Tuesday, November 6, 2012
Psychiatry, Psychology, and Philosophy
One of the more puzzling features of the mental health profession is the refusal to engage in a rigourous analysis of their own assumptions. It is as if they ignore the warning of Bertrand Russell when he advised that one of the first goals in philosophy is to recognise that a problem exists. Psychiatry is wedded to an excessively reductionist view of behavior , it is as if they have never encountered the concept of emergent properties let alone realised that a bottom up approach to understanding a complex system is almost always doomed to fail when there are many variables in play. The brain is the penultimate complex system. (Perhaps, given we don't know what brains do it may turn out that the processes are very simple, like a series of reiterations of very simple processes.) The psychologists catch and grab and whatever therapy comes along until it is eventually seen to be just another therapy offering little more than the placebo effect. Carl Rogers may deserve more credit than he is given today. Paradoxically the placebo effect may be the principle benefit in many therapeutic interventions but of course neither psychiatrists or psychologists would admit that because that would constitute a problem for them. No-one likes having the foundations of their concepts challenged. It is painful and could demand a complete re-appraisal of a conceptual structure. Hard work.
Therapy is typically conducted in the therapist's office which has specific environmental contingencies that can have profound implications for behavior modification. For most people the therapist is an authority figure, someone to be revered and someone who is going to provide a solution to their problems. Therapists can only facilitate change they cannot enforce it. What needs to be realised here is that the mere presence of the therapist is potentially a placebo effect. In itself that can be a very good thing but therapists can then fall into the trap of asserting it was the specific therapeutic intervention that did the trick when they may not be true at all. There is no easy way to distinguish these causal factors and perhaps that isn't even necessary. What is necessary though is for the therapist to appreciate that any given therapeutic intervention is not an isolated causal agent, that many causal agents are in play and can be very important in therapeutic interventions. Psychiatrists, moreso than psychologists, can be guilty of focusing too much on the therapeutic strategy and so fail to realise that their presence, how they conduct themselves as a person interacting with another person, can have profound implications for treatment.
The therapist as an authority figure will alter the nature of self-reports and this alteration will very much depend on the patient's therapeutic aims. If they think they need more treatment they will overstate their problems. On the other hand they may be the type of person who wishes to please the authority figure and so be inclined to assert that the therapy is working and they are feeling better. Self reports, like surveys, are riddled with problematic claims yet the therapist is in a bind here because of confidentiality issues. It is nigh impossible to get "inside the head" of the patient which is why when a depth psychoanalytic approach is undertaken it takes many months and even then confounding contingencies still make this exercise highly problematic. Indeed the ongoing therapeutic intervention creates a behavioral context that can be vastly different from the context in which the patient needs to alter their behavior: in the world at large.
Wherever possible the self-reports of the individual should be analysed with reference to the reports of others about the behavior of the patient. The parents or lovers, employers, the children of the patient, even close friends or other health professionals providing treatment for the patient can provide important appraisals. What needs to be appreciated is that behavior is contextualised, the behavior the patient in the therapist's office is not necessarily a good indicator of the behavior of the patient where it really matters: in the world at large.
Yet the phrase: "in the world at large" betrays another dangerous assumption. We behave differently in different situations, our verbal behavior is typically modified for the audience we are addressing, how we behave at work can be very different to how we behave at home, when the boys get together they are not going to behave the same way as when the gals are around. There are some who argue we should be "true to ourselves", as if there is some hidden core that constitutes are our real being. Be true to yourself? How? What is that self I must be true towards? I still like Jung's idea of individuation but I think that many people misinterpret this as an individual finally becoming what they were meant to be whereas I interpret as an individual realising, either slowly or abruptly, that their behavior has been heavily determined by their culture and the cognitive dissonance that comes with that causes a movement towards new behaviors that reduce that distress. That is why Jung wrote: "When a man knows more than others he becomes lonely." If you wish to kick against the prevailing pricks in your culture it is inevitable the pricks will stab you and attempt to bring you into line. Failing that the pricks will alienate you. This is a really difficult challenge, there are no simple answers here and certainly no absolute answers here. All of us are compromising our behavior in relation to our beliefs. Which is far better than creating rationalisations. We should at least be honest about the contradictions within ourselves and recognise that these are not moral failings but an inevitable result of living with others. That might explain why some people in their latter years retreat from society. Perhaps they value integrity and honesty too much.
