A change is gonna come...

After entering this huge maze of a conference to confusion and conflict, and then forging on in search of clarity and creativity, could I find an exit on day three to concrete change?

The President of our own Society, Peter Kinderman, won’t thank me for saying this, but the early morning symposium he participated in didn’t fill me with optimism. It considered ‘the future of diagnosis – ethics, social justice, and alternative paradigms’, and as ever with this topic there seemed little to disagree with. Yes, as Anthony Pavlo (Yale Program for Recovery and Community Health) said, we surely need ‘ recovery-oriented diagnostic practice’. We need to support people in their recovery journey, making their values and goals central to the process. Yes, Jeffrey Rubin, it’s possible to capitulate to the requirement to put a DSM category on an insurance form, while still communicating with colleagues in a dogma free common language around ‘concerns’ rather than diagnosis. Yes, Peter Kinderman, we should be talking in plain and direct language to lawyers and anyone else that might listen, to show that these concepts of diagnosis and disorder are contested. ‘Imagine there’s no diagnosis,’ Kinderman urged, ‘ it’s easy if you try.’ Simply talk and write in terms of experiences the person has had, and what they are now experiencing.

But as Lisa Cosgrove (University of Massachusetts) admitted, the dominance of clinical practice guidelines in the US, and their ‘pharmaceuticalisation’, make it hugely difficult to keep ‘Big Pharma’ out of the therapy room. As she pointed out, some changes in DSM5 and in the recommendation of universal screening for major depressive disorder for everyone over 13 in the States is likely to ‘wind up with even more over-diagnosis and therefore over treatment’. Acting as discussant, Donna Rockwell (Michigan School of Professional Psychology) asked ‘How much power do we really have to make changes? How much is about control over the population, about capitalism?’

And yes, I know it’s easy to be dismissive from the sidelines (although we have published several issues and articles on the topic) when these people have formed an international coalition to make real efforts at impact. And Rockwell did point to us Brits for positive signs, such as the rise of the case formulation approach, and the public engagement efforts of psychologist and voice hearer Eleanor Longden. All I’m saying is that for my quick fix of concrete change I think I’m going to have to look elsewhere.

Perhaps ‘Big Pharma’ was uppermost in my mind when I went to my next talk, from Courtney McLaughlin (Indiana University of Pennsylvania) on mapping mental health. She explained how, using ArcGIS GeoEvent Manager, she mapped the precise location of 130,000 public tweets in 1.5 days, trawling for the word ‘depressed’. This suggests ethical interventions such as more efficiently targeting resources at areas that are emoting more, but all I could think about was a drug company partnering with Amazon Drones and dropping medication at your feet within minutes of tweeting ‘feeling a bit depressed’ for the fifth time in a week. As with much change, proceed with caution.

Maybe by 11:00 I was feeling more receptive to rousing optimism, or maybe APA President Susan McDaniel is particularly good at it. But inspired I was, and I thought it was particularly generous of her, when she is doing so much to improve people’s lot through the integration of psychological and physical health care, to hand over much of her Presidential Address to the work of others (via video inserts). For example, we met Barbara Van Dahlen, who found herself with the skills to give help to others but no structure to do it in. ‘So I built it’. Her ‘Give an Hour’ initiative has now persuaded mental health professionals to provide more than 192,000 hours of free service for veterans and their families. McDaniel urged us to follow the example of Van Dahlen and others like her, using psychology as ‘a disruptive influence to bring about positive change.’ Perform a regular ‘gut check’, she said: ‘Ask yourself, am I embracing change that could be constructive, or resisting it because it might negatively impact myself?’ In another video, Benjamin Miller alluded to the importance of teamwork in change: ‘Let’s create an entire generation of fragmentation fighters. This is about comprehensive, complete, whole, different…’

A collaborator of McDaniel’s, Eduardo Salas (Rice University), later drew on a 30-year journey to illustrate again that importance of teamwork in change. As with James Pennebaker yesterday, he has a clear passion for ‘looking at real things in the real world’. When catastrophic mistakes led the USS Vincennes to shoot down an Iranian airliner in 1988, Salas was part of one of the most funded behavioural science programmes in history. How can psychology help turn a team of experts into an expert decision-making team? In this and many other challenges on the big stage, Salas and his teams have designed training that has demonstrated significant improvements in team behaviours, safety, cognition and wellbeing, even with experts. ‘You can teach an old dog new tricks’.

