Feeds:
Posts
Comments

Posts Tagged ‘CBT’

Edmundson

Given the themes of my current sequence this two-parter from February last year seems relevant. The first part came out yesterday.

Yesterday I gave a brief account of Mark Edmundson’s disillusioned dissection of our culture based mainly on his introduction. I promised to follow this up with a sampling of two other issues he takes up in his Quixotic attack on the windmills of materialism: the demolition work of Shakespeare and of Freud.

Shakespeare:

Edmundson warned me in his introduction of what I would find when we come to Shakespeare (page 10-11):

What is true is that Shakespeare helps change our sense of human life and human promise through an almost complete rejection of ideals. Like his contemporary, Cervantes, Shakespeare has only contempt for the heroic ideal. . . . . .

Shakespeare, as Arnold Hauser argues, is a poet of the dawning bourgeois age, who has little use for chivalry and the culture of heroic honour.

This was not a problem: the militarily heroic holds few attractions for me. However, as I discovered later Shakespeare, according to Edmundson, is not just attacking heroism, though that is a main target: he is (page 140) writing for

. . . . a class that has little use for deep religion, the religion of compassion. . . . . . And he writes for a class with no real use for high thought – though Shakespeare is from time to time tempted by the ideal of contemplation.’

He then analyses in detail plays including Titus Andronicus, Othello, Macbeth, Julius Caesar, Coriolanus, and Troilus & Cressida that ruthlessly deconstruct the hero.

ShapiroInterestingly, it is not just Cervantes who influenced Shakespeare away from ideals. Montaigne, it is possible to argue, as James Shapiro does in 1599: A Year in the Life of William Shakespeare, was also an influence on Shakespeare (page 332), as perhaps he was on Freud as we will see, and an influence particularly relevant to Hamlet:

He had surely looked into Montaigne by the time he wrote Hamlet – intuitions of critics stretching back to the 1830s on this question should be trusted – but he didn’t need to paraphrase him or pillage essays for his ideas. . . . . . . There was more than enough scepticism and uncertainty to go round in England in the final years of Elizabeth’s reign . . .

What is more important, perhaps, is the influence of Montaigne on the development of the soliloquy (page 333):

Redefining the relationship between speaker and audience, the essay also suggested to Shakespeare an intimacy between speaker and hearer that no other form, not even the sonnet, offered – except, perhaps, the soliloquy.

This may help explain why the one exception, which Edmundson detects to the reductive pattern he has identified, is Hamlet.

One of the reasons for this may be, as Shapiro suggests (ibid.), that:

Probably more than any other character in literature, Hamlet needs to talk; but there is nobody in whom he can confide.

Perhaps this is why Edmundson can find in him (page 174) ‘the free play of intellect’ he values so much. Hamlet can ‘think in quest of the Truth.’ And a truth that holds for everyone across time, not just pragmatically for the specific situation in some particular play.

It may therefore be no coincidence that this is my favourite play.

Edmundson argues that we feel that Shakespeare does not advocate any specific value system because the ones that live in his plays (page 12) ‘simply echo the anti-idealist values of his current audience and of the current world almost perfectly and, so, are nearly invisible.’

In the end, however, I do not accept his contention that Shakespeare does not value compassion, whatever we argue his audience might think and no matter that we can find evidence from his life that he fell short of that ideal in person. For instance, as a grain hoarder himself, his real life position on the 1607 food riots was rather different from the empathy for the rioters that comes across in Coriolanus.[1]

How, though, can the man that wrote,

The sense of death is most in apprehension;
And the poor beetle, that we tread upon,
In corporal sufferance finds a pang as great
As when a giant dies.

(Measure for Measure Act 3, Scene 1, lines 76-79)

and

. . . . the snail, whose tender horns being hit,
Shrinks backward in his shelly cave with pain,
And there, all smother’d up, in shade doth sit,
Long after fearing to creep forth again . . .

(Venus & Adonis lines 1033-36)

not understand and value compassion? And I am not equating this with the uncanny empathy that allows him to enter the shadowy mind of an Iago or an Edgar.

NuttallSo, at this point, I am more or less convinced that he despised the heroic. I can accept that he might not have been strong on contemplation, though I do need to think more on that one. AD Nuttall would apparently not agree, given that he has written a whole book on Shakespeare, the Thinker and clearly feels that his truths are valid across time (page 22):

Shakespeare’s response is, precisely, intelligent rather than a mere cultural reflex. He thinks fundamentally, and this makes him a natural time traveller.

Even so, he may not be a million miles apart from Edmundson, as he also acknowledges that (page 12) ‘we do not know what Shakespeare thought about any major question, in the sense that we have no settled judgements of which we can be sure.’

I absolutely disagree though that he did not value compassion, while I do accept that, as a dramatist, he could have gone a long way to creating his vast range of convincing characters with high levels of cognitive empathy alone.

I am left, though, with a slightly uneasy feeling. Maybe there’s more to Edmundson’s case than I am happy to accept. This nagging doubt goes back as far as my reading of Anne Glynn-Jones’s book, Holding Up a Mirror: how civilisations declineI am always a touch sceptical about confident claims to explain how complex entities such as civilisations operate, even though I keep getting drawn to reading them, as my posts on Jeremy Rifkin’s The Empathic Civilisation testify. Glynn-Jones builds a case against Shakespeare on the basis of Pitirim Sorokin‘s social cycle theory. I would have found it easy to dismiss her case had I not felt that elements of Sorokin’s model made a great deal of sense to me as a Bahá’í.

The core of what she feels relates to Sorokin’s concept of the sensate society. He classified societies according to their ‘cultural mentality’, which can be ‘ideational’ (reality is spiritual), ‘sensate’ (reality is material), or ‘idealistic’ (a synthesis of the two). The relevance of those categories to the current issues is obvious.

She feels the Shakespeare is a dramatist of a sensate society. She quotes many examples of where Shakespeare can clearly be argued to be pandering to the basest sensation-seeking instincts of his audience. She quotes Tolstoy (pages 264-65):

Shakespeare exemplifies the view ‘that no definite religious view of life was necessary for works of art in general, and especially for drama; that for the purpose of the drama the representation of human passions and characters was quite sufficient. . . . . .

And he concludes, ‘The fundamental inner cause of Shakespeare’s fame is . . . . that his dramas . . . . corresponded to the irreligious and immoral frame of mind of the upper classes of his time.’

Because I felt that to be a distorted misreading of Shakespeare’s audience as a whole and a very selective reading of his work in its entirety, I dismissed this view of Shakespeare completely at the time, though I could also see what she meant.

I agree he side-steps directly addressing religion but feel this is because it would have been too dangerous – and almost certainly unprofitable of course as well. That does not prove that he did not have a transcendent sense of the value of all life, and I believe he was deeply aware of its interconnectedness.

I accept that he loathed the heroic. He was definitely no philosopher. But a deeply felt compassion, rather than a mercantile value system, is what for me has ensured that he lives on, and continues to attract audiences across the world. It’s just that he does not explicitly teach compassion: he demonstrates it, though, in almost every word that he writes.

And so the pendulum swings on. Enough of that for now.

Freud:

In his introduction Edmundson states (page 12) that ‘Freud takes the enmity with ideals implicit in Shakespeare’s work and renders it explicit.’ He argues (page 14) that ‘Freud stands in the tradition of Montaigne, affirming the belief that the life of sceptical, humane detachment is the best of possible lives.’

