He said however, when antidepressants are compared against an “active placebo” (another drug which is not expected to improve depression) no difference in performance is found.

It has long appeared in the literature concerning clinical trials that patients (and staff) know if they are receiving a drug or a sugar pill, by the presence or absence of side-effects. By using an active placebo all the subjects experience side-effects, confusing everyone as to who is getting the real antidepressant. Then there is no demonstrated benefit of antidepressants over placebos.

Therefore is it a good use of government expenditure to be supplying antidepressants when they don’t work? Does it concern you that people may get sexual dysfunction, anxiety, an increase in suicidal ideation, panic attacks, hostility or aggression etc, for no proven benefit? Are you concerned that doctors who do not want to prescribe antidepressants have limited choice when the prevailing “best practice” is to do so?

At a TED conference in 2011, Dr Ben Goldacre gave a 14 minute talk which was posted online. http://www.ted.com/talks/ben_goldacre_battling_bad_science.html#.TpJ6HvxNerA.email  He is an epidemiologist and was speaking about bad science, particularly in medicine. He referred to the fact that more than half the data on antidepressants has not been made available to the Cochrane group² investigating the effectiveness of these drugs.

The pharmaceutical companies are more likely to have shared the data favouring their drugs, rather than data casting doubt about them. I highly recommend the talk; it is fast paced and entertaining. He makes the point that scrutiny into research is vital for our community to make wise choices about our health practices.

There is hope

Dr Peter Breggin, an American psychiatrist, and one of the most known critics of psychiatry, reported in his blog (19th Aug 2011), “Apparently two British-based companies, GlaxoSmithKline and Astra Zeneca have announced that they no longer intend to research, develop or market any new antidepressants.” http://www.huffingtonpost.com/dr-peter-breggin/empathic-psychotherapy-_b_924494.html    He says that because of the growing evidence against antidepressants and increased law suits, “the cost of litigation — even while settling almost every case — has grown overwhelming.”

I read Peter Breggin’s more recent post (16^th Nov 2011) where he pulls together research arguing that antidepressants can perpetuate and thereby create long term depression. Rather than fixing the problem, they may be making people worse.  I encourage you to read it. http://www.huffingtonpost.com/dr-peter-breggin/antidepressants-long-term-depression_b_1077185.html

Why did I write this article?

Many colleagues I know have an interest in delivering psychotherapy. It is not always easy and we are not always successful. However, we understand there are a multitude of ways to help people with their problems. From what I have read of the scientific critiques of antidepressants, the cost-benefit analysis does not favour use of these drugs.

People often assume that even if they don’t work, they are harmless and worth a try. Breggin argues they are not harmless. Furthermore, where the client is free from obvious serious side-effects, we do not know the long term effects. And their prescription adds to the idea their “depression” is an illness rather than something they do – I do not use this phrase to blame sufferers. I want people who feel depressed to understand they can learn skills and new perspectives, and take actions which will make them forever likely to better manage life’s challenges.

I am concerned the idea of this alleged ‘illness’ lessens the likelihood that people will see themselves as resourceful and capable of solving problems. (I acknowledge some will need help to do this.)

What can we all do about this?

Do we want to stand idle while drug companies promote false ideas like there is a pill which will dissolve unhappiness?

If we want Medicare and government to support the provision of psychotherapy, then it seems useful to break down the false rhetoric of a chemical imbalance causing depression. Such misinformation sees antidepressants routinely used as the first line of treatment.

In the public mental health services, psychotherapy is offered to a tiny proportion of its clients, out of errant conclusions, from poor science.

I think that much more assistance can be delivered by a trained workforce who are not restrained by misinformation, which is then translated into practices and policies.

A helpful strategy is to circulate information which will inform people, counter past ideas, and promote discussion, as I am doing.

1. 1.     [Dr Colin Ross is an author of several books including, “Pseudo-Science in Biological Psychiatry: Blaming the Body,” Colin A. Ross and Alvin Pam, John Wiley & Sons Inc, NY. 1995. I read this in 2000 and kept reading this literature ever since.]
2. 2.     [The Cochrane group is a highly respected, non-profit collaboration of researchers. They seek access to the data of all clinical trials, assess the methodology, the analysis and conclusions.]

Many colleagues are not aware of authors who write and train in methods appropriate for psychotic disorders. Senior staff have told me they cannot believe that psychosis can be resolved without medication. Drug therapy dominates any talk of treatment for these disorders. This perpetuates the idea that these difficulties are somehow especially biologically caused and require medication. (Essay 5 will raise questions about the claimed efficacy of psychiatric medications.) This essay says there are approaches that could be included in the treatments offered by mental health services.

Apart from references to a few authors at the end, this paper is chiefly an extract of 10 pages from one book, detailing 2 case examples. They were enough to make me buy the book, which deals with a wide array of psychological disorders.

This essay is longer than the others, but is essential reading to understand that even psychotic disorders are changeable through talking therapy. Reading many examples from different family therapists has made me truly wonder why antipsychotics are ever tried first.

In the extract below, some information from previous chapters is assumed, so a greater understanding is gained by reading the whole book, which I heartily recommend.

Comment: Some may criticise the use of case studies such as those below, preferring “hard science.”  Elsewhere I refer to scientific studies. Here I offer the case studies to advertise that there are alternatives to medications, approaches that have theoretical underpinnings which are written down and taught. As colleagues do not talk about them, I presume they are not widely known.

*******************************************************************************

Extract from “Knowing Through Changing: The Evolution of Brief Strategic Therapy,” by Giorgio Nardone & Claudette Portelli (Crown House Publishing, Wales, UK, 2005)

Presumed psychosis

We use the term presumed psychosis because we believe that often a wrong diagnosis of psychosis is conducted, and that it is this labelling that eventually “invents” the illness (Nardone and Portelli, 2005). From our point of view, to assume from the very beginning that a patient is psychotic means, to be caught up in a prophecy that sees no or very little possibility in treating the patient. We strongly believe that a therapist should always try to do something to alleviate the suffering of the patient and his / her loved ones, even when the case is considered clinically untreatable.

By saying it is a psychotic case, the therapist, like all the other agents around the patient, can be easily caught up by a consequential overwhelming feeling of helplessness. As Watzlawick used to say “Words are like bullets” — and they are, without doubt, responsible for the construction of one’s reality.

The word “presumed” sheds a ray of hope and thus one feels that something might still be done. Then, if the treatment works well and “the patient recovers from his psychotic symptoms, we can affirm that it was no case of psychosis, if not, at least we have tried our best to better the situation and often small positive changes still take place that help the patient and his beloved ones adjust better. But, again, we come to discover a problem by means of its solution: “Knowing through changing.”

At our Center we have had many diagnosed psychotic patients who have completely overcome their presumed psychosis. In saying this, we do not mean that we have healed psychotic patients, but only shown through successful therapies that these persons were not afflicted by a real psychosis but by invalidating symptoms defined as signs of psychosis in traditional nosographic classifications.

Having clarified this fundamental assumption, we can now proceed in presenting the phases of therapy in the treatment of these highly intimidating patients.

In the first stage of treatment, the most important therapeutic action is the complete acceptance of the distorted reality presented by the patient, as if it were actually real. In order to do this, the therapist needs to trace the logic of the patient and use his language. At a communicative, relational, and strategic level, the therapist needs to follow the patient’s narration of his reality, without alienating himself to what the patient is saying, and thus openly show that he acknowledges his suffering. This permits the therapist to establish a good and suggestive relationship with the patient and also with his family.

Once this is accomplished the first session goes into the second stage of therapy: to construct and introduce an invented reality, which realizes concrete results. In other words, the therapist must build a therapeutic representation usually followed by a ritual prescription that fits with the pathological patient’s perception and reaction, which drives it toward self-destruction.

This amounts to a strategic form of art on the therapist’s part, because he first has to follow the logic and structure of the patient’s representation of reality, then invent and introduce something tailored to patient’s non-ordinary logic, capable of achieving an effective change. This normally takes up the entire first session, so as to be able to make this new representation, based on the patient’s logic, more credible, more artistic and ”real” for the patient. The representations of reality, or the delusions, of patients with presumed psychosis follow a non-ordinary logic. To be able to alter their dysfunctional balance, we cannot disregard the patient’s delusions but, in devising therapeutic strategies, we need to use the non-ordinary logic that underlies these specific delusions. In other words, the therapist needs to follow the seemingly crazy logic that underlies the patient’s ideas and actions by inexplicitly showing the patient that what he is thinking and doing makes sense, while gently intervening by sowing seeds of doubt in what the patient has always held as absolute. This should be done with great caution so as not to dispel his delusions.” On the contrary, the therapist should make use of counter-delusions to introduce some different aspects that serve to divert the delusion toward a new, more functional balance but without driving out the old convictions.

Furthermore, we need to modify the dynamics within the patient’s interactive system with others and the world. This is carried out by the prescriptions such as the Conspiracy of Silence, the Nightly Family Ritual (both prescriptions have been already described in previous sections) and others, which help frustrate the secondary advantages offered by the symptoms.

The third and fourth stages of therapy are the same as previously described treatment protocols: guiding the person and the family to build a new balance based on the new reality after an often dramatic change. For the sake of clarification, we will use real clinical examples.

Riccardo, a shabbily dressed, bearded twenty-year-old, was brought to therapy by his father for his bizarre attitude, which had been diagnosed as “monomaniac behaviour.” Two years earlier he started attending university, where he joined the Socialist Revolutionary Political party, which became his sole and exclusive interest and encapsulated his entire existence. He left home, because he was truly convinced that the family was a social constriction that suffocated personal growth and self-fulfilment, to join party comrades at the university campus, but failed to attend lectures. His entire existence whirled around political issues and debates. He would isolate himself for days to study political treatises and texts.

[The classical definition of delusion is a false, personal belief, based on incorrect inferences regarding external reality, which is firmly upheld by the individual despite everyone else’s contrary beliefs.]

His conversations with family members and flatmates were monothematic. He would passionately lecture and try to convince others of his political ideologies, while losing his temper when others objected. He was hospitalized a number of times because he had undergone critical moments when his behaviour had gone out of control. His father tried to talk sense into him while his party comrades avoided him, annoyed by his bizarre behaviour and repetitive speeches. He came to therapy depressed but not defeated by his failed attempts to be taken back by the party.

This was a fundamental aspect that we recognized as useful so as to be able to divert the patient’s delusion to a more functional balance. This was the right lever to exploit, since he wanted, more than anything else in the world, to be taken back by the group. But the patient was convinced that to be reaccepted by the group he had to find more persuasive words. Thus, his attempted solutions were to study more about his ideology and then preach his knowledge to show his full commitment to the revolution and to the party. This was his conviction, his delusion. During the first session, it became clear that the patient would have done anything to be taken back by his party. We showed him that we could help him. And yet, following the logic of his delusion, we started sowing doubts about whether finding more persuasive words was actually the right way to be accepted back into the group.

Therapist: So the group does not want you anymore?

Patient: No, no.

Therapist: OK. But what are you doing so that you can get back to your group, so that you are accepted once more?

Patient: Yeah, in fact, that is what I need to understand.  I need to understand better what I need to do.

Therapist: Hmm, but what have you done till now so that they would take you back?

Patient: No, I mean, that is no…continuing in this way, for example, I don’t know, doing my best to diffuse the left-wing ideology in all schools, however, within normal limits, like others do, within normality…

Therapist: Hmm [nodding], and this is all that interests you? There is nothing else in your life?

Patient: Right now, no.

Therapist: So, when you can’t meet people, you have your texts, which you study in great depth so that you will be well up in them? Do you speak about your texts with anyone or you keep them to yourself?

Patient: Yes, I do, but then people speak less to me, they become rubber walls (an Italian expression meaning words just bounce back off people; people do not understand)  I come to face rubber walls.

Therapist: So, you try to speak to them but they refuse you, therefore the more you speak the more they refuse you.

Patient: It’s a great mess.

Therapist: So, correct me if I’m wrong but trying to convince them with words is the best way to draw them always more away from you?!

Patient: Yes, in fact

Therapist: However, for you, the desire to profess your faith, your ideology is uncontrollable or else you have come to understand that the more you speak the more this distances you from them. What do you think is best now?

Patient: Now it’s best to calm down a bit.

Therapist: Are you able to do so?

Patient: Yes. However, I manage quite poorly.

Therapist: Well, I’ll help, OK? [Pause] Well, when they keep you away, this provokes in you depressive moments, i.e. you feel bad that they ignore you or you get angry?

Patient: I get angry and bury myself in my books.

Therapist: As if like saying, “Since you people are like that, I’ll isolate myself and read, or else …”

Patient: Look for others.

Therapist: Others?

Patient: Yes, others, who knew what was happening in my life but who led their own tranquil life

Therapist: But these people listen to you for five minutes and then they send you away and tell you to go to hell.

Patient: Yes, they greet me, “Hi, Riccardo”—and that’s it.

Therapist: Or maybe even if they see you around, they would try to avoid you.

Father: He’s monothematic.

Therapist: Monothematic. However, you have come to comprehend that the more you run after them, the more they run away.

Patient: The more they run away.

Therapist: You said that you would like to speak up, state your case, but nobody is now willing to listen to you

Patient: Yes.

Therapist: Or else they listen to you for five minutes and then they tell you to go to hell? On the other hand when you talk to your dad, your dad discusses it with you? But after a while you will start to quarrel, true?

Father: We do not quarrel: we discuss.

Therapist: You start to quarrel because you [toward the father] are not so much in agreement with his ideas. You get into a sort of political debate and you clash

Father: [Nods.]

Therapist: OK, we would like you to follow our indications to the letter, that is, we would like you to allow a precise period of time for your orations. We would like you to give out a speech every day while [speaking to the father] you and your wife are in his presence. Therefore, what we would like you to do during the coming two weeks, every evening, you get together in your living room, you and your wife seated in absolute silence, you [pointing to the patient] standing. You set an alarm clock to ring after half an hour, because your speech should be managed within an adequate period of time and you, for half an hour, should carry out your speech on a chosen argument regarding  your ideology and for half an hour you have to stand there and give, out your speech—talk and talk.

You and your wife [referring to the father] should remain the entire half an hour in absolute silence. When the alarm rings, stop, it’s all over until the following evening you have to avoid to speech about your ideology and studies  you have to keep what we call conspiracy of silence: you [to the father] have to really avoid it if it happens that he starts speaking. Tell him, “Tell us about it this evening during the half an hour.” Postpone it. Riccardo, this goes for everyone. I mean, during the coming two weeks we would like you to restrict your need to speak about this important thing to the half-hour. Therefore, we would like you to avoid speaking about it with anyone–after all nobody really listens to you, they avoid you! But since you feel the need to express your faith, your belief, you will do so with them [pointing at the parents]; for now let us limit ourselves to at least educate them. Let us start off from this first stage so that we can then move onto the rest, you agree?

Patient: Yes, yes.

The following session, Riccardo reported that he followed the prescription and that every evening, in just half an hour, he managed to develop his speech and bring it to a closure. He also declared that, besides the half-hour oration, he did not try to persuade the world of the revolution. He said he kept at heart what we had said the previous session. So, on meeting his friends, especially a female friend, he avoided speaking about his revolutionary ideology and he noticed that people started to hang around with him more.

The prescription also changed the family dynamic. Both Riccardo and his dad said that they had more tranquil days, when they spoke about sport, cinema, university, and other topics that had hitherto always been put aside to leave space for their usual political debates. At the end of the second session Riccardo was invited to continue giving out his speeches during the half-hour once a day, underlying their fundamental didactic purpose, while keeping a silence throughout the rest of the day just as he had managed to do so far. Furthermore, he was asked to carry out an experiment. We told him, “At a specific hour of the day, which you are free to choose, we want you to ask yourself, ‘What would I do with my time if I were no longer interested in my revolution project? How would I spend my time differently from what I do now, if I were no longer interested in the revolution?’ And for an hour every day, not more than an hour, carry it out. Let’s see what you would choose to do for an hour a day, just an hour, not more, as if you were no longer interested in the revolution.”

The patient arrived at the third session gladly itemizing all the new things he managed to do during the past two weeks. He confessed that he even had a date with a girl he liked, when they spent a pleasant evening talking about sweet nothings. Furthermore, during the last Week, he felt the need to start reading other books such as novels.

Even though the as-if prescription was limited to just an hour a day, it triggered off what Thom (1990) has called the “butterfly effect” (which we touched on earlier) throughout the patient’s entire daily routine. At the end of the session he claimed that, even though he was still loyal to his ideals, he thought that, every now and then, one had to take one’s mind off things.

Patient: Well, observing other people’s daily activities, even though they have not taken big life decisions-—however, they have chosen their life—each one of them has an occupation or something else .. . but they try to take their minds off it by doing something else. For me life was just commitment to my ideals and that’s it. Then I tried to understand what other people do in their free time, go to the cinema, read novels and magazines…

Therapist: Therefore, what you are saying is that what you previously considered as anti-revolutionary miseries now you look at them differently?

Patient: That is, not as anti-revolutionary but as a form of distracting, uninterested attitude;  now I’m trying to be more interested in art, there are so many beautiful things here in Tuscany, even in Arezzo, Piero della Francesca…

Therapist: Not only, Poliziano and others.

Patient: I know. In fact this brings to mind even linking this to the commitment of certain historical leaders such as Trotsky and Lenin when they visited London. Lenin said, “Look, Westminster, it is wonderful.” But Trotsky showed no interest: “No, I want to look at Russia… just let me be.” He did not want to see…

Therapist: He did not want to see beyond his ideology. Therefore, you mean that your boundaries are getting elastic, more flexible?

Patient: Yes, a bit, yes.

During the following sessions, Riccardo reported that he went back to university, that he was dating other girls and that he no longer needed the half-hour podium. At home they finally had pleasant conversations. Every time, we acknowledged Riccardo’s good work but suggested he continue with the prescriptions, each time increasing the length of the as-if session by an hour. This was fundamental at this stage, where we needed not to be blinded by results but work to consolidate the results achieved so far.

At the fifth session, we asked him to continue observing others just as anthropologists do, so that he would get to know more about others, especially about the female world, so that he would come to understand better what to do to enhance his practical capability. We also started working on his appearance, which still had something of the “revolutionary” about it, giving him some problems when he approached others. He was very rather taken by Oscar Wilde’s maxim that it is only superficial people who don’t judge by appearances. A “new” Riccardo arrived at the next session: he had shaved his beard, trimmed his hair and wore a clean T-shirt and a pair of denim jeans; he also looked and behaved his age, as a handsome, pleasant twenty-year-old.

Another exemplary case is of another twenty-year-old (whom we shall call Roberto) who arrived at our centre with his parents after having been to various specialists in the field, who held divergent opinions and diagnoses of his “mental state.” For more than five years, Roberto had segregated himself within a sector of his parents’ mansion because he feared that certain people such as the handicapped, old people, and also his own brother would draw “beneficial energy” out of him. So, he avoided all sort of contact with the outside world and the few times he eventually went out he would perform some sort of “preventive ritual” before leaving the house and then a “repairing ritual” on his return to block the “draining process.” But, since his brother still lived at home with them, for Roberto the danger was also inside the house, so the family—-even though at first they tried to convince him of how much his brother loved him and that he should not be afraid of him—finally gave up and proceeded partitioned the house to prevent the two brothers from meeting.

However, the curious aspect of this case was that therapy began before our first encounter. Before coming to us, Roberto had read various books about our approach and. treatment and so, in the time span between his call to fix the appointment and our actual meeting, he had tried to face his fear and embraced his brother, but this frightened him even more, so he had decided not to do it again.

Once more, our intervention was first to follow the patient’s seemingly “crazy logic,” enter his delusion by utilizing his same language, identify the attempted solutions put into operation by the patient and also by the family that maintained and worsened the situation, and then proceed to block the attempted solutions, by sowing a seed of doubt in the patient’s convictions, and then proceed to find a creative yet credible way of turning the logic against itself.

Therapist: And yet you did something you were afraid to do before: you touched and embraced your brother and he did not drain all your beneficial energy? How do you explain this?

Patient: I don’t know.

Therapist: Therefore, you have, till now, held a wrong idea. Until now, you have protected yourself from him. You could not even stand to see him, thinking that if you touched him he would suck out your beneficial energy. Now you have touched him and nothing happened on the contrary you we able to hold it back, true? Let me explain to you one thing. In such situations as this, when you feel that some sort of osmosis takes place, where beneficial energy passes from you to your brother—OK?—what one tends to rationally do is to think, “I need to defend myself by avoiding such situations; therefore, I need to avoid him; I should avoid to touch him, to even look at him.” Or, better still, you have come to practice total avoidance.

Patient: What?

Therapist: You had come to a point where you had constructed extreme evasion  you could not even stand to see. Unfortunately, this rational reaction does not function. Because, in case of energy influx, the more you run away, the more energy gets lost.  So if you want to learn how to keep your beneficial energy, you need to gradually start doing the very opposite … the more you avoid the feared situation – that is the more you avoid your brother, afraid that he would drain energy from you, the more energy will get lost by itself and passes on to him. In fact, when you embraced your brother, you did not lose all your beneficial energy, true?

Patient: No, I did not lose all my energy.

Therapist: OK.

Patient: But then I decided not to embrace him anymore because when I was in the car getting here, I thought about my brother and energy escaped out of me.

Therapist: Be careful! It escaped without his being present. You have imagined it. Once more you did everything by yourself. Just think that during the past years, in reality, you’ve built your own trap, which you’ve got into but can’t get out of. ln what way? By avoiding confronting something that could have enabled you to hold in your beneficial energy. Instead, running away has made you weaker and weaker, so weak that energy gets lost by itself. Now to fortify yourself we are very glad that we can start doing this with you from today because you have already set in motion a great change while you were waiting to come here. You have spontaneously found your way out. Now we have to proceed without getting frightened and return to the trap. In these days, you have to get used to gradually holding within you your beneficial energy, by gradually coming into contact with your brother. From now till the next time we meet, we would like you, every morning, to wake up and embrace your brother before he goes to work. OK? When he gets back, embrace him once more and then before going to bed. You have to keep in mind that this is the first step, which you discovered spontaneously, in starting to hold in your energy. By running way-

Patient: But I have to give him my energy?

