This post is by Jason Moehringer, a doctoral student in clinical psychology at George Washington University
As part of my duties in a part-time job, I recently spent three days in a conference listening to experts and industry leaders discuss the intersection of technology and neuroscience. Specifically, so-called “brain training” as a primary or secondary treatment for chronic psychiatric disorders is being explored. The idea is that cognitive deficits (for the uninitiated: difficulties with concentration, organization, memory, attention, or emotional recognition and/or regulation) are frequently, if not always, an underlying component of psychopathology. These deficits derive from subtle brain dysfunction: their brains “misfire” or don’t have the proper “wiring.” So, treating these deficits (in this case, through remediation or skill-building provided by video games, ranging from Medal of Honor to Lumosity) will improve individual functioning and treatment outcome. Additionally, these improvements will be visible in changes in brain functioning or structure that can be seen in MRIs.
Alongside this, a growing trend in mental health treatment is to measure outcome based on how a patient’s functioning “improves.” In this context, “functioning” represents the idea that the individual or group in question can perform the activities necessary for living. So, a low-functioning individual may have trouble with personal hygiene, holding down a job, forming or maintaining relationships, or controlling their impulses (anything from inappropriate angry outbursts, to excessive shopping, to wearing tin-foil hats in public). As you might have guessed, a high-functioning individual will have little difficulty completing these activities.
As a clinician in training who works intensively with individuals who have moderate-to-severe personality and psychotic disorders – a population that was of particular interest to a subset of the attendees of this conference – I was hard-pressed to set aside my attention to the undercurrents of social control implicit in this approach to mental health treatment. Central to this unwitting adherence to conformity is the unquestioned fallacy of the emerging mainstream clinical phenomenon of “functioning.”
Without intending to (I hope), this metric involves all sorts of elements of social control. Deviance from accepted norms of behavior is a sign of sickness that must be addressed through increasingly intensive and onerous treatments. As my colleague frequently critiques on this blog, health is understood as having a job, a nice haircut, a spouse, and a capacity to sit quietly on the subway. To a distressing degree, illness is essentially understood as anything non-normative. Screaming at pigeons in the park? I can construct a rationale to understand that as a symptom of illness. But an eight-year-old boy staring out a window in school has a disease? Surely there have been people whose lives have been destroyed by ADHD. However, slowly but surely, idiosyncratic elements of the individual are re-labeled as beyond the pale and thus necessitating treatment and psychological intervention.
While this is a trend that inevitably runs through all forms of mental health training (we are asking people to change, after all, and “for the better” is hopelessly relative), I had the time to reflect on this unfortunate and destructive tendency while watching endless PowerPoint presentations. The compulsory aspects of these treatments are incredibly clear. Symptoms – i.e. divergence – are observed, catalogued, and quantified. I thought it was indicative of the spirit of the conference when one expert framed his talk about the wonders of computerized brain training for ADHD by reminding the audience of how sufferers can play video games for hours: if we can just disguise our treatments as video games, we can finally get through to them! His response to this fact was not to wonder why, not to question the paradigm that there is something wrong with the individual’s brain that interferes with attention – given that there is something that he can attend to quite well – and never to ask anybody with the disorder about the nature of their experiences. Modern mental health research periodically throws up its hands at the fact that individual sufferers don’t report the same symptoms or similar histories. Remarkably, this is seen as a failure of the individual as an accurate source of information. This is a true shame, for ignorance of the individual’s experience separates any other knowledge about the disease from its crucial foundation in the viscera of life – and thereby renders it meaningless.
As we have seen over and over (I think), this kind of knowledge without meaning invites a particularly insidious kind of domination. Researchers and therapists, armed to the teeth with quantified correlations and brilliant statistical models, are free to impose their personal projections onto the life of their clients, of whom they have little, if any, real understanding. This has been the consequence (or possibly purpose, depending on your opinion of “industry-sponsored” research) of most of the psychological and psychiatric research in the United States in the last 50 years: to construct “knowledge” about individual lives without needing to become involved in the dirty, difficult work of being interested. How much easier to already know it all!
Of course, deriving such specific information from an aggregated average limits the scope of what can be tolerated in thoughts, feelings, and behaviors of individual patients. “Functioning,” in the sense that I discussed earlier, comes to represent this aggregate, and this in turn informs the expectations of modern mental health. As a mental health provider, I strenuously resist this implied position of equating norms with health. I think it is imperative that we collectively maintain the position that we do not, in fact, know what is best for other people in most situations, and that we do violence to their freedom and integrity as individuals, and therefore ourselves, by imposing the will of the third/big other. Towards this end, I am frequently reminded of something once said by the prominent psychoanalyst Otto Will: “As I see it, my task is to help this person look at, and evaluate, his life and his prospects. I don’t know how he should live, but I may be able to help in discovering this for himself. I am not an expert at living.”