Contents Introduction: Collaboration – voices apart and together 3 Erica Brostoff Principles of change: A brief review of progress in 54 its first year Editorial committees: Invitation 4 Larry E. Beutler, Louis G. Castonguay & Michael Constantino Letter from the Chair 5 Philip Cox Part 3: Collaborative opportunities to network 59 Review of Patricia Churchill’s Consciousness: Strategic Aims and Goals of the Section 7 The origins of moral intuition Philip Cox Steve Heigham

Editor’s letter 9 Music and (narrative) psychology: 60 Erica Brostoff A literature review Ghislaine T.M. Regout Future Issues 9 Collaboration as the theme of this Issue Mind-forged Manacles 2: Science and Practice 69 Sheelagh Strawbridge Part l: Collaboration in meeting clients’ needs 11 Understanding ‘Ed’: A theoretical and empirical The past and future of psychiatry and its drugs 77 view of the internal eating disorder ‘voice’ 12 Joanna Moncrieff Matthew Pugh Exploring Integrating Mindfulness Chinese 84 Food practices, eating distress and the perils of 24 Calligraphy Enhanced Therapy (CCET) as a bewildering interventions in eating disorders’ Complementary Psychotherapy to Bridge Psychotherapy Section treatment settings Underrepresented Chinese Clients in the UK John Adlam Juan Du A client’s experience of coercive treatment 38 What it means to see neurons rush into the brain 86 Review Joy Goodall-Leonard Letizia de Mori How did I get here? A narrative exploration of 42 Student mentoring reports No. 65 Winter 2020 arriving at talking therapy in a neuro-rehabilitation My experience in attending my first psychology 87 setting, co-written by a young adult patient conference and her therapist Ting Ting Ling Helen Molden & Jess Walling What makes a psychologist? – A beginner’s voice 89 Part 2: Collaboration between clinicians and 51 Wiktoria Dziurowicz with Ho Law researchers Covid Issue Review of: Principles of change: 52 How psychotherapists implement research in Collaboration: Voices apart and together practice (Eds.) Louis Castonguay, Michael J. Constantino and ‘Listening to the client’ Larry E. Beutler Erica Brostoff

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© The British Psychological Society 2020 Incorporated by Royal Charter Registered Charity No 229642 ISSN: 2396-958X (Online) Printed and published by the British Psychological Society. Copyright for published material rests with the British Psychological Society unless specifically stated otherwise. As the Society is a party to the Copyright Licensing Agency (CLA) agreement, articles published in Psychotherapy Section Review may be copied by libraries and other organisations under the terms of their own CLA licences (www.cla.co.uk). Permission must be obtained from the British Psychological Society for any other use beyond fair dealing authorised by copyright legislation. For further information about copyright and obtaining permissions, go to www.bps.org.uk/ permissions or email [email protected]. Contents Introduction: Collaboration – voices apart and together 3 Erica Brostoff Editorial committees: Invitation 4 Letter from the Chair 5 Philip Cox Strategic Aims and Goals of the Section 7 Philip Cox Editor’s letter 9 Erica Brostoff Future Issues 9 Collaboration as the theme of this Issue Part l: Collaboration in meeting clients’ needs 11 Understanding ‘Ed’: A theoretical and empirical view of the internal eating disorder ‘voice’ 12 Matthew Pugh Food practices, eating distress and the perils of bewildering interventions in eating disorders’ 24 treatment settings John Adlam A client’s experience of coercive treatment 38 Joy Goodall-Leonard How did I get here? A narrative exploration of arriving at talking therapy in a neuro-rehabilitation 42 setting, co-written by a young adult patient and her therapist Helen Molden & Jess Walling Part 2: Collaboration between clinicians and researchers 51 Review of: Principles of change: How psychotherapists implement research in practice 52 (Eds.) Louis Castonguay, Michael J. Constantino and Larry E. Beutler Erica Brostoff Principles of change: A brief review of progress in the first year 54 Larry E. Beutler, Louis G. Castonguay, Michael Constantino Part 3: Collaborative opportunities to network 59 Review of Patricia Churchill’s Consciousness: the origins of moral intuition Steve Heigham Music and (narrative) psychology: A literature review 60 Ghislaine T.M. Regout Mind-forged Manacles 2: Science and Practice 69 Sheelagh Strawbridge The past and future of psychiatry and its drugs 77 Joanna Moncrieff Exploring Integrating Mindfulness Chinese Calligraphy Enhanced Therapy (CCET) as a 84 Complementary Psychotherapy to Bridge Underrepresented Chinese Clients in the UK Juan Du What it means to see neurons rush into the brain 86 Letizia de Mori Student mentoring reports My experience in attending my first psychology conference 87 Ting Ting Ling What makes a psychologist? – A beginner’s voice 89 Wiktoria Dziurowicz with Ho Law POLICY UPDATES UPCOMING BPS CONFERENCES & EVENTS CPD OPPORTUNITIESNEWS PUBLICATIONS

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2 Psychotherapy Section Review 65, Winter 2020 Introduction Collaboration: Voices apart and together Erica Brostoff

HE ARTICLES in this issue are of excep- harm in psychotherapy in our future Issue tionally high quality. on this topic. T Please make time to read these Part 1 contains articles on eating disor- during your Christmas break, and establish ders which are striking for their detailed a regular pattern of turning to the Psycho- approach to exploring below the superficial therapy Section Review for up-to-date accounts appearance of a clients’ problems. of thinking and research in our field. Over Part 2 describes an exemplary collabo- time, the Section committee hopes to ration between clinicians and researchers. increase the influence of the Section, and we A future agenda will include noting research can best do this by collaboration in various developments for readers of the Review. ways, as this issue aims to promote. Part 3 invites collaboration with exciting As Editor, I have gained a strong sense of developments in the field by our own a malaise affecting some aspects of psycho- members. Contact an author to share your therapy, of ‘not listening to the client’ – the views! by-passing of painful experience in favour of labelling and routinisation. This is some- Enjoy your reading! thing I have experienced myself as a client, even outside the NHS, though not in the context of eating disorders as described here. It is intended to explore this topic of ‘not listening to the client’ in relation to

Note on Issue numbering Issue no. 64, Winter 2019: Group Psycho- Future issues therapy was the most recent issue of the Issues 66 and 67 should appear in 2021 as Review, edited by Terry Birchmore. the Psychotherapy Section Review should revert This Issue no. 65, Winter 2020 and other to two or three issues per year. BPS publications have been delayed by Covid-19, and other unavoidable factors. This Issue no. 65, contains several articles that Terry Birchmore commissioned from the Psychotherapy Section Conference on Eating Disorders held in October 2018. He was unable to complete an issue on this topic at the end of his six year tenure.

Psychotherapy Section Review 65, Winter 2020 3 Advance Invitation to Readers Editorial Committees An editorial committee will be set up for This important topic is implicit in all the topic of the forthcoming issue on the material that has been published in ‘Improving Therapy and Avoiding Harm’. the Review over past years. This topic will You are invited to put your name be developed most successfully if views are forward now to join this committee. The freely shared. aim is to identify the important themes Offers to join a committee to explore for this topic, and to suggest the names of how we can effectively include research in expert contributors. psychotherapy research are also welcome. Whether or not you wish to join this committee, please send your thoughts and experiences in any format, such as prelimi- nary ideas, letters, commentary or articles to the Editors at: [email protected]

4 Psychotherapy Section Review 65, Winter 2020 Letter from the Chair Philip Cox

Our centenary year T NOW seems prescient that in the last Jamie Giles. I am delighted to welcome letter from our outgoing Chair, Jo North Martin Pollecoff, the elected Chair of Iwrote ‘Life is always changing and some- UKCP as an external representative to times we are challenged to keep up with the our committee. This is bridge building in demands that this brings to us’ (Winter 2019). action. In our centenary year, the tension between understating or overstating the impact of New activities and objectives Covid-19 upon our lives feels very present. The committee has been working hard To balance the tension, the Psychotherapy across a range of areas. We have updated the Section is meeting the challenge by adapting Section’s strategic aims and goals. A BPS stra- how we will serve the Section’s members and tegic goal is to ‘Promote the advancement in the field of psychotherapy. psychological knowledge and practice’. We are extending this to ‘Promote equality and Personnel changes diversity in psychotherapy’. A key Section Before outlining the committee’s work, it aim is ‘To work closely with other Sections, comes to me as the new Chair to thank Divisions and Special Groups of the society Jo North for her years of contribution, and and to collaborate with external agencies to honour the friends and supporters who and organisations’. A key Section objec- have retired or resigned from our executive tive is ‘To actively reach out to marginal- committee. Susan Eppel, who spent 30-years ised and diverse groups and engage with working for the BPS and was our much a collaborative approach across people and respected and appreciated go-to person for communities to enhance the input of as all BPS-related queries has retired. Our new many voices as possible’. link person, Kate Brudenell, has already These aims and goals underpin the become a great asset. Terry Birchmore, who philosophy of the Section and my personal edited this Review for six years has resigned. philosophy. These aims and goals are being The quality of the Review is a testament to actioned from multiple angles. Internation- Terry’s years of commitment to the Section ally, we have continued to fund the training and (group) psychotherapy. The demands place of a group psychotherapist in India. of Review editor are being met by Erica I’m delighted to report the students are Brostoff, who is developing exciting new now engaged with advanced training and ideas. Ho Law continues to present consist- living the philosophy of help one to help ently sold-out Psychotherapy and Mind- another… mentoring made easily accessible. fulness Workshops. I have the pleasure of Nationally, the BPS has recently intro- welcoming many new committee members. duced a new mentoring scheme for all Emma Tullet is our new e-letter editor and members, which offers the opportunity Nina Cioroboiu is our new Facebook page to support the development of another co-editor. Emma and Nina are inviting member/s. Anyone who seeks to benefit contributions and likes. We also welcome from the mentoring has only to join the Juan Du, Nisha Gupta, Tara Taheri and Section for a nominal small fee. This will

Psychotherapy Section Review 65, Winter 2020 5 Philip Cox operate across all geographical areas, train- services. Televised images beamed into ings, modalities or professional bodies. homes across the world are highlighting how marginalised groups, with particular refer- Annual conference 2020 online ence to the disparity in black and minority This years’ conference moved online with ethnic groups who are socially margin- the topic of The Brave New Wold of Psycho- alised whilst providing care and dying to therapy. We aim always to deliver a conference save the more privileged, are denied equal that will build upon the Section’s strategic involvement in mainstream economic, polit- aims & goals by exploring the multidimen- ical, cultural and social activities. This has sional inequality and diversity in psycho- implications for psychotherapeutic employ- therapy. Covid-19 has thrown a broad beam ment, practices, training, power-relations of light on existing inequalities in society. and so forth. In this Letter from the Chair, I suggest we psychotherapists join hands and Likely changes to future psychotherapy: take a lead in discussing and exploring such Leading the debate issues so that we can influence how the land- Current social changes created by the impact scape changes. of Covid-19 will change the landscape of psychotherapy. The NHS will increasingly Philip Cox, PhD, Chair 2019–2021 Psycho- develop online services. This will exacerbate therapy Section the colonisation of therapy by IAPT and the ongoing closure of funded psychotherapy

6 Psychotherapy Section Review 65, Winter 2020 Stategic Aims and Goals of the Section Philip Cox

S ONE of the oldest specialist groups 6. Develop our Section to support change within the BPS, the Psychotherapy 7. Promote equality and diversity in psycho- A Section has a long and distinguished therapy (Strategic Goal 7 is not in the history as a meeting space for discussion of BPS Strategic Plan) psychotherapy and related issues. Over time, the landscape of issues around The aims of the Psychotherapy Section psychotherapy continues to develop – we are: face new challenges and welcome new voices ■ To further psychological understanding to the discussions. of the personal, social and cultural issues; (Strategic Goal 1) Strategic Goals of the BPS ■ To promote scientific investigation of 1. Promote the advancement in psycholog- psychotherapy which employs research ical knowledge and practice paradigms appropriate to its subject 2. Develop the psychological knowledge matter; (Strategic Goal 1) and professional skills of our members ■ To provide a forum for the discussion 3. Maximise the impact of psychology on and exchange of ideas in relation to the public policy above which avoids aligning itself with 4. Increase the visibility of psychology and any school within the broad discipline of public awareness of its contribution to psychotherapy; (Strategic Goal 7) society ■ To work closely with other Sections, Divi- 5. Attract new members and broaden our sions and Special Groups of the society in membership pursuit of these aims, and where appro- 6. Develop our organisation to support priate, to collaborate with external agen- change cies and organisations. (Strategic Goal 6)

Within the context of psychotherapy, The objectives of the Psychotherapy these translate into the following aims Section are: (Strategic Goals) of the Psychotherapy ■ To disseminate information about such Section: new ideas and approaches by means of 1. Promote the advancement in psycholog- a Review, e-newsletter and Facebook ical knowledge and practice of psycho- page; (Strategic Goal 1) therapy ■ To explore and communicate issues 2. Develop the psychological knowledge of importance for the discipline of and professional skills of our members psychology which are especially high- within the context of psychotherapy lighted within psychotherapy and which 3. Maximise the impact of psychotherapy challenge more simplistic notions of on public policy science; (Strategic Goal 1) 4. Increase the visibility of psychotherapy ■ To make available information about and public awareness of its contribution psychotherapy within the society and to to society relevant external bodies; (Strategic Goal 1) 5. Attract new members and broaden our ■ To actively reach out to marginalised membership and diverse groups and engage with

Psychotherapy Section Review 65, Winter 2020 7 Philip Cox

a collaborative approach across people and ■ To represent interests in psychotherapy communities to enhance the input of as and the psychology of psychotherapy many voices as possible; (Strategic Goal 7) on the Society’s Council and Scientific ■ To organise a varied and accessible Affairs Board; (Strategic Goal 6) annual programme of events, which ■ To work towards becoming a Special promotes the discussion of new ideas Interest Group. (Strategic Goal 6) and approaches within psychotherapy and are relevant to the Section’s aims Philip Cox, PhD, Chair 2019–2021 Psycho- (Strategic Goal 1) therapy Section ■ To increase the numbers and breadth of our membership base; (Strategic Goal 5)

8 Psychotherapy Section Review 65, Winter 2020 Editor’s Letter Erica Brostoff

The role of the Psychotherapy Section Review HE Psychotherapy Section Review is an ‘Collaboration’ as the theme of this opinion periodical and is an excep- issue Ttional means to exchange ideas and The need for collaboration of several kinds try new approaches. In the past there has links the various articles into an overarching been an editorial committee, a practice that theme. may be revisited. Several Special Issues on Part 1: the need for collaboration is particular themes are planned and already explored, between internal voices within part-commissioned, as described below. the client, between services and clients, and There is plenty of space for additional arti- between individual psychotherapists and cles from readers, on these and other topics. clients. Lip-service is often paid to a move General plans for future editions are under away from ‘one-person psychology’ and consideration. towards a two-or-more interactive view of psychology, yet many would agree this is an Future editors aim still in progress. In practice, it is easy Erica Brostoff and Nina Cioroboiu will be to fall back into the one-person, one-sided future joint editors. viewpoint, leading to stunted interactions Dr Renaud Evrard, clinical psychologist and limited therapeutic success. at University of Lorraine, will be joint editor Part 2: collaboration between clinicians of the Special Issue on Clinical Parapsy- and researchers is explored, in the context chology. of the recent work of leading psychotherapy A conference on this topic is planned for researchers in the USA Chapter of Society May 14 and May 15, 2021, with a workshop for Psychotherapy Research. on case histories. News on how to participate Part 3: collaboration in networking if this goes ahead will appear in the next between readers and authors is proposed; Issue of the Review. to give mutual support, exchange of ideas, and, in due course, reporting back to future A view of the Editor’s role: providing issues of the Review. New formats for collabo- context ration through letters, commentary or other Part of a periodical editor’s role can be in innovations are possible, as well as continued providing context to contributors’ articles. publication of articles and reviews of books I have tried to do this here within the several and events. Previous issues of the Review have limitations caused by the Covid pandemic. contained abundant excellent articles on The ideal would be to provide more context forward-looking themes. We can build upon so that themes could be followed up through these further over time, by active sharing and other publications, seminars and confer- ideas about actionable plans. ences, and it is planned to do this more systematically in future issues. Future issues of the Review Some articles already have been commis- sioned for future issues of the Review.

Psychotherapy Section Review 65, Winter 2020 9 Erica Brostoff

Readers are invited to contribute on these Connection with mentalisation and themes. Ideas for full-length articles or other theories of intuition formats can be discussed in advance with the I plan to emphasise in my own article, editors at [email protected] continuity between anticipation of events, as premonitions, and the familiar concept Future issue 66: The brave new world of of mentalisation. Other articles will throw psychotherapy light on individuation versus enmeshment, Papers from the Annual Conference of the adult or child conceptualisations, societal Section, October 2020. versus personal interpretations of experi- ence and more. The topics should expand Future special issue 67: clinical our thinking about intersubjective experi- parapsychology ences in everyday psychotherapy, partially This is not a topic likely to be familiar to addressed by Freud and Jung among others. therapists in the UK, but touches on our Potentially, these are now open to explo- beliefs and practice around intersubjectivity. ration by neuro psychoanalysis and other This issue of the Review is well-advanced emerging disciplines. The topic is included in terms of articles accepted, with articles as an issue in the Review not because of its from a network of specialists in EU countries dramatic aspects, but because of the potential and in the UK and USA. Thanks to Professor light thrown on personal development and Ho Law, Editor of BPS Transpersonal Review, also therapeutic practice. Several University a companion issue of Transpersonal Psychology Departments in the UK have research into will appear. A notice about dates of publica- this field, see also future information in the tion and contents will appear in our e-letter. Section e-letter.

The relevance of this special issue on Future issue 68: improving therapy and clinical parapsychology avoiding harm In the UK, clients with concerns about There is much to explore on this topic. unusual/anomalous experiences, can Please send ideas and experiences, positive approach various University departments or and negative especially, as these are less the Society for Psychical Research and similar often explored, and themes for potential bodies. This topic is well-represented clini- articles to the editors. cally in EU countries, with a service funded by the German Department of Health in Future issue 69: special contexts for a clinic in Freiberg. Reports of widespread psychotherapy anomalistic/exceptional experiences in Articles by a prison psychotherapist and many cultures can be linked theoretically by a leading woman rabbi who is also with unverbalised and sometimes shared a psychotherapist, have been promised in perceptual experience between people close principle. All other suggestions welcome. to one another, also with early attachment experiences and with personal traits such as All future issues perceptual sensitivity. As such, there is conti- All ideas for future topics and future issues nuity between unusual, sometimes troubling are welcomed by the Editors: Please contact experiences, and everyday shared experi- us on [email protected] ence on the one hand, experiences in the consulting room, and even beyond these ***** limits in certain circumstances. Potential links with everyday psychological processes are not necessarily obvious at first, but the more rewarding for deeper investigation.

10 Psychotherapy Section Review 65, Winter 2020 Part one: Collaboration in meeting client needs

ATTHEW Pugh’s fascinating article ting’ of organisational needs and separation on ‘voices in eating disorders’, draws from the clients’ lived experience, as early Mattention to the many functions of research has shown. ‘Splitting’ is likely to internal voices, in an innovative approach always be a tendency in a service dealing with to an aspect of eating disorders that is little strong emotions and painful experience, as explored, tendency towards ‘splitting’ of the described by Isabel Menzies Lyth in rela- self in eating disorders (and, indeed, more tion to nursing practices (Lyth, I.M., 1988, generally). To encourage these parts of the Containing anxiety in institutions. Selected Essays client’s self to work together in collaboration Vol. 1. Free Association Books, and other towards survival and cohesion is the outcome published articles.) desired by clinicians treating these clients. Recognition of ‘experts by experience’, Articles by John Adlam and client an important and welcome initiative to Joy Goodall explore the over-riding of clients’ counter this tendency is reflected in the experiences and clients’ voices in much recent recognition of clients as ‘experts by standard treatment of eating disorders. experience’ by the BPS Division of Clinical Helen Molden and client Jess Walling Psychology. This move includes the possi- write a collaborative article on the careful bility of a fee paid to clients for advisory approach to the client’s engagement in work, according to the circumstances. A step psychotherapy. forward! The editor notes the pattern of ‘split-

Psychotherapy Section Review 65, Winter 2020 11 Voices apart: Collaboration between parts of the self Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’ Matthew Pugh

Many individuals with eating disorders make reference to an internal eating disorder ‘voice’ or ‘self’ (EDV/S): a phenomenon which is poorly understood. This paper reviews conceptual and empirical literature relating to the EDV/S. Criticisms and controversies surrounding such experiences are also discussed with reference to current research. In order to clarify how and why internal voices contribute to disordered eating, four theoretical frameworks which help contextualise the EDV/S are presented: cognitive theories of voices; interpersonal theories of voices; trauma-based theories of voices; and dialogical self theory. The paper concludes by proposing a preliminary, multifactorial model of the EDV/S which is composed of four maintaining factors: EDV/S dialogical patterns, EDV/S appraisals, EDV/S relating styles, and early trauma and associated interpersonal schemata. Directions for treatment and future research are discussed. Keywords: Anorexic voice, dialogical self theory, eating disorders, eating disorder voice, voices.

Introducing ‘Ed’ T IS STRIKING just how often individuals ment. Moreover, direct investigations of this with eating disorders (EDs) describe an phenomenon have only emerged within the Iinternal ‘voice’ of their disorder (Brous- last decade. Albeit preliminary, this research sard, 2005; Tierney & Fox, 2010). For others, has highlighted links between core features disordered eating is represented not so much of disordered eating and various aspects of by a voice, but rather a discrete compo- the EDV/S including its perceived power, nent of personality: an anorexic or bulimic hostility, and intensity (Noordenbos & Van ‘sub-self’ which is composed of ‘needs, feel- Geest, 2017; Pugh & Waller, 2016, Scott et ings, perceptions, and behavior that has al., 2014) been dissociated from the patient’s total self-experience’ (Sands, 1991, p.37). Refer- Nature of the EDV/S ences to the eating disorder ‘voice’ or Conceptual tensions surround the EDV/S, ‘self’ (EDV/S) are apparent in early clin- with some describing it as a metaphorical ical descriptions of eating psychopathology experience (Graham et al., 2019) and others (e.g. Bruch, 1978; Dym, 1985; Torem, suggesting that it reflects the multi-voiced 1987) and feature in personal accounts nature of human personality (Pugh & of recovery (e.g. Woolf, 2012). While the Waller, 2018). The EDV/S has most recently EDV/S has received some recognition within been defined as a hostile internal dialogue cognitive-behavioural (Mountford & Waller, (i.e. second- or third-person commentary) 2006), psychodynamic (Davis, 1991), expe- related to eating, shape, weight, and their riential (Dolhanty & Greenberg, 2009), and implications for self-worth (Pugh, 2016). systemic treatments for EDs (Schwartz, 1987), Single EDV/S are most frequently reported these experiences are rarely a focus for treat- by individuals, although two or more voices

12 Psychotherapy Section Review 65, Winter 2020 Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’ are not unusual (Noordenbos, 2017). later stages of illness; a toxic ‘inner bully’ Such experiences also appear to be rela- which demands strict obedience and moti- tively common across ED diagnoses, with vates increasingly destructive eating behaviours an estimated incidence of around 75 per (Williams & Reid, 2012). Caught between these cent (Pugh et al., 2018). While most individ- polarised experiences of the EDV/S, many indi- uals recognise that the EDV/S is internally viduals feel entrapped, defeated, and subordi- generated, it is usually described as alien nate to the voice of their ED (Pugh & Waller, to one’s sense of self, possibly as a result 2017). Consequently, attachments to this of dissociative processes. This distinguishes aspect of the self are often insecure (Mantilla the EDV/S from the auditory hallucinations et al., 2018b). Consistent with these findings, found in psychosis to some degree, as well as research suggests that changing the ways in the amnesic ‘alters’ described in dissociative which individuals perceive, relate, and respond identity disorder. However, given that EDs to the EDV/S may play a role in recovery from and psychosis appear to overlap in multiple disordered eating (Eaton, 2019). ways (Rojo-Moreno et al., 2011; Solmi et al., 2018), it may be more accurate to hypoth- The EDV/S over time esise that EDV/S lies at varying points on Longitudinal research is yet to examine how a continuum between inner speech and the EDV/S changes over time. However, auditory hallucinations for different indi- a recent synthesis of qualitative studies viduals, at different points in time1 (Pugh & suggests that experiences of the EDV/S pass Waller, 2018). through a series of stages (Pugh et al., 2018) (Table 1). To summarise, the EDV/S is usually Relating to the EDV/S seen to enter individuals’ lives during periods Individuals often describe meaningful rela- of insecurity and instability. For others, crit- tionships with their EDV/S – so meaningful, ical internal voices are present before the in fact, that it may represent a primary onset of disordered eating but intensify along- object relationship (Davis, 1991). Usually the side the emergence of ED symptoms. Often EDV/S is seen as possessing some positive a supportive presence at first, the EDV/S is qualities such as being reassuring, offering observed to become hostile and demanding companionship, and regulating distress, over time, resulting in an escalation in disor- particularly during the early stages of illness dered eating behaviour. For some, submission (Tierney & Fox, 2010). Accordingly, it has to the EDV/S is gradually replaced by a desire been suggested that the EDV/S may partly to escape this relationship, motivating acts of function as a substitute system for fulfilling rebellion and culminating in recovery. While individuals’ core emotional needs, particularly the EDV/S often fades over time, it does those which were unmet in early attachment not always disappear. Furthermore, new and relationships (Sands, 1991). It follows, then, unexpected challenges may accompany the that maintaining proximity to this alternate, process of emancipation: individuals may seemingly positive attachment figure may grieve the loss of their relationship with the limit motivation to change and contribute to EDV/S, while others fear that it will escalate the maintenance of ED symptoms (Mantilla in the future. Similar changes in how indi- et al., 2018b). viduals relate to voices have been reported At the same time, most individuals describe in other clinical groups (e.g. De Jager et al., the EDV/S as a highly critical, coercive, and 2016). controlling presence, particularly during the

1 It has been suggested that experiences of childhood trauma and dissociation-proneness may be responsible for generating EDV/S which are experienced as more differentiated and ‘split-off’ from individuals’ sense of self (Watkins, 1978).

Psychotherapy Section Review 65, Winter 2020 13 Matthew Pugh

Table 1: Time course of the EDV/S Stage Description 1. Direction The EDV/S initially fulfills positive functions. Relating to the EDV/S is mainly affiliative, albeit contingent upon compliance, resulting in attachment. Internal dialogues are generally cooperative but increasingly monological. Positive EDV/S appraisals become established and motivation to change the relationship is often low. ED symptoms emerge. 2. Domination The EDV/S is experienced as increasingly hostile and controlling. Relating to the EDV/S is characterised by dominance and coercion. Internal dialogues are increasingly imbalanced and hierarchical. Negative appraisals regarding the intent and relative power of EDV/S emerge. ED symptoms escalate, although motivation to change may remain limited. 3. Disempowerment The EDV/S is experienced as punitive and overwhelming, generating submissive and defeated responses. The EDV/S dominates internal dialogues and undermines self-esteem and self-efficacy. Individuals are motivated to change their relationship with the EDV/S but may doubt their ability to do so. ED symptoms may continue to escalate. 4. Defiance Individuals begin to oppose the EDV/S. Power differentials begin to shift, generating fervent EDV/S counter-attacks. Internal dialogues are conflictual and polarised. ED symptoms may begin to improve, although setbacks and periods of disempowerment still occur (see stage three). 5. Deliverance Power differentials now favour the individual rather than the EDV/S. Individuals are better able to ‘step back’ and decentre from the EDV/S. Internal dialogues are less conflicted and more harmonious. More adaptive internal voices begin to emerge. ED symptoms continue to improve. 6. Disquiet The EDV/S fades over time or is considerably less powerful. Recovery from disordered ED may be accompanied by feelings of anxiety or loss: individuals are vigilant to the EDV/S returning or miss its positive aspects. Intermittent ‘skirmishes’ with the EDV/S are not uncommon.

