Identity and Change

This was the blog I wrote a few days before the US election. After the election I felt like the other stuff was more pressing, so that skipped the queue. I’d be interested in feedback about the topics and intervals of this blog, and whether the pot-luck and intermittent nature of it is disconcerting for readers. So do feel free to tweet or comment to let me know. Anyway…

My kids were given brass instruments at school recently, that they will get to use for the next 4 years. Every child in the school gets the use of a brass instrument for free, along with the group lessons to learn how to play it. One chose a trumpet, the other a baritone. It seemed like a nice idea, but I wondered why there was a scheme to learn brass instruments in particular, rather than woodwind, strings or percussion. The penny finally dropped when I searched for clips of brass bands on youtube and ended up with colliery bands and a poignant scene from Brassed Off! We now live in an area in which the coal mining industry was a major employer until the 1980s. There were nearly 200 mines in the county at the turn of the last century, and there are none now. So presumably the brass music scheme is linked with the idea of preserving local cultural heritage.

It made me think about other disappearing parts of British culture, from learning Gaelic and Welsh to Morris dancing, and how each culture around the world has different bits of heritage and culture to keep alive. There are stories told through the generations, losses to commemorate, celebrations to mark particular dates and events, rituals and arts to keep alive. Language and history seem to be bound into our identity. But why do we want to keep some parts of the past alive, and does it have any value? I’d hope that at least we can learn from our collective experiences, avoid repeating problems and continue the things that give us joy and bring us together. Which brings me back to music.

Music has been an integral part of human existence for an extraordinarily long time. Wikipedia tells me that “Music is found in every known culture, past and present, varying widely between times and places. Since all people of the world, including the most isolated tribal groups, have a form of music, it may be concluded that music is likely to have been present in the ancestral population prior to the dispersal of humans around the world. Consequently, music may have been in existence for at least 55,000 years and has evolved to become a fundamental constituent of human life”. Maybe that is why it is such an enjoyable thing to participate in. I know I value the half hour of singing I do with the children each night before bed as a time to wind down, but it also reconnects me to past experiences and brings out particular emotions dependent on the songs I choose.

I think there are loads of skills to be gained from being part of playing music with others. These include patience, persistence, co-operation, and other aspects of social skills and executive functioning. It reminded me how powerful various musical projects have been in changing the identity of people in socioeconomically deprived situations. The El Sistema project in Venezuela, although criticised for its strict regime and some examples of exploitation, has been praised for opening opportunities for young people from disadvantaged backgrounds and getting over 2 million children involved in orchestras. The Landfill Harmonic helped children living in a slum community on a rubbish dump to learn to play classical music and to have aspirations that were previously unthinkable to them.

The Big Noise project in Scotland has drawn on El Sistema but applied it to deprived Scottish communities. Independent evaluations cite positive impacts on different facets of the children’s lives, beyond just the gains in musical skills. Their education shows improvements in concentration, listening, co-ordination, language development, school attendance and school outcomes. Their life skills show improvements in the domains of problem solving, decision-making, creativity, determination, self-discipline and leadership. Their emotional wellbeing shows increased happiness, security, pride, self-esteem, emotional intelligence, an emotional outlet, resilience. Their social skills have improved along with increased mixing, cultural awareness, strong and diverse friendships and support networks. The project also has wider benefits to health, as there has been encouragement for healthy diet and lifestyle choices. The children have also had additional adults to confide in, a calm, safe environment and report reduced stress.

What I like about all these projects is that they help people to learn new skills and change their own identity to reflect that. Instead of being members of a deprived and devalued community pervaded with hopelessness, they have a new identity as musicians who can enjoy the process of creating, sharing and performing and gain aspirations outside of their previous horizons. Even the sense of belonging when singing along to a well-known track being performed live at a festival is up-lifting. How much more so to be performing music in front of an audience, and to travel to new places to perform.

