The Flawed Assumptions of Psychology and Psychiatry: A Martian Analysis
After what seemed like an eternity of watching David’s moods shifting to such radical extremes, it had become more difficult to recognize him than it was to recognize his mood state. He had levelled out for a while. He had been profoundly low, desperate, demented and crawling with the agony of an ever present anxiety for too many months to remember. He was now back on the up. Nobody knows why. He didn’t know why. From experience I gave him about 2 or 3 weeks before the mania really took hold. Before the abuse, the anger, the incoherence, the wild spending, the voices, the discussions about how to counter the people who were following him in order to train him into the secret services, the newly discovered superpowers, the false texts telling me our dad had died, and the repeated threats of suicide. Then the promises that all of these would stop. Then more abuse, anger, rogue secret service agents and dead dads. Our dad must have died more times than Freddy Krueger over the years. Sure enough it was about 2 or 3 weeks. I got a call to tell me that he had gone AWOL leaving a message that he was going to drown himselfin the sea. After driving around for 2 hours looking for David I finally found him on the beach staring at the sea. He said he wanted to be left alone so that he could throw himselfin. I told him that as he wasn’t on a platform it would probably be easier to walk in. If he threw himself, he’d bang his face on the © The Author(s) 2017
C. Walker et al., Building a New Community Psychology of Mental Health, DOI 10.1057/978-1-137-36099-1_2
shingle. This raised a smile. The momentary thrill of levity are pretty much all you have in these circumstances. We talked for a while. He said that he couldn’t control the buzzing in his head Everything was happening so fast inside his head that he couldn’t control it. I said that it might be useful if he talked to a doctor. He thought the same and we walked back from the beach. One day the sea might get its man but not this time.
It is generally understood that when we start talking about things like ‘minds’ and ‘mental health’, those of us who populate the psy institutions, that is, psychiatrists, psychologists, psychoanalysts, psychotherapists and counsellors, are the people to listen to. Or if they are not the people to listen to, then at the very least, they are worth listening to. Through decades of hard-won empirical research and therapeutic practice, these professionals have, through their institutions, built up a corpus of knowledge upon which rests our best understanding of human beings and the psychological distress that they experience. This chapter will suggest, however, that some of the key assumptions that much of these professional understandings are based on is flawed, and in many cases problematic.
There are a number of ways in which people can come into contact with the professionals whose job it is to treat distress. Let us, for example, take a person meeting with a GP, who in the UK at least, is generally the first medical doctor one would see when ill, and the gatekeeper to other health services. If a person walks into a consultation with a medical professional, there may well be a number of unspoken assumptions about the person walking in. And these assumptions are profoundly important because on these assumptions rest a whole range of practices, therapies, medications, conversations and approaches. For instance, the fact that many people who go to their GPs in 2016 experiencing what they understand to be depression, feeling down, sadness, anxiety or worry will find themselves treated with cognitive behavioural therapy (CBT), or some close approximation, and/or psychotropic medication, suggests a number of things. The first is that the person is a patient. Once the person steps through the GP’s door to talk about the misery, fear or confusion that he or she is experiencing, the person changes from a citizen to a citizen/patient. As we’ll see later this can have some profound consequences for the people experiencing distress.
So the newly anointed ‘patient’ will probably have conversations with their GP, and this will broadly take the form of responding to a number of questions about how they are feeling and what their thoughts are like, and possibly they will be asked about recent events in their life. Experiences vary widely depending on a number of factors, not least the person and the doctor. A number of assumptions underpin this line of questioning. The first one is that the key area of focus should be the newly anointed patient’s mind. There will be questions about sleeping, eating and physical agitation, but questions on thoughts and feelings will likely predominate.
