New Foundation for Excellence in Mental Health Care Project in the Works

Gina Nikkel, PhD
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The Collaborative Pathways project at Advocates, Inc. in Framingham, MA has received an FEMHC grant to develop and evaluate their highly innovative new program. This community-based team approach provides a safe, welcoming, and respectful environment in which young people who are experiencing early episode psychosis can explore with their families and other natural supports all the options available for dealing with their experience. The new initiative incorporates immediate help, person-centered care, and intensive, ongoing support with shared decision-making about the use and timing of psychiatric medications.

The Collaborative Pathways approach was inspired by the work of Dr. Jaakko Seikkula and his team at Keropudas Hospital in Tornio, Finland and of Dr. Mary Olson in the US, in developing “Open Dialogue,” which has achieved impressive outcomes for early psychosis and other challenging conditions. The Collaborative Pathways team, led by Dr. Christopher Gordon, a psychiatrist and Associate Clinical Professor of Psychiatry at Harvard Medical School, has completed one year of an anticipated two-year training program with Dr. Olson at the Institute for Dialogic Practice in Haydenville, Massachusetts.

The team also is completing additional training in Tornio in August 2012. The Collaborative Pathway team hopes to emulate the Open Dialogue values of responding to people experiencing early-episode psychosis with compassionate listening, respect, and optimism, and to offer medications judiciously when desired or needed, consistent with scientific evidence and as part of an overall approach to recovery. Learning from the successful long-term outcomes of Keropudas Hospital, the Collaborative Pathways team hopes that demonstrating the safety of this approach similarly will help improve outcomes for young people in the US who are experiencing first-episode psychosis.

This project builds on the longstanding and pioneering commitment of Dr. Gordon and his team at Advocates to recovery-oriented thinking and practice as the basis of effective mental health care.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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Gina Nikkel, PhD
Expect Recovery: The executive director of the Foundation for Excellence in Mental Health Care tells of how the foundation is partnering with private philanthropy to discuss the implications of Anatomy of an Epidemic, and create a new mainstream for mental health.

13 COMMENTS

  1. Psychosis is just a pseudomedical slapped on a crisis where someone is thinking and feeling things someone doesn’t want them to think or feel. Affixing the “early” or “first episode” prefix to it, just further compounds us deeper into the mire of viewing these experiences as part of a grand “illness narrative”, and while the program described sounds less and probably is less damaging than mainstream psychiatry, and good, I’m all for that, when I see the way it is peppered with management language, and the artifice of technocratic intervention into something so human and profoundly individual, I weep for this world.

    I’d never be part of such a program. Anyone who prejudges my problems as a “health” problem, or the “first episode” in presumably a “course of illness”, is someone I’d run a mile in the other direction from.

    “to offer medications judiciously when desired or needed, consistent with scientific evidence”

    Is this code for forced drugging? If they are not desired by me, am I going to be subject to someone else’s interpretation of when they are “needed”?

    When a response to human problems of distress and crisis as said to require rigorous standardized training, needs to play on the prestige of Harvard Medical School, when it is filled “teams” of people with M.D after their name, when it is littered with the soulless management speak that infects the corporate world, and yet claims to be ‘person centered’, excuse me while I go and forge my own plan for a person centered response to any future crisis with people who actually know me.

    The Finland stuff IS obviously much, much, much, better than the standard crisis psychiatry intervention, and if we are going to live in a world that thinks there is such a thing as experts on the crisis a young person they’ve never met is going through, then let this positive move continue. I’m glad these people are training in Finland, I’m glad they won a grant, I’m glad it wasn’t funded by the government or pharma, good, it’s good, but it’s not what I’d want.

    In a crisis I wouldn’t want to be anywhere near anyone who thinks nothing of the medicalized phrase “first episode psychosis” coming out of their mouths.

    But if anything can play a small role in stopping the depraved violent ordeals governments put young people through when they label them psychotic and detain and drug them, I’m supportive. I just wanted to express the reasons I wouldn’t want to be in the room with anyone who interprets what I’m going through as a “medical” event if the S— ever hit the fan again.

  2. “In a crisis I wouldn’t want to be anywhere near anyone who thinks nothing of the medicalized phrase “first episode psychosis” coming out of their mouths.”

    This wonderful statement should guide the development of a crisis response alternative for people like A. Put this on the brochure, above the front door, on the letterhead, etc. Let it guide hiring decisions and operational decisions.

