Mental Health and Control

This is the fifth and final post in a five-part series discussing different aspects of the current mainstream, biomedical approach to mental health diagnosis. Earlier versions of these five posts were part of an online forum called the “Global Summit on Diagnostic Alternatives,” which ceased operating in 2015 and is no longer accessible.

[For the sake of brevity, I’m assuming readers already have some understanding of things like: what the DSM is; the massive influence it has on the way we think about and address mental health; the industry it has become; and the extraordinary amounts of revenue it generates for the American Psychiatric Association.]

There is widespread agreement in the mental health field that change is required. There is much less agreement, however, on what it is that needs to change. Some have gone so far as to call for a paradigm shift, although it’s not entirely clear what paradigm we are currently in, much less which paradigm we need to move towards.

Part of the problem may be that there is no standard definition of our core business. Without unambiguous definitions, it’s difficult to see substantial progress being made. Craddock (2013) illustrates where reasoning that is not constrained by specific definitions can lead. He suggests that voltage-gated calcium channels “were initially implicated in bipolar disorder in 2008, but have subsequently been linked to other psychiatric disorders. This was not a pathway that researchers had considered. It is, however, well understood when it comes to heart disorders.” (p. 31). In the absence of a clear definition, it’s not at all obvious that it is appropriate to compare mental disorders with heart disorders. With a heart disorder, the heart is disordered. What is the “mental” that is disordered with a mental disorder?

Source: Dima Zahar/123RF

In many ways, we seem to be at the same stage now that geocentric astronomers were at when they created increasingly complex epicycles to account for the planetary pathways they observed. What improved models of planetary orbits, the thing that radically changed the state of play was not increased sophistication with measurement, technology, or analysis; it was a different perspective.

A similar shift in perspective might occur in the life sciences by changing the way we consider human activity. Rather than thinking of life as a series of behaviors emitted in response to various internal and external factors, life can also be understood as an ongoing process of creating and maintaining desired experiences. “Life is control—an uninterrupted process of specifying, creating, and maintaining—a process in which all that is not essential is free to change, preventing change in what is essential. Surroundings change, genotypes change, phenotypes change, and self-replicating molecules survive. Environmental conditions change, behavioral actions change, and selected results of actions remain as intended by the actors.” (Bourbon, 1995, p. 151).

It is self-evident that control is important in psychopathology. Psychological distress is experienced when people feel unable to control their thoughts, actions, emotions, or some other aspect of their day to day living. Control has also been recognized as fundamental to health generally. Marmot (2006) describes control as an organizing principle in the social determinants of health. He uses control as a framework to explain inequalities in health within and between countries. He suggests that “control over life circumstances reduces chronic stress and has favorable biological effects.” (Marmot, 2006, p. 565). Crucial to the notion of control is the ability of people to lead lives they have reason to value. “What is important is not so much what you have but what you can do with what you have.” (Marmot, 2006, p. 565).

The idea of control and its importance in leading a life of value gets to the heart of the current problem in the mental health field. A mental health problem is, primarily, a problem in living. It is not simply a problem in brain circuitry. “Schizophrenia” won’t be found in a petri dish.

Barrett (2011) lucidly argues that brain circuitry can only be accurately understood by paying attention to the way in which this circuitry influences, and is influenced by, the environments in which the circuits are situated. Biology, psychology, and social context cannot be as easily separated in the process of living as they can in our current programs of research.

Knowing that control is important, however, is not enough. It is crucial to understand how control works. Since the 1950s and 1960s, a science of control has been developing based on the idea of a hierarchy of closed, causal, negative feedback loops and using the methodology of the physical sciences in terms of building functional models that simulate the phenomenon under investigation to rigorously test basic principles and mechanisms (Powers, 2005; Powers, Clark, & McFarland, 1960). The theory underpinning this approach is Perceptual Control Theory (PCT, Powers, 2005). Many elements of PCT are not new. Negative feedback, for example, is well recognized as an important neural mechanism (e.g., Tyrka, Burgers, Philip, Price, & Carpenter, 2013). PCT, however, clarifies and explicates how elements such as negative feedback function in an integrated unit. PCT provides an elegant and sophisticated framework that could unite disparate programs of research and help make sense of apparently anomalous findings (e.g., Marken, 2001, 2009, 2014).

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Some of the learnings from PCT will be surprising. For example, rather than explaining severe psychological distress as a brain disorder or dysfunction, PCT suggests that distress of this kind arises when well-functioning, high-gain control systems become conflicted (Powers, 2005; Carey, 2008a). From this perspective, it could be argued that the control systems are functioning too well, rather than not well enough.

The principles of PCT have been used to build an a-diagnostic cognitive therapy called the Method of Levels (MOL; Carey, 2006, 2008b; Carey, Mansell, & Tai, 2015; Mansell, Carey, & Tai, 2012). MOL focusses on the distress that underlies symptoms and symptom patterns, rather than addressing the symptoms themselves. It takes the individual’s perspective as the starting point, and provides therapy flexibly and responsively in whatever time frame is necessary to achieve the resolution required by the distressed person.

PCT certainly doesn’t encompass everything. It is a theory about organic control as it arises to enable entities to live. It is not an approach for finding answers to existing questions. More than anything it is a way of asking new questions. PCT informs an investigation of the process of control: what variables are controlled by different individuals; how do these variables change as an individual develops; what conditions promote good control and what conditions interfere with it; and so on.

Approaching health and well-being from the perspective of control might help us define more accurately life as it is lived. Health, in fact, could be defined more accurately and useful as control at all levels of biological, psychological, and social functioning (Carey, 2016). PCT provides the framework for a genuine biopsychosocial model of health and wellbeing (Carey, Mansell, & Tai, 2014). A framework such as this might help us understand the conditions required for a flourishing life, and the resources we can provide to help promote that. From a PCT paradigm, large amounts of what we currently think we know would need to be revised or would just become irrelevant. In many areas, there would be substantial upheaval and disruption. For some, however, PCT won’t be a sea change so much as a more accurate explanation of why the things they have been doing have been so effective. With a more accurate explanation, people will be able to be more effective, more of the time.

Large scale upheaval for many and a streamlining or fine-tuning for others. Isn’t that just what we’d expect from a genuine paradigm change? PCT offers the beginnings of a science of life from the perspective of life as it is experienced, not as it is observed. Considering PCT seriously and understanding its implications could be defining for our field.