Now forgive us for appearing flippant, but we’re going to use an example of a Martian here; let’s call her Martha, not because we like being selfconsciously zany but because it offers the reader a perspective shorn of the many cultural social assumptions that govern mental distress treatment that are so commonly mobilised that they become invisible. So, were our Martha (who is visiting Earth for the first time; a Martian who has been resident on Earth for a couple of years is no good here) to watch this consultation, she might feel bold enough to make one or two statements. She might observe that there is an unusually regimented formality between the professional and the ‘patient’ that isn’t generally there between people during most other social transactions. She might note its brevity—seven minutes—wondering if this is long enough to learn anything significant about the ‘patient’ while being impressed with just how many ‘patients’ the man in the small room with astonishing bladder control encounters that morning.
She might also guess that whatever is wrong with the person is in some sense a predominantly cognitive process. She might assume that there is some sense of constancy both in the experience of the person’s distress and in the person’s thinking on a daily basis more generally. Moreover, she might conclude that people are generally taken to be capable of accurately reporting their distress and using a series of concepts that both the ‘patient’ and the doctor share (like depression, anxiety, esteem, misery, pain, suicidal thoughts, sadness). Martha might watch the patient be told that the most up-to-date evidence base suggests that certain treatments are appropriate for them. The GP rattles off that NICE, the National Institute for Clinical Evidence, is the respected authority on what constitutes depression and its associated treatments and that NICE has isolated the most effective treatments for the patient. At this point, Martha might note down ‘NICE’ on her Martian Ipad.
The ‘patient’ might then be prescribed an antidepressant to address levels of specific neurotransmitters in the brain, and so our Martian friend might assume that whatever is troubling our patient has a biological basis and can be treated by this medication. Depending on the patient’s reaction, Martha might conclude that these treatments are either controversial or uncontroversial. Or she might not, because she is picking up on a power dynamic where the patient person defers to the doctor person and so it might be hard to tell whether they are agreeing on the things that they say they are agreeing on (or indeed whether that is important).
If the patient is prescribed CBT, then he or she might assume that the key to addressing misery is conscious, guided reflection and action on thoughts, feelings and behaviours by a skilled professional person, and that if you teach a person how to think and feel and indeed act differently, his or her misery will recede. This seems to be based on the premise that human beings are essentially rational creatures. This hasn’t been Martha’s experience up until now but she is willing to have an open mind. If they are not thinking rationally, then they need a little guidance so that this unitary, rational-thinking self can once again assume control of their steering wheel because misery is irrational and needs to be corrected so that people ‘think straight’.
This all might strike Martha as odd. First, a little picture of what Mars might look like to help contrast human with Martian misery. On Mars there is a general acceptance that Martians are not essentially rational. Martians don’t think that they have a unitary self; instead they see themselves as sites of interplay between their histories, their social environments and their nervous systems.1 Martians don’t believe that their memories are fixed concepts stored in a computer that can be accessed and changed via a skilled professional through rational exercises. Instead, they barely trust their memories since Martians are notorious for changing them to justify their actions. Unlike human beings, Martians don’t see themselves as their own bosses but instead see themselves as an assemblage of changing voices, some talking about things that happened a long time ago, some about yesterday. And the voices change with context.
Interestingly the Martians appreciate that while they have access to these different voices, they don’t necessarily control them and only partially understand them. For them, individuals exist, but all of their experiences are thoroughly and completely social at the same time as being singular and personal.2 The idea of a social versus individual dichotomy, which our little Martian heard talk of in the UK (and Martians haven’t yet visited places in the world where there are more people who see things a bit more like they do), doesn’t make sense. For Martians, what people call ‘cognitions’, that is, the mechanics of thinking, are secondary to the social relationships and shared social understandings that make the cognitions possible and that shape them. The Martians have nervous systems but they don’t cause things any more than the nerves in their legs cause them pain after they take a painful kick playing Martian football (played with three balls, one for each leg). They simply enable relationships between what happens outside the body and what they come to experience as misery, joy, happiness and so on.
The Martians don’t really buy into an idea of subjective experience that fragments into something mental and something physical and which you can then train specialised Martians to work on this newly fragmented mental bit. Misery for them is all too often beyond the reach of words or transient rational exercises, so nobody bothers trying.
