Is clinical psychology fearful of social context? Professor Mary Boyle



well I'm probably not going to be pulling any punches this morning either so as you can see I've taken the conference theme standing up and speaking out about social context as the basis for my talk and I think the themes wording is interesting is it that the current stands or our current stance on social context is rather reticent sitting down and speaking quietly or is it that if we want to be heard when we do speak about context we're going to have to be very assertive well I think both of these are true and that's what I want to explore this morning so if we start with the first question is clinical psychology fearful of social context well a few years ago I published a chapter on our relationship with context how it was placed in our theories and therapies and I meant by context the exterior rather than the interior aspects of people's lives their class their wealth their ethnicity gender their position in hierarchies of status and power I suggested that overall our approach to context was marked by levels of avoidance strikingly odds with the abundant evidence for its importance in the development and persistence of emotional and behavioral problems and it was this gap that suggested fear or threat now I'm not suggesting that the avoidance was planned or conscious instead I think it shows itself is taken for granted ways of speaking of theorizing researching and practicing which we all quickly learn to the point where the relative absence of context is scarcely noticed but on the other hand the avoidance of context which I found isn't a straightforward absence and I divided it roughly into two categories I won't list all the avoidance strategies I discussed in that chapter but just give one or two examples from each strategy sorry from each category the first category is I called pure avoidance and that meant that context was more or less entirely absent from accounts of psychological problems and the main way of doing this was to focus on inferred intrapsychic attributes for example perfectionism faulty source monitoring dysfunctional cognitions and so on and this strategy works very well indeed with psychiatry's or an avoidant focus on diagnostic categories because diagnoses are often used as the starting point for researching intra psychic processes now the second category that I named is much more subtle and I called it safety behaviors sorry about safety behaviors because these widely used strategies these safety behaviors acknowledge that context is important but at the same time ensure that it's never seems as important or more important than the activities of people's minds or brains in explaining or relieving their problems now I should say that like pure avoidance these safety strategies have shared with psychiatry and that greatly increases their impact so I'll just give two if examples the first one adverse contexts as consequence not cause and this involves presenting the kinds of contexts which are so often associated with distress such as poor family relations discrimination poverty unemployment or domestic violence as consequences of having a mental disorder and of course there is some truth in this but it's the popularity of this stance together with the frequent accompanying silence on the fact that these are also causes of mental health problems which suggests that this is something much more than just a neutral presentation of fact now the second safety behavior is vulnerability stress hypotheses well it certainly wasn't the intention when this was introduced but over the years this hypothesis has become an extremely pervasive and effective way of minimizing the importance of social context it acknowledges a causal role for the environment stress but context is no sooner invoke than its sidelined by the implication that the impact of negative experiences comes less from their objective qualities and than from someone's pre-existing vulnerability so that only the vulnerable are seriously affected and this vulnerability rather than the environment then becomes the focus of research and this vulnerability stress can be invoked even for the most adverse environments for example the suggestion that Chung some children might respond badly to severe sexual abuse because of inborn deficits and information processing or even that abuse itself isn't the main factor with psychosis it's just that children who are genetically vulnerable to schizophrenia are more likely to be abused now possibly some of you might feel it's an exaggeration to talk about widespread avoidance of context and that many of us do include it in formulations and that's true certainly true but I think I've come to see this as a kind of privatization of context the choice of individual practitioners which hasn't become a unified and audible public message but just to emphasize the point I'll give three more brief general examples of avoidance the first one this was an example of pure avoidance this was a prize-winning essay on preventing mental health problems it was published in the psychologist a few years ago and it didn't even mention the possibility of prevention by changing the material world only by changing people who might suffer from mental disorders and a second I looked at the last four years of the British Journal of Clinical Psychology and even using the most generous criteria I found that the majority of editions contained either no articles or one article which engaged with context but even when they did it was in a very limited way with the focus still very much on intrapsychic processes and a third one the depression report which initiated the iocked program it mentioned context only once and that was to dismiss it by suggesting that if we asked what was the biggest single cause of misery most people Dancer poverty but the report says they would be wrong and that prior mental illness explains more current unhappiness than poverty unfortunately the report didn't say what caused the prior mental now in a more recent publication on the I act program airily of this year and this is aimed at the general public Richard Laird and David Clarke do engage more with context but in such convoluted and avoidant ways as certainly to suggest to me extreme discomfort with the topic so for example they separate external problems such as poor housing poverty lack of education and unemployment which they imply have been addressed by the welfare state and they separate those from the yet to be addressed internal problem of what they call mental illness whose causes are psychological and psychophysical so they present mental illness and their terms as a kind of freestanding internal entity which independently causes more misery than any aspect of social context which seems to me rather like claiming that lung cancer causes more misery than tobacco now Laird and Clark also go to some lengths to play down the considerable evidence for the psychological importance of social class poverty and income inequalities and echoing the avoidance strategy I described earlier they mentioned domestic violence but mainly as a consequence of as they say having a mental illness for both victims and perpetrators they don't mention racism or sexism or inequalities of power and I got the very powerful impression that Laird and Clark seemed to sense that fully engaging with context would make it much more difficult to pursue their core arguments that the main causes of misery are anxiety and depression that the major reason for miseries persistence is how people think and that a major part of the solution is individual therapy now it would certainly complicate