Criticisms of ‘Ed’ have proved remarkably popular in treat- While the EDV/S appears to play a role ments for AN (Treasure, 1997), particularly in the maintenance of some EDs, this line family-based therapies (Lock et al., 2002). of research has attracted a degree of criti- However, two observations conflict with cism (Pugh, 2016). Some of the conceptual this argument. First, the EDV/S has been controversies surrounding the EDV/S are described by individuals who have not yet now discussed alongside alternative perspec- entered mental health services or talking tives garnered from the literature. therapies (Williams et al., 2016). Second, and more convincingly, references to the The EDV/S is a product of therapist EDV/S predate use of externalisation tech- socialisation niques in psychotherapy (e.g. Bruch, 1978; It has been suggested that the EDV/S may Dym, 1985; Schwartz, 1987). This is not to partly stem from therapists’ use of ‘external- say that EDV/S is never a product of thera- ising conversations’ (White & Epston, 1990): peutic socialisation – sometimes it is. Rather, an intervention originating from Narrative such experiences might also represent Therapy which aims to separate the person a legitimate feature of disordered eating for from the problem by placing it outside of some individuals. the self. Indeed, externalisation techniques

14 Psychotherapy Section Review 65, Winter 2020 Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’

The EDV/S is indistinguishable from voice experiencing) have failed in research dysfunctional beliefs about eating settings (see Moskowitz & Corstens, 2007, for Dysfunctional beliefs relating to the impor- a review). Moreover, such distinctions offer tance of shape, weight, and their control little in terms of clinical utility. These points often play a role in the maintenance of have led to the conclusion that voices might EDs (e.g. Fairburn, 1997; Fairburn et al., be best conceptualised as a dissociative, 1999). Perhaps the EDV/S is simply another rather than psychotic, experience which is way of describing these cognitions. If so, related to the multiple ‘selves’ and modes of near-perfect associations between meas- information-processing which are common ures of the EDV/S and negative attitudes to all individuals (Moskowitz et al., 2012). As towards eating would be expected. However, we shall see, experiences of self-multiplicity research indicates that this is not the case and dissociation-proneness are particularly (Kay et al., in press; Pugh & Waller, 2016). relevant to EDs. Furthermore, many individuals distinguish the EDV/S from other patterns of nega- Making sense of ‘Ed’ tive thinking associated with EDs, such as Research indicates that the EDV/S plays self-criticism (Noordenbos et al., 2014). a role in some EDs (Aya et al., 2019). However, several observations require exploration. The EDV/S is a redundant feature of First, a significant proportion of individuals eating disorders who experience critical internal voices – While the EDV/S represents a feature of some including those related to eating, shape, and EDs, such experiences might not be clini- weight – do not experience ED symptoms cally relevant. Recent research would suggest (Nordenboos et al., 2014). Second, it appears otherwise. As already noted, significant asso- that the EDV/S sometimes persists in indi- ciations exist between key dimensions of viduals who have recovered from disordered eating psychopathology (e.g. negative eating eating (Bell, 2013; De Giacomi, 2019). Third, attitudes and duration of illness) and charac- research indicates that conspicuous features teristics of the EDV/S (e.g. its power relative of the EDV/S including its frequency and to the self) (Noordenbos et al., 2014; Pugh distressing nature are inconsistently related & Waller, 2016, 2017). Preliminary research to eating psychopathology (Pugh et al., also indicates that the EDV/S influences 2018). These findings beg the question: how, responses to psychotherapy, although the and why, does the EDV/S influence attitudes exact nature of these interactions requires and behaviours related to eating, shape, and clarification (Hormoz et al., 2019). Most weight? Theories of voice-experiencing may importantly, many individuals with EDs iden- provide some answers. tify the EDV/S as an important feature of their illness and one which warrants clinical Dialogical self-theory attention (Tierney & Fox, 2010). Dialogical self-theory views the self as being composed of multiple, autonomous ‘parts’ The EDV/S is not a ‘True’ perceptual or ‘voices’ which are capable of engaging experience in dialogical relationships with one another It has been argued that because the EDV/S is (Hermans, 2004). These voices are also not a ‘true’ hallucinatory experience, it does believed to be subject to power dynamics, not represent a meaningful feature of psycho- with some dominating or suppressing others. pathology (for exceptions, see Rojo-Moreno Dialogical self-theory suggests that psycho- et al., 2011). It is worth noting that attempts logical impairment stems from discordance to differentiate types of voice experience between internal voices. Causes of such (internal versus external voices; ‘true’ versus disharmony include the dominance of mala- ‘pseudo’ hallucinations; voice hearing versus daptive voices (tyrannical internal dialogues),

Psychotherapy Section Review 65, Winter 2020 15 Matthew Pugh limited numbers of voices (uniform internal common (Beavan et al., 2011). Furthermore, dialogues), non-cooperation between voices not all voices result in distress or functional (conflictual internal dialogues), rigid organi- impairments (Lawrence et al., 2010). These sations of voices (inflexibleinternal dialogues), observations suggest that factors other than or chaotic interactions between voices (disor- the presence of internal voices contribute ganised internal dialogues). In extreme cases, to the emergence of psychopathology. The traumatic events may cause internal voices cognitive model of auditory hallucinations to become entirely dissociated and ‘split off’ (Chadwick & Birchwood, 1994) suggests from one another, resulting in a fragmented that emotional and behavioural responses sense of self (Watkins, 1978). to voices are influenced by their appraisal. Individuals with EDs describe an inner Specifically, voices that are perceived as world which is often markedly multi-voiced omnipotent (all-knowing), malevolent (with and dialogical (Schwartz, 1987). These hostile intent), and more powerful than the voices are often highly conflicted, with some self tend to generate emotional distress and encouraging disordered eating and others resistant responses. In contrast, individuals opposing it (conflictual dialogues) (Bruch, are more likely to engage with benevolent 1978; Tierney & Fox, 2010). Other individ- voices. That said, benign voices can also lead uals describe their EDV/S as overwhelmingly to social impairments as a result of preoccu- hostile and capable of ‘taking over’ their pation (Favrod et al., 2004). Birchwood and internal world during acute illness (mono- Chadwick (1997) have gone on to suggest lithic dialogues) (Williams & Reid, 2012). In that how individuals come to appraise voices both cases, ED voices are characteristically may originate from their ‘core interpersonal repetitive, perseverative, and ruminatory schemata which… embody the individu- (inflexible dialogues). Recovery from disor- al’s past experiences of interpersonal rela- dered eating also appears to be related to tionships, particularly early relationships’ changes in the dialogical self. These include (p.1352). the strengthening of adaptive internal voices Originally developed within the context of which counteract the EDV/S (e.g. ‘compas- auditory hallucinations, the cognitive model sionate’, ‘healthy’, or ‘recovered-focused’ also provides insights into how internal voices voices), distancing oneself from toxic state- contribute to other disorders. In a series of ments arising from the EDV/S, and the studies, Pugh and colleagues explored relation- emergence of higher-order meta-voices ships between EDV/S appraisals and aspects which enable decentred reflection on the of eating psychopathology (Pugh & Waller, EDV/S (Bell, 2003; Salvini et al., 2012). 2016, 2017; Pugh et al., 2018). Results indi- In summary, accounts of the EDV/S are cated that voices perceived as more powerful largely consistent with dialogical self-theory. than self were associated with negative eating More specifically, existent research suggests attitudes across diagnoses (anorexia nervosa, that the EDV/S influences eating pathology bulimia nervosa, and ‘unspecified’ EDs), via hostile-monolithic, inflexible, and while positive beliefs about the EDV/S were conflictual internal dialogues. Studies also linked to unhealthy food-related attitudes in suggest that decentring from the EDV/S, two studies. Furthermore, individuals diag- alongside the development of more func- nosed with anorexia nervosa who reported tional internal voices, contributes to improve- a strong EDV/S tended to suffer from more ments in disordered eating. severe EDs, characterised by longer durations of illness and greater use of compensatory Cognitive theory behaviours (e.g. purging). Research is yet Researching exploring auditory hallucina- to determine whether EDV/S appraisals are tions in community groups indicates that related to maladaptive interpersonal schemas. voice-related experiences are relatively However, such an association seems plausible

16 Psychotherapy Section Review 65, Winter 2020 Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’ given that early maladaptive schemas are ation between interactive patterns in external pronounced in EDs (Pugh, 2016). relationships and relationships with voices EDV/S appraisals may account for the (Figure 1). Perceptions of low social rank, interactions between internal voices and for example, are likely to generate submis- disordered eating-related attitudes. Specifi- sive responses within both social (self-other) cally, it appears that ED voices that are relationships and internal (self-self) relation- perceived to have the dual characteristics of ships. These patterns of interaction are also being more powerful than the self (domi- like to be complimentary in that certain nant) and with positive intent (benevolent) relational behaviours (e.g. domineering tend to exert the most deleterious effects voices) tend to elicit reciprocal responses upon attitudes towards shape, weight, and (e.g. obedience to voices) (‘interpersonal eating. Assessing, re-evaluating, and testing complementarity’) (Carson, 1969). Finally, out appraisals about the EDV/S may, there- attachment is believed to influence relating fore, represent a target for psychological to voices insofar as one’s experience of early therapies. Positive beliefs about ED voices relationships will inform how individuals may also contribute to the high levels of treat themselves in later life (‘interpersonal ambivalence found in many EDs. copy process’) (Benjamin, 2003). Interper- sonal theories of voice are supported by Interpersonal theory a growing body of research which highlights Many individuals describe coherent and the overlap between social interactions and personally meaningful relationships with interactions with voices in psychosis (e.g. internal voices. Interpersonal theories of Hayward, 2003; Hayward, et al., 2011). voices such as Gilbert’s (1989) social rank Individuals with EDs tend to perceive theory and Birtchnell’s (1996) relating theory themselves as inferior and lower in rank suggest that voices can be understood within compared to their EDV/S; a power differ- relational frameworks. Specifically, interper- ential that has been linked to increased ED sonal theories propose a bidirectional associ- symptomatology (Pugh & Waller, 2016; Pugh

Figure 1: Interpersonal model of voices

Psychotherapy Section Review 65, Winter 2020 17 Matthew Pugh et al., 2018). Furthermore, responding to which situate the EDV/S in the context the EDV/S in subordinate ways (e.g. submit- of past and present relationships. Second, ting or sulking) is associated with more treatments will need to address how indi- significant ED symptoms (Mantilla et al., viduals relate to ED voices: useful interven- 2018a). Consistent with interpersonal theo- tions might include limiting dysfunctional ries of voices, these styles of relating to the responses (e.g. submitting, complying) EDV/S mirror the interpersonal patterns alongside the development of new func- commonly found in ED groups. For example, tional ways of relating to the self and others individuals with EDs tend to view themselves (e.g. compassionate assertiveness). Third, if as inferior to others and struggle to assert individuals are to give up their connection themselves in external relationships (Arcelus with the EDV/S, it seems important that et al., 2013). Changing how individuals relate the needs underlying this attachment are to the EDV/S also appears to play a role in fulfilled within the therapeutic relationship, recovery from disordered eating; however, at least temporarily. research is mixed in terms of which styles of relating are most beneficial. Several studies Trauma-related theory suggest that learning to oppose and control The trauma-dissociation model (TDM) the EDV/S contributes to reduced ED symp- of auditory hallucinations proposes that toms (Bell, 2013; Duncan et al., 2015; Jenkins distressing internal voices reflect dissociated & Ogden, 2012; Mantilla et al., 2018a), while traumatic content arising from maltreatment other research has associated ‘fighting’ the (Longden et al., 2012). To illustrate, parental EDV/S with more severe ED symptoms and emotional abuse is likely to be internalised emotional distress (De Giacomi, 2019; Pugh in the form of distressing images or intro- & Waller, 2017). These latter findings are jected self-criticism. As a result of dissocia- consistent with research demonstrating that tive processes, however, these mental events aggressive counter-responding (i.e. rejecting are experienced as alien and ‘voice-like’. forms of anger) is not only an ineffective Numerous studies have supported the way of managing self-criticism, but also risks trauma-dissociation model of voice expe- stimulating threat-focused affective systems riencing, demonstrating that dissociation and heightening attention towards voices reliably mediates the relationship between (Gilbert, 2010; Kramer & Pascual-Leone, childhood abuse and auditory hallucina- 2016; Pugh, 2016). Rather, responding to tions in psychosis (e.g. Perona-Garcelan et distressing internal voices with healthy asser- al., 2012). tiveness rather than maladaptive anger has The TDM seems relevant to EDV/S for proven effective in other voice-experiencing two reasons. First, disordered eating has groups (Hayward et al., 2017) and may be been linked to multifarious forms of child- more constructive in EDs. Alternatively, it hood abuse (Molendijk et al., 2017), most may be that responding to the EDV/S from notably emotional abuse (Kent & Waller, a distanced, rather than interactive, rela- 2000). Second, dissociation appears to be tional position is most advantageous (Bell, relatively common in ED groups (Dalle et 2013; Pugh & Waller, 2017). al., 1996). To determine whether trauma While EDV/S research is consistent with and dissociation are related to ED voices, interpersonal theories of voices, studies Pugh and colleagues (Pugh et al., 2018) are yet to directly explore the associations explored associations between the perceived between relating to ED voices and relating power of the EDV/S, dissociation prone- to external individuals. Assuming that such ness, and experiences of childhood trauma a link exists, interpersonal theories have in a mixed ED group. Consistent with the important implications for treatment. First, TDM, ED voice power was found to be posi- individuals may benefit from formulations tively related to childhood emotional abuse,

18 Psychotherapy Section Review 65, Winter 2020 Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’ but not other early traumas, and this asso- relating to the EDV/S; and 4) predisposing ciation was partly mediated by dissociation. factors such as childhood trauma and, Albeit preliminary, these findings suggest relatedly, negative interpersonal schemas. that the EDV may reflect experiences of early While support for some aspects of this maltreatment such as criticism and rejection. model is reasonable (e.g. EDV/S-related These findings have recently been corrobo- appraisals and response styles), other rated by qualitative research highlighting the components require further testing (e.g. thematic links between the content of the the roles of childhood maltreatment and EDV/S and the voices of critical caregivers interpersonal schemas). Other biopsycho- (De Giacomi, 2019). social factors are also likely to contribute Regarding treatment implications, the to EDV/S experiences. For example, starva- TDM suggests that the EDV/S are partially tion effects in anorexia nervosa will almost memory-based and can be understood within certainly exacerbate cognitive processes a developmental-interpersonal framework. associated with distressing internal voices Situating the EDV/S within individuals’ biog- (e.g. repetitive, perseverative, and inflex- raphy may help support meaning-making, ible patterns of thinking), while the social therefore. The TDM also points towards isolation and withdrawal accompanying the potential value of trauma-focused inter- disordered eating is likely to increase preoc- ventions when working with the EDV/S. cupation with the EDV/S. These could include grounding techniques for managing trauma-related symptoms Overview of the model and experiential exercises for resolving It is hypothesised that vulnerability to the attachment-related injuries related to EDV/S is conferred by several interrelated internal voices (e.g. empty-chair confronta- factors including attachment-related difficul- tion of past abusers or imagery rescripting) ties, early trauma, dissociation proneness, (Arntz, 2012; Pugh, 2019). and the development of maladaptive inter- personal schemas, alongside temperamental A multi-factoral model of the EDV/S factors (e.g. perfectionistic and obsessive Studies exploring the EDV/S are consistent personality traits). Experiences of severe with several theoretical frameworks for childhood abuse and a greater tendency making sense of voices. Based upon this towards dissociation are likely to give rise research, a preliminary model of the to an EDV/S which is experienced as more EDV/S is now presented. This model takes differentiated and disconnected from the the view that rather than being a purely self. For some, the EDV/S will emerge metaphorical experience, the EDV/S reflects alongside the development of ED symp- the multi-voiced internal worlds which are toms; for others, pre-existing critical-internal common to all individuals. It is also hoped dialogues become orientated around eating, that this model will generate testable hypoth- shape, and weight in response to critical life esises for future research and inform psycho- events (e.g. body-related bullying). therapeutic interventions for addressing the During the initial stages of illness, ED EDV/S. symptoms are positively reinforced by affili- In summary, existent research suggests ative EDV/S responses (e.g. praise, reassur- that four inter-related factors play a role ance) and associated emotional reactions in perpetuating EDV/S-related experiences (e.g. pride, gratitude). This has the effect of which in turn contribute to eating psycho- ameliorating aspects of psychological distress pathology: 1) characteristics of the internal (e.g. down-regulating distressing emotions, dialogues linked to the EDV/S such as their distracting from low self-esteem), leading to rigid and monolithic quality; 2) dysfunc- the formation of positive appraisals regarding tional appraisals of the EDV/S; 3) styles of the functionality of the EDV/S (‘my ED voice

Psychotherapy Section Review 65, Winter 2020 19 Matthew Pugh is helpful’). Attachment to the EDV/S and, with EDV/S could provide therapists with relatedly, positive EDV/S appraisals are likely a means to engage ambivalent individuals, to emerge at this point and contribute to address treatment-resistant EDs, and stand ambivalence about change. shoulder-to-shoulder with clients against Gradually, and particularly during the a feature of disordered eating (Pugh, 2016). later stages of illness, ED symptoms are nega- Appreciation for the EDV/S might also tively reinforced by hostile EDV/S responses promote understanding for the lived experi- regarding the individual’s shape, weight, ence of EDs amongst mental health profes- and eating (e.g. criticism, humiliation). In sionals, as well as establishing a common order to avoid or ameliorate the negative language for treatment (Graham et al., emotions accompanying EDV/S attacks 2019). Unfortunately, limited guidance (e.g. shame, anxiety), individuals will tend exists as to how internal voices might be to adopt submissive counter-responses addressed in EDs. Based on this review, and (e.g. compliance, appeasement) resulting informed by the EDV/S model presented in increased ED symptomatology. This earlier, several targets for working with the subordinate style of relating has the effect EDV/S seem relevant. These might include: of strengthening dysfunctional appraisals ■ Building motivation to change about the dominance and omnipotence of one’s relationship with the EDV/S. the EDV/S, prompting further capitulation ■ Formulating the EDV/S with reference and compounding feelings of defeat and to past and present experiences in social entrapment. relationships. The biopsychosocial effects of disordered ■ Minimising biological factors which are eating are likely to become pronounced at likely to exacerbate the EDV/S (e.g. star- this point. Isolation, interpersonal tensions, vation) through improved nutrition. the abandonment of personal interests, ■ Clarifying the functions of the cognitive changes, and difficulties adhering EDV/S through direct ‘voice dialogue’ to the demands of the EDV/S all contribute (Stone & Stone, 1989) and identifying to deteriorations in mood, self-esteem, and alternative ways to fulfill these needs. self-efficacy. This results in increased preoc- ■ Re-evaluating and testing out maladap- cupation with the EDV/S and an inner tive appraisals of EDV/S appraisals (e.g. world that is monopolised by repetitive, its perceived power and benevolence). critical, and distressing forms of dialogue. ■ Developing more adaptive ways of Furthermore, the negative consequences of responding to the EDV/S such as compas- disordered eating may be interpreted as indi- sionate assertiveness. cating a greater need to adhere to EDV/S, ■ Establishing and investing in healthy, prompting more extreme eating behaviour. external relationships. ■ Addressing underlying factors such as Treatment implications childhood trauma and associated sche- Current treatments for EDs have produced mata. modest outcomes characterised by short-term symptomatic improvements, high rates of Future directions for research relapse, and significant levels of dropout. Additional studies are needed to elucidate Psychological therapies for AN remain the nature of the EDV/S, its interactions with particularly dissatisfactory, with relatively low disordered eating, and to test the compo- success rates reported across different forms nents of the model presented here. It is hoped of psychotherapy. In light of these findings, that continued research in this area will be novel interventions for EDs are needed. buoyed by the development EDV/S specific The EDV/S represents a fruitful direc- measures (Gant, 2016), as well as adapted tion for ED treatment. In particular, working study designs and voice-related instruments

20 Psychotherapy Section Review 65, Winter 2020 Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’ taken from other voice-experiencing groups EDV/S have only just begun to emerge. This (Pugh, 2016; Pugh & Waller, 2016). Impor- research, albeit preliminary, suggests that tant questions regarding the EDV/S which the EDV/S may contribute to the mainte- require exploration include the following: nance of some EDs. Theories of voice expe- ■ How does the EDV/S differ from the riencing developed in other clinical grounds voices found in other disorders (e.g. provide some insight into how eating psycho- psychosis and emotionally unstable pathology and the EDV/S interact. Based personality disorder), if at all? on these insights, the current research, and ■ Which longitudinal factors predispose clinical experience, a preliminary multifacto- individuals to experience an EDV/S? rial model of the EDV/S has been proposed. ■ Is the EDV/S related to underlying inter- It is hoped that this will provide a useful personal schemas? framework for both formulating and working ■ Are relationships with the EDV/S with the EDV/S. Additional studies are now reflective of early attachments and needed to clarify the nature of the EDV/S, external patterns of relating? test its clinical significance, and evaluate ■ Which ways of responding to the components of the presented model. EDV/S are most problematic and which are helpful (e.g. ‘fighting back’ versus Matthew Pugh ‘stepping back’?)? Central and North West London NHS Foun- ■ How does the EDV/S change during dation Trust recovery from disordered eating? ■ Do EDV/S characteristics influence Correspondence responses to therapy and does working Matthew Pugh with the EDV/S improve treatment Vincent Square Eating Disorders Service, outcomes? Central and North West London NHS Foun- dation Trust, 1 Nightingale Place, London, Conclusions SW10 9NG Despite being a relatively common expe- Email: [email protected] rience in EDs, studies exploring the

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22 Psychotherapy Section Review 65, Winter 2020 Understanding ‘Ed’: A theoretical and empirical review of the internal eating disorder ‘voice’

Moskowitz, A. & Corstens, D. (2007). Auditory hallu- Salvini, A., Faccio, E., Mininni, G., Romaioli, D., cinations: Psychotic symptom or dissociative Cipolletta, S. & Castelnuovo, G. (2012). Change experience? Journal of Psychological Trauma, 6, in psychotherapy: A dialogical analysis single-case 35–63. study of a patient with bulimia nervosa. Frontiers Moskowitz, A., Corstens, D. & Kent, J. (2012). in Psychology, 3, 1–9. What can auditory hallucinations tell us about Schwartz, R.C. (1987). Working with “internal the dissociative nature of personality? In V. and external” families in the treatment of Sinason (Ed.) Trauma, dissociation and multiplicity bulimia. Family Relations, 36, 242–245. pp.22-34). East Sussex: Routledge. Solmi, F., Melamed, D., Lewis, G. & Kirk- Mountford, V. & Waller, G. (2006). Using imagery in bride, J.B. (2018). Longitudinal associa- cognitive-behavioral treatment for eating disor- tions between psychotic experiences and ders: Tackling the restrictive mode. International disordered eating behaviours in adolescence: Journal of Eating Disorders, 39, 533–543. A UK population-based study. The Lancet Child Noordenbos, G. (2017). Critical thoughts and voices and Adolescent Health, 2, 591–599. in eating disorder patients. Paper presented at the Scott, N., Hanstock, T.L. & Thornton, C. (2014). Alpbach conference. Dysfunctional self-talk associated with eating Noordenbos, G., Aliakbari, N. & Campbell, R. (2014). disorder severity and symptomatology. Journal of The relationship among critical inner voices, low Eating Disorders, 2, 1–11. self-esteem, and self-criticism in eating disorders. Stone, H. & Stone, S. (1989). Embracing our selves: Eating Disorders, 22, 337–351. The voice dialogue manual. Novato, CA: Nataraj Noordenbos, G. & van Geest, Z. (2017). Self-criticism Publishing. and critical voices in eating disorder patients Tierney, S. & Fox, J.R. (2010). Living with the and healthy controls. JSM Nutritional Disorders, 1, anorexic voice: A thematic analysis. Psychology 1003–1008. and Psychotherapy: Theory, Research and Practice, 83, Perona-Garcelán, S., Carrascoso-López, F., 243–254. García-Montes, J.M. et al. (2012). Dissociative Torem, M.S. (1987). Ego-state therapy for eating experiences as mediators between childhood disorders. American Journal of Clinical Hypnosis, 30, trauma and auditory hallucinations. Journal of 94–103. Traumatic Stress, 25, 323–329. Treasure, J. (1997). Anorexia nervosa: A survival Pugh, M. (2016). The internal ‘anorexic voice’: guide for families, friends, and sufferers. New York: A feature or fallacy of eating disorders? Advances Psychology Press. in Eating Disorders: Theory, Research and Practice, Watkins, J.G. (1978). The therapeutic self: Developing 4, 75–83. resonance – key to effective relationships. New York: Pugh, M. (2019). Cognitive behavioural chairwork: Human Sciences Press. Distinctive features. Oxon: Routledge. White, M. & Epston, D. (1990). Narrative means to Pugh, M. & Waller, G. (2016). The anorexic voice therapeutic ends. New York: W.W. Norton and and severity of eating pathology in anorexia Company. nervosa. International Journal of Eating Disorders, Williams, K., King, J. & Fox, J.R. (2016). Sense 49, 622–625. of self and anorexia nervosa: A grounded Pugh, M. & Waller, G. (2017). Understanding the theory. Psychology and Psychotherapy: Theory, ‘anorexic voice’ in anorexia nervosa. Clinical Research and Practice, 89, 211–228. Psychology and Psychotherapy, 24, 670–676. Williams, S. & Reid, M. (2012). ‘It’s like there are two Pugh, M., Waller, G. & Esposito, M. (2018). Child- people in my head’: A phenomenological explo- hood trauma, dissociation, and the internal ration of anorexia nervosa and its relationship to eating disorder ‘voice’. Child Abuse and Neglect, 86, the self. Psychology and Health, 27, 798–815. 197–205. Woolf, E. (2012). An apple a day: A memoir of love and Rojo-Moreno, L., Plumed, J.J., Fons, M.B. et al. recovery from anorexia. Berkeley, CA: Counterpoint (2011). Auditory hallucinations in anorexia Press. nervosa. European Eating Disorders Review, 19, 494–500. Sands, S. (1991). Bulimia, dissociation, and empathy: A self-psychological view. In C.L. Johnson (Ed.) Psychodynamic treatment of anorexia nervosa and bulimia (pp.34–50). New York: Guilford Press.

Psychotherapy Section Review 65, Winter 2020 23 The over-riding of clients’ voices – the need for collaboration Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings John Adlam

‘Mental health policies should address the “power imbalance” rather than “chemical imbalance” ... and abandon the predominant medical model that seeks to cure individuals by targeting “disorders”.’ (UN Special Rapporteur, 2017, p.19)

‘Co-production requires give and take, an interaction in which participation is more likely to be welcomed and willingly entered into when the ‘objects’ exchanged are words, opinions, ideas, food for thought. However, when the ‘matter in hand’ becomes substantial, in the most literal sense of the word, an actual giving and receiving of food, ready co-operation may come far less easily ... To take what has been given, to accept the nourishment offered, is to acknowledge the existence of a need and recognise the legitimacy of the caregiver ... In more ways than one, accepting what is needed can be hard to swallow.’ (Anonymous expert by experience, from Adlam et al., 2016)

‘This has been a truly collaborative process (rather than the normal “token-istic” nod to Service User involvement). This is reparative and “bridging” – reaching across the chasm between Creon(s) and Antigone(s). I have felt seen, heard and respected (the antithesis, I feel, of my in-patient treatment). In this sense the author has/is practising the “hope” driving this project and creating the beginnings of the collaborative re-imagining he is advocating.’ (Anonymous expert by experience, from Adlam et al., 2014)

N THIS ARTICLE I will set out a set of ideas line of argument around food practices and concerning the phenomenology of eating eating distress is appended to this article. Idistress which arose out of my experiences I must begin by expressing my grati- and observations – but also, I hope I may say, tude and respect to my colleague Joy my listening – during my time running inpa- Goodall-Leonard, who agreed to act as tient psychological therapies on an eating Respondent to my talk – in role as an expert disorders inpatient unit. I presented this from lived experience on eating distress line of argument at the BPS Psychotherapy and the treatment approaches of the system Section annual conference on 26 October of care – and who co-facilitated with me 2018. If there was something of a polemic the plenary large group that followed on feel to my presentation at that event, then from the end of our presentation. Joy has I make no apology and here I will attempt very generously agreed to offer a written to replicate some of that feel in my writing. piece in response and this follows on from A visual diagrammatic representation of the this article. Without Joy and her survivor

24 Psychotherapy Section Review 65, Winter 2020 Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings comrades (some of whom are credited as noses made under DSM-IV were ‘EDNOS’ authors here and some who must remain (‘Eating Disorder Not Otherwise Specified’ anonymous) this piece of writing would have – a non-diagnosis by any other name). been in no wise conceivable. This statistic rather suggests that neither the ‘specifying’ nor the ‘not specifying’ is 1. Introduction functioning under the existing classifica- There are three conceptual issues that come tion system. To get that percentage down, together to form the foundation of this DSM-5 has broadened its categories, so that paper and which I wish to present by way of ‘anorexia’ is now scarcely recognisable from introduction. its core criteria in DSM-III; a ‘bulimia’ diag- The first arises from my increasing nosis now requires a much less significant conviction that the existing diagnostic and ‘symptomatic’ frequency and ‘binge eating treatment frame for ‘eating disorders’ is disorder’ has now become a codified illness inadequate and needs to be challenged: entity. Other new illness entities (Avoidant in similar ways, and for similar reasons, Restrictive Food Intake Disorder, anyone?) to the continuing critical opposition to have also appeared. the contested diagnosis of ‘personality Some of these changes may possibly disorder’ (see e.g. Timoclea et al., 2018; be progressive (it’s far too early to say, in for a sustained assault on all concepts of ‘clinical’ terms) and some people may disorder and pathology in mental health and now feel better ‘described’ than they did social care, see Watson, 2019). This proposi- before. Certainly, some treatments can tion perhaps needs a whole book to develop, now be accessed through health insurance and I only have a few paragraphs spare; but schemes, that couldn’t be accessed before. a moment’s reflection at least justifies the But my point is not to get lost in the endless question being put. fine-tuning of the DSM and ICD committees, It is well known that ‘anorexia nervosa’ as they negotiate their compromise forma- is a misnomer predicated upon a very tions with pressure groups and special inter- fundamental misunderstanding (the states ests both internal and external. Neither am connected with the diagnosis have nothing I presuming to instruct anyone that they to do with loss or lack of hunger). It has no should not feel helped by being classified more intrinsic validity as a signifier than, in particular ways. My point is simply to say say, ‘moral insanity’ or ‘dementia praecox’. that none of this appears clear enough, or Dressing the idea up in Latin garments, has produced clear enough evidence bases doesn’t make it any more of an identifiable for intervention, or has made sufficient illness entity. We continue to play ‘hunt the inroads into the suffering that is ‘out there’, biomarker’ for all these concepts, but so far to have earned the right to go unquestioned in vain. in itself. My own suspicion is that there is too ‘Bulimia nervosa’, like ‘Borderline much bad science here; my own experience personality disorder’, is a diagnosis we’ve and observation tells me that far too many only had on the books since DSM-III codi- people have fallen into oblivion through the fied it in 1980, at the very dawn of the cracks in this crumbling edifice. neo-liberal turn. Moreover, DSM-III came It partly follows from this that we with the significant disclaimer, which quickly don’t make sense to the patients – an expe- disappeared from DSM-IIIR, (having no rience we push away, I think, by holding doubt been perceived to be bad for busi- tight to the position that the patients ness) that its system was so imprecise that it don’t make sense to us. On inpatient units should never be used for forensic or insur- in particular (because the whole encounter ance purposes (Van Der Kolk, 2015, p.29). is more intense and claustrophobic), I have More than half of all ‘eating disorder’ diag- become convinced that our interventions

Psychotherapy Section Review 65, Winter 2020 25 John Adlam are bewildering as well as terrifying (and our makes it a very uphill struggle indeed, in non-interventions: to give one example, my observation and experience, to mobilise gatekeeping or triaging by BMI means that something resembling a practice of equality a given individual might be told their BMI is and a culture of open enquiry in the field, too high for inpatient treatment; might then and on the ward; and mostly the endeavour feel that forcing their BMI further down- is not even attempted. wards is the only way to get help; and then The third issue arises from the comments be told that their BMI is too low for outpa- of the UN Special Rapporteur on coercive tient psychotherapy). ‘Why do you treat me psychiatry (United Nations, 2017) and its this way?’ is the cry that goes up (on both interdiction under the terms of the United sides of the staff-patient divide, in fact; see Nations Convention on the Rights of Scanlon & Adlam, 2009). In some sense, Persons with Disabilities (United Nations, we who have worked in such places tend to 2006; for a critique of the ‘abolitionist’ posi- take for granted our rationale for a range of tion and the possible distinction between interventions; and we somehow assume that ‘non-consensual’ and ‘coercive’ interven- the same unarticulated rationale is available tions, see Martin & Gurbai, 2019; for the to our patients. In this, I believe that we are ‘abolitionist’ take on the Convention, see entirely mistaken. Minkowitz, 2007, 2010). I have looked at this My second preliminary conceptual issue issue in some detail in my previous piece arises from the observation that ‘eating in this Review (Adlam, 2019); for present disorder’ services and the ‘eating disorders’ purposes (i.e., in order to think about eating field in general are extremely reluctant distress as a psychosocial disability) I propose to take their patients seriously in terms of to bypass some of the debates and legal asking them what troubles them: what they and ethical controversies. I will therefore think is ‘the matter’. It is never quite said here simply accept the Special Rappor- outright, but the tangled logic of the medical teur’s position and concern myself with what model, for ‘anorexia nervosa’ in particular, might follow from that acceptance. How exits its own Gordian knot in the off-stage then might we ‘dust off our ethics, recon- mutter: ‘they’re too ill to be asked’. I believe sider our practices and shift our paradigms’ this is a central cause of the difficulties I have (Adlam 2019, p.9)? adduced under my first point. The reader will note the anecdotal nature 2. Beyond the medical model: of this second point. But consider how the A ‘rainbow’ phenomenology following discourses current in systems of These three conceptual issues come together care become intermingled and what might in one specific although wide-ranging ques- be the outcome: the psychiatric discourse tion. If we are to creatively re-imagine of ‘over-valued ideas’, mixed in with the (Adlam, 2018) the whole field in line with psychoanalytically-tinged usage of the term the guidance of the Special Rapporteur, we ‘psychotic thinking’ to signify loss of reality would need to put the patient back at the orientation; the determinism of ‘impaired centre of care planning and we would need cognition’ in starvation; the clinical and soci- to abandon not only coercive psychiatry/ etal resistance towards, and sometimes down- mental health care but also medicalised right hatred of, the patient with ‘complex discourses around eating ‘disordered’ ‘symp- co-morbidities’, and the concomitant clin- toms’ and ‘pathology’ in favour of a new ical and societally located fearful forgetting phenomenology (see Martin, 2017). of the possibility of hidden trauma in the My question therefore looks something history. All of these phenomena combine like this: What would a phenomenology of eating together in what I consider to be a damaging distress look like if we took the testimonies of experts and perhaps even toxic ideological brew that from lived experience as our evidence base – and