Freud, Edmundson claims, takes this to an altogether different level (page 165):

One of the main functions of Shakespeare’s great inheritor, Freud, is to redescribe the ideals of compassion and courage and the exercise of imagination as pathologies and forms of delusion. . . . . Freud makes the middle-class people who live by half measures feel much better, allowing them to understand that the virtues that intimidated them are forms of sickness and that normality – clear-eyed and stable – is the true achievement. What a reversal!

I have read almost no Freud in the original, so strong has been my distaste for his views[2] as they have reached me through secondary sources, many of them his admirers. However, I am aware that it is possible to share my suspicion of his value without seeing him as exactly the kind of reductionist Edmundson identifies.

WebsterTake Richard Webster for example in his book Why Freud Was Wrong, in its way as brilliant as Edmundson’s. In his introduction he outlines his case against Freud. After explaining his sense that psychoanalysis is to be valued, if at all, not because it is truly scientific and valid, but because it enshrines imagination, something which has been side-lined by modernist reductionism, he makes a second telling point (page 9):

There is another reason why the vitality of the psychoanalytic tradition should not be taken as confirmation of the validity of Freud’s theories. This is because a great deal of it is owed not to any intellectual factor but to Freud’s own remarkable and charismatic personality and to the heroic myth, which he spun around himself during his own lifetime.

This is intriguing in the light of Edmundson’s case that Freud was a debunker of the heroic, but is not incompatible with it. In fact, it suggests that Freud failed to analyse himself dispassionately.

Webster takes this a step further (ibid.):

Freud himself consciously identified with Moses, and the prophetic and messianic dimensions of his character have been noted again and again even by those who have written sympathetically about psychoanalysis.

So, not just a hero, then, but a quasi-religious figure in his own eyes. Even more intriguing. Webster even goes on to claim that Freud (page 10) ‘went on to use the aura and authority of scientific rationalism in order to create around himself a church whose doctrines sought to subvert the very rationalism they invoked.’

His final point on this thread is hugely ironic in the light of Edmundson’s claims that Freud demolished the cult of the heroic ideal (page 11):

If Freud has not been seen in this light it is perhaps because the very success which he has enjoyed by casting himself in the role of intellectual liberator has brought with it the kind of idealisations and projections to which all messiahs are subject.

Towards the end of his book, Webster draws another conclusion about where this has helped to take us, which resonates with my recent explorations of Shelley, and with Edmundson’s rants against the aridity of much current lyric poetry in Poetry Slam. He argues for redressing the current bias against imagination and states that (page 504-05):

. . . . [u]ntil we have done this it seems likely that we will remain in thrall to the dissociated intellectual culture which we inhabit today, where an austere and politically influential scientific and technological culture, devoid of human sympathy and understanding, exists side by side with a weak literary and artistic culture which, because it has unconsciously internalised the image of its own superfluity, is prepared both to the stand back from the political process and to concede to the natural sciences the exclusive right to explore reality systematically and to pronounce authoritatively upon it.

Returning in more detail to Edmundson’s attack upon Freud, he defines the main focus of psychoanalysis as being on one ideal in particular (page 232):

History (and Shakespeare) have dealt with the myth of courage; history (and the Enlightenment) have dealt with the myth of faith. Love is Freud’s primary antagonist among human ideals, and he attacks it from every plausible direction.

In terms of love’s great exemplars, including Jesus and the Buddha, Freud argues (page 237) that they are ‘asking too much of human beings.’

How can we love our fellow men? Freud asks. Our fellow men, in general, have at best a mild contempt for us; at worst, they nurse murderous rage. . . . . There is only Self. Soul is an illusion.

I have dealt already on this blog with Matthieu Ricard’s utterly convincing refutation of such debasing cynicism in his book Altruism, which demonstrates beyond reasonable doubt, and on the basis of a huge amount of systematically gathered data, that we are innately capable of developing high levels of altruism, fairness and compassion. My last sequence of posts revisited his brilliant book from a different angle.

Edmundson goes on to quote Karl Kraus (page 243): ‘Psychoanalysis… is the disease of which it purports to be the cure.’ He goes on to explain what he believes this means. Having listed various ways human beings can rescue themselves from meaninglessness, such as love, creativity, compassion, courage or idealistic thought, he rounds his cannon upon Freud’s benighted cul-de-sac (page 244):

… all these activities are out of the bounds. Embracing them, for Freud, causes only trouble.

It is possible that to deny human beings these primary satisfactions makes them sick. It causes a disease, it does not cure it. If you live life without courage, compassion, the true exercise of intellect and creation through love, then you will not feel very well. You may even get quite ill.

before he delivers the coup-de-grace:

Then, when the banishment of ideals has made you ill, Freud can show you, through psychoanalysis and through the ethical program of his thought, how to feel a little better than you do. Psychoanalysis helps the culture of Self create a disease. And this disease psychoanalysis will happily help cure.

He feels the legacy of this, for psychotherapy as a whole, is deeply damaging (page 245):

Therapy can have many values, but they will never be idealistic. All therapies are about learning to live with half a loaf.

He is probably selling psychotherapies such as Psychosynthesis short when he uses that dubious word ‘all.’ But his point is valid for mainstream approaches. Spirituality and idealism are seen by them as suspect.

I hope this all too brief helicopter review inspires you to buy the book and read it, and I hope you then enjoy it as much as I have. Life is a lot richer than our materialistic gurus would have us believe, thank goodness.

Footnote:

[1] This side of Shakespeare was revealed in research done by Dr Jayne Archer, a lecturer in medieval and renaissance literature at Aberystwyth University.

[2] I am aware, from January’s Guardian article by , of the recent study which goes some way toward rehabilitating psychoanalysis as a treatment for depression.

He writes:

. . . . . [R]esearchers at London’s Tavistock clinic published results in October from the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. For the most severely depressed, it concluded, 18 months of analysis worked far better – and with much longer-lasting effects – than “treatment as usual” on the NHS, which included some CBT. Two years after the various treatments ended, 44% of analysis patients no longer met the criteria for major depression, compared to one-tenth of the others. Around the same time, the Swedish press reported a finding from government auditors there: that a multimillion pound scheme to reorient mental healthcare towards CBT had proved completely ineffective in meeting its goals.

So I need to clarify, perhaps, that it is Freud’s quasi-mythical beliefs such as the Oedipus Complex that repelled me as being too absurd to qualify as a universal truth. Other aspects of his thinking, taken over and used by other schools of therapy, have their place, such an projection and denial, as well as the acknowledgement that for some people it can be imperative that they understand their inscape deeply before they can move on, and that this can take years. Even so these are not universally applicable components of an effective therapy at all times. There is no one size fits all panacea – not psychoanalysis, not CBT.

I don’t think Burkeman would disagree with that as he concludes ‘. . . . . many scholars have been drawn to what has become known as the “dodo-bird verdict”: the idea, supported by some studies, that the specific kind of therapy makes little difference. (The name comes from the Dodo’s pronouncement in Alice in Wonderland: “Everybody has won, and all must have prizes.”) What seems to matter much more is the presence of a compassionate, dedicated therapist, and a patient committed to change; if one therapy is better than all others for all or even most problems, it has yet to be discovered.’

Stuck in memory from my first degree in psychology, there was an interesting piece of meta-analysis from 1979 that pulled together all the studies of the efficacy of psychotherapy that had included an advance measure of how credible clients found the therapy they were undertaking. When all other variables were controlled for, the strongest predictor of effectiveness was how much the client believed the therapy would work. Unfortunately I have not been able to track that down recently.

And for me, if it has no place for a spiritual dimension, such as can be found in Jungian analysis and Psychosynthesis, there is still a major defect in the approach.