funding discussions with government as you can imagine if they did engage with context so this brings me to my second question what is it about confronting the well evidence major role of social context in both the development and the persistence of mental health problems which seems so difficult even threatening well I think that's quite a list of possibilities and I'll deal with just a few briefly but for me the overall theme is one of our insecurities as both a discipline and a profession so the first threat is it's not science now psychology as a whole is intensely concerned about its academic and social acceptance as a science and to Morford once said recently we still suffer from an inferiority complex making us do things just because they appear scientific so we emphasize our similarity to the biological and Natural Sciences we give the highest status to the methods of Natural Sciences we're also very preoccupied with avoiding accusations of social and political bias of being influenced by subjective values rather than objective facts problem is there is not easy to research the meaning of experience or the wider significance the wider social significance of someone's cognitions using experiments on numbers so that if we engage more with context it carries the threat that we might not just have to reduce our dependence on numbers and quantification but rethink the entire basis were claimed to be scientific so the second threat is it's not psychology where I think we fear that engage with context could mean an identity crisis will we be confused with sociologists or anthropologists and as we know their scientific status is even less secure than ours and then third I think that confronting the role of context in mental health problems can int induce understandable feelings of helplessness I mean how can we reduce poverty or create racial or gender equality well of course we can't and then fourth our need to be accepted by psychiatry which has its own problems with context and this I think is vital and I'll return to it later and finally and perhaps most threatening of all it is the prospect of telling truth to power so just thinking of that last one if we list some of those aspects of context which are consistently related to distress and problem behavior child abuse and neglect school and workplace bullying domestic violence discrimination unemployment poverty if you look at that list it's really not difficult to work out that these involve relatively powerful groups including government's corporations men white people adults damaging less powerful groups so that in the case of emotional distress context really does seem to include or even equate to the operation of power and this suggests that another way of looking at the strategies I described for avoiding or minimizing context is to say that they're actually ways of obscuring the operation of power and of protecting relatively powerful groups from scrutiny now this threat of telling the truth to power provides a link to the question of why our avoidance of context matters so much why it's so important I mean couldn't we argue that there are other disciplines which study context there are many people who research and challenge the misuse of power or the impact of government or corporate policies so perhaps we could argue that our role is to understand what's going on in people's minds and leave the other stuff to other people well I'd argue that our understanding of people's minds will always be limited if not distorted unless we make social context much more central I'd also argue that downplaying context is one of the most effective ways we have of reinforcing the medicalization of emotional and behavioral problems now I'm going to return to both these issues but for the moment I want to look at some wider social implications of our avoidance of context through the possible links between theory and research social policy and wider social influence they there is a US policy theorist called Carol vise whose work I found very illuminating and she suggested that when we think about this relationship between theory and research and public influence most of us probably implicitly hold what she calls a linear model now in this model researchers provide objective data with implications for policy and practice which may or may not be taken up and this model assumes a clear distinction between the disinterested objective nature of scientific research and the value Laden nature of policymaking or social attitudes it speaks of meetings where objective evidence is presented and the case made for policy and funding and this linear model has sir inform the development and presentation of the iocked program now contrasting with that is what veidt's calls a reconceptualization model and this model sees theory and research and policymaking and social influences influence as processes of conceptualization both they and wider social attitudes involve values and most important all of them are based on implicit constructions of people and problems so in this reconceptualization model theory and research are seen as gradually changing the way people think about an issue or indeed about themselves but also is being influenced by social constructions so this model presents a much more subtle less direct picture of how our theory and research exerts social influence now has several implications but for this question of why our avoidance of context matters so much one major implication is that our theories and research are always potentially influential whether we approve it intend it or whether we're even aware of it what we say and do will have influence insofar as particular psychological ideas become part of a construction of reality which can then be drawn on by those with the power to frame social problems and their perceived solutions so this reconceptualization model draws attention to the highly permeable boundaries between psychological theory and research public discourse and public policy and it suggests that the relationship between research and social influence is both fundamental and pervasive in a way a linear model can't capture it suggests that the way we as psychologists sexualized people and their problems becomes a kind of cultural resource and above all and in relation to this avoidance of context I think this model shows how our theories can help maintain the social and economic status quo but I very much doubt that any of us ever arrive at work in the morning thinking to ourselves I'd really like to do something today to maintain the current structures of power and privilege in our society and of course it doesn't work like that as we know but one way it can work is through narratives of justification now it's often been pointed out that maintaining harmful social practices or social inequalities usually need some sort of public story which makes them seem reasonable and if we look at it from the point of view of those who benefit from inequalities an especially powerful narrative is one which distracts attention from context which could help us understand why some groups are persistently disadvantaged or suffering why their behavior seems difficult and instead focuses on mental or biological characteristics which seem to explain these outcomes now is not something we want to think about but historically psychology has played a major role in providing these narratives not least by claiming stable psychological differences for example between women and men black people and white people the mad and the same now it's important to emphasize again that we don't have to intend social harm but collectively our discipline and professions