Papering over the cracks, obscuring the problem…
Conor McMullin, Clinical Associate Applied Psychologist trainee talks to Penny Priest, retired consultant clinical psychologist, about her debut novel, Team Of One.
In the story, Frances Fisher is a seasoned mental health professional. While her colleagues dutifully push treatment programmes to keep up with soaring demand, Frances remains skeptical. At the heart of the novel is Zen Psyonics—the most fashionable therapy of the moment. But as the story unfolds, cracks begin to show.
First of all, I want to say I really enjoyed Team Of One. You’ve created a novel in its own right, but there’s an undertone of it being a near mirror reflection of reality in the NHS, which makes it a strong call for social change. A recurring theme in the book is the idea that therapy is often presented as a solution to individual problems, while systemic issues go unaddressed. Do you think therapy can ever bridge the gap?
It sometimes seems as if those two things are inversely related – the more we turn to therapy, the less likely systemic issues get addressed -because you’re sort of papering over the cracks, obscuring the problem. Focusing on therapy means that you’re not focusing on systemic issues. Though we can at least try to address things at multiple levels.
I really like how in the book you put a new therapy at the end of each chapter. It had this feeling of relentless pursuit of therapy and that the therapies are all the same. What are your thoughts on the growing trend of trademarked therapeutic models?
I think the growing trend of trademarked therapies makes it clearer that ‘mental health’ is a market now. And I think that’s problematic for so many reasons. For example, it’s much harder, compared to non-mental health markets, to know what you’re buying. And with all those different therapies, how do people make sense of that? It’s much harder to know whether it’s going to work, whatever that means. And it’s also not like a market because in most other markets, even when it’s a service, what you get is more obvious and more measurable. If you pay somebody to paint your windows, you can see when it’s done. But if you pay somebody to fix you…
…it’s vague and amorphous.
And if you’re not happy with the end result, you don’t get your money back.
In the book, Paula, the character who is referred from oncology services, experiences tokenistic consultations. She has the feeling that what’s on offer isn’t going to address her problems, but she’ll attend anyway. How can we move from that kind of tokenism to genuine collaboration with patients?
When I think about tokenistic consultation, I’m often writing about this from my experience of stakeholder consultations, as a worker. They’re trying to gather proof that people have been consulted. I can’t think of a consultation that wasn’t just a rubber-stamping exercise. It’s often about saving money. When I’ve seen real meaningful patient collaboration, it’s been when people have been employed as consultants, representing patient views on interview panels and research ethics, and when they’ve been paid for their involvement in teaching on training courses. That’s where I think it’s effective. But even having said that, in NICE guideline development groups, they often have patients on those groups but those people sometimes don’t feel that they have the clout when they’re up against however many psychiatrists or professors.
There’s a power dynamic built into that from the beginning. In the book there’s tokenism in terms of how people are assigned to group therapy. Frances has agreed to lead the group reluctantly, and Paula has also been signed up. There’s a depressing aspect that people are just doing this as part of the system. But it’s also interesting that they both in their own ways gain a lot out of it. If you put any two people in a difficult situation, within a difficult system, does human nature come through so that you make the most of it? And is that the most that Zen Psyonics can do?
I like the idea that human nature maybe wins out. But in terms of group therapy, I’d say first that Zen Psyonics is not group therapy. It’s more like psychoeducation and skills training. Lots of managers wouldn’t call it therapy either because they’re mindful that many of the people running the courses aren’t trained therapists. I think there’s probably a place for those skills type courses. But only as one of a number of options. What’s happened in mental health care is that Payment by Results was introduced in England, and that meant that services had to be reorganised according to care pathways. Different care pathways attract different amounts of money. When a referral is received, a decision is made about which care pathway the person should be on, and then certain treatment is offered depending on that. Groups like Zen Psyonics tend to be offered to people who are given the personality disorder label. It’s all linked up with NICE guidelines, which give therapies status and legitimacy. Groups can inadvertently help, as people might not feel so alone and it can be useful to hear from other people about how they’re managing to survive. But that wasn’t why they were set up. The evidence base isn’t saying this helped somebody feel less alone or this person learnt something really useful from this other person. It’s saying it was this treatment which addressed their problem with emotional regulation, and so on.
But is there any role for evidence in psychology and therapy?
My brief response to that would be yes, but we need to be honest about the evidence and we need to be transparent about it.
Do you think psychology as a profession is striving too much to be like the medical model and at a dear cost?