 

Advertisements

Read Full Post »

focus-of-exploration

For many years it was believed that psychotic symptoms were discontinuous from `normal’ psychological functioning. This position is becoming increasingly untenable in the light of research evidence that positive psychotic symptoms can be understood with reference to normal psychological processes. This paper will outline the evidence from current psychological conceptualizations that psychotic symptoms are closely related to a person’s psychological functioning and that they are therefore amenable to psychological intervention (Yusupoff et al., 1996). Current psychological conceptualizations of hallucinations and delusions hold that the content of these symptoms contain material which is personally relevant to the individual. Indeed, this personal relevance is critical to the understanding of, and cognitive interventions with psychotic symptoms.

(From An Interacting Cognitive Subsystems Model of Relapse and the Course of Psychosis by Andrew Gumley, Craig A. White and Kevin Power – page 262)

In the previous post I began to outline a picture of the kind of traumatic life experiences which can give rise to psychosis.

There’s more to add to the list of factors.

Additional Factors

Many who experience psychosis also, for example, according to Murphy at al (Modelling the co-occurrence of psychosis-like experiences and childhood sexual abuse), have experienced heightened levels of social deprivation, discrimination and isolation even beyond the age of 16. Additionally, members of the group with no history of Childhood Sexual Abuse were more likely to have experienced Childhood Physical Abuse, PTSD, social isolation and neurotic disorder. Interestingly, members of this class were also more likely to be male.

This profile seemed to indicate that, in the absence of Childhood Sexual Abuse, individuals who experienced psychosis were likely to endure a wide range of other traumatic experiences. It seemed that the composition of this class, particularly in terms of sex, suggested that, while psychosis may be a phenomenon highly associated with traumatic experience and adversity, the precise nature of this trauma and adversity may be dependent upon the sex of the individual. The Child Sexual Abuse-only class was more likely to be female and was characterised by elevated probabilities of childhood physical abuse and adult sexual trauma, neurotic disorder and cannabis consumption.

It may be worth spending sometime teasing out the exact level of risk of psychosis represented by trauma.

Longden and Read (The Role of Social Adversity in the Etiology of Psychosis – page 7) focus on two substantial meta-analyses (ie collated data from a number of well validated studies). The first screened 736 articles, retaining 41 of the best designed. When results were pooled, individuals with a history of childhood trauma (child sexual abuse, physical abuse, emotional abuse, neglect, bullying, parental death) were shown to be 2.8 times more likely to develop psychotic symptoms than those who had not. The second meta-analysis retained 25 studies from a search result of 1104, and found that rates of childhood adversity (including child sexual abuse, physical abuse, emotional abuse, neglect, witnessing domestic violence, and loss events) were 3.6 times greater in people diagnosed with schizophrenia relative to “healthy controls.”

It is important that we make sure we are not being misled into attributing cause when we have only correlation. By this I mean that just because, when I am holding my key to either open or lock my front door, the light goes on, I should not jump to the conclusion that my door key is switching the light on. I need to understand that my mere presence with no key is enough to trigger the motion sensor. The key is a confounding variable that needs to be eliminated, for example by leaving the house without locking the door one night. I’d be wise not to go further than strictly necessary to prove the point though.

Longden and Read (pages 7-8) deal extensively with this problem:

Large-scale population studies have shown that associations between adversity and psychotic experience remain significant when controlling for possible confounders, including: family history of psychosis and other mental health problems (which negates the notion that psychosis only occurs in those genetically predisposed), age, sex, ethnicity, marital status, exposure to discrimination, other psychiatric diagnoses, education level, neuroticism, and substance use. Furthermore, the association has repeatedly demonstrated a dose-response relationship; that is, the likelihood of psychosis increases relative to the extent of adversity exposure.

 

Lucretia by Rembrandt

Lucretia by Rembrandt (For source of image, see link)

Even this does not end the list of factors (ibid.):

Despite much emphasis on childhood abuse, this is by no means the only environmental adversity associated with psychosis. Other cited factors (Larkin & Morrison, 2006; Read, 2013a; Scott, Chant, Andrews, Martin, & McGrath, 2007) include discrimination, witnessing domestic violence, prenatal stress, war trauma, torture, adulthood rape and physical assault, excessive marijuana use in adolescence (in some instances this may represent attempts to self-medicate posttraumatic symptoms . . . ), and disturbed attachment relationships with one’s caregivers, including abandonment, being the result of an unwanted pregnancy, being raised in institutional care, dysfunctional parenting (often intergenerational), and parental death or separation. Another factor receiving significant attention is poverty and inequality . . .

Longden and Read feel (page 9): ‘that erroneous reports of sexual victimization are no different between patients diagnosed with schizophrenia and the general population,’ so we have as much reason to believe a patient diagnosed with schizophrenia as anyone else, and we have already established in the first post of this sequence that this level of credibility is basically compelling.

The Brain

Now is the time to return to a closer examination of the role of the brain in all this.

Longden and Read describe what they intimidatingly label (page 12) ‘the traumagenic neurodevelopmental (TN) model of psychosis’ by which they mean how, during our formative years, trauma can affect the brain in ways that make psychosis more likely. They argue that there are similarities between abnormalities in the brains of abused children and those of adult patients with psychosis.

A key point is this: ‘A major premise of the TN model is that the heightened stress sensitivity consistently found in patients with psychosis is not necessarily inherited, but caused by formative exposure to abuse and neglect.’ This is key because it moves the debate away from genes to life experience.

They give various examples of the research including (pages 20-21):

A . . . study with 45 individuals considered at clinical high risk for psychosis found significant positive associations between trauma exposure (psychological and/or physical bullying, emotional neglect, emotional abuse, physical abuse, Childhood Sexual Abuse) and feelings of being watched or followed, as well as false beliefs about power or status. . .

An equally important finding is the relationship between psychotic content and precipitating trauma (ibid.):

Comparable work with 41 patients experiencing a first episode of psychosis found that attributes of stressful events in the year preceding psychosis onset were significantly associated with core themes of both delusions and hallucinations.

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

Implications for Therapy

How might this realisation help?

Murphy et al (Modelling the co-occurrence of psychosis-like experiences and childhood sexual abuse) feel that:

. . . . identifying and evaluating trauma specificity in the onset and maintenance of psychological distress may aid clinicians and service users alike, in

(1) clarifying sources of distress and

(2) understanding symptom content and expression, while enhancing treatment design and efficacy also.

They emphasise that point that ‘symptoms of psychosis are often characterised by content that can be meaningfully attributed to past personally significant experiences.’

Longden and Read (page 22) feel that their evidence points in this same direction and  ‘reinforces a standpoint formed in the earliest days of psychiatry and that has gathered a striking momentum in the past two decades; that it is no longer a scientifically or morally tenable position to view psychosis as a purely biogenetic disease.’