    I know programs like this do exist, but we need many many more. MIA has featured Cornwall and others.

    Non-medicalized options for persons in severe distress/crisis should be the norm not the exception.

    • Thank you, I want to make clear though, that when I said that, it was nothing against the author of this piece, Gina Nikkel, I’m sure most days, in a non-crisis, I’d be more than happy to meet her and I’m sure she’s a personable person.

      It was I hope clear, that it was a statement about how very important it is, that only people who share my views to a large extent, are who I feel could guide me in a crisis.

      I have plans in place, to a large extent, on what to do in a crisis. I’m very fortunate to have been able to cultivate a wonderful understanding on this issue with some family members and friends, for instance. I am well aware some people don’t have that kind of understanding. In fact, tragically, all too many people have family members who are gunning for their “loved one’s” rights to be immediately stolen away in a crisis.

      • Could you describe in a bit more detail, what you think the best approach would be for a person who comes to us (meaning the current established system) for care when there has not yet been the opportunity to have the people in place who have developed the kind of understanding that you have found to be so helpful?
        I ask this with a spirit of true curiosity and interest in your opinion; this is not at all meant to challenge what you are saying.
        I may be one of the doctors on this site who you and others may be chagrined to have here, yet I am not at all unsympathetic to what you and many others are suggesting. Getting people to the help they might need and prefer, however, is often a challenge.

        • My primary reason for having plans in place for a crisis to be safe from the “current established system”. If someone is “coming to your for care” they obviously believe their thoughts and behaviors, feelings, are a “medical problem” and it is their right to take that leap of faith and see where the chips fall.

          If “coming to you for care” includes people handed over to you by force, then there is nothing you can do to stop many of them being brutalized and traumatized for life.

          It was not the ultimate concern of abolitionists to offer a utopian solution on how ex-slaves would use their freedom. It is my primary concern that freedom be won in the first place.

          I didn’t “have the opportunity” to establish a solution for myself in the beginning, because that opportunity was stolen from me, by the government, and those in its employ who stand ready to rob those opportunities from people by using forced one size fits all interventions.

          I’m not chagrined to have you here. I believe for every coercive psychiatrist that is here, tens of thousands are not here, so it is good that you are here, and willing to expose yourself to the survivors of your profession’s actions.

          Now, and forever, I would never go to a doctor for anything other than a problem with my body. What I can say is that it doesn’t matter nearly as much what the solution, what the assistance, what the intervention is, so long as it is not something we DON’T want.

  3. I am not sure what I think of what Gina Nikkel wrote. Surely it is better than what we usually have now.

    But I commend the person who says she is very skeptical of it.

    There are a lot of mental health professionals on this website who seem to think of themselves as our saviors, whether we want to be saved or not.

    Their attitude toward us (psychiatric survivors)is very condescending. I view them not as allies in our movement for our own liberation, but as just factions within the mental health professions. They want to be the ones running the system without really changing the disrespectful attitudes that we constantly have to cope with.

    And yes, I am sick and tired of the deference people show toward anyone connected with Harvard. Harvard has been an oppressive institution in America for 400 years now. Being a Harvard graduate is not a reflection of intelligence. It’s an indication of how much money you have.

    We need to develop a supportive culture for ourselves, and places where people can get real help. And we don’t need any more condescending saviors.

    • Thank you for your honest post here. You’ve put into words what I’ve been feeling ever since I started looking at things here on MIA. And the minute you disagree with or call into question something that one of these professionals stated they go into high gear and carry on about how you’re attacking them. They seem to think that we should trust them simply because they’re posting on MIA. No matter what kind of doctor you are, you must prove to me first that it’s worth my time to listen to you, let alone accept, hook, line, and sinker, what you’re posting.

      Thank you again for your post.

  4. What I have read of Open Dialogue sounds very good. As far as I know the drugs really are given in collaboration with the person in distress and there family. However the separation between the person in distress and the professionals is somehow preserved and I can see how this might be a problem for some, especially if they have experienced the damage of the psychiatric system.

    As a long time moderately distressed person who has used both services for therapy and a whole host of self help groups and other forms of social support I have come to some simple conclusions on therapy, counselling and other forms of social support. They all rely on forming trusting relationships between the person who is need of help and the person offering help. All forms of therapy rely on the values of understanding, solidarity and encouragement. These are what good therapists, counsellors, group workers and our good friends offer.