But music isn’t the only thing that inspires change. We are all changing all the time. Life changes move us from being a child to an adult, through education and into professional or employment roles, bring changes in living arrangements and new relationships. In turn, aspects of our identity are sometimes defined by our role within those relationships and settings. We take on certain expectations and responsibilities when we become a being a partner, parent, aunt/uncle, grandparent. Our educational or work experiences can similarly add a facet to our identity (I am very much a psychologist as part of my core identity, even outside of work). So can being part of many different positive community projects or group activities, or even the act of learning new skills or trying new things at an individual level. I learnt to scuba dive a few years ago, and gained a new identity as a diver and a new world to explore. Likewise, the random act of supporting a friend who wanted to set up as a personal trainer introduced me to weight lifting, and for a couple of years that became part of my identity too (frustratingly since an RTA injured my shoulder I have not been able to lift for over a year, though I do hope to get back to it soon). I also like to grow fruit and vegetables, and to make preserves and bake, adding gardening and cooking to my repertoire and identity. And of course I am now a writer and blogger! Likewise I watch other members of my family gain new skills. This year we moved to a dilapidated farmhouse, and my husband has gained a new identity from learning to cut wood, keep chickens, and mow the fields with a tractor. As well as learning their brass instruments, my kids are learning to swim, ride bikes, write stories and poems, make art, and take part in outdoor activities. Their identities have expanded to include facets of artist, poet, writer, scientist, explorer and many more.

Changes to our identity can also be out of our control, and negative as well as positive. Many of us survive traumas, or difficult relationships, or experience rejection or failure. From redundancy to car accidents, cancer to infertility, losses of people we care about, changes of home, job and relationships, we are each shaped by our experiences even as adults. I have blogged before about the impact of adverse childhood experiences, but how we recover from these also forms part of our identity. Do we remain wary and cynical, or learn to trust again. Do we try to shut out the past, or work through it. Do we aim to get closure. These questions have never been more live than in the aftermath of institutional abuse, and in the wake of the historic sexual abuse cases that were triggered by Savile and other cases coming to public attention.

Over the last few years I have been talking to a man in my extended social network who was groomed and then raped as a child by a member of the Catholic church, whilst at a Catholic school. He has had to make a series of decisions about whether to disclose his experiences to anyone at all, whether to share them with members of his family, with his therapist, with his partner, and with friends. Then he has had to decide whether to come forward as a witness and victim in a public enquiry, and whether to seek compensation from the government and/or church. Each decision has an impact on his sense of identity, which has been slowly evolving from a victim hiding the shame of his experiences into a survivor who is able to look back and place the blame firmly where it belongs and manage the consequences on his life successfully. That isn’t an easy journey.

Over the time I have known him, he has talked very movingly about how his childhood experiences made him question his gender identity, sexuality, sanity, and whether he would in turn present a risk to others (something I know not to be the case, but which has been his darkest fear, based on the fact that many perpetrators report having been abused themselves in childhood, despite the fact that the majority of survivors do not go on to perpetuate the cycle of harm). He felt that he did not want additional sympathy or allowances making, and said that other people had been through much worse. Nonetheless, his experiences have had a considerable impact on his well-being. He has experienced intrusive flashbacks and images, panic attacks, stress, depression, time off work sick, and at times coped through self-harm. He has struggled to have enough self-belief to assert himself appropriately, and always tries extra hard to please others even at great personal cost – a trait that has been exploited by some members of his network and employers. I know he has had mixed feelings about giving evidence in an enquiry; wanting to come forward to represent and protect others and to ensure that concerns are not dismissed or covered up, but knowing this will be at some personal cost. And he has had very contradictory thoughts about applying for any form of redress, whether an official acknowledgement and apology from the church, or compensation from the fund for victims.

I can empathise with the ambivalence about accepting money. I can understand that survivors don’t want paying off and that money doesn’t make their abuse go away. And yes, possibly things could have been worse, there are people who have crappier experiences or less positive aspects to their lives in mitigation. I get that the people who are in the lucky position of considering claims are already survivors, and probably don’t want to look backwards to the time when they were victim and to have to relive that experience for another second, let alone in statements and testimony and the flashbacks that will bring. I also know there is a discomfort with the idea of financial settlements as a panacea, and that it feels wrong to benefit in any way from the harm that was done to them.

But when we look at the population level we can see that experiencing abuse changes the path of people’s lives. There is impact to the person’s sense of self, their ability to form healthy relationships and to be happy. People who are abused in childhood have their norms and expectations about themselves, other people and the world changed compared to those who aren’t. They have neurochemical pathways that are more primed for fight or flight, and perceive threat that others do not see. As a result they are less able to concentrate and focus, more likely to switch to anxiety or anger, less able to aim high and achieve in school and employment, less able to trust in relationships. Their self-esteem and sense of identity is damaged, and this permeates their ability to enjoy life in the present and to plan for the future. So whilst that doesn’t have a monetary value, there is a quantifiable loss to their earning power and quality of life, and the compensation is just making a nod towards acknowledging that.