This has clear implications for the approach we should adopt. They remind us that the British Psychological Society ([BPS] Division of Clinical Psychology) recently published a report emphasizing the utility of psychotherapeutic approaches to psychosis. The executive summary opens with the observation that “Hearing voices or feeling paranoid are common experiences which can often be a reaction to trauma, abuse or deprivation. Calling them symptoms of . . . psychosis or schizophrenia is only one way of thinking about them, with advantages and disadvantages” (BPS, 2014, p. 6)

Unfortunately the evidence I find in what I read now suggests that the situation that confronted someone I worked with in the 1990s may not have changed much. She wrote me as follows, after she moved to another city:

Today I saw my new CPN. He’s called D, and I’m feeling very upset as a result of our meeting. I’d be able to give you a ten foot long list of insensitive things he said, if I wanted to! His main objection was that I’m not out there working, earning money and contributing to the country. He said he’s going to phone the DRO tomorrow and get her to come out and see me to assess me for a job. . . . D was also very heavy-handed in his approach to “disability”. He said there’s people much worse off than I am and they’re using their abilities to the benefit of other people. I think one of the worst things that anyone can say to someone who’s got my kind of disability is that there are people worse off than they are. It has to come from the individuals themselves to say that sort of thing. I’ve applied to do a BA at the Open University — D wasn’t even satisfied with that, because it won’t lead to a “practical skill.” He questioned the intensity of my voices, the fact that I’m not sleeping . . . and he also physically tried to stop me rocking. I’m feeling really upset by it all.

[Later] My new CPN is . . . . refreshingly gentle and unassertive, but he’s only here for another couple of weeks. It’s very unsettling all this changing around, because I can’t work consistently with them, and by the time I feel ready to talk in confidence it’s time for them to move on to another post. I think it will be like this for the next six months until the permanent CPN comes back from maternity leave.

ThriveLayard and others certainly do not think things have changed for the better. It is an indictment of our society’s approach to mental health that effective treatment for many forms of mental problem is not sufficiently available to meet the need. Writing in 2014, Layard and Clark’s in their book – Thrive – draw this forcefully to our attention. The data the authors use to prove their case include the fact that (page 381):

. . . while over 90% of diabetes sufferers receive treatment for their condition, under a third of adults with diagnosable mental illness do so. This is largely because good evidence-based psychological therapy is not readily available

If anything things have got worse in the intervening period. The value of talking therapy for psychosis is clearly not sufficiently well recognised to guarantee that it will be funded and, if funded, that it will be safeguarded and prioritised. In the few areas seeking to provide some form of psychological support, Health Care Commissioners, even while knowing that CBT for psychosis should be available in 12 session packages, in itself a minimum requirement, frequently fund only six sessions or less. If this policy were followed for the prescription of antibiotics or the provision of cancer treatment there would be a national outcry.

Part of the reason for this blindness is the still prevailing implicit conviction that psychosis is basically a biological problem and is best treated with drugs not psychotherapy. Hopefully this sequence of posts will go some way to adding momentum to the increasingly powerful wave of dissent from this conveniently short-term cost-saving point of view.

In fact, it doesn’t save any costs at all in the long-term. With even the minimum basic intervention of CBT mounted early enough, sufficient benefits would accrue for enough patients to save the costs of relapse and readmission further down the road.

Beyond this though, in my view, we need more widely effective forms of ‘talking cures’ before we will see really major benefits long-term. But better half a loaf than none at this point.

So, having dealt at some length with the relatively straightforward issue of trauma and psychosis I plan to embark in the next sequence of posts on the trickier issue of thresholds of consciousness and psychosis. Wish me luck!

Read Full Post »

Talking to Ian

Talking to Ian

There is now overwhelming evidence that psychological approaches can be very helpful for people who experience psychosis. However, there remains a wide variation in what is available in different places. Even the most successful approaches, such as early intervention and family work, are often not available, and nine out of ten of those who could benefit have no access to CBT. There is a pressing need for all services to come up to the standard of the best and to offer people genuine choices. Perhaps most importantly, we need a culture change in services such that the psychological understanding described in this report informs every conversation and every decision.

(From Understanding Psychosis and Schizophrenia published by the British Psychological Society – page 93)

At the end of the previous post in this sequence, I shared an example from my own experience that confirms the idea that psychosis might be a way of protecting oneself from what one experiences as even greater pain and terror. Here is another example before we move forward.

Ian’s Story

My experience in 1993 with another client, Ian, who did not want to be shown in full in the video we made at the time, pointed in this same direction (see a previous sequence of posts for a more detailed account). He was an ex-soldier whose traumatic experiences in the army, riding on the back of a difficult childhood and a recent intense and distressing relationship with a woman who had a serious drink problem, had led to a deeply disturbing psychotic experience involving persecutory voices. In many ways he made good progress and for almost a year he kept moving forwards.

It is perhaps worth quoting an extract from a videoed interview with him that exactly explains what for him were key components of the effectiveness of what I call collaborative conversation. In his explanation we find references to the recent reactivating trauma (his abandonment of the woman he was living with and the guilt that ensued), the way that avoidance of the feelings this triggered led to persecuting voices, and how facing the feelings defused the voices.

At the point we pick up on the conversation after a question about how the easing of the voices had helped, he had learnt how to negotiate with the voices to give him breaks from their constant harassment: J. was his care worker where he was living.

I.: Because I’d got time to think about it. And I was thinking about different things, you know? And different things from the past that needed to be talked about. And I could remember things from the past, you know and the thoughts just kept coming into my head of different things. `I must mention that to Pete.’ That’s what I kept thinking.

P.: I know this sounds a very stupid question, but in terms of when you then came and talked about them, what was valuable about just talking about them?

I.: Because it made it real. When I was ill, it didn’t seem real. You know what I mean? My memory didn’t seem real. It was like a dream. And it was as if I’d never done anything. But talking to you reminded me that I’d actually done these things, you know? And that it was memory. And that I’d actually done the things. It was reality.

P.: And how did knowing that it was reality prove so helpful? What did it do?

I.: Well, it proved the voices wrong for a start.

P.: Ah. Why? Were they saying that they were real and your memories weren’t?

I.: Yeh. It proved the voices were wrong. And that my memory was right. And talking to you fetched it out into the open. . . . . .

P.: It sounds as though being able to think about things and about the past or about what’s happening to you now was a very important thing that began to happen.

I.: Yeh. It was very important. Getting in touch with reality. And finding out what things were real. And what things wasn’t real.. . .  I needed to think about getting well. And what it was going to be like without the voices. And what it was going to be like without going in and out of hospital all the time. And I needed to think about it. And I couldn’t think about it when the voices were talking to me.

P.: Do you think that when we were talking about things it was only a question of remembering and then realising that the memories were real or were you also doing something else with the memories once you got them remembered?

I.: I was putting ’em in order. I was sorting ’em out. Things from the past that shouldn’t haunt me no longer. That I could put in the past and leave there, you know? I had to talk about ’em. I had to think about ’em. I had to feel about it, yeh. I thought it would never stop, you know. . .  It wasn’t easy

J.: You actually hurt a lot, didn’t you?

I.: Yeh. I hurt so much that I thought it wasn’t worth being well, you know? . . .

J.: We tried hard to put the good things in the now, didn’t we? You started to feel them more as well, didn’t you?

I.: Yeh.

J.: Tell me if I’m not getting this right. My belief was that you were feeling all these bad things that hurt. When we went and did something that was pleasant and you realised that you could enjoy that more now it helped you to realise that feelings could be good as well as bad.

I.: Yeh. I thought feeling was all bad. But feeling – like I feel good now – I feel really good now . . . (Pause)

P.: Are you saying that you’ve come to realise – it’s like not being anaesthetised – anaesthetic stops you feeling pain but it also stops you feeling anything else as well – and now it’s like you’re no longer under anaesthetic so you can feel very bad . . .

I.: Yeh.

P.: . . . but you can also feel very good. Is that a price worth paying? Sometimes feeling bad, is that a price worth paying for quite often feeling good?

I.: Yes. ‘Tis a price worth paying. Getting your feelings back is a painful thing, you know? And it really hurts. Makes you cry. But once you done your crying and you’ve realised that that’s real, you know, then you come to terms with it. You can put it in the past without worrying about it.

