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21st April 2016

‘Evidence Based’ Psychotherapy in the House of Cards.

The ‘Sciencey’ thread of this blog is partly a description of the context within which art therapy has to survive.

There are fashions in psychological therapies, (like anything else people do). Cognitive Behaviour Therapy, (CBT), demonstrates when fashion becomes tyranny.

'Evidence Based' practice sounds like an unarguable good doesn't it? We legitimately want to know if something works before paying for it, and are led to believe that Scientific Research will give us reliable yes/no answers to that question.

The research into psychology research demonstrates that the accuracy of its yes/ no answers is in fact less than you’d achieve tossing a coin to answer the question.

A key concept in the scientific method is reproducibility: repeating the same experiment should yield the same evidence, right? Wrong. This was recently tried with 100, very 'credible' peer reviewed psychology research publications. Less than 40% of the original research findings were confirmed. Our evidence is a very shaky house of cards indeed. (This seriously shocking fact can be verified, as reported in 'Nature', in 2015 here).

Valid ‘evidence’ is defined in a bizarrely inappropriate way within the house of cards: The Randomised Control Trial, (RCT), is believed to be sole arbiter of ‘The Truth’. RCTs isolate and compare single variables. Nothing to do with human beings is that neat. You can't learn anything meaningful about a wave by putting a bit of one in a bucket and weighing it. Yet this is the 'gold standard' evidence by which psychological therapies are rationed by state services. Its’ why you will probably not be offered art therapy by your GP if psychological therapy looks like it could help you.

CBT, to play by RCT rules and get superficially ‘sciencey’ ‘evidence’ purported to be a ‘clipboard’ therapy, (i.e. allegedly  identical therapy ‘scripts’ were trotted out to experimentees,), so there was no variation between therapists: ‘treatments were ‘identical’ so they had their ‘single variable’: whether CBT was offered or not. (Of course this assumes that the ‘Depressions’ being treated were all the same too…)

Even then, The National Institute for Clinical Excellence, found in 2006, (in very small print), that ‘there was insufficient evidence to determine the efficacy of individual CBT for depression compared to either pill placebo (plus clinical management), or other psychotherapies’

Overwhelmingly, psychological therapies research evidence shows that working alliance is the key to efficacy. Many CBT therapists know this and have the necessary skills. I have many friends among them. Some, (especially hastily, narrowly and formulaically trained ones), don’t. People respond to relationships, not scripts, and can tell the difference. Who’d have thought it?

Thousands of people in despair, distress and disturbance are failed, (and often left feeling patronised, unheard, invalidated, and angry), by the CBT lobby’s simplistic hubris, misrepresentation of the evidence and deliberate exclusion of human and social complexity.

Demanding ‘Happy Thoughts’ from unhappy hearts doesn’t work. If it did, unhappiness is merely a personal stupid choice, and CBT could teach us better in 8 sessions. Inequality, exploitation, abuse, neglect, deprivation, oppression, fear, lovelessness, hopelessness and powerlessness would be irrelevant. Conveniently for capitalism, insultingly to people, that’s what CBT tells us.

The ironically titled ‘Improving Access to Psychological Therapies’, (IAPT, i.e. CBT), programme was funded by The Department of Work and Pensions, not Health, because our depression epidemic is economically damaging. CBT was meant to ‘fix’ broken profit-friendly, unit-shifting, consumer work-drones, and it hasn’t achieved even that.

The backlash to this psychotherapy of ‘blame the victim’ is inevitable, predictable, and probably imminent.

We will no doubt be returning to the subject here. In the meantime, keep thinking those happy thoughts everyone!

ML

The image is House of Cards.  Jean Michel Liotard  (Swiss, Geneva 1702–1796 Geneva)  After François Boucher (French, Paris 1703–1770 Paris)

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16th March 2016

Seeing and Experiencing 3. Bad Dog! Global Catastrophe!

 

Seeing and experiencing: Bad Dogs! Global Catastrophe! 3.

