Sunday, November 27, 2022

Yet Another Problematic Example of the Medical Model of Mental Health

Was working this week on an article about the concept of setting personal boundaries. While doing research on the topic, one of the top web search results I found was this one-pager FAQ sheet. It was developed in 2006 by and is hosted on a UC Berkeley website.

The second sentence about personal boundaries says this...

"A person with healthy boundaries can say “no” to others when they want to"

Note the heavily lifting done by the word can. If you can, you're healthy. If you can't, you're unhealthy. As I've pointed out numerous times over the years*, the barriers preventing a person from being able to say "no" effectively might originate from any or all of factors including..

- Issues with self

- Issues with community 

- Issues with broader society  

 People in positions of low power are disempowered from saying no effectively. They don't have the luxury of privilege. They are at high risk. Saying "no" sometimes isn't just ineffective - it can be downright dangerous. More dangerous than the already existing harm from the "no" being ignored. It could risk physical or emotional abuse. It could result in getting fired from a job. It could risk smaller but still impactful microaggressions. And these are often people who do not have the privilege to just go somewhere else when these things happen (which is a topic deserving it's own article).

Do we call these people "unhealthy"? Are the poor "unhealthy"? Are marginalized people of any or all kinds "unhealthy"?

I hope it feels uneasy thinking about that. We may identity these people as "in distress". But I don't think "unhealthy" is the correct term. Maybe, on some technical level, health does not imply cause. Mental health professionals I've interacted with rely on this technicality a lot. Technically, they say, they know and account for social factors. In practice though...

The term health, in contexts like this, is often solely linked to and heavily implying that the issue is an issue with self. That you are unhealthy and that the tools of psychotherapy and relationship advice are all that is needed to fix you and solve the problem - in this case the problem of boundary violation.

Instead of calling boundary violation "unhealthy", call it what it is - boundary violation. 

Begin with a much more explicit separation of experience from cause, which is often not currently done. Put another way, I argue that, in practice, when professionals say "you are unhealthy" what they are also saying is "you are the problem". 

Much like medical disease, we center the problems within the self. And we focus solutions at the level of self. Not the environment. Not the community. That, in my estimation, is one of the key aspects (not the sole one, but a major one) of what it means to discuss the medical model of mental health and why it's problematic.

All the tools of emotional and relationship aid are aimed at what the individual is not currently doing and what they could/should be doing differently. Which, put another way, is telling them that they are doing it wrong and that we need to correct and fix them until they do it right. Being corrected and fixed is sold as the key to freedom from distress.

I am not opposed to the notion that individual-focused self-change strategies sometimes help. But when it becomes the only thing we talk about, it's a massive problem. Because no, individuals are not the sole and only source of their own problems and distress. Period.

*A tool I developed for helping map out causes between self, community, and society is The Accountability Triangle, available here

Wednesday, November 9, 2022

The Philosophy Cliff: Why Applied Philosophy Matters ... Sometimes

Here's an age-old question about the field of philosophy - why is it useful? 

Can't we go about living our lives, studying the "real" and "more useful" sciences, and be perfectly content? Do the questions of philosophy actually matter? Rather than a simplistic yes or no, my preferred answer is to think of philosophy like checking the air pressure in the tires of a car. 

A person can spend years never checking, or even knowing about, how inflated their car tires are. It might cause certain problems, even severe ones, but it's rarely complete and outright failure. It's the bliss, and danger, of ignorance. The reverse of never checking is checking every day. If we expend all day worrying and checking about air pressure, we'd never even drive the car. It therefore seems, arguably, most sensible to be aware that tires run on air pressure inflation, ask what problems might crop up, check in occasionally, and then otherwise mostly not worry about it.