P.: What do you think is the effect of that on the voices?

I.: Well, they got no worries. So, they leave me alone.

P.: Do you think they fed on the worry and pain and distress you were keeping under?

I.: Yeh. They kept feeding on my suppression, you know? . . . They kept getting worse and worse until it got unreal.

P.: Yeh. There were certain things that you had done that really you felt very bad about, weren’t there?

I.: Yeh.

P.: That you felt really guilty about. In a sense you had never quite faced up to that perhaps?[1] The loss, the grief, the pain, you’d not faced up to. Am I right that these were all different bad feelings you had?

I.: Yeh. I felt bad about L. [his ex-partner] you know? I felt really bad about her. And I thought I’d done her wrong. And that’s why I was ill. The voices fed on it, you know?

P.: Do you think you actually deserved to be ill?

I.: No. Nobody deserves to be ill.

To show us the limits of what can be done, and how psychosis can seem preferable to raw reality, it was then that we discovered that there were two anniversary effects that triggered a resurgence of the hostile voices: these related to two traumatic army experiences whose pain and guilt he was never able re-experience and integrate, preferring instead for the voices to get worse at that time of year. We realised that the guilt at what he felt he had done to his ex-partner, the trigger to the hospital admission that led to my involvement, had been reactivating an earlier and far deeper sense of guilt. An increase in the intensity of the voices was in this case the lesser of two evils for him, even though it risked relapse and consequent hospitalisation sometimes.

Further Implications

It was experiences like these that convinced me that the medical model had to be complemented, or maybe even superceded, in some way.

In explaining his model, Shields, whose work I examined earlier in this sequence, is not discounting the role of biology (ibid):

However, this hypothesis does not view these psychological processes as operating independently of biological factors; these psychological and existential factors work closely with the structural or functional integrity of the brain in producing psychotic episodes.

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

Graph of the Model that states Psychosis is on a continuum with Normal Functioning (Source: The route to psychosis by Dr Emmanuelle Peters)

He is singing from the same hymn sheet as Bethany L. Leonhardt et al in arguing that there is a continuum (page 146):

. . . psychotic symptoms exist on a continuum even in healthy individuals (Stefanis et al., 2002). This, too, seems to be explicable if psychosis is a way to cope with existential distress – as psychosis would be quantitatively, rather than qualitatively, different from normal. . . .

They go on to make a particularly subtle but potentially crucial point (pages 146-7:

This hypothesis can explain another aspect of psychosis: psychotic individuals do not choose realistic explanations for their experiences (Freeman et al., 2004). If the explanations chosen by psychotic individuals were more realistic, then the problem of reality would continue to intrude on an individual that cannot deal with reality.

This possibility paves the way towards explaining why some people with psychotic experiences are desperate to be helped to get rid of them while others work hard to hold onto them against every attempt to persuade them otherwise (page 147):

Psychotic breaks that do not entirely allow psychotic individuals to avoid dealing with the issues that prompted their psychosis would leave these individuals no way to avoid reality – though they desire to. Therefore, individuals in this state would want to rid themselves of reality and their experience however necessary – if their psychosis is, indeed, an attempted escape from an unbearable reality. Alternatively, for psychotic breaks that do truly allow individuals to avoid dealing with the issues that prompted their psychosis, these individuals would cling to their psychosis with certainty, as their psychosis is what permits them to cope with the crushing distress that prompted their episode.

The implications of this would explain why the drugs prescribed prove to have a positive effect of any kind at all (page 150):

This paper’s hypothesis – that psychosis might function as a mechanism for coping with existential distress – explains the efficacy of antipsychotic drugs by their ability to help a patient avoid existentially distressing issues. . . . . After a lengthy review of the evidence for and against the dopamine hypothesis, one psychiatrist proposed that antipsychotics primarily work not by modifying dopamine but instead by inducing neurocognitive suppression, which diminishes the severity of psychotic symptoms (Moncrieff, 2009).

This leads to another disturbing conclusion (page 151):

However, if the hypothesis outlined herein is true, the nature of the antipsychotic cure is temporary rather than permanent; the individual still has not dealt with the issues that prompted their psychotic break. This temporary nature may explain why antipsychotics increase the chronicity of psychosis: antipsychotics are simply another measure in avoiding the same issues that need resolved.

Shields recognises that his hypothesis is not without its weaknesses (page 152):

[One] limitation of this hypothesis is that many individuals undergo existential crises without having a psychotic break. However, it may be that individuals who do not have a psychotic break do not attempt to avoid the existential issues they are facing; instead, they may accept these issues or deal with them. Again, though, this is speculation, and it does not easily lead to predictions for further research. A final possible limitation of this hypothesis is that it implicitly assumes that psychosis is a unitary phenomenon, potentially manifest in differing ways, but some argue that a single concept of psychosis ought to be abandoned for a pentagonal model (Os & Kapur, 2009; White, Harvey, Opler, & Lindenmayer, 1997).

Rethink said cognitive behavioural therapy could help cut long-term costs of care (for source of image see link)

Rethink said cognitive behavioural therapy could help cut long-term costs of care (for source of image see link)So what?

So what?

What for me is of compelling interest in the arguments these papers put forward has two aspects.

The first is that they all seek to confirm in one way or the other that psychosis is a meaningful response to experience.

The second follows on from that. If psychosis is a meaningful response to experience, then it needs to be explored in the light of that experience if the person is to move on. Shields favours some form of existential therapy but admits that he lacks the evidence to support his preference. The study he would like to see run has not happened yet (page 153):

In a randomized trial of treatment for psychotic individuals, those treated with existential psychotherapy – especially a type of existential psychotherapy that provides an ontological ground for the resolution of existential issues, such as the one provided by Bretherton (2006) – should have significantly better outcomes than those treated with biological methods.

I also am drawn to existential therapy, and it influenced my own approach, not least because of the emphasis it places upon developing the capacity to think about one’s thinking (metacognition), something widely recognised as a problem for people with psychotic experiences.

I am aware as well that there is a great deal of scepticism about the efficacy of Cognitive Behaviour Therapy for schizophrenia, partly because its implementation has been half-hearted, to put it mildly, but also because it may not be the optimal response in every case. I am not convinced by any one-size-fits-all model.

I need to explore all this more deeply still, but I know what I feel is likely to be the case.

These writers are right, despite all caveats. Psychosis is a response to extreme experience that cries out to be worked with in a way that helps the person come to terms with what for them is unendurable.

I know from my own experience that this is not going to be easy. Some people would choose not to go down that road at all, just as there are those who would rather take painkillers forever than begin to use exercise to help their bodies heal. But I also know that if our society and its institutions gave far more support than they do to this model (in fact they all too often rubbish it at least implicitly) far more people would be empowered to use it and leave the real and imagined terrors of the psychotic state behind.

I also recognise that more needs to be done to fashion and test the best psychotherapeutic approach to these issues. But that is no reason for failing to do anything on a larger scale to remedy this deficiency.

Footnote:

[1] I may have been missing the crucial point that links suppression of painful feeling with increasing loss of contact with reality and the ascendancy of the voices. This pertains to the difficulty he had explaining what the point of talking about memories was.