Therapist: No, you will hold it within you. This will help you keep it for yourself and not give it to him. Before, by running away, by hiding, by avoiding contact, you were always making yourself weaker and weaker and energy passed to him. You are right in wanting to keep your energy and the attention of your parents to yourself. He has his own, he has other things and the same goes for the outside world.  Do the same thing, OK? Besides this ritual, you [addressing the parents] should avoid—from now till the time we meet again—talking or asking about his fears. The more you speak about it, the more you work together to overcome it, the weaker Roberto becomes. So, throughout the day, you should keep what we call conspiracy of silence. You should avoid speaking about his fear and difficulties, or else this will exacerbate them, OK? You will get weaker and beneficial energy will get lost. But in the evenings, after dinner, get together all the family in the living room, get an alarm clock and set it to ring after half an hour, during which you [to the parents] will remain seated in absolute silence, and you, Roberto, standing. You will tell them all about the fears you felt throughout that day, all your worries, all those things that disturbed you. You [referring to the parents] should listen in absolute silence. When the alarm rings, stop—it is all over. Until the following evening avoid speaking about it.

Mother: There has to be his brother too?

Therapist: I would prefer the brother to be present too so that in this way you fortify yourself even more…  OK? And why not? In this way we send him some unbeneficial energy, the other type … no? [Everyone bursts into laughter.] But do not let him know, OK? We won’t tell him.

Patient: OK, we won’t tell him [laughing].

The family arrived the next session overwhelmed by the “miraculous” change that took place. They reported that Roberto carried out the (counter-) ritual three times a day throughout the entire two weeks, without fearing his brother; on the contrary, Roberto starting looking forward to his brother’s return from work, when they spent time chatting, watching TV, playing with videogames, etc. Furthermore, from the following session, Roberto was seen alone in therapy, and reported that he had started going out, going to the gym (with his mum), and to mass, and was eager to go back to school the following academic year. On one of his outings, he had met a disabled child whom he hugged lovingly, and, in therapy, he exclaimed that he could not understand why he used to fear handicapped people – they were so unfortunate and yet so caring. The rest of the therapy focused on establishing a new, more functional equilibrium both for Roberto and for the entire family. It is necessary to consolidate successes that have already been gained, so, by the end of the ten sessions, we had started working with the patient in developing social skills.

These clinical examples show that even such severe disorders can be treated in a short time, without recourse to traditional therapy. We do not “eliminate the delusion” but direct it toward its self-destruction. The principle that forms the basis of our treatment with presumed psychosis is “to add so as to reduce.” Our intervention aims to circumvent the patient’s resistance (Type 4 resistance – patient unable to collaborate) and to lead him to change his perception of reality. We use his own logic and mode of representing reality, and lead him through a series of “corrective” emotional experiences, until he begins to doubt his previously inflexible convictions.

As Goethe wrote, things are actually much simpler than one might think, but much more complicated than one might realize.

A few resources

Elsewhere on my site you will find a case study of a client I assisted – she was diagnosed with Schizo-Affective Disorder. I utilised a systemic approach for psychosis, described by Jay Haley, a prominent American family therapist. [Ref: “Leaving Home: The Therapy of Disturbed Young People,” Second Edition, Brunner/Mazel, 1997.]

[Cloe Madanes also wrote describing that approach: “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-191.]

http://www.isps.org/  This site is “The International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses.” It has many resources, including links to numerous published books for professionals and consumers.

“A Way Out of Madness: Dealing with your family after you’ve been diagnosed with a psychiatric disorder,” by Daniel Mackler & Matthew Morrissey, 2010. This book can be found at the US branch – http://www.isps-us.org/  The stated purpose of the book is a “guidebook to help people diagnosed with psychiatric disorders to deal more effectively with their families…”  The second half has stories from 12 contributors, mostly who have been consumers with diagnoses of schizophrenia or bipolar disorder. All have freed themselves from the psychiatric system and medications, some after very long involvements. For those who do not believe people can do well without medications could benefit from reading these stories. And many clients will find hope from such examples.

(Go to essay 4.)

My first essay explained constructivism by referring to the anecdote of the three umpires.  It highlighted that we make ‘reality’ by the parts of experience we select, emphasize and describe.

Next a case study showed the grave error of diagnosing a client (Josie) with schizophrenia, an error which is a direct consequence of not understanding constructivism.

The third and fourth essays gathered examples of therapy that I do not hear discussed in mental health services. They reveal more possibilities when working with those diagnosed with psychosis and other disorders.

The fifth essay raised questions about the efficacy of psychiatric medications. It suggested that review articles and meta-analyses are more trustworthy than individual studies. It encourages people to examine claims of efficacy rather than believing the information we are given is accurate and unbiased.

Essay six returns to constructivism. It questions the objectivity of psychiatric diagnoses, and uses more examples of therapy to show why therapy should be favoured as the first choice of treatment.

Essay seven summarises some of the harm that arises from the biological paradigm, and adds that we should be honest with clients about the diverse views regarding medication in this field.

Essay eight explains there are errors in thinking, which easily occur and lead people to think psychiatric medications are more effective than they are. Promoting medications, particularly as a first choice may diminish clients’ belief in their own capabilities.

Essay nine highlights the famous Pseudo-patient study and reminds us of the message of constructivism, that psychiatric labels are not objective and reliable. Doing without them might remove a cause of harm, and promote a focus on behaviours and difficulties, which are more solvable than an alleged ‘illness.’

CONCLUSION

I encourage you to spend 15 minutes watching the story this link takes you to…

Caroline Casey, talks about her life. She is inspiring and courageous. She shares something she discovered about herself at age 17 – it is amazing, unimaginable, and challenging. There are lessons for the listener about disability and how we handle it, and what we aim for in our lives. [Warning: the TED website is addictive!]

http://www.ted.com/talks/caroline_casey_looking_past_limits.html

I wonder what it would be like to have this and similar stories playing in the waiting rooms of mental health offices; or run group discussions about finding meaning in our lives, about doing things regardless of disability, contributing to people’s lives.

Mental health services label people, causing harm. People are capable of so much more than the labels we give. Rather than correct what some claim to be some biological fault, how can we inspire them to dream of doing more?

If we see a person as a schizophrenic, (or “a person with schizophrenia”), we have already built a construction in our mind (and our client’s) of limitation.

If you have skipped over Caroline Casey’s talk, stop and listen to it now…J

People have the capacity to surprise us again and again. When we keep that alive in our minds, we can help them surprise us, and perhaps even themselves.

More than once a week (though it seems like a daily occurrence as I am much sensitised to this constructivist error) I hear staff in mental health services comment that one of the patients is refusing to admit s/he has a mental illness, which usually means s/he is reluctant to take medication. As with the pseudo patient study (Essay 9), patients are often required to conform to a belief system in order to gain something (eg discharge from hospital, support.)

Constructivism tells us ‘mental illness’ is just a construct, preferred by some… generally by those who have authority to control patients.  This of course can lead to a struggle…staff may struggle to convince patients they are ‘ill’; patients may struggle to convince staff they are not. How do we maximise our connection with patients rather than battling to make them comply with a belief?

Struggles like these lose opportunities to collaborate in non-medication therapies that are consistent with constructivism. Struggles lose chances of engaging in discussions about meaning and passion that Caroline Casey’s talk illustrates. Clients who do not believe they are ‘ill’ have differing beliefs. There are many choices for collaborating on a meaningful and happier life.

I have written these essays, not as a final word, but rather a beginning. I wish constructivism becomes part of everyday thinking in mental health services.  I wish we focus on people’s potential, keep exploring new ways to intervene, and inspire one another through our discoveries.

Solutions for everyone’s problems are not as simple as reading some essays or books. But these essays are to highlight information that is increasingly circulated.

By presenting stories of uncommon therapy examples I want to show possibilities.

If some practitioners get great results with therapy, how might we also achieve this with our clients? A small percentage of our workforce is devoted to exploring these? How much more can we achieve, if more are trained and encouraging each other?

What You Can Do

You can circulate these articles to your colleagues for broader discussion.

These articles will soon be posted onto www.tomblackford.com.au  where there are further articles.

You can encourage discussion of such ideas in your professional training meetings.

Perhaps agencies could enlist the services of leading therapists (eg Nardone) to demonstrate and train staff; the costs could be recouped if just a few clients avoided a lifetime career as psychiatric patients.

I am interested to receive emails to let me know what you are doing, and what ideas you have for disseminating these ideas further.   Email: tblack01@gmail.com

At some point I may suggest a meeting of those interested, to exchange information, concerns, resources and ideas about how the public mental health services can be impacted by such perspectives. So let me know if you would like to be contacted.

Thankyou for reading.

Can we tell who has a ‘mental illness’ or not? That was the question raised in a famous psychology experiment in 1969. It showed how poorly the experts can tell. Read part of my speech below, given at a public speaking club. Most of the content of the speech was taken from information you can find on YouTube by searching “David Rosenham experiment” and related videos.

http://www.youtube.com/watch?v=jXp-ANr8jAQ

Extract from my speech, entitled, “The Pseudo Patient Study”

Imagine yourself as David Rosenhan, a psychologist in 1969, sitting around with friends saying, “I have an idea for an experiment. I will get 8 volunteers to join me, and each go to a different psychiatric hospital and say we are hearing a voice, which says a single word, Thud, or Empty, or Dull. We’ll say it in a way that convinces them that it is real and a concern, and see if you get admitted. After you get admitted, say that it has stopped and see what happens?”

So he and his volunteers went ahead and did this. Other friends were concerned but he said, “I’ll be all right; I can get out as soon as I want to.” He did not realise he would be in there nearly 2 months. All the pseudo patients were admitted; one was diagnosed with Bipolar Disorder and the rest with Schizophrenia. They were all prescribed antipsychotic medication.

After admission, the pseudo patients acted normally and told staff they had not experienced any more auditory hallucinations. Instead staff believed all patients exhibited symptoms of ongoing mental illness.

When they did tell staff why they were there, they were not believed. The pseudo patients openly kept notes on the staff’s behaviour but this was just seen as odd. They were kept in from 8 – 52 days; the average was 19 days. Their instructions were to get out without outside help. Eventually they realised to get out they had to agree with the doctors they were ill, but they were getting better; and they promised to continue taking their medication after release. All were released as being in remission; none were judged as sane.

Of the 8 pseudo patients, one was a psychiatrist, another was a paediatrician, 3 were psychologists, and Rosenhan said none had any psychiatric condition.

One moral of this story is never volunteer for a psychology experiment!

More importantly, this was pointing out that psychiatry is not very good at judging people – since they expect to see mental illness, they see it everywhere. They are loath to regard people as normal, a thought I have occasionally in clinical meetings I attend.

After Rosenhan reported his experiment, one psychiatric hospital boasted he could not do that with them; they could spot phony patients. So with their agreement he arranged over a 3 month period to send pseudo patients there to see if they were better at detecting them. He asked them to rate how certain they were. Of 193 patients, they considered 41 as imposters, and a further 42 as suspects. He then revealed he had sent none! This time they were identifying a large number of regular patients as imposters.

The American Psychiatric Association was embarrassed and publicly angry. They worked to tighten their criteria so they could differentiate between those with real problems and others. At least that is what they would have you believe. Are they any better at telling normal from abnormal?

Last year (2010) on Australian TV there was a BBC show, “How Mad Are You?” They gathered 5 people who had a psychiatric diagnosis, and 5 with none; then they got them to do some tasks (5 minute stand-up comedy to the group; and cleaning out a cow-shed) and asked the panel of 3 mental health experts to observe them. They identified 2 patients correctly, gave another an incorrect diagnosis, and incorrectly diagnosed 2 people who had no diagnosis. [My speech continued but is not relevant to this article.]

Conclusion

It is tricky to use psychiatric labels – they are not that objective really. They amount to deciding how strange or different is abnormal. In this age of Ethics committees and financial restraints, David Rosenhan’s experiment will never be repeated. The BBC program is the closest that will be devised. My impression however, is that many patients still experience the need to admit they have a mental illness, and must promise they will continue with their medications in order to be discharged from hospital.

From the perspective of constructivism this is a gross error. It is elevating one belief system (that of the professional) above another (the client’s) on the basis that one group has more power than another. There is the presumption of objective reality and the professionals are right. Rosenhan’s experiment cautions us on the danger in such thinking.

(Go to Summary & Conclusion, essay 10.)

It is easy to be misled into thinking that medications work, especially as it is in the interests of drug companies to make it seem so. Hence clinical trials are the attempt to use science to determine if they work.  Drawing conclusions on the basis of personal experiences with individual clients is risky. Below are some considerations.

Possible Errors in Thinking

1. Some staff are convinced antipsychotic medication works for the following reason.  Following use of these medications staff see a reduction in symptoms; the presumption is the medication caused it – possibly so.  Or there can be a different explanation.

Some family therapists posit there are times the person being labelled as sick stabilises a fragile family or marital situation (as described in my article, “There’s an Underlying Biological Illness,” http://www.tomblackford.com.au/2011/04/24/theres-an-underlying-biological-illness/ ) By labelling a symptomatic individual as ‘ill’ and medicating him/her, the focus is changed; the original crisis (often hidden) in the family is postponed while they attend to a more immediate concern.  This may stabilise the situation for months, but if the patient returns to normal behaviour the original crisis returns. Where they are still unable to manage it, the patient may relapse so the family once again focuses on him/her.  If the hidden crisis is not addressed successfully, the person labelled as a patient may become locked into the role of a sick person.

The above explanation is only a theory, just as medication improving symptoms is only a theory. I point out there are different theories, so one will recognise that occasional successes with psychiatric medications do not prove there is a biological illness.

2. Doctors might believe a medication is working because the patient may report a reduction in a symptom. That sounds good, especially if the client is happy.  However, if they are not living their life more functionally is it necessarily a success? For example, if they are now sleeping and they don’t feel so dreadful, but they have headaches, dizziness or fatigue, to the point they still stay at home, isolated and bored, do we claim progress in treating the depression?

I think it is just human that we cannot pay attention to many difficulties at the same time. If you were deeply troubled by some relationship difficulty, but then broke your leg and you suddenly could not earn money, most people would be consumed by the pain and financial worry. Most likely the original trouble would take a lower priority. With patients, they can sometimes exchange symptoms for side-effects, which is not necessarily progress.

Yet I hear doctors tell patients they are getting better, and just need to find a way to manage the side-effect; or perhaps to change to another medication with tolerable side-effects. Sometimes after 12 months of treatment they are still trying to find a suitable medication. They eventually may settle for the best compromise, but are they living life well? I wonder would they be just as good with no medication, or learning ‘mindfulness’, or exercising more?

3. I hear psychiatrists say, “S/he has been depressed for years; you can’t expect the medication will work immediately.” Or, “her delusions are less intense,” implying improvement (but still delusional, and perhaps only given up talking about them to people who don’t believe them.)  Or, “we know it works; s/he just cannot tolerate a high enough dose.” It seems unacceptable to conclude it doesn’t work, so medications once started are rarely stopped. Usually they are added to, premised on the belief of proven efficacy.

Perhaps a Different Standard is Required

Contrast the above with Jay Haley’s personal standard. (He was a noted family therapist.) Early in his career he dismissed his own talking therapy as proven if he took many months to solve a person’s depression.  He noted that the person might have changed work, a relationship, or other important circumstances. Those could equally be the cause of improvement. Hence he focused on developing brief therapy methods. If these interventions caused lasting change in a short number of weeks then he felt successful.  Essays 3 & 4 show there are tools for serious problems that might well be tried before medications.

Years on Medication Can Be a Problem

Some people on medication can gain the desired benefit, which is great. However when they don’t, should the medication be stopped? By continually searching for a medication solution, another problem can emerge.

I know a client who is receiving 3 antipsychotics, one by injection. He is on a ‘mood-stabiliser’ morning and night; he is also on an antidepressant, and some non-psychiatric medications. He willingly accepts the medications and even seeks higher doses, hoping for improvement with his symptoms.

The last 2 or 3 years have not given a good result. I do not know in detail the level of functioning for the decades before. Perhaps there were better periods; if so, they could well have been from life circumstances as much as medication.

While he is diagnosed and the dominant paradigm is that he needs medication, carers in his life call for medication reviews to solve his symptoms and behaviour. His history of trauma and past behaviour tell us he needs connection with people, acceptance, a way to contribute meaningfully to others, and opportunities for fun. However, his carers did not see they had a responsibility to address his needs. They did the minimum by involving the mental health service.

The mental health service uses much of its resources in listing symptoms, deciding on medications, and reviewing changes. This uses resources that could be used to advocate and help meet the human needs of its clients. Since carers and families are mostly convinced of the biological theory, they frequently want medication tried – this delays other necessary interventions, sometimes permanently.

Maximising Efforts of Clients

Some psychological approaches rely on reframing people’s problems as ‘not illness,’ so they realise they have capacity to effect change in their lives. If mental health services communicate to people they have an illness, doesn’t that undermine their belief that they can find solutions other than with medication?  Is it fair to doubt them?

Conclusion

Many times I hear statements made to clients with certainty about medication being valuable, useful, proven. It seems the professionals are offering their beliefs, which is contradicted by the information I read. While medication may be useful to some clients and worthy of trying, are clients being given accurate information?  What do we want clients to believe about their innate capacity to find solutions? Do we want to instil reliance on others, or on themselves? What is the best way to proceed?

(Go to essay 9.)

I have written above that there are alternatives to using medications to treat psychotic disorders. Medications and placebos do work to some degree, and would be better than not giving anything, so why am I making a fuss?

There are harmful physical effects from the medications, harmful psychological effects from labelling behaviour into illness categories, and harm by limiting the options that are made available to clients.

The Harm

1. Physical Health – education by the government agency I work for revealed that those patients diagnosed with a major psychotic disorder (eg schizophrenia) have a reduced lifespan of approximately 20 years. The reasons would be many and intertwined. The medications would be one factor – medications contribute to obesity, diabetes, heart, kidney and thyroid problems. Such clients tend to smoke more, feel sedated and live a more sedentary lifestyle etc. If therapy can be provided and obviate the need for medications (at least for some), we are a long way forward from where we are.

2. Psychologically there is much harm. Readers will understand the difference between labelling behaviour, and labelling a person. We might notice a person behave in a clever way, and we might generalise and say “s/he is a clever person.”  Generalisations contribute to the formation of that person’s identity (or beliefs about self); in contrast describing or reporting one clever instance is less impactful since it is just one among many.

Being thought of as a clever person (or thinking of oneself in that way) implies it is likely to be frequent and an enduring part of the person’s nature. Since beliefs tend to be self-fulfilling, it encourages more of the behaviour.

If a behaviour is undesirable (eg clumsy) it is kinder to describe a clumsy instance as a behaviour, rather than describe the person as a clumsy person. But with mental health diagnoses, it is so easy for people to form the identity that they are Bipolar or Schizophrenic, which massively shapes their future expectations. There have been suicides where reports from colleagues suggest the persons saw no hope following their diagnosis. The diagnosis is a label, which shapes the person’s identity and thus their beliefs about future potential. Diagnoses can demoralise.

Instead it is helpful if we treat people as having ‘difficulties’ and we then collaborate to find solutions. I recall Michael White (Narrative therapist) say, “We cannot be neutral,” meaning it is not possible to be neutral. If we tell someone they have schizophrenia, we are shaping their mind in a way that is different than saying “the voices” seem troubling. The first is a package of ideas that may shape their identity; the latter is one recurring experience they have mentioned and we can collaborate to find a solution.

If we say, “You need to take medication for the voices,” we are implying a solution is outside their control. If we offer a range of alternatives, we are undermining the paradigm of biological causation and treatment. We are not being neutral, nor is it ever possible. Offering alternatives posits people have capabilities, not limitations. If people have capabilities we can collaborate and build on them. If we view them as limited, we may find ourselves forcing medication onto them via legal orders. If they then comply, have we not already harmed them by communicating a belief they are incapable? This is a belief communicated not just to the patient, but his/her family and the community.

In contrast to this belief, I do recommend watching a British award winning documentary about psychologist, Rufus May. It is a re-enactment and follows him working with a client who hears voices. His approach is unconventional, and would stimulate debate, but it does show his utter belief that the client can manage without antipsychotic medication, which supports the client’s wish. It is available on YouTube in 6 parts (for those with extra time…about 60 minutes.)

http://www.youtube.com/watch?v=si_tCGuPg9E

3. Parentalism – (It seems to me that “Parentalism” is the modern non-sexist term.)

The biological paradigm is maintained by selecting and promoting certain information to clients and families. Other information which is likely to jeopardise their belief in the paradigm, and their adherence to medication treatment is not highlighted.

For instance, in September 2008 a blog reported Dr Nancy Andreasen’s research findings that antipsychotic medication causes brain shrinkage in patients. Essentially it reports that the larger the dose, and the longer it is taken, the greater the brain shrinkage. I cannot vouch for the veracity of her research. However, I understand she is a psychiatrist and scientist of very high standing.  Among other achievements she served as Editor-in-Chief of the American Journal of Psychiatry for 13 years, a leading journal in the field.

Andreasen said she delayed announcing her findings for 2 years, concerned that patients would not continue on their medications.
http://www.furiousseasons.com/archives/2008/09/psychiatrist_and_neuroscientist_says_antipsychotics_cause_brain_shrinkage.html

Information such as the above is not likely to be shared with patients.  But I would certainly like to know if I was the patient, or a family member. And I would like to know of the alternatives I could consider.

Conclusion

Current day mental health organisations do cause harm, physically and psychologically. If we want to build collaborative relationships with clients, we must be courageous and share our knowledge. With honesty we can find better ways forward.

(Go to essay 8.)

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.)

Since 2000 I have been reading the literature about clinical trials for psychiatric medications. While some people do benefit, I think there is substantial doubt whether antidepressants and antipsychotics are generally any better than placebos.

Many colleagues take for granted that psychiatric medications are proven to work. I will offer some information to question this assumption. When we scrutinize the evidence a different picture emerges.

Clinical Drug Trials

a) Being shown results from selected clinical trials can be misleading. Multiple trials are conducted on a particular drug and only a small percentage will be reported in the literature. These will mainly be the successful trials, and we may not know of the many other trials. So if we hear of a good result, it could be there are more trials that found no significant benefit compared with placebo; this is common. Adding all the trial results together we might find the drug is no better than placebo. Hence scientific papers that review multiple clinical trials or conduct ‘meta-analyses’ on the collective results are more reliable.

