Essay No 6. More on “Constructivism.”

January 9th, 2012

Essay No 6.  More on “Constructivism.”

Introduction

Remember the anecdote of the three baseball umpires from essay 2. The third was the constructivist as he recognised he was not reporting reality (whether the batter was out or safe); he was making reality through his declaration. Through Constructivism we understand that our involvement in exploring and describing something, affects the end result. How we examine it, what our starting knowledge is, our biases, the questions we ask, all shape the conclusions reached.

False Presumption of Objectivity

If the starting premise in psychiatry is that patients have a biological condition, (inferring that cognitive/family/environmental factors are less important) then already one pathway is favoured over others. Maybe in some instances the problem is largely biological, but if that presumption generalises to all instances, options are closed.

Constructivism points out the system of classifying psychiatric diagnoses lacks objectivity.  Case stories such as that of Josie in essay 2 are not just mistakes. They occur repeatedly. Professionals fail to appreciate the message of constructivism, that is, their role in gathering information and defining the problem is shaping what follows, not just objectively stating ‘facts.’

If a family is told their family member has schizophrenia, they will soon receive ‘education’ about what to do and what to expect, coupled with further information from the internet and relatives / friends in similar situations.  This is not wrong; it is unavoidable…people in crisis want information. However, what information is selected from all the possible information available? The paradigm we favour will filter the information we offer.

The biological paradigm will mean the patient and family will progressively learn about brain biochemistry, medications, early detection of symptoms of relapse; this all shapes the whole patient-family-service system. They are likely to respond in certain ways (possible hyper vigilance by the patient, or the family, or case-worker; possibly arguments about compliance with medication; possibly lowered expectations about a speedy and full recovery, and not much chance that it can happen free of medication….)

What may seem to some, as an objective determination of the diagnosis followed by a treatment plan, has led to a pathway for the client and family.

It is one pathway among several. It is however a pathway that closes other doors.

Nardone, the author from essay 3, would likely not call it schizophrenia, but pragmatically investigate the interpersonal patterns that influence the continuation of the problem behaviours. In the two examples he presented, there were no predictions of chronic difficulty, or mental impairment that might necessitate medication.  His therapy begins with curiosity and optimism that change can occur. He looks to join with people and employ techniques in a collaborative fashion.

The fact that Nardone and other authors get results with clients that others would medicate, illustrates that mainstream treatment of those with psychotic disorders is not the treatment of necessity. Rather it is a treatment selected by professionals with limited knowledge of therapy options.

The construction of a person’s experience as an ‘illness,’ may in itself lead to a chronic course, since powerful alternatives are not employed.

Once a psychiatrist declares the diagnosis and announces the required treatment, seldom is anyone questioning whether schizophrenia is “real” as opposed to a ‘viewpoint.’  That is why patients can be managed as Josie was.  The construction has become reality.

Is This Another ‘Josie’ Type Story?

Please take a moment and watch the video link below. Although we know only a little of this patient, it raises some interesting points. The clip is of a clinical psychologist.  He tells how he got lucky in a session with a 38 y.o. patient who had a lifelong diagnosis of schizophrenia.  The patient’s problematic symptom was that she regularly heard a voice telling her, “Kill, kill.”   In this session, the woman’s command hallucinations stopped and at 12 months she was still hallucination free.

http://www.youtube.com/watch?v=wyL0jjI93OI  In this case it is evident how important the family context was.  She was weaned off her 3 medications and functioned.  In his view she no longer met the criteria for schizophrenia.

There are some things to note: firstly, irrespective of the length of the problem, the resolution will not necessarily be a lengthy process.  Examples of rapid success such as this and those in essays 3 & 4 undermine the suggestion that a person has a biochemical imbalance in their brain, (implying it has taken time to develop and may need medication to correct it.) Alternately, one may better say the person needs a different perspective; or as in essay 4, different mental strategies.

Secondly, the context of symptoms is vitally important.  Family therapy has always maintained that symptoms are best understood in context; this is why family members are so often included in therapy…not that they are necessarily part of the problem, but they often know more about the context, and do afford more possibilities for intervention. The examples in essay 3 illustrate this well.