    I sometimes lead drama sessions on problems that communities face. I have the same values of trying to create trusting environments where we can discuss things of importance and create plays that explore the problems of the community and try to find solutions to them. Perhaps all good teachers have the same values?

    Usually I am not working with people in severe distress. When I do meet people in severe distress however I try to do the same thing, forge a trusting relationship, try to understand the person as best I can, be on their side and be encouraging where ever possible.

    What Open Dialogue seems to have done is to create a system that does these things in people’s homes. It tries to offer understanding, solidarity and encouragement to the person in distress and also tries to encourage the persons family and friends to do that too. However they are professionals working in a mental health system. They have created a two year training and use ideas that to my mind are a bit obscure, such as quoting some Post Modern philosopher when the ideas underlying what they do are probably as old as humanity.

    Both Ted and Anonymous raise the question as to whether Dr’s and the medical profession should be entrusted with offering help to people in serious mental distress, or indeed if the state should provide this service at all.

    I personally would want the state to provide help to people who are mentally distressed but probably not under the medical system. If mental distress is seen as a health problem then there will always be temptations to use medical solutions and on the whole they have always proved to be of more harm than help and they also dehumanise and de-contextualise the problems so both on an individual and societal level they are less likely to be dealt with. However I also know someone from the Disability Rights movement who is generally appalled by the help provided to disabled people who have physical disabilities, so maybe the state is not to be trusted with offering help to people in emotional distress either?

    Maybe we need a strong survivor movement and critical service providers who try to understand survivors and work along side them?

    I recently went to a conference where Geroge Lakey, a non-violence trainer who was active in the civil rights movement, as well as other struggles, was talking about strategy. He said you don’t need everyone to take up the radical position to win. You just need most sections of society to move towards your position. He also said your enemy is unlikely to move at all and that concentrating on trying to get them to change is usually not very helpful (ie don’t talk to the white supremacists, but talk to the rest of society so the support for the white supremacists falls away). Hard line psychiatrists and drug companies are unlikely to change their opinions. But service providers who use drugs in every case may decide that they don’t always need them and some workers who work with people in severe crisis might start to investigate and use Open Dialogue and some legislators might question compulsory treatment and the prescribing of ritalin and the media who promote prozac for every ill might start to question that and “consumers,” or as we say in the UK, “Service Users,” might be more critical of services and more active in campaigning for less medical services while a radical survivor movement keeps on saying that drugs are not the answer, that services are dangerous, that ECT should be banned and that peoples human rights are being abused by mainstream psychiatry.

    So I’d like to see as strong a survivor movement, supported by allies. I like to see professionals who promote Open Dialogue and such like encouraged, but not to be the core of the movement. Strategically I think this is likely to bring the most results.

    • To John H, I appreciate your very thoughtful comment, but perhaps I said something misleading if you think I believe the state should not be offering services to people in emotional distress. I do think there are places (like Soteria Houses) that should be available to people who want them. And the only practical way, as far as I can see, that large numbers of such places can be funded is through the government.

      But first we have to convince legislators and other government officials that putting such services into the hands of the Church of Psychiatry is not the way to go.

      I call it the Church of Psychiatry because it has convinced the government and the public that it works virtual miracles, when in fact anyone who pays attention can see that in fact most of its interventions are very destructive.

      So I think along with trying to develop such constructive alternatives like Soteria Houses (and of course others), our task has to be breaking the hold of the Cult of Psychiatry on public opinion and government decision-makers. I think a lot of people working on alternatives are not thinking about this, but I believe those two tasks (developing alternatives and taking away the power of psychiatry) go hand in hand.

      I’m struggling now with writing an article about this for MIA, and I hope it will stimulate further thinking on this issue with other readers/writers of MIA.

  5. “This community-based team approach provides a safe, welcoming, and respectful environment in which young people who are experiencing early episode psychosis can explore with their families and other natural supports all the options available for dealing with their experience.”

    How much will it cost the family?

    “New Foundation for Excellence in Mental Health Care Project in the Works. (Our groups elite program?)

    The Collaborative Pathways team, led by Dr. Christopher Gordon, a psychiatrist and Associate Clinical Professor of Psychiatry at Harvard Medical School. (In the consensus reality of a hierarchical nature to society, here’s proof that we know what we are doing?)”

    I’m sure the intentions are well meaning and will provide a better approach to those that can afford such a service. Yet I wonder if this is a rather “elite” facility out reach for the majority of young people suffering the existential crisis, others label psychosis?