simply have to provide the intellectual framework and of course give it scientific respectability others will do the rest now this isn't just to historical matter and I want to give three more recent examples this is a claim by a major autism researcher that people with what he calls the female brain who are apparently mostly women are more suited to a list of careers which just happened to be lower status lower paid and lower social influence than the careers claim to suit people with the male brain who are mostly men for example primary school teachers nurses therapists and carers versus scientists engineers bankers and lawyers it's not very difficult to see how claims like these that they can and certainly already have become part of public discourse they're available to prompt implicit attitudes and selection committees or in men and women themselves making career choices and of course they're also available to help to explain women's difficulties in getting to the top and to ensure they might never feel entirely confident in some careers now this may seem a bit distant from clinical practice but there's a good deal of evidence that inequalities in the labor market from lower pay to the strain of trying to prove yourself in male-dominated occupations are very much linked with women's distress a second example is the alcohol and gambling industry's heavy and very successful use of the vulnerability stress model to resist government regulation and they argued that only a small number of vulnerable people were liable to serious damage from alcohol or gambling and that this could be handled by the companies supporting treatment programs now these arguments are fraying as the profile of people who are obviously harmed by alcohol and gambling comes to resemble the general population but their being now supplemented by equally context-free narratives of individual responsibility and choice and then finally there's the psychologize ation of poverty illness unemployment and low social mobility well I think it's a fair bet that I'm one of the older if not the oldest people here and I find myself struggling to absorb the massive cultural shift of the last thirty years this move from social to psychological accounts of poverty ill health and unemployment we're having no money no job and poor health are increasingly presented as driven by psychological characteristics which seem to require an often bizarre mix of punishment education and therapy and this move from the context jolt of psychological has greatly intensified in the last few years and one of many examples is the targeting of psychological change for example on self-efficacy or resilience on some mandatory workfare programs and reporting these soft outcomes as success even when the program has no impact at all on actual employment now some of this this framing of a whole range of social issues in terms of individual minds or brains might have happened anyway but at the very least and recalling this reconceptualization model I think it would have been far more difficult to achieve far more difficult to convince the public of its reasonableness without psychological theories and research which focused more on people's mental than on their material worlds now this state of affairs seems to me to have at least three important social consequences first of all it provides far more protection from psychological scrutiny to those who create or benefit from harmful context than it does to those who are harmed and as I said earlier it obscures the operation of power and second it can look as if producing positive change in people's mental or physical health their employment or their social mobility is as much or more a matter of changing their mental characteristics than their social context but if we think about it those with most problems in these areas are of lower social status so that people who are already working hardest to manage their difficult lives are now also expected to work hardest on themselves and third any society which combines high levels of inequality with the ready availability of intrapsychic accounts of problems risks fostering the just world or people generally get what they deserve beliefs which have been extensively studied by social psychologists and are associated with the justification of inequalities and the lack of effort to change them so what can we do about this well quite a lot I think but I'm just going to make three suggestions first one is not just to include social context in our theories and formulations and above all our public statements but routinely to fully integrate it now for example both the vulnerability stress and cognitive models include context but as I said tend to see the environment as life events or triggers which enter people's lives and interact with their vulnerabilities their styles of information processing to produce negative feelings or behavior and this is often summed up in cognitive therapy by the much quoted line from epic that men are disturbed not by things but by the view they take off them now it's not so much that this is wrong but that it leaves so much out it encourages us to focus not on things but on the individual minds viewing them and to treat these viewing habits as personal characteristics which can be measured or manipulated more or less independently of context and most especially it leaves out the social nature of cognition the human thinking isn't simply something inside one person's head that it reflects the outer workings of society so for example even in psychosis the content of voices can run along the same gendered lines as society itself with women much more likely to hear abusive voices criticizing their appearance or sexual behavior what's also missing here is the broader context beyond the immediate circumstances of someone's life in other words the social patterning of things which might disturb us and these obviously don't appear randomly in people's lives they're systematically linked to social and economic structures which create very unequal patterns of exposure so let me give an example there's a great deal of evidence that many women's feelings of depression are strongly linked to the social expectation that they're mainly responsible for the domestic sphere for childcare and the emotional quality of family relations and these expectations are underpinned by social constructions of a good woman one who puts the needs of her family first and certainly before outside work and where the domestic contribution of partners is often called help but these social norms which become part of women's and men's mental life are also underpinned by or structures such as the gender pay gap in flexible work practices lack of childcare and this can make it very difficult for women to step outside domestic roles or achieve economic independence now all of this will be played out in the minutiae of Family Relations and it seems to be really – a range of negative outcomes with women judging themselves and being judged against the cultural standards of a good woman perhaps feeling exhausted trapped humiliated or frightened censoring self-expression repressing anger and blaming themselves for the problems they encounter they might also show room additive coping style but not because this is characteristic of depressed women is likely to characterize anyone in context which lead to anxiety resentment and guilt but also make effective action difficult or even dangerous now it's not surprising that the evidence we have on women and depression also strongly suggests that for women in this situation recovery involves a kind of reclaiming of themselves with attention to their