Editor’s Note: Over the course of several months, Mad in America is publishing a serialized version of Sami Timimi’s book, Insane Medicine. Part 1 of this chapter was published last week. In Part 2, he contrasts the folk psychology brands of CBT and McMindfulness with empowering frameworks such as Open Dialogue and the Power Threat Meaning Framework. Each Monday, a new section of the book is published, and all chapters are archived here.
Western therapy brands are extensions of Western folk psychology
As with psychology in general, the “technologies” that structure models of psychotherapy are essentially cultural constructs that have been developed in a particular Western cultural context and researched in predominantly Western societies, raising questions about their suitability when working with communities who come from other backgrounds.
Pretty much all the models we use have been developed in a Western setting. Some can trace their origins to non-Western cultures, for example “mindfulness,” but in order to become a “psychotherapy” it has to be McDonaldised. More on that later.
The high dropout rate from mental health treatment for particular groups, such as those from a low socioeconomic or ethnic minority background, may reflect a mismatch between systems of meanings employed by the mental health professionals and those more commonly held by those groups.
Actually, calling these psychotherapies “technologies,” is giving them more legitimacy than they deserve. There have been no breakthroughs or innovations that have improved outcomes from therapy. In fact, most are simply versions of Western folk psychology. They are basically what make up the Western bourgeoisie’s idea of common sense, with an exclusive language and rules (to create a guild with boundaries) and the cheek then to call their model “scientific” (well, they have to, in order to fit in with the dominant cosmology of the West).
Take the king of the therapies, CBT. Google CBT and you get something fancy sounding like, “Cognitive behavioural therapy (CBT) explores the links between thoughts, emotions and behaviour. It is a directive, time-limited, structured approach used to treat a variety of mental health disorders. It aims to alleviate distress by helping patients to develop more adaptive cognitions and behaviours.”
CBT basically focusses on thinking patterns, and patients are encouraged to analyse how their thinking affects their feelings and then behaviour. It looks for examples of “dysfunctional” thoughts that result in the patient feeling worse and then behaving in a way that doesn’t help. So, if you’re depressed, you think about how bad things are and notice things that go wrong and interpret most things negatively, which confirms how bad you feel, and so you feel hopeless, and because you feel hopeless you don’t do things that might make you feel better, like going out and meeting friends.
The treatment, then, involves teaching you to recognise these “dysfunctional” thoughts and challenging them. Take away all the fancy pretence, language, and rituals and it boils down to, “stop focussing on the negative.”
More than that, it contains certain popular Western-centric ideas. It views emotions as something suspect, to be managed and controlled by promoting a rational, logical, scientific approach to thinking, which can then be used to control our emotions and our behaviour. Improving your thinking and logic is how you regain control of those pesky irrational emotions. It also has a managerial flavour to it, with the idea of analysing the components of the problem (the thoughts) and essentially using your will power to apply a better thought to the situation.
Now there is nothing wrong, per se, with CBT. Like I said, the evidence shows that it fares no better or worse than other therapies, but the technical aspects have a negligible impact on outcomes. However, there is nothing more to it than a “tarted up” form of Western common-sense.
Take another popular example—behaviour therapy. This is used for fears, phobias, obsessive compulsive phenomena, and other anxieties. Like CBT, versions of it exist for most psychiatric conditions. If you have a phobia of dogs, for example, then two forms of behaviour therapy could be used.
One is called “graded (or “systematic”) desensitisation” and involves exposing the person to things to do with dogs in gradual steps, starting perhaps with images, then toy dogs, then looking at a dog at a distance, then closer, until you first stroke a small placid dog etc. Each step in the “treatment” gets closer and closer to the feared object, so that you gradually acclimatise.
The other approach is called “flooding.” In flooding, you essentially go for it all in one go, exposing the person to the feared object (in this case a dog) and supporting the person to stay around the dog for as long as it takes for their fear level to come down. Behaviour therapy, in a nutshell, is a treatment that is no deeper than the common phrase “face your fears.”
Counselling involves empathic listening. Many therapies have an idea of catharsis—an extension of the confessional. Stripped down to their essentials, our most used therapies are just fancy versions of Western folk psychology. They contain nothing special. It’s therefore not surprising that in these days of mass therapy we are seeing no particular breakthroughs that radically change outcomes.
