Article
Culture
Film & TV
Psychology
5 min read

Who’s missing from Inside Out’s internal family?

Where Riley’s writers could go next.
Cartoon characters of emotions at a control desk.
Inside Riley's head.
Disney.

Once upon a time a man got angry. Then he got angry at himself for the fact that he got angry, which of course didn’t help. As the Buddhist monk Thich Nhat Hanh would say, “If we become angry at our anger, then we will have two angers at the same time.” Similarly, there was an occasion when he got really nervous that he might make a mess of giving a speech, and his nerves became so overwhelming that he delivered the speech badly. A self-fulfilling prophecy, one might say.  

These are not my examples; they are examples given by psychologist Richard Schwartz in his introduction to Internal Family Systems (IFS). This therapy (sometimes also called “parts therapy”) is a form of self-analysis in which participants learn to resist supressing or controlling their difficult thoughts or emotions, the different “parts” of their inner world, and instead adopt a posture of curiosity towards each of them. This posture allows people to be in a beneficial relationship to their emotional lives, rather than being ruled by them.  

Fundamentally, the relationship that emerges is one of compassion, understanding that our thoughts and emotions have a job to do, even the uncomfortable or shameful ones. So, anxiety, for example, guards us from committing social faux pas, whilst joy helps us to keep hold of a sense that life is ultimately worth the living, no matter how hard things get. Even sadness and grief, as much as we fear being overtaken by such emotions, have an important role to play, for example by helping us to define what things and people are most valuable and important to us. 

For those who haven’t seen the Inside Out films, the writers cleverly take this idea of the “internal family” of emotions and create five relatable characters that embody them – Joy, Fear, Sadness, Anger and Disgust. In the first film, we see how these characters interact inside the head of a little girl called Riley. They are helping her to hang on to her sense of self despite the upheaval she experiences in her outside world, when her family relocate to a new city, and she must settle in to a new home and school. In the sequel, we rejoin Riley as she enters the turmoil of puberty, and the five initial characters are abruptly forced to work alongside some new arrivals – the “teenage” crew of emotions: Anxiety, Ennui, Envy, and… the biggie… Embarrassment.  

This Self is transpersonal – it exceeds the boundaries of who we each are as an individual person and connects us to something large.

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When he first developed IFS in the 1980s, Richard Schwartz was, by his own confession, a committed atheist, with what he describes as “a distain for religion”. Schwartz writes of the frustration he felt at that time when several Christians got excited about IFS in its early stages of development. His peer, Robert Harris, even went so far as to publish a book that set out a Christian version of the therapy. Initially, Schwartz felt the biggie – embarrassment – that his therapy was being taken up by Christians. However, as time went on, and as much as Schwartz tried to push aside the spiritual dimension of IFS, he increasingly found that spirituality could not be eliminated from the picture: 

“As I used the model with clients through the eighties and nineties, increasingly they began having what can only be described as spiritual experiences. These vicarious encounters with the mystical profoundly affected my own spirituality and I became interested in Buddhism, Hinduism, Taoism, shamanism, Kabala – everything but Christianity.”

Over time, Schwartz’s antipathy to the relationship between IFS and Christianity began to wane. He saw how much he had been working on the basis of prejudice, limiting his own exploration of Christian ideas in response to some unhelpful encounters he’d had with a few heavy-handed fundamentalists. He made deliberate moves to engage with Christian dialogue partners across the breadth of the tradition and began to see how congruent IFS was with the teaching of Jesus. The posture of curious compassion towards oppressive and uncomfortable emotions that Schwartz was encouraging his clients to adopt was mirrored perfectly in the attitude that Jesus advocated towards “enemies” in the outside world: do not judge, instead seek to engage them with kindness, and work towards their healing.   

In recent decades, Schwartz has come to rethink IFS as an integration of psychology and spirituality, rather than as a form of psychotherapy. He speaks of “spirituality” as an innate essence at the core of each person, which he calls the “Self”, and acknowledges that many of his more religious students prefer to think of this essence as “the soul” or “Atman” (the eternal self within Hinduism). And, whilst he still describes himself as fundamentally agnostic and is wary of making his own definitive religious commitments, he has come to agree that this Self is transpersonal – it exceeds the boundaries of who we each are as an individual person and connects us to something larger.