Those responsible for compensation are also massive organisations, and in the case of the Catholic church, organisations that have accumulated massive wealth that for the most part they are not using to benefit the needy – it is kept in stocks, shares and property, and some is used to fund the legal defence of the perpetrators and those who knew about the abuse within the church. That is one of many reasons that lead me to say that victims should always apply for any compensation on offer. My general advice is to “take what you can get, use it for whatever feels right, and build upwards from where you are”.

It seems there is a good message in that for us all: Don’t let your past define you. Build your identity on who you are now, your values and aspirations, and the things that you enjoy. Then find a pathway towards self-actualisation and happiness in the future. Take on new facets to your identity. Become the diver, the weightlifter, the mother, the partner, the poet, the film buff, the cook, the gardener, the video gamer, the artist, the builder, the bookworm, the collector or whatever combination of roles and interests makes you happy. And seek out personal and professional allies for the journey to support you until the wounds of the past heal to become scars that don’t stop you from doing the things you enjoy.

How do we know what we need: differentiating evidence based treatments for the public

I am interested in making a website to help direct people at the right kind of sources of support when they are hitting a block or feeling unhappy with their lives. So I started to look at what was out there. I found lots of small silos full of professional jargon that would help people to identify a counsellor, psychotherapist or psychologist if they knew that was what they needed. But I also found lots of sites that point people at all kinds of snake oil that has no evidence of efficacy at all. For example, Findatherapy.org lists the following categories as “therapies”:

Abdominal-Sacral Massage
Acupressure
Acupuncture
Alexander Technique
Allergy Therapy
Aromatherapy
Arts Therapy
Autogenic Training
Ayurveda
Biofeedback
Bioresonance Therapy
Body Stress Release
Bowen Technique
Chiropody
Chiropractic Treatment
Clinical Pilates
Cognitive Behavioural Therapy
Colon Hydrotherapy
Colour Therapy
Counselling
Craniosacral Therapy
Crystal Therapy
EMDR
Emmett Technique
Emotional Freedom Technique
Energy Medicine
Flower Essences Therapy
Foot Health
Havening Techniques
Healing
Herbal Medicine
Homeopathy
Homotoxicology
Hydrotherapy
Hydrotherm Massage
Hypnotherapy
Indian Head Massage
Kinesiology
Life Coaching
Manual Lymphatic Drainage
Massage Therapy
Matrix Reimprinting
Maya Abdominal Therapy
Meditation
Microsuction
Mindfulness
Myofascial Release
Naturopathy
NLP
Nutritional Therapy
Osteopathy
Physiotherapy
Pilates
Psych-K
Psychotherapy
Reflexology
Regression Therapy
Reiki
Relationship Therapy
Rolfing
Sex Therapy
Shiatsu
Speech Therapy
Sports Therapy
Structural Integration
Tension and Trauma Releasing
Thai Massage
Thought Field Therapy
Yoga Therapy
Zero Balancing

That’s a list of 70 “therapies” of which at least 40 are obvious quackery, and very few could be said to have any form of persuasive evidence base for efficacy*. But the practitioners of each are persuasive, and the websites use pseudoscientific rationales that might fool those who are not as cynical or conversant with the scientific method as we are. So how do the public know what kind of help to seek out? How does someone who is feeling miserable, has a job they hate, financial difficulties and problems in their relationship know whether to get financial advice, careers advice, life coaching or therapy? And if they pick “therapy” how do they know whether to get CBT, psychoanalysis, art-therapy or non-directive counselling? And how do they know whether to get it from a therapist or a psychologist or a counsellor or a mental health specialist or any of a hundred other job titles? And within psychology, how do they know when to seek a clinical psychologist, a health psychologist, a counselling psychologist or any of the job titles that the HCPC don’t register?