26 Psychotherapy Section Review 65, Winter 2020 Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings how might we develop non-coercive treatment possi- emancipatory research in a written piece bilities using such an evidence base? when I am not speaking from my own lived In pursuit of a possible response, I am experience of the difficulties I am trying to going to reverse the imbalance inherent describe and map here? How far might I be in the ‘clinical’ literature (which almost at risk of being seen here to adopt some kind entirely ignores the ‘patient voice’ and of colonial move or Bolshevik-style ‘intel- disparages survivor testimonies as ‘grey liter- lectual vanguard’ posture? These are pitfalls ature’) and, for this paper, as for my talk I may not be entirely able to avoid – but I am on which it is based, I am going, recipro- looking out for them, and I will do my best in cally and in return, to ignore that clinical what follows to foreground other voices and literature in (almost) its entirety. I am also present them unfiltered. going to dispense altogether with the diag- nostic framework upon which that literature 3. Food practices is problematically predicated. I am going A foundational term, then, to begin with, and to make reference, here on in, only to the to conjure with: ‘food practices’. My focus in published work of experts from lived experi- this article is on food practices and on eating ence (which I prefer to term ‘rainbow litera- distress. By the latter term, I mean to denote ture’: see Adlam & Turner, 2017b) or to my that distress that can be either causative of own infant observation field notes. However, or consequent upon, or simply contingent I do make reference to patient testimonies with, what it feels like when anyone’s food recorded, I believe faithfully and respect- practices get into (often, are forced into) fully, by Hilde Bruch in The Golden Cage a tangle of some kind – when the offering (1978) – and therefore make this one excep- of food (by the self or by another) and the tion in the bibliography. receiving of food come together in a process Most of the ‘rainbow literature’ refer- that somehow goes awry. ences I am going to rely upon are taken What do I mean by the former term, food from two edited collections, both available practices? The term comes from sociology, online and open access as of time of writing. where food studies is a sub-discipline all of its The second (Adlam & Turner, 2017a) owes own (and the writing team from our ‘Offering a great debt, which I now have the oppor- food – receiving food’ project presented tunity publicly to acknowledge, to the first a symposium at the British Sociological Asso- (Pembroke, 1992), which latter is the orig- ciation Food Studies Group biennial confer- inal source for the term ‘eating distress’ – ence in 2017). We all have practices around a term I am going now to prefer for the rest food. And so intensely affect-loaded and of this article. The blogosphere and Twitter- life-essential is the consuming of foodstuffs, sphere are both replete with invaluable such that practices very quickly form and become testimony: I will mention just one weblog habitual. here, by way of excellent example: Emma’s Consider this material excerpted (with https://progressnotperfection.co.uk/. permission of both mother and baby (who There are also many powerful survivor testi- is now in her twenties)) from my contem- monies in book form (see e.g. Sister Marie poraneous notes of the first half-year of the Therese of the Cross, 2008; Allison, 2009). two-year, once-weekly infant observation One last point before I offer my hypoth- which I undertook for my training as a group esis: I note and mark the obvious difficulty psychotherapist in the late 1990s. here, that I am at risk of being seen to be writing ‘on behalf of’ people who have Mum fetches B’s bib and puts it on her. not in fact authorised me to ventriloquise She brings in the bowl of baby food and them. How can I advocate deployment of B immediately reaches out for it on the little this ‘rainbow’ literature and the ethos of table of the high chair, tipping it over although

Psychotherapy Section Review 65, Winter 2020 27 John Adlam

it does not spill. Mum makes an ‘uh-uh’ noise I want to let this material speak for itself to indicate that B should not do this and to the reader (I have used it in teaching places it just out of reach while she fetches a number of times now and everyone sees a stool for herself. B protests at this, using her different things in the scenes described). new language of sounds, but Mum has now I hope that it gives context for and some illus- got everything ready and she starts to offer tration of my broad opening proposition that B the baby food on a plastic spoon. B wrinkles our food practices emerge developmentally up her nose at the first nibble and expels it onto with our very early attachments and social her bib, but readily accepts the second. interactions and that a complex range of influences go into their formation, including Mum gently talks to her as she feeds her, the possibility of genetic inheritance but also, wondering if really she does like the food or more simply and observably, the food prac- whether she finds it as unappealing as Mum tices and patterns of affect regulation in our does and is thinking to herself why Mummy is familial, systemic, societal and cultural herit- dishing out such unpalatable fare. B does seem ages (see Appendix, Figure 1). to be unsure whether she likes the food, but she is definitely in to the process of eating it, eagerly 4. Food practices, adversity and eating reaching out for the spoon as it approaches her distress lips and gazing intently at her mother. Here is another scene of a ‘family meal’, equally replete with examples of food prac- After a while Mum can no longer bear to tices both established and emergent, but continue with this particular food and opens an experience perhaps of a very different up a can of cherry flavoured something which kind to the one co-produced by the feeding goes down much better. After the first mouthful pair in the infant observation (different, but of this it is clear that B likes it better, and she note the resonances – in both stories there becomes eager, almost impatient for the next is a feeding pair, and an audience that is mouthful and happily voicing her approval. witness to the transaction; there is someone Mum wonders if she would like some water (in both these cases, as it happens, the figure and she comes back with a cup, having been of mother) in the would-be offerer role, and unable to find the beaker. B again reaches for whose own food practices are strongly bound the bowl and Mum again makes the ‘uh-uh’ up in the offer; in both stories there are noise to signify she will not allow B to do this. threads and flashes of disgust). She offers the cup gently to her lips. B takes a gulp of the water, reaching for the cup with We’ve finished our cheese on toast and Mum both hands. brings out the pudding. It’s light brown and speckled and, however lightly you breathe, you At the second offering B becomes distressed and can’t get away from the stink. ... gives out a wail, because in her eagerness to drink she tries to do it over the handle, which ‘What’s that?’ says Fran. doesn’t work for her and she can’t get at the liquid. Mum calmly says that there is no need ‘Prune fool,’ says Mum. ‘Come on, try a bit.’ for her to become flustered and presents the cup so that she can drink and then mother and I feel like my talking doll. Someone’s pulling baby sit there together, both with their hands the string in my back and it’s the pause before around the cup, as B slurps her way through one of the recorded phrases comes out. Thank the drink. B is very focused on her and also you Mummy. It looks nice. Please may I leave looks over at me from time to time over the rim the table. But nothing comes out. Only silence. of the cup. I take a tiny mouthful and my tummy jumps in, sending a sick taste up into my mouth.

28 Psychotherapy Section Review 65, Winter 2020 Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings

I swallow the sick back down. Mum’s watching entail that food practices emerge out of me and all of a sudden her face looks like the a preconditional adversity. I do not favour woman on the front of Dad’s Picasso book. quite so deterministic a meta-narrative She’s very still and tears are falling down myself; however, my hypothesis aims at inclu- her cheeks in slow motion. Tears are running sivity, for (social) exclusion is the ailment down my face too. She takes my bowl, and which precisely it is aimed at, so I will say standing with her back to me she slowly eats the here that adversity is always located in more rest of my fool. I keep still, so still, not knowing than one nodal point. To say that it did what to do. not pre-exist and then suddenly it presented itself is always a schematised and stylised way Dan stares ahead frowning. He pushes his of seeing things. Without further preamble, bowl away a fraction of an inch. though, let us hear from two further voices of lived experience. ‘But it’s yucky,’ says Fran, pulling a face. I think I probably lost my ability to control my ‘Oh, for goodness sake. Get out, all of you,’ eating from an early age. I have always had says Mum. ‘Be unhealthy, see if I care.’ a feeling of panic and desperation when I am (Nott, 2017, pp.107–108) hungry, as if I am afraid I am going to starve, which may be the result of the advice to mothers We none of us can help but have food of the 1940s and 1950s to leave their babies to practices, around which habit and pattern cry if it wasn’t time for the four hourly feed. form and expand in ever-increasing circles. How we source, store, prepare, consume, I think poverty was another cause of my eating metabolise and discard our foodstuffs – in problems. My father had a low paid job and all such matters, individually as well as in his wages never seemed to last the whole week. groups, families, communities and societies, By mid-week there wasn’t much to eat, so when we have our food practices, they are distinc- pay day came, my sister and I would binge on tive and personal blends of countless influ- fish and chips, sweets and fruit. Eating was ential other practices, but only in certain comforting, pleasurable, an attempt to make circumstances are these going to become up for everything I didn’t have. The worse connected to experiences of eating distress things became for me out in the world, the and only in certain further and consequen- more I ate for comfort, or to tranquillise myself, tial circumstances will such distress also be and the more I ate, the more the other children caught up in and become entrenched within called me Fatty and the more freakish and the habit and pattern of these practices. rejected I felt. It was a vicious circle that took Whereas the infant observation material me over thirty years to begin to break. sits at the nexus of an infinity of possible futures and is predictive of no one of these ...on bad days I still feel like the pits, the futures over another, Nott’s fictionalised bottom of the heap, the one everyone else looks autobiographical writing brings us to a pivotal down on from their security as part of a group. moment, which may be captured in the ques- (Jan, 1992, p.20) tion: what happens to emergent food prac- tices when adversity is encountered? At the age of 12 I became the victim of multiple Now, it must at once be allowed that, perpetrator rape and spent the next ten years whether in the geneticist or the sociological making use of my spiritual framework and (or even the psychiatric) narratives, adversity ascetic ideals to try to make sense of my trau- may begin in the womb and innate vulner- matic experience. I entered the mental health abilities or phenomena associated with the system at the age of 17 after a voice instructed transgenerational transmission of trauma me to attempt suicide. …

Psychotherapy Section Review 65, Winter 2020 29 John Adlam

The belief that my body was a shell, a mere The cooking takes the sting out.’ I don’t believe vessel, enabled me to give meaning to my expe- her. ‘You need to try it. Only a mouthful. rience of sexual violence and focus on main- It’s full of minerals.’ taining the unblemished innocence and purity of consciousness that was me, dissociated from I pick up the bowl in both hands, hold it high the shell. (Timoclea, 2017, pp.94–96) in the air and throw it with all my might. It smashes down onto the black and white lino Adversity, then, would seem to mean psycho- squares. The bowl breaks and the soup oozes social adversity, and it floods or percolates out over the floor. Some splashes up the wall into people’s lives under many different and runs down the pine panelling like pale flags, from the debilitating consequences of green tears. poverty and social exclusion to moments of unimaginable traumatic intrusion and viola- Except I don’t. I couldn’t. The feeling got tion. For purposes of this line of argument, stuck. It came roaring up from my tummy, it is important to note that adversity does through my chest and into my arms and here not necessarily impact upon food practices. it is, trapped. My arms are as still as stone. When it does, then, if enough protective The feeling’s fizzing between my shoulders and factors are in place – and here I do NOT elbows, between the skin and the bone. No mean ‘resilience’ – if the individual has thinking, no words, no running out. Just the a strong enough sense of themselves, their tiny pin pricks, buzzing in my arms. From qualities and values and resources – and high up in the corner where two walls meet the if this is marked and validated by attach- ceiling, I watch the me below. (Nott, 2017, ment figures who are able to bear witness to pp.108–109) adversity and not turn away from, deny or replicate it – if resistance can be sufficiently All the testimonies adduced in evidence in mobilised – then it may still be that, whatever this article have to do with eating distress. other harm ensues, food practices survive Here I shall limit myself to the comment and continue to develop (see Appendix, that an emergent phenomenology of eating Figure 1). distress (considering the distress discretely, This is not to dismiss other ‘harms’ as without reaching yet too far into the ques- less harmful – not by any means – but this tion as to what practices and survival strate- article is looking at food practices and eating gies may then emerge) would seem possible distress, not at trauma theory in the more to map under four broad headings (but general sense. And it is eating distress that this list is not intended to be exclusive, as follows on from the meeting point of food though some other form of distress would practices and adversity, if protective function not ‘count’). in the system around the individual is for These headings are (broadly) arousal whatever reason insufficient. (agitation, anxiety, panic, terror, dread, In order to understand the usage of the rage); melancholy (for my extensive joint term ‘eating distress’ more clearly, let’s hear exploration of this theme with an anony- again from ‘Fran’: mous group of experts by experience, see Adlam, 2015); withdrawal and dissociation. ‘What’s that stuff?’ says Fran. After several These last two do of course start to shade weeks of usual food, Mum’s spooning some- into explicit survival strategies in themselves, thing green and slimy into our bowls at dinner as Nott (2017) so vividly and starkly evokes; time. and the first two can implicitly also be under- stood in such terms. ‘It’s stinging nettle soup,’ says Mum. As was noted in relation to the schema- Fran’s mouth is a big letter O. ‘Don’t worry. tised ‘advent of adversity’, so too with the

30 Psychotherapy Section Review 65, Winter 2020 Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings emergence of eating distress, it is impor- particular to me only, a woman within society, tant to eschew determinism and to say that but equally one with her own standing. food practices could yet come back into their previous trajectory of development There was a great fear that if I gave up my and creativity, if enough resources can be struggles I would be sucked into the collective, mobilised both internally and within familial I would be forced to conform to the norm of systems and other networks; but the direc- womanhood. Like the two faces of Eve, I would tion of travel, so to speak, from emergent be forced to play both femme fatale and the food practices encountering adversity and housewife and child rearer – all smiles and eating distress manifesting itself, represents sweetness, never expressing any of my feelings a gathering momentum, with ominous of anger, desperation or fully realising my future consequences, and will otherwise power. If I became sucked into that, for me it propel the individual sufferer into (and would be synonymous with death, indeed it here I introduce some carefully constructed would be death of the self, and of my spirit. language) emergent practices of starving and I would have failed my higher self, the part experiences of malnutrition (see Appendix, who knew there was more to life than role-play; Figure 1). and such a thought was almost more terrifying than starving. (Rosalind, 1992, p.16) 5. Practices of starving and experiences of malnutrition My thought processes became very unrealistic. What becomes of language if we imagine I felt I had to do something I didn’t want to abandoning the whole idea of ‘eating do for a higher purpose. That took over my disorder’? One thing that I think can be life ... I created a new image for myself and readily perceived is that inpatient ‘eating disciplined myself to a new way of life. My disorder’ units, and by extension the whole body became the visual symbol of pure ascetic pathway that they sit at the end of, exist and aesthetics, of being sort of untouchable in the context of carer and system anxiety in terms of criticism. Everything became very (sometimes, but not always, patient anxiety) intense ... Being hungry has the same effect about malnutrition and starvation and their as a drug, and you feel outside your body. physical consequences but also the ways of You are truly beside yourself – and then you being that lead to this bodily states. Low are in a different state of consciousness ... potassium; low sodium; low body mass index; That’s what I did with hunger. I knew it was low haemoglobin; postural drop; osteopo- there ... but at that time I did not feel pain. rosis and many besides – these are symp- (‘Gertrude’ from Bruch, 1978, pp.17–18) toms, properly understood, of malnutrition or starvation and related food practices. 6. Rigidity and chaos We don’t need the framework of ‘eating To recap: food practices emerging out of disorder’ to start to think about these prac- all the complexity of social life and human tices – we could listen to those who are and/ development have met with adversity and or have been caught up in them. Here are eating distress has emerged and evolved two testimonies – they speak for their selves... into practices of starving and experiences of malnutrition. At this stage in our timeline In some ways, and I speak for myself here, a number of feedback loops start to further in a paradoxical way, starving myself was complicate matters for the individual in the only thing that was keeping me alive – pursuit of what by now are safety or survival my search for my Self, even though I nearly practices laden with intense affect. The first destroyed myself in the quest. Much of that feedback loop, or ‘double arrow’ in Figure 1 search was a looking within, trying to locate (see Appendix, is that these emergent prac- an identity for myself, something that was tices of starvation and experiences of malnu-

Psychotherapy Section Review 65, Winter 2020 31 John Adlam trition do not eliminate eating distress (or all-important. Another set of moves (and only do so transiently); they tend rather to it’s evidently not either/or) takes the indi- complicate and add to the tension needing vidual towards chaos (‘dysregulation’ in somehow to be held and to reinforce the some other languages – ‘multi-impulsivity’ eating distress (remember the list roughly in one particular system-of-care dialect, no stated above – arousal, melancholy, with- longer much spoken). Chaos and control drawal, dissociation). – perhaps the oscillation between these two territories is the essence of the human condi- I started dieting in a bid to lose weight. It began tion. When food practices get caught up as healthy eating but it became an obsession: in this oscillation (or tilt definitively one my sole focus was restricting and losing weight. way or the other), it can then be as if the … I lost around 8.5 stone in 10 months whole system gets caught up in the reso- as I reached a low healthy weight for myself nant frequency. Whatever may have been the through restricting more and more. However, original or originating anxieties, the anxiety the bingeing returned as my body was starved about whether one has just made the right of nutrients and needed food. I understand move in the right direction now comes to that in hindsight but I couldn’t see it at the fore. the time; I was terrified of gaining weight so I began to vomit. The more I binged and 7. Agonies of deliberation; habit and vomited, the more I felt I needed to binge and pattern; safety practices and terrifying vomit, both physically and psychologically. interventions When I was in this mode I binged and vomited constantly and then I could stop for a few It is as if you create a robot and then you days where I would restrict myself to 500–800 can’t control what it is thinking. After calories a day. In my mind when I binged a certain point, I really felt full. And then you I was being bad and when I starved myself get tormented by this awful guilt feeling after I was being good. Bingeing was loss of control, you have eaten any food. I became tense and and vomiting and starving were my furious unhappy, all joy and spontaneity had gone out attempt to fix past mistakes. My life revolved of my life. I felt as though a slavedriver were around my eating disorder. I rarely slept; I had whipping me from one activity to the other. damage to my car that I couldn’t account for (‘Helga’, from Bruch, 1978, pp.19–20) as I had lost consciousness while driving. I also struggled to maintain friendships. ...I could not eat the food that they ate. It I recall going to the cinema with friends and was too much: too oily; too rich; too sweet... leaving during the film because I had eaten too unknown. Too early; too late; too expen- something I considered bad and felt I had to go sive; I really just fancied a drink. I was like and vomit. (Goodall, 2017, p.40) Goldilocks but everything was wrong. Plates cleared, I seized my moment, came in from As Goodall’s testimony suggests, there are in the cold where I’d stood looking in – waiting, broad essence only two directions in which watchful – persona non grata while the to turn in pursuit of resolution of the mutu- others took their fill. Taking up my place with ally reinforcing and amplifying feedback a flurry of distracting greetings, I batted away loop between eating distress and practices the reasons I hadn’t ‘made it’ for the meal. of starving. Traffic. Work. Family. (There are two Ryvita One set of moves takes the individual in my bag and I can’t stop thinking about towards positions of greater rigidity, in them.) These people might linger for hours pursuit of experiences of control or mastery yet, replete with the glow of companionship, over often very narrowly defined areas of the bonhomie from sharing that extra pudding human existence that may (have) become (‘Diet starts tomorrow!’) while I sit here and

32 Psychotherapy Section Review 65, Winter 2020 Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings

starve. I could not eat their food, had to stand to naso-gastric tube feeding under restraint outside waiting for them to finish – and now to PEG (Percutaneous Endoscopic Gastros- they insist on my presence here: these people are tomy) feeding. Here is where the Mental cruel. I am being denied access to those plain, Capacity Act will be restrictively invoked dry crackers which I’d packed in a plastic bag to exclude the possibility of building care to eat furtively, in a far corner of the tube planning around the patient’s own experi- station, or dark street corner – wherever I might ence, just in case anyone is tempted to be hide my squirrel-like nibbling and finally expe- so audacious as to suggest this. All of this, rience the long-delayed relief of the longed-for let’s remember, in arguable violation of the food ... I need to leave. Work. Traffic. Family. obligations of States Parties to the United (Ryvita in my bag, and more in the packet at Nation Convention on the Rights of Persons home). (Beth, 2017, p.24) with Disabilities. Here also is where, instead of structure Here is where the developmental line which and flexibility, treatment models and systems I have been mapping, through these various veer off into their own oscillations between testimonies, reaches its own precariously chaos and rigidity (see Appendix, Figure self-sustaining conclusion. It is not that 1). Here is where the system in its own there is no way out, although I think that version of panic, fires bewildering interven- this is why the mortality rate is so high. tions at the patient’s ‘symptoms’ instead of But because the agonies of deliberation, working through with the patient’s distress. second-guessing and self-reproach further Here, where choice and agency has existen- intensify the oscillation between rigidity and tially collapsed, is where hostile attributions chaos and accentuate the eating distress, the of intent into the patient are intensified: terrified subject becomes entrenched in the ‘it’s behavioural’ (whatever on earth that reflexes, the habit and pattern of his or her is supposed to mean); ‘she’s doing it delib- safety practices. Here is where the nonsense erately’; ‘he’s splitting the team’ – and of ‘you could just snap out of it and eat so on. Here, when asylum and respite something’ – the neo-liberal ‘on your bike’ might be supposed to be just the thing, of the system’s frustration with the individual is where ‘hostile environment’ practices who declines to be a ‘happy consumer’ – is are consciously implemented on inpatient made painfully stark. Here there are very units to deter the ‘complex patient’ from few choices, in the sense of a psychic ‘fork in getting too ‘comfortable’ or ‘dependent’. the road’, where one can consider the pros Here, lastly, in the moment when terror has and cons of taking either path and come to become the patient’s universe, is when we a decision one can sit with. In this self state somehow find ourselves least likely to under- or way of being, the neural pathways light up stand terror as the key factor driving safety each time the shortest path from terror to practices. safety practice. It’s easy to critique and so it is worth also Now, I know it’s easy enough to critique recognising that it’s not easy to do this work. existing systems of care and tough to rein- No work of engagement with extreme distress vent new ones – but here, sadly, is where the and suffering is easy. This the ‘patients’ also system of care, in all kinds of ways, makes know – ‘they’ can be more patient with ‘us’, the opposite moves to those that might be then sometimes ‘we’ are with ‘them’: indicated. Here is where a range of ever more powerful and potentially intrusive How can you keep offering, in the face of such medico-legal technologies are deployed – hollow-eyed and relentless refusal of all the from Community Treatment Orders to good that you would seek to instil? How do Mental Health Act detention, from enforced you not, sometimes, feel the rejection of the food bed rest and nursing observations through to be a symbolic refusal of your best attempts

Psychotherapy Section Review 65, Winter 2020 33 John Adlam

to care, support, deliver what you were able... from his report, by way of conclusion, just so or not occasionally feel irritation with the we’re clear that I’m not just off on one on person who hurls the meal you’ve meticulously my own and that the system of care would measured out (at the optimum temperature, as right now be facing a real and immediate per individual preferences, in the ‘right’ cup, challenge to its very foundations – if only it without a single speck of ‘dirt’ – and just one, would face it! clean tissue – because you know the details I also trust that the testimonies I have matter) to the floor, all because you forgot to brought together here may successfully use the agreed wording when you handed it and perhaps even powerfully anticipate the over...? (Beth, 2017, pp.27–28) criticism that I have nothing to propose in place of what presently happens and how 7. Conclusion things are presently understood. We could very easily, in fact, obey the first instruction Coercion in psychiatry perpetuates power imbal- of the Special Rapporteur, and abandon all ances in care relationships, causes mistrust, talk of ‘mental disorders’ – in this or any exacerbates stigma and discrimination and other field. We could discard the arcane and has made many turn away, fearful of seeking pathologising language of ‘eating disorder’ help within mainstream mental health services – who would mourn it? – and we could ... Immediate action is required to radically start to think in terms of food practices and reduce medical coercion and facilitate the move eating distress – and to see how thinking towards an end to all forced psychiatric treat- like this might change our thinking more ment and confinement ... States must not deeply. We could be much, much better at permit substitute decision-makers to provide asking the patients what happened to them, consent on behalf of persons with disabilities what’s going on for them, what the matter on decisions that concern their physical or is and what might help. We could abstain mental integrity; instead, support should be from dismissing their responses as evidence provided at all times for them to make deci- of ‘incapacity’ and we could get a whole lot sions, including in emergency and crisis situ- better at what the law already says we should ations ... There is shared agreement about the be doing, which is to say, supporting the unacceptably high prevalence of human rights patient in his or her decision-making and violations within mental health settings and not deciding for them. that change is necessary. Instead of using In my previous piece for this Review, legal or ethical arguments to justify the status I noted that the Special Rapporteur quo, concerted efforts are needed to abandon observes that we lack the clinical tools to it. Failure to take immediate measures towards try non-coercive options. I asked there, and such a change is no longer acceptable. (UN I ask again: ‘What if the increasing power Special Rapporteur, 2017, p.15) and potency and even sophistication of our medico-legal technologies ... has deskilled I am sure that as we have gone along, there us in some simpler forms of intervention? have been many mutterings or exclamations Suppose our coercive muscles are so well of ‘yes, but...’ or ‘hang on a second...’ ringing developed, that our engagement skills have out. As I write, and indeed each time that become rather flaccid and feeble with I try to work through this line of thought, disuse?’ (Adlam (2019), p.8). We could use I catch myself doing the same thing. Have we the outline I have sketched here as the foun- really got it so wrong? Do these things really dation of a new evidence base, located in happen? Surely sometimes the end justifies a different set of values about what consti- the means? And so on. I recognise the force tutes ‘acceptable evidence’ (and thus in the of these objections, just as does the Special process break the stranglehold which Big Rapporteur – and I quote again, just above, Pharma and the old medical guilds still exert

34 Psychotherapy Section Review 65, Winter 2020 Food practices, eating distress and the perils of bewildering interventions in ‘eating disorders’ treatment settings upon our own capacity to think our own own thoughts into ‘a language patients can thoughts). We could then avoid the hidden understand’ – we’d be speaking in kindred pitfalls of the bewildering intervention, tongues, from a practice of respectful equality because we wouldn’t be having to translate and a cherishing of our shared humanity. (or choosing to abstain from translating) our

Appendix: Eating distress – A phenomenological description I have attempted to render the develop- ‘core’ elements are represented in blue. mental trajectory of eating distress in Correspondence on this or any other diagrammatic form below (Figure One). aspect of this paper is very welcome via The central line begins with food practices [email protected]. and moves through to the force of habit, pattern, reflex and safety practices. Red John Adlam elements indicate threat; green elements signify protective or ameliorative factors;

Figure 1

Psychotherapy Section Review 65, Winter 2020 35 John Adlam

References Adlam, J. (2015) ‘Refusal and coercion in the treat- Jan (1992) from L. Pembroke (Ed.) (1992). Eating ment of severe Anorexia Nervosa: the Antigone distress: Perspectives from personal experience. paradigm’, Psychodynamic Practice, 21(1), 19–35. http://www.arwtraining.com/wp-content/ http://dx.doi.org/10.1080/14753634.2014.989 uploads/2015/02/04-Eating-Distress-Perspectives- 714. from-Personal-Experience-First-Hand-Experience- Adlam, J. (2018) ‘Violent states in feeding distress: Testimonies.pdf the Antigone paradigm and the creative possi- Martin, W. (2017) ‘Human rights and human bilities of collective re-imagining’, in J. Adlam, T. experience in eating disorders’, p.111-121 Kluttig & B.X. Lee (Eds.) Violent states and creative in J. Adlam & K. Turner (Eds) (2017) Special states: From the global to the individual. London: Issue: “Offering food ↔ Receiving food”. Jessica Kingsley Publishers. Journal of Psychosocial Studies 10(2). http:// Adlam, J. (2019) ‘The story of Janeway and Seven of www.psychosocial-studies-association.org/ Nine: coercive psychiatry and human rights in wp-content/uploads/2017/10/Wayne-Marti ‘eating disorders’ inpatient units’, Psychotherapy n-Human-Rights-Human-Experience-in-Eating- Section Review, 63, Spring, 4–9. Disorders.pdf Adlam, J., Hewitt, H., Hursey, R., Lazenby, K. & Martin, W. & Gurbai, S. (2019). ‘Surveying the Plumb, C. (2016) ‘Fine words in theory butter Geneva impasse: coercive care and human no parsnips in practice’: critical approaches to rights’. International Journal of Law and Psychiatry, ‘co-production’ on an inpatient eating disorders 64, 117–128. ward’. Poster presentation, Eating Disorders Minkowitz, T. (2007) ‘The United Nations conven- International Conference: London, March 2016. tion on the rights of persons with disabilities doi:10.13140/RG.2.1.3611.8161 and the right to be free from nonconsensual Adlam, J. & Turner, K. (Eds) (2017a) Special psychiatric interventions’. Syracuse Journal of Inter- Issue: “Offering food ↔ Receiving food”. national Law and Commerce, 34, 405–408. Journal of Psychosocial Studies 10(2). http:// Minkowitz, T. (2010) ‘Abolishing mental health www.psychosocial-studies-association.org/ laws to comply with the convention on the volume-10-issue-2-october-2017/ rights of persons with disabilities’, pp.151–177 Adlam, J. & Turner, K. (2017b) ‘An editorial tea in B. McSherry & P. Weller (Eds.) Rethinking party?’ pp.1–6 in J. Adlam & K. Turner (Eds.) rights-based mental health laws. Portland, Oregon: (2017) Special Issue: “Offering food ↔ Hart Publishing. Receiving food”. Journal of Psychosocial Studies Nott, S. (2017) ‘Dandelion’, pp.105-110 in J. 10(2). http://www.psychosocial-studies-asso- Adlam & K. Turner (Eds) (2017) Special Issue: ciation.org/wp-content/uploads/2017/10/ “Offering food ↔ Receiving food”. Journal of AASpecial-Edition-editorial-FINAL.pdf Psychosocial Studies 10 (2): 105-110. http:// Adlam, J. with an anonymous group of experts www.psychosocial-studies-association.org/ by experience (2014) ‘Project Antigone’: wp-content/uploads/2017/10/Sadie-Nott- A psychosocial exploration of the dynamics of Dandelion.pdf food refusal and force feeding’. Poster presenta- Pembroke, L. (Ed.) (1992) Eating distress: Perspectives tion, Psychosocial Studies Conference: Preston, from personal experience. http://www.arwtraining. December 2014. doi:10.13140/2.1.4963.2328 com/wp-content/uploads/2015/02/04-Eating- Allison, M. (2009) Dying to live. Brentwood: Chip- Distress-Perspectives-from-Personal-Experience-First- munkapublishing. Hand-Experience-Testimonies.pdf Beth (2017). ‘Persona non grata’, pp.23–33 in J. Adlam Rosalind (1992) from L. Pembroke (Ed.) (1992) & K. Turner (Eds) (2017) Special Issue: “Offering Eating distress: Perspectives from personal experi- food ↔ Receiving food”. Journal of Psychosocial ence. http://www.arwtraining.com/wp-content/ Studies 10(2). http://www.psychosocial-studies- uploads/2015/02/04-Eating-Distress-Perspectives- association.org/wp-content/uploads/2017/10/ from-Personal-Experience-First-Hand-Experience- Beth-Persona-non-grata.pdf Testimonies.pdf Bruch, H. (1978 [2001]) The golden cage: The enigma Scanlon, C. & Adlam, J. (2009) ‘“Why do you treat me of anorexia nervosa. Cambridge, MA: Harvard this way?”: reciprocal violence and the mythology University Press. of ‘deliberate self harm’’, pp.55–81 in A. Motz Goodall, J. (2017). ‘Starved of power’, pp.39–43 (Ed.) Managing self harm: Psychological perspectives. in J. Adlam & K. Turner (Eds) (2017) Special London: Routledge. Issue: “Offering food ↔ Receiving food”. Sister Marie Thérèse of the Cross (2008). The silent Journal of Psychosocial Studies 10(2). http:// struggle. Chawton: Redemptorist Publications. www.psychosocial-studies-association.org/ wp-content/uploads/2017/10/Joy-Goodall- Starved-of-Power.pdf

