In recent years, there has been an annual commemoration of ‘Mental Health Week’, a period in which Australians are subjected to ‘awareness campaigns’ by various media organisations. We tend to receive a familiar style of ‘messaging’, namely, tokenism (‘Are You Ok Day?’), advocacy for more bureaucracy, and censorship of views that do not conform to simplistic biomedical paradigms. It is in this context that the national broadcaster screened ‘Changing Minds’, a series which ‘journeys with mentally ill patients on their road to recovery, from breaking point to breakthrough.’ The setting for the doco is a hospital in Sydney, and patients and staff apparently consented to the footage being made public.
I approach footage such as this with a critical perspective on the psy-disciplines and as a practicing psychoanalyst, two positions emphatically excluded from mental health week. From my perspective, the doco showed numerous moments that were as concerning as they were revealing, in terms of patient treatment. Note, for instance, the moment when a young man is attempting to get himself discharged. The hospital psychiatrist asks him to give an account of his condition, and he says he has a ‘chemical imbalance’ in his brain. This is false, of course, even at the level of general explanation, but this rote-learned utterance suffices for him to win the approval of the medical staff, who assure him he is quite right. Discharge is clearly, albeit subtly, contingent upon discipline.
I will limit my focus here to 29-year old ‘Jason’, a man who has been involuntary committed to the hospital for several weeks. (The exact length of his stay is unclear; you can find his place in the doco around the 23 minute mark onwards). He is diagnosed with schizophrenia, and the voiceover tells us that he initially sought help in a state of intense fear, after receiving death threats and being subject to sinister plots by aliens. By now, these themes of persecution are not prominent (or are omitted from the doco) and he instead has delusions about his body, specifically, that his bones are broken.
Contemporary psychiatry and clinical psychology are not, in the main, very rigorous when it comes to delusions. The voiceover tells us that Jason lacks ‘insight’, which is to say, he disagrees with the views of clinicians. In the mental health system (and in contrast to psychoanalysis, or even classical psychiatry), a delusion is basically just a belief that a clinician finds bizarre. The content rather than the form is at issue. If I present at a hospital with a story that the police/CIA are moving objects around in my house to make me think I’m going crazy, and that I am absolutely certain of this despite a lack of evidence, I will be assessed as delusional. If I attend the same hospital with a story that my spouse/parent/child/housemate is moving objects around in my house for the same purpose, and that I am absolutely certain of this despite a lack of evidence, I will get a very different response, even though formally, the propositions are nearly identical. I will probably be told that my spouse/parent/child/housemate is a ‘narcissist’, and I should get relationship counselling, if not an intervention order.
But let’s return to ‘Jason’. The voiceover indicates that he has been medicated (probably very heavily), and his delusions about bodily disturbances do not appear to provoke the same distress as the ideas of persecution. Nevertheless, his psychiatrist concludes that Jason is ‘a risk to himself’. (This ‘risk’ is not specified). For this reason, he has been sectioned, but the psychiatrist himself hints that, on such flimsy grounds, this arrangement cannot last for long.
Jason is given the opportunity to speak to the camera, and to staff. He outlines the various places where he believes his body to be ‘broken’. He cannot prove it, but ‘it’s real’. ‘I can’t be a fully functional person’ he says.
The psychiatrist follows the standard evidence-based approach of supplementing drugs with cognitive therapy. (In fact, the evidence does not support the use of CBT with psychotic patients, but zealots read evidence their own way). In the cognitive paradigm, Jason holds his beliefs about his body essentially because he is ignorant, a bit stupid even. If only he can be given an education in medical assessment, his views will ‘shift’. Let us not forget, in this homely atmosphere of casual contempt for the patient, that this doco is intended to remove ‘stigma’.
Nonetheless, Jason’s delusions do not ‘shift’. (Indeed, by the end of the doco, Jason still holds to the notion of his body being broken). The psychiatrist berates him: ‘You’re not hearing what we’re telling you’. The same words could be more aptly applied to Dr Psychiatrist and his colleagues, who stubbornly refuse to consider Jason’s words as having any significance other than as an indicator of idiocy. Jason’s discourse could be easily construed as consisting of signifiers. We might ask how he arrived at his beliefs, or what it means to be ‘broken’, and not ‘fully functional’. We might ask whether such delusions have a stabilising function relative to Jason’s mortal terror upon initial presentation. Such questions are not admitted to contemporary clinical practice.
After a failed attempt to correct Jason’s distorted cognitions, the psychiatrist chuckles at the camera. ‘Never a dull moment’, he smiles. One wonders what he might have said had a camera not been present.