Some examples of large combined studies:

• Kirsch and Sapirstein (1998), in a meta-analytic review of nineteen studies involving 2,318 people, showed that 75 percent of the response to antidepressants was duplicated by placebo. They speculated that the remaining 25 percent of the positive antidepressant effect may be attributable to the un-blinding power of side effects. [My explanation: this means the obvious side-effects of the medication usually reveal to staff and patients who are receiving the medication and who get the placebo; this biases studies in favour of the drug.] Adding to the critique, Kirsch, Moore, Scoboria, and Nichols (2002) analyzed the efficacy data submitted to the US Food and Drug Administration (FDA) for the six most widely prescribed antidepressants approved between 1987 and 1999. Approximately 82% of the response to medication was duplicated by placebo control groups—57% of the studies failed to show a drug-placebo difference. When a difference was found, the drug/placebo difference was only, on average, 1.8 points on the clinician-rated Hamilton Depression Rating Scale (HDRS). FDA memoranda intimated that the clinical significance of such a small difference was questionable (Laughren, 1998).  [My comment: The HDRS has a maximum score of 53, and commonly people will need a score of more than 20 to enter a trial. Studies on antidepressants using a clinician-rated measure are more likely to find significant changes than when using a client-rated measure, suggesting clinicians report improvements that clients do not experience.] [Ref: Barry L Duncan’s book, Heart & Soul of Change, 2010; Ch 7 Psychiatric Drugs and Common Factors: An Evaluation of Risks and Benefits for Clinical Practice.]

• Kirsch et al.(2008) provide further evidence that the belief in antidepressant efficacy is scientifically unfounded. Meta-analytically examining all trials submitted to the FDA for the licensing of four popular SSRIs (antidepressants), the authors found no clinically significant differences between placebo and the drugs, with the exception of the most distressed in the severely depressed group. Even this negligible difference was found to be due not to the drug, but to a decreased response to placebo. [Ref: Barry L Duncan, above.]

• The World Health Organization’s studies of outcomes for schizophrenia in developed versus non-developed countries found that symptoms tend to dissipate within 5 years when medication is never used or when clients wean themselves off. Surprisingly, outcomes were better in nondeveloped countries, where most individuals did not take medication—people spent less time in hospitals with lower rates of relapse and were more likely to be employed and socially connected (de Girolamo, 1996). Harding, Zubin, and Strauss (1987) tracked 269 clients admitted to Vermont hospitals with a diagnosis of schizophrenia 32 years after their first admission. They found that about two-thirds of these former patients showed no signs of schizophrenia and had long since stopped their medications. In the Soteria Project (1971-1983) persons diagnosed with schizophrenia and randomly assigned to residential treatment with minimal use of antipsychotic medication had better 2-year outcomes than those assigned to “usual hospital” treatment (Bola & Mosher, 2003). More recently, a 15-year follow-up study of persons diagnosed with schizophrenia found that a larger percentage of those un-medicated showed better global functioning and intervals of recovery than their medicated counterparts (Martin & Jobe, 2007)—65% of those taking antipsychotics were experiencing psychosis compared to only 28% of those not medicated. Antipsychotics can remain part of the discussion, but should not be privileged. [Ref: Barry L Duncan, above.]

b) Clinical trials can be designed to get favourable results. There are endless critics of the methodology of clinical trials. For example: “Richard Smith, who resigned as editor-in-chief of the British Medical Journal because of rampant industry influence in academic research, explains that the number one aim of industry sponsored trials is to find favourable results for the company drug (Smith, 2003). He notes a host of strategies that help accomplish this goal, including comparing the industry drug against another known to be inferior, comparing a low dose of a competitor’s drug to prove efficacy and high dose to prove less toxicity, using multiple endpoints, then picking the one that casts the drug in the best light, or conducting subgroup analyses and selecting for publication those that are favourable. According to Smith, the design, conduct, analysis, and publication of clinical trials are, essentially, marketing issues.” [Ref: Barry L Duncan, above.]

c) The pharmaceutical industry in America has the most political lobbyists of any industry, far bigger than even the gun lobby. Why do they need to lobby so much if science is on their side?

Resource Information on Drug Company Behaviour

1. Below is a link to a British documentary video (approx. 60 minutes) detailing one drug company’s behaviour to increase its sales of the antidepressant known in Australia as Paroxetine. It also highlights the risk of increased suicide from using SSRIs in young people.

http://seroxatsecrets.wordpress.com/seroxat-videos/

2. The link below allows you to listen to past radio programs by Barry Duncan on “Mind Matters,” which deals largely about the mental health industry, including drug companies.

http://heartandsoulofchange.com/resources/audio-presentations/

Conclusion

Human beings and their biology are infinitely variable. It is not beyond possibility that occasionally a psychiatric medication has the effect the makers intend, and a placebo would not have benefitted. However, given the information from large review studies, it does not seem the norm.

If psychiatric medications are seldom better than placebos, are they worth the risk of the serious side-effects? Our society has become a society that believes them, so I do not expect they will disappear. However, as Barry Duncan says, they can “remain part of the discussion, but should not be privileged.”

Acknowledgement: I would like to thank all the doctors who take professional risks by speaking out and writing about the poor science and poor medicine in psychiatry. Psychiatrists Peter Breggin and David Healy are two authors the public may know, but there are many.

(Go to essay 6.)

It is easy to read in areas that we already know, but we may miss easy or valuable tools. One area I read is NeuroLinguistic Programing. For those who are unfamiliar, below are three brief examples which might stimulate your curiosity to learn more. They are not fully explained for those unfamiliar with NLP, but indicative of just how quickly serious problems can be changed.

These are taken from the first of 2 e-books by Steve Andreas, entitled, “Help With Negative Self-Talk.” (Vol 1 & Vol 2, 2009 © Real People Press.)  As you read them, you might consider that some NLP techniques are like ‘hypnosis without the trance,’ in that the client becomes absorbed in their internal experience and the therapist leads them in useful directions. This is not true of all NLP techniques, but is applicable to the first two examples below.

While mental health services might diagnose and consider medication interventions in these quite serious problems, resolutions were achieved in only a single session.

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1.

Changing the location in space also works with internal images. Recently Lewis Walker, an NLP-trained MD in Scotland, (Walker, Lewis. Changing with NLP: a casebook of neuro-linguistic programming in medical practice. Oxford, UK. Radcliffe Medical Press, Ltd. 2004) saw a young woman who had witnessed two of her friends killed in a motorcycle accident the day before: When she came into my office she had already dissolved into tears before she sat down. Through the sobs she told me about the smash. One friend was decapitated, the other with a bit of leg thrown across the carriageway. As she described how “The pictures are all in front of my face,” both hands were gesturing about 2 inches from her eyes.

I said something like, “Let me take these for you,” as I reached over with my right hand and grabbed her pictures, while simultaneously making a “ripping” noise as I stood up and hauled them off to her left side, and then diagonally behind her. I asked her to “Look at all these pictures in my hand as they shrink way down in size and all the color drains away,” cupping and closing my right hand as I did so.

At this point her body in the chair was facing ahead, while her head was looking over her left shoulder. I took the images to the corner of the room near the door and said. “Now just imagine they’re fixed right here by a nail, and I hit the door post with my fist. “Now knowing that they’re fixed here, in your mind’s eye look straight ahead and tell me how things are different now. . . .”

She visibly relaxed, the tears subsided, and she felt more in control. As I sat down again in front of her I said, “Keeping them nailed over there, what happens as you take this into tomorrow, and the next day, into next week and next month (gesturing with my left hand along her future timeline out to her right) knowing that with each passing day that (pointing to her images of the accident) gets farther and farther away as it recedes into the distance.”

She was much calmer now and could tell me about what happened after the accident, and how their motorcycle group was still planning to go on a tour to Germany in 3 weeks, and that she was going to go out on her motorcycle with her husband when he got home that night.

The whole consultation lasted no more than 15 minutes, and probably saved weeks—perhaps years—of the standard approach of “talking it through.”    (Vol 1, p.4)

2.

Most psychiatrists think of compulsive hand-washing as a problem that is very difficult to treat. Below is a lovely example of using a meaningful piece of music to quickly change this problem in a single brief session. This example was sent to me about a year ago by Ron Soderquist, an NLP-trained hypnotherapist in the Los Angeles area.

Anxious parents called, each in turn, about their 17-year-old daughter Bev, who for the past six months had obsessively washed her hands 3-4 hours a day. Both parents reported they had “tried everything.” including counseling and drugs. They were so desperate they were now exploring hypnosis, about which they were very skeptical.

Somewhat worn down by their skepticism I said to the anxious mother, “Look, because you are desperate and because you worry that once again you will be throwing money away, I will offer you a complimentary consultation. I will evaluate your daughter’s symptoms and only schedule a therapy session if I believe I can help her.” With this assurance, she made an appointment.

As family members settled into their chairs, they all appeared relaxed. They communicated with ease, and there were no overtones of hostility. Turning to the girl I asked about school and extracurricular activities. She immediately replied, “I have studied piano for many years and enjoy it very much.” Because I play both classical and ragtime piano, this was a natural opening for building rapport.

When I asked about her favorite composer, she quickly said, “Chopin.” Because Chopin is also my favorite, we were now in perfect sync. We agreed we both loved Chopin’s Nocturnes and we both played most of them. I asked about her favorite and she hummed the melody. I said, “When I practice a nocturne in the evening I often can hear that melody in my head all next day,” and she nodded in agreement. “You can hear that melody right now, can’t you?” I said. She smiled and slipped into a nice little trance. As she did so, I ventured, “Perhaps, when you get the urge to wash your hands, you might enjoy turning on that nocturne instead.”

I observed her trance deepen as she considered this, and then she nodded her head and said quietly and confidently, “I can do that.” After some further rehearsal, and talk about other matters, I concluded the session. I didn’t suggest another session. The mother wondered, “Do we need to make an appointment for Bev?” I looked at Bev as I said, “Perhaps she has already found a solution,” and Bev nodded her head.

A week later the mother called to say Bev was doing fine. I was a little annoyed with myself for solving the problem when I should have held back and scheduled a regular appointment with a fee. But I just couldn’t help myself; it was too much fun just to do it. And while there was no fee, I did get a good story, and the mother soon referred a friend.

When I followed up some months later, I asked for more details of what she experienced internally. She said that when she got stressed, she first “felt germs on my hands, and then pictured them on my hands. Then the voice in my head that said, ‘You have germs on your hands. You have to wash them,’ went faster and louder and got more intense. When I turned on the nocturne, I would usually just hear the music, but sometimes I would imagine myself playing it.”

Commentary by Steve Andreas: Bev was already talking to herself in a way that made her feel bad, and that bad feeling triggered her hand-washing. The Chopin nocturne was powerful in eliciting a positive state in which she had no urge to wash her hands. If Ron had added some cheerful words, that could have created conflict. However, adding instrumental music does not create conflict, because the music does not have any words to contradict what she was saying to herself.

In addition, music is processed by the opposite brain hemisphere than the one used to process language, so any conflict would be between the hemispheres, rather than within one of them. Adding any music without words is a fairly safe intervention, especially if the person chooses the music that they think might be appropriate—and tests to find out how well it works.    (Vol 1, p.33)

3.

Some readers might think that this example was a unique case, but it is actually fairly common. Ron sent me a report about another client he saw recently. A 30-year-old male who had hung out in his bedroom for several months, couldn’t drive a car etc. because of panic attacks, was brought in by his stepmother.

He was too anxious to leave the back seat of his car, so I went out and started the session beside him in the back seat—a first for me! He was creating his anxiety with a habitual internal voice: “You’re going to go ‘weird’ ”—which was what he called having a panic attack.

He’s a guitar player, so together we found an alternate audio, a “favourite riff” that triggered his confident musician self. (I told him the Bev story while he was searching for a trigger for his confident self, and this seemed to strike a chord with him (pardon the pun). After we practiced that for a while (I did get him into my office) he went off with his stepmother. I called the next day and he had been out hiking and feeling great, using his favorite riff to keep his musician self in charge.    (Vol 1, p.35)

I recommend Steve Andreas’ two e-books, and they can be purchased from his website. Help With Negative Self-Talk: http://www.realpeoplepress.com/pages.php?page=Downloads

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I highly recommend seeing the following demonstrations of NLP applied to clients’ problems. Steve Andreas has posted some examples of his work on YouTube. The videos are a maximum of 10 minutes. Some are complete examples, and some are extracts from a larger client session.

1. Original NLP Fast Phobia Cure Part 1 – Steve Andreas.  Short clip showing the phobia cure process. The second part shows the follow up interview 25 years later.

http://www.youtube.com/watch?v=VtUatMghbHg&feature=related

http://www.youtube.com/watch?v=TjjCzhrYJDQ&playnext=1&list=PL0BD8436D9A1B2390

2. Eliminating a Compulsion FAST with NLP – Steve Andreas.  A great demonstration of the “Compulsion Blow-out” technique, where you see the person responding differently immeditately.

http://www.youtube.com/watch?v=UwxvUofenC4

3. Resolving Shame Quickly with NLP – Steve Andreas. A segment from a larger interview, where he demonstrates using “sub-modalities” (aspects of visual and auditory representations.) As these are altered her feelings change.

http://www.youtube.com/watch?v=zHaADVfKZoY&feature=related

4. Treating Loss and Depression with NLP – Steve Andreas. A segment from an interview which shows him using a “Tempo Change” process; follow up interview shows the impact.

http://www.youtube.com/watch?v=bNDA47hbhss&feature=related

5.   24 Years of Night Terrors GONE in 1 NLP Session – Steve Andreas. A segment showing use of mental rehearsal to attach a positive resource. Positive report at follow up interview.

http://www.youtube.com/watch?v=wnvAl_C-O84&feature=related

6. NLP Eye Movement Integration with a Vietnam Veteran (PTSD) – Steve Andreas. A segment from a larger interview – it shows the process, and there is evidence at the end that the feelings towards the traumatic memories are different.

http://www.youtube.com/watch?v=GnoqWqijYvQ&feature=related

(Go to essay 5.)

There are three baseball umpires that are disputing.  The first one says, “I call ‘em as I see ‘em.”  And the second guy says, “Well, I call them as they are.”  And the third guy says, “They ain’t nothing until I call ‘em!” (taken from Constructive Therapies, Michael F Hoyt Ed. Guilford Press, 1994, P.34)

The third umpire above is the constructivist, since he understands he is authorised to ‘call’ or name an action. He is not reporting reality; he is actually creating the reality …the play is Safe! or Out!, by virtue of his call.

In mental health services we create ‘the reality’ by naming what we see. For example some behaviour such as deluded thinking may be labelled a psychotic disorder and called a ‘mental illness.’

Medicalising bizarre behaviour saved the mistreatment of those previously labelled as witches and ‘possessed’.  Doctors took over as psychology developed later, but the medicalising of behaviour is not straight forward.

What follows is a case study of a young adult woman, diagnosed with paranoid schizophrenia and treated for 10 years. It illustrates how there can be radically different labels to the one person.  These consequently shape the treatment offered, and the course of a person’s life.

Like the three umpires, we can look at the information in front of us (the client’s behaviour and reported history) and call it as we see it (eg schizophrenia); or we could criticise the first call and claim to give the real diagnosis; or thirdly we can recognise that how we are trained shapes the ‘lens’ through which we see the information.  This then determines what we see as relevant, noteworthy, or useful.  In turn this will shape our plan of intervention.

The Case of Josie

Josie was a young adult who lived with her mother. They migrated from a war-torn country.  They both spoke limited English. Josie rarely went out of the house, did not understand television programs, and the only news she got of the world was from her mother.  However, Josie’s mother had problems of her own.  Her fears infected Josie, making her wary of people.  Somehow she came to the attention of the authorities, and was deemed paranoid.  She was hospitalised, medicated and diagnosed with schizophrenia.

Josie was treated for 10 years in the standard way.  She had a number of psychiatric admissions, and in between she was treated by a psychiatrist who spoke her native tongue.  Eventually Josie was referred to Bill, a clinical psychologist.  He quickly decided that Josie did not have schizophrenia, but rather agoraphobia with avoidance.  Her life context had impacted her to be fearful and avoidant.  Together with her lack of language, Josie was not confident to go places and interact with others, which left her fearful belief system unchallenged.

Gradually inroads were made.  Bill negotiated with the psychiatrist to withdraw and cease her medication.  He arranged supports so that Josie could get out more; she learned more English, which meant she was able to gather information from more sources.  She then developed independent views, no longer reliant on her mother.  She eventually grew sufficiently confident and she moved out of home.  Josie then was able to develop a normal set of interests and activities and so lead a normal life.

What Can We Learn From This?

Josie may well have seen over a dozen psychiatrists and doctors over the course of her involvement with the psychiatric system, along with many other health professionals.  Why did she get started on antipsychotic medication, which she almost certainly did not need?  Why did she get a label of schizophrenia, instead of the more useful and less harmful one of agoraphobia?

Constructivism points to the trap that we can see what we look to find.  Expecting to find ‘mental illness,’ senior psychiatrists found it and called her behaviour, “schizophrenia.” This became the reality that everyone saw, even the consultant psychiatrist who spoke her native language.

Sadly Josie did not get effective treatment for 10 years.  We know that people diagnosed and treated for psychotic disorders have their lifespan reduced by 10 – 20 years, so she has been at risk of physical harm and perhaps psychological harm through her detentions.

Josie’s example highlights the risk that can come from diagnosing behaviour as ‘illness,’ rather than considering the person’s larger context.

This Is Not An Isolated Experience

Consider the debate about Bipolar Disorder and Bipolar Disorder Type 2…when is behaviour (eg moodiness) considered part of the normal continuum and when is it considered an ‘illness?’  Basically when a doctor says it is illness, is the answer; or actually a group of doctors and other professionals who by committee formulate the criteria to name a particular disorder. Then it becomes an official label in the DSM4 manual (one of the primary books used to classify psychiatric disorders.)

In practice it means that an individual doctor sees a patient, collects information about symptoms and history, views it through his or her professional lens, and decides whether to call it ‘illness.’  That is what happened to Josie above.  Those of high status named her as ‘ill’, then those with similar training, were inclined to see it in the same way.  Consensus is assumed; others with dissenting views see no point in arguing against a system that operates out of a dominant paradigm. And a life is changed.

An Italian female psychologist told me she used to do psychological assessments for a psychiatric ward. She would tell the psychiatrists from time to time that particular Italian patients were not “Bipolar;” their homicidal expressions to their husbands were their style, understandable in the Italian culture. Yet the psychiatrists dismissed this objection, continued with the medications and the psychologist gave up her attempts to educate the doctors about her culture.

Conclusion

Even if some Italians might disagree with her, it still illustrates the constructivist position that diagnoses are not objective – the most powerful in the professional hierarchy gets to name what is normal and what is ‘mental illness.’ Patients like Josie then experience the substantial consequences.

The following essays show that behavioural and psychological interventions do exist for mental disorders, even psychotic disorders.

(Go to Essay No 3.)

Some already understand that concepts such as ‘mental illness’ are constructs of language, not something that is established as fact. For others this will be new information.

It is bold to say that “mental illness does not exist”, but in a way one can indeed say this, despite the crazy ways that some people behave. To call some behaviour (eg being delusional) an ‘illness’ because it is bizarre, and other behaviour (eg shyness) not an ‘illness’ is a convention, an agreement by a group of professionals.  It is a choice about the way people decide to use language, and not really detailing something factual.

This is what Constructivism is about. It tells us that we construct our view of the world, through the way we use language. This has profound repercussions, particularly in the area of mental health, as I will show in this series of essays.

By calling some behaviours ‘illness’ results in certain thinking, about causation and remedy. Not surprisingly doctors and psychiatrists often think biology and medication. This has been the dominant thinking, but unfortunately has shut out much that is helpful.

There are better ideas. Even those with the most pessimistic labels should be viewed hopefully. The purpose of the following essays is to show with examples, powerful tools in the field of talking therapy.  In contrast, information about psychiatric medications has misled professionals, consumers and their families.

I will give an easily understood explanation of constructivism. I have collected therapy examples from various sources which describe amazing changes. They are either amazing as they happen so quickly, or they happen with problems that ordinarily are deemed to require medication; or they change after being stuck for years.

THE ESSAYS IN THIS SERIES

Following this introduction, my first essay gives an easy explanation of constructivism. It highlights that we make ‘reality’ by the parts of experience we select, emphasize and describe.

My second essay presents a case study showing the grave error made diagnosing a client (Josie) as having schizophrenia.  The case shows it is easy to make this type of mistake, which is a direct consequence of not understanding constructivism. (1,046 words)

The third (5,047 words) and fourth (1,820 words) essays gather examples of therapy that I do not hear discussed in mental health services. They reveal more possibilities when working with those diagnosed with psychosis and other disorders.

In the fifth essay questions are raised about the efficacy of psychiatric medications. It suggests that review articles and meta-analyses are more trustworthy than individual studies selected by companies whose primary focus is to maximise sales of its products. I encourage people to examine claims of efficacy rather than presuming we are given accurate unbiased conclusions. (1,160 words)

Essay six returns to constructivism. It questions the presumption of objectivity in psychiatric diagnoses, and uses more examples to show why therapy should be favoured as the first choice of treatment. (1,628 words)

Essay seven summarises some of the harm that arises from the biological paradigm, and adds that we should be honest with clients about the diverse views in this field. (898 words)

Essay eight explains there are errors in thinking, which easily occur and lead people to think psychiatric medications are more effective than they are. Promoting medications, particularly as a first choice may diminish clients’ belief in their own capabilities; instead patients learn to rely on solutions outside of themselves. (1,111 words)

Essay nine highlights the famous (and amusing) “Pseudo-patient study” of the early 1970s and reminds us of the message of constructivism, that psychiatric labels are not objective and reliable. Doing without them might remove a cause of harm, and promote a focus on behaviours and difficulties, more easily solved than an alleged ‘illness.’ (818 words)

Essay ten is a short conclusion arguing that psychotherapeutic methods have been greatly under-utilised. People are amazing. Their capacity to exceed expectations is vast. Once we operate from such a mindset, great changes can be achieved. (1,004 words)

[The essays are numbered in the order to be read, and each builds on the previous. Number 2 & 3 are essential in understanding the overall idea of these articles, and the fourth gives further examples of powerful therapy techniques. Essay 3 is longer, and essentially is an extract of two examples of dealing with people labelled as psychotic. The other articles are 2-4 pages each. Some have links to video clips.]