    I wonder, if like the label, this approach has more to with defining other peoples sense of themselves than defining what that descriptive label “psychosis” actually is? Is this how human beings actually function, with a sense of self defined more by what we are not, than what we are? Do we build a socialized sense of self by projecting that need onto “pitiful” others, as Murray Bowen points out?

    In my own experience of psychosis, fear and a profound sense of threat at an unconscious level of being, stimulates my flights into euphoric psychosis, yet I struggle to articulate a conscious sense what this profound physiological dis-ease is, using our assumptive language “as if” its “objectivity” has holds any meaningful analogy for the hidden systemic interactions of the organism, affected by both internal & external environments?

    Psychosis, is a descriptive label applied by observing others and do we cover up our individual need to feel superior, by diagnosing lesser others, in our need to maintain our socialized sense of self?

    As member of the elite in an ivy league tower points out, “No one should be proud that we have a descriptive system,” Allen Frances tells me. “The fact that we do only reveals our limitations.” Instead of curing the profession’s own malady, descriptive psychiatry has just covered it up.” Inside the Battle to Define Mental Illness By Gary Greenberg. Wired Magazine.

    Cover-up seems to be what we all do, when comes to the way we actually function, beneath the self-soothing rationalizations.
    As a long term survivor, I prefer an effort to determine what so-called psychosis actually is, than the endless “us & them” debate about its treatment?

    As Paris Williams points out in his Doctoral Dissertation;
    “The Evidence Suggests that Mystical and Psychotic Experiences Both Arise From a Common Process.

    The desire to make the distinction between mystical and psychotic experiences is certainly understandable if it is believed that the most helpful interventions are vastly different for each category. What is particularly ironic, however, is that while, by definition, transpersonal psychologists believe that the root foundation of our experience is not material (Cortright, 1997), a number of the major transpersonally-oriented contributors to this topic continue to validate the psychiatric medical model category of mental illness when attempting to make these distinctions.” _Paris Williams, PhD.

    In our survivor community do we need to focus on more energy on defining what the experience actually is, rather than maintain a focus on treatment interventions?

    Personally I think a paradigm shift will only come through more clarity about the actual experience, which can be used by each individual in deeper self-realization-actualization?

    Again from Paris Williams;

    “Supportive therapy. Perry (1999) suggested that when supporting a person going through a psychotic process, it is important to keep in mind that it is not the psychotic process from which one needs to be healed—this process itself represents an attempt of the organism to heal itself from the limitations of the self-image and the world-image of the person. Therefore, the best support we can offer is to support the process itself, rather then try to suppress or reverse it; and the best way to support it is to offer the individual our “clarita (clarity) and carita (caring)” (Perry, p. 80) above all else.

    Perry’s use of the term clarity refers to our ability to be genuinely present with the person, to offer our efforts to understand and support the person in finding meaning for their experiences. In this regard, it is important to acknowledge that no amount of education or training could ever put us in a position where we know more about the meaning of the person’s experience or the experience that they need to have at any given moment than their own psyche. Our job is simply to facilitate this process to the best of our ability. Perry’s use of the term caring refers to our aspiration to hold the person and all of their experiences, no matter how challenging they may be, with respect and unconditional positive regard.”

    I believe there is emerging clarity within the latest science, as articulated by people like Allan N Schore & Stephen Porges, and to really help the younger generation, by-enlarge the most educated generation in human history. We need to leave behind old-world language, like “psyche” which is about as helpful in clarifying actual experience, as “chemical imbalance” and get more real and honest about what really makes us tick?

    Like how we say that word Evolution, yet fail to embody its essential meaning? Just why are the words “animal & instinct” purged from our socialized definitions, of what is to be a functioning human being? Why has this strange experience historically affected about 1% of humanity? What does that figure mean in terms of our evolution?

    Does an existential crisis mean;

    “One might say that the Self wants to know itself, or that God is trying to discover himself, the Anthropos we are living in is trying to wake up, the collective unconscious is trying to express itself or the universe is evolving in such a way as to make us more aware of the meaning of life.” _ Mindell (2008)

    If we change our metaphors of self-definition to “chemical” will the reality of the the Universe within, begin to make sense? Why an epidemic of divine madness, otherwise known as mental illness,at the beginning of a 21st century A.D.

    Perhaps there is a bigger picture, than the immediately obvious reality, we tend to categorize & label? That nit-picking tendency of the left-hemisphere, in search of the Devil in the detail?

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