Screenwriting for a popular audience of all-faiths-and-none, it is perhaps unsurprising that the makers of Inside Out have thus far eschewed the deep and fascinating spirituality of IFS. Riley’s “sense of self” is at the centre of both films, but the way it is depicted implies that it is something that only comes into being at birth and exists entirely to regulate Riley’s engagement with the outside world. So far, there has been no exploration of more existential questions such as faith and eternity. However, the concept of the film is so brilliant, and for a complex idea it is so well executed, that I am sure we can look forward to many more Inside Out films to come. If that is the case, then just as Schwartz found himself going on an unexpected journey of spiritual exploration, the writers of Riley’s may well find themselves doing the same. I, for one, look forward to finding out what Riley discovers.  

Review
Books
Care
Comment
Psychology
7 min read

We don’t have an over-diagnosis problem, we have a society problem

Suzanne O’Sullivan's question is timely
A visualised glass head shows a swirl of pink across the face.
Maxim Berg on Unsplash.

Rates of diagnoses for autism and ADHD are at an all-time high, whilst NHS funding remains in a perpetual state of squeeze. In this context, consultant neurologist Suzanne O’Sullivan, in her recent book The Age of Diagnosis, asks a timely question: can getting a diagnosis sometimes do more harm than good? Her concern is that many of these apparent “diagnoses” are not so much wrong as superfluous; in her view, they risk harming a person’s sense of wellbeing by encouraging self-imposed limitations or prompting them to pursue treatments that may not be justified. 

There are elements of O-Sullivan’s argument that I am not qualified to assess. For example, I cannot look at the research into preventative treatments for localised and non-metastatic cancers and tell you what proportion of those treatments is unnecessary. However, even from my lay-person’s perspective, it does seem that if the removal of a tumour brings peace of mind to a patient, however benign that tumour might be, then O’Sullivan may be oversimplifying the situation when she proposes that such surgery is an unnecessary medical intervention.  

But O’Sullivan devotes a large proportion of the book to the topics of autism and ADHD – and on this I am less of a lay person. She is one of many people who are proposing that these are being over diagnosed due to parental pressure and social contagion. Her particular concern is that a diagnosis might become a self-fulfilling prophecy, limiting one’s opportunities in life: “Some will take the diagnosis to mean that they can’t do certain things, so they won’t even try.” Notably, O’Sullivan persists with this argument even though the one autistic person whom she interviewed for the book actually told her the opposite: getting a diagnosis had helped her interviewee, Poppy, to re-frame a number of the difficulties that she was facing in life and realise they were not her fault.  

Poppy’s narrative is one with which we are very familiar at the Centre for Autism and Theology, where our team of neurodiverse researchers have conducted many, many interviews with people of all neurotypes across multiple research projects. Time and time again we hear the same thing: getting a diagnosis is what helps many neurodivergent people make sense of their lives and to ask for the help that they need. As theologian Grant Macaskill said in a recent podcast:  

“A label, potentially, is something that can help you to thrive rather than simply label the fact that you're not thriving in some way.” 

Perhaps it is helpful to remember how these diagnoses come about, because neurodivergence cannot be identified by any objective means such as by a blood test or CT scan. At present the only way to get a diagnosis is to have one’s lifestyle, behaviours and preferences analysed by clinicians during an intrusive and often patronising process of self-disclosure. 

Despite the invidious nature of this diagnostic process, more and more people are willing to subject themselves to it. Philosopher Robert Chapman looks to late-stage capitalism for the explanation. Having a diagnosis means that one can take on what is known as the “sick role” in our societal structures. When one is in the “sick role” in any kind of culture, society, or organisation, one is given social permission to take less personal responsibility for one’s own well-being. For example, if I have the flu at home, then caring family members might bring me hot drinks, chicken soup or whatever else I might need, so that I don’t have to get out of bed. This makes sense when I am sick, but if I expected my family to do things like that for me all the time, then I would be called lazy and demanding! When a person is in the “sick role” to whatever degree (it doesn’t always entail being consigned to one’s bed) then the expectations on that person change accordingly.  