(Go to Essay No 2.)

Imagine her husband, working fulltime, doing a double load of running the household as well, wondering how long before his wife returns to normal, if she ever will.

Think about the context of therapy we face. We work amongst clients who can behave in bizarre ways. They can confuse us and their families; they can frighten. We can be under pressure to fix these situations. We care and want to do our best. With a psychotic individual, possibly without exception a diagnosis is made and antipsychotic medication is commenced. This would be considered “Best Practice.” Is Mary’s treatment really best practice?

Three months after first meeting Mary, her husband, Dave, phoned asking to meet. I was pleased to do so. After meeting him, I stopped seeing her. I planned with him to change his behaviour, so she would change. Her medications continued but I said I had no faith in them working. But if he did what I asked I felt we could help her. He listened enthusiastically. I understood it would be hard, but he probably didn’t.

The general plan was simple. Instead of patiently waiting for her to get better, I wanted Dave to demand she act better immediately. I coached him how to pressure her, insist, and remain determined. For example, instead of cooking tea when he arrived home from work, he should make her do so! This demonstrates a belief she can do things, rather than conveying ideas she is ‘ill.’ Rather than organise and put the children to bed, he should insist she do this.

I motivated Dave by forecasting that the marriage would eventually end if things continued as they were. Although he seemed very committed to his wife and family, he agreed that it could not last like that for ever. And I forecast that this approach would make changes happen quickly.

We met weekly to review his actions and the responses it generated. Understandably he acted firm for a bit and then stopped. He was naturally soft and accommodating and I was asking very different behaviour of him. I took note of any success or partial success he mentioned following his actions. I kept a record of these so I could remind him later when he faced tough times. If she helped a bit with the food and then returned to bed, I would point out that she was giving evidence that she was able. I used this to encourage him to persist.

He would report some things that were obvious positive signs – they were at a parent-teacher night; he said she acted normally for 2 or 3 hours; “No-one there would know she had a problem.” Then at home she reverted to her non-coping behaviour. If I was not meeting with Dave, discussing and recording, he would not have accorded significance to such behaviours. So these and Mary’s many small efforts encouraged him to continue.

I coached him how to speak to her; I did not encourage abusive language, but I was encouraging firm insistence so that he could be effective. I did not want him to ask, but expect, insist, require responsible behaviour. It was a challenge to tread a good line. I did not want him to encourage her with praise or gratitude, but when she did something just say a simple, “Thanks,” as anyone would normally say. I did not want him to ‘lecture’ her about what being a good mother meant. I was concerned that could make it difficult to get started, as she might ‘lose face.’ I just wanted him to consistently and unequivocally communicate his expectation, which also communicated his belief she was able to do these things.

He did get frustrated and after a number of weeks felt worn down. I suggested that he take a mental holiday; for a week or two, just look after the children and himself, stop trying to influence Mary, and then start again. This was around Christmas. He was taking the children shopping for presents, when Mary asked to join them. He declined, informing her she could when she behaved properly again. Similarly he made meals for the family but did not include her, indicating she had to get her own.

At Christmas there was a large gathering of the extended family. One relative with a history of depression had a conversation with Mary and said, “You can’t just rely on the medication; you have to make an effort.” Three days later Mary told her husband that she was going to do things again. She began and within a week, Dave reported she was behaving normally. [Christmas was 7 weeks after I first met Dave.]

I saw him a month later and he was very happy. A further month passed and he was still happy, and we agreed we did not need to meet again. I rang Mary briefly, my first contact for more than 4 months. Her voice was totally different to the woman I had known. She concurred she was better. She said she was past her problems. Her outpatient doctor had stopped her antipsychotics, but she remained on her antidepressant.

Fourteen months after that Christmas conversation I rang to follow up. Mary answered. Her voice was normal. She referred to her “depression” in the past, and told me about her family. She was living a normal life. Dave spoke later and reiterated that the changes had lasted. He was happy that he had his wife back. He was keen that people know about “my approach.”

This is not my approach, of course. It follows from my understanding of what Jay Haley (family therapist) and others have written. Haley does not want people to be regarded as ‘ill,’ as that implies they need medical intervention. Rather he emphasises firm direction from the family members, regardless of whether the official diagnosis is Schizo-Affective disorder, Schizophrenia, or heroin addiction, or anorexia. Haley wants the important people in the client’s life to use their influence, which can be much more powerful than strangers (professionals) that clients often do not care about and do not want to see.

There is no reason to think the medications suddenly began to work for Mary. There were numerous reports in the 7 weeks of her responding to Dave’s actions. He saw she could do things, but then she would stop. He came to doubt she was ‘ill,’ and expected different behaviour from her. This created a context where she had to think about what she was going to do. Without this she quite likely would still be languishing as a mental patient, as many do.

She had been hospitalised and told she was ‘ill;’ she lost confidence that she could behave effectively. We turned this around.

All people can turn their lives around quickly, but labelling them as ill can tremendously hamper them. They may need compassion and care, but also expectation. It helps immensely when families are involved to help steer them forward.

So many believe they have to wait for the medication to work; but so often it does not. Months go by, which can stretch into years. Haley has advocated taking people off psychiatric medications as soon as possible (but preferably never starting it.) He wants to avoid the dulling and sedating side-effects which can justifiably hamper recovery; and he wants people to think of themselves as normal, and needing to solve a problem.

Even when medication appears to work, does it? Would they have got better without it, with firmness and appropriately high expectations? Many clinical trials show no significant difference between the active drug and placebo; these will seldom make it into psychiatric journals and thus a false impression of efficacy is created.

[Most readers will know of some cases where medication has made remarkable changes. I do too. I do wish to acknowledge that some people have been helped enormously, and there are some contexts where talk therapy has not worked, nor is likely to.]

Haley’s approach is not easy. It often creates family conflict before resolution. But imagine if you can get them back to work or school within days and weeks, rather than months and years. What a saving in money, and lost living.

Imagine if you didn’t have to tell them they are sick and coerce them into taking medications that they often resist, not to mention serious side-effects (eg diabetes, kidney damage, heart damage, thyroid impairment, weight gain.) These risks may seem acceptable to some, but are they really necessary?

Is it fair to leave patients like Mary on medications that give results she was getting? She was existing, not functioning. Her marriage was fragile. The future was bleak. Is it really “Best Practice” to tell people they are ill?

The ‘Mental Illness’ Metaphor

I favour telling people they “have problems” rather than being ill. Is it clear that ‘mental illness’ is only a metaphor, a way of describing Mary’s behaviour? This metaphor implies that mental problems are like physical illnesses. However there are rarely any measurable signs of a biological ailment.

If Mary can change through redeciding, what does it say about the message of mental “illness?” Should we create an environment of normal expectation, or lowered expectation that follows from believing the person is ill?

In the future I hope patients and families will routinely be told there are solutions that do not necessitate medications. There are alternatives.

The end.

My Introduction

I have enclosed a large segment from an article by John H Grohol (D. Psy, which I presume means psychology,) written in March 2006, on the Treatment of Depression – the whole article is available on-line and following is the link – http://psychcentral.com/disorders/sx22t.htm

John Grohol’s early version of the article (written in 1995) was one of the first pieces of literature that informed me of the methodological biases, and problems with the biological leanings in public mental health services.

What follows was new information to me about 8 years ago when I read it and I think it is still valuable reading.

The Extract

Psychotherapy, Medication or Both?

I think this question is best answered by researchers who’ve studied this issue extensively. This excerpt from an article that appeared in the American Psychological Association’s Monitor nicely summarizes the research. The preponderance of the available scientific evidence shows that psychological interventions, particularly cognitive-behavioral therapies (CBTs), are generally as effective or more effective than medications in the treatment of depression, even if severe, for both vegetative and social adjustment symptoms, especially when patient-rate measures and long-term follow-up are considered (Antonuccio, 1995 [43]).

Yale psychiatrists (Wexler & Cicchetti, 1992 [50]) conducted a meta-analysis (a large, comprehensive review of the research literature). When dropout rate is considered with treatment success rates, pharmacotherapy alone is substantially worse than psychotherapy alone or the combined treatment. The review concluded that in a hypothetical cohort of 100 patients with major depression, 29 would recover if given pharmacotherapy alone, 47 would recover if given psychotherapy alone, and 47 would recover if given combined treatment. On the other hand, negative outcome (i.e., dropout or poor response) can be expected in 52 pharmacotherapy patients, 30 psychotherapy patients, and 34 combined patients. This meta-analysis suggests that psychotherapy alone should usually be the initial treatment for depression rather than exposing patients to unnecessary costs and side effects of combined treatment (Antonuccio, 1995 [43]).

Moreover, a consistent finding across studies is a higher dropout rate among those receiving medication, either because of side effects or because the medication has not helped. These patients are treatment failures but are not included as treatment failures in the data for their studies (Karon & Teixeira, 1995 [48]).

Often times you will find doctors and researchers discussing “double-blind placebo controlled” studies as being the “gold standard” within this area of study. This simply is either ignorance or naivete. Seymour Fisher and Roger Greenberg (1993 [50]) among others, have shown the double-blind placebo controlled study is not blind. Side effects are so obvious that more than 80% of the patients know whether they are on active medication or placebo, patients are equally accurate about other patients on the ward, and nurses and other personnel are privy as well. In some studies the only people who claim to be blind are the prescribing physicians, and in other studies the prescribing physicians admit being as aware of the patients’ condition as everyone else (Karon & Teixeira, 1995 [48]).

Greenberg, Bornstein, Greenberg, and Fisher (1992 [47]) conducted another meta-analysis, covering 22 controlled studies (N=2,230). This study calls into serious question the perceived efficacy of tricyclic antidepressant medications, which are shown only to be more effective than inert placebo and only on clinician-rated measures, not patient-rated measures. If patients cannot tell that they are better off in a controlled study, one must question the conventional wisdom about the efficacy of antidepressant drugs. The newer selective serotonin reuptake inhibitors (SSRIs, such as Prozac, Paxil, and Zoloft) do not appear to fare much better (Antonuccio, 1995 [43]).

With active placebos, so that the patients and psychiatrists are not easily informed, the empirical data show that medication effect sizes are hard to distinguish from the placebo. Also not mentioned is that most antidepressant medications habituate, and the patients’ symptoms return. Most patients believe they would feel even worse if they were not taking their medication (Karon & Teixeira, 1995 [48]).

While everyone knows that it often takes years to provide evidence of safety and effectiveness and be approved by the Food and Drug Administration (FDA). But what is not known is that although these studies often have large number of participants, patients may have been given the medication for only short periods of time — much shorter periods of time than in clinical practice. Prozac, for example, has been advertised as having been administered to either 11,000 or 6,000 patients in preapproval clinical trials. But in all the controlled preapproval trials there were only a total of 286 patients on Prozac, and the controlled trials lasted only six weeks (Breggin & Breggin, 1994). In all the preapproval data submitted, 86% of the patients received Prozac for less than three months. Only 63 patients out of thousands had taken the drug for two years or more — the way it is used in clinical practice (Karon & Teixeira, 1995 [48]).

Important points that should be taken from the above excerpt:

• Combined treatment of psychotherapy and medication is the usual and preferred treatment of choice for depression. This is likely the most commonly-used treatment for depression today and there is absolutely nothing wrong with it, since it, too, has been proven very effective. Never go against professional advice given with regards to your treatment, unless you have first discussed it with your treatment providers. Especially with depression, it is better to play it safe, than be sorry.
• Psychotherapy is likely the second treatment of choice for depression, regardless of the depression’s severity or symptoms. Multiple meta-analyses have come to this conclusion, so it is not a conclusion based on just one lone case study or the like. (No one study, even the NIMH study on depression, should ever be used to draw far-reaching, generalized conclusions about a treatment’s effectiveness. Meta-analyses are always preferred by research scientists.)
• Medication alone should be your last choice and only used as a last resort. Although you will likely gain some short-term relief of the most outward symptoms of your depression, the above-cited meta-analyses and multiple studies have shown that medications don’t work very well in the long-term.
• Always consult your physician or psychiatrist before beginning or stopping any medications. This article is not meant as advice to your specific situation, but as overall education.
• People who are taking psychotropic medications should better inform themselves as to the negative and adverse side effects of those medications. Ask your physician about these, or consult the insert for the medication (which you can also request from your doctor if you do not already have one). Also, drug handbooks found in many larger bookstores in the medical section might come in handy, as will the PDR. You might also benefit from a more thorough understanding of how political and un-scientific the drug approval process is in the United States by reading Breggin & Breggin’s book, Talking back to Prozac (1994 [45]). I don’t usually like Breggin or the positions he takes, but I found this to be a fascinating account of the FDA workings and the actual numbers used in the Prozac trials, obtained through the Freedom of Information Act. They concerned me and they should concern you too.

As Consumer Reports noted in their two articles, Pushing Drugs (Feb., 1992) and Miracle Drugs (March, 1992), physicians are actively marketed to by drug companies, given free gifts and vacations. That “professional” you think you’re paying to receive the best and most thorough treatment available may be in the pocket of a pharmaceutical company. So don’t be too surprised that when a new antidepressant medication is marketed (such as Serzone) that you suddenly see a whole host of psychiatrists prescribing it, not based upon the medical research, but because it’s new.

References

1. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER: Depression: A Neglected Major Illness. Journal of Clinical Psychiatry 1993; 54(11):419-24.
2. Elkin I, Shea MT, Watkins JT, Imber SD, Sotsky SM, Collins JF, Glass DR, Pilkonis PA, Leber WR, Docherty JP, et al: National Institute Of Mental Health Treatment Of Depression Collaborative Research Program. General Effectiveness Of Treatments. Arch Gen Psychiatry 1989; 46(11):971-82.
3. Piper A Jr: Tricyclic Antidepressants Versus Electroconvulsive Therapy: A Review Of The Evidence For Efficacy In Depression. [Review]. Annals of Clinical Psychiatry 1993; 5(1):13-23.
4. Souza FG, Goodwin GM: Lithium Treatment And Prophylaxis In Unipolar Depression: A Meta-Analysis. Br J Psychiatry 1991; 158:666-75.
5. Stuppaeck CH, Barnas C, Schwitzer J, Fleischhacker WW: Carbamazepine In The Prophylaxis Of Major Depression: A 5-Year Follow-Up. Journal of Clinical Psychiatry 1994; 55(4):146-50.
6. Hubain PP, Castro P, Mesters P, De Maertelaer V, Mendlewicz J: Alprazolam And Amitriptyline In The Treatment Of Major Depressive Disorder: A Double-Blind Clinical And Sleep EEG Study. J Affective Diss 1990; 18(1):67-73.
7. Shea MT, Elkin I, Imber SD, Sotsky SM, Watkins JT, Collins JF, Pilkonis PA, Beckham E, Glass DR, Dolan RT, et al: Course Of Depressive Symptoms Over Follow-Up. Findings From The National Institute Of Mental Health Treatment Of Depression Collaborative Research Program. Archives of General Psychiatry 1992; 49(10):782-7.
8. Kendler KS, Kessler RC, Neale MC, Heath AC, Eaves LJ: The Prediction Of Major Depression In Women: Toward An Integrated Etiologic Model. American Journal of Psychiatry 1993; 150(8):1139-48.
9. Ezquiaga E, Ayuso Gutierrez JL, Garcia Lopez A: Psychosocial Factors And Episode Number In Depression. J Affective Dis 1987; 12(2):135-8.
10. Weissman MM, Markowitz JC: Interpersonal Psychotherapy. Current Status. Archives of General Psychiatry 1994; 51(8):599-606.
11. Hollon SD, Shelton RC, Davis DD: Cognitive Therapy For Depression: Conceptual Issues And Clinical Efficacy. Journal of Consulting & Clinical Psychology 1993; 61(2):270-5. [REVIEW]
12. Watkins JT, Leber WR, Imber SD, Collins JF, Elkin I, Pilkonis PA, Sotsky SM, Shea MT, Glass DR: Temporal Course Of Change Of Depression. Journal of Consulting & Clinical Psychology 1993; 61(5):858-64.
13. Fava M, Bless E, Otto MW, Pava JA, Rosenbaum JF: Dysfunctional Attitudes In Major Depression. Changes With Pharmacotherapy. Journal of Nervous & Mental Disease 1994; 182(1):45-9.
14. Svartberg M, Stiles TC: Comparative Effects Of Short-Term Psychodynamic Psychotherapy: A Meta-Analysis. Journal of Consulting & Clinical Psychology 1991; 59(5):704-14.
15. Beardslee WR, Hoke L, Wheelock I, Rothberg PC, van de Velde P, Swatling S: Initial Findings On Preventive Intervention For Families With Parental Affective Disorders. American Journal of Psychiatry 1992; 149(10):1335-40.
16. Stokes PE: Current Issues In The Treatment Of Major Depression. [Review]. Journal of Clinical Psychopharmacology 1993; 13(6 Suppl 2):2S-9S.
17. Rutz W, von Knorring L, Walinder J: Long-term Effects of an Educational Program For General Practitioners Given By The Swedish Committee For The Prevention And Treatment Of Depression. Acta Psychiatrica Scandinavica 1992; 85(1):83-8.
18. Isacsson G, Boethius G, Bergman U: Low Level Of Antidepressant Prescription For People Who Later Commit Suicide: 15 Years Of Experience From A Population-Based Drug Database In Sweden. Acta Psychiatrica Scandinavica 1992; 85(6):444-8.
19. Isometsa ET, Henriksson MM, Aro HM, Heikkinen ME, Kuoppasalmi KI, Lonnqvist JK: Suicide In Major Depression. American Journal of Psychiatry 1994; 151(4):530-6.
20. Simon GE, VonKorff M, Wagner EH, Barlow W: Patterns Of Antidepressant Use In Community Practice. General Hospital Psychiatry 1993; 15(6):399-408.
21. Kapur S, Mieczkowski T, Mann JJ: Antidepressant Medications And The Relative Risk Of Suicide Attempt And Suicide .. JAMA 1992; 268(24):3441-5.
22. Nemeroff CB: Evolutionary Trends In The Pharmacotherapeutic Management Of Depression. [Review]. Journal of Clinical Psychiatry 1994; 55 Suppl:3-15; discussion 16-7.
23. Piccinelli M, Wilkinson G: Outcome Of Depression In Psychiatric Settings. [Review]. British Journal of Psychiatry 1994; 164(3):297-304.
24. Greden JF: Antidepressant Maintenance Medications: When To Discontinue And How To Stop. [Review]. Journal of Clinical Psychiatry 1993; 54 Suppl:39-45; discussion 46-7.
25. Lonnqvist J, Sintonen H, Syvalahti E, Appelberg B, Koskinen T, Mannikko T, Mehtonen OP, Naarala M, Sihvo S, Auvinen J, et al: Antidepressant Efficacy And Quality Of Life In Depression: A Double-Blind Study With Moclobemide And Fluoxetine. Acta Psychiatrica Scandinavica 1994; 89(6):363-9.
26. Peet M: Induction Of Mania With Selective Serotonin Re-Uptake Inhibitors And Tricyclic Antidepressants. British Journal of Psychiatry 1994; 164(4):549-50.
27. Tignol J: A Double-Blind, Randomized, Fluoxetine-Controlled, Multicenter Study Of Paroxetine In The Treatment Of Depression. Journal of Clinical Psychopharmacology 1993; 13(6 Suppl 2):18S-22S.
28. Stokes PE: Fluoxetine: A Five-Year Review. [Review]. Clinical Therapeutics 1993; 15(2):216-43; discussion 215.
29. Nemeroff CB: Paroxetine: An Overview Of The Efficacy And Safety Of A New Selective Serotonin Reuptake Inhibitor In The Treatment Of Depression. [Review]. Journal of Clinical Psychopharmacology 1993; 13(6 Suppl 2):10S-17S.
30. Kishimoto A, Kamata K, Sugihara T, Ishiguro S, Hazama H, Mizukawa R, Kunimoto N: Treatment Of Depression With Clonazepam. Acta Psychiatr Scand 1988; 77(1):81-6.
31. Fava M, Rosenbaum JF, McGrath PJ, Stewart JW, Amsterdam JD, Quitkin FM: Lithium And Tricyclic Augmentation Of Fluoxetine Treatment For Resistant Major Depression: A Double-Blind, Controlled Study. American Journal of Psychiatry 1994; 151(9):1372-4.
32. Brown WA, Harrison W: Are Patients Who Are Intolerant To One Serotonin Selective Reuptake Inhibitor Intolerant To Another?. Journal of Clinical Psychiatry 1995; 56(1):30-4.
33. Delgado PL, Price LH, Charney DS, Heninger GR: Efficacy Of Fluvoxamine In Treatment-Refractory Depression. J Affective Dis 1988; 15(1):55-60.
34. Feighner JP: The Role Of Venlafaxine In Rational Antidepressant Therapy. [Review]. Journal of Clinical Psychiatry 1994; 55 Suppl A:62-8; discussion 69-70, 98-100.
35. Joffe RT, Singer W, Levitt AJ, MacDonald C: A Placebo-Controlled Comparison Of Lithium And Triiodothyronine Augmentation Of Tricyclic Antidepressants In Unipolar Refractory Depression. Archives of General Psychiatry 1993; 50(5):387-93.
36. Howland RH: Thyroid Dysfunction In Refractory Depression: Implications For Pathophysiology And Treatment. [Review]. Journal of Clinical Psychiatry 1993; 54(2):47-54.
37. Nelson JC, Mazure CM, Bowers MB Jr, Jatlow PI: A Preliminary, Open Study Of The Combination Of Fluoxetine And Desipramine For Rapid Treatment Of Major Depression. Arch Gen Psychiatry 1991; 48(4):303-7.
38. Schaff MR, Fawcett J, Zajecka JM: Divalproex Sodium In The Treatment Of Refractory Affective Disorders. Journal of Clinical Psychiatry 1993; 54(10):380-4.
39. Warneke L: Psychostimulants In Psychiatry. Can J Psychiatry 1990; 35(1):3-10.
40. Partonen T, Partinen M: Light Treatment For Seasonal Affective Disorder: Theoretical Considerations And Clinical Implications. [Review]. Acta Psychiatrica Scandinavica, Supplementum 1994; 377:41-5.
41. Rothschild AJ, Samson JA, Bessette MP, Carter-Campbell JT: Efficacy Of The Combination Of Fluoxetine And Perphenazine In The Treatment Of Psychotic Depression. Journal of Clinical Psychiatry 1993; 54(9):338-42.
42. el-Mallakh RS: Complications Of Concurrent Lithium And Electroconvulsive Therapy: A Review Of Clinical Material And Theoretical Considerations. Biol Psychiatry 1988; 23(6):595-601.
43. Antonuccio, D.O. (1995). Psychotherapy for depression: No stronger medicine. American Psychologist, 50, 450-452.
44. Antonuccio, D.O., Danton, W.G., & DeNelsky, G.Y. (1994). Psychotherapy for depression: No stronger medicine. Scientist Practitioner, 4(1), 2-18.
45. Breggin, P.R., & Breggin, G.R. (1994). Talking back to Prozac. New York: St. Martin’s Press.
46. Fisher, S., & Greenberg, R.P. (1993). How sounds is the double-blind design for evaluating psychotropic drugs? The Journal of Nervous and Mental Disease, 181, 345-350.
47. Greenberg, R.P., Bornstein, R.F., Greenberg, M.D., & Fisher, S. (1992). A meta-analysis of antidepressant outcome under “blinder” conditions. Journal of Consulting and Clinical Psychology, 60, 664-669.
48. Karon, B.P., & Teixeira, M.A. (1995). “Guidelines for the treatment of depression in primary care” and the APA response. American Psychologist, 50, 453-455.
49. Munoz, R.F., Hollon, S.D., McGrath, E., Rehm, L.P., & VanderBos, G.R. (1994). On the AHCPR depression in primary care guidelines: Further considerations for practitioners. American Psychologist, 49, 42-61.
50. Wexler, B.E., & Cicchetti, D.V. (1992). The outpatient treatment of depression: Implications of outcome research for clinical practice. The Journal of Nervous and Mental Disease, 180(5), 277-286.