That, in essence, is how I view philosophy. Except, unlike air pressure, we're not as fully sure about what life runs on or how it works. We have some models and theories, some that seem quite useful and correct. But also, in other places, much less pure certainly (more on that in a moment). These fundamental aspects surely affect us. But, like the car driver, we can also just go about our day, driving the car, living our life, and not even check the air pressure. Not checking may result in some avoidable problems, but it's not, per se, outright essential. Foolhardy perhaps and even blissful at times. 

A brief note on certainty - something doesn't need to be 100% certain to be useful. Many medical drugs, for example, work on correlation alone. Person takes pill. Person, on average, gets better. We don't know why. That might cause problems. But it also might be fine, and so we sometimes just "drive the car" and ignore the underlying questions we could ask.

A main goal of this blog is to show that we can sometimes dive deeper, check questions at the level of more fundamental level of "how this all works", and by doing start avoid certain problems of varying levels of severity. 

I call this the philosophy cliff.

We can live some, or ever all, of our lives at the top level of the cliff. It's possible that the clifftop level is where we seem to naturally exist. We don't eat food by asking fundamental questions about it. We realize we're hungry and we go grab and eat what we understand to be food. That, to me, is living up on the cliff. Sometimes though, we go and check what food is and what food means to us. Questions include...

Where does our food comes from? Is it nutritious? Is it sustainable? Is there suffering along the way? What even counts as "food"? How much health is "full health"?

Some of those answers might affect life at the top of the cliff. Some might not. It might vary from person to person (under the Fundamental Principle of Human Uniqueness). Also note that those questions about food cover a wide range of knowledge, at varying levels of known and unknown, and are knowledge about very different types of things, from chemicals and atoms to economic systems and core human values.

There are almost endless questions about food, depending on how far down the philosophy cliff you go. It is said that all science and knowledge starts as philosophy - as attempts to dive down the cliff underlying the reality of living life. Almost everything atop the cliff - even seemingly certain things, are full of questions if you probe deep enough.

So a question becomes - how much do we probe? How often do we check the tires for the air, metaphorically speaking?

My perspective is that, broadly speaking, a great many avoidable problems occur because we don't check "down the cliff" nearly enough. We take certain concepts for granted and think of them as real and true in our atop the cliff life. A perfect example of this is this recent report about how the US reports on the national crime rate. Consider this quote (edited and condensed for clarity and brevity)...

"We generally talk about - crime is up or crime is down. It's referring to sort of this small core set of what the FBI calls index one crimes. That's murder, robbery, rape, aggravated assault, larceny, burglary and auto theft. Sometimes arson, sometimes not. Someone shoplifting tampons or diapers from a pharmacy counts as a crime. But a corporation stealing millions of their workers' wages doesn't. Tax evasion doesn't.Tax evasion doesn't. Big companies committing environmental crimes? Nope - because those aren't investigated by traditional police. In our system, perpetrators of what we call crime are more likely to be poor people - not because poor people commit more crimes or hurt more people - they don't - but because that's how crime is defined. It's not just which crimes count and which don't, Vargas says. It's also who police target.

On one level, the idea of "national crime is going up or down" feels workable and understandable. But, when look under the cliff of how the "national crime report" is built as a concept, important complications and nuance arise. Deep-seated ideology and bias emerges from what surficially (atop the cliff) seemed quite factual and real. And this happens everywhere, with all kinds of concepts. I'm been slowly compiling examples of such oversights, here on this blog.

As my work on this blog expands, I hope to provide more examples of times when checking "down the cliff" both did and didn't matter (to at least some group's perspectives) across a range of disciplines. I believe it's fairly objective to say the cliff exists, and it's my mission in life is to try and label where we're at exploring said cliff accurately. How often you want to check what's down there, especially in your own personal life, is up to you. 

However, we also live in deeply interconnected societies, and choices made based on certain understandings of reality can and do impact others greatly. Errors in understanding matter, which is why I desire to have the best signage possible about what's deeper down in the cliff, the best ways to explore it, the best ways to handle uncertainty, and so on. Philosophy, in some sense, is the field where such work and guidebooks are crafted.