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Timoclea (2017) ‘Anorexia Mirabilis’, pp.93–104 United Nations (2015) ‘Dignity must prevail’ – an in J. Adlam & K. Turner (Eds.) (2017) Special appeal to do away with non-consensual psychi- Issue: “Offering food ↔ Receiving food”. Journal atric treatment World Mental Health Day – of Psychosocial Studies 10(2), 99–104. http:// Saturday 10 October 2015. https://www.ohchr. www.psychosocial-studies-association.org/ org/en/NewsEvents/Pages/DisplayNews. wp-content/uploads/2017/10/Robyn-Timoclea- aspx?NewsID=16583&LangID=E Anorexia-Mirabilis.-Voluntary-self-starvation-and- United Nations (2017). Report of the Special Rapporteur the-role-of-spirituality-as-a-legitimate-response- on the Right of Everyone to the Enjoyment of the Highest to-sexual-violence.pdf Attainable Standard of Physical and Mental Health Timoclea, R., Turner, K., Adlam, J. (Independent (2017) UN General Assembly – A/HRC/35/21. Research Collective) (2018). ‘Leaving person- https://reliefweb.int/sites/reliefweb.int/files/ ality out of it’: reframing forensic mental health resources/G1707604.pdf treatment pathways for traumatised people’, Van der Kolk, B. (2015) The body keeps the score. Quality Network for Forensic Mental Health Services London: Penguin. Newsletter MSU/LSU Issue 37, April, pp.21–22. Watson, J. (Ed.) (2019). Drop the Disorder! Challenging United Nations (2006). Convention on the Rights of the Culture of Psychiatric Diagnosis. Monmouth: Persons with Disabilities https://www.un.org/ PCCS Books. development/desa/disabilities/convention-on- the-rights-of-persons-with-disabilities.html

Psychotherapy Section Review 65, Winter 2020 37 The client’s experience of coercive treatment Joy Goodall-Leonard

This article is a response to John Adlam’s ‘Food Practices, eating distress and the perils of bewildering interventions in “eating disorders” treatment settings’. This response was first presented in the form of a talk at the BPS Psychotherapy Section Conference on 26 October 2018. I am writing in the capacity of a survivor researcher, an expert through lived experience. In the spirit of disclosure I must acknowledge that I also work within the mental health system, in the role of a mental health support worker, and while I endeavor to use my experience to inform my practice, there are times when these dual identities can come into conflict with each other.

VER THE course of my life I have treatment in London and the possibility of received a number of differing diag- me losing the opportunity to receive this Onoses. The first came at aged 13 when treatment was used as a way to control my I was diagnosed with PTSD, at 16 came behaviour. I was told that if I didn’t stop the label of depression. By 22 I was told losing weight, I wouldn’t get the help that I suffered from Bulimia (multi impulsive) I so desperately wanted. which then became reclassified as EDNOS When I arrived for treatment in London, when I didn’t fit neatly enough into the I was presented with a standardised treat- diagnostic criteria and finally the stigma- ment plan (keep in mind that this is my tising diagnosis of borderline personality interpretation of the treatment plan) – disorder followed at 23. In 2006 after years ■ Stop all ‘eating disorder behaviours’. of struggling with my mental health as ■ Eat and Drink what we have prescribed you. a result of trauma I experienced at a young ■ Pass our admissions test – basically make age, and falling between the cracks after the right noises about treatment, follow being discharged from CAMHS at 18, the the rules or you will lose your opportu- deterioration in my mental health came to nity of treatment. be severe enough to warrant the attention of ■ Go to the groups and therapies we have Adult Mental Health services, who admitted prescribed. me to an acute admissions ward for assess- ■ Follow all ward rules – how you eat your ment. Within a few days of my admission food, what condiments you can use and to the ward it was decided that my primary rules on when you can use the bathroom. problem was that I had an ‘eating disorder’ ■ There were also some accepted rules that which required treatment. I was considered you picked up pretty quickly. For example, unsuitable (too sick) for outpatient ‘eating we will allow you a couple of f**k ups but disorder treatment and with no inpatient any more than that and you’re out. Time or day patient options in Northern Ireland, out was used as a punishment for these they sent me to London for treatment. indiscretions. My experience with treatment was coer- ■ If you don’t follow these rules then we cive from the beginning. This is not some- can’t help you, we will have to let you go thing I realised at the time because I was back to where you were. so desperate for help. My first engagement with treatment before I was sent to London Not once was the question put to me; What was an acute admissions ward. When my is the matter? What might help. Yes, I was in weight continued to drop while an inpatient, treatment voluntarily but that fails to recog-

38 Psychotherapy Section Review 65, Winter 2020 The client’s experience of coercive treatment nise the huge power imbalance which exists. Many of these may seem minor taken in To receive treatment, I was expected to hand isolation, but it created an overall unhealthy over all responsibility for my most basic culture of fear and mistrust. It gave me the needs to a stranger. I was given an outline of impression that I was imprisoned with no the treatment plan and the ward rules which control over my life, when I should have I had to agree to, or I would not receive treat- been in a supportive environment to help ment, I was desperate for help, I would have me regain healthy control over my life. agreed to anything. I was expected to accept I struggled at various points during my treat- the treatment offered without question ment with ‘eating disorder’ practices but and I would argue that this is not informed felt unable to confide in any of my care consent. One might say that it was in my providers because of fear that I would be got best interests but was it? The threat of how rid of because of my indiscretions. I suffered terrible things would be if I did not agree in silence and was made to believe that their and conform to the treatment offered was treatment was my only option. often used as a tool to facilitate compliance. I feel that my diagnosis of mental illness, What changed? in this case ‘eating disorder’ was used as I completed my treatment programme a licence to use coercive and restrictive prac- and returned to the outpatient’s service tices. In fact, many of the restrictive practices in Northern Ireland. I was supposed to go used were employed because it was easier to to a follow-on support group facilitated by apply them to the group. However, restric- liaison nurse from the treatment team in tive practices should not be enacted because London but was denied entry to it because it is more convenient to staff or applied to I wasn’t ‘behaviour’ free. I was told if a group as a whole because it is easier, the I didn’t cease my ‘behaviours’ they would focus should be person centred care. have to let me go back to the way I had Examples of Coercion and restrictive been prior to treatment; they wouldn’t help practice I experienced: me. Fortunately, I had encountered a kind ■ Being coerced to things I was not and compassionate consultant in the outpa- prescribed because the nurse believed tient team who offered to take me on as my diet plan was different. This was the a patient and assured me that they would result of a culture of the nurse is always support me even if I was still struggling with right and the patient is being deceptive ‘eating disorder’ practices. This was prob- because of their ‘eating disorder’. ably the first time in my treatment that I was ■ Being accused of eating outside of my given a choice. Having this choice gave meal plan when I wasn’t and being told me the strength to tell the treatment team that I must have blanked it out because it in London that I no longer wanted their was too distressing for me to remember. involvement in my care. It wasn’t a straight This made me feel like I was losing my road to recovery, but I did recover. mind and that I could not trust my own In John Adlam’s article he suggests asking memory. This is ‘Gaslighting’ and again the question that is often not asked what was a result of the belief that the nurse the matter is and what might help to those was always right. experiencing eating distress. I have answered ■ I was subject to strict rules, many of them these questions below with the benefit of restrictive practices that were applied to all. hindsight of one in recovery. ■ Assumptions were made about why I presented with an eating disorder What was the matter? without proper consultation with myself. ■ I have used disordered food practices The patient should be considered an from childhood as a way of coping with active participant in their own treatment. the deep unhappiness I’ve felt from

Psychotherapy Section Review 65, Winter 2020 39 Joy Goodall-Leonard

a young age. Food was a way to cope with It was always the elephant in the room the trauma of my family and the sexual throughout all treatment I received assault I experienced at age 13. because I was afraid to talk about it or ■ I came from a dysfunctional family when I was being coerced to talk about it environment in which my mother used when I wasn’t ready. bingeing as a way to self-medicate to cope with her own trauma. My mum controlled Of course, it is hard to speculate how the food the whole family ate. She passed one’s recovery may have been different these practices on to her daughters. When had the approach taken by professionals I tried to be assertive and take control been the one Adlam suggests. However. back my mum refused to support my wish I do believe that had I been asked what the to eat healthier and continued to provide matter was and what might help from the only unhealthy food. I see this as a form of outset, my experience of treatment may have coercive control. been more positive and beneficial. I imagine ■ I lost a large amount of weight between my answers may not have been as articulate the age of 21 and 22 in a bid to take back at the time, but just asking me those ques- control but I only switched the method in tions may have helped me think beyond which I used food to help me cope with the ‘eating disorder’ practices I was using my unhappiness and feelings of power- and be curious as to why I was using them. lessness. I believe that the people involved in my ■ Restriction was an attempt to have care were doing what they thought would control. Bingeing represented the loss help me recover. I too have been in the of control and vomiting was the furious position where I have found myself guilty attempts to fix past mistakes and regain of feeling paternalistic need to swoop in control – damage limitation. and save someone from their psychological ■ Food is an addiction for me, used like distress without asking them what the matter a drug to temporarily provide relief from is and what might help, but I still believe they emotional distress. are important questions to ask.

What helped? Joy Goodall-Leonard ■ Being accepted at where I was in my recovery journey. Knowing that someone Note: had my back and that they wouldn’t give John Adlam elsewhere refers to the impor- up on me even when I sometimes did. tant conclusions of a report by the UN ■ Not having treatment and the threat of Human Rights Council. The future Issue its removal as a tool to coerce compli- on Improvement in Psychotherapy and ance. Avoiding Harm, will refer to this. ■ Person centred care – a treatment plan In 2017 the UN Human Rights Council individual to my needs. published the ‘Report of the Special Rappor- ■ When I was ready – Group psychotherapy. teur on the right of everyone to the enjoy- ■ Photography – Through my degree in ment of the highest attainable standard of media studies with photography. I used physical and mental health’ (UN, 2017). The my photography projects as an opportu- secretariat prefaces the report by observing nity to explore my relationship with my the Rapporteur’s call ‘for a shift in the para- body, my fear of my own femininity and digm, based on the recurrence of human my desire to erase any sign of my sexu- rights violations in mental health settings, all ality from my body. too often affecting persons with intellectual, ■ NEXUS – specific counselling in rela- cognitive and psychosocial disabilities’ (UN tion to the sexual assault I experienced. 2017, p.1).

40 Psychotherapy Section Review 65, Winter 2020 The client’s experience of coercive treatment

Another article title by John Adlam The ‘Barrelman’. The original blog can be found story of Janeway and Seven of Nine: coer- at https://barrelblog.org/2018/02/18/ cive psychiatry and human rights in ‘eating janeways-dilemma-coercive-treatment-and- disorders’ inpatient units. This article is human-rights-in-eating-disorders-inpatient- based upon and adapted from a blog which units/ I published on 18/2/18 under the handle

Psychotherapy Section Review 65, Winter 2020 41 How did I get here? A narrative exploration of arriving at talking therapy in a neuro- rehabilitation setting, co-written by a young adult patient and her therapist Jess Walling & Helen Molden

Aims: This narrative case study explores some of the themes and process behind the referral process in a neuro-rehabilitation multidisciplinary team (MDT) outpatient setting. It aims to give a central focus to the patient experience, in this case, Jess, one of the co-authors, who at 19, experienced a life-changing spinal injury causing paralysis and pain in January 2017 while she was in her first year at university. Jess is doing well with her recovery, back at work part-time, and started back at university in September 2019. Methodology: The data was gathered through two interviews held to reflect specifically on what life was like in the run up to coming to talking therapy services as an outpatient and the impact of that first session. The interviews were facilitated by, Helen the other co-author, a counselling psychologist and integrative psychotherapist, and the participants were Jess, and her referring physiotherapist and occupational therapist. The data was then analysed thematically by Jess and Helen. Findings & Discussion: Five themes were identified: 1) The point when ….I knew that I needed a bit of extra help, even though I didn’t really want to… 2) How this ‘different kind of conversation’ might fit in with the rest of rehabilitation, 3) Could this be the right time ‘to open the box …?’ 4) The moment when it felt like talking therapy might be OK and 5) How starting talking therapy began to change things. Jess’s experience and reflections provide a client-centred view as to the added value psychotherapy can bring within a physical healthcare MDT setting. The findings also support existing evidence that it is less the therapeutic approach or modality that is paramount, but the fit of the therapeutic relationship that counts (Norcross, 2002; Cook et al., 2017). The authors offer this piece of work for wider discussion within the context of practice-based research, promoting the voice of the client experience within talking therapy discourse. It also fits with the wider objectives of embedding co-production with the BPS Experts by Experience initiative. The authors present a summary with reflections and learning points in the conclusion.

Introduction HIS IS a co-written narrative explora- January 2017. Jess explains what happened tion by Jess, a young woman (20) who that year: Tloves Nandos fries and Love Island, and Helen (43) a counselling psychologist and ‘Whilst on the way to university for the start integrative psychotherapist with a passion of my second term there, in January 2017, for supporting people towards better inte- I was overcome with a burning sensation that grated healthcare and getting outdoors started in my neck and quickly spread to my whatever the weather (and also loves a good left hand. My boyfriend of the time told me Nandos). They worked together with fort- to pull over in the nearby road which is when nightly psychotherapy sessions for just over the burning started to spread around my body. a year starting in June 2017, while Jess When we eventually got to our uni flat the has been making progress in her recovery burning pins and needles sensations made me from a life-changing neurological injury in sick and I ultimately collapsed. I was taken

42 Psychotherapy Section Review 65, Winter 2020 How did I get here? A narrative exploration of arriving at talking therapy in a neuro-rehabilitation setting

into hospital with a suspected migraine. How scared, alone and, quite honestly was the wrong they were. hardest part of my journey so far. It was such a different environment to my previous I went into what felt like thousands of machines hospital that I struggled to recover my mental and blood tests; doctors came to examine me, state all while my body was improving. all confused by why I was so ill. Initially they Eventually, I came to outpatient care, with told me I had a spinal stroke at C2 level, which me back at home, balancing the demands meant everything from my neck down was of physiotherapy, occupational therapy, paralysed and they didn’t expect anything to medical appointments, everyday life and then recover. Me being stubborn, I refused to accept psychology …’ this news and soon after I proved doctors wrong leading them to conduct more studies. One of the aims of this collaborative piece Eventually, I was diagnosed with idiopathic is to explore some of the aspects that played longitudinal extensive transverse myelitis, an a part in establishing a good working alli- autoimmune disorder that causes the white ance (as defined by Clarkson 1995, and later blood cells to attack the spinal chord. I was added to by Murphy and Gilbert’s model, placed on high dose steroids and went through 2000), specifically in the first and second five rounds of plasma exchange to clean my stages; 1) whether it’s possible to work blood. together, the first meeting and assessment and 2) building trust through the working After two months in a busy hospital environ- alliance. ment, I was transferred to a spinal unit where The title of this piece was inspired by an I continued to recover and gain movement. in vivo quote from Jess’ assessment session, Hospital for me was a complete mixture of and illustrates something of the psychoge- emotional turmoil, due to medication, being ography of the client arriving at the begin- away from my family and being surrounded ning of talking therapy in recovery from by people that were in a similar situation a serious illness.1 During her recovery, Jess to me. I struggled mentally to come to terms has been keen to take part in research where with what had just happened. In the acute her voice and experience can be recognised hospital environment that I look back on now within the field of neuro-rehabilitation with fond memories, my family were with me and beyond. She has frequently taken constantly, my nurses became my friends due part in neuro-physiotherapy demonstra- to being so young and chatty, and I genuinely tions, and continuing professional devel- had the best stay. I’m not saying that there opment sessions for practitioners in the weren’t times where I cried myself to sleep, neuro-rehabilitation field. I screamed and also felt extremely vulnerable This article is part of that process, with but the staff were honestly the most profes- the aim of looking at some of the explicit sional best friends I could have ever wished and implicit co-constructed processes on for. coming to psychological support from the patient’s perspective (something The spinal unit was completely different; I felt we believe is under-represented in the

1 Helen considers this to be reminiscent of Sontag’s (1978) seminal quotation at the beginning of her book Illness as Metaphor, an exploration of the socially constructed nature of illness: ‘illness is the night-side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.’ Arriving as a ‘citizen of that other place’ happens both suddenly in its acute form as described above, and episodically, over the course of loss, adaptation and recovery, as Jess’ experience will testify.

Psychotherapy Section Review 65, Winter 2020 43 Jess Walling & Helen Molden literature2). As part of preparing for this describes it, ‘I felt really like shut off from article, we had a discussion outside of the everything, and like, really like just down therapy room, based on what the experi- constantly, and I’d go home and I’d be ence of arriving at therapy was like, and crying all the time, and a lot of the time my involved Jess’s physiotherapist and occu- mum had to like… try and calm me down pational therapist also in that discussion. and I think it started getting to a point Our approach to our subject is based on where everyone was just arguing at home narrative theory, applied with a postmodern because of me being really really upset all paradigm (Bruner 1990; Griffith & Griffith the time.’ This underlines the fact that 1994). Within this epistemological frame- recovery from a serious neurological health work, personal experience and reality are condition impacts not just the young person viewed as constructions created through the but changes the relationships for that person process of telling stories, to our own self systemically, across family, friends and their or others. Reality is not fixed but rather wider support system. Exploring the changes co-constructed. Sense making, or meaning, across those relationships forms a key part of is negotiated within the social context. the work, so in Jess’ case that meant univer- As Weingarten and Weingarten-Worthen sity, and work as well as her close family (1991, 1997) have highlighted in their work support, boyfriend and friends. on understanding the experience of illness, Recognising that Jess was tearful in much from this perspective, the self continually of their recent sessions, her OT raised the creates itself through narratives that include possible idea of seeing Helen for a talking other people who are reciprocally woven into therapy assessment, based at the outpatient these narratives. The meaning-making aspect neuro-rehabilitation centre. Helen’s focus as of this piece of work has been in the crea- a counselling psychologist and integrative tion of a narrative of self in relation to Jess’ psychotherapist is to work with the patient illness and our joint understanding of that at (and their therapeutic team) to maximise the recovery stage represented in this article. their wellbeing, using evidence-based What follows are some of the themes and practice such as Acceptance and Commit- reflections that arose during our interviews: ment Therapy (ACT) and systemic therapy. In the therapeutic space, she works with The point when… I knew that I needed patients exploring issues such as adjusting a bit of extra help, even though I didn’t to living with a chronic health condition, really want to… changes in family relationships, impact of Jess had been attending treatment at the stress around medical or surgical interven- outpatient neuro-rehabilitation facility for tions, loss of confidence and issues around about two months when she realised that appearance or visible/invisible difference. ‘I had got into a really horribly dark place’. Helen’s theoretical framework has a central Working several times a week with her physi- focus on attachment theory, trauma and otherapist (PT) and occupational therapist developmental disruption with an existen- (OT), she had been making progress and tial underpinning, essential when working was still well engaged in her therapeutic in the healthcare sector with the key tasks goals, but both therapists noticed indepen- of adaptation, adjusting to loss and reaching dently that Jess was increasingly less chatty, an understanding of an evolving embodied although ‘usually a bubbly person’. As Jess identity.

2 It has been hard to find similarly collaboratively written articles in the neuro-rehabilitation or even health- care sector, though it is a growing area within the field of narrative therapy research (Denborough, 2008; Young & Cooper, 2008). The DCP publication The Child and Family Clinical Psychology Review, No. 6 Autumn 2018 also focuses on participatory practice with all the articles written in collaboration with children, young people and families engaged in the projects.

44 Psychotherapy Section Review 65, Winter 2020 How did I get here? A narrative exploration of arriving at talking therapy in a neuro-rehabilitation setting

One of the challenges for Jess’s outpatient or speech and language therapy where the team who were keen to involve psycho- concentration is around specific goals, e.g. logical services, seeing Jess ‘as less bubbly ‘I have to work on a muscle group, I have and now beginning to voice her difficul- to stretch my arm’. Instead, talking therapy ties around adjustment to her injury, mainly offers a space where it might be possible to fatigue management and relationships in the hold in mind what Yalom (2008) describes as family’, was that Jess ‘already had preconcep- the ‘four ultimate concerns – death, isolation, tions of psychology.’ She had had a strongly meaning in life and freedom’, all apposite negative previous experience which, under- for the patient recovering from a healthcare standably, made her feel considerably less crisis. By ensuring that these concerns are like reaching out for help now. As Jess says, also attended to as part of the overall treat- ‘I had a psychologist in a previous in-patient ment process, there is a huge benefit to the setting, and I didn’t get anything out of it the more necessarily agenda-driven aspects because I was so like het up, and it was done of healthcare. This ‘different kind of conver- in a personal space, in my hospital room, so sation’ with its curiosity and focus on process I felt like I could never escape…’ as well as content, within an engaged and Although Jess recognised that ‘a lot was safe working therapeutic alliance, can shed spilling out into my OT sessions’ and that light on each stage of rehabilitation, with it might be a good idea to seek professional multiple intra and interpersonal levels of counselling help and not just rely on her tension, fear, celebration and negotiation. PT and OT, she was extremely nervous and Jess’ OT had allowed a bit more space resistant about going to see a psychologist, ‘a chatty kind of environment, where even just for the one-off initial session I’m doing a lot of work but also, a chance to suggested by her OT. ‘I’m really not sure chat, so we’d chat about how my home life is, how it’s going to go, like I don’t know if how I’m getting on, what I’m progressing in’. I’m going to feel comfortable…’ It was in OT that Jess first felt able to share The anxiety that Jess was experiencing some of the anxiety and low mood symptoms at the time of coming to therapy proved that she was experiencing: ‘I would get to a considerable barrier to getting help for a point where I would like have a few tears how she was feeling, plus the sense of stigma rolling down my face and then, as I got more around ‘not being able to cope’. With comfortable, here, I started getting more a natural coping style of ‘I would always be and more open with my OT about how I was like, oh I’ll be fine, I’ll be fine, and I’m very feeling, and things like that.’ Other signs much like that…’, Jess reflected that ‘it took were feeling less motivated, more withdrawn a lot for me to kind of, be like, oh maybe from friends and the sense of needing to I actually do need to see someone and try ‘put a mask on’ around them, and an intense it out…’. Her OT remembers that ‘initially sense of feeling ‘different’ – both visibly and Jess really wasn’t keen and then after a while, inside as a result of all her experiences in the a few weeks later, it got to a point where she last six months. sort of said, OK I think I need it now’. One of the major signs that talking to a psychological professional might help was How this ‘different kind of that Jess felt ‘like I was…I was making a lot conversation’ might fit in with the rest of progress here at the time when I first of rehabilitation … started seeing you and… on the whole, like One of the interesting aspects of talking I was making loads and loads of progress in therapy is that it is a rare space in rehab but my mind wasn’t, so I felt like… a rehabilitation schedule where there are like I was making good progress in my body fewer explicit goals as such. This is in contrast but I was still really really upset and down to physiotherapy or occupational therapy about it’ – making sense of that discon-

Psychotherapy Section Review 65, Winter 2020 45 Jess Walling & Helen Molden nection became an increasingly important a post to friends and family from the time theme with her OT and PT and led to the running up to making the decision to come idea that discussing these feelings in more to therapy reflects the growing themes of detail might help. fragmentation of self, vulnerability and fear of being a burden to family and friends. It reads: ‘I was like so close to being on my feet again and I think driving was a new thing I was ‘The past few days I haven’t been good at all exploring so like I think the whole stigma and I haven’t been stable enough to be on my around it was…I was getting a lot better own, every night I have had a breakdown myself, in my body, but not in my self.’ and left my mum to pick up the pieces which isn’t fair, but every night I can’t sleep because Jess also recalls the beginning of a post she I’m scared that if I shut my eyes and start to made on social media that feels important to relax I’ll go backwards and lose something I’ve record here as part of reflecting on the decision fought so hard to get. I keep a happy smiley process of considering talking therapy: ‘Today face on to all of my family and friends and someone asked me how I get through everything very rarely do I drop it but on Wednesday two that’s happened? I smiled and laughed and very important people in my life saw it drop said that you just have to keep going, when the for the first time and I was mortified that reality is I’m not, I put on a face for everyone, someone had seen my weakness and seen that I say I’m doing really well when in actual fact I’m not OK and I’m not happy. It made me feel I’m broken inside...The reality of being para- like a failure. And while I know they’re there lysed at the age of 19 isn’t pretty…’ always to support me I never in a million years wanted them to hear some of the things I was Could this be the right time ‘to open the saying, I didn’t want them to see me give up!’ box …?’ One of the key themes we talked about when Despite her fears about what therapy might Jess first came was the idea of Jess not wanting evoke, looking back, there was a sense that to be a ‘burden, on my family…if that’s the six months after the initial shock of the right term for it’. We explored the process injury, the timing might be right for Jess: of how worry, guilt and anxiety might be being held and transferred between family ‘I remember the night before, I was really really members ‘I would shove it all on them, then upset and I was like I really don’t know how feel really relaxed but then my parents would I’m going to cope, I don’t want to dip into the be like, oh my god, she’s really worried about box of how it all happened, and things like that, this, and this and this…My sister would be and I think you have to …to come to something like, I don’t need this, like I don’t need to be like this, you have to be at the right stage.’ worrying, like as much as she was…’ Deciding to come to therapy was some- At interview, we reflected on how it can be thing that Jess talked about with her mum, hard to get a sense of when it might feel OK especially as she was frightened that it would for you to talk to someone in more detail: be a negative experience and potentially feel intrusive as it was in hospital. ‘I remember ‘In the second hospital I feel like I was still very just before I came to see you I was very very… fresh and new. It must have been about four nervous and I was saying to my mum, like months in, so I feel like I’d …I don’t think I cried the night before to my mum, and I’d come to terms with it properly and things I was like I don’t know if I am going to be like that so I think to come to something like able to do it…’ this you have to be in the right, in the right Jess also explored some of her feelings frame of mind to do it.’ and thoughts by posting on social media, so

46 Psychotherapy Section Review 65, Winter 2020 How did I get here? A narrative exploration of arriving at talking therapy in a neuro-rehabilitation setting

As a psychologist at assessment working that establishing trust within a relational alongside the medical model, Helen dynamic was important from this first session: recalls holding the tension of assessment Jess commented that ‘I wasn’t just speaking, form-filling, questionnaires and the more I was speaking to someone. I wasn’t just formal pieces at that first session, but recog- letting all my emotions… babble out of nising more than that the importance of my mouth, like, I, we were actually having sitting with Jess and her story so far. Jess a conversation…’ arrived at the first session in considerable Elton-Wilson (1996) draws a distinction distress: tearful, not sleeping well, in pain between the three main ways that a client from tension in her body, particularly around might arrive at the start of talking therapy: her neck, concerns over her diminishing in crisis, visiting (i.e. testing out the process) weight and expressing ‘dark thoughts’ which or ready to engage, and how important it is made her anxious. From a risk assessment for the therapist to gather a sense of this at perspective, it was key to try and gain an assessment. There was the sense of Jess being understanding as to how Jess understood life at a good time to connect in talking therapy, now, what areas caused her the most distress ready to engage and prepared to look at and her ideas for moving forward. aspects of the distress she was feeling even This included building up a picture of though it felt painful and difficult to do so, Jess’ life both before her condition devel- as opposed to her initial experience which oped, and gaining an understanding of the felt, for Jess to be too soon, and in hospital, immediate issues at this first session: a sense somehow, too intrusive. of hopelessness, fear and uncertainty around Even in the first session, Jess felt that diagnosis, exhaustion from recovery journey she moved from ‘being really reserved and so far and loss of embodied status as a young I think it was about ten minutes towards the woman at university as before. Working end I really like started blurting it out, and together to name and acknowledge some oh I wish I had more time, like I remember of the emotions that appeared to be envel- that, because I started getting more and oping Jess at this point felt very important, more comfortable and maybe this could even at this early stage in building our thera- actually benefit me.’ peutic working alliance. The risk was that by doing so Jess might not have come back for How starting talking therapy began to a second session, but the risk for not doing make a difference, changing things in so was that Helen would not be offering my rehabilitation treatment and beyond a safe, transparent therapeutic space. So reflecting on coming to talking therapy, Jess believes it has helped in several ways: The moment when it felt like talking Firstly, that she has a better awareness of therapy might be ok … anxious thoughts and how she can deal with Jess explains that one of the central pieces for them – that she has some degree of control, her in being able to talk through things with a space between the thought or feeling that Helen was the emerging sense of trust that at first seemed overwhelming… was established between them even from the first session. From a clinical perspective Helen ‘I think I just, I worry about everything and made sure that she paid careful attention to I work myself up about everything, and I still aspects of the working alliance such as pace, do now but I’ve learnt how to control it… so tone of voice, cadence and the non-verbal I think…its definitely helped…that I’m not… body language and affect regulation. like…het up about everything now.’ Reflecting on some of the things that contributed to this sense of it being a safe ‘I feel because I came here and I was speaking place and space to work together, it was clear about everything and like yeah I’d cry and

Psychotherapy Section Review 65, Winter 2020 47 Author name

be upset but I feel like, then it would just be need someone to talk to that’s like, that’s like, out…I was getting out all of these emotions understands it, you can always speak to me, which was then helping my body because and things like that, so I think…its opened up I wasn’t being so het up.’ a lot of doors.’