Remember the Second Umpire

Professor Marius Romme (psychiatrist, and contributor to the Hearing Voices network and website http://www.intervoiceonline.org/ ) has challenged the validity of diagnoses such as schizophrenia. Such people are often dismissed as extremists.  I suggest detractors are not conversant with constructivist ideas.  I suggest they may be like the second umpire and think the first person got the diagnosis wrong, and they would have determined the diagnosis correctly.  But Josie probably saw a dozen doctors who also got the diagnosis wrong.  Most likely too with the YouTube patient who was treated for more than 20 years.

The Training of Doctors and Psychiatrists

It is easier for doctors and psychiatrists to entertain the notion that ‘illness’ constructions have significant shortcomings if they have a full range of intervention strategies they can employ.  Many doctors do study psychotherapy, train others and write articles.  Unfortunately the standard training psychiatrists receive does not include extensive knowledge and training in therapy models.

The majority of psychiatrists and trainees I have met in more than 20 years never indicate it is possible for patients to recover from psychosis without medication. To a lesser degree they believe medication is a valuable treatment for other conditions, or at least won’t do harm as part of the treatment plan.  There are differing viewpoints on this, as discussed in essay 7.

I expect psychiatrists feel vulnerable if they do not treat with medication.  Since the dominant paradigm is faulty biology, they justifiably anticipate being blamed if they do not medicate and a negative outcome was to occur.

Constructivism is a way out, as it rids the idea that clients are ill and medication is essential.  Constructivism can open more choices than an ‘illness’ paradigm.

Explicitly Acknowledging Constructivism

In the fields of family therapy and NeuroLinguistic Programing, many authors explicitly acknowledge constructivism, and write of approaches which do not include the creation of labels such as schizophrenia. Such authors look for pragmatic interventions to interrupt personal and interpersonal patterns that perpetuate symptoms.  In the case of De Shazer’s “Solution-focused therapy” the emphasis is on not mentioning the problem, but asks what will the solution look like; what part(s) of that are already happening; how so, and can we do more of that etc?

Constructivist therapies such as Solution-focused therapy cannot make the mistake made with Josie, since they explicitly acknowledge they are co-creating reality with the client; they don’t look for pathology, but strengths and resilience, which they foster.  By way of example, I wrote an article, “About Hope In Psychiatry – Not Labels And Limitations.”  http://www.tomblackford.com.au/2011/04/24/about-hope-in-psychiatry-not-labels-and-limitations/

At the beginning I include a story by Steve De Shazer working with a couple, both with extensive psychiatric histories.  Despite his medication, the husband was frequently hearing voices; he admitted to being bossy and angry.  They were on the verge of separating again.  Rather than thinking about medication or exploring his symptoms, De Shazer focused on how to make the relationship better.  Over the course of 5 sessions, their relationship improved and the symptoms as well.

Out of fear, a doctor might have felt compelled to recommend medication changes, taking time away from doing therapy.  Instead De Shazer engaged in a process which implies they can act powerfully to improve whatever is happening.

Can We Support Clients’ Belief In Their Capacities?

An ‘illness’ construction tends to steer patients away from believing they have the inner resources to find solutions without the aid of medication.  This undermines clients’ faith in their abilities.  The ‘illness’ construction also contributes to the over use of medication, metabolic problems and shorter life expectancy.  Where patients do not agree with the illness model, arguments can result (sometimes loudly, sometimes silently) and collaboration lost.

Many doctors and psychiatrists criticise psychiatry for placing too much faith in the claims of the pharmaceutical industry. We all know of clients who have improved while taking medications.  Yet claims of medication’s efficacy above placebo and psychotherapy are tainted by drug companies’ many tactics to increase sales.

Regardless of any “success” by a psychiatric medication, it will never show that a drug is essential for a disorder, only that it made a difference with that client (as therapy might also have done.)

Conclusion

While mental health services focus resources on determining the ‘correct diagnosis’ and delivering medication, less time is available to learn effective interventions which are premised on people being capable of recovery.

Many practitioners do not understand that constructing people’s problems as ‘mental illnesses,’ close psychotherapeutic options that rely on reframing problems differently.  In contrast most therapy options do not prevent a person from trialling medication and noticing what effect it has. Thus constructivism allows both options to coexist.

Constructivism adds perspective and choice to consumers. Once constructivism becomes an explicit part of the discourse in mental health services, we can find new ways to collaborate with clients.

(Go to essay 7.)


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