This brings us to mindfulness. Is this not an example of a popular psychotherapeutic approach that comes from Eastern philosophy? Mindfulness refers to training the mind to move away from thinking (such as about the past and future) and instead focussing on fully attending to the here and now experience.
As a therapeutic approach, it’s become popular as a standalone treatment, as part of promoting “wellness,” as a treatment for work stress, and as a component of what is referred to as “third wave” CBT and other formal therapy models. It is claimed to be have been researched and found to be “effective” and “revolutionary” by its advocates.
Anything that offers success in our unjust society without trying to change it is not revolutionary. It may help some people cope, but it could also accidentally make things worse for others. Mindfulness implicitly says the causes of suffering are disproportionately inside us and so joins the market of mind fixers, feeding the beast that implores us to accept that we are dysfunctional in the way we react to our circumstances.
It isn’t that mindfulness practice can’t help some. Tuning out of mental rumination can help reduce stress and allow people feel calmer and potentially kinder. However, in mindfulness we see what happens when ideas that come from another culture are expropriated. Mindfulness is derived from Buddhism, but has been stripped of the teachings on ethics, philosophy, and the spirituality it embodies that promotes the liberating aim of dissolving attachment to a false sense of self, while enacting compassion for all other beings.
Mindfulness does not exist as a stand-alone practice in Buddhism, but in its Western therapeutic form, it has been extracted from its origins, given a label to enable branding, and packaged into a discreet easy to ingest “McDonaldised” form and marketed for profit to enable the individual consumer to live better. In this form, it nourishes and refreshes the individualist ego, rather than dissolving it.
By practising mindfulness, individual freedom is supposedly found within “pure awareness,” undistracted by external corrupting influences. All we need to do is close our eyes and watch our breath. With the retreat to the private sphere, mindfulness becomes a religion of the self.
Unlike the Buddhist holistic ideal of expanding our sense of connection to the world we are embedded in, the Western version of “mindfulness” encourages us to be compassionate to our individual self. Westernisation excavates a Buddhist practice, detaches it from its roots, and puts it into a Western folk psychology paradigm that emphasises the individual and de-emphasises their context and social world. Mindfulness, like much of positive psychology and the broader happiness industry, depoliticises stress.
The term “McMindfulness” was coined by Miles Neale, a Buddhist teacher and psychotherapist, who described “a feeding frenzy of spiritual practices that provide immediate nutrition but no long-term sustenance” to describe this crass Westernised marketisation of an Eastern practice.
It is the latest example of how traditions of non-Western, particularly Asian, cultures have been subject to colonisation and commodification since the 18th century, producing a highly individualistic spirituality perfectly accommodated to dominant cultural values and requiring no substantive change in lifestyle. Such an individualistic spirituality links nicely with the neoliberal capitalist agenda of privatisation, especially when masked by the exclusive and mystical language used in the mindfulness literature.
According to research, is mindfulness any better than other therapies, or does it improve outcomes when added as a component of other therapies (such as CBT)? No.
Mental health practitioners are philosophical guides
The science tells us that outcomes from psychotherapy have not improved in the many decades of research into its effectiveness. In fact, some studies have found that in formal trials of treatment outcomes, the popular therapies like CBT had better outcomes in the trials conducted several decades ago than more recently.
In most healthcare fields, it’s possible to see a gradual, and sometimes a sudden, improvement in outcomes. A few decades ago, about half of those who suffered a heart attack died within a few days. Nowadays only about 10% will die in these early stages, thanks to increased understanding of the physiology, leading to better treatments. Average cancer survival years have improved for most cancers, and vaccination programmes have reduced the prevalence and lethality of many diseases. That’s what happens when the technical aspects of care are central to outcomes.
Outcomes in psychotherapy—in fact, outcomes for all psychiatric presentations—have not improved as a result of technical breakthroughs or innovations. A reasonable interpretation of this finding is that mental health treatments should not be constructed as belonging to the realm of the technical. Therefore, the diagnosis, treatment guidelines, and process standardisation found in the rest of medicine is not a rational or evidence-based basis on which to design services for conditions we label as mental health.