We discussed a bit more what ‘being het up’ ‘It took me a while before I could openly speak meant for Jess: about it but I feel like I’m in a better place for it…definitely in my head, I mean before ‘I was like working myself up about everything I didn’t want to wake up in the mornings, and like, and like…oh I don’t know, like I wanted to stay in bed, and I still get like that everything, it was becoming too much and but I know it’s not because of the depression I was getting really like…I was getting a lot and anxiety, it’s because I’m lazy..(laughs) of tension headaches and like holding a lot but like it’s that whole things like…to be able of tension in my upper body because I was to come to terms with it, and I feel like I have getting so worked up about everything …so.. to make a joke out of things, so to come to terms yeah I think all the emotions were just building with me being in a wheelchair, I make jokes inside of me. And like, het up is like when you out of it, and I feel like I now have to be open want to say stuff and you wanna get stuff out about it for people to understand, so for me but you feel like you can’t.’ to be like, yeah I have these, and I’m seeking help for it, and I feel like people now look at What this has meant is that Jess’ physio- me and are maybe she is having an off day, therapy and OT has improved also: maybe I should just ask her if she’s alright? Just to check and let her know that I’m here if ‘I feel like, like definitely coming here has you need her, so I think being open about it, meant that my progress has got better because has definitely helped.’ I’m not, …I’m not like holding a lot of things in. I’m really open now, like…to you I will say Reflection and learning points anything, like I feel like that will help me, and Aside from posts on social media to family it helps my recovery ‘cos I’m not shutting away and friends, this is the first time that Jess has from it, I’m not just putting it to the back of spoken explicitly, and publicly, about the my head.’ mental health challenges she has faced at this stage in her recovery. As co-authors, we have And crucially, she is suffering less physical had continual discussions throughout the pain from the tension that she was holding process of writing, pulling apart the tensions in her body much of the time. over the different issues that could cause And the key point is that Jess has been a dilemma in how Jess’s voice might best be able to start a conversation, a dialogue in heard e.g. whether to waive anonymity and many areas that previous felt difficult to do the impact of the existing therapeutic rela- so, whether that is with her treatment team, tionship, dynamics of difference and power. friends, workplace colleagues or family: In offering her experience to readers, Jess has decided it is important for her to ‘I really think that if I hadn’t have come to claim that experience as her own, rather talking therapy, I’d be very closed off and than the more usual route of an anonymised I wouldn’t, …I would kind of be in denial case study. Jess’s primary reason for doing so that I have mental health issues, but now is so that other young people facing similar I’m very open and I can speak to anyone about challenges will be able to take something it, and a lot of my friends have actually come from this account. Unfortunately, it is not to me and have been like, I have depression, the case that every young person is offered I have a lot of anxiety, like if you need, if you the chance to access talking therapy from

48 Psychotherapy Section Review 65, Winter 2020 How did I get here? A narrative exploration of arriving at talking therapy in a neuro-rehabilitation setting a psychologist or counsellor who special- ■ Social media might be useful for updating ises in neurological conditions or even the friends and family – the responses were adjustment process in living with a long-term positive and gave me a bit of encourage- health condition. ment, but it does mean a lot of people are We are grateful to the experienced clini- constantly wanting to know everything. cians acknowledged below who have helped ■ Asking for help is not a defeat! It us in this collaborative process, thinking doesn’t mean you are weak, a lot of the through the important points around these time I was just scared of talking. issues, and for a more detailed discussion ■ Use apps that work for you – together around research-based practice, waiving we searched and found a number of anonymity and empowerment, we recom- different calming, and anxiety based mend the work of Anne Grinyer writing on apps that were really useful. her experience interviewing cancer patients ■ Talking in therapy is new and scary but (2001, 2002). once you get going it gets easier. ■ Lastly, crying is inevitable, embrace it! From Helen’s perspective as a researcher- practitioner, it has been a unique opportu- Jess says that she feels ‘very fortunate to nity to reflect, discuss and look back over be offered therapy when I did as I was in a therapeutic interaction with the patient a very dark place. Having a good connec- themselves, and the treatment team – a highly tion with Helen helped massively, she was unusual occurrence in her clinical work. Helen calming and asked questions that prompted offers outpatient consultations both at the responses that I was too scared to otherwise neuro-rehabilitation centre where she met Jess, say.’ Jess’s experience backs up the evidence and separately, in the NHS as senior counsel- that it is less the therapeutic approach or ling psychologist for a paediatric psychology modality that is paramount, but the fit of service, where she is also attached to the paedi- the therapeutic relationship that counts. atric diabetes MDT. In the NHS, Helen works (Norcross, 2002), a point emphasised by with children and young people living with Cook et al. (2017) in their recent review a wide range of physical health conditions and of the various factors associated with the their families, taking general referrals from the optimal implementation and application of paediatricians. Through individual sessions evidence-based psychotherapies. or group workshops, Helen uses a collaborative As both patients (and Helen as approach, informed by an integrative model a psychologist working in the NHS), we rooted in the developmental, narrative and feel that improving access to mental health systemic approaches. The use of metaphor and services, empowering the patient and their creative ways of working, inspired by the young families and integrating this support with our person, is central to Helen’s way of working, physical health services is important. This e.g. the creation of diabetes Jenga game, at is something that will affect all of us either a workshop with eight children recently diag- personally as a patient or someone that we nosed with Type 1 diabetes. love, at some point throughout our lifetime. Writing this article is another part of the Concluding thoughts process of Jess having her voice heard, with So, in conclusion, we would like to highlight the basic integrity of her story and position the following around the referral process, as as an expert of knowledge, her experience Jess explains in her own words: of this neuro-rehabilitation process, and ■ Trust is key, finding someone you are has given her a greater sense of empower- comfortable around allows you to be ment around it, for her, and we hope, for open and honest especially at the begin- others – practitioners and patients – through ning of the process. increasing understanding and exposition.

Psychotherapy Section Review 65, Winter 2020 49 Author name

We would like to finish this article with and worried for my future and everything a final quote from Jess’ social media post that’s being thrown at me! Finally, if you’ve around the time of first starting therapy … read all of this I give you a huge round of applause because I probably would’ve stopped ‘The point of this post is to tell myself it’s ok to at the first paragraph.’ cry it’s ok to feel like you’ve lost yourself and everything around you but I have to allow Ms Jess Walling, Expert by Experience myself time, I can’t just click my fingers and [email protected] it all be normal again, it’s a long road ahead and while at the moment there’s more sad Dr Helen Molden, HCPC registered and days than happy, it will start to pick up and Chartered Counselling Psychologist, & Inte- I have to start finding myself again and doing grative Psychotherapist. things that make me really happy rather than [email protected] thinking of the what ifs start think of the what can I do? And the truth is if I want it I will With particular thanks to Dr Stephen Weath- get it even if I have to fight tooth and nail erhead, Senior Academic and Clinical Tutor, I never nor would I ever give up on something University of Liverpool, Consultant Clinical I love! …So next time you ask how do you Psychologist and Dr Philippa Braithwaite, do it and stay so positive? You know I’m not Clinical Psychologist in Neuropsychology, and even though I’ll still laugh back at you Hobbs Rehabilitation, and Dr Susanne and say anyone would do it if they were in my Robbins, Carpe Diem Psychology Services position you know that deep down I’m scared for their help and discussion for this article.

References Bruner, J. (1990). Acts of meaning. Cambridge: Murphy, K. & Gilbert, M. (2000). A systematic inte- Harvard University Press. grative relational model for counselling and Clarkson, P. (2003). The therapeutic relationship, 2nd psychotherapy. In S. Palmer & R. Woolfe (Eds.) edition. London: Whurr Publishers. Integrative and eclectic counselling in psychotherapy. Cook, S.C., Schwartz, A.C. & Kaslow, N.J. (2017). London: Sage Publications Ltd. Evidence-based psychotherapy: Advantages and Norcross, J.C. (2002). Psychotherapy relationships that challenges. Neurotherapeutics: the Journal of the work: Therapist contributions and responsiveness to American Society for Experimental NeuroTherapeutics, patients’ needs. New York: OUP. 14(3), 537–545. Sontag, S. (1978). Illness as metaphor. New York: Denborough, D. (2008). Collective narrative practice: Farrar, Straus and Giroux. Responding to individuals, groups and communities Weingarten, K. (1991). The discourses of intimacy: who have experienced trauma. Adelaide: Dulwich Adding a social constructionist and feminist view. Centre. Family Process, 30, 285–305. Elton-Wilson, J. (1996). Time conscious therapy, a life Weingarten, K. & Weingarten Worthen, M. (1997). stage to go through. London: Routledge. A narrative approach to understanding the Griffiths, J. & Griffiths, M.E. (1994).The body speaks. illness experience of a mother and a daughter. New York: Basic Books. Families, Systems & Health, 15(1), 41–54. Grinyer, A. (2002). The anonymity of research Yalom, I.D. (2008). Staring at the sun: Overcoming the participants: Assumptions, ethics and practicali- dread of death. Carlton North, Vic: Scribe Publica- ties, Issue 36, Social Research Update, Spring 2002, tions University of Surrey. Young, K. & Cooper, S. (2008). Toward co-composing an Grinyer A. (2002). Cancer in young adults: through evidence-base: the narrative therapy re-visiting. parents’ eyes. Buckingham: Open University Press. Grinyer A. (2001). Ethical dilemmas in nonclinical health research. Nursing Ethics, 8(2), 123–132.

50 Psychotherapy Section Review 65, Winter 2020 Part two: Collaboration between clinicians and researchers

Editor’s introduction OT ALL UK therapists are likely to designed to show that the gap can be bridged know about the International Society and that clinicians find this worth-while. Nfor Psychotherapy Research. Research The study reported had the intention of is a valuable resource if it focuses on the prob- triggering further collaborations, and the lems to which the research can be sensibly book review is followed by reports on some applied. As each client brings specific prob- achievements of the first year after the work lems it is not surprising that generalisations was completed. This further report was put from research may seem unwieldy, clinicians together very kindly and at speed by the turn to more experienced colleagues when authors of the reviewed book, on request of in difficulty, and research and application the Editor, who reviews the book below. seem to belong to different universes. There One of the three authors, Professor are very active members of this international Larry Beutler was twice President of the USA Society in countries throughout the world, Chapter of the Society for Psychotherapy with a UK Chapter whose current President Research and his co-authors are very distin- is Dr Felicitas Roth, based at UCL. I plan to guished researchers with books well-known invite her to contribute to future issues of in the field of psychotherapy. the Review, and to have a regular ‘Research The BPS Psychotherapy Section may have Section’. an advantage in promoting the use of research Research can illuminate processes by clinicians, so avoiding re-inventing the between therapist and client in a very direct wheel. Many of our members will have way – for instance, research on impasses and first degrees in psychology, and so look to how to manage these. I suspect that many research as one part of their armoury. I invite therapists lose touch with current develop- ideas as to how we could make dissemina- ments which would be valuable to them. tion of research findings more systematic, I believe that members of this Psychotherapy perhaps through our regulatory bodies, as Section could put our heads together and Professor Beutler has recently suggested, via devise a way of making research findings an editorial research committee. alive for therapists and so beneficial for clients too. We will explore this in future Jeremy D. Safran Ph.D., J. Christopher Muran Ph.D Issues. & Alexandra Shaker M.A. Research on Thera- peutic Impasses and Ruptures in the Therapeutic This section starts with a book review. Alliance, Contemporary Psychoanalysis, 50: 1-2, The book reports on an impeccable 211-232, Link: http://dx.doi.org/10.1080/0010 research study into collaboration between 75.30.2014.880318 clinicians and researchers in the USA,

Psychotherapy Section Review 65, Winter 2020 51 Book review

Principles of Change: How Psychotherapists Implement Research in Practice Louis Castonguay, Michael J. Constantino and Larry E. Beutler (Eds.) Oxford University Press (2019). Reviewed by Erica Brostoff

This is an exceptional guide to how clini- cians can use findings from psychotherapy research, in a rich and challenging format, It is striking endeavour to demonstrate that should be in every training institute and how expert clinicians can apply change prin- in handy reach for practising clinicians. ciples to client needs that are very commonly Clinicians have often claimed that they feel encountered, with commentaries that can be sidelined by psychotherapy researchers, not returned to again and again, for thoughtful easily able to set their own research agenda, reflection. The value of this volume lies and presented with piecemeal findings that in the individual voices of the therapists are not easy to apply in a real-life setting. This from different theoretical traditions, illus- book describes a direct two-way collaboration trating that each clinician brings a different between researchers and clinicians, aimed at emphasis to the principles as they are system- changing this potential impasse. atically presented. The format gives each UK clinicians may not be aware that there clinician their individual voice in a cascade is an international Society for Psychotherapy of reflection on their own and other thera- Research, with a UK chapter of well-known pists’ approach to the use of the principles, researchers in this field. The origin of the with a commentary by the researchers on the Society was in the USA. In this volume, three clinicians’ differences and similarities. of the leading USA researchers, each with Clinicians and researchers summarise numerous studies to their credit, have set out by proposing how their experience of this to answer the divide between clinicians and project could feed into training, especially, researchers, giving clinicians their voice in for example, in emphasising the impor- an unusual challenge. tance of learning how to build and maintain The format of the book describes clini- a therapeutic alliance with clients from the cians’ use of research findings relating to first session, which clinicians felt was crucial five categories of change principles: Client and not adequately taught. The ability to prognostic principles, client moderating be flexible in applying principles was also principles that influence intervention effi- judged likely to be the hallmark of expert cacy, client process principles – behaviours clinicians, also a skill that could be learned. that facilitate or interfere with improve- Clinicians and researchers were tempted by ment, therapy relationship principles, and the future challenge of determining the key therapist intervention principles. Clinicians characteristics of the most effective thera- regarded as exemplars by their peers, were pists, the ultimate question, and whether asked to apply these principles to standard- these characteristics can be taught. ised case histories of six notional clients, This volume is encyclopaedic in providing each with a presenting profile of depression examples of how principles of change can or anxiety – with or without substance abuse be put to work by clinicians of varying alle- or personality disorder. giances. It is a step towards more direct

52 Psychotherapy Section Review 65, Winter 2020 Book review collaboration between researchers and The aims of this volume are elegantly clinicians, and as Beutler et al. are quoted, expressed and the interactions between ‘Scientists may be missing important avenues clinicians and researchers are deeply consid- for critical areas of research. They may do ered, as are clinicians’ reflections on each a better scientific job if they were more atten- other’s work. Properly used, this masterly tive to the writing and ideas of their clinical study could point towards a more dynamic colleagues.’ and self-critical approach to practice by both Although the authors do not specif- researchers and clinicians, and a needed ically draw attention to this, in the final move away from complacency and ostrich section entitled ‘Harvesting the fruits of tendencies among clinicians, researchers, clinician-researcher collaboration and training institutes and professional bodies. planting the seeds for new partnership’, The range of thought and experi- the bibliography relates to a wide range ence shared here, perhaps deserves more of mental health care settings, to private generous page space, as the material is practice, administration and policy, super- tightly presented, but against this there is vision, college counselling, psychotherapy, the benefit of much. consulting and clinical and counselling psychology, psychiatry and the study of clients’ experience of psychotherapy.

Psychotherapy Section Review 65, Winter 2020 53 Principles of Change (Castonguay, Constantino & Beutler, 2019) A brief review of progress in its first year Larry E. Beutler, Louis G. Castonguay & Michael Constantino

INCE psychotherapy’s inception, many approach to psychotherapy (and one that theorists have articulated different does not facilitate theoretical biases or foster Sideas about the specific strategies that an oversimplistic ‘what works best’ attitude)? promote therapeutic change. Such theories We set out to answer these questions in our have often evolved from older theories, with book, Principles of Change. various degrees of adjustments and adapta- Principles of Change is the sequel to Princi- tions, in the service of improving how we ples of Therapeutic Change that Work (Caston- predict and understand patient improve- guay & Beutler, 2006). In these volumes we ment. With the perpetual pushing of osten- extract from extant research theoretically sibly new ideas forward, there soon became cross-cutting principles of change that have a distinct theory for every treatment and indeed reached the aforementioned critical a hundred different nuances for every theory. mass of replications. We then proposed that One could argue that such a ‘Tower of Babel’ therapists’ action be guided by these empir- full of theories has stunted the field’s ability ical principles in lieu of, or as enhancements to mature as a science and to communicate to, a psychotherapist’s preferred theoret- effectively around evidence-based practices. ical change model. Whereas the original But what if theory proliferation could be Castonguay and Beutler volume primarily reduced? Also, what if instead of looking to catalogued the range of empirically based prior theoretical explications to find princi- change principles, the current volume had ples that can guide clinical practice, we were two objectives: (1) as indicated in an updated to look directly and primarily at our rich literature review, we aimed to consolidate body research findings? Instead of asking and reduce the 61 principles obtained in ‘What theory is the closest to truth?’ what the first volume, and (2) we examined the if we instead asked, ‘What knowledge can translatability (or lack thereof) of the revised be extracted from the amassed research to list of principles as applied by experienced, identify theory-common, or agnostic, “prin- front-line psychotherapists. ciples” that can serve to empirically ground The success of the first objective is our practice?’ Moreover, what if we circum- readily apparent. Owing to either insuffi- vented theoretical jargon for a moment and cient evidence or insufficient distinction, we simply sought to identify patient, therapist, reduced/consolidated the total number of dyadic, and contextual factors that explain principles from 61 to 38. For the second variance in patients’ personally relevant and more forward-looking objective of treatment outcomes? Finally, what if we this book, we recruited six clinicians who could then translate such findings, once were widely recognised for their work with they reach a critical mass of replication and depressed and anxious patients, and who trustworthiness, into a fully principle-based used a range of theory-based practices.

54 Psychotherapy Section Review 65, Winter 2020 Principles of Change – A brief review of progress in its first year

We explored with them how they would the same book written by an expert clinician approach their work with several carefully (Dr Dina Vivian) who participated in the crafted fictional patients presenting with writing of the book. The chapter assigned primary symptoms of depression or anxiety, to students in this phase described in detail and varied secondary problems (e.g. prob- how Dr Vivian implements the 38 empiri- lematic substance use). After reviewing the cally based principles of change in her daily case, the therapist authors offered insights clinical practice. In the third phase, partici- and helpful critique into their potential use pants attended a three hours workshop given of the empirical principles of change. by Dr Vivian, during which she expanded on Of course, these considerations are her implementation of principles of change. only of substantive value if they continue to Finally, in the fourth phase, the partici- predict patients’ outcomes beyond therapists pants took part in weekly supervision relying on their theory alone. Over the past meetings with Dr Vivian, meetings which year, we each have continued to evaluate the focused on helping students to work with principles and to determine their impact. their respective clinical cases based on Dr Acknowledging our separate interests, our Vivian’s integration of the same principles of differing contexts, and the diverse places in change. Before each of these phases, partici- which we work, we summarise here just a few pants were asked to fill out a questionnaire of these relevant efforts over the past year about their expectations with regard to (and since the publication of Principles). both the helpfulness and feasibility of the specific modality of training. Participants Castonguay were also asked to fill out a questionnaire During the past year, a training study at the end of each phase regarding if and directly based on the process of training how they perceived these respective phases clinicians to use the principles described in to be helpful and feasible. With the data Principles (Castonguay et al., 2019) has been collection having just been completed, both conducted at the Pennsylvania State Univer- quantitative and qualitative analyses will be sity. This study has taken place in the Depart- conducted during the next several months ment of Psychology Training Clinic, which in order to address several questions such is a Practice-Research Network created to as: Are all phases of training necessary and/ simultaneously meet the clinical, training, or helpful? Are some phases more helpful and research needs of students in the Adult than others? Are some modalities of training Clinical Doctoral Program (see Castonguay, more easily implemented then others? What Pincus, McAleavey, 2015, for description). could be done to increase both the feasi- As a pilot, ongoing investigation, the goal bility and helpfulness of each of the training of this study is to assess the potential helpful- modality? ness and feasibility of different modalities of training based on principles of change. Constantino Specifically, participants recruited from Dr Constantino has published both empir- graduate students seeing clients at the clinic ical and conceptual papers on topics were asked to participate in four distinct addressed in the book. As just a few exam- phases of training, the duration of each of ples, he has tested, at the dyadic level, asso- them being approximately three weeks. In ciations among patient outcome expectation the first phase, the participants were asked (OE), patient-therapist alliance quality, and to read, as frequently as they see fit, the list patient outcomes, demonstrating not only of 38 empirically based principles that was that OE predicts outcome (replication), published in Castonguay et al., (2019). but also that alliance quality is a candidate In the second phase, the participants mechanism through which it does so (repli- were asked to read one of the six chapters in cation and extension). Moreover, this

Psychotherapy Section Review 65, Winter 2020 55 Larry E. Beutler, Louis G. Castonguay & Michael Constantino research showed a partner effect, meaning The focus of the most recent study that when patients had higher OE at one followed two groups of student therapists, session, it results in greater therapist-rated each group being identified as working alliance at subsequent sessions (extension either with one of the supervisors who to dyad-level process-outcome associations). was trained in principle-based supervision Dr Constantino has also examined empiri- (SAS) or one who provided supervision as cally the principle of therapist attunement to usual (SAU). Those SAS supervisors focused patient OE and its association with outcome, supervision on teaching eight empirically demonstrating that higher convergence in derived principles as developed in the ratings of patient and therapist OE over time preliminary study described earlier. All SAU promoted greater subsequent improvement. trainees were yoked by entry date to patients Conceptually, Dr Constantino has published entering treatment in the clinic. Incoming articles or chapters on evidence-based thera- patients were assigned on rotation schedule pist responsivity to disruptive clinical process to either an SAS or SAU and a therapist who and context-responsive psychotherapy inte- was supervised by that supervisor. Supervi- gration as applied to cognitive-behavioral sion was conducted in a group format. In therapy. Both of these reports draw heavily SAU groups, supervision as usual focused on principles discussed in the Principles of on the advice, theory, and preferences of Change book. the supervisor. SAS trainee volunteers were Beutler’s research group has been stud- assigned to a participating SAS supervisor ying what we consider to be very critical who had been trained to follow a weekly relationships in understanding the roles of (either 8 week or 16 week) protocol by which principle-based psychotherapy. Thus, histori- to teach eight principles extracted from an cally, our research has been on the rela- early draft of Principles of Change. Supervi- tionship between utilising a principle-based sion included a sequence of introducing therapy and treatment efficacy. We’ve accu- one principle per week and then practicing mulate nearly a half dozen randomised trial a method for introducing it in the coming research studies and a similar number of week. Subsequent sessions followed up on studies using alternative designs. The results the assignments. have been positive in demonstrating the The eight principles, themselves, value-added role played following a set of followed a protocol that introduced principles. What has been missing in these a sequence paralleling therapy processes studies is evidence of training effects. Our described in the book. Thus, one principle most recent studies have attempted to was aimed at adapting to patient impairment address this omission. levels (a prognostic factor), three principles In a preliminary study designed to develop focused on establishing and maintaining and pilot test a clinical supervision model for a solid therapeutic relationship (relation- teaching the principles described in Principles ship principles). Two principles emphasised of Change (Holt et al., 2015). Using a replicated moderating processes by which treatment N = 1 research design, we had demonstrated could be tailored to the client. One of these that doctoral trainees in clinical psychology addressed patient receptivity vs resistance obtained better results among mixed outpa- (moderating principles). The other prin- tients when they had been systematically ciple addressed the patient’s method of trained in the use of several of the principles. coping with conflict (a moderating prin- We followed this study with one based on ciple). Finally, the last principle directed comparison groups that we will describe in the therapist to respond differentially to the the following paragraphs. A third study using patient’s stage of readiness (a prognostic different (random) assignment procedures is principle). still in process. As expected, patients whose therapists

56 Psychotherapy Section Review 65, Winter 2020 Principles of Change – A brief review of progress in its first year were trained using STS principles (SAS) between the two groups over time. Further- showed significantly greater symptom reduc- more, the length of treatment (8 versus 16 tion than those whose therapists were super- weeks) did not have a significant impact on vised in the usual manner (SAU). A large treatment outcomes. effect size (d = .62, 95% CI [.05, 1.18]) existed

References Stein, M, Beutler, L.E., Kimpara, S. Haug, N. Someah, Coyne, A.E., Constantino, M.J., Gaines, A.N., Laws, K, Edwards, C. & Macias, S. (in press). Casting H.B., Westra, H.A. & Antony, M.M. (in press). and Advocacy Model of Training Helpers: The association between therapist attunement to Principle-Based Supervision in a training clinic to patient outcome expectation and worry reduc- strengthen health and well-being. In A. DiFabio tion in two therapies for generalized anxiety (Ed.). Psychology of sustinability in organizations: disorder. Journal of Counseling Psychology. new perspectives for healthy business, harmonization Constantino, M.J., Goodwin, B.J., Muir, H.J., Coyne, and decent work. New York: Springer Publishers. A.E. & Boswell, J.F. (in press). Context- respon- Constantino, M.J., Aviram, A., Coyne, A.E. et al. sive psychotherapy integration as applied to (2020). Dyadic, longitudinal associations among cognitive-behavioral therapy. In J.C. Watson & patient-therapist outcome expectation and H. Wiseman (Eds.) The responsive psychotherapist: alliance quality, and their indirect effects on Attuning to clients in the moment. American Psycho- patient outcome: A within- and between-dyad logical Association. analysis. Journal of Counseling Psychology, 67(1), Castonguay, L.G., Pincus, A.L. & McAleavey, 40-50https://doi.org/10.1037/cou0000364 A.A. (2015). Practice-Research Network in Constantino, M.J., Coyne, A.E. & Muir, H.J. (2020). a psychology training clinic: Building an infra- Evidence-based therapist responsivity to disrup- structure to foster early attachment to the tive clinical process. Cognitive and Behavioral Prac- scientific-practitioner model.Psychotherapy tice. Advance online publication. https://doi. Research, 25, 52–66. org/10.1016/j.cbpra.2020.01.003 Holt, H., Beutler, L.E., Kimpara, S. et al. (2015). Evidence-Based Supervision: Tracking Outcome and Teaching Principles of Change in Clinical Supervision to Bring Science to Integrative Prac- tice, Psychotherapy, 52, 185–189.

Psychotherapy Section Review 65, Winter 2020 57 Note: Principles of Change – A brief review of progress in its first year

Note for this developing our techniques through Dr Beutler fully retired from academic and learning from one another, and recognising clinical practice in 2018 and is no longer resistances in therapists as well as clients. actively involved in developing new research These ideas are far from new, yet the clini- programmes. The research reported above cians feel they are not put into action espe- has been carried out by past students and cially at the crucial training stage. The Review collaborating faculty who are pursuing will pursue these topics in the future Issue themes of the collaboration. on Improving Therapy and Avoiding Harm. Future issues of the Review will contain This research shows that direct collabo- a dedicated research section. Clinicians are ration between clinicians and researchers invited to suggest topics on which they would can be a big step forward professionally. like past or future research reports. Research is not the first port of call for most clinicians, who prefer to turn to more experi- Conclusions from the above summaries enced colleagues when in difficulty. But with This section reports on the learning from closer contact, clinicians could give voice to a major USA research study with outcomes their direct concerns and invite researchers pointing to the key importance of: to explore these issues. This could be 1. Training that teaches how to build an productive in broader and more system- alliance with clients from the first session. atic understanding of difficult moments in 2. Delivering treatments flexibly, whether psychotherapy, as well as in understanding in therapy or in other mental health ‘moments of meeting’, and the vital but services. potentially neglected elements in training that prepare for these events. This surely comes down to adjusting tech- nique and theory to meet the needs of the client in the room, making mental space

58 Psychotherapy Section Review 65, Winter 2020 Part three: Collaborative opportunities to network between readers and contributors Book review on to how, through linking in to our reward Conscience: The origins of moral intuition system neurology, values and social norms Patricia S Churchill. and expectations evolved, giving us expecta- New York, W. W. Norton, 2019. tions of fairness and honesty, and an inter- Reviewed by Steve Heigham nalised sense of conscience. Interestingly, on this point, she shows that individual level Ostensibly this is a book about how neurosci- differences in these traits shape personality, ence can help us understand moral matters and that strength of reaction to frightening that have exercised philosophers for centu- or disgusting stimuli correlate highly with ries; after all the author is the founder of political allegiances, which research shows to the emerging field of Neuro-philosophy. be also fairly highly heritable. However, viewed from the perspective of the In the final section, the author history of ideas, this is another tome in the relates much of the experimental and growing field of cultural evolutionary studies neuro-scientific research presented so far, to that are increasingly explaining the present the many ways that philosophers have, over situation of mankind and the many difficul- the ages, tried to conceptualise morality. Her ties we face in the modern era. In this case it overall conclusion is that rule bound theories is by explaining the many genetic and epige- of morality that try to explain moral behav- netic mechanisms that have evolved to give iour as universal principles, though they us a sense of right and wrong, and how these have been invaluable in developing legal have manifested in different epochs and in frameworks that are acceptable across whole different cultures. societies, they are too narrow to explain The first part of the book examines how we actually behave. Instead, looking what research has shown about the origins at the complex interplay between instincts, of our hard-wired instincts to care about habits, and highly evolved problem-solving others, which arose in the transition from skills give a more realistic picture; in this she reptiles to mammals. The author then goes advises the reader to be skeptical of policies on to explore the rapid development of the that try to enforce arbitrary, universal, ideo- Prefrontal Cortex as the organising super- logically based moral positions in society. structure that has enabled us and higher This is a good book for practicing primates to coordinate impulses of percep- psychologists – counselling, clinical and tion, memory, thought and emotion in forensic, as it helps explain how very flexible complex sequences of action that pursue people’s extension of empathy is, and how our main life agendas through cooperation changeable their adherence to moral behav- and competition, in the highly social world iour patterns. It also helps us to understand we have lived in for the past several million why these matters can so greatly vary across years. cultures and eras, which is important for The author examines in great detail the taking cultural and sub-cultural influences actions of Oxytocin, Vasopressin and other into account in our work with clients. neurotransmitters to explain how these have evolved and given us such flexibility in our behaviour, developing our capacity to learn massively from the environment. This leads

Psychotherapy Section Review 65, Winter 2020 59 Music and (narrative) psychology: A literature review Ghislaine T.M. Regout

Previous research has shown that music can have a positive influence on mood, and memory, and a positive effect on learning and shaping of identity, as well as the treatment of mood disorders, and dementia, has also been found. Consequently music may be of use during therapy. This review explores these effects and discusses possible implementation of music in various forms of psychotherapy. Consequences for these findings, and possible future research, is discussed.

