Wednesday, March 26, 2014

Challenging Orthodoxy in Mental Health

Every profession has its orthodoxies, opinions or philosophies which have been accepted as truth, either implicitly or explicitly.  The field of mental health is no different.  At times these are presented with an air of sanctimony and imperialism which are serious obstacles to further inquiry or maturation of the field.  Given that many of us are involved in improving human welfare, this ought to be viewed with suspicion, if not derision.  When it comes to the study and advancement of human beings, everything is open for further questioning.

Here I list a few of the orthodox assumptions in our field, along with comments from my point of view.

  1. Confidentiality is absolute.  Though it is without doubt the bedrock of good psychotherapy, a healthy degree of which is required for success, confidentiality has never been absolute.  There are exceptions both in law and ethics, such as risk for harm to self or others, which are commonly known.  Lesser known, perhaps, are exceptions which in the judgment of the therapist are necessary for the welfare of the individual.  Sometimes this orthodoxy is taken to extreme and ridiculous levels, such as when therapists block any communications with third parties, nor allow them physically near the facility "in order to protect privacy".  Many times good therapy involves working with a broader system of people, organizations, or policies which offer wider possibilities for the advancement of human causes.
  2. There is a superior paradigm for mental health.  Advocates for this orthodoxy, often from medical disciplines, proclaim their model as "best practice", and cite evidence for this position.  But rarely is disconfirming evidence cited even though it is easily found (as it is for any position).  Too often, other evidence is not considered or acknowledged, nor is the existence of other paradigms or models.  These include developmental, contextual, feminist, and culturally-bound models, all of which have profoundly important things to say about the human condition and its improvement.
  3. There is a hierarchy in the mental fields, and the topmost is the leader of the "team".  This orthodox view is closely related to number two above.  This is part of an imperialistic attitude which has no place in mental health.  It runs counter to basic concepts of respect and egalitarianism which are central to the therapeutic process.  Regardless of marketplace values, all fields have important things to contribute and their diversity is to be held in high esteem.  Also, the most important unit is the therapist-client dyad, and nothing can alter this fact.
  4. Suffering should not be a part of healing.  Even on the most basic level of our physical selves this is a falsehood.  All wounds hurt, and this hurting is a sign the body is doing what it is built to do.  The body and brain are capable of self-correcting if we give them a chance.  Many people, clients and therapists alike, appear to operate from a position that all symptoms, all pain, should eliminated from the start.  This posture, promoted by the pharmaceutical and insurance conglomerate, leads to premature diagnosing, premature intrusive interventions such as medications, and often, the premature conclusion of therapy.  Suffering is a part of life, and it is not always "diagnosable".  As we come out of our unconscious stupors, our avoidance and fetishes, we are bound to feel bad.  And probably for a while.  This is a part of healing and it is to be embraced and understood.  Then real and lasting progress may occur.
  5. A toolbox of "interventions" is what makes therapy work.  Though such a toolbox is important to possess, as is knowing when to use its contents, non-specific factors account for the lion's share of progress in therapy.  These include the personalities and styles of the therapist and client, and the quality of their relationship.  In spite of all our technological advances, adequate time, good listening, a deeply trusting and understanding relationship, and the ability to communicate from the client's experience are the most fundamental components of good therapy.  Without these your toolbox is useless.
Orthodox positions usually derive from economic, political, legal, and even religious points of view.  In reality these may have little to do with a heartfelt, caring and professional relationship between two human beings.  To the extent that such points of view are given space in the therapy room, we may impair the healing process which is before us.