It’s not catastrophizing if it’s a catastrophe: lessons from the pandemic for psychotherapy.

By Sahanika Ratnayake

The pandemic seems to have shaken the orthodox understanding of mental health. Instead of seeing mental illnesses —  such as depression and anxiety — or psychological distress as being based primarily in the individual and their various patterns of thoughts, behaviours and emotions (the approach favoured by the DSM), the pandemic exposed the relationship between contextual factors — such as a looming health and economic crisis, or months of loneliness —  and mental health.

This is old news to the various social psychologists and demurring psychiatrists, who have been raising the relationship between mental health and background issues for some time, often with reference to structural inequalities such as the economic deprivation and racism. These academic debates have now become a matter of public concern, with the issue being raised in mainstream avenues such as the Nature blog (with explicit discussion of race), mainstream media and strangely enough, even by the likes of Britney Spears.

Though the causes of mental illness and psychological distress are coming under new scrutiny, we have focused less attention on how we currently address mental illness and psychological distress.

The various problems with psychopharmeceuticals, their overprescription and the way in which they may provide a band-aid solution for deeper problems are well known, but as a result therapy has come to be seen as the obvious alternative, with no problems of its own. In light of current insights into mental health we should not take this for granted. Two of the most common schools of psychotherapy – Mindfulness and Cognitive Behavioural Therapy (CBT) – seem to be unable to accommodate these insights about mental health.

Mindfulness, now a staple of various schools of contemporary psychotherapy and taught as a standalone skill for addressing everything from workplace stress to depression and chronic pain, involves observing the state of one’s mind and body with a “non-judgemental awareness of the present moment”.

The awareness that is central to mindfulness is acontextual, side lining the various factors that gave rise to the distress in one’s mind or the tension in one’s body, in the first place. Someone might note that they have developed the habit of clenching their jaw and feeling anxious, but without a thorough examination of context, using critical judgement and scrutinising both the past and the likely future, mindfulness does little to address what might turn out to be the causes of ones problems and how to resolve them.

CBT falls more explicitly into the trap of discounting context. CBT takes as one of its core principles the idea that it is the way individuals think about or conceptualise an issue that is the cause of their psychological troubles. Certainly, an overly pessimistic or risk-averse conceptualisation of a problem is counterproductive to solving it and will invite unnecessary suffering, yet sometimes the problem will turn out to be not in the heart or in the head, so to speak, but rather in the background context. As the pandemic is starkly pointing out, the problem is not necessarily one of conceptualisation, sometimes it is the appropriate response to the problem in the first place — it is surely not a mistake to feel anxious about what is in fact a global catastrophe.

Certainly, a skilled therapist may be able to direct attention to contextual factors, but it is a worrying tendency when the therapy itself discounts context so readily, especially in a time when context matters so much.  One might argue that in light of events that are outside one’s control, it is best to avoid dwelling on context and focus on managing one’s emotions and behaviour

However, the health inequalities and outright injustice that have been exposed by the pandemic are issues resulting from hitherto neglected economic and racial disparities. This reveals the dangers of ignoring the root causes of mental illness. Furthermore, in light of the client’s distress, a simple acknowledgement that they result from actual problems rather than problematic patterns on the client’s part, does not seem to be too much to ask from psychotherapy.

Apart from the therapeutic tools at hand, an increasing worry is the way in which these tools are accessed. While we are in the throes of realising the debilitating effects of loneliness and the importance of physical proximity, therapy is increasingly moving online or offered via self-service avenues. If it is the case that social interaction is so pivotal, to the extent that some theorists have identified the efficacy of therapy with elements of the therapeutic relationship itself, then this is an alarming and possibly even unethical trend.

In light of the stark lessons from the pandemic, it is time to take a closer look, not just at the problem of mental health, but how we go about trying to solve it.

 

Author: Sahanika Ratnayake

Affiliations: PhD student, Philosophy, University of Cambridge

Competing interests: None.

Social media accounts of post author(s): @SahanikaR

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