HETHER it is relaxing after a long 2019). Meanwhile, another report published day at work by listening to your in 2018, pointed ‘how research has shown Wfavourite singer, going emotionally a positive effect of music therapy on the ‘back in time’ to your awkward teenage years reduction of dementia-related symptoms by after getting your favourite song of that time delaying the early onset, but only 5% of the stuck in your head, or wondering how it is care homes using the therapy effectively’ possible to get that tune ‘stuck in your head’ (The Guardian, January 18, 2018). Assuming in the first place; even for lay people it will it is true that music has an impact on a wide probably not come as a surprise that music range of topics such as memory, learning, can have a profound influence on everyday and self-esteem, it might be of interest to life. Previous research supports this state- study how this particular form of art can ment, and often suggest studying the role of have a positive influence on individuals, and music in relation to psychology, has clinical how it can be used in therapy. After all, relevance to psychologists working in various previous research has shown that memory, settings, such as schools and clinics. However, for example, can be impaired in various there is much debate concerning the role of psychological illnesses, such as dementia – music within these aforementioned profes- in which the patients struggle with severe sional settings To give an example: there is memory loss, depression, and anxiety – currently an ongoing discussion concerning patients often struggling with remembering the lack of proper music education within the negative far more easily than the positive schools, or the lack of funding for art- in both mood disorders. If music influences and music therapy within clinical settings. memory – and if so, how? – how could it be Earlier this year, The Guardian reported used when memory is impaired? (Thayer et that ‘A School music report revealed cuts, al., 1994). If music can boost self-esteem, inequality and demoralized teachers’ (The like the teachers in the aforementioned Guardian, April 2, 2019). According to the article claim, how can this positive effect be newspaper, music lessons were in danger of harnessed in therapy for those who struggle becoming accessible only to those who could with confidence issues? One relevant field afford it, and even were seen as a luxury, not of research is music psychology, which a necessity. The teachers, however, point out focuses on how to describe the patterns of how music lessons could not only encourage musical development. Some of the research creativity, but also boost confidence, and discussed in this review will address subjects support learning, making the lessons crucial that fall under this category (Clarke, Dibben for the curriculum (The Guardian, April 2, & Pitts, 2010). However, this review will

60 Psychotherapy Section Review 65, Winter 2020 Music and (narrative) psychology: A literature review concentrate on a wider range of topics, such that music came first in the ‘chicken-or- as how music is processed in the brain, and the-egg’-like debate, is the fact that in music how this knowledge can be applied in prac- processing, evolutionarily older parts of tice – showing that studying music in relation the brain are involved. To be more precise, to psychology can be applied in various ways. the amygdala, a part of the brain that plays a key role in emotion, also plays a role in Music and the brain music processing. Previous research has Due to the technological progress made in suggested that this involvement ensures that neurological research, previous studies have music often ‘feels’ more emotional to us shed a light on how the brain processes than general speech (Storr, 1992), which music, which in turn explains the influ- might explain partially why one can feel ence this artform has on various cognitive an emotional bond with a specific piece of functions. Previous research has shown that music. Furthermore, previous research also listening to music involves various neuronal showed neuronal connections between the patterns, and the different aspects of musical amygdala and the nucleus accumbus, as well processing recruit almost all regions of the as the cerebellum; if music triggers emotion, brain (Overy, 2009). The neurological effect the nucleus accumbus releases dopamine of music, is unlike any other stimulus or in the pleasure centre of the brain, and the cognitive process, therefore. Listening to cerebellum triggers movement. This leads music starts at the eardrum, before sounds to liking a certain piece of music, and move- get segregated by pitch. Then, speech ment to its beat. and music are separated to be processed The final function that plays a large individually. The speech circuits analyse role in the enjoyment of music, is memory the signal to study and process individual (Sacks, 2007). Previous research has shown vowels and consonants, whereas the music that culture dictates how music “should” circuit decomposes the signal and analyses sound like. When one is exposed to the timbre, pitch, contour and rhythm. The music of its culture multiple times, memory hippocampus and temporal lobe, mean- schemas are built by the brain for musical while, are involved to check whether there is elements such as genre, song arrangements, a relevant memory that can help to process and melody. In turn, these schemas are this signal. Emotion is interconnected in the used for musical processing; after sound process as well (Levetin, 2006). Listening to has entered the eardrum, the hippocampus music automatically triggers memory, and and temporal lobe are triggered to analyse memory triggers emotion. Due to the role the current soundwave and match it with that both play in various mental illnesses, an earlier memory of a similar soundwave and the therapeutic process, this article will (Levetin, 2006). As a result, there is a certain take a closer look at these functions specifi- expectation of how music should sound cally – and how music could help to counter like, and when hearing a certain note, there impairments (Levetin, 2006; Sacks, 2007). is also an instinctive prediction of which Music, Memory, and Emotion tone will come next in a specific melody, As discussed previously, music and speech a phenomenon called musical expectancy. are analysed separately in the brain, and However, previous research has also shown there has been scientific debate regarding that – to an extent – there is a stronger the origins of this evolutionary development. neuronal response and dopamine release It is still unknown whether music developed when that next note does not match with first as a way of communication, which lead its prediction, and the musical schemas are to speech, or music came as a consequence edited as a result; the brain likes the surprise, of the development of speech (Storr,1992). is rewarded with a dopamine release, and One powerful argument for those who claim is motivated to trigger this response again,

Psychotherapy Section Review 65, Winter 2020 61 Ghislaine T.M. Regout which leads to seeking out more music. (Clarke, Dibbens & Pitts, 2010). Consequently, Nevertheless, the pleasure received from previous research has shown multiple exam- listening to music that does not match the ples in which music in combination with memory schemas, is limited; while hearing repeated exposure, influenced knowledge new music is rewarded by the dopamine and memory. Musical expectancy, for instance, release, and certain genres are known for involves implicit, unconscious knowledge, as drawing highly loyal fans due to having well as learning through (repeated) exposure. learned ‘how to listen to it’- such as jazz or Previous research focusing on the music of the heavy metal – listeners do tend to prefer Aboriginal Tribes in Australia, for example, music of their own culture (Storr, 1992). have shown that the children of the tribe This is most prevalent when the differences become familiar with ‘their’ music at a young between western, eastern and Arabic music age, which shows you literally learn to listen are studied; due to using different musical (Hallam, Cross & Thaut, 2011). Additionally, notations, not all notes exist within the nota- research has shown that people who have tions, and notes that sound common to learned how to master an instrument, have one listener, may sound off-key to another. a larger portion of the brain dedicated to fine (Western music notation is developed by finger movement. When you learn how to the Gregorian chorales during the Middle play an instrument, you therefore train your Ages, and is heavily influenced by the Cath- brain since playing music involves complex olic church, which therefore explains why motor skills, which are repeated often due to non-Christian cultures tend to work with practice (Clarke et al., 2010). Examples like different notations.) Besides culture, it is these might explain why the teachers in the a matter of personal taste – depending on introduction claim that music can be bene- the memory schemas of the individuals – ficial for memory and learning due to the which music triggers the release of dopa- repeated practice and exposure that music mine, and is liked. lessons offer. Moreover, previous research also The neuronal links between the nucleus showed that musical memory schema’s, and accumbus (pleasure), the hippocampus implicit memory in general, is relatively spared (memory), and amygdala (emotion) have in several types of dementia, including Alzhei- various consequences that are relevant for both mers’ disease (Bowell & Bamford, 2018). This psychological research, and practice. After all, leads to a strong focus on the effect of music songs that matches the memory schemas to on dementia, due to the way memory processes a certain extent is more easily remembered, music. This research will briefly pay attention and therefore can more easily trigger an to this topic later on. emotional response, be it positive or nega- tive. One example is the so-called ‘earworm’, Music, emotion and identity the phenomenon of getting a song stuck in Arguably the biggest role that music can your head. Research has shown that getting play in relation to psychology, however, is a tune stuck in your head, a commonly expe- tied to self-development, once again due rienced intrusive thought, can occur when an to the triggering of emotion, pleasure, and environmental cue is encountered (Hyman memory. During the age in which person- et al., 2013). While it is still unclear why this ality is shaped, adolescence, music can have phenomenon exists, it is often used to study a far-reaching impact. In adolescence, the memory as a whole. A second example is brain develops rapidly, and due to these the use of music in learning, since both are developments, adolescents often are most strongly tied to (emotional) memory. The open to new experience, and create fresh body of knowledge concerning learning and memories as a result. After all, adolescence how humans learn in general, has grown into is the time in which many people experi- a field of research, called musical psychology ence the most important life-events, such as

62 Psychotherapy Section Review 65, Winter 2020 Music and (narrative) psychology: A literature review falling in love for the first time, discovering of musical therapy, can help the listener who they are as a person, and consider who to understand his/her own emotions better they want to be as they grow up. These (Hesmondhalgh, 2013). Previous research developments are not only tied to the rapid states that since music can imitate/reflect, changes in the brain during this particular arouse, and express emotions, it helps us to period, but are also commonly experienced self-reflect, which might be another reason as highly emotional, due to the develop- why making music is such a well-loved way ment of the amygdala (Levetin, 2006). The to spend one’s time (Hesmondhalgh, 2013). brain connects the music heard during the This point is supported by DeNora (2013), creation of those emotional new memo- who has suggested as well that music can ries, to the (neurological) developments create conditions that are conductive to well- themselves. Consequently, the music heard being. These conditions are created because during those hectic times, is tied to the this particular form of art ‘can communicate cognitive and emotional development that directly to the listener – with or without takes part during adolescence. This can have needing language, can create a sense of far reaching consequences: even years later, togetherness and is often seen as medicinal’ hearing the music loved during adolescence (DeNora, 2013). Sustained musical practice can trigger strong memories immediately. can even contribute to a better quality of Moreover, since music can trigger strong life, it can afford narrative and foster the emotion, the artform itself is often used as aforementioned mood regulation, and so a tool when adolescents start to define them- consolidate identity. selves in terms of individual personality, and Previous research has shown that music who they view as peers. Consequently, the and the development of identity are inter- taste of music can influence membership connected in various ways, due to the role of of a certain social clique, the selection of memory and emotion in music-processing, friends and romantic partners, hobbies and so can influence the way an individual sees interests, the clothes bought and worn – himself, and the world around him. Previous regardless if school uniforms are mandatory research has also shown that several psycho- or not – and how one presents him- or herself logical disorders, like mood disorders and to the world (DeNora, 2000). Due to the dementia, often distort these factors. Previ- selection of a certain social group based on ously, it has been outlined how music could musical taste, and the importance the social be used as a tool in treatment for those group places on that music as a whole, the disorders as well. In fact, some of those individual listener, obtains even more posi- evidence-based treatments are already in tive experiences in which a specific type of use; COMET, a manualised treatment based music is tied to. In other words; the brain ties on Cognitive Behavioural Therapy (Korrel- music that is heard during the developments boom, 2011) that can be used in the treat- during adolescence to those developments ment of low self-esteem and depression, themselves, ensuring a link between musical is a known example. Nevertheless, further taste, emotional experience, and identity. research is needed in order to discover how Due to seeking out others with a similar taste, music can be properly implemented in any this link is consolidated further, ensuring other therapy besides music therapy. a strong emotional connection with a certain piece of music. Additionally, due to recog- Music and the daily practice nising the emotion the music tries to convey Nevertheless, what is known is that previous due to musical expectancy, a listener might research has suggested that studying the experience an ‘interaction’ between himself effect of music can be beneficial for therapy, and the music (Hallam et al., 2011). This since it can influence one of its key ingredi- interaction, which is also a fundamental part ents; emotion (Sacks, 2007). Since music can

Psychotherapy Section Review 65, Winter 2020 63 Ghislaine T.M. Regout conjure emotion, its effect on mood regula- accompanies depression, based on Cognitive tion has been demonstrated multiple times. Behavioural Therapy (Korrelboom, 2011). To give a short overview; Erber, Therriault The therapy is created especially for those and Wegner (1996) found that listening to who are aware they have an unrealistically either sad or happy music can influence low point of view of themselves, but struggle participants to prefer materials incongruent to gain more perspective. By using methods with their mood, in order to restore how rooted in CBT, the client learns how to pay they felt before listening to the music. In more attention to the positive aspects of a study focusing on which methods are most their personality. Korrelboom (2011) points effective when trying to change a bad mood out that often, people who seek help for (Thayer et al., 1994), listening to music was problems related to mood-regulation, be it considered by the participants to be one of depression, anxiety, eating disorders or other the most successful strategies to cheer you illnesses, also struggle with low self-esteem, up, reduce tension, and get more energy. and even if those aforementioned problems Moreover, research by Wang, Kulkarni, are treated, the low self-esteem remains. In Dolev and Kain (2002), Nilsson (2008) and that case, COMET, which consists of helping Knight and Rickard (2008) all suggested that clients to pay more attention to the good music can lessen anxiety, for example the qualities they have, might help. Further- pre-operative anxiety patients struggle with more, the training helps clients to chal- as they mentally prepare themselves for the lenge the negative thoughts they might have operation. Interestingly enough, not only about themselves. As a result, the clients the perceived anxiety decreased when the learn how to embrace the qualities they patients heard music, they also experienced already know they have, but do not truly less pain. Due to results like these, models feel yet, and become more critical of their (Saarikallio & Erkkila, 2007) and question- presumed negative qualities (Korrelboom, naires (Saarikallio, 2008) have been created 2011). According to the manual, there are to explain and measure the influence of five steps in the programme, which contains music on mood regulation. Lastly, Brotons, several homework assignments. One of those Chapin and Koger (1999) have suggested crucial homework assignments, especially that music/music therapy in general can handpicked due to its ability to conjure have a highly significant positive effect. emotion, so that the clients do not only Unfortunately, Brotons, Chapin and Koger know there is nothing wrong with them, but (1999) have also stated that it is not always also feel it…is music (Korrelboom, 2011). clear which factors within music therapy can In the assignment, the client has to select have a positive effect. They did discover that music that symbolises their positive charac- the therapy as a whole has a general positive teristics, makes them feel empowered about effect on dementia, and both mood disor- themselves, and helps them remember the ders (depression and anxiety). However, due moments in which their negative thoughts to the lack of clarity regarding which specific were contradicted. During the session, the factors within music therapy help and why, clients are taught to remind themselves of more research on this subject is advised. those characteristics, while listening to the selected music, which leads to a link between Music as a tool in treatment the music, and the positive thoughts and In other cases, previous research focusing memories, helping them to get the perspec- on how to understand the effects of music, tive needed. Also, they are advised to listen and how to properly implement it in to the music whenever they struggle with therapy, was more successful. One example the aforementioned low self-esteem, and is COMET-training, a manualised treatment other negative thoughts. Various studies used to treat the low self-esteem that usually to prove its effectiveness showed that the

64 Psychotherapy Section Review 65, Winter 2020 Music and (narrative) psychology: A literature review

COMET method improved the self-esteem to connect with the client on a deeper level. of the participants (Korrelboom, De Jong, In fact, even Nathalie Rogers, daughter of Huijbrechts & Daanen, 2009; Korrelboom, Carl, suggested using art in order to help Marissen & Van Assendelft, 2011). These clients discuss difficult emotions (1993). results not only underline the effect music Later on, Gladding et al. (2008) studied can have on mood regulation, or the role how song lyrics selected by the client could music can play in defining one’s own view be used in therapy. In research focusing of him or herself, it also showed that music on grief, the study showed that editing or can be implemented successfully as a tool rewriting pre-existing lyrics to fit their own used in therapy, due to its effect on memory, situation better, provoked an even stronger learning, and mood regulation. emotional response, which then would help Naturally, the clients who might benefit expression of grief. Also, the researchers from the COMET training discussed above, suggested using song lyrics as coping skills struggle with how they view themselves and by constructing a helpful playlist in order to their place in the world, but this training motivate clients and discussing the emotional is not the only form of therapy with a focus effect of those songs in the therapy session. on how the self and identity are defined. Meanwhile, Sawyer and Williams (2011) Another example of a therapy that has the conducted a pilot study in order to research way someone views himself or herself and the effect of digital storytelling (using multi- his/her life story as its focal point, is narra- media when telling a story) and music lyrics tive therapy (Vassilieva, 2016). Narrative on self-reflection, within a secondary school therapy is a psychotherapeutic approach context. The 30 adolescent participants had based on the theory that people construct to create a story on positive coping strate- stories about themselves in order to give gies, and socially appropriate behavior. The meaning to life. Psychological problems are participants specifically chose songs that seen as the consequences of constructing conveyed the tone and emotion in their problematic narratives, and the purpose of stories, and the results showed that mixing therapy is to help the client narrate their life narrative and music seemed a powerful way stories in a healthier way. Previous research for the teens to express themselves. These by Lopes, Concalves, Machado, Sinai, Bento results suggest that using music as a tool and Salgado (2014) suggested Narrative in Narrative Therapy can have a positive Therapy as an alternative option for CBT in effect on mood disorders like depression, the treatment of moderate depression. The helping the client express him or herself. results showed that both CBT and Narra- However, future research is needed to study tive Therapy were effective, but Narrative this hypothesis further, and to ensure an Therapy seemed to be more effective for evidence-based method is created, and prop- those who dropped out of CBT-treatment. erly implemented. Further evidence that If NT focuses on how a client narrates his seems to suggest that using music as a tool in or her own life story and forms his or her order to narrate a life story, is the Soundtrack own identity, and music also plays a role in To My Life (STML)-method used in dementia defining that same identity, using music as treatment. In order to study the effectiveness a tool in Narrative Psychology, might not of the treatment Subramaniam and Woods be a far-fetched theory. However, future (2016) asked six participants to create their research is needed to study this hypothesis. life story, using Windows Moviemaker. The Previous research sounds promising; a study story was divided into six segments; child- by DeDiego (2013) for example suggested hood, teenage life, career, mid-life, retire- that using song lyrics in counselling might ment, and current time, and materials be effective, mentioning the long history of included the narration of their story, as well using prerecorded music in therapy in order as the original book used, favorite songs,

Psychotherapy Section Review 65, Winter 2020 65 Ghislaine T.M. Regout photographs, and background music. The and partially emotion, are impaired. In fact, results showed that the project helped to there are therapeutic methods already in trigger memories in participants who strug- use that use music in a constructive way, gled with Alzheimers’ disease. Moreover, it such as COMET, a CBT-based training also improved their mood. Based on these focused on improving low self-esteem that results, The Utely Foundation has recom- often accompanies depression, as well as mended further research and implementa- other disorders. Possible implementation tion of therapy using music – as well as music of music in other forms of therapy, such therapy – in dementia care settings (Bowell as Narrative (Psycho)Therapy, is discussed. & Bamford, 2018). However, future research is needed in order to gain more knowledge of the effectiveness Discussion of music within a therapeutic setting, and Previous research has suggested that music to ensure professional implementation. In can have a positive influence on mental the studies mentioned, participant groups wellbeing, and therefore using it as a tool were often small, and there was not always within a therapeutic setting, could be benefi- a control group. As a result, statistically cial (Sacks, 2007). The aim of the current stronger research is recommended. This study was to further research why music recommendation is in line with the report has a positive influence, and how it could of The Utely Foundation (2018), which also be properly implemented within therapy. pointed out that lack of funding in various Previous research has shown that the amyg- settings, such as care homes and the NHS, is dala, hippocampus, and nucleus accumbus, another hurdle relevant to this topic. Mean- among others, are actively involved in the while, similar problems are mentioned when neurological processing of music, ensuring discussing positive effects of music (lessons) that music can have an effect on emotion, within therapy catering to children and memory, and the experience of pleasure young adults in a school setting. Hopefully, (Levetin, 2006). Consequently, music is used the current study, as well as others, shows in order to consolidate one’s own identity, that music in relation to therapy deserves to and that as part of a specific cultural group be studied in greater depth. (Storr, 1992), as well as playing a role in memory training/learning. Due to these Ghislaine T.M. Regout effects, it has been suggested that music could be a helpful tool for therapists when treating The author invites readers to form various disorders such as mood disorders – a collaborative network on the use of music in which emotion, and partially memory is in psychotherapy. impaired, and dementia – in which memory,

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66 Psychotherapy Section Review 65, Winter 2020 Music and (narrative) psychology: A literature review

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Sacks, O. (2007). Musicophilia. Amsterdam: Uiter- Vassilieva, A. (2016). Narrative psychology: Identity, geverij Meulenhoff. transformation and ethics. Kindle Edition: Palgrave Scherder, E. (2017). Singing in the brain. Amsterdam: Macmillan. Atheneaeum – Polak & van Gennep. Van de Winckel, A., Feys, H. & De Weerd, W. (2002). Storr, A. (1992). Music and the mind. London: Harper Cognitive and behavioural effects of music-based Collins. exercises of patients with dementia. Clinical Reha- Sung, H.C.C. & Chang, A.M. (2005). Use of preferred bilitation,18, 253–260. music to decrease agitated behaviours in older Wang, S.M., Kulkarni, L., Dolev, J. & Kain, Z.N. people with dementia: A review of the literature. (2002). Music and preoperative anxiety: Journal of Clinical Nursing, 14(9), 1133–1140. A randomised controlled study. Ambulatory Anaes- Svansdottir, H.B. & Snaedal, J. (2006). Music therapy thesia, 94, 1489–1494. in moderate and severe dementia of Alzhei- mer’s type: a case-control study. International Psychogeriatrics, 18(4), 613–621. Thayer, R.E., Newman, R. & McClain, T.M. (1994). Self-regulation of mood: strategies for changing a bad mood, raising energy, and reducing tension. Journal of Personality and Social Psychology, 67(5), 910–925.

68 Psychotherapy Section Review 65, Winter 2020 A commentary on the history of science and simplistic concepts which contribute to the treatment of clients’ ‘problems’, rather than the clients’ ‘life experience’ Mind-forged manacles1 2: Science and practice Sheelagh Strawbridge

Ideas in this article are a development of those in Strawbridge (2016).

N MY previous article (Strawbridge, 2019) When I first studied psychology there was I explored some aspects of ideological a strong emphasis on its status as a science. Icontrol that we can be caught up in as prac- With ‘A’ levels in biological sciences and titioners. That article considered how we can having trained as a science teacher I enrolled be implicated in depoliticising psychological on my degree in psychology in 1966. I had distress by working with models that fore- a strong, if naïve, belief in the power of ground the individual and which can divert science and an attraction to psychology influ- attention from its socio-political contexts. enced by my reading of Skinner, as a science I referred to Adlam’s approach to ‘eating capable of improving human society through distress’, conceptualising it in the context behavioural engineering. This was reinforced of social practices, as one example of a way in the very first lecture in which psychology of challenging the category of a ‘disorder’. was described as the ‘science of behaviour’ (Adlam, 2018) I want here to continue this and Freud dismissed in a sentence as unsci- exploration of ideological control by focusing entific. Subjective experience was not yet on the particularly narrow model of scien- considered amenable to scientific study by tific knowledge and evidence-based practice mainstream psychology which was very much that dominates the provision of therapeutic ‘rats and stats’. Despite some disillusionment services through the policy of ‘managed and a developing interest in the history and care’. As there is already a good deal of criti- philosophy of science, ethics and political cism of this policy, I want to focus here on activism, I stayed the course and graduated questions concerning the nature of science in 1969 with a BSc. Others graduated with and its relation to practice. I am conscious BAs, a distinction determined by ‘A’ levels of trying to link a range of ideas within rather than the university course, though, a complex matrix, but I hope my attempt as the promotion of psychology’s scientific to sketch a broad picture can contribute to credentials affected its funding, it was impor- ongoing debates and conflicts by placing our tant for it to be linked with a Faculty of own struggles in a wider context of current Science. socio-political issues. This potted personal history seems rele-

1 In his poem ‘London’ William Blake coins the term ‘mind-forged manacles’ to indicate how the dominant ideology of a society shores up its power structure by obscuring the awareness of oppression.

Psychotherapy Section Review 65, Winter 2020 69 Sheelagh Strawbridge vant because, despite all that has happened its most dangerous ‘science’ can be elevated in our discipline since the sixties, we are into the model of rationality itself, bestowing struggling again with the same issues in legitimacy over and above all other domains relation to the nature and establishment of of knowledge including politics, the arts and scientific credentials. This is reinforced by ethics – which was for a time viewed purely some tendencies within psychology and, in as emotional expression not amenable to the field of psychotherapy, NICE’s narrow rational argument (see e.g. Ayer, 1934). As version of evidence-based practice. All the Midgely (1992) argues, science can function work to establish a human science perspective as ‘a myth of salvation’ when seen as the on the exploration of subjective experience key to solving all our problems. It seems by qualitative methods and the legitimation important to question this image of science of psychotherapy and counselling as genuine that is widely taken for granted. psychological practices is being pushed aside The notion of science emerged histori- in favour of a technical-rational definition cally, in the seventeenth century, and chal- of ‘scientific’ research deemed to set the lenged the prevailing religious word-view. ‘gold-standard’. As I was, in the sixties, prac- The universe was imagined as a giant titioners are required to oversimplify the clockwork mechanism, at first seen as put richly complex ways in which we encounter, in motion by God, though in more secular experience, understand and interact with times divine intervention is no longer ourselves, others and the wider social and invoked. This guiding mechanistic metaphor natural worlds we inhabit. favoured a technical-rational approach to Within this reductive frame, understanding the natural and social worlds. socio-political issues are redefined as indi- The power of science and technology would vidual ‘mental health’ problems to be drive social progress, improving human addressed by a formulaic approach domi- life by combating disease, famine and nated by a simplistic application of CBT and other social ills. It is not difficult to see why social protest is discounted or even criminal- claiming scientific status became important ised. Cognitive behavioural engineering is for psychology as it emerged as a distinct very much alive, not only as championed by discipline. Layard, but in increasingly sophisticated and Central to this vision of science was the disturbing forms (see e.g. Davies, 2015). All aim to understand the complex phenomena of this helps to construct and legitimise the of reality in terms of their most fundamental ‘mind-forged manacles’ of the individual- elements and unifying principles across the izing neo-liberal ideology dominating the sciences were sought. ‘Higher level’ expla- West. nations, such as those of biology, were As noted above, managed care in considered to be ultimately reducible to general, and in particular, the IAPT model, ‘lower level’ explanations, with the laws of has been widely critiqued, Dalal’s (2019 a & physics seen as the most fundamental, and b) analyses being amongst the most detailed the search was for the basic components of and telling. Therefore, I want to ask a more matter by empirical methods. Some of the general question about how we understand most successful scientific ideas of the nine- the nature of science itself and its relation teenth and twentieth centuries were inspired to practice. Science is complex. It is not by this powerful idea. For example, it under- value-free but value-full, observations are pinned the spectacular developments in shaped by theories and it is a social activity. molecular biology arising from the discovery It implies an ethical stance in relation to of the structure of DNA (Watson, [1953] evidence and truth, but it is also culturally 2012) and Crick declared the ultimate aim situated. It can perform an ideological func- was the explanation of all biology ‘in terms tion and is prone to political influence. At of the level below it, and so on right down

70 Psychotherapy Section Review 65, Winter 2020 Mind-forged manacles 2: Science and practice to the atomic level’ leading to ‘a great influx biotics. Losing sight of the systems within of physicists and chemists into biology’. which a problem is embedded is blinkered ([1966] 2004: 14) More recently Dawkins has and can be disastrous on many levels. In described us as survival machines for DNA psychology the behavioural and the later molecules, ([1976] 2006: 21–22) and has cognitive-behavioural models fit the mech- evoked the clockwork image of the universe anistic vision well, as do some neuropsy- through his metaphor of a ‘blind watch- chological approaches to understanding maker’ ([1986] 2006). Mapping the human consciousness. In our own areas of profes- genome has been one of the triumphs of sional practice it has led to individualising this approach. The achievements inspired socio-political issues into a virtual epidemic by this mechanistic image of the universe of personal ‘mental health’ problems and and the reductionist drive to discover its the imposition of formulaic systems of fundamental building blocks and unify the managed care. sciences are not to be underestimated. As well as questioning reductionism, This conception of science has, never- studies in the philosophy, history and theless, generated intractable problems and sociology of science have also undermined raises persisting questions about the limits the notion of a unifying ‘scientific method’. of our knowledge. For example: There are Science can no longer be conceived as unitary unresolved tensions between determinism and socially detached but as characterised by and moral responsibility, dependent on diversity and embedded in communities of free-will, as well as between consciousness scientists guided by shared conceptual maps. and material reality (Velmans, 2009). The These may remain stable for long periods realisation that experience is inseparable but can undergo significant shifts. Chalmers from techniques and instruments of observa- (1999) usefully introduces differing concep- tion (including telescopes, MRI scanners and tions of science, continuing controver- the Large Hadron Collider) and is ordered sies and key thinkers including Popper, and made intelligible through conceptual Kuhn, Lakatos, Feyerabend and Foucault. maps, challenges naïve notions of objectivity. We can no longer think in terms of an The image of a stable clockwork mechanism all-encompassing ‘modern’ world-view with requires modification in the light of theories rationality defined within a hierarchically of evolution and thermodynamics. Notions ordered but unified science. It now seems of matter, space and time are rendered prob- appropriate to think more modestly, in lematic by theories of electromagnetic fields, plural terms, of the sciences, alongside relativity, subatomic particles and quantum other disciplines including the humanities, mechanics. as charting important domains of knowl- Moreover, this view of science involves edge and inquiry. Sciences, such as molec- isolating specific problems to analyse and ular biology, chemistry, ecology, quantum solve, which is also problematic. Whilst mechanics and climatology, map particular breaking down complexity for the purpose domains of inquiry with sometimes radically of analysis can be effective, whether it be the different guiding metaphors and metaphys- anatomy of a plant, human liver function, ical assumptions. Their research methods, the mutations of a virus, the structure of the theories and explanations are generated and atom or a person’s psychological distress, it maintained within the discourses of their can result in unforeseen and unintended respective scientific communities. This is consequences for interconnected natural recognised by the ‘Human Mind Project’, and social systems. For example, the wide- School of Advanced Studies, University of spread use of plastics has caused enormous London, launched (2013) and resonates problems as has the large-scale use of ferti- with Serres’ (1995) contention that no lisers in agriculture and the overuse of anti- domain is sole arbiter of reason. He sees it as