own needs and not just those of their family but the research also shows what a huge struggle this is for many women they battle against material constraints such as lack of time lack of money childcare or even physical safety the battle against subtle and not-so-subtle pressures to maintain their domestic roles and again social constructions which always threaten to position them as uncaring selfish and bad women now we could see all of this in a framework of vulnerability stress or the woman's cognitive schemas or even family systems but I don't think any of these models and certainly not a diagnostic approach would do justice to the intricate relations between the social the economic and the psychological or indeed the importance of gender relations of power and subordination not just in how people act but in how they think and feel I also wonder how far these traditional models would focus attention on the potential mental health consequences of austerity budgets even the Treasury admits that these have disproportionately affected women and children from benefit cuts to restrictions on legal aid for domestic violence so this brings me to my second suggestion of how we might stand up and speak out about context and that is to consider a faculty of public mental health within the DCP this is only a suggestion I emphasize but I think it's one that's worth thinking about it could act as a focus for discussion and debate and a resource for disseminating research and practice it could also help us become a much needed leading voice in debates about prevention and then third and perhaps more contentious even than that is that we should rethink our relation to mainstream psychiatry I'd go much further than that and say that unless we rethink this we will never be able to have a truly evidence-based relationship with social context now the reason for this is that psychiatry's difficulties with context are very different and much more fundamental than ours and the reason for that is that it's context which makes thoughts feelings and behavior intelligible even if they seem extreme or bizarre but as the DSM makes absolutely clear the diagnostic system is based on the assumption that those behaviors and experiences which are said to be symptomatic of mental disorders are not intelligible in terms of on circumstances that instead their outward symptoms of an internal pathology and that they're therefore not subject to the same rules as so-called normal behavior or distress and it's this assumption rather than any objective evidence which justifies the switch to a medical framework now this state of affairs the absence of objective evidence for a medical framework plus the fact that social context constantly threatens to make emotional and behavioral problems intelligible amenable to a non diagnostic analysis all of this is very awkward for psychiatry and rarely spoken about openly it helps to explain why at least in mainstream psychiatry the social can only be admitted in strictly controlled ways and it is admitted because we have psychiatry to thank for much of the evidence on correlations between demography life events and psychiatric problems but if we look very carefully we can see the efforts made by psychiatry to keep context under control often by the use of the avoiding strategies I mentioned earlier so that context never threatens the basic diagnostic and medical framework now perhaps these difficulties with context can also explain the result of a recent review by John Reed and his colleagues who found that around 20 times more public through cert punc there was 20 times more published research looking for biological causes of mental health problems than social causes so we may have problems with context but we don't have those problems context doesn't threaten to leave us without a conceptual framework in fact fully integrating context into our theories and formulations can only help us in our aim not of diagnosing illnesses but of understanding people's difficulties and it poses no conceptual threat but I do wonder whether we're willing to acknowledge just how far psychiatry's fundamental difficulties with context influenced so much of what it says and does and how far we can be misled by often sophisticated attempts to gloss over the problems and to present the social and biological as having equal status in a diagnostic system now let me emphasize that this is not a call to open hostilities arrival is which would benefit no one but it is a plea for intellectual or theoretical independence we gained professional independence in the 1970s with the truth'll report which allowed clinical psychologists to take referrals direct from GPS rather than going through psychiatrists 40 years later surely it's time that we should feel able to take a stance of confident mature theoretical independence in the way we understand emotional and behavioral problems now we often think of diagnosis as the key issue here it's certainly a key issue but lying behind it is social context and how it makes so cold symptoms intelligible how it enables us to see patterns and distress very different from the patterns and diagnostic manuals and it seems to me all the more urgent to think about this at a time when arguments about parity of esteem for physical and mental health services are being openly used to advance our arguments that both services deal with physically-based medical problems now we've already taken the first steps to intellectual independence with the position statement on classification and diagnosis the guidelines on formulation and the updated report and understanding psychosis and other planned projects but this is still fragile and going it's going to need a great deal of persistence and commitment if it's to have a lasting impact so just to finish I want to return briefly to these threats that I mentioned from social context and reassess them first it's not science and threatens to politicize us well given the evidence for the importance of context it's difficult to see how this can apply and as I hope I've shown not making context integral can be seen as a profoundly political act more likely to serve the interests of the powerful than the powerless then it's not psychology well perhaps an identity crisis wouldn't be a bad thing if it helped us reflect on what we could learn from other human sciences but surely they'll always be a place for a discipline able to theorize emotional problems in the same way people have no option but to experience them as inseparable from their context and then induces feelings of helplessness well of course we can't fix society or even agree what that might mean but context rich accounts offer new cultural resources to people in thinking about themselves and others and make it much more difficult for those in power to focus on lower status groups as primary targets for change context rich accounts also make it much more difficult for them to avoid addressing the psychological impact of social and economic policies and also they are not incompatible with helping individuals of course and then the last two threats acceptance by psychiatry and telling the truth to power well I don't think it's an exaggeration to say that clinical psychology is at a watershed in terms of who we are and what we stand for and I we'll acknowledge that how we relate to social context is absolutely central to those questions and I also hope we'll choose to implement the conference theme in major and very public ways I think we can be confident that we have both a scientific and an ethical mandate but also I think we might be surprised at just how many allies we would have thank you you