Chapman points out that the dynamics of late-stage capitalism have pushed more and more people into the “sick role” because our lifestyles are bad for our health in ways that are mostly out of our own control. In his 2023 book, Empire of Normality, he observes,  

“In the scientific literature more generally, for instance, modern artificial lighting has been associated with depression and other health conditions; excessive exposure to screen time has been associated with chronic overstimulation, mental health conditions, and cognitive disablement; and noise annoyance has been associated with a twofold increase in depression and anxiety, especially relating to noise pollution from aircraft, traffic, and industrial work.” 

Most of this we cannot escape, and on top of it all we live life at a frenetic pace where workers are expected to function like machines, often subordinating the needs and demands of the body. Thus, more and more people begin to experience disablement, where they simply cannot keep working, and they start to reach for medical diagnoses to explain why they cannot keep pace in an environment that is constantly thwarting their efforts to stay fit and well. From this arises the phenomenon of “shadow diagnoses” – this is where “milder” versions of existing conditions, including autism and ADHD, start to be diagnosed more commonly, because more and more people are feeling that they are unsuited to the cognitive, sensory and emotional demands of daily working life.  

When I read in O’Sullivan’s book that a lot more people are asking for diagnoses, what I hear is that a lot more people are asking for help.

O’Sullivan rightly observes that some real problems arise from this phenomenon of “shadow diagnoses”. It does create a scenario, for example, where autistic people who experience significant disability (e.g., those who have no perception of danger and therefore require 24-hour supervision to keep them safe) are in the same “queue” for support as those from whom being autistic doesn’t preclude living independently. 

But this is not a diagnosis problem so much as a society problem – health and social care resources are never limitless, and a process of prioritisation must always take place. If I cut my hand on a piece of broken glass and need to go to A&E for stiches, I might find myself in the same “queue” as a 7-year-old child who has done exactly the same thing. Like anyone, I would expect the staff to treat the child first, knowing that the same injury is likely to be causing a younger person much more distress. Autistic individuals are just as capable of recognising that others within the autism community may have needs that should take priority over their own.   

What O’Sullivan overlooks is that there are some equally big positives to “shadow diagnoses” – especially as our society runs on such strongly capitalist lines. When a large proportion of the population starts to experience the same disablement, it becomes economically worthwhile for employers or other authorities to address the problem. To put it another way: If we get a rise in “shadow diagnoses” then we also get a rise in “shadow treatments” – accommodations made in the workplace/society that mean everybody can thrive. As Macaskill puts it:  

“Accommodations then are not about accommodating something intrinsically negative; they're about accommodating something intrinsically different so that it doesn't have to be negative.” 

This can be seen already in many primary schools: where once it was the exception (and highly stigmatised) for a child to wear noise cancelling headphones, they are now routinely made available to all students, regardless of neurotype. This means not only that stigma is reduced for the one or two students who may be highly dependent on headphones, but it also means that many more children can benefit from a break from the deleterious effects of constant noise. 

When I read in O’Sullivan’s book that a lot more people are asking for diagnoses, what I hear is that a lot more people are asking for help. I suspect the rise in people identifying as neurodivergent reflects a latent cry of “Stop the world, I want to get off!” This is not to say that those coming forward are not autistic or do not have ADHD (or other neurodivergence) but simply that if our societies were gentler and more cohesive, fewer people with these conditions would need to reach for the “sick role” in order to get by.  

Perhaps counter-intuitively, if we want the number of people asking for the “sick role” to decrease, we actually need to be diagnosing more people! In this way, we push our capitalist society towards adopting “shadow-treatments” – adopting certain accommodations in our schools and workplaces as part of the norm. When this happens, there are benefits not only for neurodivergent people, but for everybody.

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