“You never ask the barber if you need a haircut…”
I used to use this phrase, jokingly, in presentations about the importance of psychological approaches to understanding health. The (admittedly not very funny) joke was that, as a psychologist myself, obviously I was going to claim that psychology was crucial to understanding and helping people with their health problems.
I’d like to think I’ve never been someone who valued psychology exclusively though. Certainly working in academic Primary Care, you rub shoulders with clinicians, sociologists, health economists, statisticians and more, and you get a great sense of what each contributes, and the need to consider both a bigger picture and the same picture from different angles.
Nevertheless, I worry that there are times when it’s easier – or more self-serving – to emphasise the contribution of psychology when other issues are more deserving. Specifically, I think psychologists can sometimes over-egg their ability to ‘change’ cognitions, attitudes, beliefs and so on, as opposed to ‘unchangeable’ factors like social deprivation, family troubles, traumatic past events and the like.
(I should point out here that I’ve never been accepting of the criticism that psychology ‘blames’ the individual however – I think that you can talk about helping someone understand their own internal life without this being about their weakness or responsibility, and in fact it’s about better understanding their internal struggle, and supporting them to find ways to cope with it. It used to massively frustrate me when I’d speak to, for example, advocates of mindfulness, who’d swoon over the ideas of ‘learning to view thoughts as clouds’, but who would also attack cognitive therapies as ‘trying to make people change their minds’ or ‘blaming people for their thoughts’.)
The problem with claiming that thoughts can be changed while social, economic or historical problems cannot is two fold. Firstly, I think it’s arguably dubious in it’s accuracy – I remember reading once a quote that “It’s an easier job to kill a man than it is to change his mind.” Secondly, and more importantly for this post, I think it can lead us to ignore opportunities to demonstrate the importance of social or economic factors, to help make the case that they do indeed to be changed. To illustrate, this comment I spotted on twitter is an extreme example of this:
This seems horrible and outdated now (despite being only 40ish years ago.) The idea that rather than shouting from the rooftops about the horrible impact of domestic violence or the need to support women to escape abusive relationships, let’s lobotomise the women instead. Because we can’t change the fact that they’re abused, but brain surgery is a completely valid option.
At the less extreme end, but suffering the same problem, I was chatting to some psychology folk a while ago about the need to encourage people in poor neighbourhoods to get out of the house more (for exercise, social connectedness and so on). They were chatting about various behavioural and cognitive interventions, and then – only half jokingly – acknowledged that the real reason people don’t go out much is because there aren’t enough working street lights in those areas and they worry about their safety. They went on to say, consistent with the arguments above, that the issue is we can’t change what local councils spend money on, but we can help people individually change their own behaviours to cope with their fears or concerns.
I have a big problem with this, in that I think actually it’s pretty important that we as health researchers make the case to councils and politicians that if they want to tackle the obesity crisis, maybe take a look at the neighbourhoods people live in and whether they actually have any opportunity to go for a jog like we keep telling them to. I don’t think the approaches need to be exclusive – helping individuals isn’t an antithesis to this more social approach. But I think there can be a risk that the narrative we put across is only about individual behaviour and ignores the fact that real impacts can be made by considering funding and security issues.
I think this is a classic example of where PPI (patient involvement in research) could be helpful, but could be dismissed. If we started chatting to a group of people from those neighbourhoods about our latest whizz bang sexy cognitive intervention, and they said “Well actually I’d really like better street lights,” I suspect it would be quite easy to roll our eyes and dismiss their input. In the past I’ve certainly heard colleagues complain in studies for example that “they (the participants) just wanted to talk about other stuff, like funding or resources” rather than about the attitudes or perceptions that we wanted to focus on.
Now I will accept that if you have expertise in psychology and your job is to consider the psychological factors that are important, then you might say that considering all the other factors (social, economic and so on) is someone else’s job – and not as a way of dodging responsibility, but of understanding that we all contribute within our own areas of expertise and to the best of our ability within those areas. I’m certainly not expecting every psychologist to become an expert in social policy or economics. But I think we can still acknowledge those factors, and the important role – sometimes limiting role – they play within our own psychological approaches. Simply put, I would never want to emphasise a behavioural intervention at the expense of encouraging more funding for street lights. For me, this would bring us perilously close, perhaps not in action but certainly in philosophy, to those professionals who thought domestic abuse could only be ‘changed’ by lobotomising the victim.
PS. I’d be delighted to hear from psychologists what they think about this – do you agree/disagree? Have I straw-manned individual approaches – would you argue they never neglect social factors in this way? Is the dubiously relevant picture of a cute rat just a step too far? Let me know in the comments or on twitter @dr_know.