On the Analysis of Mental Health and Psychotherapy

Bernard Guerin:  Interviewed by Marcela Ortolan for Boletim Contexto: (magazine of the ABPMC, Brazil). Extracts from the English version.

MO:  You have just published the third book of your “rethink” trilogy, “How to Rethink Mental Illness”.   Could you tell us about your mental health conceptions?

BG:  This book follows from the other two books by expanding on what we mean by people’s ‘environment’ and applying that to the question of mental health.  People’s behaviour is shaped by their environments so ‘mental health’ behaviours are presumably shaped by bad environments.  If we want to change those behaviours we must change the environments.  The concept is an old one: that ‘mental health’ behaviours are just normal, regular behaviours we all do but they have gone wrong or become exaggerated from bad environments, and at some point become dysfunctional.

The tricks, therefore, are to first describe the behaviours typically labelled as ‘mental health issues’, then describe those environments from which the common ‘mental health’ behaviours arise, and last, describe the common functional relations which have been set up between these two.

For the behaviours, I ‘deconstructed’ the DSM to find all the behaviours which are listed in the criteria of the main DSM ‘disorders’ (Table 4.4).  This enabled me to see the actual behaviours which are observed and used in diagnoses.  As expected, most are common behaviours but which have been trapped in conflictual environments (Table 4.1) and either remain chronic or get exaggerated (“Shocked, blocked and locked in!”).  I was also able to suggest a tentative new way of grouping these ‘raw’ behaviours, but into 9 functional groups (Table 4.5) rather than topographical or disease-based groups like the DSM.

For the environments, I looked at a broad range of natural environments or contexts: social relationships, cultural, historical, the opportunities available to people, and economic (Chapter 2).  These are all vital contexts for shaping any of our behaviours.  I then also explored some more specific contexts in which people live and have their behaviours shaped, contexts of: oppression (women, those in poverty, refugees), devastation (Indigenous peoples), and modernity.

The latter was interesting because modernity is the major context in which we all now live, and I suggested that many of the common ‘mental health’ issues arise purely from these recent conditions we are forced to live within (Table 5.2).  The contingencies of modernity arise from:

  • changing the majority of our social relationships from being family-based into relationships with strangers who have no other obligation or responsibility towards us, so we can only influence them through money or other strangers (police, courts, etc.)
  • the imposition of capitalist resource distribution methods into all facets of our life, thus changing all our contingencies between behaviour and outcomes (Table 5.1)
  • the use of stranger-run bureaucracies to shape 90% of our behaviour with specific patterns
  • the change from family-based patriarchy contexts (Freud) to societal or stranger-based patriarchy which has new social properties (and in some ways worse!)

For the functional relations between these environments and behaviours I noted that most of the ‘mental health’ issues involve functional relations which for various reasons are not easy to observe (Table 2.1).  This means that psychiatrists and others have simply ‘not looked hard enough’ for the functional relations and do not have the methods to do so (social anthropology does a better job of observing real environments).  The trap is that when you cannot observe easy functional relations then attributions are made to hypotheticals such as personality, brain, DNA, evolution, race, etc. (Table 1.1), or in the present case, to fictitious underlying ‘mental diseases’ which have neve been found.

So what this amounts to is that psychiatrists and psychologists since the late 1800s have been given only those clinical cases in which functional relations are difficult to observe without spending a lot of time observing the person in-their-contexts.  These professionals have not had the time to do this (that is not their fault) so abstract ‘causes’ and theories have been invented in psychology and psychiatry to fill the gap. Other cases of life conflicts and problems are given to social workers, life coaches, counsellors, religious authorities, or are just dealt with within friendships and family.

I will give some examples to make this clear.  If a person is in crisis (normal crying and anxiety) because they have a large debt then the functional relations are easy(ish) to see and they will be referred to a social worker or financial planner probably to deal with these.  If a person is too anxious to go out of the house because of a dangerous dog loose on the street, then it seems there is an easy functional relationship for this conflict, and we would get the dog catcher from the local council to fix the problem or ask the owner to lock the dog up.  But if a person cries a lot ‘for no reason’ and is too anxious to go out of the house but cannot say why, then we cannot see any easy functional relationships, and that is precisely when they will be referred to a psychologist or psychiatrist.