(The End.)

I Love Psychology

I really love reading the books. I especially loved reading the social psychology experiments when I was at Uni. I think it was Zimbardo and the prisons, and Milgram with the experiments around authority, ordering volunteers to administer electric shocks….. They were powerful studies.

They were about INFLUENCE. That is what psychology is about, in my view. We learn about people and what effects what. And we use that to influence people and systems.

Self-Fulfilling Prophecies

Along with the above studies, the idea of self-fulfilling prophecies was a HUGE revelation to me. That is why it features early in my first essay, where among other things I wrote about labelling and diagnosing.

I think psychology may have wanted to aid research in the mental health field by trying to make diagnostic categories systematic, but the disadvantages of these categories outweigh any advantage.

What has resulted is the idea that people ‘are’ their label – they are Schizophrenics, they are OCDs, or Borderlines – staff refer to them in casual conversations every day. The clients sometimes refer to themselves like this. But worse is that they (and staff and families) think they have some limitation inside of them because of this use of language.

Those who surpass their labels, or who quickly exceed our predictions, should make us question our forecasting abilities. Yet we continue to diagnose; and our diagnoses often carry a lifetime prediction of difficulty

– We are INFLUENCING their future. Should we do it in this way?

Psychologists’ Role

It seems to me that psychologists are best placed to critique the practices of labelling and diagnosing our clients – historically you uncovered and explored these ideas. Yet this issue is rarely mentioned in mental health services today.

What do you recommend, given the significant harm that arises from negative and limiting thinking?

We all know that people frequently exceed predictions in all fields of life – how can we foster this in our clients? Is this compatible with telling them they have an ‘illness’ (with inherent limitations?)

Do you think it is possible to have staff remember clients are not their labels, while they go ahead and use them on a daily basis? I don’t.

With the client who is in front of you, can you do your utmost to find that person’s successes and capabilities, when simultaneously you feel a need to diagnose them and consequently search for information about their difficulties, the variety of them, the worst level they have reached in their life (recently and historically?)

Is reminiscing about those experiences even necessary to assist the person to develop the skills they need to reach their goals? Solution-focussed practitioners suggest it makes it more difficult to focus on their successes and capabilities.

A Challenge

Despite medications, people are often left with significant symptoms that they must learn to cope with….and they do. People have great capacity to cope with symptoms and make improvements in their lives.

The idea that medication must be given to people with psychological symptoms is just an idea that has arisen out of bad science and bad medicine. I think that psychological interventions have more to offer than medications. Much of the research supports this.

I heard once of an experimental ward that used almost purely psychological treatment; the results were favourable compared to a psychiatric ward run in the traditional way. However, the experimental ward was nonetheless closed down! (Ref – see below.)

I hold great hope for your profession to be more helpful to the clients of mental health services. Certain ideas get in the way, and the idea about ‘mental illness’ is one key concept that needs close examination. It leads on to the practice of labelling and creating limitations.

Call to Action

For the benefit of clients for decades ahead, the Psychology profession can place itself to have the major role in this field. The idea of ‘mental illness’ is a limiting and untherapeutic construct that holds back clients and professionals in achieving great outcomes.

What can you do today to begin creating change?

(The End)

Reference

1. Deikman AJ, Whitaker LC (1979). “Humanising a psychiatric ward: Changing from drugs to psychotherapy.” Psychotherapy: Theory, Research, and Practice; 16(2):204-14.

What Is Unique About The Social Work Profession?

When social workers get together there is an affinity or bond that many of us recognise, which arises out of our concern for social justice and empowerment. Coupled with that is the breadth of our knowledge base; in particular I am thinking of constructivism, and of systems theory. These are core to our ways of viewing clients and groups.

Many staff (not just social workers) privately indicate they oppose the customary management of clients that relies so heavily on medication. They dislike the labelling of clients but do it as required. The systems require a focus on problems and symptoms, yet our knowledge base tells us that people are more likely to find solutions when we assist them to get in touch with their strengths and past successes.

Is it already apparent that defining people’s problem behaviour as ‘illness’ shapes the beliefs and responses of clients, families and organisations? Is it already apparent that this definition has resulted from powerful groups with vested interests?

Oppression In Mental Health Services

,p>iscussions and literature of psychiatry, is that one often hears comments such as, “He should realise he has a mental illness, and just take his medication.” I find this oppressive. It is one group’s definition being imposed onto another.

The premise is the belief that the powerful group’s construction of ‘illness’ is right.

There are other constructions offered in the literature (e.g. family roles, trauma) but they are not currently in favour. Consequences flow from the construction that dominates.

What are we doing about it? Do the majority of social workers agree with the theories of biochemical imbalances? If so, is this based on the critical appraisal of the evidence, or passively accepting what is commonly expressed?

What Do Social Workers Believe?

Do we know what the majority of our social work colleagues believe? Shouldn’t we find out? There is little or no discussion about these concepts. There is no way for our profession to move forward to highlight the misuse of professional and organisational power unless there is a better understanding of what we believe.

A colleague told me about a nurse who attended a workshop on “Recovery.” The nurse said, “Why didn’t anyone tell me (before today) that people can recover from psychosis without medication? I’ve always been telling the patients they must take their medication.”

Staff unaware of constructivist ideas are likely to accept ‘mental illness’ as the truth, blinding them to the actual experience of people. The evidence that people can recover without medication comes from the success of placebos in every clinical trial.

With increasing information becoming available about the dubious science and ethics employed by multinational pharmaceutical companies, one needs to be sceptical of claims of medication effectiveness.

An Opportunity and Responsibility

I think social workers are very capable of raising discussion about the dominance of certain ideas, and the consequences for our clients. If enough agree, there is an opportunity to lead people to critically reflect on the practices that often harm people physically and emotionally.

Many know there are alternative approaches to assist people. Many know the harm associated with labelling. Many know the harm associated with the medications given to people. We have a responsibility to assemble our knowledge and find avenues to raise concerns, and promote alternatives.

Call to Action

We need to develop forums to share our knowledge, our concerns, alternative views. We need to plan how and where we can influence the structures and systems to take more heed of constructivist knowledge.

We need to collaborate for change, celebrate each step, and continue until we succeed.

(The End.)

[1.] Sitting at the lunch table with my friend Ruth, she happened to mention that she had a bad dream the night before and was very tired. In fact she had a bad dream the night before that, and the night before that. It was the same dream and it had happened every night for perhaps ten years!

I was flabbergasted when I heard this. Each night she had the dream of an airplane falling out of the sky, crashing into the ground, with blood, dead people, flames, carnage. It woke her up in a sweat, making it difficult to go back to sleep for a significant period, and making her tired each morning.

I wanted to know what she had done to try and change this. I recall she had not tried very much. She basically just felt it was her mind’s way of dealing with and processing the day’s events.

Can you imagine the sort of daytime experiences that one would be having that required that sort of processing?! Maybe a soldier in a battle zone would need processing like that. But she was not, nor an ambulance officer nor a nurse in Emergency. It amused me that one would have thought such a night-time experience would be required.

I suggested she try something. [I operate pragmatically so if this did not work, I would try something else.] I explained that there most likely was a ‘part’ inside of her that was making this happen, and that it had a good intention behind its action, even though we may have no idea what the intention is. We don’t need to know, I told her. But if we wanted its help it would pay to be nice to that part and respectful.

I recommended that at night when she was laying in bed she address the part and say something like… “Tom says that I should say ‘Thanks’ to you because he believes you are trying to do something that is helpful for me. But it is disrupting my sleep and making me very tired, so could you please change the way you are trying to help me? Thankyou.”

The following day, she reported a change to her dream. She was aware that the airplane was falling down to the ground as usual. Just as it reached one metre from the ground, the plane did a 90 degree turn, flew out of her view, and then crashed. But because it was out of her view she did not see any carnage; she just knew that it crashed. She did not wake up in the night.

The dreams continued in this more comfortable way, until later we did something else to improve them further.

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[2.] Most people do not like picking up spiders, but Robert had no fear of them. Whenever he found a spider in his house, he would gather it up and put it out in the garden. Although I knew Robert, his partner told me of his frequent nightmares involving spiders. She said that it got resolved when his church minister, who must also have been a pragmatist, directed that instead of taking the spiders out into the garden, Robert kill them.

Bad luck for the spiders, but the nightmares stopped!

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[3.] One evening I was visiting Karen’s house for a meal. Prior to dinner we were sharing our news of the day. She had a very upsetting day. She briefly mentioned her concern, and then said that she didn’t want to talk about it; it was still that upsetting.

Later while she was breast-feeding her newest baby, she mentioned that she was feeling the beginning of mastitis, which is an infection of the milk ducts, and can be extremely painful. [This was something she had experienced 7 times previously, always treated with antibiotics, and so I expect she knew what was ahead for her.]

Being friends I had previously shared some of my life experiences with her, where I had noticed the link between squashing down my emotions and the emergence of physical symptoms very soon after.

So I reminded her of my experiences and suggested that perhaps her beginning mastitis was resulting from her desire not to feel her feelings associated with her worry. And therefore she might very well be able to reverse the mastitis if she was to receive the feelings and stay with them until she could mentally find a satisfactory resolution.

This made sense to her, as she could see that she had decided she didn’t want to think about the matter. She told me she would try what I suggested after dinner when I had gone.

Some days later I got the feedback that she had been successful.

[Recently another friend read the above story. She also had several rounds of mastitis and antibiotics. Her stressor involved the child’s father. She determined that she would heed my advice by staying with her feelings rather than fleeing them. Thus she put an end to her pattern of infections too.]

{NB. If our emotions are signals to attend to important matters, then there are disadvantages of medicating people where the result is that they cannot feel their emotions – no longer do they feel the internal pressure to resolve their stress. Furthermore Ernst Rossi showed, in the extract from “The Psychobiology of Mind-Body Healing” the value of beginning with the person’s feelings, and using this to achieve a resolution. If we can’t feel, because of medications or from any other cause, we lose an important source of information that can be helpful to solve problems.}

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[4.] Kelly had to undergo major abdominal surgery. She knew that I might be able to use NeuroLinguistic Programming to help her, so we met. I asked her to tell me what outcome she wanted. She wanted help with the pain, post-operatively. (She had previous experience of surgery.) I asked her more specifically what she wanted.

Initially she answered that she wanted to cope with the pain, or have less pain. Such phrasing as this is usually not very satisfactory. This is more a statement of what would not be happening than what she would be experiencing. So I coached her until she was able to state a desired outcome that specified only what she did want.

She detailed what she wanted to feel around her abdomen, namely a cool feeling all over the area of the incision. I had suggested a feeling of ice-water which she rejected, recognizing that it too can be painful. So once she had identified the desired feeling/sensation (also known as a ‘kinaesthetic’ representation), I then asked her to internally create the tone of voice that she wanted to use when talking to herself and others after the operation; and then how she would look. She now had ‘sensory representations’ in the three major sensory systems.

This use of the visual, auditory and kinaesthetic senses creates a destination for her mind. Intrinsically there is also an inner ‘road-map’ of how to get there. Without this her ‘unconscious mind’ is not guided in the optimal way. (By ‘unconscious mind,’ I am referring to the idea that there is a part of us that operates independently, separate from our conscious mind. There is no consensus on its definition, but most people recognise that a part of us organises our dreams, can remember things under hypnosis, that had been forgotten and so on. Some people might equate it with their spirit, or call it their ‘inner self’ or it might be the summation of all their hopes and dreams.)

The outcome statement she settled on did not include the word ‘pain’ at all and therefore neither did the sensory representations of the outcome. The initial phrasing of ‘coping with the pain’ is less than optimal, as it presupposes that she will have pain. This would then automatically be included in the sensory representations, and thus be part of her experience to some extent. (It is important to appreciate that sometimes pain may be very important following surgery, so the person has feedback and will act within appropriate limits, so as to facilitate healing.)

Now she had detailed the outcome, I was expecting to engage in a therapeutic process of negotiating with her unconscious mind to facilitate the outcome. However despite Kelly’s conscious understanding and agreement, there was no agreement by her unconscious and we abandoned doing any of the work we planned, much to her disappointment.

Days later I received a phone-call from her hospital bed, joyously exclaiming her success. While she indeed had a degree of pain, she was amazed at the result. She had felt the coolness before the surgery, and was continuing to feel it, to such an extent that extra blankets had to be brought to her bed. I was delighted for her, but not totally surprised; I have plenty of personal experience that shows the power of setting detailed outcomes as described above.

Final Comments

I wanted to illustrate that change often can happen quickly and perhaps easily. The last experience details the value of specifying one’s outcome, which is invaluable in all forms of therapy. Most often more is then required to achieve it, but at a minimum this step allows the therapist and the client to know what is being aimed for, and when the goal has been achieved.

These experiences might not surprise some people. Upon hearing these tales, some people recount their own similar stories. However in the professional world I inhabit, namely psychiatry, these sorts of ideas do not seem to be prominent. These five experiences simply illustrate the connection between one’s experiences/thoughts and bodily symptoms. Authors on NeuroLinguistic Programming and related areas point out these connections explicitly.

(The End)

Some years back a manager did not favour some of my writing similar to the essays on this site. That person essentially said, “I find it difficult to believe that people can get better from psychosis without medication.” Such is the influence of the medical paradigm. Fear was being expressed that patients may stop their antipsychotic medication and this was the only possible way they may get well.

I didn’t think to tell that manager that people recover from psychosis without antipsychotic medication, frequently. The evidence is in clinical trials – placebos are given to contrast the active medication being studied. Earlier I wrote (my essay, “Some Thoughts on Psychiatric Medication”) that in one meta-analysis of chlorpromazine (an antipsychotic medication that was used extensively for years,) in 11 of 55 clinical trials (17%) placebo was as effective as the drug. (Ref. Ch. 2, P.86. Errors of Logic in Biological Psychiatry, in Colin A. Ross and Alvin Pam, “Pseudo-Science in Biological Psychiatry: Blaming the Body.” (John Wiley & Sons Inc, NY. 1995)

Further on P.86 Ross & Pam cite another large study involving Chlorpromazine – the improvement of the drug over placebo was ‘one point’ on a 7 point rating scale – this means that on average the drug was more helpful, but certainly individual scores would have shown some clients improving markedly on placebos, while others did poorly.

It is obvious when one thinks about it, that many people improve without antipsychotic medication. People get better from all sorts of ailments when given placebos, even cancer (see footnote), so we should not regard psychosis as exceptional. A former colleague, who later worked as a drug representative in the psychiatric field, mentioned improvement seen by placebos has increased over the years – as a culture are we more believing of science and medicine, and hence the effect of placebos?

Change After ‘Long Term Treatment’

I have referred to Jay Haley (in my essay, There’s an Underlying Biological Illness.) In his early time as a therapist he learned the customary “talk therapy.” He was treating an adult woman for depression and over many months she improved. He pondered over the fact that during the period of therapy she entered into a relationship, she changed jobs, and there were other significant changes she made. Was she no longer depressed because of therapy, or because of the changes she instigated?

She may have made the changes because of the therapy and consequently became less depressed. Or maybe she would have made those changes regardless, and got herself better. Haley realised that with long term treatment, many things change in a person’s life and it is not possible to reliably attribute improvement to therapy. This spurred Haley towards his interest in short term methods – if change then results, therapy more likely was important.

This also applies to long term drug therapy. Large numbers of psychiatric clients are treated for years. Some are compelled by legal orders; some are detained to hospital numerous times, and coaxed by staff and/or families to comply with the prescribed medication. When in hospital staff are required to manage behaviour and influence patients to behave acceptably.

Both in hospital and when followed up by community appointments, a patient’s behaviour is modified. S/he learns that there are behaviours which will result in certain consequences or rewards. For instance in hospital, staff may take control of the patient’s cigarettes. If one ‘misbehaves’ it may be more difficult to get another cigarette. If one is combative to staff, one may be roughly treated or punished in some way to deter any repetition. If one is troublesome in the community, one may find oneself detained to hospital. If one finds hospital a negative experience, it will act as a deterrent. If one finds hospital a positive experience and one has too many admissions, staff will seek to deter admissions and manage unwanted behaviour in other ways.

There are many ways that patients’ behaviours are influenced over years of treatment. When some patients, who were previously difficult to manage, become easier to manage after months or years, we might assume that the medication has improved the situation. Almost certainly many other things have played a part…the parents or spouse may have changed their attitudes or expectations, the person may have made different friends, got onto a disability pension and no longer be pressured to work….etc.

Mounting Evidence

A search on the net will quickly find an unending supply of studies and reports which question the validity of drug effectiveness claims, and the questionable behaviour of drug companies.

From a site by John H. Grohol http://psychcentral.com/ referring to studies using antidepressants with people diagnosed with bipolar disorder:

“The most surprising finding, though, was that the placebo outperformed the antidepressants in the study in helping to relieve depressive symptoms.

27% percent of patients getting a placebo held off depression for at least 8 weeks during the 26-week study while antidepressants only worked in 23.5 percent of patients.”

Reference
http://psychcentral.com/blog/archives/2007/12/21/mental-health-year-in-review-2007/

From a site www.clinpsyc.com there is a blog entry about Zoloft, a leading antidepressant medication, and used for Post Traumatic Stress Disorder:

“Convenient Honesty and Zoloft (1. Ref Below)Recently, a study (2. Ref below) was published which cast doubt on the efficacy of sertraline (Zoloft) for PTSD, finding that the drug was no better than a placebo.

‘The kicker is that the patent has expired for Zoloft, which is why the data are now flowing more freely. I’ll make the case here that data were buried until they would no longer hurt sales to any meaningful extent, at which point data were published, at least partially as a public relations move to show just how “honest” the companies are with sharing both positive and negative results with the psychiatric community.

“The Research: The latest study, (Reference 2) which appears in the May 2007 Journal of Clinical Psychiatry, showed no benefit for drug over a 12-week period. Placebo tended to outperform Zoloft on the majority of outcome measures, though the differences were of a small and statistically insignificant degree. Patients were significantly more likely to drop out of treatment on Zoloft. It was unclear if there were any serious adverse events (e.g., suicide attempts, notable aggression, etc.) because the article did not mention them at all. Patients started this study between May 1994 and September 1996. The original draft of the study was received by the journal in March 2006. Nearly 10 years passed between study completion and writing up the data for publication.

“Two prior studies found positive results for Zoloft and were published quickly, while these negative results languished until the Zoloft patent had expired. One earlier positive study did not list the dates during which the study occurred, but it seems clear that it was rushed to publication much quicker than the negative study. Another positive study was conducted between May 1996 and June 1997 and was published in 2000. It’s quite obvious why the positive studies were rushed to press and the negative study languished, is it not?”

Reference
http://clinpsyc.blogspot.com/2007/05/convenient-honesty-and-zoloft.html

Also from www.clinpsyc.com there is a blog entry about another common antidepressant, Paroxetine, and its use with children:

“Dr. Graham Emslie, who has participated in a number of psychiatric drug trials for children, appeared in a brief interview clip on an Austin TV station’s investigation into SSRI use among children. Emslie was contracted by GlaxoSmithKline as an investigator in a study examining the effects of paroxetine (Paxil) on child/adolescent depression. As such, he was aware that data showed that Paxil was no more effective than a placebo, but (and here’s the killer quote):

“I couldn’t talk about it because it was proprietary.

“In other words, Emslie had an agreement with GSK that he would not share their trial data without GSK’s permission, even when it showed that Paxil was no more effective than a placebo and related to poorer safety outcomes than placebo.”

Reference
http://clinpsyc.blogspot.com/2007/01/one-quote-says-it-all.html

Conclusion

Are we using psychiatric medication too much? Are staff confident that they have other skills to offer, if clients do not want medication? If not, what is being done to raise the skill level, so that consumers have choices when seeking help for their concerns?

(The End.)