I think apart from word of mouth and google, they don’t. Most people ask their GP or their friends for recommendations, and then go with something available locally within their price range. They don’t read the NICE guidance or understand the various professional bodies or regulatory systems. They trust that they’ll get a gut feeling as to whether it is going to help or not from the first session, and most of that “gut feel” is probably based on personality and charisma, and whether or not they feel listened to. The decision then rests on whether the therapist wants to work with them and has the capacity to take them on, and the price they ask for (assuming the service is in the private domain rather than the NHS).

Even the NHS itself isn’t very consistent about evidence based practise. For example, the NHS still funds some homeopathy – possibly wasting up to £5million per year on this placebo treatment that is entirely without evidence or credible rationale. Likewise I’ve seen NHS therapists who have done training in models of therapy that are implausible and without evidence (eg ‘energy therapies’ like EFT). Perhaps this is why the majority of clients doubt the efficacy of talking therapies. Yet, despite this scepticism, most would prefer to try therapy than medication yet the use of psychotropic medications has risen much more rapidly than the use of psychological therapies.

So where do we draw the line? If we only deliver fully evaluated treatments and those where we understand exactly how they work, then the amount the NHS can do when it comes to therapy will be much more limited. Lots of therapeutic interventions in practise are derived from other models or by combining aspects of various models. This allows individualisation of care. Similarly, there are many therapies which are being developed that have promising methodologies and are tightly rooted in scientific knowledge, but have not themselves been subjected to RCTs that prove efficacy yet (eg DDP). And many RCTs seem far removed from actual clinical practise where clients have a variety of overlapping conditions and clinicians deviate substantially from the treatment manuals.

The other confounding factor is that when it comes to talk therapy, it turns out that the modality or adherence to the manual matters very little compared to the relationship between the therapist and client. It seems the key ingredients are listening to the client, genuinely caring about them, giving them hope that things could be different, and giving them the confidence to try doing things slightly differently. Whether we have years of training and follow the manual diligently or whether we are newly qualified and muddling through seems to make much less difference than we think. In fact, therapist variables are much more powerful in influencing outcomes than modality, and even than the difference between treatment and placebo. That is no surprise to me as I’ve personally benefited from physiotherapy that included acupuncture – despite having read studies that show it to be no more effective than ‘sham acupuncture’ where random locations are pricked with a cocktail stick!

In the paper I’ve linked above, Scott Miller argues persuasively that we don’t need to focus on understanding how therapy works, or in using the medical model to work out what works for whom with endless RCTs. He shows evidence that experts are defined by having deep domain-specific knowledge, earned by a process of gathering feedback and focusing on improvement. So he argues that in the same way, expert therapists are those who collect and learn from client feedback. So his answer to the issue of evidence-based practise is for us each to collect our own outcome data to show whether our work is effective according to our clients (and by comparison to other options), and to see if we can improve this by using simple ratings within each session that check we are working on the right stuff and that the client feels we understand them, and that the working relationship is good.

So what does this mean for the proliferation of made up therapies? Does it mean that we should leave the public to buy a placebo treatment if they so wish? Or does it mean we need to focus on the modality and evidence base after all? The ideal would obviously be better regulation of anyone purporting to provide therapy of any form, but given the HCPC remit doesn’t even include counselling and psychotherapy, I think we are far from this being the case. To my mind it throws down a gauntlet to those of us providing what we believe are effective and evidence based treatments to collect the outcome measures that demonstrate this is the case. If we are sure that what we offer is better than someone having an imaginary conversation with an imaginary ‘inner physician’ by feeling imaginary differences in the imaginary rhythm of an imaginary fluid on our scalps then surely we ought to be able to prove that?

And what does that mean for my idea of making a website to point people at helpful places to start a self-improvement journey? To me, it shows there is a clear need for simple and accessible ways to identify what might be useful and to allow the public to differentiate between sources of support that have evidence of efficacy, professional regulation, a credible rationale for what they do, reputable professional bodies and/or personal recommendations. Maybe such a website can be one contribution to the conversation, although I’ll need both allies and funding to get it to happen.

 

 

*I’d say EMDR, physiotherapy, speech therapy, CBT and some types of psychotherapy and counselling probably reach that bar. Mindfulness is probably getting there. Art therapy probably suits some people with some issues. Yoga, sports massage, pilates, osteopathy, meditation, life coaching and (controversially) even acupuncture probably have their place even though the evidence for them as therapy modalities is limited. Most of the rest are quackery.