So what are we actually doing when we “treat” what we call mental health conditions? If the models we use cannot be thought of as being technical, but rather extensions of folk psychology, what role do mental health practitioners have to play?
Earlier in this chapter I proposed that psychology does not belong to the field of the natural sciences, but rather to philosophy. Philosophy is commonly defined as the study of general and fundamental questions about existence, knowledge, values, reason, mind, and language. Is that not a reasonable definition of what those of us who work in the mental health field engage in when we encounter a person experiencing mental distress or behavioural change?
Given that we have no technical advances that enable us to see the mechanics of the mind at work and so we cannot empirically capture anything that happens between input (environmental stimuli) and output (behaviour and functioning), then all we have is interpretation of what might be going on and how change might happen. All we have are meaning-making frameworks.
Therefore, the most appropriate way to think about what we do as mental health practitioners is, in my opinion, that we act as philosophical guides. Our treatment models are meaning-making frameworks we use to interpret a patient’s experience and a symbolic system for imagining how change might happen. Different meaning-making systems have different implications.
The common philosophical systems we use, like CBT, the medical model, and mindfulness, are derivations of Western folk psychologies loaded with that philosophy’s assumptions, such as individualisation, rationalisation, suspicion of emotions, control of emotions, and surface meanings. These approaches shape the research conducted and the therapies we provide. They are seamlessly incorporated into a commodity driven market economy. They are good for some short-term relief but, like most “McDonaldised” consumables, provide little long-term sustenance.
A market economy requires ongoing selling to sustain itself. It needs consumers to feel a bit better, but not in any sustained way, so they keep coming back for more. Western folk psychology therapies do this function well. The market for medications, psychotherapies, and wellness products more generally, continues to expand without evidence of sustained population-wide improvements. This is perfect for profit-generating markets.
I did say most psychotherapies. Not all of the philosophical systems we use therapeutically conform to the McDonaldised versions I’ve described. Psychoanalytic approaches have delved into the human psyche, opening up the great dramas at play in the universe beyond our everyday consciousness.
Psychoanalytic thinking has influenced our culture more than the other way round, sensitising us to layers of meaning that can develop as our animal instinctive selves clash with the restraints imposed by our civilisations through the medium of our caregivers, giving rise to internal conflicts and tensions.
These deeper layers of meaning are revealed through the language we use, the night and day dreams we have, and the slips of the tongue we make. Our early relationships and our personal interpretation of these early relationships create a “blueprint” that sits beyond our daily consciousness, but subsequently structures our feelings toward others and, thus, our thoughts and behaviours.
Therapy involves a deep awareness of how these interpersonal dramas, present from infancy, keep repeating themselves in subsequent relationships, including the relationship with the therapist. As a philosophical model, the work is slow, possibly punctuated by epiphanies (many can be false epiphanies), involving a “working through” of these deep conflicts in order to develop a better insight that allows you to have more sustaining relationships.
Where I might fall out with some psychoanalysts is that, like everyone else, they have no special access to the inner workings of the mind. It is a philosophy like any other, albeit a more interesting one than the Western folk psychology versions.
The other area of theory that went beyond folk psychology is systemic philosophy. Starting in the late 1950s and influenced by anthropology, systemic theories placed the human subject in a nexus of surrounding relationships that moved from the family into communities and societies. Influenced by several philosophical positions including social constructionism, Marxism, and postmodernism, it spurred on several therapy models that took into account the influence of power, gender, race, sexuality, and politics more broadly.
Systemic theory suggested that the systems of knowledge we use are relative and arise from those who have the power in any society to influence the common social narratives. It understood that we are a product of our broad circumstances, from personal, to family, to broader community histories and practices. This means we have finite ways of making sense of our experiences through the stories our cultures provide us as meaning-making vehicles.
Such a philosophical stance resonates strongly for me, with my understanding of the evidence and an ethic that seems appropriate, humane, and capable of sitting with difference. In this way of imagining, “treatment” may involve helping patients look beyond a consumerist model of care or cure that may inadvertently trap them in patient-hood that requires endless mental health consumption. It also sensitises practitioners to helping patients locate the ills as being external to them and encourages the involvement of a social network to help support improvement.