Initially, new events need conscious attention to yield new knowledge or awareness. This usually then ‘sinks’, becoming part of the sieving process applied to newer events. It is not necessarily carried in awareness, but ready to be activated, re-cognised, by a ‘fit’, a detected pattern.

The function of the system is to make the future more predictable, and our responses to future events better tuned. (‘Experience’ originally meant ‘to have tried or tested something out’). In a way, we are all scientists. Events prompt a hypothesis, based on previous findings. We test it by an experiment: acting. If the results are what we hoped, our hypothesis is confirmed and becomes more embedded. Or it can be invalidated, telling us this situation demanded a different or new understanding. Ideally.

This event/ experience/prediction/ testing cycle works brilliantly for most events most of the time. It builds up a relatively stable internal working model of the world. In every day speech we often, without noticing, use looking and seeing as synonyms for this process of taking in and comprehending. We will say ‘I see’ as shorthand for it. (This was brought home to me by my friend Blind Steve, who, blind from birth, would still say ‘I see’, in this sense, without batting an eye).

Say I was badly bitten by a dog. That event will have its significance marked by a powerful emotional tag, making me avoid dogs. My hypothesis is that ‘All dogs in all circumstances are dangerous’. The emotional response makes me avoid testing it. Not so scientific. So when I say ‘I see’, on the subject of dogs, I may be seeing only my templates (‘schemata’ ), not dogs. To some extent most of us are doing this most of the time.

This is how the ‘sieves’ we perceive through are grown. Like a coral reef, the growing points are tiny compared to the mass and form of the relics of previous growth on which they rest.

 

There are other flaws in the system, of course. If the stability of the model feels easily threatened we will tend to actively defend it against any invalidating evidence.

This is called ‘confirmation bias’: we stop attending to the new, the anomalous, and, frequently, to what is right in front of our noses. Our anxiety to have robust sieves can lead us to over-engineer them to the point that new information can’t get through. Things can get so clogged we barely see anything or anyone outside of ourselves at all, and exist in the dead coral of past experiences, rather than live on the growing tip.

That defensive constriction strangles respiration, the breathing flow between inner and outer that is essential to looking, seeing, comprehending and adapting. It often leads to personal tragedies of unlived life. It can also make us terrifyingly stupid, individually and collectively. I think we can call those poor mental health outcomes. And as any coral reef would tell you, our poor mental health is manifesting as global catastrophe.

 

 

Brain Coral, Jan Derk, Public Domain

So can art therapy save our hides? (In the long run, the planet will be fine). Probably not. But it does embody a practical methodology, working with the grain of the human mind, which opens us to new possibilities, questions assumptions, encourages safe experiments, and nurtures more creative and less destructive ways of being with ourselves, one another and the world. Art making is a way to experience and learn to trust that breathing in and out that keeps us psychologically and creatively alive, autonomous and choice-making.

 

Autonomous? Choice –making? Environmental degradation as a symptom of mental illness?  It seems like we can’t go far down this road before another characteristic of an art therapy perspective emerges: it acts like the political is personal.

 

It’s the intention to make these blogs as plain speaking as possible. They are not therefore referenced or playing by academic rules. I don’t want to seem to claim originality for many of the ideas, and do want to encourage people to find sources, (without doing all the work for them!). Some ideas I am simply attempting to succinctly apply; others are used as starting points. James Hillman, (Archetypal Psychology), did great thinking about experience, George Kelly’s insight about the predictive intent of how minds work has huge implications, (Personal Construct Psychology) and ‘The Internal working model’ derives from John Bowlby, (Attachment Theory). Daniel Kahneman opens scary doors into what makes us humans so smart, yet so terrifyingly dumb. (Heuristics and Bias). ‘Heuristics’ here means ‘Rules of Thumb’, more or less. That statement  was a rule of thumb.

