Dr Vaughan Bell tweeted the link to my previous post and commented on neatly packaged psychology. I want to comment on it in this post.
Here is Bell’s tweet.
Interesting subsequent question as well: why has the mental health world become so characterised by presenting neatly packaged guides to 'correct' talk and language use that are seemingly oblivious to complex interpersonal contexts in which communication occurs?
— Vaughan Bell (@vaughanbell) August 23, 2021
and I think it raises a very important point. Psychology is losing engagement with complexities of the individual encounter. Communication, which is governed by more-or-less rules, is constructed as if it were all-or-nothing. Say this, you will be fine. Say that, you will do badly.
I suspect psychology is going the way of medicine. There is much literature on proceduralisation of medicine, done mostly under the banner of quality. That is to say, if all medics do the same thing in the same circumstances, they will have done well. Obviously, questions about treating a unique person not circumstances could be asked, but procedure it is anyway.
Now, is psychology following the same path? Let me offer two stories. The first is about teaching psychologists.
I taught graduate students in psychology for years. One of my classes was on clinical communication. It was a practical sort of class, so we had a lot of role play and, for the most part, I played a patient who sees a psychologist for the first time.
Over the years, I saw a very clear pattern. Whenever I cooperatively played along, immediately answered questions, always offered enough in what I said, the interviews went reasonably well. The students were always keen to consider the form and the order of the question the ‘clinician’ asked. Inevitably, the students drew upon the rules of clinical communication (even after discussing time and again the nonsense of banning closed questions, the students would avoid them at any cost), trying to paraphrase, mirror and whatever else. (Incidentally, whenever I asked later why they paraphrased, the answer was always the same – I don’t know, we were told paraphrasing was good).
Yet, often the patient (i.e., me) chose not to play along. I took time to answer, sometimes became silent for an extended period. I would challenge the questions and the assumptions behind them, often refusing to answer, laughing at them. Often, I would say I had no answer to the psychologist’s questions. Whenever I did this, the atmosphere in class changed completely. The clinician would panic into either doing nothing or doing random things (like snapping fingers in front of my face, throwing me out, shouting at me etc. etc.), the rest of the students would breathe heavy sighs of relief that they were not subjected to such treatment. The free-flowing discussion was gone, getting the students to speak was a chore.
The reason is obvious, isn’t it? There was nothing to paraphrase or mirror. Silence was crushing, while the fear of asking another question was palpable. What do you ask if patient doesn’t play by the rules? The future clinicians’ inability to adapt to the situation was quite astonishing. Before me no one taught them they could simply wait for an answer in silence. They somehow didn’t understand that saying something private, shameful, difficult might take time.
Of course, they were loath to believe me, so I told them about a patient of the Polish psychiatrist (and psychotherapist), Bogdan de Barbaro, who told a story about a session during which de Barbaro said something like: ‘I don’t know what to say, so let’s just sit together’. When all else fails, you can simply be there. The patient’s story was one of gratitude for the presence. My students were shocked.
But there’s more. Whenever I didn’t play along and became a ‘difficult patient/client’, the students inevitably asked for simple answers: what do I say? My answers were always something like: I don’t know, there cannot be a simple answer to such a question. Rather, you should consider what you want to do, where you want the conversation to go. What do you want to achieve with what you say?
My response inevitably resulted in disbelief and accusations that I was being difficult. There must be a simple answer, there must be a procedure, a simple pattern the student will be able to implement and Bob will be their uncle. Why can’t I simply say? No matter how much I explained context, communication goals, all that was rejected, the students, about to enter their professional (often meaning clinical) work wanted a procedure.
And here we come to the point of this post. This is at least one possible source of psychology losing sight of the individual. There was a palpable push for, we could say, technologisation (the term was coined by Norman Fairclough and meant something different from what I want to suggest here) of psychological discourse. In the students’ narratives, psychology became a conveyer belt with patients approaching and leaving the psychologist’s station. When at the station, the psychologist will offer an appropriate treatment package, having selected the appropriate communication procedure. Just as Captain Janeway would order evasive pattern delta, the psychologist will bring up communication procedure 3.
The drive to offer an easy solution is so clear that even though the study of perceptions of phrases referring to suicide (I discussed it here, you will also find the link to the study itself) showed that ‘commit suicide’ was very divisive and many people used it, the authors of the study still decided to recommend banning it. No context, no negotiation, let’s just offer a 0-1 rule, which we, of course, happen to like. Don’t think, just don’t use it.
And here we come to the second story. A few years ago, I was on the recruitment panel for specialisation in clinical psychology (equivalent of UK’s doctorate in clinical psychology). At interviews, very quickly the panel observed that most of the applying psychologists (already working in clinical roles) were reporting using tests (time and again the same tests appeared). When we enquired, one candidate said that their hospital (through medics in charge of wards) was uninterested in an interview or any other stupid talking, they were interested in the ‘objective’ results of an objective test (for which, incidentally, the hospital could charge more for the test). The psychologists obliged and provided what was becoming standardised care for the patient.
And here you see the beginning of a feedback loop. As institutions required a standardised approach to the patient, psychologists provided it, while trainees wanted to get it. The fact that I was teaching them to talk didn’t matter – they still wanted a procedure.
And indeed, they do get it. I have written a few times about communication guides both in psychology and in medicine. You must say this, you must say that, ask open questions, paraphrase and mirror (just don’t ask them why), and, ideally, lean forward (it is true advice). To complete the picture, Twitter provides clinicians with daily recommendations on what they should or mustn’t say.
In such a way, we come to a paradox. With the push for more of rigid patterns and communication procedures, you will also read about patient-centred care (in medicine) and about social context (in psychology). And somehow the fact that these two tenets are contradictory is lost on those asking for the way to square the circle.
The moment you introduce an all-or-nothing procedure you lose the context, you lose the ability to speak to me, Dariusz, and not your generic patient. There cannot be communication procedures, there cannot be communication chunks you will assemble to use on your conveyer belt. You must understand that communication is contextual, here and now, it serves attaining your communicative (and other social) goals.
And as I write it, I am reminded of a famous Polish professor of psychiatry. When I was an intern in the clinic in Krakow, I heard a story after a story of his, shall I say, unique way of speaking to his patients. And so, patients reporting delusions would apparently have heard something like:
What kind of fucking nonsense is that?
(For those of you who speak Polish, it was “A co mi tu pan/i będzie pierdolić?”). Except that, so the stories invariably went, he said it in a way that not only were his patients not offended, but they loved him. He was a very popular shrink.
When I told the story at a conference some time ago, everybody was horrified…..Clearly, he was uninterested in communication procedures.
And here we come to Vaughan Bell’s question. How did it happen? It happened because psychology, as a set of social practices, is subject to economic and ideological control (often from outside psychology). In order to satisfy the controller, you must change the way you practice psychology. Communication patterns help you make such a change. Very quickly, you must start teaching your trainees the new way, which by that time became the right way. If your hospital is paid by the test, you are more than likely to do tests, as they become the current technological solution. If the trick is to apply the same communicative strategies, you will simply learn them and reproduce to your heart’s delight. You quickly realise that your context talk is not much more than orthopractic display behaviour.
But I’ll end with one last story. One of the candidates worked in end-of-life settings, including with patients about to die. I asked her how she worked with them. Her response was something like:
I can’t do much. So, I mostly sit down and hold their hand.
I was smitten by that answer. This is how you resist the new context-free technological psychology.