A key starting point for me is understanding that we do live atop this cliff of deeper unknown questions, for both better and worse. Hence why I built this model. It helps me give some space for valuing and critiquing  what times it's useful to stay atop the cliff, and what times call for us to delve as deep in as needed.


Friday, November 4, 2022

Moving Beyond The "Effective" or "Ineffective" Dichotomy in Occupational Therapy

Today online a community member in one of my support groups asked whether weighted and/or compression materials (such as weighted blankets) were a useful tool in occupational therapy (OT). As a professional OT themselves, they were noting that their professional groups weren't recommending such items as a therapy tool anymore.

The conversation got me thinking about this desire we seem to have for "well, does it work or not?". As I've continually detailed, such questions seemingly ignore the Fundamental Property of Human Uniqueness (post coming soon on that). The idea being that each human has their own unique needs. We can find commonalities but no two humans are exactly alike.

What follows then is my reply to the notion of how we discuss effectiveness in behavioral health and therapy contexts...

Post Reply

The entire paradigm of "effective" or "ineffective" as some kind of binary is absolutely ludicrous, and an artifact of social science being forces to use techniques designed for natural sciences (p-values, etc.)

Thousands upon thousands of anecdotal reports include some people absolutely loving using weights/compression as a tool for self-care (in some but not all situations), and others not liking them at all.

And we're also lacking the context. If a child is watching their parent get violently assaulted every day, a weighted blanked is not the solution for the distress - a better home environment is. But if that same child is simply a bit overwhelmed about a test they actually are equipped to handle, then a weighted blanked to help with a bit of a calm break before calling a friend or trusted adult for support could work excellently.

This sort of nuance seems, sadly, so often absent from OT efforts, broadly, as a field.

Also note that what I'm describing above is absolutely evidence-based. What it isn't is packaged into the only forms of research accepted by institutional power structures (formal academia, journals, government agencies etc.). Places that are, on average, extremely hostile to working with lay-persons, service users, on-the-ground efforts, and alternative forms of knowledge generation.

Response to the Question of Neuroplasticity

Community Member Question:

"With the increase in awareness of neurodivergence, where does science stand on neuroplacticity?  It's great people are embracing difference but 10 years ago we were being told we could retrain our brains.... has this gone by the wayside or has its effects been understood as more limited?"

My Reply:

A reasoned conversation is going to need to be had about the limits of neurological explanations for human emotional and cognitive distress. As a starting point - there is no mechanistic explanation for how higher-level cognitive functions, including learning abstract concepts, experience emotion, and so on, emerge from neural networks."

This has at times been labeled the Hard Problem of Consciousness.

At best, neurology relies on correlation. A person reports trauma and we see differences in various measures of their neurology. But we know that correlation does not imply causation.

As such, we can only rely on individual reports of experience. And those accounts seem to show that some things feel more "hard-wired" and unchanging, other things don't, and some things feels a bit more in the middle.

We can compare psyche experiences to other sensations. Our sense of taste seems innate (we like what we like and to some extent don't choose). But it changes over time. Similarly, one's sexuality seems innate ((we like what we like and to some extent don't choose). But it changes over time.

Some things are trainable. We can go the gym and make amazing strides in increasing strength and flexibility. We can likewise train certain things in our mind, such as learning and applying new concepts (math, language, etc.)

Some things seem wholly unchangeable. Our height throughout adulthood is what it is. Apraxia (difficulty with motor planning to perform tasks or movements) is a lifelong condition. Various forms of colorblindness are lifelong conditions.

The most honest truth to answer these questions is probably - "we just don't know". To me, that means we should've ever proclaim authority in insisting that certain behavioral traits MUST change, and likewise should stop insisting that change or growth MUST be impossible.

Open-ended, open-minded curious inquiry that's respectful of the individual experience seems like a useful starting point, as does relying on lived experience wisdom and anecdotal account as equally valid and valuable as more formalized institutional research methods and their own strengths and flaws. 