Read Full Post »

WebsterA recent Guardian article by  points up the evidence that is beginning to call into question the reigning assumption that Cognitive Behaviour Therapy (CBT) is not only the most effective but also the cheapest form of therapy for most common mental health problems.  It seemed a good time to flag this up when I have just finished blogging about Mark Edmundson’s sceptical attack on Shakespeare and Freud, and quoting Richard Webster in support. Burkeman looks at the relative merits and drawbacks of both forms of therapy in this probing article (no Freudian pun intended!). It niggles me even so that insufficient emphasis is still being placed on the need for the inclusion of a spiritual dimension in all therapeutic models if they are going to work for more than the circumscribed needs of a narrow band of clients. Burkeman rightly emphasises at the end of his article the primary importance of the relationship between client and psychotherapist. Below is a brief extract: for the full post see link.

Cheap and effective, CBT became the dominant form of therapy, consigning Freud to psychology’s dingy basement. But new studies have cast doubt on its supremacy – and shown dramatic results for psychoanalysis. Is it time to get back on the couch?

Freud (this story goes) has been debunked. Young boys don’t lust after their mothers, or fear their fathers will castrate them; adolescent girls don’t envy their brothers’ penises. No brain scan has ever located the ego, super-ego or id. The practice of charging clients steep fees to ponder their childhoods for years – while characterising any objections to this process as “resistance”, demanding further psychoanalysis – looks to many like a scam. “Arguably no other notable figure in history was so fantastically wrong about nearly every important thing he had to say” than Sigmund Freud, the philosopher Todd Dufresne declared a few years back, summing up the consensus and echoing the Nobel prize-winning scientist Peter Medawar, who in 1975 called psychoanalysis “the most stupendous intellectual confidence trick of the 20th century”. It was, Medawar went on, “a terminal product as well – something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.”

A jumble of therapies emerged in Freud’s wake, as therapists struggled to put their endeavours on a sounder empirical footing. But from all these approaches – including humanistic therapy, interpersonal therapy, transpersonal therapy, transactional analysis and so on – it’s generally agreed that one emerged triumphant. Cognitive behavioural therapy, or CBT, is a down-to-earth technique focused not on the past but the present; not on mysterious inner drives, but on adjusting the unhelpful thought patterns that cause negative emotions. In contrast to the meandering conversations of psychoanalysis, a typical CBT exercise might involve filling out a flowchart to identify the self-critical “automatic thoughts” that occur whenever you face a setback, like being criticised at work, or rejected after a date.

Yet rumblings of dissent from the vanquished psychoanalytic old guard have never quite gone away. At their core is a fundamental disagreement about human nature – about why we suffer, and how, if ever, we can hope to find peace of mind. CBT embodies a very specific view of painful emotions: that they’re primarily something to be eliminated, or failing that, made tolerable. A condition such as depression, then, is a bit like a cancerous tumour: sure, it might be useful to figure out where it came from – but it’s far more important to get rid of it. CBT doesn’t exactly claim that happiness is easy, but it does imply that it’s relatively simple: your distress is caused by your irrational beliefs, and it’s within your power to seize hold of those beliefs and change them.

Read Full Post »

EdmundsonLast Monday I gave a brief account of Mark Edmundson’s disillusioned dissection of our culture based mainly on his introduction. I promised to follow this up with a sampling of two other issues he takes up in his Quixotic attack on the windmills of materialism: the demolition work of Shakespeare and of Freud.

Shakespeare:

Edmundson warned me in his introduction of what I would find when we come to Shakespeare (page 10-11):

What is true is that Shakespeare helps change our sense of human life and human promise through an almost complete rejection of ideals. Like his contemporary, Cervantes, Shakespeare has only contempt for the heroic ideal. . . . . .

Shakespeare, as Arnold Hauser argues, is a poet of the dawning bourgeois age, who has little use for chivalry and the culture of heroic honour.

This was not a problem: the militarily heroic holds few attractions for me. However, as I discovered later Shakespeare, according to Edmundson, is not just attacking heroism, though that is a main target: he is (page 140) writing for

. . . . a class that has little use for deep religion, the religion of compassion. . . . . . And he writes for a class with no real use for high thought – though Shakespeare is from time to time tempted by the ideal of contemplation.’

He then analyses in detail plays including Titus Andronicus, Othello, Macbeth, Julius Caesar, Coriolanus, and Troilus & Cressida that ruthlessly deconstruct the hero.

ShapiroInterestingly, it is not just Cervantes who influenced Shakespeare away from ideals. Montaigne, it is possible to argue, as James Shapiro does in 1599: A Year in the Life of William Shakespeare, was also an influence on Shakespeare (page 332), as perhaps he was on Freud as we will see, and an influence particularly relevant to Hamlet:

He had surely looked into Montaigne by the time he wrote Hamlet – intuitions of critics stretching back to the 1830s on this question should be trusted – but he didn’t need to paraphrase him or pillage essays for his ideas. . . . . . . There was more than enough scepticism and uncertainty to go round in England in the final years of Elizabeth’s reign . . .

What is more important, perhaps, is the influence of Montaigne on the development of the soliloquy (page 333):

Redefining the relationship between speaker and audience, the essay also suggested to Shakespeare an intimacy between speaker and hearer that no other form, not even the sonnet, offered – except, perhaps, the soliloquy.

This may help explain why the one exception, which Edmundson detects to the reductive pattern he has identified, is Hamlet.

One of the reasons for this may be, as Shapiro suggests (ibid.), that:

Probably more than any other character in literature, Hamlet needs to talk; but there is nobody in whom he can confide.

Perhaps this is why Edmundson can find in him (page 174) ‘the free play of intellect’ he values so much. Hamlet can ‘think in quest of the Truth.’ And a truth that holds for everyone across time, not just pragmatically for the specific situation in some particular play.

It may therefore be no coincidence that this is my favourite play.

Edmundson argues that we feel that Shakespeare does not advocate any specific value system because the ones that live in his plays (page 12) ‘simply echo the anti-idealist values of his current audience and of the current world almost perfectly and, so, are nearly invisible.’

In the end, however, I do not accept his contention that Shakespeare does not value compassion, whatever we argue his audience might think and no matter that we can find evidence from his life that he fell short of that ideal in person. For instance, as a grain hoarder himself, his real life position on the 1607 food riots was rather different from the empathy for the rioters that comes across in Coriolanus.[1]

How, though, can the man that wrote,

The sense of death is most in apprehension;
And the poor beetle, that we tread upon,
In corporal sufferance finds a pang as great
As when a giant dies.

(Measure for Measure Act 3, Scene 1, lines 76-79)

and

. . . . the snail, whose tender horns being hit,
Shrinks backward in his shelly cave with pain,
And there, all smother’d up, in shade doth sit,
Long after fearing to creep forth again . . .

(Venus & Adonis lines 1033-36)

not understand and value compassion? And I am not equating this with the uncanny empathy that allows him to enter the shadowy mind of an Iago or an Edgar.

NuttallSo, at this point, I am more or less convinced that he despised the heroic. I can accept that he might not have been strong on contemplation, though I do need to think more on that one. AD Nuttall would apparently not agree, given that he has written a whole book on Shakespeare, the Thinker and clearly feels that his truths are valid across time (page 22):

Shakespeare’s response is, precisely, intelligent rather than a mere cultural reflex. He thinks fundamentally, and this makes him a natural time traveller.

Even so, he may not be a million miles apart from Edmundson, as he also acknowledges that (page 12) ‘we do not know what Shakespeare thought about any major question, in the sense that we have no settled judgements of which we can be sure.’

I absolutely disagree though that he did not value compassion, while I do accept that, as a dramatist, he could have gone a long way to creating his vast range of convincing characters with high levels of cognitive empathy alone.