And then of course there is evidence. Martians worry about evidence. They worry about it a lot, about what constitutes evidence and how it is used, probably a lot more than we do. Sometimes they worry about it so much that they can’t sleep. For them, all knowledge claims are provisional and tentative; some are incredibly useful but they appreciate that the way that they saw Mars 100 years ago is quite different from now so they are confused that humans don’t seem to take much heed of this. They think that evidence is never neutral or objective3 and that anything that someone says, whether through the tools of science or not, is tied up with the specific claims of autonomy and status of any given Martian.
It is confusing for Martians that what NICE talks about as ‘evidence-based medicine’ serves the political purpose of strengthening the authority of presently dominant clinical experts, and yet few humans seem to talk about this. As a result, NICE only seems to include some ways of collecting and recognising what evidence is. When they look at how we ‘do’ evidence-based practice, they see bureaucracies of health policy makers, professionals and academics who together collect certain forms of evidence in order to make multiple recommendations that promote evidence-based treatment practices and evidence-based prevention strategies.4 This model of public health sees mental health and mental disorder in a very specific way, and a culture of efficiency and efficacy is generated so that policy makers can get the maximum return from the modest investment.
The Martian sees a couple of problems with this approach. The first is that it tends to privilege forms of evidence that are produced by professionals, big pharma and professional academics. Lay people and community organisations (and publishers of accessible psychology books) also participate in this process of generating authoritative forms of knowledge on what misery is and how it can be assuaged. However, the Martian has observed that these forms of knowledge aren’t really important unless they agree with the beliefs and practices of professional experts. Another problem that Martians have is that it seems to them that what is being called ‘evidence-based medicine’ only concerns interventions that are focused on individual people and not the social contexts that govern much of their health experiences.4 A visiting Martian may claim Robert McNamara, the former United States Secretary of Defense from 1961 to 1968, as one of their own based on his thoughts on making decisions based solely on quantitative observations and ignoring all others. McNamara was talking about what led to quantifications of ‘success in the Vietnam war (e.g. enemy body count)’ and ignoring other variables:
The first step is to measure whatever can be easily measured. This is OK as far as it goes. The second step is to disregard that which can’t be easily measured or to give it an arbitrary quantitative value. This is artificial and misleading. The third step is to presume that what can’t be measured easily really isn’t important. This is blindness. The fourth step is to say that what can’t be easily measured really doesn’t exist. This is suicide.5
This perfectly sums up the Martian belief on the limits of the scientific rational and quantitative objective forms of knowledge that humans seem to love, yet that seem so antithetical to what human beings actually are. It frustrates Martians because different ways of generating knowledge that aren’t based on science and on quantification become completely invisible.
The Martians think that humans are like them—essentially plural beings, fluid, changeable and open to being articulated and rearticulated in different contexts and places—but most humans themselves don’t seem to be interested in this. Much of the evidence on mental health converts mental experiences into numbers with little questioning on whether the attribute in question is quantifiable.6 The Martians don’t use questionnaires to measure mental states because evidence shows that during the rating process, respondents are mistakenly assumed to have direct access to their personal and stable meanings of the given scale attribute; they can’t accept the assumption that complex attributes can be understood by a continuous measure between two points. Martians don’t assume that all respondents understand the scale questions and answers the same way.6
Trying to get into a Martian’s headspace, let’s take, for example, The Beck Depression Inventory (BDI), a standardised and popular measure of ‘depression’. Let’s say we have a single parent who works an 80-hour week and who lives in a damp flat that means their daughter’s asthma requires regular hospital treatment. Despite the hours of work, she might be in debt and receiving letters through the door telling her she will lose her belongings. And she is in conflict with her neighbours because their dog barks at night when she’s trying to sleep. As these things have happened for a while, she is miserable and goes to see her GP who may give her the BDI. This confirms that she has the thing called ‘depression’. According to many professionals and academics, this is an illness that seems to be related to neurotransmitter activity, and thinking/feeling patterns. And she will probably receive an antidepressant and/or be put on a waiting list to talk to a well-paid professional who will help her to change the way she thinks and feels. These things have happened because the questionnaire designated her as depressed. Now imagine the questionnaire asked the following:
- 1. Is your damp housing, that is making your daughter ill, making you feel miserable, guilty and anxious?