Salas tries to cut through the messy, dynamic environment of teamwork with ‘more parsimonious, powerful theoretical engines, fewer variables.’ He says that ‘the number one killer of teamwork in any domain is that team members don’t have clear roles and responsibilities. That’s something that takes three minutes to fix.’ Then teams need a compelling purpose to exist – a goal, vision, objective. A leader needs to promote, develop, reinforce that, in an environment of ‘psychological safety’ (mutual trust). Self correct performance through huddles, debriefs – ‘this is a most powerful yet under utilised tool. Again, it can be just three minutes’. Salas is now turning his keen understanding of the science of teamwork to science teams themselves, pointing out that whereas patents and publications used to be a largely lone endeavour, the team is now completely central to scientific change and progress.

Appropriately, my day ended with a talk about an area where there has already been local change. Marijuana was legalised here in Colorado in 2014, but Carl Hart (Colombia University) wants much wider change. His reasoning, in a title he admitted was provocative: ‘pot can cure racism’.

Hart explained that marijuana makes up half of drug arrests in the US, and at State level blacks are four times more likely to be arrested despite similar levels of use. ‘This is not a racial disparity, an implicit bias, this is racial discrimination.’ Black males comprise 6 per cent of the general population but nearly 40 per cent of the incarcerated population. One in three black boys born in the US are projected to spend time in prison. Marijuana law enforcement plays a role in many deaths.

Black people are clearly a vulnerable group here, and Hart reminds us that psychologists are comfortable thinking about other vulnerable groups. ‘We should think about black people in the saw way in terms of drug law enforcement.’ So what has happened in terms of the race data in Colorado? There has been a 38 per cent drop in Latino arrests; a 54 per cent drop in White arrests; but a 23 per cent drop in black arrests. Blacks are still three times more likely to be arrested than counterparts. ‘Marijuana legalisation not a cure,’ Hart admits, ‘but it offers some relief. It has partially removed one tool used to racially discriminate.’

Hart argues passionately that if laws were to change nationally, science can be used to educate and keep people safe. ‘The main thing I have learned from a career of giving people drugs as a neuropharmacologist’, he said, ‘is that drugs are predictable. And as psychologists we know about dose, about user experience, about the importance of setting and of routes of administration.’

‘What about the children?’, Hart hears you cry. Yes it’s true that most users of cocaine and heroin have used marijuana, but most don’t follow that path. ‘It’s no more a gateway to heroin than it is a gateway to the White House!’, Hart smiled, in front of photos of the last three Presidents (who have all admitted to smoking marijuana in the past). Hart acknowledged the numerous reviews on cannabis and psychosis – ‘The Lancet really has become the marijuana/psychosis journal’ – but said that his own review suggests cannabis does not in itself cause a psychosis disorder… It’s just that both early use and heavy use of cannabis are more likely in individuals with a vulnerability to psychosis.

As for simple, concrete change, Hart would require law enforcement agencies to report and justify arrest data. ‘As tax payers, we pay their salaries, we need to see this data. And we need to call out discrimination and those who support it.’ We need better drug education, Hart says, and for more people to ‘come out of the closet as drug users’ in order to provide a more realistic picture of what a drug user looks like. He hopes that, along with legalisation, might ‘allow us to focus on the real issues, and why some people are developing problems with drugs … Psychosocial effects are so important, but they’re just not sexy. You may have to have a picture of the brain to convince people that it’s important.’

Rowing back from his title, Hart warned that ‘we can’t expect legalisation to make us un-American, and racial discrimination is as American as apple pie.’ But he had a message for the younger members of the audience: ‘Your generation must be impatient with the level of progress. You should push for society to be more progressive and change.’

If I had to pick out one thread from all three days, it would be that – of a large number of individuals looking to create change, towards a progressive society, with all sorts of pressing real world concerns. But also an acknowledgement from those individuals that they don’t have all the answers – it’s only through collaboration, and reaching out beyond our discipline, that ‘a change is gonna come’. That’s a pretty healthy message for any conference.

- Dr Jon Sutton is Managing Editor of The Psychologist. His reports from three days of the APA conference can be found on the website and as a free edition in our iOS/Android app. There will be more coverage in the October edition.