10 comments

  1. does keeping the curtain pulled on context and therefore keeping the responsibility to change with the pathologised consumer have a lot to do with self interest? – the IAPT service appears only concerned with processing people in order to meet targets for 'recovery' and access – recovery in this context means the pathologised consumer scores below a 'clinical' score on self assessment measures such as the PHQ9 and GAD7. These measures tell us nothing except for the consumers best subjective guess as to how they may or may not feel in a given moment. It matters not that your life is falling apart around you if you score below clinical you are deemed 'recovered'. How can you recover from the many toxic aspects of the culture?

    Management structures constantly reinforce this focus on targets in group emails applauding the hitting of these targets and its also reinforced in the micro management of each worker. These self assessments are meaningless in terms of helping us understand the context the consumer/we are struggling with but they are linked directly to service funding.

    How is it possible that thousands of highly trained people can simply go along with such empty and harmful ideas? self interest? debt?, mortgages? perceived status? class? fear? training? bias? stress? burnout? probably all and more

  2. Psychology is a language that is mostly understood by Psychologists, to quote Nietzsche " Whoever gives advice to a sick person acquires a feeling of superiority over them,whether the advice is accepted or rejected. Proud and sensitive sick people hate advisers more than their sickness. This video is more about Psychologists than Psychology, same, same same regurgitated clap-trap.

  3. Very good, well done! Psychiatry/Sickiatry. Informative exposition by Prof Mary Doyle, getting to the root of the matter.

Leave a Reply

(*) Required, Your email will not be published