All Stats Lie - Examples of Social Science Data and "Evidence-Based" Failures

We live in an era guided by what, at times, is a near dogmatic faith in data-driven science and policy-making. Yet, time and again, we fail to account for underlying biases and flaws in how these approaches are applied.

The following is an on-going list of stories and examples where "evidence-based" is causing preventable harm and distorting our view of the reality of situations and events. 

Time and again, we fail to heed the lesson of stories like this or work to challenge or fix how data is defined and how science is done in practice.

Crime Statistics

NPR article - Rising crime statistics are not all that they seem

We generally talk about - crime is up or crime is down. It's referring to sort of this small core set of what the FBI calls index one crimes.That's murder, robbery, rape, aggravated assault, larceny, burglary and auto theft. That list was chosen by a group of police chiefs almost 100 years ago, and it hasn't changed since.

Someone shoplifting tampons or diapers from a pharmacy counts as a crime. But a corporation stealing millions of their workers' wages doesn't. 

When people talk about a crime wave, they're basing that on very distorted set of data the police themselves are manipulating and curating for their own political reasons.

C-section Health Risk Screenings

Reveal News - Reproducing Racism

Reporter Julia Simon takes a look at a commonly used calculator that may be leading black and Latina women to C-sections they don't need.

Wednesday, November 2, 2022

Why It's Problematic That Self-Regulation Is The Main Solution On Offer For Emotional Distress

This post is going to be unfair, but I feel compelled to say that all the calm corners in the world aren't going to solve a kid getting beaten or otherwise abused at home or at school.

I worry that regulation, sometimes, is just teaching a kid that it's actually not okay to be feeling what they feel, that it's their job alone to control themselves, and that by extension they alone are the reason they are suffering and that they themselves are to blame if they can't regulate.

There is an entire segment of issues that "regulation skills" doesn't do anything to effectively solve and I'm tired of having no way to assist those situation. I'm tired of regulation being sold as the capitalized The Solution for so-called mental health "problem behavior" and "disorders". I'm tired of casting the individual alone as the sole responsible party for emotional or cognitive distress they are experiencing.

It's not a binary discussion here. Sometimes a five minute calm down area, for certain smaller emotional issues, is a great thing. There's a time and place for some individual accountability in some cases and situations. But we rarely/never talk about where those lines are or that such a line even exists.

Accountability can lie beyond the individual, and we are not being equipped to resolve and combat those external causes of ongoing and continued trauma. I'm tired of feeling and being hopeless and disempowered on that front.

I'm tired of not being allowed or empowered to work on such matters, and I know many of you all are as well. 

As a first step, I need to hear more loudly from the community that this is the truth of the matter. It is depressing and destroying my psyche that regulation and resilience (the individual focused solutions) are touted and offered everywhere in mental health spaces while projects and solutions for social accountability for mental health is almost nowhere.

On average, the "trauma-informed" communities are not, in my estimation, acknowledging this nearly enough. Probably, in part, because no-one lets us work meaningfully on social change.

Can we please, as a start, stop insisting (whether explicit or implied) that individuals can regulate and cope through most anything? They can't. They mask and deflate and we applaud them because they're not acting out anymore. We beat the defiance out of them. It's oppression and not healing but it still shows up as a success in the behavior metrics.

Our kids are showing us how unhealthy modern life is for so many. Society's response is to instead label them as defective and then ask us to "fix" them.

Why are we so barred from working on social change? What kind of nightmare society is this? 

The first step, in my mind, is demanding that mental health experts acknowledge everything above and explicitly state it in every lecture, training, or advice column they offer.

Stop attempting to fix individuals. Stop framing the kids as broken and needing to be repaired. Start articulating that society is the broken thing, that individuals are disempowered to fix it on their own, and start speaking up about and working within that space of truth.