- 2. Do you think you would sleep better and feel better if it wasn’t for that bloody dog?
- 3. Does working 80 hours a week, and not being able to see your kids much, make you miserable?
She might well have answered yes to these questions and that might have produced another person, a different picture. But it didn’t because these questions won’t be relevant to many people who are miserable/dis- tressed/troubled, so they can’t be put on a general questionnaire. And so on the general questionnaire we put general things that have been completely disembodied from the things that might have caused them. And then we’re back to McNamara’s first step—we measure that which is easy to measure. And we don’t measure the other things that are not easy to measure. And if we keep giving the BDI out again and again to many people over many years, the results that it produces will be important and the things that it doesn’t produce won’t be important. And so on and so on.
Our Martian is frustrated. She is frustrated because to understand misery and human experience requires more than the process of asking people to complete a questionnaire that strips the person from their social world, history and culture, generates a number or series of numbers for that person depending on their answers to a group of disembodied questions on a given day, and then puts those numbers in with a batch of thousands of other numbers and makes statements based on the outcome. The Martian is frustrated because any kind of opposition to evidence-based practice and the randomised control trials that serve as the gold standard is understood and constituted as irrational or less valid.6 What it doesn’t do is recognise that if people give the same responses to a questionnaire on misery, it does not mean that their experiences are standardised or similar, that people’s reactions to a single factor in an experiment tell us little about how they react in contexts where other things aren’t controlled and that a science carried out by humans on humans has a variety of failings and there is a scope for oversimplifying causal relationships that don’t take so many other things into account.6 And the reason that Martians ditched their evidence-based preoccupation phase thousands of years ago was that they saw the impacts of a narrow, means-end rationality imposed by Martian public service agreements at the time. They helped contribute to a performance/audit culture which had a really bad impact both on the Martians using services and on those delivering them.7 And because they got Martians completely wrong.
The Martian might scoot off back to Mars and report on the results of her mission to understand sad and suffering human beings quite confident that she can say a number of worthwhile and interesting facts about what misery, and indeed people who are miserable, are on Earth.
Now the more eagle-eyed among you will of course have spotted that, through this laboured analogy of little green people on Mars (we didn’t mention the colour but they are of course green), we are actually suggesting that all of those attributes that we are attributing to Martians and that may seem unusual or foreign to many people, are of course a more useful way of also describing humans and their distress. And that all of the assumptions that the little Martian took from the GP consultation are in fact a range of fallacies reproduced and disseminated, often with the best will in the world, through the machinery of the psy institutions. Many of the assumptions that we hold about human beings and the way that they relate to other human beings are very limited ways of tuning into human experiences and particularly misery. At their core are a range of ways of thinking about people that bear only a passing resemblance to our everyday experiences. That many of them have a widely shared popularity in western society in 2016 does not make them any more useful, although they are certainly seductive. They are simply ways of thinking about people and their misery that have been talked into being or ‘reified’.
This is not an antipsychiatry/antipsychology book. Well it is a just a little bit, but there is no desperate urge to throw the baby out with the bathwater. Psy professionals, institutions, manuals of disorder and treatments may produce a range of misunderstandings about human beings and their forms of misery, but that is not to say that they have no value to people. In fact, often the opposite can be true. They can and often do have value to people. However, the understanding that advances in medical treatment have had little discernible impact in improving longer-term rates of recovery7 and the knowledge that there is no consistent evidence for biological causes for the overwhelming majority of the things that we understand to be ‘mental disorders’8 need to be addressed. Despite the tendency of contemporary psy logic and naming to suggest otherwise, intrapsychic and interpersonal distress and misery are likely to have a fundamentally social context. This is something only fleetingly and tangentially appreciated by the mental health industries that have formed around the forms of knowledge produced by the psy institutions.