I am left, though, with a slightly uneasy feeling. Maybe there’s more to Edmundson’s case than I am happy to accept. This nagging doubt goes back as far as my reading of Anne Glynn-Jones’s book, Holding Up a Mirror: how civilisations declineI am always a touch sceptical about confident claims to explain how complex entities such as civilisations operate, even though I keep getting drawn to reading them, as my posts on Jeremy Rifkin’s The Empathic Civilisation testify. Glynn-Jones builds a case against Shakespeare on the basis of Pitirim Sorokin‘s social cycle theory. I would have found it easy to dismiss her case had I not felt that elements of Sorokin’s model made a great deal of sense to me as a Bahá’í.

The core of what she feels relates to Sorokin’s concept of the sensate society. He classified societies according to their ‘cultural mentality’, which can be ‘ideational’ (reality is spiritual), ‘sensate’ (reality is material), or ‘idealistic’ (a synthesis of the two). The relevance of those categories to the current issues is obvious.

She feels the Shakespeare is a dramatist of a sensate society. She quotes many examples of where Shakespeare can clearly be argued to be pandering to the basest sensation-seeking instincts of his audience. She quotes Tolstoy (pages 264-65):

Shakespeare exemplifies the view ‘that no definite religious view of life was necessary for works of art in general, and especially for drama; that for the purpose of the drama the representation of human passions and characters was quite sufficient. . . . . .

And he concludes, ‘The fundamental inner cause of Shakespeare’s fame is . . . . that his dramas . . . . corresponded to the irreligious and immoral frame of mind of the upper classes of his time.’

Because I felt that to be a distorted misreading of Shakespeare’s audience as a whole and a very selective reading of his work in its entirety, I dismissed this view of Shakespeare completely at the time, though I could also see what she meant.

I agree he side-steps directly addressing religion but feel this is because it would have been too dangerous – and almost certainly unprofitable of course as well. That does not prove that he did not have a transcendent sense of the value of all life, and I believe he was deeply aware of its interconnectedness.

I accept that he loathed the heroic. He was definitely no philosopher. But a deeply felt compassion, rather than a mercantile value system, is what for me has ensured that he lives on, and continues to attract audiences across the world. It’s just that he does not explicitly teach compassion: he demonstrates it, though, in almost every word that he writes.

And so the pendulum swings on. Enough of that for now.

Freud:

In his introduction Edmundson states (page 12) that ‘Freud takes the enmity with ideals implicit in Shakespeare’s work and renders it explicit.’ He argues (page 14) that ‘Freud stands in the tradition of Montaigne, affirming the belief that the life of sceptical, humane detachment is the best of possible lives.’

Freud, Edmundson claims, takes this to an altogether different level (page 165):

One of the main functions of Shakespeare’s great inheritor, Freud, is to redescribe the ideals of compassion and courage and the exercise of imagination as pathologies and forms of delusion. . . . . Freud makes the middle-class people who live by half measures feel much better, allowing them to understand that the virtues that intimidated them are forms of sickness and that normality – clear-eyed and stable – is the true achievement. What a reversal!

I have read almost no Freud in the original, so strong has been my distaste for his views[2] as they have reached me through secondary sources, many of them his admirers. However, I am aware that it is possible to share my suspicion of his value without seeing him as exactly the kind of reductionist Edmundson identifies.

WebsterTake Richard Webster for example in his book Why Freud Was Wrong, in its way as brilliant as Edmundson’s. In his introduction he outlines his case against Freud. After explaining his sense that psychoanalysis is to be valued, if at all, not because it is truly scientific and valid, but because it enshrines imagination, something which has been side-lined by modernist reductionism, he makes a second telling point (page 9):

There is another reason why the vitality of the psychoanalytic tradition should not be taken as confirmation of the validity of Freud’s theories. This is because a great deal of it is owed not to any intellectual factor but to Freud’s own remarkable and charismatic personality and to the heroic myth, which he spun around himself during his own lifetime.

This is intriguing in the light of Edmundson’s case that Freud was a debunker of the heroic, but is not incompatible with it. In fact, it suggests that Freud failed to analyse himself dispassionately.

Webster takes this a step further (ibid.):

Freud himself consciously identified with Moses, and the prophetic and messianic dimensions of his character have been noted again and again even by those who have written sympathetically about psychoanalysis.

So, not just a hero, then, but a quasi-religious figure in his own eyes. Even more intriguing. Webster even goes on to claim that Freud (page 10) ‘went on to use the aura and authority of scientific rationalism in order to create around himself a church whose doctrines sought to subvert the very rationalism they invoked.’

His final point on this thread is hugely ironic in the light of Edmundson’s claims that Freud demolished the cult of the heroic ideal (page 11):

If Freud has not been seen in this light it is perhaps because the very success which he has enjoyed by casting himself in the role of intellectual liberator has brought with it the kind of idealisations and projections to which all messiahs are subject.

Towards the end of his book, Webster draws another conclusion about where this has helped to take us, which resonates with my recent explorations of Shelley, and with Edmundson’s rants against the aridity of much current lyric poetry in Poetry Slam. He argues for redressing the current bias against imagination and states that (page 504-05):

. . . . [u]ntil we have done this it seems likely that we will remain in thrall to the dissociated intellectual culture which we inhabit today, where an austere and politically influential scientific and technological culture, devoid of human sympathy and understanding, exists side by side with a weak literary and artistic culture which, because it has unconsciously internalised the image of its own superfluity, is prepared both to the stand back from the political process and to concede to the natural sciences the exclusive right to explore reality systematically and to pronounce authoritatively upon it.

Returning in more detail to Edmundson’s attack upon Freud, he defines the main focus of psychoanalysis as being on one ideal in particular (page 232):

History (and Shakespeare) have dealt with the myth of courage; history (and the Enlightenment) have dealt with the myth of faith. Love is Freud’s primary antagonist among human ideals, and he attacks it from every plausible direction.

In terms of love’s great exemplars, including Jesus and the Buddha, Freud argues (page 237) that they are ‘asking too much of human beings.’

How can we love our fellow men? Freud asks. Our fellow men, in general, have at best a mild contempt for us; at worst, they nurse murderous rage. . . . . There is only Self. Soul is an illusion.

I have dealt already on this blog with Matthieu Ricard’s utterly convincing refutation of such debasing cynicism in his book Altruism, which demonstrates beyond reasonable doubt, and on the basis of a huge amount of systematically gathered data, that we are innately capable of developing high levels of altruism, fairness and compassion. My last sequence of posts revisited his brilliant book from a different angle.

Edmundson goes on to quote Karl Kraus (page 243): ‘Psychoanalysis… is the disease of which it purports to be the cure.’ He goes on to explain what he believes this means. Having listed various ways human beings can rescue themselves from meaninglessness, such as love, creativity, compassion, courage or idealistic thought, he rounds his cannon upon Freud’s benighted cul-de-sac (page 244):

… all these activities are out of the bounds. Embracing them, for Freud, causes only trouble.

It is possible that to deny human beings these primary satisfactions makes them sick. It causes a disease, it does not cure it. If you live life without courage, compassion, the true exercise of intellect and creation through love, then you will not feel very well. You may even get quite ill.

before he delivers the coup-de-grace:

Then, when the banishment of ideals has made you ill, Freud can show you, through psychoanalysis and through the ethical program of his thought, how to feel a little better than you do. Psychoanalysis helps the culture of Self create a disease. And this disease psychoanalysis will happily help cure.

He feels the legacy of this, for psychotherapy as a whole, is deeply damaging (page 245):

Therapy can have many values, but they will never be idealistic. All therapies are about learning to live with half a loaf.