MO: So how do these analyses make us rethink mental health and illness?

BG: Mental health issues, therefore, are merely those attempts to solve normal life problems which become trapped or exaggerated in bad environments and have difficult-to-observe functional relations.  Otherwise they are no different, and are still just behaviours shaped by functional relations in our worlds.  They do not form a special class of behaviours at all and there is no special underlying ‘disease’.  If there are patterns in the behaviours, as the DSM suggests, then that is because the environments are patterned or structured.

One common case of difficult-to-observe-functional relations is that of language use.  We rarely know or can observe the social-functional relations which lead us to say what we say, so uses of language which have become dysfunctional will be common and will likely be referred to psychologists or psychiatrists for treatment.  This shows in the huge increase in cognitive (language) behaviour therapies and the emphasis in third-wave therapies on dealing with normal language uses gone wrong.  But in these cases we need long and hard observations of the social relationships which are shaping what we say and think; who are the audiences for our thoughts and talk?   Who has shaped our thoughts?  Who in out lives are shaping contradictory thoughts and causing conflict?

The message for us from all this is that cases of ‘mental illness’ are precisely those with difficult to observe contingency relations, so a lot of time and participatory observation are needed to unravel the functional relations arising from these normal behaviours which have been in bad environments and therefore become chronic or exaggerated as the initial functioning became dysfunctional.  Behaviour analysts have the analyses to deal with this best but they have been too immersed in micro-functional analyses and not the broader contexts for human lives, and they have not used participatory methods for better contextual observations.  My research all works by participatory observation methods with people with DSM diagnoses and describes their life contexts closely over time.

MO: Recently you published an article in a free-access Brazilian journal, Revista Perspectivas em Análise do Comportamento, about how different psychotherapies work. In that article you looked at the psychotherapist’s behaviour and discovered that different psychotherapies are very similar.  Based in your studies of mental health, do you think that we should change our way of doing psychotherapy? In what ways should changes occur?

BG: I have some radical suggestions for the future of psychotherapy, but let me give some background first.

The paper you mention follows from the mental health book, and would have been included if I had done the analysis earlier.  The question was: if ‘mental health’ behaviours are just normal behaviours shaped by bad environments but which have gone wrong (becoming chronic or exaggerated) and dysfunctional, then what do psychotherapists do to change these?  I assumed that most psychotherapies are effective in some ways (they cannot all be totally misguided!) but that the ‘theories’ and words we are given about what is happening in therapy are probably fictitious to a large extent (but well-intentioned).

What I did was similar to the ‘deconstruction’ of the DSM which I described earlier to you.  I got two of the most well-known textbooks on psychotherapies and listed out all the goals of each therapy and all the behaviours used in the therapy.  This gave me a big list to which I then added by reading more psychotherapy textbooks, reading books by the therapists themselves, reading transcripts of the therapies, and watching a large number of videos of these psychotherapies in action.

So I compiled a large number of therapy goals and behaviours from 19 of the most well-known therapies, including psychoanalysis, CBT, ACT, narrative therapy, DBT, feminist therapy, etc.  I then discussed how the ‘theories’ and ‘concepts’ from each of the therapies could be seen in a common behavioural/ contextual frame.  What I found was that there was a huge amount of similarity once we removed the theoretical approaches away from the words being used and looked at the concrete behaviours.

To give an example: Existential therapy talks about an important goal of achieving ‘authenticity’ through therapy.  In a contextual sense, this means that the person should have a way of thinking (that is, a way of talking) about themselves and their life which is acceptable or explainable to their main life audiences.  This becomes conceptually identical to narrative therapy’s emphasis on building and modifying the stories which people tell about themselves to their audiences, and to Jung’s emphasis on finding new ways to think and talk about ‘self’ during a process of ‘individuation’.  In all these cases, and some more, this is a process of re-shaping a person’s language use when talking about themselves so this will be maintained by their main audiences (who do not have to actually agree with it, notice, just shape it; you can shape someone’s beliefs by disagreeing with them).  This social re-shaping in therapy is accomplished by their therapist of course.

