Response from Haley Peckham

Last month we posted a report of a MHN classroom discussion here in the UK. It was part of a module in which student nurses were encouraged to consider the range of ideological forces at play in their work and the real-world consequences. The module had the strapline: “There is always another side to every story”. The students are currently all working away at an essay (Happy Christmas!) in which they identify effects of reductionism in mental health services and offer up nursing skills that will counteract those problems.

The author of the startling paper that was discussed, Dr Haley Peckham, has very kindly written us a response. Thank you so much, Haley!

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Hey! I am thrilled that you have all read and engaged with my paper at a depth that has provoked important questions and challenges. I am very grateful for your attention to it, as I hope many of your future patients will also be.      

So – to your first question!     

Question 1: If I may paraphrase…. Why on earth is the author saying that trauma-informed approaches lack a biological narrative if she is also appreciative of the work of Van der Kolk and Herman?      

My answer is that our tendencies to medicalise and to explicitly and implicitly think within (rather than outside of) a pathologising framework run deep and although I am tremendously appreciative of the important work of both Herman and van Der Kolk in recognising the impact of trauma on our neurophysiology, BOTH advocate for framing the impact of trauma in diagnostic therefore pathologising terms. Now, this may be a pragmatic move in a system which has made it impossible to access help without a diagnosis but in doing this van Der Kolk and Herman follow the ideology of the medical model. I do not wish to do this. The Neuroplastic Narrative does not suggest that trauma damages people, makes them ill or injures them. It frames our understanding in evolutionary terms of adaptation. We adapt to our experiences for better and worse – there is no pathology in the neuroplastic mechanisms that allow us to adapt to our experiences; the mechanisms are doing what they were ‘designed’ by evolution to do. However, that does mean for some – people who have experienced multiple categories of abuse and trauma and are – as a result on a faster life path so are likely to have shorter healthspans and lifespans. This is culturally undesirable but not pathological (because it is successful in evolutionary terms) so the Neuroplastic Narrative frames this as a SOCIAL JUSTICE issue. Instead of pathologising and treating the individual, as the medical model does, the Neuroplastic Narrative identifies there is an imperative to address the adverse traumatising and inequitable circumstances that many individuals have to choice but to adapt to. This is what I mean when I say: Trauma informed approaches lack a non-pathologising biological narrative and the Neuroplastic Narrative provides one.      

Question 2: I understand your confusion. My suggestion that The Neuroplastic Narrative is not intended to replace the medical model but to sit alongside as an alternative framework is not intended to imply they are compatible. The premise of pathology is not compatible with a premise of adaptation. Some people may prefer to have their distress and suffering medicalised, diagnosed and treated and other people may prefer to think of themselves as having adapted and survived.     

Think of the two ideologies as being like ketchup and brown sauce! Almost everyone has a preference and being able to choose what you have on your scrambled eggs is important. There isn’t a *right* or *wrong* here (at least not one that could definitively be proven by either ideology currently) but a preference, a utility in offering people who struggle with their thoughts moods and emotions a choice about the sense they make of those struggles. It is important to be able to choose what stories we tell ourselves about who we are, why we are the way we are and what we may be able to do to change it. Whereas the medical model puts these answers into the hands of psychiatry, the Neuroplastic Narrative encourages our ownership and empowerment; our becoming experts on ourselves, learning what works for us and crucially, seeking out the experiences we need. It does exactly what you’ve recognised though, ‘flips the positions of power’! Not everyone wants that though.      

Question 3: Quite right. I have avoided all pathology associated words like ‘psychosis’ ‘hallucination’ ‘voices’ ‘delusion’ ‘depressed’ that are often stultifying and dripping with the invitation to pathologise. I am not asking you to apply the Neuroplastic Narrative to ‘personality disorders’ or ‘PTSD’. I am asking you to, if you can, completely step outside the medical model framework and see if you can make sense of distressed and distressing thoughts feelings and behaviours in another way. Often people’s responses and behaviours make emotional sense if we are prepared to be patient and humble and look and listen carefully for the emotional sense, often the trauma logic that lies behind them. When we deeply think and feel our way into our patients’ experiences and their perspective – the sense they were able to make of those experiences, their behaviours and responses become less like ‘symptoms’ and more like meaningful responses. Think how common it is for any of us to hear a loved one’s voice after a loss; how understandable it is to have internalised, and to anticipate, the mocking voice of a cruel and shaming parent, teacher or bully; or to have a need to bolster ourselves with grandiose ideas of being important or powerful to stave off feeling insignificant, helpless or worthless. It’s understandable too that when we have been harmed or neglected to want to take control of the harm or neglect done to us, to do it to ourselves, deriving a grim satisfaction that no one can hurt or punish us more that we do. It’s not ideal, but wanting to have control over it makes sense.     

