You might remember, about 5 years ago the National Institute of Mental Health in the U.S. finally said enough! This whole idea of clustering symptoms of mental ill health into diagnostic categories was a great idea, but it just hasn’t got us anywhere.

I remember my heart lifting and a cheer tried to escape but was quickly crushed by what I read next. They were now  going to focus on neural pathways. So instead say of studying PTSD, anxieties and phobias say, as separate entities, they were going to look at fear pathways, with modern laboratory techniques and neuroimaging, and I felt my heart sink. I think because what I read didn’t really sound like a change in paradigm, or how we think about human suffering, just a new thing to look at with old eyes.

Ive checked in now and then since then and have not felt my spirits lifted.

So, this morning, after a week of frustrating conversations with the old old paradigm I thought I’d check in again. Now this is not new, it’s a talk from 2013, and it may have been on the NIH website for some time, but it lifted my spirits. I think there’s still a bit of blindness from looking through the medical model, but in relation to my frustrations about psychotherapy research I think it’s fantastic.

I said to Rob, “you should listen to this” and he said “give me the short version!” So here goes.

In the old paradigm when we make a mental health diagnosis, we are making it with symptom clusters, and that’s like saying “You have a headache disorder, or stomachs ache disorder” without going any further, and then giving that diagnosis the same authority that we might give diabetes. And that really isn’t any more advanced than the ancient Greeks description of melancholia.

The major problem though, is that with all the modern techniques for neuroimaging, for structural and functional analyses of the brain, the findings don’t map on very well to the disorders. I’ve often thought it will turn out to be like diabetes, which was described early on in relation to excessive urination, but when we finally discover some biochemical cause, we have two distinct entities, diabetes mellitus, and diabetes insipidus, which are so dramatically different in their cause and physiology that had they been discovered biochemically  would never have been given the same name.

And that seems to be the problem. That DSM has given a whole lot of heterogeneous symptoms the same name, so no wonder we haven’t come up with a specific diagnostic test or specific treatment. From a paper titled “The drug hunters” the report is that “On average, a marketed psychiatric drug is efficacious in approximately half of the patients who take it.” He presumes that those are the people who have the thing wrong that the drug treats.. (a bit of a stretch but an interesting idea)

(At this point I want to caution myself about this seductive pull to turn the mysterious unfathonableness of the human condition into a simple machine, but for the sake of the short version I will press on.)

So RDoC,  stands for Research Domain Criteria. The statement in RDoC’s strategic plan states, “Develop for research purposes new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.”

There are four components.

The first component Is to identify these fundamental components that may span multiple disorders. So they look at circuits in the brain. Circuits responsible for dealing with threat, looking for food, memory, that kind of thing, and you start to see how lots of these circuits will be at play in different ways in different people who might all say fall under the current umbrella of depression.

The second component is “To determine the full range of variation from normal to abnormal.” This is very cool I think, because they are starting to see all symptoms on the spectrum of normal, and that there has been some adaptive behavior say that has taken a normal behavior to extreme. Watch the video for some useful observations about Schizophrenia and Bipolar. I think clinicians have long seen symptoms on a spectrum of normal, but for researchers to finally get this is a huge step forward I think.

The third component is to integrate genetic, neurobiological, behavioral, environmental, and experiential components, so that the complexity of the human experience is not lost in the science. And they are not just giving lip service to that complexity the way the “biopsychosocial model” did.

And the fourth component is to develop some measure, which might just start with what can be measured and seeing what that lines up with. They seem to be starting from a position of not knowing, and being willing to discover, even if it’s at odds to what they think they know.

The other heartening thing is that they are looking at neurodevelopment. Acknowledging that things that happen to the developing human have an impact at many levels, and understanding more about that impact can inform what to do about it, both with treatment and prevention. They are also looking at the impact of environment, both positive and negative.

So that’s the short version, and I recommend the long version….

 

How would you describe the experience of being loved? A newborn thrives in its presence. You can see it on their faces. The well loved child. It’s hard to describe. Perhaps a sort of contentment. The faint smile of satiety.  Nothing missing. And in its embrace the experience of being allowed to just be who you are.

Judgements are suspended. Both good and bad. If you are distinguishing beauty, charm or whit, you are not there.

The space where negations delivered under the guise of love are felt for what they are, not heard for what they might be, and are not allowed in.

And in that space, awareness expands. Synergy is created.

Is this the space where healing happens?

Can it be that simple? As simple as….

As you wish…..

 

 

Jay Haley once supervised a therapist who said that the family she was having trouble working with had a mother and daughter who were symbiotically attached to one another. Haley, famously said “I’d never let that be the problem.” (Brief Therapy: Myths, Methods and Metaphors. Zeig and Gilligan)

Pickpockets on a Nudist Colony: The Systemic Revolution in Psychotherapy, a book by Ben Furman and Tapani Ahola sums up beautifully what psychotherapy does. You have to sew a pocket on a nude before you can pick it.

