Conferences: Who is psychological science for?
I recent got back from a psychology conference, for the Association of Behavioral and Cognitive Therapies, of which I am a member. For the first time, I presented material of my own (outside of a poster way back in 2008). It was exciting, and nerve-wracking. And the convention got me thinking (which, of course, is part of the point).
In many fields, people are happy to have discussions that remain within the fold. I mean where people use the jargon of the specific area, discuss specific nuances of a small chunk of the field, and get caught up together in sharing complex ideas and trying to push the limits of those ideas into uncharted territory. Psychologists, generally suspected of being people ourselves, are no different. In my specific chunk of the field, we use jargon like psychosis, delusion, and hallucination, recovery, dysfunction, cognition and metacognition, etc. We toss around acronyms like CSC and FEP, S(P)MI and CHR.
Here’s the catch, though. (This catch ultimately ensnares all sciences, but is most prominent in psychology.) We’re not debating about chemical interactions, quarks, or even liver cells. Those are not irrelevant, but ultimately, we are trying to learn about human experience. That’s what it’s all about.
And it’s weird and problematic to talk about people behind their backs.
Conferences and disjoined science
I’ll stick with my area as an example of how things can easily go off course. I attended an excellent panel entitled, “Affirmative Therapies Means Psychosis Too: Bridging the Research-practice Gap in Doctoral Training for SMI.” The panel addressed the problem that the vast majority of psychologists who come out of graduate lack adequate training. They are unequipped to handle situations where someone voices a belief or is experiencing a sensation that does not conform to social expectations (in pathologizing words, a delusion or hallucination), or many of the myriad challenges that currently intersect with these challenges.
This is an important topic: it is absurd that so few psychologists have a basic understanding of the fundamentals, and instead spread incorrect information that creates a feedback loop with descriptions in undergraduate texts and “abnormal” psychology classes. The panel shared their wisdom on their efforts and ideas for how to tackle this issue.
Those are vital course-corrections. As I was listening, however, one linguistic piece stuck out: SMI. “Severe Mental Illness.” What is this? On the surface, it is self-explanatory. Someone whose behavioral challenges are connected with a major impairment. For instance, not able to work, or frequently getting hospitalized. Logically, any type of challenge could become severe.
However, this is not how it is used in practice. Instead, it gets equated to people with very specific diagnoses. Schizophrenia. Bipolar Disorder. Major Depressive Disorder. Why? Good question. If the goal is to capture people in greatest need, then you want both sensitivity and specificity: capturing most people in need, and not capturing people not in need. Are those diagnoses adequate categories to do this?
I think you know what the answer will be.
Poor Specificity
At one of my first positions working with people who have experienced psychosis, at the Social inclusion, Hope, And Recovery Program in London, part of their initial training involved a video. The video was made by Scandinavian researchers. The researchers interviewed people in their communities who experienced psychosis yet had never felt the need to interact with a mental health worker. People who fit into and contributed to their communities just like anyone else. Some found individualized ways to cope with their experiences. Others found positive meaning in them and made good use of them. Still others were indifferent and simply ignored them. For the first time, I questioned the assumption that psychosis = severe.
The evidence has only grown since then. More and more studies at all phases demonstrate that, just like for people dealing with any experience, those who report psychosis fit on a dimension.
Poor Sensitivity
The opposite problem is equally apparent. Any clinician can talk about people going through really rough circumstances. Where everything seems to be conspiring to drag the person down: not doing well at work or school, isolated from or in conflict with other people, and feeling stuck in the same patterns of thinking, feeling, and acting. This may go with broader problems: financial strain, poor resources for health, nutrition, access to information, etc. But clinicians are not the only ones who know this: we all do. We all know someone who is or has been in this situation. And many, if not all of us, go through a period like this at some point in our lives. Would requiring certain features, like psychosis, to be present, help identify such moments for the people who need it?
Certainly not. Only for a very small, select group.
Over the past couple of decades, the “CSC” (Coordinated Specialty Care) model has developed to provide a wide range of services for people who have recently begun to experience psychosis. The team provides synergistic care that can help people address crisis situations. But where are these models for people in crises who do not experience psychosis? There have been (a few) similar efforts for those diagnosed with bipolar disorder. And there are parallel models for people in crises related to substance use, and dangerous eating behaviors. Yet except for a few niche areas, most people are excluded from access to these team-based models.
Weren’t we talking about misinformation and conferencess?
I would argue that the concept of “severe mental illness” is currently a cover for the above diagnosis-based discrimination of who is more dysfunctional. Instead of individualizing to specific circumstances, entire groups get lumped in (or out). This is an issue for access: people in need of services who cannot get them. It is an issue for freedom rights: people who do not need services who are pressured to get them. Most impactfully, it is an issue for our culture. This meaning of SMI supports the notion that you can judge a person’s capacity to succeed based on diagnosis, i.e. how their experiences at a given time and context happen to match criteria in the diagnostic manual.
Conferences as community: A solution to the misinformation
When the same people talk to the same people, using the same jargon, especially in the absence of the people they are talking about, ideas become fixed. Perhaps simply from mental processes like the availability heuristic, people take SMI as a useful, accurate label. This is a tendency to take as accurate an idea because it is simply easier to bring to mind. If SMI gets repeated enough, it comes to mind, and seems meaningful.
However, when you have to cut the jargon and explain what you are talking about to the people you are saying it about, assumptions get tested. My panel included someone with their own, personal experiences of what we were discussing. This enabled us to engage the audience from a better position to challenge assumptions (including our own) about appropriate and meaningful care.
Psychological Misinformation and Conferences
In summary, insular conversations, as happen in conventions, and jargon, as happen in scientific communities, can be mechanisms that hide assumptions and spread misinformation. The term SMI can be seen as an example of this. If psychology is to fulfill its responsibilities to describe and aid the human condition, then we must share power and communicate collaboratively with all communities.