Those words used above can easily be so ‘othering’, they create distance and are so closely associated with pathology and ‘mental illness’. The picture looks different when we are interested in the detail and uniqueness of a person’s experience. When we are patient and humble and listen with our minds and hearts to our patient, the ‘sacred unknown other’ (a phrase I picked up from the psychoanalyst Phil Mollon) perhaps they will share something of themselves with us and we can make some sense of it together.     

Question 4: This question gets to the heart of what I believe is the value of the Neuroplastic Narrative- that it offers compassion and supports accountability. The essence of the narrative is that – experiences shape brains, and more specifically, past experiences shape brains (and physiology) to anticipate more of those same experiences and thus virtuous and vicious cycles of anticipation are set up. Anticipation has a kind of creative power and so often those vicious and virtuous cycles are realised (made real). Obviously as infants and children we have little or no autonomy to make choices about the kinds of experiences we have so cannot be held accountable for the way our experiences have shaped us. However, as experiences shape brains throughout life (that’s neuroplasticity) we can use the autonomy we have to intentionally seek out the experiences that we need or desire to shape us in a direction we choose. Knowing experiences shape brains and physiology gives us compassion for our pasts, the way we have been shaped and gives us hope for the future, neuroplasticity means we can seek out new experiences that can change our outcomes. I have had this note on my fridge for more than a decade “It’s not your fault but it is your responsibility.” The medical model and some trauma-informed narratives can rob people of their agency or autonomy when ideas of trauma as damage and a diagnoses of mental illness become reified and people feel the illness or damage is fixed and cannot be changed – except (in the case of the medical model) by expert psychiatrists who can write prescriptions for drugs to treat the disease. The Neuroplastic Narrative returns our agency or autonomy to us. Wherever we start from (it is a profoundly unlevel playing field) it encourages us to take as much responsibility as we can for the experiences we have. This means curating our experiences, making decisions about who we are with, how we spend our time, and importantly whether we prioritise comfort in the short term at the expense of what is beneficial in the long term. We could for example choose to go to a recovery meeting rather than pursue our addiction – we could make that choice many times until it becomes who we are – a recovering addict (See Atomic Habits by James Clear). Or we could choose to go into psychotherapy – to get a new experience of a relationship rather than only being saddled with the anticipations we carry from our earliest relationships. Thomas Szasz who wrote ‘The Myth of Mental Illness’ conceptualised psychotherapy as an intervention that helped people increase their sense of agency or autonomy, he writes about it the ‘The Ethics of Psychoanalysis’.

We don’t yet know the degree to which the brain can be modified by new experiences, how powerfully the new experiences can mitigate the old experiences and we also shouldn’t necessarily assume that it is always desirable to do so. That would be making the same implicit assumption of damage or harm that I’ve challenged. I’d like to introduce you to the work of Bruce Ellis and the Hidden Talents Lab – He writes “Research in the Hidden Talents Lab focuses on the enhanced social-cognitive skills and abilities that develop in high-adversity contexts and can be leveraged in education, jobs, policy, and interventions.” It a refreshingly non-pathologising take on our adaptive responses to high-adversity environments. It can be found here: https://hiddentalents.psych.utah.edu/

Finally I’d like to say thank you again for engaging with this labour of love that I am sure – reading between the lines – you know is a personally motivated piece of theory. I hope you feel empowered by it and I hope that carries through in your relational work with patients. Relationships are the most powerful experiences. “The strongest drug that exists for a human is another human being” Ella Frank.