References

1. http://clinpsyc.blogspot.com/2007/05/convenient-honesty-and-zoloft.html

2. Randomized, double-blind comparison of sertraline and placebo for posttraumatic stress disorder in a Department of Veterans Affairs setting http://www.ncbi.nlm.nih.gov/pubmed/17503980?dopt=Abstract

Footnote

[For those interested to read a powerful article about the politics of cancer treatment, and many references pointing to alternatives to chemotherapy being worthy of consideration, see “DoCS - STEALING OUR CHILDREN FOR MEDICINE? One Australian Family's Nightmare Loss Of Health Freedom,” by Eve Hillary. http://www.evehillary.org/docs.stealing.children.revised.1.htm

Since I have written that psychiatric disorders are not usefully called ‘illnesses’ (About Hope), and that there are useful therapeutic approaches (Solution-Focussed therapy; Jay Haley’s family approach to schizophrenia), I favour clients and families being offered choices such as these. These are largely precluded when a simplistic description such as ‘illness’ is used to explain complex life problems.

Some people do benefit from medication and it can be offered. However there is no need to perpetuate ideas of ‘illness’ as a rationale for using medication – if it has been found to be useful, it can be offered; if people then find it to be useful they will use it. If it’s not adequate they will consider alternatives.

Presently in Western societies many clients are largely told, “This is the treatment, and you must take it,” (irrespective that symptoms may remain after trialling it for months already.) “And if you don’t want to continue we will get legal orders to make you, because it is an ‘illness’ and you need treatment.”

Mainly I favour, if it’s not working, let’s look at alternatives.

Dangerous Clients

There will always be some clients the community wants to control because they are dangerous. Psychiatry tries to delineate between those it deems to be bad, as opposed to ‘mad.’ Those deemed bad are left to the justice system. Those deemed mad and need controlling are usually called ‘ill’ and medication is forced onto them. For those who are dangerous, if the justice system is not going to control them, I favour the use of medication (or something) to control them. But there is no necessity to mislead people by saying they are ‘ill.’ Wouldn’t it be better to be honest and declare we are controlling you because of the way you have been behaving? They can then choose to change or behave the same; this avoids arguments and denials about being ‘ill.’

Troubles Caused Through Illicit Drugs

Many individuals, who repeatedly abuse drugs and behave in mad/strange/bizarre ways, are often hospitalised if they have not behaved criminally. There is no need to label these people as ‘ill.’ They are behaving in ways that are annoying to the community, utilising time of the police and other services that cost money.

They are treated as ill and rescued from many financial consequences (welfare services supply more housing, clothing, and food etc.) There often is no hardship that might motivate them to review their choices and change their life. Families have often been told these individuals have an ‘illness’ which invites them to continue providing financial and other material support, which perpetuates irresponsible choices.

When questioned some families respond with, “They are ill; they can’t do any better.” The concept of ‘illness’ is yet again an obstacle to people considering more effective alternatives – would these family members excuse irresponsible behaviour of young children, or rather would they understand people need limits and consequences to learn? The same will help some of the people who repeatedly abuse drugs.

Informed Decisions and Choice

How well informed are clients at present? What choices of treatment are they offered? Are they likely to be discharged from the service if they do not want medication treatments, rather than be offered help in other ways? Are clients’ problems explained primarily in biological terms?

Should clients be told they have a biochemical imbalance in their brain when there’s no evidence for what amounts to a metaphor? [See my article, “About Hope” and its section on Linguistics.]

Is family therapy available at your local service?

Informed choice is also compromised when multinational companies largely control the testing of drugs and reporting of findings. (Elliott S. Valenstein – “Blaming the Body: The Truth About Drugs and Mental Health.” See also, the last two chapters of “Mad in America: Bad Science, Bad Medicine, and the Enduring Maltreatment of the Mentally Ill,” by Robert Whitaker. See below for full references.) Vested interests can be tempted to bias research design and reporting. The two authors above (especially Valenstein Ch. 6) detail examples which suggest this is common in an industry where bringing a new drug to the market costs hundreds of millions of dollars. Valenstein (page 189) also notes that Clinical Trials conducted by pharmaceutical companies result in successful findings much more than when independent government funded bodies conduct trials.

There is much written about the influence that these companies have over prescribing patterns of doctors; much can be found at the following websites:

http://healthyskepticism.org/
http://pharmedout.org/
http://www.nofreelunch.org/

Increasingly one might wonder whether the medications we are prescribed, result from the appraisal of scientific studies or the marketing tactics of the drug companies.

An alternative that would restore impartiality and confidence is that companies could develop new drugs to the point of clinical trials; then hand the experimental drug over to truly independent bodies to evaluate and report. Claims of effectiveness would then be powerful. Are we likely to see pharmaceutical companies eagerly accept such a proposal? Or will they fight to maintain independent control as much as possible?

In some clinical trials of approved drugs no difference has been detected between the medication and the placebos! Dr. Colin A. Ross (“Pseudo Science in Biological Psychiatry,” p86, See full reference below) quotes from Kaplan’s “Comprehensive Textbook of Psychiatry” Vol 3 (Kaplan, Freedman, & Sadock, 1980) that “in a meta-analysis [a large, comprehensive review of the research literature] of double-blind chlorpromazine studies in schizophrenia, the drug was found to be superior to placebo in 55 trials, but equal to placebo in 11 (p.2258) This meant that in 17% of trials, chlorpromazine is no better than placebo in treatment of schizophrenia.” [Does it make you wonder whether the 17% were conducted by government/independent researchers, and the rest were conducted by drug companies?]

Chlorpromazine was a drug commonly used for schizophrenia for decades. Does this make you wonder how good psychiatric drugs really are? When you read in this field, you wonder whether there is anything different about the drugs used in psychiatry today.

Consumers and Families

This information is rarely shared with consumers/families. It would obviously make it difficult to convince them to accept the medications, since many have significant and/or serious side-effects. Yet to be equal participants in decisions about their health, shouldn’t consumers and families be informed? Not doing so perpetuates a parental approach, and supports the simplistic view that people’s complex problems are personal ‘illnesses.’

Sharing the available knowledge will lead to greater debate and participation by consumers, and has the potential to foster greater collaboration as we search for answers together.

(The End.)

References

1. Elliot S. Valenstein PhD, “Blaming the Brain: The Truth about Drugs and Mental Health” (The Free Press, NY. 1998)

2. Colin A. Ross and Alvin Pam, “Pseudo-Science in Biological Psychiatry: Blaming the Body.” (John Wiley & Sons Inc, NY. 1995)

3. Robert Whitaker, “Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.” (Cambridge, MA. Perseus Publications, 2002.)

For those that think therapy is confined to practices where people have to talk about their problems and “get in touch with their feelings (meaning emotions)” to solve their problems, then read below.

Following is a description of a single session by Ernst Rossi, a psychologist trained by Dr Milton Erickson, both of whom utilized hypnosis and unconscious processes in their work. Rossi would use hypnosis to describe what he is doing in the session below, but I think most readers would be puzzled – there is no effort to develop a trance – they begin talking and he follows where this leads. As you will learn, he is not seeking content to work with; he works with the “responses” the body gives, to his precisely crafted questions. He expects he will get responses and this feedback (from the unconscious) will lead to a resolution of the person’s problem. This is illustrated below.

Excerpt

A woman graduate in her middle twenties complains that for the past few years she has had “a series of mysterious gynecological problems.” She has seen many physicians, taken many medical tests, and even had an exploratory operation “down there.” Several excellent internists she greatly respects have now told her that there is nothing medically wrong with her. “One wonderful woman doctor,” she says, “finally told me that I do not need another exploratory operation with a surgical knife, I just need to be nicer to myself, so here I am.”

On the very first therapy session she enters the consulting room announcing that she has given herself a “migraine headache today.” With a sympathetic manner I ask her, “Tell me what you are actually experiencing with that headache at the moment.” She responds with a wrinkled face of pained distress and speaks of “A terrible, tight band all around my head that won’t leave me alone—it has been pounding all day since I have been worried about my boyfriend. I couldn’t sleep at all last night since I can’t get it out of my mind. I just don’t know what to do to get rid of this migraine! I can’t even think straight right now; my mind is all fuzzy-like. How am I supposed to study?”

With continuing sympathetic interest I again ask her, “What are you actually experiencing right now?” The supportive tone of my voice and my optimistically eager, exploratory manner imply that her symptoms are of great interest and may already be changing. She responds with a moment of puzzlement as she apparently tunes into herself, she then wrinkles her brow with even greater distress and loudly says, “The migraine is coming on even worse! Oh, gosh, it’s flashing on and off in the worst way! And now it even seems to be spreading down the back of my head and I’m starting to get a stiff neck! Oh, I just hate this; it is like a burning sensation is spreading from my head and neck to my right shoulder. My whole body is just a mess!”

I respond to this worsening crisis with, “Well it really seems as if your whole mind and body are trying to tell us something, especially about your relationship with your boyfriend, so let yourself receive whatever comes all by itself right now.” She tentatively talks about her difficulties with him for a few moments and then seems to breakdown with loud sobs, shaking, and crying that momentarily threaten to get out of control so I respond with a therapeutic dissociation: “That’s fine, you can continue to let yourself feel that as strongly as you need to because here is another part of you that can watch wisely and keep you safe so you can understand what these feelings are telling you.” She then lapses into quieter sobs and finally a silence for two or three minutes, apparently deeply engrossed within herself. I remain absolutely still not daring to move a muscle least I disturb her excellent self-absorption. She then softly notes, “Oh, my cheeks are hot, so hot now, why is that? It’s almost as if I’m embarrassed about something. Why am I so embarrassed?”

She looks at me with wide open eyes in apparent expectation and puzzlement looking to me for an answer. I note that the pupils of her eyes seem dilated and I wistfully respond, “Yes, I wonder what it is? I don’t know if you need to keep some of that private. Just continue to receive whatever comes to you all by itself now—only telling me what I really need to know to help you further.” She remains silent for a few minutes and then with rapidly fluttering eyelids says with some surprise, “Oh, my whole body is hot and full of energy—it’s like my whole body is shaking and vibrating. Why am I so nervous? What is happening to me, what is this vibrating all over my skin, I don’t know if I itch or what? What is this burning energy I feel all over?”

With quiet eagerness I whisper, “Yes, I wonder what it is. What is coming to you? Let’s see just what it is?” (Of course, this was a technical error; I made an error by mentioning the word “see” and thereby unwittingly suggested the visual modality to her.) She remains silent for a few moments and then with a slow tear rolling down her cheeks she whispers, “I see myself writing him a ‘Dear John’ letter. I’m not blaming him or myself. I’ve always known this, I’ve always known it could not really work between us, but it was such fun for the both of us in the beginning that I wanted it to go on. I realize now that we really are such different people. I so much enjoyed his parties and social friends at first, but I now know I am different than they are, I need my solitude—that’s when my poems come, like little children tugging at my skirt, and then I write. The poems have all vanished from my head since we have been going out together, but I cannot live without my poems, they are me. It’s just the dynamics, you know, it’s just the dynamics that don’t work between my boyfriend and me. I just hate these dynamics but it’s true, you know? I hate it, but it’s good to know what I have to do.”

She closes her eyes, rolls her head about slowly and takes a few deep breaths. With a wry smile she says, “See, I told you I just gave myself that migraine- it’s completely gone now! I feel so much better, oh, I feel so good now, thank you. Oh, the whole world suddenly seems brighter, like I can actually see this room more clearly.” She remains rapt in silence for a few minutes and then her eyes and lips move slowly as if she is in communion with herself. She finally says, “Umm, just the wisp of a phrase, it is the beginning of a poem coming on, I can really feel it. Oh, thank heavens; it’s like an epiphany of clear crystal ice at the moment of melting with spring in the North Sea.”

She seems to have found her own solution but I tentatively test it by humorously playing the devil’s advocate, “Oh, you’re really going to write him a ‘Dear John’ and tell him all the dynamics!?” She playfully responds, “Oh, no, you silly! I’m just going to write him a nice letter….who knows, maybe even a poem! He knows, he knows the truth already and I’m going to deliver the letter to him myself tonight and get this thing done with so I can really sleep tonight. Oh, what time is it? Oh, I’m sorry, I have to go! I’m committed to going to my women’s group this afternoon; they will really understand. Then I will write the letter and deliver it personally. Thank you so much, you really have been a help, even though you don’t seem to say much!”

Final Comment

In this book and Rossi’s later book, “The Symptom Path to Enlightenment,” he gives many examples of using a specific pattern and style of questions which can remedy physical and psychological issues. Little conversation and content is the norm. No trance induction is required, although sometimes the client will spontaneously develop what is commonly thought of as a trance.

Rather than wish away symptoms or take medication to quell them, Rossi regards symptoms as ‘information’ the body is making available to the individual and therapist. This information can be utilized therapeutically to lead to a solution. Precise language is critical, even down to particular words – for example above he analyzed his phrase, “Let’s see just what it is?” Rossi said it was a technical error, leading the client into the visual sensory field; instead he should have remained neutral so she would choose.

Those who train and use these and similar ideas, believe symptoms are better used as a starting point for therapy, than to be ‘treated,’ resulting in opportunities lost.

When symptoms become defined as an ‘illness’ we can limit our view of how to be helpful.

(The End)

References:

1. “The Psychobiology of Mind-Body Healing: New Concepts in Therapeutic Hypnosis,” Ernest Lawrence Rossi
(Revised Edition, Norton, NY. 1993)

2. “The Symptom Path to Enlightenment: The New Dynamics of Self-Organization in Hypnotherapy: An Advanced Manual for Beginners,” Ernest Lawrence Rossi
(Edited by Kathryn Lane Rossi, PhD. Palisades Gateway Publishing, California, 1996)

People make all sorts of choices in life. They will sometimes behave and speak as if they cannot do something (eg they cannot walk and so need a wheelchair or a carer; they cannot manage their money and so involve someone to hold their ATM card; they say they cannot use public transport which excuses them from looking for work…) What evidence exists for their claims? Often it is their statement alone.

Family Effort

I once gained a family’s agreement to disregard their son’s claim that he was too paranoid to use public transport. The family and I met, including the son. I outlined my proposal that the parents should make sure he was outside the house before the father left for work. If the son did not cooperate, and would not get dressed, the parents were to put him and his clothes outside, and not let him in before 5pm – it would be up to him to entertain himself, which might include using public transport or not.

He used public transport the first day. He reported that he felt so free. He too hadn’t believed in himself. Doubt, in the form of limiting beliefs can be infectious.

Low Expectations

Family members and staff often want to help someone in difficulty; it makes us feel good, and often someone might need help, initially. But if it develops into an ongoing pattern it becomes difficult to differentiate between inability and unwillingness. Some clients are deemed unable to clean the house they live in; they reportedly lack ‘motivation.’ However when they want to access more marijuana, they find the motivation for the things they really want.

Consequences?

What are the consequences for lacking motivation to clean their home? Often it can be that a support person is employed to do it “with them,” but they might end up doing most of it. Or they learn that they can only develop sufficient motivation if someone else is giving them a ‘pep talk.’ Or a kind parent will visit regularly to ensure they do not live in squalor. With some individuals there are too few negative consequence that might propel the client to make the effort personally.

In my essay,There’s an Underlying Biological Illness, I’ve written how families can be divided about what demands / expectations to place on the symptomatic individual. Even single parent families can experience division where a grandparent or an ex-spouse is involved. Where families are unsure what to expect, they are easily guided by professionals.

What is the effect when those professionals are working from a biological paradigm? This often implies that the person is not capable and so not responsible. Just as one might help someone who has a broken leg, family members might help their loved one. And support / involvement is important, but not the sort that alleviates the pressure to change, or the sort that communicates a belief about inability.

It does not necessitate acting harshly. The young man who cooperated in using public transport did not oppose my proposal for his parents to ensure he was outside. I suspect he knew I was aware of the family difficulties, and he was willing to cooperate in my effort to resolve them.

Yet not all individuals will cooperate and willingly let go of the advantages of being helpless, or of being aggressive. What are the options for individuals and families when this occurs? Do we hold them responsible? Do we enlist the family as a force to influence the individual? Do we assume the individual is ‘sick’ and unable to behave differently until s/he is treated and becomes motivated to help her/himself, or give up the drugs etc?

Pressures in Normal Life

You may recall your experience of having to push yourself to make a change. Perhaps this was about changing from a job you had grown tired of, but did not want to face the prospect of job interviews. Perhaps it was about dating, as a solution to being single; or perhaps leaving a marriage.

Often we change after a period of anguish. We benefit greatly from stretching ourselves, but before crossing the ‘point of no return’ you likely hesitated, perhaps for many months.

Often it is the pain of things being the way they are that creates the necessity to act.

When we take the pressure off clients, they may well be less likely to act. Where families or individuals accept the idea of an ‘illness’ as the cause (of low motivation, bad temper, drug use, bizarre behaviour, irresponsible choices etc) and hope that medication will easily change things, are we doing them a disservice? Are we adding to the problem?

Inability or Choice?

Solution-Focussed therapy uses “scaling questions” with clients’ goals – this amounts to asking the client to rate out of ten their commitment to their stated goal – “If ten out of ten means that you are willing to do anything and everything to make it happen, and one out of ten means you think it’s a good idea, but you are really not that interested in doing anything about it, where would you put yourself at this moment?”

When asking clients this question about a particular goal (or wish,) the therapist will soon discover whether the client is committed to that goal. If s/he answers eight or higher, you can expect the client will undertake action towards the successful completion of that goal. Depending on their score, the therapist has different options for responding.

This question immediately identifies which goal(s) the client is interested in working on. They may not be at all interested in the goals that we or the family might hope for; it becomes clear why they are not taking the necessary steps. Then we can consider whether the family (or other social systems such as the police/courts) can be influential?

When the individual is not choosing to work towards goals deemed appropriate by the family (resuming study / work, cooperating at home, cleaning their room…) or the society (cease drugs or other antisocial acts) should we label that as ‘illness’ or choice?

We have a choice here.

The Family’s Choices

If the problems are not defined as an ‘illness,’ the family may legitimately become impatient with certain behaviours. This may be more useful than being tolerant (of drug use, sleeping 12 – 14 hours a day, watching TV, not contributing domestically.) The family may stress over their situation and need help to consider the most useful strategies; but they can often be more influential than strangers.

The family may invite professionals to change the situation with the symptomatic individual and one must take care; the pressure they feel may be necessary to motivate them to work for change.

Just as in the title, pressure can be necessary for change. Crises can be opportunities for individuals and families.

How do we best use the opportunities and communicate hope with the client?

(The End.)

What happens when we give advice or perform some great therapeutic intervention that works? The person may go away satisfied, or partly satisfied and find a new problem to be focussed on, and to test your therapeutic skills. Yet therapists get paid to intervene, and it can be useful. However, there are many occasions when the client has tried many therapists and many techniques to no avail.

Sometimes the best way to help a person is to not help!

One option then is a technique described in the Brief Therapy literature as “Declaring Therapeutic Impotence.” [See reference below for more information.] This is when the therapist listens to the person and his/her problem, sympathises regarding their frustration and the seriousness of the problem, but says they are not sure what to do, and suggests that they need to meet again and perhaps then they can work out what to do. Sometimes this is not a technique, but the truth.

Michael did have some work skills but had not worked for 10 years. It sounded to me that it was going to be hard work on the phone with this man. But having been inspired by re-reading Solution-Focussed Therapy books I launched into questions that would identify this man’s better times and his achievements, no matter how small.

His achievements were not difficult to find at all. I thought it was a positive that he was not suicidal, given his misery, his chronic pain, and isolation. But more obvious was the fact that he had given up using speed for 3 years. He described that he had been addicted, having used it “all my life.” And he had also not used marijuana for the last 4 days, compared to his normal daily use. I thought these were terrific achievements, and evidence that he had capabilities that he could draw upon to reclaim his life. But over the course of at least 75 minutes I could not make any significant headway in terms of identifying progress around his depressed mood and anxiety symptoms.

Nonetheless he did have some hope, and he persisted with my questions. He seemed quite committed to making changes, but we grew quite tired through such a lengthy phone call. Searching for times when he was even a little bit happier, he could only think of a time when he had taken a pain-killing tablet. Eventually we decided that we would end the call, but I would ring him again, 8 days later. Despite my lack of “success” he probably did form the impression that I tried hard.

When the day came for me to ring again, I was not really sure what I would say; there was not really any progress in the last session that I could use to build hope and encourage him to continue.

When I did call, he was glad that he “did not miss me” (confirming that we had built some degree of connection.) He was going out (!) and he did not have long to talk. He was going out to meet some friends that he had got re-acquainted with, who shared his main passion for music; he had already seen them once since our phone conversation.

I had formed the impression that he was severely agoraphobic; yet he was going out, the second time in a week! He had been miserable, experienced chronic pain, and now was doing remarkable things.

He explained to me that he knew I couldn’t help him, and that “you have to pull yourself out of it.” He said he realised, “I have to face my fears with a smile.”

I expressed my genuine amazement, congratulated him and wished him well. I was ending that employment so I did not offer to contact him again. I don’t know how he is continuing. I hoped that if any therapist meets him in the future, s/he will not get caught up with his problems. I hope s/he will seek and discover this success (and others) and help him remember how he moved himself on, so he can do more of what works for him.

I am a ‘fan’ of Solution-Focussed Therapy; I love the stories that I hear. People seem to be struggling so much and then do the amazing. Our job often is not to make it happen, but to notice when it happens. The client, and perhaps many others fail to notice significant occurrences; we need to make a big deal of what they do (or have done in the past)….so they can’t forget it, and they wonder what else they might be able to do.

With the man above it was easy to be amazed. From the outset he impressed me as being committed to improving. He confirmed this by initiating changes when he knew he couldn’t rely on me.

I generally don’t aim to apply the “therapeutic impotence” option, and I’m not really advocating it. His story is a reminder of clients’ capacity to change, despite our limitations. Would we have been as helpful if we had got in with another pill, or shock treatment, or other offerings?

Sometimes I think people will do better if we get out of their way. But we should always be optimistic. People do change. We need to believe in them and find ways to foster their ability. They all have this ability.

(The End)

Reference for “Declaring Therapeutic Impotence.”

http://books.google.com/books?id=YNdF4rqbouIC&pg=PA166&lpg=PA166&dq=%22therapeutic+impotence%22&source=web&ots=mqErb2KIQ-&sig=OKZIHqsJVIeRXVdevqnQGQkMqU8#PPA166,M1

In mental health services when staff assess new clients they often enquire if anyone else in their family has a psychiatric disorder. It is common to hear staff comment that a person’s problem must be genetic…because of other family members having similar problems.