He is probably selling psychotherapies such as Psychosynthesis short when he uses that dubious word ‘all.’ But his point is valid for mainstream approaches. Spirituality and idealism are seen by them as suspect.

I hope this all too brief helicopter review inspires you to buy the book and read it, and I hope you then enjoy it as much as I have. Life is a lot richer than our materialistic gurus would have us believe, thank goodness.

Footnote:

[1] This side of Shakespeare was revealed in research done by Dr Jayne Archer, a lecturer in medieval and renaissance literature at Aberystwyth University.

[2] I am aware, from January’s Guardian article by , of the recent study which goes some way toward rehabilitating psychoanalysis as a treatment for depression.

He writes:

. . . . . [R]esearchers at London’s Tavistock clinic published results in October from the first rigorous NHS study of long-term psychoanalysis as a treatment for chronic depression. For the most severely depressed, it concluded, 18 months of analysis worked far better – and with much longer-lasting effects – than “treatment as usual” on the NHS, which included some CBT. Two years after the various treatments ended, 44% of analysis patients no longer met the criteria for major depression, compared to one-tenth of the others. Around the same time, the Swedish press reported a finding from government auditors there: that a multimillion pound scheme to reorient mental healthcare towards CBT had proved completely ineffective in meeting its goals.

So I need to clarify, perhaps, that it is Freud’s quasi-mythical beliefs such as the Oedipus Complex that repelled me as being too absurd to qualify as a universal truth. Other aspects of his thinking, taken over and used by other schools of therapy, have their place, such an projection and denial, as well as the acknowledgement that for some people it can be imperative that they understand their inscape deeply before they can move on, and that this can take years. Even so these are not universally applicable components of an effective therapy at all times. There is no one size fits all panacea – not psychoanalysis, not CBT.

I don’t think Burkeman would disagree with that as he concludes ‘. . . . . many scholars have been drawn to what has become known as the “dodo-bird verdict”: the idea, supported by some studies, that the specific kind of therapy makes little difference. (The name comes from the Dodo’s pronouncement in Alice in Wonderland: “Everybody has won, and all must have prizes.”) What seems to matter much more is the presence of a compassionate, dedicated therapist, and a patient committed to change; if one therapy is better than all others for all or even most problems, it has yet to be discovered.’

Stuck in memory from my first degree in psychology, there was an interesting piece of meta-analysis from 1979 that pulled together all the studies of the efficacy of psychotherapy that had included an advance measure of how credible clients found the therapy they were undertaking. When all other variables were controlled for, the strongest predictor of effectiveness was how much the client believed the therapy would work. Unfortunately I have not been able to track that down recently.

And for me, if it has no place for a spiritual dimension, such as can be found in Jungian analysis and Psychosynthesis, there is still a major defect in the approach.

 

Read Full Post »

Van Gogh's Prisoners Exercising: nine out of 10 prisoners have mental health issues when they enter prison. Photograph: Alamy.

Van Gogh’s Prisoners Exercising: nine out of 10 prisoners have mental health issues when they enter prison. Photograph: Alamy.

It is an indictment of our society’s approach to mental health that effective treatment for many forms of mental problem is not sufficiently available to meet the need. The strength of Layard and Clark’s book – Thrive is to draw this forcefully to our attention. The Guardian Review quoted at length below gives a good sense of the case they make.  

The data the authors refer to in the book include the fact that (page 381):

. . . while over 90% of diabetes sufferers receive treatment for their condition, under a third of adults with diagnosable mental illness do so. This is largely because good evidence-based psychological therapy is not readily available. 

They are also quite scathing about the absence of adequate provision for children, a position which Wednesday’s BBC News item suggests is apparently shared by the government:

Mental health services for young people in England are “stuck in the dark ages” and “not fit for purpose”, according to a government minister. Norman Lamb told BBC News he was determined to modernise the provision of psychiatric help for children.

Although some reviewers have reservations about some aspects of the book, in my view the relevance of its message to the desperate needs of this group of people makes it vital that it be read, understood and implemented in terms of its basic case.

It is interesting also, from my point of view as a retired clinical psychologist and Bahá’í, that they recognise that there need to be changes in the thinking, practice and values of the wider society if we are to prevent, rather than simply fight, the fires of depression, addiction and anxiety to name only the commonest problems.  

Emotional well-being should be taught in school (page 387), our society should become ‘less macho, with more emphasis on collaboration and less on competition.’ We also need to see a continuing ‘feminisation of our values – with more importance attached to relationships and to peaceable and harmonious living. This will be helped greatly as more women come to the top of their professions.’

They also recommend (page 388) that there should be ‘a cabinet minister for mental health’ and, no surprise this one, they hope that ‘mindfulness may become a regular practice taught in schools and practised by many adults.’

Some reviewers have felt that this prescription for society goes way beyond the evidence and, by implication, their brief. I don’t share that view. The book is a powerfully worded invitation to think about the issues facing our society in its approach to mental health. Obviously there is far more to be said, but this is a good place for anyone to start.

Below is an extract from the Guardian Review: for the full article, see link.

Guardian Review

“I once broke my leg in 10 places. As I was taken to hospital, someone shut the door on my leg. You can imagine the pain. But I can tell you the pain of depression is many times worse.”

This powerful quote from businessman Dennis Stevenson illustrates how mental pain can be just as real and even more agonising than physical pain. It opens a punchy polemic that demands action to tackle the misery of mental illness, pointing out the strange inequality that sees broken bones treated but shattered spirits ignored.

Many readers will know this from personal experience. One in six British adults suffers from depression or anxiety disorders that disrupt, even destroy, lives. Mental illness is often more disabling than chronic conditions such as angina, arthritis or diabetes, while it shortens life expectancy as severely as smoking. One in three families contains someone who suffers mental illness, with one in 10 children having diagnosable mental disorders – yet fewer than one-third of these people receive treatment.

Such shocking statistics litter the pages ofThrive, the latest blast by former “happiness tsar” Richard Layard in conjunction with David Clark, professor of psychology at Oxford University. Lord Layard is a celebrated labour economist who deserves plaudits for promoting the concept of placing wellbeing alongside wealth as a government goal – an idea promoted by David Cameron in opposition, then sadly shunted aside in office after coming under fire from critics who failed to understand the issues.

The book’s central point is that the failure to place mental illness on a par with physical illness costs the country dearly. This is perhaps most obvious with suicide rates. The vast majority of people who kill themselves are mentally ill – and as many people die worldwide at their own hand as from murder and warfare combined. Twice as many men take their own lives as women, something I have seen from traumatic personal experience like too many people – and perhaps most poignantly, youth suicide is rising in most nations.

Beyond these individual tragedies, the authors argue, the entire country suffers from this mental health crisis since it imposes such costs on society. “The scale of mental illness is mind-boggling,” they write. It accounts for almost half of absenteeism, keeps big numbers out of work and drives up the benefits bill; the combined effect on the economy reduces national income by an astonishing 4%. Nine out of 10 prisoners also have mental health conditions upon entering prison.

This barrage of data is bad enough. “But what is really shocking is the lack of help,” say Layard and Clark.

It may not make for the most scintillating reading but it is hard to argue with their case that the failure to help those in mental distress is an injustice. Anyone with the slightest experience of mental illness knows how crushing these conditions can be; we should be thankful that the courage of some sufferers, in discussing the impact in public, is starting to end an irrational social stigma. It also makes economic sense, since helping people to recover from their problems generates immense savings for national economies.

Read Full Post »