I do agree to an extent with that. I think it’s potentially useful to incorporate alternative approaches like arts, community, sports, all sorts of different things. I ran a writing group once with a trainee and we published the evaluation. I think there’s something like a duty to be able to say that what you’re doing is helpful. So how do you prove that? In the writing group, we used qualitative and quantitative measures. It was really small numbers, so it’s hardly scientific, but I think it was a useful way of being able to offer things which might cater for diverse needs at the same time as trying to establish whether what’s happening is helpful, and if so, why is it helpful? And if not, why not? And obviously, if not, well, let’s not do that then because that’s not helpful. A good friend of mine, a psychiatrist in a team I used to work in, said that in his experience, when people found ways of improving their mental health and/or the situation that led to it being a problem, it was often a random thing that the person came upon by chance, that made the difference. I think there’s something in that.
Frances criticises the overuse of neuroscience to justify therapeutic models. She calls out the way brain scans and neuroplasticity claims are often used to make interventions seem more scientific than they are. How do you see the role of neuroscience in modern mental health care?
I guess Frances just picks that up as yet another way that claims are made about therapies, and it recognises how people can be persuaded by supposedly scientific facts. And you know, neuropsychology is probably a bit sexier than something like behaviourism.
In a sense it’s about a picture of certainty. If there’s something you can point to almost physically, then this means I have this illness and I need this treatment.
Yes. Us human beings forever find ways of managing uncertainty, so I guess we shouldn’t be surprised. Frances Fisher didn’t really talk about that. I could imagine that she could have talked about certainty and uncertainty.
I see Frances’s experience and her arc through the book as quite uncertain. Maybe there’s certainty in her convictions, but there’s an uncertainty too, as she ends up leading the group and she reluctantly sees the positives. There’s that kind of dynamic about holding two things at once. I was also interested in the generational differences she experiences. Has it been similar for you in your work?
Writing about generational differences wasn’t something I planned even though that comes through. If you start picking it apart, you can see how it’s not just between older and younger practitioners. There’s a thing about wisdom in the book, and I have often associated wisdom with age. But there’s a kind of wisdom that comes with youth and curiosity, a sort of questioning, curious, not knowing stance. There’s also the wisdom of patients. For example, Mandy is really wise when she says to Owen, maybe it’s not you, Owen, maybe the CBT was crap. We need more people like Mandy, who aren’t confused by all the complexity, who can just see something for what it is. In my own work, my conflicts were more with people who were very uncritical of what we were doing, regardless of their age. And if anything, I experienced the opposite of generational divides, because I always loved having trainees from a different generation with a different perspective.
I can’t help but hear a lot of your voice in the character Frances. Her resistance to Zen Psyonics reflects her fear of compromising her values. How do therapists balance systemic pressures with personal ethics?
I know Frances talks about her values but I think a lot of what she struggles with is not just about values. It’s her frustration with what she sees as the lie – the idea that therapy has been oversold – because for a lot of people it’s just not getting great results, especially the conveyor belt of group skills programmes.
Frances repeatedly questions whether therapy is being used as a Band-Aid for larger social issues like poverty, inequality and loneliness. Do you believe mental health services are being used to compensate for failures in social policy?
I don’t so much think that they’re being used to compensate for failures because I don’t believe that they are compensating. Nor can they. I think it’s more that they’re obscuring our understanding of what’s going on. They’re continuing to direct our gaze towards individuals and individual pathology. That can mean that underlying structural problems in society continue to go unaddressed.
I think the key idea there is obscuring the view. It’s almost worse than a Band-Aid because it’s actually redirecting attention, and the person is more likely to internalise problems that might not all be internal.
Obscuring is like the opposite of David Smail’s idea of clarification. Clarification is demystifying what’s going on. That’s what outsight is, actually being able to see what’s going on out there.
In the book I wondered about how it might have been satisfying to have Jason have a bit of a U-turn, or perhaps even Alexander, and for things to turn out for the better. However, I really liked your ending in the sense that it reflects reality more accurately. I think the feeling of uneasiness is what makes it so powerful.
Yes, my partner felt a bit disappointed with how things turned out in the end because he wanted some sort of consequence for either Alexander or Jason. He at least wanted Jason to have an about-turn and realise the error of his ways. When I originally started thinking about the book a couple of years ago, that was pretty much what I imagined, but I just let the writing go where it took me, which I agree is much more a reflection of real life. I also think there’s the ghost of the Chinese horse lurking in the background. Who knows what might happen in future?
You can purchase Penny Priest’s book ‘Team of One’ here
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