Bill O’Hanlon once said that there is a place in a modern therapist’s room for a couch. Any time they get a theory about their patient they should lie down and wait for it to pass. (In one of his 30 plus books)

Most therapists would know those three tidbits, and we all chortle, genuinely, and yet there we go again, when we find a client difficult, we attribute some theory of maladaption that is impossible to surmount.

It’s sometimes a challenge to remember that all psychological theories are made up. None of them are true or real. They are also made up by human beings. A brain writing a theory about the brain…. there has to be something intrinsically dodgy about that.

As soon as you say that someone has a maladaptive attachment, has trauma stuck in their body, has a disordered personality or disordered thoughts, you are in trouble. You have constructed a problem that has the potential to be difficult to solve. You have also added something that wasn’t there. You have sewn a pocket on.

One of my heroes, Heinz von Foerster describes the way we do this kind of thing as an attempt to turn the amazing unfathomableness of human beings into a trivial machine. Trivial meaning if you input A you can predict output B.

A more universal example is the way schools attempt to turn children into trivial machines. Questions, it is understood, have answers that are already decided, and a good grade on the resultant test is proof of successful trivialisation.

He was the kind of fellow who could get seriously excited by the child who, when asked what is two times three answers green.

Something that hit me hard when reading his work and had a big impact on the way I raised my children was his notion of illegitimate questions. These are questions that when you are asking, you already know the answer to. They generate a yucky experience in the asker and the asked. We all remember that feeling from school that goes with a prayer that it will not be you that will be the chosen one…. even when you know the answer the teacher is thinking of.

I think that working therapeutically with a human being from a position or psychological theory will inevitably be an attempt to turn this person into a trivial machine. I suspect that a good grade from the therapist about the client will be evidence of trivialisation, but a good grade from the client about the therapist will reflect the respect the therapist had for the non-triviality of the client.

I used to think that the questions we ask reveal the client, disclosing who they are and what they care about. Then I realised it is not important for the therapist to see what the questions reveal, but for the client to discover. Now I wonder if the discourse is just a distraction for the thinking mind as the healing happens in the space between two people.

How else can diametrically opposed dogmas result in equal effectiveness?

Do you ever get sick of ideas and thinking and just want to hang out in experiences and doing?

I’ve been immersed in a rich tapestry of experiences fostering cats for a local animal shelter. I had become interested in the power of communities to heal, particularly in relation to the small group of people who don’t do well with psychotherapy. At the cats home I found a community healing orphaned, damaged, abandoned cats and kittens and there were so many parallels with my work and what I was exploring that I got immersed, while also enjoying some kitten company.

I recall a conversation with Rob on Christmas Eve when I had a homeless mother cat and her kittens upstairs in our bathroom but downstairs I had a one hour session with a homeless teenager and then she left through the front door into the big harsh world.

I reflected on her life in foster care and beyond, and the parallels between the cats home and the human system wondering why one seemed to work well and the other didn’t. Bad behavior in the cats was more likely to be understood as the result of cruelty or neglect and not some intrinsic badness.

The confronting difference was that antisocial cats were euthanaised…. but not always. There are definitely a handful of people braving the teeth and claws and having success at rebuilding trust in antisocial cats.

The feline family moved on and were adopted and we ended up with a motley crew of 6 teenagers who had ringworm and were thrown together by circumstance. Now ringworm, which is just a glorified form of tinea has some serious prejudices and baggage attached in the cat world, and cats are commonly euthanaised in shelters to prevent the spread of this highly contagious fungus. Take a moment to imagine if children were euthanaised for having ringworm. The parallel in therapy for this mob was probably in the Axis 2 realm. Not many people wanted to touch them.

This mob became a tight knit group, united by the trauma of twice weekly antifungal baths. Two of them must have grown up with a dog and taught the others that dogs are fun. The leader of the group, a big black panther named Sambucca was a beautiful goofy loving felllow but when he was cured and went back to the Cat’s Home he suddenly behaved as if he hated cats. He was relegated to a single cage in the boarding section and we went in to bat for his good character. In the end it was his love of dogs that got him adopted by a German Shepherd who had recently lost his pet cat.

I wondered how many clients I see in the nasty bitter stage, and how different it would be if I got to glimpse before and after to see what is possible.

The next foster was Snowflake, a 2 1/2 week old innocent who apart from being abandoned for a day and a half had known no trauma. Food, warmth and a tender touch and she was putty in our hands.

Then, as she grew and started to play she was missing the learning that comes from siblings about not playing too roughly. So after we put the word out, Louis arrived.

Now Louis had a very different beginning. He was found abandoned in a barn at the age of 4 weeks, but it was clear his innocence had been rocked. The story was that he liked other cats and played hard, but if a human approached he froze, flattened himself to the ground and became paralyzed. My guess is that something had toyed with him. Maybe a dog that chased if he ran, taunted harder if he moved, so he had leaned to play possum.