I have no evidence to suggest any of my preferred philosophies improve outcomes more than others. Unfortunately, systemic theory has itself been branded into “family therapy” or “systemic therapy” and the particular trainings produce “family therapists” who then set up family therapy clinics, or patients get offered family therapy as a brand in the same way they might be offered “CBT.” Branded “family therapy” does no better or worse in research than other branded therapies.
Well, maybe. There is one exception.
“Open Dialogue” is a model of mental health care which involves a family and social network approach where treatment is carried out via whole system/network meetings which always include the patient. It is both a philosophical/theoretical approach to people experiencing a mental health crisis and their families/networks, and a system of care.
It was first developed in Western Lapland in Finland. In the 1980s, psychiatric services in Western Lapland were in a poor state—in fact, they had one of the worst incidences of “schizophrenia” in Europe. The mental health team there, drawing on a Scandinavian model of narrative therapy, developed a whole-team approach to helping those who presented in mental distress, including those considered to have a psychotic presentation.
All the team members: psychiatrists, psychologists, nurses, and therapists, adopted the philosophy of seeing people’s experiences through the prism of human rather than technical challenges. Diagnosis was not used, medication used sparingly and mostly short-term, and the meaningful social network was engaged from early in the patient’s care. Most of the meetings enabled an open exploration of the possible meanings that arose from the stories patients and those around them told, to create a collaborative effort to make sense of what had happened and what might help.
After 20 years of running their regional mental health service using these principles, they documented the best outcomes for psychosis in the Western World. For example, around 75% of those experiencing psychosis had returned to work or study within two years and only around 20% were still taking antipsychotic medication at two-year follow-up.
What is particularly unique about the Open Dialogue is that it is not an alternative to standard psychiatric services or an add on (such as having an Open Dialogue clinic), it is the psychiatric service in Western Lapland. This has afforded a unique opportunity to develop a comprehensive approach with well-integrated inpatient and outpatient services.
Working with families and social networks, as much as possible in their own homes, Open Dialogue teams help those involved in a crisis situation to be together and to engage in dialogue. It has been their experience that if the family/team can bear the extreme emotion in a crisis situation, and tolerate the uncertainty, then, in time, shared meaning that is useful for all can emerge. There is no attempt at didactic teaching this or that strategy, and therefore a much lower risk of disempowering the patient and their families.
The incredible success of Open Dialogue has resulted in its export with a growing portfolio of training and research developing in many countries. I confidently predict that they will not replicate the findings and success found in Finland. This is because Open Dialogue is becoming branded, and so people are setting up Open Dialogue clinics to take referrals or be researched. They are not being set up as the service. They are not being set up in the same manner it was in Lapland as a service, owned and authored by the staff of that service and with a different philosophy to the technical diagnostic model that dominates other mental health services.
Another philosophy worth mentioning: The “Power Threat Meaning Framework,” published in 2018, was developed over the course of five years by a group of UK-based senior psychologists and service user campaigners to serve as an alternative to models based on psychiatric diagnosis.
The PTMF summarises and integrates a great deal of evidence about the role of various kinds of power in people’s lives, the kinds of threat that misuse of power pose to us, and the ways we have learnt to respond to those threats. The PTMF can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient, or “mentally ill.”
It highlights and clarifies the links between wider social factors such as poverty, discrimination, and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour that can sometimes then emerge. It also shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning, and identity.
As such, it is a philosophy that radically departs from medicalised and consumerist friendly approaches, creating meanings that are not reduced to “symptoms” or “disorders.” Instead, it looks at how we make sense of these experiences and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear, and guilt.
There are others who’ve created viable whole service models that use a more context-rich, human-relational guiding philosophy as an alternative to the individualising, technique dominant approaches. For example, some feedback-based services, such as that developed by Bob Bohanske in Arizona or Birgit Valla in Norway, have done away with diagnostics and instead use a model that incorporates ongoing feedback from the patients and families they meet, so that the therapeutic process is constantly co-constructed as a joint effort between patient, their network, and their therapist(s).
Alternatives are there. The evidence is there. Technical diagnostic philosophies do not work in mental health. They make things worse. They trap patients into becoming long term consumers. It’s time to scrap them. Totally.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.