Psychotherapy Section Review 65, Winter 2020 71 Sheelagh Strawbridge the job of philosophy to negotiate channels elled widely collecting specimens, making of communication between the sciences and detailed observations, finding connections humanities. (and see Brown, 2002). everywhere and arguing that no single fact Despite all the questions the could be considered in isolation. He viewed technical-rational vision of science still the natural and human worlds as funda- exerts ideological power. Some historians mentally relational, linking together plants, of ideas have linked it to the Promethean animals, climate, geography, agriculture, myth of a masculine hero, who, in his quest politics and economy. Seeing the environ- for freedom, progress and mastery over the mental devastation of colonial plantations natural world has, ‘constantly striven to differ- and deforestation, he became the first scien- entiate himself from and control the matrix tist to write about human-induced climate out of which he emerged’ (e.g. Tarnas, 2010: change that could have serious conse- 441). Feminist critiques have noted that the quences for future generations. Humboldt language of the technical-rational vision described nature as a ‘web of life’, stressing of science is infused with sexual imagery. the interrelationships vital to the balance of Nature has been imagined as female with the complex system. Together with Schelling knowledge created in a process of interro- and Goethe he adopted an organic rather gation in which she is unveiled, penetrated than a mechanistic metaphor. A mechanism, and forced to reveal her most intimate such as a clock, can be dismantled and reas- secrets. (Merchant, 1983; Harding, 1986). sembled, whereas an organism, such as an Moreover, it has been argued that we ignore animal, cannot. In an organic system it is the latter part of the Promethean myth at the whole that shapes the parts and in this our peril. (Neville, 2012: 32). This tells us he perceived a vulnerability to unbalancing that our liberation from the gods or nature interventions (Wulf, 2016). However, this is illusory. In focusing on resolving specific holistic interdisciplinary perspective became problems, but failing to comprehend the eclipsed by the competing tendency to sepa- complex interactions of whole systems, our rate fields of study into distinct disciplines, technical solutions often cause new prob- often driven by the desire to control nature lems. McGilchrist (2009) has associated this and harness natural resources in the interest reductionist tendency with the increasing of progress. dominance of left-brain mentality in Western There were, nevertheless, still those culture. Whilst resisting an oversimplifica- who perceived the danger in this desire. tion of divided brain theories, he argues In Shelley’s novel Frankenstein, published and presents a wealth of evidence for the in 1818 four years after volume one of increasing bias in Western culture towards the Humboldt’s Personal Narrative, her scientist abstract, analytic and instrumental thinking creates a monster he cannot control. Mellor characteristic of the left hemisphere over the (1989) cites this as highlighting the dangers more contextual, humane, imaginative and of scientific hubris. Jung also warned: holistic perspective of the right hemisphere (and see Rowson & McGilchrist, 2013) ‘our progressiveness, though it may result in Such concerns are not new. Though it a great many delightful wish-fulfilments, piles persists as a dominant vision the mechanistic up an equally gigantic Promethean debt which world view with its motivation of power and has to be paid off from time to time in the form control has been contested from the start. As of hideous catastrophes’. (1980: para. 276) early as the eighteenth century some scien- tists questioned the mechanical model of Current fears and attempts to address nature. Amongst them Humboldt proved the likely devastation of pandemics, the a key figure who became the most famous decreasing effectiveness of antibiotics, and and influential scientist of his time. He trav- the climate crisis, suggest such a debt. In

72 Psychotherapy Section Review 65, Winter 2020 Mind-forged manacles 2: Science and practice the light of these challenges, the organic, ‘the tacit dimension’ and explored many holistic and systemic worldviews of some everyday examples, such as recognising faces natural scientists are becoming more widely and the moods they express, using tools accepted. Indeed, the Promethean myth is and riding a bike. From a different perspec- countered by Lovelock’s alternative myth of tive Kahneman (2011) has added to our Gaia, prefigured by Humboldt, which sees the understanding of the tacit dimension distin- Earth as a self-regulating system unbalanced guishing fast intuitive from slow delibera- by the depredations of humanity. (Lovelock, tive thinking and showing the significance 2006). This is capturing imaginations beyond of the former in making judgements and the confines of ecology and climatology and decisions. Polanyi, was particularly inter- entering political debates advocating sustain- ested in the role of the tacit dimension in ability over exploitation. (see also Capra & scientific discovery. He argued that creative Luisi, 2014 and Foster, 2000) acts are driven by strong personal commit- The nature of ‘science’ is and always has ments, guesses and hunches. Drawing on been contested. However, much of science Merleau-Ponty’s work (e.g. 1945 and 1981), is esoteric and what many scientists actually also Gestalt psychology, he argued that do is incomprehensible to most of us. There- discovery is akin to perception; going from fore, seduced by the technological wonders an awareness of many particulars to grasping it generates, it becomes easy to mythologise their joint meaning in a coherent whole. science into the sole source of our salvation. It involves skilled, imaginative integration We can see this happening in a more limited rather than formal reasoning, and he stressed way in psychotherapy in the grandiose claims the value of dialogue within an open commu- made for managed care which seeks to imple- nity in fostering creativity. Polanyi’s work ment a simplistic notion of evidence-based prefigured that of Kuhn (1962) in pointing practice to solve complex issues. For exam- to the importance of scientific communities ple,‘depression’ and ‘anxiety’ are decon- and Schon draws on it in his discussions on textualised as ‘disorders’ with prescribed reflective practice. ‘treatments’. This grandiosity is underpinned Also following Polanyi, Collins (1985, by the notion that it constitutes a scientific 2013) has led research into the part played by approach based on solid evidence and this is the tacit dimension in science. For example, maintained in the face of extensive criticism. scientists found it impossible to replicate It is not my intention to deny the contribu- building a laser from research papers or tion to practice of well-designed scientific detailed written instructions. Only those who research but to dispute the reduction of were shown how to do it by others who practice to the technological application of already had the experience, were successful. a single model of science. Schon (e.g. 1983) Collins argues that this kind of research has made an important contribution to the suggests two models of learning. One he understanding of practice in a number of terms ‘algorithmical’ which rests on formal fields that shows how limited a view this is. instructions, as in a computer programme. I want to look more closely at science, or the The other he terms ‘enculturational’ which sciences themselves, as forms of practice. he likens to learning a new language or Subsuming practice to science is linked to culture. Enculturational learning requires a tendency to associate knowledge with what personal interaction and guidance, showing can be made explicit. Ryle (1949), however, rather than telling, involving watching, visu- made an important distinction, significant alising and copying bodily movements. In for practice, between ‘knowing that’ and psychology, this relational construction of ‘knowing how’. The latter acknowledges that our shared worlds is perhaps most strongly skilful action reveals that we can know more emphasised in Gestalt theory and practice. than we can tell. Polanyi (1967) termed this So ‘knowing how’ involves knowing more

Psychotherapy Section Review 65, Winter 2020 73 Sheelagh Strawbridge than we can tell in language, and scientists of living systems at all levels of life. (e.g. learn as much from experience and interac- Varela et al., 1993). Strongly influenced tion with colleagues as from formal papers. by Merleau-Ponty’s emphasis on embodi- Learning from experience within ment and the primacy of perception, they a community of practitioners is crucial for see cognition as increasing in complexity acquiring the competence demanded in along with the evolution of sensory organs. complex practice situations of all kinds, This extends the notion of cognition beyond including those of science. This suggests the conscious awareness, recognising the physi- value of the kind of apprenticeship required cality of a whole organism’s learning from in learning any skilled craft. Sennett (2009) interactions with its environment; a brain has explored the tacit dimension in crafts- being one specific, highly-evolved, struc- manship across a wide variety of practices ture through which the process operates. including pottery, musicianship, and medi- Consciousness is conceived as a particular cine. He stresses the intimate connection kind of cognitive process that emerges when between head and hand, ‘the dialogue a sufficient level of complexity is reached. between concrete practices and thinking’ These ideas situate cognition in an evolu- (2009: 9) as well as the importance of guid- tionary context and have opened up new ance by experienced teachers. This emphasis avenues of research in cognitive science. on the embodied nature of skill acquisition, They resonate with Damasio’s (2000) challenges the Cartesian conceptual split notions of ‘core’ and ‘extended’ conscious- between body and mind that has bedevilled ness and suggest a neuroscientific founda- British education. Academic ‘knowing that’, tion for understanding embodied learning is the highly valued province of universi- and unconscious processes. They also seem ties. It is regularly separated from ‘knowing somewhat akin to Rogers’ conception of how’ with arts and crafts in particular being organismic knowing and valuing, which relatively undervalued and often learnt in Neville (2012) links with theories of deep specialised schools or apprenticeships. ecology, whilst Rogers himself (1995) makes Learning the craft of those professional reference to complexity theory and the practices, including psychology, counselling process philosophy of Whitehead ([1927–8] and psychotherapy, that have found their 1985). way into universities, is largely delegated Recognising the tacit dimension then to placements outside the institutions and points to the significance of both embodied often inadequately integrated. learning and direct contact between people. Recognising ‘know how’ also shows how It helps to understand the difficulty in limited is the view of cognition central to being explicit about the crucial interper- cognitive-behavioural psychology and prac- sonal connection between client and prac- tice in linking it too closely with thinking. titioner in psychotherapy, which implies the Systems theory, however, suggests a way possibility of knowing (and communicating) beyond the mind-body split, conceiving mind more than we can tell, and of entering and consciousness as processes not entities. the world of another and relating in ways Bateson (1973) was one of the first to view not amenable to causal explanations or mental processes, such as learning, memory explicit interpretations. Rogers’ humanistic and decision making, as systems phenomena perspective has been central in drawing characteristic of all living organisms, conse- attention to the importance of the thera- quent upon certain level of complexity, but peutic relationship, ‘being-with’ rather than not dependent on brains and highly devel- ‘doing-to’, and Buber’s distinction between oped nervous systems. Maturana and Varela ‘I-It’ and ‘I-Thou’. Stern (2004) too, from have independently proposed a similar a psychoanalytic perspective has explored the theory of cognition as the organising activity profound impact of ‘moments of meeting’as

74 Psychotherapy Section Review 65, Winter 2020 Mind-forged manacles 2: Science and practice distinguished from ‘moments of interpreta- but which has proved difficult to explicate. tion’, whilst Gestalt approaches stress the (e.g. Cozolino, 2006) co-constructed nature of client-therapist I am only too aware of ranging widely perceptions. over what I see as interconnecting issues and Our capacity for knowing from the inside I realise that many threads could be teased as well as the outside is, as recognised in out and pursued in more depth. However, in the human science tradition, a feature of painting in broad brush strokes it has been our common humanity. We are the same my intention to try to gain a more holistic kind of beings as our clients and research perspective for myself as a psychologist, subjects and this is at least as important in a psychotherapist, a citizen of a troubled our work as the understanding that scientific society and an inhabitant of an endangered research can provide. Comparing the heroic planet. It seems important to me to return fictional detective Sherlock Holmes and the to fundamental questions in facing current self-effacing, but equally successful Father challenges posed by the ‘mind-forged Brown, illustrates this well. Holmes is a man manacles’ of a narrowly defined, ideologi- of action, amateur scientist and logician. cally driven notion of science and practice, He is an acute observer who sees from the together with a limited view of cognition. outside, focusing on factual evidence and For psychotherapists, these concepts are employing remarkable powers of deduction. particularly restrictive to those who work In contrast, Brown puts himself imaginatively in medicalised settings delivering managed into the minds of criminals and in discov- care. It is sad to recognise that our parent ering them through his empathy, grounded discipline of psychology, contributes to these in their shared humanity, discovers his difficulties in so far as it fails to resist the own capacity for sin. In disclosing Father domination of this single technical-rational Brown’s secret Chesterton (1981: 461–67) model of science and practice. It seems tells us something about his art as a writer, imperative that as well as examining our own excavating his own experience to enter the individualising therapeutic models, as previ- lives of his characters. Similarly in writing ously discussed (Strawbridge, 2019), we ask about being an actor, Callow says: these broader questions about the nature of science and practice. I believe that drawing ‘To interpret human life requires unending on a range of perspectives may help us resist observation, profound sympathy, wide reading, current constraints, situate our struggles the ability to open yourself to strange and in a wider socio-political context and find unexplored areas of your personality and to ways of contributing to understanding and penetrate deep into the lives of others’ (Callow, addressing both the professional and the 2004: 230). enormous global issues confronting us.

Neuroscience may now be contributing to Sheelagh Strawbridge our understanding of the tacit dimension Chartered Psychologist, Retired Counselling and our capacity for deep empathic connec- Psychologist/Psychotherapist tion in close relationships; the direct under- [email protected] standing that most of us have experienced

Psychotherapy Section Review 65, Winter 2020 75 Sheelagh Strawbridge

References Adlam, J. (2018). Presentation at BPS Psychotherapy McGilchrist, I. (2009). The master and his emissary: The Section Conference: Food: Disorder and wellbeing. divided brain and the making of the Western world. Ayer, A.J. (1934). Language, truth and logic. London: New Haven: Yale University Press. Gollancz. Mellor, A.K. (1989). Mary Shelley: Her life, her fictions, Bateson, G. (1973). Steps to an ecology of mind: Collected her monsters. Abingdon: Routledge. essays in anthropology, psychiatry, evolution and epis- Merchant, C. (1983). The death of nature: Women, temology. St. Albans: Paladin. ecology and the scientific revolution. New York: Brown, S.D. (2002). Michel Serres: Science, transla- Harper and Row. tion and the logic of the parasite. Theory, Culture Merleau-Ponty, M. ([1945] 1981) trans. Smith, C. and Society, 19(3), 1–27. Phenomenology of perception. London: Routledge Callow, S. (2004). Being an actor. London: Vintage. and Kegan Paul. Capra, F. & Luisi, P.L. (2014). The systems view of life: Midgley, M. (1992). Science as salvation: A modern myth A unifying vision. Cambridge: Cambridge Univer- and its meaning. London: Routledge. sity Press. Neville, B. (2012). The life of things: Therapy and the Chalmers, A.E. (1999). What is this thing called science? soul of the world. Ross-on-Wye: PCCS Books. Maidenhead: Open University Press. Polanyi, M. (1967). The tacit dimension. London: Rout- Chesterton, G.K. (1981). The complete Father Brown. ledge and Kegan Paul. London: Penguin. Rogers, C.R. (1995) A way of being. New York: Collins, H.M. (1985). Changing order: Replication and Houghton Mifflin. induction in scientific practice. London: Sage. Rowson, J. & McGilchrist, I. (2013). Divided brain, Collins, H. (2013). Tacit and explicit knowledge. divided world: Why the best part of us struggles to Chicago: Chicago University Press. be heard. RSA Social brain project. http://thersa.org Cozolino, L. (2006). The neuroscience of human rela- Ryle, G. (1949). The concept of mind. London: tionships: Attachment and the developing social brain. Hutcheson. New York: Norton. Schön, D.A. (1985). The reflective practitioner: How Crick, F. ([1966] 2004). Of molecules and men. New professionals think in action. USA: Harper Collins, York: Prometheus Books. Basic Books. Dalal, F. (2019a). CBT: The cognitive-behavioural School of Advanced Study, University of London. tsunami: Managerialism, politics and the corruptions (2013). The human mind project (http:// of science. London: Routledge. humanmind.ac.uk/). Dalal, F. (2019b). How could they? Hyper-rational Sennett, R. (2009) The craftsman. London: Penguin. responsibility and the ethics of managerialism. Serres, M. (1995, trans. James, G. and Nielson, J.) Psychotherapy Section Review, 64, Winter, 81–92. Genesis. Michigan: University of Michigan Press. Damasio, A. (2000). The feeling of what happens: Body, Stern, D.N. (2004). The present moment in psychotherapy emotion and the making of consciousness. London: and everyday life. New York: Norton. Vintage. Strawbridge, S. (2016). Science, craft and professional Davies, W. (2015) The happiness industry: How the values. In B. Douglas, R. Woolfe, S. Strawbridge, government and big business sold us well-being. E. Kasket & V. Galbraith (Eds.) The handbook of London: Verso. counselling psychology (4th edn). London: Sage. Dawkins, R. ([1976] 2006) The selfish gene, 30th edn. Strawbridge, S. (2019). Mind-forged manacles: Social Oxford: Oxford University Press. justice and the politics of psychological distress. Dawkins, R. ([1986] 2006) The blind watchmaker. Psychotherapy Section Review, 63, Spring, 66–71. London: Penguin. Tarnas, R. (2010). The passion of the Western mind: Foster, J. B. (2000) Marx’s ecology: Materialism and Understanding the ideas that have shaped our world nature. New York: Monthly Review Press. view. London: Pimlico. Harding, S. (1986) The science question in feminism. Varela, F.J., Thompson, E. & Rosch, E. (1993). The Milton Keynes: Open University Press. embodied mind: Cognitive science and human experi- Jung, C.G. (1980) Collected works, 9 Part 1: The arche- ence. Cambridge, Mass: MIT Press. types and the collective unconscious, 2nd edn. New Velmans, M. (2009). Understanding consciousness. 2nd York: Princeton University Press. edn. London: Routledge. Lovelock, J. (2006) The revenge of Gaia. London: Allen Watson, J. D. ([1953] 2012). The double helix. London: Lane. Phoenix e-book. Kahneman, D. (2011) Thinking, fast and slow. London: Whitehead, A.N. (1927-8] 1985). Process and reality. Allen Lane, Penguin. New York: The Free Press. Kuhn, T. (1962) The structure of scientific revolutions. Wulf, A. (2016) The invention of nature: The adventures Chicago: University of Chicago Press. of Alexander von Humboldt the lost hero of science. London: John Murray.

76 Psychotherapy Section Review 65, Winter 2020 The past and future of psychiatry and its drugs Joanna Moncrieff

From the Editor: This following article pointing towards non-drug treatments in psychiatry and describing a Norwegian intervention recently put into law, is reminiscent of an initiative by the Quaker movement, such as the York Retreat and other creativity-based rehabilitation approaches: so that the preferred treatment might over time come round in a circle to client-based, rather than drug-based treatments and healing environments.

AM DELIGHTED to be able to contribute are much more subtle. An interesting prop- to this issue on my work. It has provided erty of mind-altering substances is that Ia useful stimulus to think about what people are not always able to appreciate or my ideas about drug treatment mean for communicate the changes they experience the future of psychiatry, and more broadly while they are under the influence of the for the care of people classified as having drug. In David Healy’s fascinating study of ‘mental health problems’. the effects of droperidol in volunteers, for example, people were only able to describe The implications of theories of drug the complex emotional and cognitive altera- action tions they had experienced after the effects My theory of drug action is obvious and unde- of the drug had worn off (Healy & Farquhar, niable on the one hand, but on the other 1998). it is profoundly challenging to mainstream The characteristic ways in which drugs psychiatry and its assumptions about the like neuroleptics change normal thinking, nature of mental disorder and how it should emotion and behaviour were welcomed by be treated. It is not possible to deny that the psychiatrists who first prescribed them, psychiatric drugs cause mental and physical who recognised that it was these very altera- alterations to normal functioning, nor that tions that were responsible for the benefi- these are likely to interact with the behav- cial effects the drugs seemed to produce iour, expressions and feelings we refer to as in people who were acutely psychotic or mental disorders. This is what I have called disturbed for other reasons. As French the ‘drug-centred’ model of drug action, psychiatrist, Pierre Deniker, remarked, and if we accept that it is even credible, it drugs that diminish people’s responsiveness challenges the currently accepted ‘disease- to their environment in general can cause centred’ model that suggests that drugs work people who are in a psychotic state to lose by modifying some underlying biological interest in their delusional preoccupations mechanism that is involved in producing the (Deniker, 1960). symptoms of the disorder (Moncrieff, 2008, This drug-centred model of drug action Moncrieff & Cohen, 2005). was soon abandoned, however, not because Some of the drugs prescribed in psychi- of empirical evidence supporting the atry have stronger effects than others. Most disease-centred model, but because it came people who take a dose of haloperidol can to be profoundly challenging to psychia- feel the alterations it produces pretty quickly, trists’ views of themselves and their practice. but those produced by an SSRI, for example, Psychiatrists have always been deeply inse-

Psychotherapy Section Review 65, Winter 2020 77 Joanna Moncrieff cure about their medical status. As general medical conditions, it is sometimes difficult, medicine started to discover effective and even for the most critical of thinkers, to step disease-specific treatments during the 20th outside this paradigm. Yet, mental disorders century, it became increasingly important for are not identified within an individual like psychiatrists to present themselves as having diseases of the body. Mental disorders are sophisticated treatments that targeted under- problems of social groups or units. We too lying biological mechanisms (Moncrieff, often think just of the individual’s emotional 2008). The idea that drugs target an under- state, whether they are depressed or anxious, lying biological defect is one of the strongest for example, and not of what social expecta- justifications for claiming that mental disor- tions or obligations they are failing to fulfil ders emanate from the brain or the body, that makes their emotional state problem- just like other illnesses. Concrete evidence of atic to them and to others. Similarly, when a causal association between biological vari- someone is diagnosed with schizophrenia, ations and symptoms of mental conditions is we focus upon their unusual beliefs, rather lacking, or at best inconclusive. than looking at how these impact on their Challenging the idea that the ability to get along in the world. drugs target an underlying disease or Historical scholarship, however, reveals symptom-mechanism makes it difficult to how mental health problems are problems maintain the notion that mental disorders of communities. Modern psychiatric care are akin to medical conditions and to assim- and the legislative framework that surrounds ilate the practice of psychiatry to that of it, emerged out of the mechanisms devised medicine. by local communities for maintaining social Although the drug-centred model of drug order and providing care for dependents. action challenges the notion that mental Before formal legal systems were intro- disorders are medical conditions, it does not duced, early societies such as Anglo Saxon deny the utility of pharmaceutical interven- England, had informal ways of maintaining tions and hence of forms of medical knowl- the safety and order of the community, edge. The drug-centred model suggests dispensing justice and caring for those who that the alterations some drugs produce were sick and incapacitated (Dershowitz, may be useful in suppressing the manifesta- 1974). In England and Europe religious tions of mental distress in some situations. institutions played a role in providing care This approach demands a better knowledge and sustenance for those who could not of psychopharmacology, as understood in provide for themselves. With the dissolution a drug-centred framework, than most psychi- of the monasteries under Henry VIII, a new atrists currently have. It demands that profes- state-sponsored system of social welfare was sionals have a comprehensive understanding introduced in England called the Poor Laws. of the phenomenology of drug-induced These laws, which were updated periodically alterations and how these might interact with over succeeding centuries, placed an obliga- different forms of mental and emotional tion on local communities to care for their disturbance, as well as detailed knowledge poor and needy and to help safeguard the of the results of effectiveness research and safety of the community as a whole. Family of all the possible complications that drug members could apply to the Poor Law offi- treatment can entail. cials of their local area for food and clothes if the harvest failed, or if some other catas- Mental disorder as a variety of social trophe meant they were unable to sustain problems themselves, including situations in which We have been so indoctrinated into the idea one of the family breadwinners became that mental disorders are problems that incapacitated due to a mental disorder. If are located in individuals, just like other the family were unable to look after the

78 Psychotherapy Section Review 65, Winter 2020 The past and future of psychiatry and its drugs individual concerned, the Poor Law officials behaviour cannot be addressed within the could make arrangements for other local confines of the criminal law due to a lack of people to provide care. If the safety of the rationality or capacity. community was threatened, the officials Just as in pre-Victorian days, much of this would also ensure the individual was placed system now operates outside the concrete somewhere safe and secure, sometimes, if institutions that exist to contain the most no local solution could be found, involving severely disturbed. The state spends consid- transfer to the nearest prison (Rushton, erable resources supporting people who are 1988). Wealthier people made their own not able to provide for themselves in the arrangements, since they could not call on form of sickness and disability payments the resources of the state. for depression, anxiety and other ‘common For the next few centuries, the Poor mental disorders’. The fact that these have Laws provided the framework within which increased, more rapidly than payments for people without their own assets were cared other medical conditions, despite a huge for if they could not provide for themselves. increase in the availability of treatments, Although most people remained in their own suggests not only that the treatments are homes, and received aid or welfare known as ineffective, but that they miss the point ‘outdoor relief’, institutions such as Poor (Viola & Moncrieff, 2016). What the system Houses and Workhouses, grew up to house is providing is money and care for those who those poor people who did not have homes, are unable to provide for themselves either or who could not be supported within the temporarily or permanently. family home. Michel Foucault and historians, Similarly, the idea that people diagnosed such as Andrew Scull, have documented with schizophrenia or ‘bipolar disorder’ how the mental asylums and the practice of have a disease, provides the justification to psychiatry emerged out of these institutions, lock them up against their will and forcibly providing supposedly specialist care for change their behaviour with drugs, as if this those who were too incapable or disruptive process were as uncontroversial as treating to be managed within the meanly-funded pneumonia or lung cancer. Some individuals and brutally managed Victorian Workhouses will later be thankful that measures were (Foucault, 1965; Scull, 1993). The asylums taken to contain their behaviour when they continued the dual functions of the Poor were ‘not in their right mind’. Others never Law system by providing care for those who see the world quite as others see it, and for could not provide for themselves, and safety these people treatment means forcible modi- for the community from individuals who fication of their behaviour in the interests of were behaving in a threatening or disruptive maintaining social peace, often on a life-long manner, and were too mentally disturbed to basis. be amenable to the dictates of the criminal The current system, built as it is upon the law. ‘myth of mental illness,’ that is the unsub- stantiated claim that mental disorder is just Modern mental health care like any other medical condition, serves When we look at the history of psychi- the useful function of keeping potentially atric care in this way, we can see that the controversial issues out of the public arena. modern system fulfils the same social func- Just as the rate payers of old complained that tions. Behind the façade of treating an indi- hordes of ‘undeserving’ poor took advantage vidual’s medical pathology, what the system of the benefits provided by the Poor Laws, provides is care for those who are not able to people nowadays might begrudge their look after themselves, and containment and hard-earned taxes being paid to those who policing of those who present a threat to the appear to be physically capable of earning peace or safety of the community, but whose a living. The state, too, occasionally becomes

Psychotherapy Section Review 65, Winter 2020 79 Joanna Moncrieff alarmed at the extent of welfare costs, and ards to be, self-defeating, but they can still makes tentative efforts to rein in disability be genuine and meaningful. Meyer reflected spending from time to time, but it cannot the influence of psychoanalysis, but thinkers afford to dispose of the system altogether. and practitioners from many other tradi- Sickness and disability benefits in the western tions have also described mental disorder as world are overwhelmingly paid to those in a meaningful response to life’s challenges, or manual social classes for whom decently simply as ‘ways of being human’ (Jenner et paid, reliable work has disappeared over the al., 1993) that are not fundamentally different last few decades. They are the price that from ordinary, more familiar forms of behav- western capitalism pays for the outsourcing iour. If we understand mental disorder in this of unskilled jobs and heavy industry to the way, how should we, as a society, respond? How developing world where labour is cheaper. are we to help people whose behaviour causes This process has left devastated communities themselves distress, and how should society in its wake, rife with the demoralisation and react to people whose behaviour causes harm insecurity that is labelled as depression and or inconvenience to other people? What role, anxiety, so that individuals can be emotion- if any, should psychiatrists have in an alterna- ally subdued using chemical suppressants, tive system? and any challenge to the system as a whole is stifled before it is even born. Helping people to change First, if we understand mental distress as The future: An alternative a reaction to life circumstances, then the first understanding of mental disturbance question we must ask is what is it about our The future of psychiatry is thus intimately current society that drives so many people to entwined with the future of society as a whole. feel anxious or unhappy or that they cannot As long as society needs a myth to keep the manage the demands that are made of them? peace and manage disorder and discontent, Mental disorder can often be usefully seen then a system that fosters the idea that mental as a ‘signal to change’, an indication that illness is a brain disease and that treatment is something is wrong, either with the nature a sophisticated medical process will continue of society as a whole, or with an individu- to flourish. People may benefit from the al’s current way of life. Insecure employment, financial support the current system offers inequality of wealth, lack of meaningful in the absence of opportunities for more opportunities for communal engagement all fulfilling ways of living, but they may be take a toll on people’s emotional wellbeing. harmed too by the implication that they People in more advantaged situations may are biologically flawed, chronically impaired, still be under immense pressure to perform that their problems are beyond their control and compete, to work long hours and to and that toxic chemicals represent a simple sacrifice time they could spend in more and benign solution. personally fulfilling activities. The solution Accepting that mental disorder is not to much current mental distress is not the a disease, but simply how some people are or tweaking of individual brain chemistry or come to be, did not used to be a particularly cognitive inclinations, but political pressure radical idea. Adolf Meyer, the leading Amer- to create a society that provides accessible ican psychiatrist of the mid 20th century opportunities for everyone to lead secure suggested that what we refer to as mental and rewarding lives. illness could be thought of as ways in which Sometimes, however, an individu- some people respond to the world around al’s reactions and behaviour seem to be part them and the challenges it can pose (Meyer, of the problem. There are many ways that 1948). Some ways of reacting to the world people can be helped to change. Traditionally may be, or appear by conventional stand- people turned to family, friends, colleagues or

80 Psychotherapy Section Review 65, Winter 2020 The past and future of psychiatry and its drugs religious leaders for guidance about how to But modern antidepressants like Prozac conduct themselves and how to address obsta- are presented in a completely different way. cles and challenges in life. More recently, They are presented as a disease-targeting people have looked to professionals including treatment, something that works by recti- therapists and councillors. Mind-altering fying an underlying chemical imbalance, drugs are another enduringly popular tech- not by putting people into a mild state of nique for changing one’s mental state and drug-induced stupor. This way of promoting behaviour. For millennia people have used antidepressants has concealed their drugs like alcohol and opium to dull grief, mind-altering properties. Although most worry and sadness. Yet, it is far from obvious SSRIs have only weak psychoactive effects, that drugs are useful in this sort of situation they do seem to induce a subtle state of when consumed on a long-term basis. emotional detachment or numbing (Gold- Many of us have had a drink once or smith & Moncrieff, 2011). People speak of twice when we have had a shock or are finding it difficult to cry, for example, and trying to deal with a crisis in our lives, and not being able to feel particularly sad or we may well have found that the intoxica- happy. Therefore it seems that, although tion it produced brought temporary relief less blatant than their predecessors, modern from our worries. Few people would think antidepressants may also help people accom- that long-term drinking is a sensible solu- modate to adverse circumstances that they tion to any emotional or personal problem, might not otherwise tolerate. Although data however. Indeed, we only have to look at from randomised controlled trials does not people who have problems with addiction convincingly demonstrate that antidepres- to drugs like alcohol or heroin to see how sants are any better than placebo (Moncrieff, using drugs to combat personal difficulties 2018), these effects may theoretically provide can become a problem in itself. Being under some short-term relief. However, this sort of the influence of a substance that numbs suppression of feelings and reactions seems emotions and dulls pain and anxiety makes unlikely to help people to deal with life people less likely to learn other techniques challenges effectively in the long run, and for managing emotions and getting by in the may help to perpetuate situations which are world, and prevents people from addressing making people unhappy in the first place. underlying problems. Under the influence Today, psychiatrists meet many people of something that diminishes one’s sensitivity who are struggling with difficult circum- and reactions, people may be able to cope stances such as divorce, unemployment, debt more easily with boredom and frustration or the feeling of lacking meaning and direc- and tolerate difficult, unrewarding or even tion in life. Psychiatrists, like other profes- abusive relationships. sionals, can help people to weigh up the There is no doubt from dozens of adver- pros and cons of using different strategies to tisements from the 1950s and 60s that address their particular difficulties, including drugs like the benzodiazepines were widely considering the use of mind-altering drugs. prescribed to mute people’s discontent, First, however, they must disabuse people of in that period very often the discontent of the idea that they have a brain disorder that women. An advertisement of that period requires a drug to put it right. Then they for Serax (oxazepam) has the headline ‘You can start a conversation about what the indi- can’t set her free, but you can help her vidual’s problems actually are and how these feel less anxious’, showing a young woman can be most effectively solved or managed. shut in by prison-like bars with brooms They can discuss honestly with people the and brushes as companions; by implication possibility of using mind-altering substances a young woman being frustrated and anxious to alter and suppress emotional reactions, – limited by the household duties. acknowledging the limited evidence that this