The first night my son spent holding him and when I walked in to check he said “I don’t know what you are saying about this kitten being scared, he is just sitting here in my arms snuggled up.” I took a closer look. He wasn’t happy, he was paralyzed. So we upped the gentleness and reassurance. I remember the day about a week later when I walked into the kitten room and he ran away! Yay, progress. The progression was then from running, to starting to run and then slowing down. Then starting to run and changing direction to approach. Then catching himself before he ran. Then approaching. And then that magical day when I walked into the room and he immediately started to purr.

Now I didn’t do any therapy. All we did was provide a safe and loving environment… and he worked it out for himself. And that, for me, is the most powerful distillation of the rich tapestry of this whole experience that also aligns with what we know about therapy.

 

Barefoot Doctors began in China nearly a century ago, to address the inequity between health care in urban and rural regions. Farmers were taught basic health care and first aid in an attempt to close this gap.

Barefoot Therapists are tackling a different gap.

The medicalisation of human suffering began after the Second World War, when soldiers were returning with shell shock into a community that had no experience or understanding of what they had been through.  Psychiatry and Psychology were called to arms, and complex political and socioeconomic forces shaped the emergence of what we know as modern Mental Health Care. We saw from the 1960’s, both the explosion of both therapeutic and pharmaceutical approaches to treating human suffering, and yet, as neatly summed up  by the title of a book: “We’ve had 100 years of psychotherapy and the world is getting worse” and pharmaceuticals have likewise not delivered on their promise.

In the wake of this bubble bursting, scientific inquiry has uncovered two interesting phenomenon. The first is that both psychological and pharmacological interventions carry with them an unusually large dose of the power of placebo. The second is a term called allegiance. The therapist/doctor’s belief that their treatment will work contributes enormously to the effective therapy, be it pill or therapy model.

Simply put, if the patient believes in the treatment they are getting, they will get better, and if the therapist believes in the treatment they are delivering,  then they will be effective, and the patient will get better.

So what is the gap?

Could it be that the medicalisation of human suffering, as described by “mental illness” has made it hard to believe?

Consider our cultural attitude to a cancer patient who doesn’t respond to treatment. Not you personally, but what our culture thinks. You see it in the headlines of newspapers. Family and community fight for their chance to try experimental new treatments. If only we had better treatment, we could cure this disease. The general message is that medicine should do better. There is no patient blaming.

Now consider our cultural attitude to a person with a mental illness who does not respond to treatment. Not you personally, but what our culture thinks. You see it in the headlines of newspapers. How often is crime and mental illness linked, to give just one example.

When our first instinct is to blame the patient if they do not respond or  are non compliant with treatment, then we have a cultural compassion gap.

In the last 70 years or so, people who are suffering have been diagnosed and sent for professional help. Inadvertently, the art of emotional healing that has historically lived in the community since the beginning of time is being lost.

No one meant for this to happen. Doctors, Pschologists and Mental Health practitioners are now faced with treating very isolated patients, who they know would benefit from community connection, but none is available.

Add to that, the fear of anyone who is different that is being fostered in our global community, and we have created a cultural inequity.

The Barefoot Therapy Project, aims to return the dying art of emotional healing, back to the community.

Our Barefoot Therapist project aims to support community mental health care by consolidating the skills of lay people who offer support to people in their communities, be it friends, family or via community groups.

The rationale came from both the obvious need, and the overwhelming evidence that complex training does not make effective therapists,  nor does length of training, or tertiary level training. While specialist services are overwhelmed with people who are suffering, it makes sense to resource the community to make a difference for people with milder levels of distress, as well as building confidence to include the more severely unwell people who are receiving specialist care in the community where healing and connection can be enhanced.

The qualities the person of the therapist brings to effective therapy are usually present before they embark on therapy training, and the overwhelming majority of programs do not focus on building those skills. In fact, it is not until recently that we had any evidence describing what those qualities are, and we merely relied on an intuitive sense that a warm and empathic person was likely to be better than a cold sociopath. Common sense, rather than evidence, drove conversations about therapist qualities.

That is beginning to change with more clinical researchers being interested in the question, and the lonely voices of clarity being joined by a crowd.

In contributing to members of our community who might want to become Barefoot Therapists we are putting the emphasis on the relationship that they build with their client, the expectancy or hope that they generate for improvement and their belief that the client can get through their difficulty. These three things continue to rise to the top of the pea soup that is outcome research.

I plan to blog about what we are producing as it happens and would welcome feedback. Our intention is that this will be online training with video talks, slides and demonstrations, and supported by video conference calls where there will be an opportunity to practice skills in virtual breakout rooms. We feel strongly that the training be free of charge, and would like to support therapists around the globe to provide it locally in their communities. We would expect therapists delivering training would increase their referral base as Barefoot Therapists are likely to refer more complex issues on. The supervision community that grows would also provide a wonderful opportunity to develop your edge.

If you are interested, or have any ideas or suggestions, please leave a comment.