnerable to worry thoughts and rumination.

I also recommend going on Youtube.  There are loads of really good Mindfulness videos that talk you through the process.  I particularly recommend the work of Dr Elisha Goldstein PhD, who you can also follow on twitter at @Mindful_Living.

 So how has it helped you and your clients?

I have found Mindfulness most useful in its approach to experiencing emotions, both personally and in my clinical work.  When stressed we normally fight the emotion, try to battle with it, over-power it.  This causes more mental tension, turning pain into suffering.  Mindfulness teaches us that if we allow ourselves to experience that emotion, in all its glory, it will pass quicker, and probably be less severe.  There are two particularly useful strategies I have found helpful:

  • Next time you’re in distress, mindfully decide to allow yourself to experience that emotion.  Not just the thoughts that are causing it, but the physical and emotional feelings that go with them.  Just like the breathing example above, describe to yourself, non-judgmentally, what is happening inside your body.  Apply the principles bulleted above.  Doing this has been shown to reduce the duration and severity of emotional AND physical pain.  Try focusing on your physical pain in this way next time your back plays up and see what happens. 
  • If you are struggling with negative thinking, and the exercise above is too difficult because the thoughts are too distracting, try this.  Use mental imagery to put yourself somewhere comfortable and relaxing.  Every time a thought comes into your mind introduce that thought into your mental image.  Observe it, and let it pass, naturally.  For example, you’re sat on a river bank (in your mind).  Every time you have a thought, instead of getting wrapped up or lost in it, or try to force it away, you watch that thought float by on a leaf on the river.  You are an observer of the thought, not a victim of it.  Allow the thought to pass on the leaf in its own time.  Watch it go.  Smile as it does.  If it comes back, do it again.  If two thoughts turn up, but both on a leaf.  Use any imagery that works for you.  One client used the image of him holding loads of helium balloons.  Every time a thought came to him he let go of the string to that balloon and watched the thought float way.

Using either of these strategies at night time, when we can be most vulnerable to negative thinking, is a great way to get some sleep.

So, what’s he evidence for it?

There is plenty of scientific evidence demonstrating the effectiveness of becoming more Mindful – some of this has recently been summarized in a great article in the LA Times.  It has been shown to be helpful in reducing anxiety, improving mood , coping with physical pain  and improving cognitive functioning (attention, reasoning etc.) to name but a few.  Mindfulness has been integrated into several forms of psychotherapy including Cognitive Behavioural Therapy and Dialectical Behaviour Therapy, and is also a stand alone intervention approach.  It is a staple part of pain management programs and can be more effective for managing chronic pain than opiates.  It has been taken up by the USA military, where it has been shown to reduce post traumatic stress and depression, and improve engagement in life activities and self-awareness.  The military have predictably rebranded it ‘mind fitness training’.  It is used across a range of health settings, is heavily researched, and is easily accessible on line, via Youtube and Google, where you can also learn more about the brain-science behind it through interesting talks and lectures

So, as well as hitting the gym in time for holiday season, start another type of training this Spring.  It might really help!

It’s About Time!

Finally, MTAS Psychology has published its first blog!  I’m Jamie Barsky.  I run MTAS Psychology, an independent psychology service specialising in psychotherapy and expert witness services.  I’ll be updating our blog with items relating to mental health, self-help and medico legal work.  I tweet fairly regularly on all of these issues, and you can follow me at @jamiebarsky.

So, our first blog.  I’ve been procrastinating over this blog for several months. So much so that I thought a piece on ‘overcoming procrastination’ might be a good introductory article, until another blog beat me to it!  That’s bad isn’t it?  Procrastinating to such an extent that I couldn’t even exploit my procrastination because other procrastinators got there first?!

I decided then to blog a little about what I do in my role as Clinical Psychologist and how some of what I have learnt about staying emotionally healthy can be distilled and used by anyone and everyone to live a more harmonious and enriched life.

Over the past 8 years I have worked with children, adolescents, families and adults, all of whom have been struggling with the anguish of mental distress, and with whom I have learnt a great deal about what it means to be a human being; not just our vulnerabilities and the challenges we face, but also our personal resources and the opportunities we can make for ourselves.

Of course, mental distress is not limited to people accessing mental health services.  It is a universal human experience.  I challenge even the most robust of us to deny struggling from time to time with low mood, anxiety, worry, self-doubt, anger, confidence, conflict, parenting, being parented, relationships….the list goes on and on!!  These experiences make us human, and all, in their own way have an important role to play in everyday life.  If we didn’t get anxious, how would we motivate ourselves to prepare for challenges?  If we didn’t feel anger, how would we know when things were happening that were not in our best interest?  If we didn’t have self-doubt, how would we reflect on our own behaviour and make changes to get the most out of a situation?

Problems occur when these normal (and very important) emotions start to get the better of us – when they make us feel overwhelmed and unable to cope.   Why does this happen?  There can be many reasons.  Normally our current situation, our environment, has a lot to answer for.  Work, money, romance, family, friends, kids – the very same things that make the world go round can sometimes make us feel that our own world is falling apart.

How we interpret and make sense of these problems when they do occur is another important contributor to our distress levels.  Imagine sitting in a café and noticing a table of people looking over in your direction.  Why are they looking?  Do you look strange and standout?  Do they like your jacket?  Do they think they recognise you?  Are they looking past you at the table behind?  Are they planning an ambush?  The interpretation you make will influence how you instantly feel and then what you do next to cope with those feeling.  Our interpretations are the missing link between event and action, trigger and response, and are often an important focus of the work I do with clients young and old.  Why we may have personal tendencies to interpret things in a specific way may be down to lots of different factors, including childhood experiences and genetics.  Becoming aware of how, why and when we do this, and then going out of our way to try out different ways of interpreting and responding to situations is the bedrock of therapeutic change.

How we cope with difficult feelings and situations will also impact on our levels of mental distress.  The skills we have to manage emotions, tolerate distress and communicate with others are central; not only for coping with things when they go wrong, but making it less likely they will go wrong in the first place.  Fortunately, as you will see over the course of our blogs (providing I keep my procrastination in check), these skills can all be learnt.  Self help isn’t the be all and end all; for some people it simply isn’t sufficient as its lack the foundation of a therapeutic relationship between client and therapist within which to explore and challenge.  Nevertheless, it can be valuable and informative.  Some of the MTAS Psychology blogs will be self-help orientated, in which I am going to use my understanding of psychological theory to tackle some of the most common forms of mental distress.  I will give tips and advice on how to avoid and cope with the challenges that we all can face.

And on that cliff hanger I’ll say farewell.  Thanks for reading.  We will be back soon.