Psychotherapy Section Review 65, Winter 2020 81 Joanna Moncrieff strategy is helpful, the risks that it entails therefore, that enable people to be treated and sharing our accumulating knowledge of without antipsychotics, if this is what they other people’s experiences. want, and to wean off antipsychotics safely after recovery where these have been used. Forcing people to change This is not a Utopian dream – in 2015 What about those people whose behaviour Norway passed a law that mandated the intro- is more severely disturbed, or disturbing duction of such facilities (Whitaker, 2017). to others? Sedative drugs of any sort are In Tromso, in northern Norway, a six-bedded likely to quieten down agitated or aggres- unit has been set up for people who wish to sive behaviour and, in my experience, avoid using antipsychotic drugs altogether, antipsychotic drugs can help diminish or who wish to reduce them in a gradual people’s preoccupation and emotional and supported way. The unit provides thera- investment in psychotic experiences. Some- peutic activities including art therapy, music times this enables people to engage in other therapy and outdoor exercise to support activities again, to look outward in a way they people during their stay. People can come were unable to while psychotic. We should back more than once, if they want to take be mindful, however, that the way this effect their medication reduction in stages. The is achieved is at the cost of dampening down directors of the unit also have the ambition people’s interest and motivation as a whole, to extend the service to provide commu- and that, quite apart from the serious phys- nity support following discharge, in recogni- ical complications of long-term antipsychotic tion that surviving without medication, or treatment, this is a high price to pay for rela- getting off medication, may be a process that tive normality. As antipsychotic user, Peter takes place over several years. Although such Wescott wrote in the British Medical Journal, services may be expensive in the short-term, ‘in losing my periods of madness I have had the costs of maintaining people who are to pay with my soul’ (Wescott, 1979). permanently impaired by the effects of We need to acknowledge that treating antipsychotics are likely to offset this in the people with mental disorder is behaviour long-run, even if it is only a small propor- modification, not medical treatment. We are tion of people who can be helped to avoid giving people drugs to change their state of long-term drug treatment. mind and the behaviour that it is manifested Where people remain acutely psychotic in, not to cure an underlying disease or for long periods, then I think antipsychotic biological abnormality. If this is done against treatment should be tried, sometimes even the individual’s wishes, this is an exceptional if this is against the individual’s wishes. This situation that requires strong safeguards and decision should not be a medical decision, ongoing scrutiny to ensure that it is properly however. Over-riding someone’s wishes in justified. this way should be a legal decision, where We need to be quite sure, therefore, that evidence of the benefits and harms for forced treatment is completely necessary and the individual, their family and society is that no alternatives are possible. Yet we know all weighed in the balance. It must also be that some people can recover from psychosis subject to ongoing legal scrutiny. naturally, without drugs and have a good The use of potentially harmful drugs long-term prognosis (Bola & Mosher, 2003; requires personnel that have some medical Wunderink et al., 2013). Non-intrusive social and pharmacological expertise, so psychia- support and activities to maintain some trists can play a role in this scenario. Again, engagement with the world would seem to however, what is important is an acknowl- be helpful in this situation, although we edgement of the actual nature of the activity; need more research in this area (Cooper that ‘treatment’ in this case involves forcible et al., 2019). We need to have facilities, modification of behaviour, often princi-

82 Psychotherapy Section Review 65, Winter 2020 The past and future of psychiatry and its drugs pally in the interests of other people rather a more transparent way, or whether it prefers than the individual, which is ultimately to keep sweeping it under the medical table. a socially-driven activity and not a medical In the meantime, critical psychiatrists can one. only continue the difficult task of trying to Whether such changes in our approach have an honest dialogue with patients within to mental disorder will come about depends a framework of understanding that has been on whether society is willing to confront the constructed to disguise the truth. complexity of addressing the huge variety of social difficulties that we currently bundle Joanna Moncrieff under the label of ‘mental disorder’ in

References Bola, J.R. & Mosher, L.R. (2003). The Journal of Meyer, A. (1948). The commonsense psychiatry of Dr Nervous and Mental Disease, 191, 219–229. Adolf Meyer. New York: McGraw Hill. Cooper, R.E., Laxhman, N., Crellin, N., Moncrieff, J. Moncrieff, J. (2008). The Myth of the chemical cure: & Priebe, S. (2019, May). Schizophrenia Research. A critique of psychiatric drug treatment. Basingstoke, Deniker, P. (1960). Comprehensive Psychiatry 1, 92–102. Hampshire: Palgrave Macmillan. Dershowitz, A. (1974). University of Cincinnati Law Moncrieff, J. (2018). Epidemiology and Psychiatric Review, 43, 1–60. Sciences, 27, 430–432. Foucault, M. (1965). Madness and Civilisation. New Moncrieff, J. & Cohen, D. (2005). Psychotherapy and York: Random House Inc. Psychosomatics, 74, 145–153. Goldsmith, L. & Moncrieff, J. (2011). Current Drug Rushton, P. (1988). Medical History, 32, 34–50. Safety, 6, 115–121. Scull, A. (1993). The most solitary of afflictions. New Healy, D. & Farquhar, G. (1998). Human Psychophar- Haven: Yale University Press. macology, 13, 113–120. Viola, S. & Moncrieff, J. (2016). BJPsych Open, 2, Jenner, F.A., Monteiro, A.C.D., Zagalo-Cardoso, J.A. 18–24. & Cunha-Oliveira, J.A. (1993). Schizophrenia: Wescott, P. (1979). British Medical Journal, 1, 989–990. A disease or some ways of being human. Sheffield: Whitaker, R. (2017). The door to a revolution Sheffield Academic Press. in psychiatry cracks open, Vol. 2019: Mad in Lehmann, H.E. & Kline, N.S. (1983). Discoveries in America Inc. Pharmacology, Volume 1, edited by M.J. Parnham Wunderink, L., Nieboer, R.M., Wiersma, D., Sytema, & J. Bruinvels, pp.209–247. London: Elsevier S. & Nienhuis, F.J. (2013). JAMA Psychiatry, 70, Science Publishers B.V. 913–920.

Psychotherapy Section Review 65, Winter 2020 83 Exploring integrating mindfulness Chinese Calligraphy Enhanced Therapy (CCET) as a complementary psychotherapy to bridge underrepresented Chinese clients in the UK Juan Du

CCORDING to the National Institute 2007), it is, in fact, a well-known and familiar for Mental Health in England (2003), way of achieving relaxation and harmony AChinese clients tend not to request of the body and the mind, which are also support from available psychological services essential for physical and psychological func- and have been described as an ‘invisible tioning (Davey, 1999). population’(Weich et al., 2004). However, Chinese Calligraphy Enhanced Therapy this does not mean that Chinese people in (CCET) is a complementary therapy the UK do not experience mental health designed as a culturally sensitive and struggles or need psychological therapy non-threatening approach to bridging support (Bebbington et al., 2007). Chinese clients’ access to psychological There are obvious obstacles for Chinese therapy. The four sessions of CCET is an clients to access psychological therapy, innovative integrative approach which including therapists offering services that also draws on cognitive theory, mindful- do not meet the clients’ social, cultural ness theory and psychoanalytic theory. The and linguistic needs (Dowrick et al., 2009; design is inspired by my clinical work with McLean et al., 2003); clients’ language Chinese clients in the UK and is also based barriers and a lack of awareness of mental on personal experience of psychotherapy health services within the minority practice and my role as a mindfulness community (Nagayama, 2001); perceived teacher for community services. discrimination from professionals (Suresh The research project method and data & Bhui, 2006). Therefore, the need for analysis are in progress, but it will be using psychological therapies to be culturally a qualitative theory-building case study appropriate and responsive to Chinese method, it will not directly aim to address the clients has been recognised (Zane et al., effectiveness of the CCET approach itself, 2004). but instead will hope to build an explanation Chinese Calligraphy Handwriting (CCH) for western psychotherapy field of how the as a mindfulness-based brush meditation approach works. intervention has been practised for thou- I hope this study will provide benefit sands of years in China, CCH traditionally for culturally sensitive psychological uses a natural ink stone with water added to therapy access for the Chinese Commu- generate ink, which is then applied on rice nity in the UK, improve the awareness of paper in strokes, using a soft-tipped brush, in a cultural-sensitive psychological approach the form of the structure of Chinese charac- in the psychotherapy community and ters (Kao, 2000). To Chinese people, callig- promote race equality in mental healthcare raphy practice is not just a national art and services in the UK. cultural-historical heritage (Qian & Fang,

84 Psychotherapy Section Review 65, Winter 2020 Exploring integrating mindfulness Chinese Calligraphy Enhanced Therapy as a complementary psychotherapy

Juan Du is a bilingual Mandarin and English of her doctorate thesis. For further enquiries speaking psychotherapist, Mindfulness about this study please contact: teacher, currently studying a doctorate in Email: [email protected] Counselling Psychology and Psychotherapy Website: https://juandutherapy.co.uk at Metanoia Institute. This research is part Twitter: @ChineseMentalHealth

References Bebbington, P., Brugha, T., &Coid, J.(2009). Adult Nagayama, H.G.C. (2001). Psychotherapy research psychiatric morbidity in England—2007, results with ethnic minorities: Empirical, ethical and of a household survey. In S. McManus , H. conceptual issues. Journal of Consulting and Clin- Meltzer & T. Brugha (Ed.) The NHS Information ical Psychology, 69, 502–510. Centre for health and social care. London. Qian, Z.Z. & Fang, D.S. (2007). Towards Chinese Davey, H. E. (1999). Brush meditation. California: Calligraphy. Macalester International,(18), Article Stone Bridge Press. 12. Dowrick, C., Gask, L. & Edwards, S.(2009). Suresh, K. & Bhui, K. (2006). Ethnic minority Researching the mental health needs of hard-to- patients’ access to mental health services. Psychi- reach groups: Managing multiple sources of atry, 5, 413–416. evidence. BMC Health Services Research, 9, 226. Weich, S., Nazroo, J. & Sproston, K. (2004).Common Kao, H.S.R. (2010). Calligraphy therapy: mental disorders and ethnicity in England: A complementary approach to psychotherapy. The EMPIRIC study. Psychological Medicine, 34, Asia Pacific Journal of Counselling and Psychotherapy, 1543–1551. 1(1), 55–66. Zane, N., Hall. G.C., Sue, S., Young, K. & Nunez, J. McLean, C., Campbell, C. & Cornish, F.(2003). (2004). Research on psychotherapy with cultur- African-Caribbean interactions with mental ally diverse populations. In M.J. Lambert (Ed.) health services in the UK: Experiences and Bergin and Garfield’s handbook of psychotherapy and expectations of exclusion as (re)productive of behaviour change (5th edn, pp.767–804). New health inequalities. Social Science & Medicine, 56, York: Wiley &Sons. 657–669.

Psychotherapy Section Review 65, Winter 2020 85 The application of technology to rare human conditions What it means to see the neurons ‘rush into the Brain’ Letizia De Mori

Future topics.The author of the following vignette will be invited to develop her short article in the Issue on Special contexts for psychotherapy in 2021–2022, with reference to emotional as well as cognitive and motive experience of these clients.

S A Neuropsychologist Researcher with rare genetic syndromes, the brain is I study how the brain works mostly in plastic as as in typical development, and such Athe field of rare genetic syndromes. children deserve a chance as with anybody In practice, my work involves studying else, to improve further. neurons active in different areas of the brain To communicate to parents good as well using the comparison of analyses between as bad results it is the most difficult part of cognitive assessment data results (neuropsy- my job. In these moments the professional chologist tests) and the neuroimaging data as a neuropsychologist, enters people’s lives (through the fMRI – functioning Magnetic and then stay there for life. Finally the fami- Resonance Imaging). lies have answers to their many questions, The most important part of my job is doubts, and fears. At the the same time it first to look at the functioning of the brain, is amazing to see how often an initial dread especially of children with rare genetic becomes the will to transform a limit into an conditions, to investigate their strengths and opportunity, for the family and their child. weaknesses. I study how the brain is func- To watch the ‘neurons rush into the tioning and see neurons literally coming to Brain’ is also to have the honor to be part life with different tasks that the client is of a common aim: to build the future, for us completing. I then devise cognitive rehabili- all, and for these clients and their families in tation programmes to improve functioning. particular. This is very rewarding work. Everybody can wish to improve their quality of life, their Dr Letizia De Mori limits, their edge: themselves! I see the chil- Neuropsychologist Researcher dren as our future, they are a step of us in BPS – Chartered Member the future, our projection in the future. Even

86 Psychotherapy Section Review 65, Winter 2020 Title Student mentoring reports

Mentoring opportunities are regarded as key stages in the development of future psychologists, by the Psychotherapy Section and by the BPS as a whole. An A-level student’s learning from a psychology conference: My experience in attending my first psychology conference Ting Ting Lin

Y NAME is Ting Ting Lin and I’m an called ‘Liberation Psychology, the Social A-level student, one of the subjects unconscious...’. Blackwell himself is an Mbeing psychology which is really accomplished writer in the field and in this great considering I had no idea what it was particular case, he looked upon the subject about beforehand. After passing my first year from a political perspective whilst also taking in A-levels my interest in psychology devel- into account the matters of social constructs oped and now I can proudly announce that and how society can consciously or uncon- I know a nice handful of facts to impress my sciously exclude others. family during visits. Additionally, another speaker that But in order to continue my studies at I rather enjoyed listening to was the pres- a degree-level, I also knew that I’d have entation by Ms Isabel Clark called ‘Compre- to have more experience outside of lessons hend, Cope and Connect...’. Ms Clark is in order to really make my personal state- a consultant clinical psychologist who spoke ment stand out so I attended my first about trauma and things of the like. Her conference; the topic being, ‘Inclusion and enthusiasm for the topic was childlike and Exclusion of therapeutic relationships’. The charming, making her very fun to listen too. speakers on the day each gave a presentation In her presentation she covered things such surrounding the idea of how to better under- as different ways to approach clients, taking stand psychotherapy and the barriers that into account their culture, boundaries and exclude marginalised groups. upbringing. Although there were some terms that I also spoke with one of the students I didn’t quite understand having only and her poster which encouraged Chinese studied psychology at a surface level, I found calligraphy as a form of therapy. Since I am the details of each presentation interesting Chinese as well, I was (not being biased!) in their own right. I commend the speakers drawn to this topic and I was able to learn for going into such depth and detail about more about the vast difference between a subject that I had thought to be a niche; western and eastern culture and how both the speakers covered areas from politics to deal with mental health issues, namely complaints to issues within therapy itself. depression. We spoke about how it could One of the speakers that caught my be possible to overcome some of the stigma attention was Dick Blackwell’s presentation surrounding depression in the east and that

Psychotherapy Section Review 65, Winter 2020 87 AuthorTing Ting name Lin calligraphy could serve as a great therapeutic Overall, the day was incredibly inter- tool in doing so. esting, especially for my first conference. Towards the end of the day, as if to prove Naturally, I wasn’t too sure what I should the point of the entire conference, we gath- expect and worried that the content would ered in a large circle and those who spoke be far too advanced for me to understand. encouraged those who didn’t to voice their Instead, I was pleasantly surprised by most opinions, thoughts and feelings, which was, of the speakers and found myself agreeing rather ironically, their way of taking the first or disagreeing (internally, of course) on steps into inclusiveness. There was a debate the points that they made; which, for the and I found my head turning from speaker most part at least, meant that I was prop- to speaker as they all raised valid points that erly engaged. Despite the content not being I hadn’t even ​thought ​about before; it was entirely relevant to the topics I’m learning the end discussion that gave me a true insight at A-level, I still felt its effect on me and my as to how life and professions function and opinion towards psychology as a whole. work for the entire field of psychology.

88 Psychotherapy Section Review 65, Winter 2020 Student mentoring reports An A-level student’s experience of an intensive BPS Mentoring Placement: What makes a psychologist? – A beginner’s voice Wiktoria Dziurowicz, with contributions from Ho Law

This article aims to describe what makes a good psychologist from the perspective of a student at the beginning of her professional journey. It also describes the role and practices of psychologists based on her experience of participating in a mentoring programme in Cambridgeshire, England, UK. Keywords: education, evaluation, mentoring, psychology, training, work experience.

AM A young ambitious student stud- as applying vital knowledge to help other ying psychology at A-level at Hampton individuals who may be struggling with ICollege, Peterborough, Cambridgeshire, mental difficulties such as depression. To with high hopes and big dreams to become me, psychologists are the future for our a psychologist of the future. For my college generation because of the huge demand work placement week in 2019, I wanted to of expertise that is required who can help gain experience of working with psycholo- these people, understand their difficulties gists. I know owing to various reasons such as and improve wellbeing. Psychologists also do client confidentiality in the practice, it is very fascinating research to discover new knowl- difficult to gain such working experience. edge about human mind and behaviour I was delighted to learn that there was which could lead to a change of approach in a student mentoring programme* supported many areas of application – from psychoanal- by the British Psychological Society in the ysis, behavioural therapy to cognitive behav- region. The programme took place in ioural therapy, all psychologists contribute by Allia Future Business Centre – a modern helping people, as well as creating research building in Cambridgeshire, designed with and theories which can have a major impact community and collaboration in mind with on today’s society. a strapline, ‘For people, planet and place’. Applications of psychology include The Centre is a home for several organi- improved employee productivity as a result sations, professionals, social entrepreneurs of work from occupational psychologists; and individuals with an aim to make posi- student happiness in school from positive tive change and address the most pressing psychologists; crime prevention and reduc- global and local challenges by developing tion and improving policing from the contri- innovative and effective solutions that can bution of forensic psychologists. All these transform peoples’ lives. As part of the appli- fields require a psychologist. cation process, I was asked to think about the However, what makes a good psycholo- role of psychologists and write an essay about gist? I would say a good psychologist is ‘What makes a psychologist?’ a psychologist who is able to help, contribute The role of a psychologist is to study to today’s society and be the future of and understand human behaviour as well psychology. First, they should be able to

Psychotherapy Section Review 65, Winter 2020 89 Wiktoria Dziurowicz, with contributions from Ho Law listen and relate to a wide range of people Each day of the week was packed with (that is the key and most important skill activities; some of the highlights were: of a psychologist). Editor: readers please Day 1, after the health and safety briefing note! This applies to all areas of psychology in the morning, I learnt how to conduct as listening skills will allow them to build a SWOT analysis to establish areas of weak- a rapport with their clients – in both research ness and strengths as well as opportunities and practice. For without trust, the collabo- and threats for myself and the organisation. ration of participants is curtailed, leading to I was instructed to prepare a questionnaire inaccurate conclusions in research or unsuc- for a semi structured interview with Dr Hau cessful outcomes in treatment. a forensic scientist to take place the next day. Second, psychologists must have good The objective was to appreciate the multi- communication skills to communicate with disciplinary work where and how the police, clients and other professionals, to articulate forensic psychologists and scientists work their thoughts, rationale and action plans together for crime investigation within the effectively and disseminate their knowl- criminal justice systems. edge and research findings to diverse stake- holders. Day 2, involved a discussion with Professor Third, analytic/problem-solving skills – Law of the in-depth interview with Dr Hau a good psychologist should be able to draw I gained knowledge about the differences inferences and examine the information between a forensic psychologist and forensic they gather and use that information to help scientist and how they worked together to create solutions for change of behaviour assist CJS to achieve its objectives. or draw valid conclusions in the research that they are conducting. Often, progress Day 3. We had another multidisciplinary is slow (certain longitudinal studies may meeting with local community leaders, take years) therefore it is very important for social entrepreneurs and other stakeholders a good psychologist to have patience when it including Jackie Chibamu, director of comes to their work. Very often, individuals African Business Network, Katrina D’souza, and families seek the help of a psychologist iDream Academy, Ghislaine Regout, because they are experiencing difficulties a psychologist in the Netherlands and Mark and they are not able to solve the problems Argent, a psychoanalyst at Cambridge. Both themselves. Psychologists therefore must Ghislaine and Mark were also musicians. The have problem-solving skills and be solution meeting was conducted both face to face at focused which may take creativity and inge- the Centre with some of the stakeholders nuity to help their clients. joining the discussion over an internet plat- I felt that I was lucky to be offered a place form. The aim of the project was combining after the initial draft essay and two interviews. music and narrative approach in an art I was told that the intensive interviewing project for community groups and organi- process was already part of the mentoring zations such as schools and hospitals who process with objectives to enable students to would gain the health benefits from the experience what it would be like in applying power of music and story telling integrated for a professional psychologist job in the real in a structural way. world, in a safe and learning environment as feedback was provided afterward. Day 4. We had an awayday to Cambridge. During the mentoring week, I had the Professor Law was showing me around privilege to work alongside a chartered and places, spaces and various Colleges of the registered psychologist Professor Ho Law, University, explaining their histories and a well-established psychologist with more significance in the scientific discoveries. than thirty years’ experience. I visited Cambridge many times, mostly to

90 Psychotherapy Section Review 65, Winter 2020 An A-level student’s experience of an intensive BPS Mentoring Placement: What makes a psychologist? do shopping with my friends. I had never from different backgrounds. An example of been into the University. Professor Law was this was the Art and Music Project, bringing trying to inspire young people to raise their many stakeholders from Cambridge, Peter- aspiration for the excellence which he said borough and the Netherlands together to the so-called ‘Cambridgeness’ represented. create a big community project which will Despite this encouragement, I did not plan benefit young and older people. This project to study at Cambridge University. I applied shows the importance of collaboration – to study BSc Psychology at Nottingham Trent psychologists coming together, combining all University instead because I found that the their skills to help boost people’s confidence, content of the course was more suitable to health and wellbeing. my interest. To me, it does not matter about Good psychologists do not only create status and privilege if I am happy and satis- research, but also practise what they know. fied with what I do; that is the most impor- They work in diverse settings with people who tant thing. In the afternoon we had another struggle with mental health, CJS and multiple meeting with Mark Argent at the University stakeholders to create a safer and healthier Centre Grads Café on the topic of psycho- community. They do this by bringing in therapy and spirituality. I was enlightened by their knowledge, skills and wisdom. Overall Argent about the importance of not labelling a good psychologist should have these skills – clients. According to Argent, ‘Not labelling’ analytical, building rapport, communication is crucial to enable the wellbeing and treat- and patience. After the week of work experi- ment of clients. I think a good psychologist ence with a psychologist at work, I should should know about the stigma which comes add on the list, leadership, ability to work behind a label. This could lead to set backs independently and in an interdisciplinary with further anxiety and stress to the clients. setting. I believe that psychologists are the future for our generation as they are not Day 5. Friday was the final day of the work simply studying human behaviour and the placement. I had to document my learning theory of mind, but also applying the vital of the week (including revising and writing knowledge to help people of all ages, diverse up this essay) and give a presentation about organizations and build a safer and healthier the whole weeks’ experience in a PowerPoint community. at the Centre which I found very chal- lenging. I was happy to comply as I know *Note communication is an important part of what The mentoring programme runs each makes a good psychologist. It was important summer to provide shadowing and work to rehearse and practise in a safe environ- experience to students or trainees in ment, said Professor Law, so that one could psychology who want to learn about various improve from constructive feedback before specialist areas in practice. It was initially set the ‘real thing’. up as part of the BPS East of England Branch (see separate article) in its foundation year In Professor Law’s company I have under- with the aim to engage volunteers to raise stood that psychology is very advanced awareness of the application of psychology and consists of many different branches of which was implemented locally by Ho Law specialism for example clinical, counselling, (the founding Chair of the Branch) and forensic, health, occupational and sport & continuously runs with support of various exercise psychology. The important job of BPS member networks and local Colleges. being a psychologist is irreplaceable today as The 2019 programme was supported by groups of experts from different fields can the Psychotherapy Section and Hampton come together and work on projects which College at Peterborough. For further infor- can benefit and help people of all ages and mation, please contact [email protected]

Psychotherapy Section Review 65, Winter 2020 91 The application of technology to rare human conditions What it means to see the neurons ‘rush into the Brain’ Letizia De Mori

Future topics.The author of the following vignette will be invited to develop her short article in the Issue on Special contexts for psychotherapy in 2021–2022, with reference to emotional as well as cognitive and motive experience of these clients.

S A Neuropsychologist Researcher with rare genetic syndromes, the brain is I study how the brain works mostly in plastic as as in typical development, and such Athe field of rare genetic syndromes. children deserve a chance as with anybody In practice, my work involves studying else, to improve further. neurons active in different areas of the brain To communicate to parents good as well using the comparison of analyses between as bad results it is the most difficult part of cognitive assessment data results (neuropsy- my job. In these moments the professional chologist tests) and the neuroimaging data as a neuropsychologist, enters people’s lives (through the fMRI – functioning Magnetic and then stay there for life. Finally the fami- Resonance Imaging). lies have answers to their many questions, The most important part of my job is doubts, and fears. At the the same time it first to look at the functioning of the brain, is amazing to see how often an initial dread especially of children with rare genetic becomes the will to transform a limit into an conditions, to investigate their strengths and opportunity, for the family and their child. weaknesses. I study how the brain is func- To watch the ‘neurons rush into the tioning and see neurons literally coming to Brain’ is also to have the honor to be part life with different tasks that the client is of a common aim: to build the future, for us completing. I then devise cognitive rehabili- all, and for these clients and their families in tation programmes to improve functioning. particular. This is very rewarding work. Everybody can wish to improve their quality of life, their Dr Letizia De Mori limits, their edge: themselves! I see the chil- Neuropsychologist Researcher dren as our future, they are a step of us in BPS – Chartered Member the future, our projection in the future. Even

92 Psychotherapy Section Review 65, Winter 2020 Contact details and further information

The Hearing Voices Network www.hearingvoices.org Also covers ‘visions’.

Experts by experience (general) Choice Support website https://www.choicesupport.org.uk/about-us/blog/experts-by-experience

Experts by experience (BPS Division of Clinical Psychology) https://www.bps.org.uk/sites/www.bps.org.uk/files/Member Networks/Faculties/Intellectual Disabilities/Easy read Experts by Experience Strategy 2018 2019 draft.pdf

Authors of articles in this issue [email protected] (Erica Brostoff, Editor) [email protected] (Dr Philip Cox, Chair) [email protected] (Matthew Pugh) [email protected] (John Adlam) [email protected] (Joy Goodall-Leonard) [email protected] (Helen Molden) [email protected] (Jess Walling) [email protected] (Beutler, Castonguay and Constantino) [email protected] (Steve Heigham) [email protected] (Ghislaine Regout) [email protected] (Sheelagh Strawbridge) [email protected] (Joanna Moncrieff) [email protected] (Juan Du) [email protected] (Letizia de Mori) [email protected] [email protected] (Wiktoria Dziurowicz)

Articles and books of interest Solms. M. (2021). The Hidden Spring: A journey to the source of consciousness. Profile Books. Affec- tive neuroscience. This offers a comprehensive new approach to affect as the determining factor in human development and pathology, marrying neurophysiological and psychoana- lytical research and concepts. Will be reviewed in next Issue of Psychotherapy Section Review.

Collaboration and internal voices Ribeiro, E. et al. (2013). How collaboration in therapy becomes therapeutic: The therapeutic collaboration coding system. Psychology and Psychotherapy, 86, 3, 294–314.

A number of useful articles if you google ‘collaboration’ and/or ‘voices’ in therapy.

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94 Psychotherapy Section Review 65, Winter 2020 Contents Introduction: Collaboration – voices apart and together 3 Erica Brostoff Principles of change: A brief review of progress in 54 its first year Editorial committees: Invitation 4 Larry E. Beutler, Louis G. Castonguay & Michael Constantino Letter from the Chair 5 Philip Cox Part 3: Collaborative opportunities to network 59 Review of Patricia Churchill’s Consciousness: Strategic Aims and Goals of the Section 7 The origins of moral intuition Philip Cox Steve Heigham

Editor’s letter 9 Music and (narrative) psychology: 60 Erica Brostoff A literature review Ghislaine T.M. Regout Future Issues 9 Collaboration as the theme of this Issue Mind-forged Manacles 2: Science and Practice 69 Sheelagh Strawbridge Part l: Collaboration in meeting clients’ needs 11 Understanding ‘Ed’: A theoretical and empirical The past and future of psychiatry and its drugs 77 view of the internal eating disorder ‘voice’ 12 Joanna Moncrieff Matthew Pugh Exploring Integrating Mindfulness Chinese 84 Food practices, eating distress and the perils of 24 Calligraphy Enhanced Therapy (CCET) as a bewildering interventions in eating disorders’ Complementary Psychotherapy to Bridge Psychotherapy Section treatment settings Underrepresented Chinese Clients in the UK John Adlam Juan Du A client’s experience of coercive treatment 38 What it means to see neurons rush into the brain 86 Review Joy Goodall-Leonard Letizia de Mori How did I get here? A narrative exploration of 42 Student mentoring reports No. 65 Winter 2020 arriving at talking therapy in a neuro-rehabilitation My experience in attending my first psychology 87 setting, co-written by a young adult patient conference and her therapist Ting Ting Ling Helen Molden & Jess Walling What makes a psychologist? – A beginner’s voice 89 Part 2: Collaboration between clinicians and 51 Wiktoria Dziurowicz with Ho Law researchers Covid Issue Review of: Principles of change: 52 How psychotherapists implement research in Collaboration: Voices apart and together practice (Eds.) Louis Castonguay, Michael J. Constantino and ‘Listening to the client’ Larry E. Beutler Erica Brostoff

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