Let's be clear here: no matter what society exists there will always be individuals within that society who will demonstrate maladaptive behaviors. That is a statistical inevitability. There is no utopian psychology or psychiatry. Satori is just a dream(David Bowie). Adaptive behavior cannot be understood without reference to the environment in which that behavior occurs. There are those who assert modern culture is breeding mental illness but fail to realise that any culture will create mal adaptive behaviors. What is truly remarkable about human beings is the tremendous adaptability of our species. Only a few hundred years ago literacy was the exception, most people were put to work before reaching their teen years. Now it is not uncommon for human beings to undergo training for productive contributions to society that can take up to 25 years of their life.
One of the more successful areas of behavior modification, if not the most successful, is in relation to phobias. How does this success arise? The patient is exposed to the stressor in varying degrees, a strategy of desensitization that slowly increases the patient's exposure to the painful stimulus until the patient has adapted their response to the stimulus. This is very important: drugs do not help, talking the fear down does not help, what helps is direct behavioral intervention to the relevant stimulus so the patient learns to adjust their own behavior. All the drugs on the shelf, all the cognitive behavioral therapy under the sun, has little efficacy here. What works is addressing specific behavioral responses and modifying those. This should be instructive but it seems to me that in most other areas of mental health we labour under the illusion that we can think our way to better behavior or drug ourselves into better behavior.
Psychiatry has moved towards the reductionist explanations and done so in the belief that this represents a scientific approach to understanding behavior. Sadly it was only in the late 1950s that ideas like chaos theory and mathematical explorations of complex systems indicated that the explanation of the behavior of a complex system is not reducible to its individual constituents. This raises some profound questions about the nature of causation in the natural world, a topic I am still exploring and probably will be til I'm dead because it is fascinating and I am insatiably curious. Psychiatry has presented so many simplistic ideas about behavior that it has exhausted its claims in this matter because these have so often been found wanting. If psychiatry had kept thinking about the limits of the reductionist enterprise, or more correctly recognise that the reductionist paradigm does not mean all phenomena are ultimately explicable in relation to the individual elements within those phenomena, psychiatry may not have then assailed us with simplistic claims like "chemical imbalance", or the dopamine or glutamate hypotheses of schizophrenia, or that ADHD is because of DAT alleles. Seeking to appear scientific psychiatry has revealed its philosophical naivety.
Psychology has generated so many theories of personality that it should have long ago recognised it was engaging in the wrong level of analysis. It too much labours under the false assumption that we have some hidden core to us, that the psychologically healthy person is one who is relatively free of cognitive dissonance and that a healthy soul is an honest soul. It seeks too often to change the whole of the person rather than the specific behaviors of the person. That is why psychologists are so often guilty of writing self help books on how to be a better person, as if being a better person is predicated on some moral absolutes that stand above our culture, as if there is some specific human nature and if we can just find that within ourselves we shall individuate towards happiness and all things sugar and spice.
Psychiatry and psychology face fundamental constraints in attempts to reduce mal adaptive behaviors. The challenge is beyond these two disciplines but our emphasis on these disciplines reveals the widespread belief that behavior is ultimately a function of the individual and that the environment only plays a minor role. The challenges for the mental health profession go beyond the treatment of individuals but mental health professionals are expected to resolve mal-adaptive behaviors by only modifying the individual rather than the environment, particularly the cultural aspects of the environment within which that individual must function. In this regard we could do well to revisit the themes explored by Jung, Fromm, and other authors. The present challenge though is to recognise that not only have psychiatry and psychology laboured under misconceptions about human behavior but that our whole culture still labours under many such misconceptions. We have a lot of hard work to do and it is not going to be finished in my lifetime. It will never be finished, it will always be an ongoing enterprise because the numbers of variables impacting on human behavior are and always will be for all practical purposes infinite. That is not cause for despair it is a recognition that in most areas of human endeavour we are always reaching towards the goal but never quite grasping it. There is no final solution.
at 6:04 PM Posted by John