We all try to make sense of our world and so it is understandable staff may conclude there is such a link. However, is it accurate? Where is the evidence? And is it helpful?

Is it accurate?

Why would staff speculate that the person’s difficulty is genetic? This comes from a tradition of thinking that psychiatric disorders are genetic. There is a history of thinking that psychiatric disorders are ‘illnesses,’ (meaning biological ailments) and if a genetic cause could be established, there would finally be a conclusion to the debate; however to date there is no proof.

The ‘evidence’ that is collected, that other family members (parents, siblings, uncles, cousins) have similar problems is taken to be significant. However, why is this ‘evidence’ not assumed to be proof that the client has modelled their family’s limited coping skills? We can accept that the young child above could copy his father’s limp, but why not conclude, “The limp must be genetic?” We are looking at a correlation in both instances, but with the child one would conclude modelling as the cause, and with psychiatric disorders some people think genetics.

Some assume that the genetics of ‘mental illness’ such as schizophrenia are proven. More likely the evidence supports the view that ‘nurture’ is responsible, not ‘nature.’ One interesting fact I read is that where a child grows up with a parent diagnosed with schizophrenia, the child has three times a greater risk than if neither parent has that diagnosis. (Ref p17-18, Ch 1 Biological Psychiatry: Science or Pseudoscience? in “Pseudoscience in Biological Psychiatry: Blaming the Body” by Colin A. Ross & Alvin Pam – John Wiley & Sons, N.Y. 1995.)

Why would one not conclude that parenting is the key factor? Most likely where families have relatives with similar problems, they share limitations in the way they manage life challenges – these can easily be learned (eg avoiding conflict rather than discussing issues, using drugs or alcohol, giving up in the face of difficulties rather than persevering.)

Statistically the expectancy rate for a child with one parent diagnosed with schizophrenia is 12%. This is far lower than predicted by Mendalian ratios – for a ‘dominant’ gene one would predict 50% of children who have a first degree relative (eg parent); for a ‘recessive’ gene one would expect 25%.

And if both parents had the diagnosis, one would expect 50% for a ‘dominant’ gene and 100% for a ‘recessive’ gene. This is nowhere near the 36% incidence found by researchers. (Reference – same as above.)

There are many discrepancies between what would be predicted by genetic theories and what is found. (For a detailed critique see Ch 1 Biological Psychiatry: Science or Pseudoscience? in “Pseudoscience in Biological Psychiatry: Blaming the Body” by Colin A. Ross & Alvin Pam – John Wiley & Sons, N.Y. 1995.)

Those who hold to genetic explanations seem to want to prove a theory, contrary to the evidence. Even the often mysterious symptoms of psychosis in adolescents and young adult children can often be explained when one understands the particular family context. (See “Leaving Home: The Therapy of Disturbed Young People,” by Jay Haley – Brunner/Mazel, N.Y., Second Edition, 1997. See also my essay on this site, There’s an Underlying Biological Illness.)

Is it helpful to believe ‘mental illness’ is genetic?

If the cause of ‘mental illness’ was clearly established as a brain problem, it would be assigned to Neurologists, which is the medical speciality that deals with brain problems. And if the genetics were clearly demonstrable, then it would be well publicised by the mass media. Neither has happened. That ‘mental illness’ has a biological cause is debatable, and clear genetic proof will likely never happen. So in the absence of proof should the suggestion of a genetic cause (and its implied life long existence) be mentioned? Does it not invite despair for clients and families? And does it not invite staff to notice similarities (difficulties) when it may be more helpful to notice and highlight differences (surprise achievements/exceptions?)

A colleague told me he can clearly remember one particular young man in an inpatient setting who suicided after being given what he termed, “the questionable diagnosis of schizophrenia,” and then told it was a lifelong illness. He had previously shared his future life plans with my colleague, which presumably now seemed unattainable. How much do labelling and the genetic explanation contribute to the high suicide rate for those diagnosed with major psychiatric disorders?

I asked above whether the genetic explanation is useful? My answer is, “No.” Shall we stop? I hope so.

(The end.)

I had been to the home of Zack, a new client, about 20 years old. He had been involved in the adult mental health service after a highly serious suicide attempt. Zack was psychotic at the time and so was put on anti-psychotic medication, and antidepressants, which is the customary response in mental health services. My role as a case-manager included monitoring his willingness to take the medication which is thought to treat a hypothesized problem with the person’s brain (the commonly speculated cause of psychosis.) If not a problem with Zack’s brain why would he behave as he did?

I met Zack with his mother Betty, and several siblings who were also home. Later I spoke to his father, who was at work.

Zack was shy, and appeared to have little interest other than playing computer games and smoking marijuana. He had a work history but not for some time. I noted that Zack’s mother was outwardly confident and capable when talking to me about Zack. She told me what had happened leading to the hospitalisation, the effect on the family, and what had been happening since returning home. My attention was caught by the fact that Betty still made Zack’s bed each day, and made him his sandwich for lunch. She did this for the other children home, who were older.

A Theory About Onset of Psychosis

One theory offered about the onset of psychotic behaviour has to do with the role and position of the individual in their family. Jay Haley, author of “Leaving Home: The Therapy of Disturbed Young People,” (See reference below) posits that ‘leaving home’ is a critical stage in some families. Where the family is one where difficulties cannot be talked about and solved, and the difficulties in the couple are serious (eg alcoholism, serious depression or suicidality) they manage, until the family changes.

The simplest example is where the last child leaves home, and the parents discover their relationship is empty. Many couples solve this, either by rebuilding their connection, or by separating.

However some couples can do neither. So what can they do when one or both partners are already functioning poorly, and they will soon be left with just each other? Perhaps desperately lonely and inadequate, one may deal with hidden suicidal thoughts through alcohol or gambling for example. The dilemma is worsened when acknowledging a problem and seeking help is taboo.

The young adult child may be caught, wanting more independence but ‘knows’ this may tip the parents into conflict or a divorce they can’t handle. [This ‘knowing’ may not be clearly articulated. As the child grows, makes friends, starts university or work, talks of moving out etcetera, there may be petty arguing / shouting between the parents, more drinking.] The couple may have found their problems to be unsolvable and so surface issues camouflage the real problems. Yet the unhappiness remains significant.

What does the child do where s/he cares but cannot find a way out of the dilemma? Remember, this family has a rule that problems are not talked about. One way out of the dilemma is for the child to abandon the goal of leaving home. This keeps the parents safe. However this is at a cost to the individual. Later if s/he ever ‘threatens’ independence, the home situation worsens inviting the child to become symptomatic and restore the status quo.

Imagine if you and your partner were on the verge of separating and your daughter had a motor vehicle accident and is critically injured – the separation would be put on hold – stability in a sense returns. Serious psychiatric troubles such as psychosis, suicide attempts, drug abuse can achieve this sort of stability in families where they cannot openly seek help. And an exacerbation of symptoms can occur whenever marital difficulty manifests again.

Haley says that these dynamics can occur and are more likely when the family is private about their difficulty – if they could easily admit their difficulty and seek help, there would no need for an indirect solution. Thus Haley speculates that a psychotic young adult will often indicate private family difficulty.

Haley’s Approach

For a detailed explanation of Haley’s approach with young psychotic individuals, his book (cited above) is excellent. The main elements are as follows:

- the individual’s problem are construed not as an ‘illness’ but as behavioural, since this is something that parents have expertise and responsibility around. Consequently Haley works with parents and staff to avoid hospitalisation and medication (or negotiates their discharge and cessation of psychiatric medication rapidly.)
- Haley works intensively with the parents (both parents are essential if they are together) to get them to clearly develop their expectations of their child’s behaviour, and articulate clear consequences for any breach. An important element of his success is ensuring the parents behave in a united fashion. Where disunity between the parents is maintained by any grandparents, they are included for part of the therapy. This similarly applies where siblings maintain the ineffective family arrangements.
- Haley expects that the symptomatic individual can behave normally, and the parents must expect normal behaviour from the outset.
- Haley states that most often the parents have significant private difficulties, but these cannot be the starting point for therapy. It would be disrespectful and insensitive to talk about private matters they have not raised, and so the focus is on the adult child. Once they are having success with the child’s behaviour, the parents’ problems soon manifest. The therapist is then invited to help because the parents have established a relationship with the therapist. However the therapist does not allow their issues to take precedence, and instead contracts that they defer their issues until they have achieved the goal with their child. Haley then works with the parents while making sure the child does not revert to being symptomatic to stabilize the marriage.

In his book, Haley details case examples where the therapist talks with the family for an hour about their specific expectations for a son to look for work; and for a teenage girl to help with housework. These conversations are the testing ground for the parents to learn unity, which puts the parents in charge. Children who were symptomatic respond normally when faced with effective parents. This goal is likely to require repeated conversations led by the therapist.

S/he utilizes a range of skills in working with such families. The therapist will frequently have family sessions, and direct who talks to whom and about what. The seating may be altered to control the flow of communication. Rapport must be built and maintained with all members of the family, despite arranging the parents to set limits and consequences.

There is no talk of ‘illness’ and limitation, but rather the focus is on the next step in their return to normal responsibilities. Therapy with individuals who have been psychotic may take 3 to 6 months, with the expectation the young adult will return to work or study quickly. The therapist must also have the skill to help the parents resolve their difficulty. Often this can occur without marital separation.

Imagine the savings through such an approach – ideally no admissions to hospital, no commencement of medication with the dangers of stigma and side-effects….and a speedy return to their usual peer group and role as student or worker.

When mental health clients are not helped to quickly resume their normal life, the tragedy is compounded by developing limiting beliefs about biology and genetics, disabling side-effects of medications, stigma, despair, use of illicit drugs, loss of employment / money / relationships, legal orders….

Haley’s book details case transcripts showing the subtle communications between family members, that when changed lead to more effective functioning in the symptomatic individual. [An excellent shorter introduction to this approach is in the journal article by Cloe Madanes, “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-91.]

Clients Can Act Capably

All clients can act capably and do so regularly. This is a premise of Solution-Focussed therapy. However, people often do not notice the instances where they are acting capably, or they don’t regard them as significant. In the early days of training in family therapy with Michael White (Dulwich Centre, Adelaide) before he coined the term Narrative Therapy, I recall a client of his who casually mentioned he had a driving lesson. This was a significant departure from his very restricted lifestyle, living at home and never going out. Neither he nor his parents thought to mention this change. If Michael had not performed his ‘falling off the chair’ manoeuvre to highlight the significance of this change, the family would not have recognised the importance, and there would have been less likelihood of building on it.

Additionally a friend who worked in a psychiatric ward shared how he could overhear the patients use the public phone on the ward; he reported their conversation on the phone could markedly alter from their usual ward conversation. At times they could be markedly psychotic, and moments later they would be totally different. It was not that people were pretending to be ‘sick,’ but rather their behaviour changes moment by moment depending on the context.

I witnessed this first hand – in the midst of a serious conversation at a client’s house he was totally lucid when the phone rang. The instant he began conversing with his mother he was floridly psychotic; he returned to the role of a needy, incapable adult child who needed her ongoing help and supervision. This reversed when he ended their phone conversation.

The context of the person shapes whether they act capably or not.

As can be seen from the above example, just because a child moves out of home does not mean they leave behind the role they play in the parents’ lives.

I have had the fortune to meet a couple of clinicians who have been trained by or worked with Haley. They confirm the effectiveness of intervening in these ways. This supports the belief in people’s capacity to change – we should be optimistic.

What does this imply for the social construction of psychosis as a ‘mental illness?’ How is it that family approaches can reverse bizarre and disabling behaviour that many think must be treated with medication? [See “Some Thoughts on Psychiatric Medication" - soon to be posted.] Do we need to question the assumption that clients’ brains are faulty?

Not all clients will respond to Haley’s approach. Some no longer have families involved, or the parents are functioning so poorly they have no interest in participating in therapy. And some clients may enjoy the benefits of their “patient” status and favour it continuing. Yet the successful examples raise questions about the treatment choices we offer clients. Another question is whether it is beneficial to label individual’s problems as ‘illness.’ This implies there is a personal cause, which will likely limit the view of the clinician, who may miss much of what is relevant to solving the problem.

Zack, his Psychiatrist, the Family.

The psychiatrist at the beginning of this article was communicating his belief in a ‘personal illness’ – family factors were noteworthy, but “there’s an underlying biological illness that needs to be treated.”

It became evident in Zack’s family that his mother had significant problems, and she was so socially anxious that she was agoraphobic. The parents had come to an arrangement that the father would do the family roles that were away from the home (taking the children on holidays, sharing sport and hobby activities) and Betty would fill her life with domestic activities.

The above arrangement could work while the children are young, but is perilous as a long term solution – they will inevitably become adults and then what will the couple do?

I made the mistake of offering my perspective to the mother – this wasn’t invited and it was threatening. It was also at odds with what the psychiatrist was saying. I lost all rapport with her and I would not do it again.

Consider the mother’s position. What would she do if she was not to continue mothering her children? What else would she do that would provide purpose and involvement? And with her son’s problem construed as an ‘illness’ (not a parenting problem) she could wait for the medication to help her son, and the status quo continues.

When a family is educated to believe in a personal ‘illness’ there is no urgency for them to consider other factors; they can wait and try an unending list of medication options.

The Creation of Chronicity

When underlying problems are not recognised as significant they are not resolved. Staff and family can then get caught in transactions around surface issues such as symptoms, medication, side-effects and compliance. This can be never-ending. If the ‘patient’ does not want to take the medication, there can be battles to make it happen, and to convince the person s/he is ‘ill.’ This is the beginning of chronicity.

Much of the resources of mental health services are spent on these activities. Families are coopted to convince their loved one to believe in the diagnosis, to convey messages that it is not their fault they are ‘ill,’ and it is not the worst thing that could happen (“it is equivalent to getting diabetes; you just need to manage it with medication.”)

These measures often are repeated over years. Families stabilise around having a sick member of the family. Expectations are lowered, and fulfilled.

In essence a pill can work to shift a crisis towards a chronic family pattern.

Some patients try to keep their non-compliance with medication a secret, which leads to ‘surveillance’ by parents, mutual distrust and arguments. These transactions further camouflage the real issues.

Some patients do not oppose the medication, but the side-effects and trials of multiple drug regimes can stretch treatment out to years.

Looking At It Differently

Perhaps some readers find it hard to consider that family factors can lead to bizarre symptomatic behaviour. It may help to consider the extreme opposite proposition.

Think of young children. If I suggested that families may treat their children in any way they wish, because it won’t have any impact at all….does that seem plausible? Obviously not.

We know that we are powerfully affected by the behaviours of people, especially those most important to us. So if a child’s mother has attempted suicide, for example, it would be understandable for the child to want to protect her. This may continue when the child becomes a teenager, or turns twenty, or turns thirty.

Does it sound plausible that families could operate in extremely undesirable ways, and this would not impact the individual child, even if now an adult? No. When family problems are apparent to the clinician, should these not be part of our formulation of why the individual has problems? It may not always be the case, but would it not make sense to consider such factors as the cause, before assuming some hypothesized biochemical cause?

For example, imagine a family who would not let their 30 year old son go out alone, have friends, or work, and insist he stay home and keep his mother company, while the father remains uninvolved in the marriage. Presume this is ongoing, yet the son is not allowed to comment or complain. Would we expect the son to be unaffected by this arrangement, and be happy and contented? No.

This is extreme, but does happen. And versions of the above can easily be seen in mental health caseloads. Yet if identified at all, this is not the focus of intervention. Nor is it very likely to be identified where the patient is identified as having a personal ‘illness,’ with its implied personal treatment (ie medication.) Families seldom opt for an exploration of family functioning, when they are led to hope that a pill can improve the problem. If clinicians do not recognise the relevance of contextual factors, they will not work to change them and thus improve the dysfunctional behaviour.

Conclusion

Haley’s ideas and others have potential, but the dominance of the ‘illness’ construction drowns out most possibilities of alternatives being tried and developed. Psychiatrists would likely face malpractice suits if they deviated from the customary treatment of psychosis. Until there is widespread and regular criticism of the ‘illness’ idea, alternatives will be underutilised.

One attraction of Haley’s ideas is the optimism that families can be helped to sort out their difficulties without singling out an individual, calling that person ‘sick’ and medicating him/her with resultant stigma and side-effects (some of which can be life shortening.)

What are the consequences for patients if we persist with the idea of a ‘personal illness’ independent of the context?

The individual may remain caught. The parents may remain unaided. The attempts by staff to assist the symptom bearer can often be of limited use, and fraught with setbacks. Frequent staff failure will likely lead to burnout, cynicism and limited capacity to assist clients. Then we resort to attempts at controlling clients’ behaviours, which is often futile.

Wouldn’t it be great for staff to feel they have the skills to intervene effectively and be optimistic with every encounter? With frequent successes how would that impact on staff’s interactions with clients and families? Imagine staff morale and enthusiasm.

Some find Haley’s hypothesis unpalatable; but the reverse – that the family/parents’ life is not at all relevant – is untenable.

Some clinicians express the fear that Haley’s approach may make parents feel blamed. Care does need to be taken. Families do the best they can. It does not assist anyone for parents to feel guilt; they need to be helped to be effective so they will feel better too.

Parents are essential to the success of therapy and Haley works to keep them on side. If there are underlying problems the parents are aware of them; we should assist them rather than being frightened of upsetting them. The alternative is often long-standing disability for the young adult, which also has major consequences for the parents.

(The End)

References

1. Jay Haley, “Leaving Home: The Therapy of Disturbed Young People.” (Second Edition, Brunner/Mazel, 1997)

2. Cloe Madanes, “The Prevention of Rehospitalization of Adolescents and Young Adults,” Family Process, 1980. pp 179-91.

Table of Contents

• Ralph & Sandy
• Labelling can affect beliefs
• Beliefs can affect outcomes
• Mental Health Services
• Beliefs versus Facts
• Fostering Positive Expectations
• Biological Explanatory Model
• Linguistics – Language is powerful
• Verb Tenses
• Nominalisations
• Lost Performative
• Does being mindful of language make a difference
• Summary & Conclusion

Ralph and Sandy were on the verge of separating again. They had been together a number of years but were having serious marital problems. They cared for each other but Sandy did not know if she wanted to remain in the marriage. She was depressed and crying frequently. Ralph was too bossy, and often angry, which he admitted. Not surprisingly there was not much sexual intimacy as they did not enjoy it. They came to see Steve de Shazer, a therapist and author on “Solution-focussed therapy.”

Prior to this therapy, Ralph had been in therapy for 14 years for his “voices” and had been diagnosed with paranoid schizophrenia for which he took medication. Sandy had been in therapy for 9 years for her “obsessive-compulsive illness.” Despite their therapy Ralph’s voices were frequent, and Sandy was unhappy, unemployed, and on the verge of separating.

They were used to therapy and talking about their ‘illnesses’ and so this could easily have become part of the conversation in therapy again. However, in “solution-focussed therapy” the focus is kept firmly on what is already working, or even partly working; exploration of problems is definitely avoided.

The therapist pays very close attention to the specific outcome the client desires; the therapist attends in great detail to all the client’s positive behaviours. This remains the focus of each therapy session. If the client mentions difficulties and failures the therapist steers the conversation back to any partial and momentary successes.

The rationale is that there are two possible pathways…a success pathway and a failure pathway (a helpful path and an unhelpful path.) The therapist wants the client to think, talk and behave according to their success pathway. The more people think those ideas, the less ‘air time’ they give their negative thoughts, and the less they entertain them and fulfil them. To have clients track their progress they are routinely asked to rate progress towards their goal on a simple scale of 1 – 10.

During five sessions spaced over eight weeks, Sandy and Ralph reported many changes. The frequency and enjoyment of sex increased; Ralph changed from being so bossy; Sandy was smiling more and feeling happier. She had described herself as “very depressed for the last 2 years,” but she reported moving up from 0 to 7 with 10 as the goal.

The frequency of Ralph’s voices had declined from the peak at 10, to 4, with 0 (the goal) standing for silence. He experienced anger less often. The therapist suggested an experiment of “pretending not to be angry” and Ralph found that effective “at least 95% of the time.” As a couple, they rated the week before the fifth session as between 6 and 7 (with 10 as the goal.) (Reference: Ch 12 Case Example Eight, “Putting Difference to Work,” by Steve DeShazer, Norton N.Y. 1991)

This therapy had not been completed prior to the publication of the book. Therefore it is not possible to know if the changes were permanent. However, the changes reported are the norm for this type of therapy.

It would be so customary in the present age for Sandy to be diagnosed and offered antidepressants or “mood-stabilizing” medication. And given the continuing frequency of Ralph’s voices (and “delusions of reference,” mentioned in the book) his medication might have been increased or altered. This would delay improvement while everyone waited to see the effect.

Instead the therapy generated improvement in their stated goals, including a reduction in the auditory hallucinations. How much better it is that medication was not the first intervention tried. Reading the book one sees that changes began from the first session; and they learned how to solve such problems. Even if medication had been used, and side-effects had not worsened their problems, would it have assisted them towards self-mastery? Would it have generated hope that they could learn to solve other difficult problems alone?

Labelling can affect beliefs

In 1968 a classic experiment in the field of education was published [ROSENTHAL R and JACOBSON L (1968) Pygmalion in the Classroom New York; Holt, Rinehart and Winston] showing that teachers’ expectations of students shaped the results of their students. The experimenters gave an intelligence test to all of the students at the beginning of the school year. They then randomly selected 20% of the students and reported to the teachers that these 20% were showing “unusual potential for intellectual growth” and could be expected to bloom in their academic performance by the end of the year. At the end of the year the students were re-tested and those labeled as “intelligent” had shown significant improvement over those who had not been singled out.

Subsequently many similar experiments have been conducted which reinforce and extend these findings. Put simply, beliefs make a difference. When teachers expect students to do well, they tend to do well; when teachers expect students to fail, they tend to fail.

Although there must be benefits to assessing people and placing them into groups (such as measuring effects of interventions between similar groups) no-one is likely to argue that labelling school children as “dummies” or “morons” would be a good idea. We know that we want children to have a good feeling about themselves and a positive self image. To get the most out of our children we would want them to think they have capabilities not limitations, and so most people know to praise successes and encourage small steps that might lead to success.