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I have read with great interest your critique on CBT and the behavioralists such as Ellis and Beck. I had a recent thought and I wonder in you would agree. As a side note, I am a current recipient of mental health services in the US. Without going into my own drama, I recently had the notion that all scientific disciplines over the last century have seen an explosion of knowledge and advancement- that slow brick by brick building of science. HOWEVER, in the practice of psychology it seems to have gotten dumbed down through out the years. The colossal achievements of Freud are not all recognized and in place we have CBT, DBT, ACT, and CET. All of the former are administrated in group therapy with a cultist flavor tainted with a patronizing tone. Of course, I am speaking of my geographic location. I hate to play victim but what qualifies as help is nothing but mental games and insults to the individual experience. I finally found Lacan which has a ring of truth but damn if you can find any therapist who even reads Freud anymore. What the fuck happened psychoanalysis? It seems to have gone backwards in some respects from the Freud- to CBT.
I think that you raise a very important question, Abraham. In brief, there are at least three factors that come to mind
1. The first generation or two of psychoanalysts were almost exclusively Central European Jews who fled or perished during the catastrophes of the 1930s and 40s. From this diaspora there emerged many different analytic schools and, naturally enough, the US schools tended to modify the theory to US conditions and ‘values’, and to emphasise adaptation, ‘ego strength’, etc. This is an over-simplification, but it does help to explain how the first CBT hucksters were essentially failed psychoanalysts (of the US ego psychology school).
2. Psychology has long consisted of disparate elements, many of which are incredibly crude and reductionist. Behaviourism, for instance, attempts to study humans on the model of animal behaviour, deriving from the glandular responses that Pavlov observed in dogs. Freud and Lacan got their ideas in the clinic, working with people. ‘Empirical’ psychology acquires its status inside the lab, publishing obscure papers for journals, and by sticking to the dog-like elements of human existence.
3. There are broader trends in political economy such that, in the English speaking world, psychotherapy is basically subordinate to neoliberal ideology. By way of contrast, consider the UK in post-WWII. There is the Beveridge report, the creation of a welfare state with different imperatives to that of the contemporary UK, and in this context, psychologists produced an array of maternal-centric, relational theories (i.e. object relations, attachment theory). The current models in psychology, whilst not necessarily unified, tend to make implicit or explicit various elements of neoliberal political economy. For instance, things are rooted strictly at the level of the individual (not dyads, etc) who is conceived as his or her own entrepreneur, whose treatment is an investment which should be calibrated for maximum quantitative return (i.e. shortest investment time in treatment possible), and who is responsible for his or her own happiness in a manner somewhat similar to the Protestant work ethic in Weber.
And further on this last point, the contemporary zealots of CBT and other technocratic treatments tend now to militantly oppose psychoanalysis, or to ignore it altogether, or to dismiss it as nonsense. This was not the early position of the founders of CBT. Beck and Ellis initially said that the problem with psychoanalysis was not that it didn’t ‘work’ in some sense, but that, when you boil things down to some very simple quantitative evaluation (quantitative reduction is the heart and soul of CBT) then CBT gives you more efficiency, more competitiveness. So, from the outset, CBT was a kind of proto-austerity project, and it remains so.
With Ellis in particular, the doctrine is striking in that it is basically a psychological recapitulation of teenage right-wing libertarian philosophy. Nobody, in Ellis’ view, has the right to expect anything in particular or anybody else; everybody is responsible for his or her own happiness (and misery, for that matter); self- reflexive and undivided rationality, of the sort assumed by rather dull-witted neoliberal economists, is held up as an imperative, a duty. So again, the ‘science’ of psychological has many points of connection with the dominant ideology, if indeed it isn’t simply a by-product of this latter.
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Yes Yes Yes!
I was aghast watching this episode play out, and gobsmacked that this so called expert is so arrogant in his thinking and seems to have no capacity for reflection on the great gift there is to explore for Jason, in engaging with his belief of his bones being broken. At best there was a token effort by the psychiatrist to refer him to physio, but even that was suggested with some contempt or amusement at the stupidity of Jason.
And when I go beyond being gobsmacked, I am incredibly sad that this is the reality in the mental health world. As a Transpersonal Counsellor & Spiritual Psychotherapist myself, it makes me feel like an alien, that society is so narrow minded, so limited in it’s thinking, to not be curios about this. To not engage with people with experiences like this, and instead just shove drugs in them, and focus on the “I am right and you must believe what I tell you’ approach.
I was also stunned that the internet was not buzzing with outrage at this episode. I popped online and googled changing minds and broken bones, and barely any discussion comes up. Where are all the mental health workers yelling with outrage at how this man (and the others) are treated?
Why does the voice of logic and reason have to be so quiet?
Thanks, Sue. It doesn’t speak well for mental health in Australia that the Changing Minds episode could be met with anything other than concern.
No it doesn’t, at all
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