 

 

 

 

 

It’s the intention to make these blogs as plain speaking as possible. They are not therefore referenced or playing by academic rules. I don’t want to seem to claim originality for many of the ideas, and do want to encourage people to find sources, (without doing all the work for them!). Some ideas I am simply attempting to succinctly apply; others are used as starting points. James Hillman, (Archetypal Psychology), did great thinking about experience, George Kelly’s insight about the predictive intent of how minds work has huge implications, (Personal Construct Psychology) and ‘The Internal working model’ derives from John Bowlby, (Attachment Theory). Daniel Kahneman opens scary doors into what makes us humans so smart, yet so terrifyingly dumb. (Heuristics and Bias). ‘Heuristics’ here means ‘Rules of Thumb’, more or less. That statement  was a rule of thumb.

 

The image: Brain Coral. Jan Derk, 2005. Public Domain

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16th March 2016

Seeing, experiencing and escaping from crocodiles. 2.

The image: Crocodile Mummies. Read on and see why.

By JMCC1 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons

Seeing, experiencing and escaping from crocodiles. 

Taking photographs can cultivate seeing, like drawing can. And, paradoxically, also absent us from experience, detach us from real presence. Gazing is a steady, patient attending, unfolding over time. The capturing snapshot may evidence my having physically stood in front of the Taj Mahal, but not that I necessarily looked at or saw it. Documenting an event does not mean we have experienced it: sometimes it actually defends us from experiencing.

The paradox of the selfie is that by stepping into the picture our experience is of taking or being in a picture. The experience we might be having is relegated to a scenic backdrop for our self-regard. Some weddings feel like movie sets because generating the photo opportunity is one of their main functions. The photograph used to function as an authentication: ‘I really did go to the Taj Mahal: they really are married. Look!’ That need for authentication easily becomes the creation of a false, always smiling, self, against a perfectly staged backdrop: a studied inauthenticity that is almost the opposite of experience. We perform.

While I suspect that a sort of ‘total documentation’ via photographs and social media will have unforeseeable psychological effects on how we structure ‘a self’, I am also using this as a metaphor for how if we don’t fashion experiences out of events, or our experiences are invalidated, it is easy to establish, and identify with, a false self. That can create real psychological problems.

The processes by which events become experiences have much in common with seeing and looking. Both demand our active engagement with what happens to happen. Both emerge from a reciprocating movement between ‘outside’: (what we see, hear, notice), an ‘inside’: (How we feel about that, which informs either a choice to act, or feeling compelled to act / not act by a strong emotion), and ‘outside’ again: (what we do, and what happens then).

We are often unaware of how many potential choices there are in this cycle, because we don’t notice it is happening. Noticing requires awareness, a place to notice from.

Experiencing is a braiding of these to and fro movements, through reflection, into an awareness, knowledge or skill that is carried forward. In other words, we are changed by it.

 

What is most likely to disrupt this continual adaptation, development and change is if a highly emotionally charged pattern is recognised, (or mis-recognised), as we sift information. Then the imperative to act short-circuits reflection, seeking new information, or trying other templates. It’s easy to understand the evolutionary imperative: it doesn’t matter what colour the crocodile’s eyes are, or that ancient Egyptians mummified sacred crocodiles at Crocodilopolis. Run, now.

‘Motion’ (and motivation) are written into e-motion. They make us move, propel us towards desired patterns or away from feared ones on the basis of very ‘fast and dirty’ recognition system. (The Buddha identified the psychological dominance of this process as the root cause of human misery.) 

Even for fleeing as stark a threat as the crocodile effectively the danger template may not be enough. Crocodiles are faster than humans on land for long enough to catch one. They aren’t good at cornering though. Running in zig-zags is the best chance. It might be hard to remember that in the circumstances. (Though if you are ever in that situation I hope you will now!). The balance to emotional reactivity is presence of mind.

This is more true when we only believe there is a crocodile, because there was one once. If that keeps happening, (and it can be inconvenient in the High Street), the looking/seeing, events/ experiences system needs some help retuning itself.  A place to notice from, and being more at ease with the to and fro of inner and outer that mediates meaning are helpful, and are the stuff of art therapy. I’ll look a bit more at how this works next.

 

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15th March 2016

Seeing and Looking 1: Look Out!

 

 

Look Out! or, The Enchanted Gaze.