To follow this example to the intervention stage, people mostly have conflicts and problems with their ‘stories about themselves’ (their self-images) in these life contexts:

  • when the stories do not match reality
  • when the person is trying to deal with multiple contradictory audiences (important people in life who expect—apply consequences for—different stories about who you are)
  • or when the stories are fine but they do not lead to the resources needed in life (telling about who you are in a job interview and being honest; or stories from earlier in your life which are no longer being useful)

So despite the different words from Existential Psychotherapy, Analytic Psychotherapy and Narrative Therapy, therefore, they are all really about re-shaping our verbal behaviour of ‘self’ through the use of the therapist as a new audience.  Working with the therapist on this is good because there is a fresh audience to work with so change can occur, but it is also bad because the natural audiences “at home” might be more powerful and so the shaping fails to maintain or else causes even more conflict.

What I found doing this sort of translation work was that all the therapies were very similar in both their goals and in the behaviours they used within therapies, once all the theories, words, marketing, and explanations were ignored.  The following were the main focus of all the therapies, even though they had somewhat different procedures and even though they used very different theories, words and marketing to ‘explain’ these:

  • the therapist-client social relationship
  • modeling, role-playing and homework
  • problem-solving
  • dealing with social relationships
  • dealing with thinking
  • dealing with talking
  • looking at wider contexts

All the therapies were doing these to a greater or lesser extent, and in different ways.  The therapist was the audience for shaping most of these, which again raises questions of how these maintain when the client goes back to their old audiences and life contexts.  I’ll say more about this below.

I will finish with one other big consideration from this paper and the book, to put therapy into a historical perspective.  The paper finished with a comparison to the goals and behaviours occurring in social work practice, and found that social workers were doing almost identical procedures but in slightly different ways and with different words to describe them (‘reframing’ covered a lot of CBT).  What they did do better than psychotherapists was that: (1) they went into the people’s life contexts more to observe, participate and intervene rather than stay in an office; and (2) they considered the economic, opportunity, political and patriarchal contexts much more than most therapists (except feminist therapy in some cases).

What this suggests is that there is historically no longer a ‘special’ role or place for psychology and psychiatry, since my behavioural/ contextual analyses suggest:

  • they are not doing anything special or unique in therapy
  • there is no specialized domain of mind, soul or psyche anymore
  • there are no special ‘diseases’ leading to the mental health behaviour, just the bad environments which need changing

It could be suggested that psychotherapies do have a unique emphasis on language issues since CBT (cognitive = language use) and third-wave therapies focus on this.  However, I also suggested in the paper that this emphasis on language could have been developed for another reason: to deal with the problem of how behaviour which is shaped by the therapist can maintain outside the office and back in the home.  If therapists participated more in the concrete lives of clients, as social workers do, then the behaviours could be shaped directly in those environments and by the people who are likely to be involved normally.  The emphasis on cognitive or language shaping might in fact only be a way of trying to guarantee maintenance outside of the therapist’s office.

Another historical leftover is also the large emphasis in all psychotherapies on the therapist-client social relationship.  This is obviously important but in fact only arises because they are two strangers in a contractual relationship—they do not know one another.  When family, community or churches were dealing with problems then the main people involved would already have a relationship and actually know most things about each other.  That is, the emphasis on building a therapist-client social relationship is an artifact itself of modernity.

You asked about what I see as changes for psychotherapies.   So the future I envisage might be this: that people will still have problems in their environments and try to change them with normal behaviours which in bad environments then become chronic or distorted and lead to further problems and dysfunctions.  To change these ‘mental health’ issues, however, we need experts who specialize in the typical life environments and how these lead (their functional relationships) to problems.  We do not need specialists in general psychology, psychiatry, social work or even behaviour analysis.  This follows from behavioural/ contextual analyses I believe.

For example, if a young person has problems with drugs then we do not need a generalized ‘expert’ in human behaviour or the mind, we need an expert in those environments which lead to drug problems in young people and how we can change those environments.  Such a person will have good participatory knowledge of the cultural, economic and relationship problems based in a good understanding of modernity, rather someone with general knowledge of an abstract human ‘mind’ or theories of cognition.

The days of the generalist psychologists, psychiatrists and other ‘mental health’ professionals might actually be over.  They will morph into specialists dealing with common bad environments or contexts which lead to conflictual and ‘locked in’ dysfunctional behaviours.  They will have participatory experience in those environments, experience in analysing the complex social strategies involved,  and work with the communities, not ‘on’ them.

 

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