Beliefs can affect outcomes

In the sporting world there are countless stories of people excelling. It is accepted wisdom that psychology makes the difference between performing well and being a champion. Coaches and winners emphasize the end prize, knowing that visualising the result is an essential component to winning. Athletes mentally rehearse their skills; their focus is on what they do want, not imagining failure and mistakes.

Personal development books which write about people overcoming adversity don’t always show the person having the inner conviction that they can achieve their goal; but the people do persevere, and they do grow in conviction as they take risks and achieve successive steps. They always have failures, but they learn from them, and are prepared to fail again because their goal is important.

People, who succeed, have the right beliefs. Is there anyone at the top of anything, who believes that they cannot do what they are good at? No. Do they doubt themselves some of the time? Yes…but to get back to the top of their ability they (or those who support them) remind them of their successes, they recapture it and visualise it and get back into their pathway of success.

Mental Health Services

In mental health services, we want to build on peoples strengths and empower people towards makings changes. At the same time diagnosing illness is based on categorising people’s symptoms into illness labels. Let us look at whether this is supportive of the patient reaching their potential in recovery, or if it is limiting. Don’t diagnostic categories inherently attribute expectations to people’s future potential? And doesn’t this inadvertently coach people to limit them? Pessimism needlessly results, and is part of psychiatry’s historical legacy. Many clients surpass psychiatry’s predictions, temporarily or permanently, but the professional mindset persists. Labelling stops us from providing maximum help to troubled people.

Ralph and Sandy above are an example where it would be easy to be pessimistic about their prospects, but in four or five sessions so much had changed. Instead of hearing their detailed problems, everyone can quickly become impressed at their strengths and abilities. This can caution us that regardless of the labels people may change quickly, if we only have the tools that are suitable.

The “labelling experiment” told above was about ‘self-fulfilling prophecies.’ What people believe, often will become reality. It is important therefore to appreciate all the beliefs we offer to others and not mistake them as facts.

Beliefs versus Facts

Differentiating beliefs and facts is already a focus in psychiatry when dealing with individual clients. For example, efforts are made to determine if the person’s story is delusional or ‘real.’ The same distinction between fact and belief can usefully be applied to the practices of clinicians. Let us consider diagnostic categories. These are very much labels with inherent beliefs and limitations.

It is self-evident to some that such categories are only ‘constructs.’ In my opinion too few understand this and the implications. For example, ‘depression’ is a concept, but many people would argue strongly that it exists, that it is ‘real.’ It depends what people mean when they say ‘real.’ To speak precisely, people ‘feel depressed,’ or stated differently they ‘depress themselves’ by virtue of the way they think and act. Yet if one was to say that depression or schizophrenia or mental illness does not ‘exist’ one may well become embroiled in an argument; at least an explanation would be required.

If one forgets that the label is a concept, one might find it hard to reconcile the experience of clients who exceed the expectations that are connected with their diagnoses. For example, many people recover from their severe difficulties without medication. These exceptions may tell us something about people’s resilience and ability to recover.

However many professionals do not heed the significance of these exceptions, and important knowledge is lost. Instead, what would happen if these exceptions are captured by staff, and used to reappraise the pessimistic theories and expectations commonly attached to diagnostic categories? We might form the view that recovery from serious difficulties is achievable for everyone, if we just find the way to be helpful.

There are exceptional outcomes similar to Ralph and Sandy in the therapy literature. There are so many I should not refer to them as ‘exceptional.’ Individuals often surpass professional expectations. How can we foster that? What do they tell us?

FOSTERING POSITIVE EXPECTATIONS AND NOT NEGATIVE ONES.

Step back to facts versus beliefs. Professionals must be vigilant. When staff, clients and families are not mindful to differentiate between facts and beliefs, they risk taking as ‘truth,’ things that may only be beliefs, and limiting beliefs at that. For example, many people believe that schizophrenia exists, in contrast to it being a concept. Consequently many people have come to believe that they have a life-long ‘illness,’ and that they will need medication for the rest of their lives.

If a client takes this belief to be fact, it could well become a self-fulfilling prophecy. How difficult might it be for a person to really believe something different, if professionals are saying the opposite? And more difficult if the professionals have convinced the person’s family members and friends? Why not leave room for the possibility that people do exceed the expectations of the professionals? Why not leave room for the possibility that the professional opinion may change with more information coming available? This has happened before in mental health, many times.

The belief that schizophrenia exists and requires long-term medication conflicts with other experiences – for example, that some people get better despite ceasing medication against their doctor’s advice. Furthermore clinical trials show that many clients improve when they receive placebo medication. People are capable of much more than is commonly discussed in psychiatry. When one mistakes beliefs for facts people may be discouraged from trialling their own pathways and finding something better than what was offered them by the ‘experts.’

Biological Explanatory model.

Professionals often confuse beliefs and facts. Mainstream psychiatry is currently biologically driven, and the main explanatory model used is that of a biochemical imbalance in the person’s brain. This model dominates the treatment of clients in many settings, leading to the almost automatic prescribing of medications, and a lack of curiosity for alternatives. Yet the explanatory model is classically a belief, and is not universally accepted as proven.

If one was to ask the psychiatrist for the proof, they would not be able to tell you what your current ‘biochemical balance’ is, nor what the ideal should be. There is no such data. Yet because this belief about the causation of ‘mental illness’ is so widely held, few think to ask these questions.

The biological explanation shapes the treatment clients are likely to receive, and can blinker other possibilities. [Caution: These paragraphs should not be taken to mean that clients should cease or never begin medication; nor is this an endorsement of medication. This is an exploration of some of the factors influencing professionals trying to help clients who experience serious difficulties in their lives. The aim of this article is to widen perspectives and so offer more choice to professionals and clients.]

What happens to beliefs amongst mental health staff when some clients cease their medication, get better and stay better? Does that provoke us to question the dominant messages that are delivered to clients? Are we encouraged to explore the exceptions and ponder what it is that we don’t yet understand? Are alternative practitioners and methods (such as family therapy) which operate from different belief systems invited to share their perspectives in an ongoing manner?

How are we using our professional training to be curious and create more avenues to help clients? Will we stop labelling, and become careful about the beliefs we deliver to clients? When clients understand the limits to our professional knowledge they may feel empowered to share their ideas. If we listen to them, where might that lead us?

LINGUISTICS:- LANGUAGE IS POWERFUL IN INFLUENCING CLIENT OUTCOMES.

Despite working for 20 years in mental health services I have not heard discussion about the following knowledge. It is common sense and can transform the interaction between clients and professionals.

Just as labelling is potentially damaging to clients because of its capacity to create limitations in the thinking of staff, clients and families, there are other equally restricting ways that people use language, without being aware of the limiting effects. Becoming aware creates more possibilities.

Since this article is chiefly focussed on the power of beliefs, so too will this brief look at linguistics. I will cover “verb tenses,” “nominalisations,” and “lost performatives.”

VERB TENSES

Verb tenses and nominalisations can insidiously create the expectation that certain experiences will continue. This largely happens through presupposing certain things. For example a clinician may use the present tense and ask, “I understand you are feeling depressed; tell me about that.” Alternatively s/he may ask, “I understand you have been (or were) feeling depressed….” This leaves the present experience undefined by the clinician, and the client may be having a different experience at that moment which they may talk about. Does the clinician want the client to have the “depressed” experience more often? If so, then mentioning it and inviting the client to talk about it will most likely achieve that!

But from sports psychology, we know the more we focus on a particular behaviour and feeling, the more we are likely to create it. So the aim would be to invite the client to talk more about better experiences. And from the story of Ralph and Sandy we can see that positives can be amplified and snowball into more of what is desired. In contrast, talking of struggle, failure and difficulty can also snowball and become large in the client’s mind.

The clinician can use several forms of the past tense. They have different impacts, some moving the problem experience (of being depressed) further into the past than others. For example, “you have been feeling depressed; you were feeling depressed; you were depressed; you had been depressed.” By using the past tense the clinician invites the client to create a different experience (“What are you feeling now? Or, “What do you want to be doing/feeling instead?)

Changing verb tenses needs to be done skilfully and respectfully, rather than ignoring a client’s wish to talk about their recent or present experience. And changing a sentence is not a solution in itself. It is an ingredient in conversing therapeutically. It has power because it does not presuppose their experience at that moment is the same as the past, even the past of a minute ago! And as stated above, shifting their problem experience to the past opens up the present to be anything. The clinician then can assist the person to create their experience at that moment, and jointly anticipate what the future may be.

In contrast, if the clinician uses the present tense when talking about problems, it invites the client to focus on their problem as a current experience. By reminding or recapturing that experience they are giving it more ‘air time’ in their life. It may grow stronger as a result, or seem to be recurring or inevitable, rather than actually the result of what they do mentally/behaviourally and what others also do (for example, clinicians and family members asking about it.) Have you ever had the experience of wishing people would stop talking about something, of not wanting to be reminded of it further? Sometimes it is easier to move on into a better future if we are not pulled back.

NOMINALISATIONS

Nominalisations are nouns; not just any nouns. They come from “nominalising a verb,” which means turning a verb into a noun. For example, ‘deciding’ is turned into ‘decision;’ feeling hungry becomes ‘hunger;’ hallucinating becomes ‘hallucination.’ Nominalisations are not concrete things, such as those things we can carry or shift (eg chair or table.) Depression is another nominalisation, from the verb, ‘to feel depressed.’

We will never converse without using nominalisations, but being mindful that we are using them has some value. For example, some people talk of “my depression” – this implies that it exists and has continuity; it is like it is alive and is always part of their life. In contrast phrasing it as a verb, “I am feeling depressed,” does not imply a ‘condition’ and leaves open the possibility that I can change at any moment.

Does ‘depression’ exist? Interestingly there used to be a category of depression called “Agitated Depression,” where people were agitated, unsettled, unproductive and troubled (evidenced by not sleeping, or managing their daily responsibilities etc.) Strangely these people, by their own report sometimes did not report feeling depressed, yet they were labelled with “depression.” Diagnoses are categories which clinicians and scientists create and apply for specific purposes. People’s experiences are so varied but there cannot be infinite categories; so people are put into the one that fits the best. ‘Depression’ does not exist; it is a category.

Yet when one believes that ‘depression’ exists, they and the community generally come to think that it is something, rather than something you do. When you think carefully, a person feels depressed. It is a verb, which by definition is an action. ‘To feel depressed’ is something we do (ie we think.) We think about something in a certain way and we feel bad. But some people are not very good at recognising what they are thinking that leads to them feeling bad – they deny they are thinking anything in particular. So some people believe that there must be some other cause. This supports enquiries for some biological cause. But rarely does anything biological show. Sometimes people with low thyroid functioning can report feeling depressed. (However some with low thyroid function do not feel depressed.)

When we describe our experience (or that of others) with verbs (eg I am feeling depressed), we describe more precisely. When we move to using nominalisations (I’ve got depression) we are more removed from precisely what the person is experiencing (eg are they agitated, not sleeping, grumpy, unhappy, unmotivated etc?) Grouping clients into categories can serve some scientific and research purposes, but conversing in less precise ways is likely to move us away from the individual’s precise experience.

Grouping clients into categories can serve some scientific and research purposes, but conversing in less precise ways is likely to move us away from the individual’s precise experience.

This will often deprive us of options to tailor interventions to the needs of individuals. If we know they say ‘depressed’ and mean ‘unhappy’ we can explore what has been happening and what they can try differently. If they mean they ‘have been unmotivated,’ we can explore what they sometimes do feel motivated about, what already works for them, and how they may incorporate that more in their life.

Too often a uniform ‘fix,’ usually in the form of medication will be the dominant offering to people who are suffering. Medication usually entails the idea of having an ‘illness.’ This word is another nominalisation, from the verb, ‘to feel ill’ and has an inherent danger. Will the person feel empowered by this description? Will it encourage them to consider all the factors that are making them feel what they are feeling? Will they feel they have their own answers and search for ways to improve?

Along with “having an illness” the person will often be told s/he has a biochemical imbalance in the brain, causing the ‘illness.’ An ‘imbalance’ is another nominalisation, from the verb, ‘to balance.’ When developing concepts like these, we are not talking about facts, but ideas. Again, an inherent danger is that people may believe such ideas uncritically, limiting them as a result.

I am not saying we should never talk like this, but I do think there are better ways. With respect to brain biochemistry, there would be a range for each of the chemicals found in the brain, but that is different than to say there is a ‘normal’ quantity found at any location, and that professionals know what it should be. Some doctors have offered a different metaphor, of the brain being in a “bath-tub” awash with many chemicals, which will have different concentrations in different areas at any one time. That sounds very different than a ‘balance.’

If we believe there is a balance and an imbalance, that may shape us to think in a certain way. If we recognise that ‘balance’ is a nominalisation we can remind ourselves to be sceptical and open-minded, rather than accept limiting categories and belief systems.

LOST PERFORMATIVE

The ‘Lost Performative’ (or lost performer) refers to the fact that when we are asserting something, or repeating something, there is an ‘author’ of the assertion or fact, which is often left out. For example, “Mental illness is caused by a biochemical imbalance in the brain.” Who says so? The ‘authority’ or source behind this remark is not stated.

One has to be alert to realise this has been omitted. Once you are aware, you realise you do not need to believe it at face value; you can seek more information.

The lost performative is about identifying assumptions and increasing awareness of the distinction between facts and beliefs. I don’t think that people are going to start prefacing every statement with, “I believe….;” or say, “I read that Dr X has shown such and such and I believe that it is proven as fact.” But contrast that with statements in ward rounds, “Mr R has severe depression, and he needs an antidepressant.” The doctor is using a high level of abstraction (depression / mental illness) which is far removed from the client’s actual experience. We don’t know what information the speaker has collected and appraised. We don’t know what knowledge the speaker has about alternative approaches. We don’t know if the speaker has identified moments where the client is not depressed, or whether the speaker has seen these but disregarded them as not significant. We don’t know if the speaker is talking in a context of being new to the profession, in a ward round where the experienced doctors would expect and ‘approve’ of the standard descriptions and recommendations. We don’t know if the speaker has doubts about the scientific validity of the clinical trials that determined a particular drug to be effective.

Without explicitly acknowledging “Mr R has severe depression…” is an opinion, people can forget this and act as if it is the truth. Clients and families often have less capacity to critically listen and identify these linguistic traps, as they are in new territory and may defer to professional knowledge.

With respect to medication in psychiatry, drugs are approved for treatment after complex processes called clinical trials, which aim to show that the new drug makes a useful difference to a psychiatric ‘condition’ such as depression. Once a drug is in use, clients are likely to assume that it has been proven. Yet this is a complex matter; the scientific method never proves a theory, but at best shows that some hypothesis is likely or not. In complex experiments such as clinical trials many assumptions are made, which may be wrong and cast doubt about the conclusions reached. Some concerns that have been raised in relation to such trials are listed below.

- Was the clinical trial designed and conducted in an unbiased manner, by truly independent researchers?
- Since the drug would have been aimed at a particular condition, were the subjects truly similar so that the drug was tested for the intended condition?
- Were a number of clinical trials conducted for the drug? If so, did they all show the drug to be effective? Were all of the results made available to the public for review and critical appraisal, or only the favourable results?
- How much difference did the drugs make? Have the benefits been over-stated and the side-effects under-stated?

I do not wish to discuss such issues in this article. I only point them out to alert people to the possibilities of error. From the moment one begins to use a nominalisation such as ‘depression’ one opens the way to discussions and research on abstractions. When considering the conclusions of drug trials will one remember to regard them as tentative, given they are based on concepts which differ to the lived experience of people?

DOES IT MAKE A DIFFERENCE TO BE MINDFUL THAT PROFESSIONAL KNOWLEDGE IS OFTEN BASED ON NOMINANLISATIONS?

I recall a keynote speaker (psychiatrist) recounting the experience of the parents of a young man who had suicided. They had been told by a different psychiatrist that the young man’s condition of schizophrenia was genetic. The genetic explanation is a mixed blessing. It is presumably used to alleviate blame in the individual sufferer; “It is not your fault, it is something you inherited.” The sufferer may be freed from blame, but the parents may or may not be so freed. I disbelieve the genetic propositions. When I read the criticisms in the literature (Ch 1 Biological Psychiatry: Science or Pseudoscience? in “Pseudoscience in Biological Psychiatry: Blaming the Body” by Colin A. Ross & Alvin Pam – John Wiley & Sons, N.Y. 1995), I found the authors’ arguments compelling, and they did not even include the extra doubts that linguistic considerations would add.

Does it make a difference to remember that conclusions in psychiatry are premised on nominalisations such as depression / mental illness? If the person suicided because he felt despair, and he felt this from believing his problems were genetic, which he may have interpreted as “life-long,” that may have been damaging. Rather, if he understood that he had difficulties that needed solutions, and no-one had attached a label with “life-long” connotations, it may have made a difference.

To mentally note the ‘lost performative’ and think, “This psychiatrist believes that my problems are schizophrenia and are genetic,” may make a difference. But it is only likely to make a difference if the person is supported by others, who likewise have a linguistic awareness and can distinguish beliefs from facts. Otherwise the individual is likely to be out of step with staff and may be regarded as difficult or “lacking insight.”

From a simple and common example of ‘depression,’ we can recognise that it is easy to depart from the actual experience of the client and think in terms of abstractions (research, genetics, proof, illness.) These abstractions can invite one to view certain ideas as a fair representation of reality, especially if ‘everyone’ is thinking and talking the same. It is important to remain aware that the concepts shape us powerfully, just as a simple change of verb tense can have an impact.

It is important to remain aware that the concepts shape us powerfully, just as a simple change of verb tense can have an impact.

One last concept from the field of Linguistics, “E-Prime;” basically English written and expressed without the “to be” verb (is, am, are, was, were, be, being, been.) E-Prime teaches that when we use the “to be” verb it has the connotation of permanence, finality, completeness (eg he is weak, she is lazy.) However in the real world everything changes. We may describe people as constant, but everything changes moment by moment. If we fail to recognise this we will continue to assume our descriptions equate to reality. The more our thinking and describing differ from reality, the more error there will be in our conclusions and our actions. (Another example of this divergence from reality is nominalising verbs, discussed above.)

In sport they talk about “the one percenters,” referring to the small details that make the difference between good, and great. In “thinking,” there are also the one-percenters, and they too can make a difference in our lives.

As an example of E-Prime (from “Working with E-Prime,” by E. W. KELLOGG III AND D. DAVID BOURLAND, JR. (3) http://learn-gs.org/library/etc/47-4-kellogg-bourland.pdf), “If you saw a man, reeking of whiskey, stagger down the street and then collapse, you might think (in ordinary English) “He is drunk.” In E-Prime you would think instead “He acts drunk, or “He looks drunk. After all, you might have encountered an actor (practising the part of a drunken man), or a man who had spilled alcohol on himself undergoing a seizure of some kind, etc. Instead of simply walking by, you might look more carefully and send for an ambulance.”

In mental health, a client may get labelled as passive-aggressive. The implication of such labels is that the person is this way, not that s/he just acts that way on occasion. In most contexts of that person’s life s/he may act fine; but in the treatment context the person may act differently, perhaps influenced by the imbalance of power with professionals. To add this label to the client may then shape how people see that client, affecting the choices and experience received. All labels have consequences.

All labels have consequences.

E-Prime alerts us to the tendency to create a static view of people and situations. We are always in a process and as such situations should be viewed as changeable. Thus we are not in a “frozen universe” but one we constantly manufacture with our language.

SUMMARY

This article began with the story of Ralph & Sandy on the verge of separation; therapy led to many changes which may commonly have been tackled with medication. Then labelling was discussed and how it can lead to self-fulfilling beliefs. We would not use labels such as ‘moron’ or ‘dummy’ as we recognise it may harm or limit the person. Yet we apply labels to clients of mental health services, and this can be limiting in just the same way. There are choices. For example, Solution-focused therapy is intrinsically optimistic, driven by clients’ goals, and does not view people as limited. Psychiatric labels focus the client, their family and the staff on symptoms and problems. The focus we choose will shape processes and outcomes.

From sport and life generally we know people can triumph. Focussing on goals and progress is a key; so too is developing and holding the right beliefs.

Negative labelling’ shapes and reinforces beliefs about limitation instead. It creates pessimism about clients’ potential. The pessimism is further fostered by ideas about ‘biological illnesses.’ The study of linguistics reveals that such descriptions are not identical to reality. Nominalisations shift us away from accurately describing experience. Verb tenses impact us by shifting our attention, often without our awareness. The ‘verb to be’ also creates a static false view of situations and problems. Collectively these ‘errors’ result in the established ideas of mental illness, biochemical imbalances, medication being essential, and clients being disabled and limited, perhaps for life.

CONCLUSION

Remember a time when you saw a movie or heard a story of outstanding achievement; you felt inspired, you felt you could do more than you previously thought. We all shift our expectations according to our mood. Our beliefs alter. If we sustain our new beliefs we will attain more. To sustain new beliefs people generally need encouragement or mentoring. The mental health services could be instrumental in creating hope of change and growth at times of crisis.

Mental health services unintentionally give mixed messages. They encourage people to recover, but offer them pessimistic labels with inherent limitations. This does not make sense. Many professionals have been limited by their beliefs. Fortunately some clients surpass the diagnostic categories and professionals’ beliefs. We can learn from these examples. We can be curious about their achievements.

Current explanations of biochemical imbalances can be limiting. Therefore we need to review what we believe. We need to clearly distinguish between facts and beliefs. We need to be mindful of the language we use and how this inadvertently distorts our professional views. We need to examine the view of clients we formulate, and leave behind the pessimism engendered by the biological paradigm.

Psychological ideas and real life examples offer optimism; linguistic ideas offer the chance to be aware. Together they can be a catalyst to examine the past and create choices for the future. With our skills and our training we have more to offer than we have managed so far. Our clients need intelligent, reasoned thinking, not labels.

We must re-think. We must critically examine the illogical ideas and practices that have continued without thorough discussion. With awareness of the power of our words we can do better. By leaving behind beliefs about limitations, we can be hopeful. And when we bring hope to our meetings with clients, greater things can be achieved.

(The End)

Further reading regarding the effect of labeling in the classroom – http://fcis.oise.utoronto.ca/~daniel_sch/assignment1/1968rosenjacob.html