 

Seeing is becoming aware with our eyes: noticing and discerning. We  sift visual information, sieving light reaching the retina through a mesh woven from memories, recognising patterns and identifying anomalies very quickly. Emotional memory ‘sieving’ primes attraction or repulsion.

The sifting happens mostly automatically: we only become aware of what is sieved out as relevant.

Seeing is co-created by light from ‘out there’ and its categorisation in terms of previous experiences ‘in here’. It is a psychological action, but with conscious visual awareness as the last step. We would be overloaded without the filters but, especially as we age and have seen more and more things, and have more and more dismissive categories, we can easily sieve out and dismiss our capacity for enchantment and find the world has gone flat.

In looking, we direct our eyes, gaze steadily and with intent. It is also something we do, an action. We often don’t notice the choice in where, how and why we direct our gaze. Learning to be as conscious as possible of looking as an activity enriches being in the world: one of the first things most people notice when they try is that ‘out there’ is fascinating, and often breathtakingly beautiful.  Repeated experiences of this, in time, percolate back to the sifting process of seeing as the internal model adjusts. We can prime ourselves to see beauty: the more you look the more you see. Life is better. Educated looking is the best succour and consolation in depression I know. Art is the best teacher of looking:

To see a World in a Grain of Sand

And a Heaven in a Wild Flower

Hold Infinity in the palm of your hand

And Eternity in an hour

Looking and seeing are processes, a braiding of visual events and what we bring to them, a reciprocal, back and forth interaction of ‘inner’ and ‘outer’, each affecting how we experience the other. These are dynamic, fluid, and complex processes, and therefore perhaps more open to change once we are aware of them, than more fixed systems of perceiving the relationship between ourselves and the world, for example pain. (Pain transmitting nerves are either ‘on’ or ‘off’ and are not evenly distributed. A pin in your back might not hurt at all, but one in your lip will, and the level of discrimination is hardwired. We can’t direct it. Most aspects of looking and seeing we can.)

Art Therapists have not generally taken a great deal of interest in the possibilities for psychological change and emotional relief in observational art making, and TV shows like Landscape Painter of the Year even less so. I have benefited from it enormously personally, and seen others do so.

Images are sometimes praised for ‘capturing’ something. : it sounds aggressive and possessive, like the ‘something’ has been snared, or brought down with a tranquilising dart. Perhaps educating our looking and seeing through image making allows us to be captured, (captivated even), by something instead. That feels like coming up for air if inner immersion is threatening to sink us, as it does in depression.

 The image: Reflections and a slightly puzzling picture seemed appropriate.

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14th March 2016

Welcome to the insiderart blog

The Insider Art blog will expand on what we are up to, and the content of the site, but we are aiming to do a bit more than that.

“Art therapy” is a way of thinking. We were once asked by an NHS manager “What would a mental health team gain from having an art therapist?” The first response that came to mind was “Someone who thinks differently”.

It is a perspective in which:

People are seen as innately, resourceful, resilient, creative, and deserving of respect.

Distress and disturbance are normal parts of life. What are called mental illnesses could equally well be called extreme experiences of the human condition.

Creativity and the arts are deep resources that should be equally normal parts of life.

People are born to relate to one another. Art Therapy is a way of working through relationship and the arts to alleviate suffering, increase well-being, put people in touch with their own resources and live life creatively.

Although the arts and relationship are innately human, their use in this way is a skill. Part of that skill is a clarity about service: we are not in service to “art” or medicine but to the well-being of the people we work with.

In other words it is the world seen as if people mattered, and as if the arts mattered.

Being in service to imagination, compassion and the arts demands clear thinking and plain English. Neither the arts nor psychotherapy are particularly good at these: both often use languages that exclude rather than include. We will do our best to explore complexity in comprehensible, and we hope interesting, ways.

We also intend to be entertaining: silly, humorous, irreverent and digressive, as the subject and mood take us.

Let us know how we are doing, and suggest questions we might be able to helpfully tackle.

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Malcolm Learmonth
Karen Huckvale

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