I have just attended the 17th International Conference on the Treatment of Psychosis in Tornio, Finland. I am full of thoughts and I keep trying to figure out how I will explain this meeting to others. Tornio is the town where Open Dialogue was developed and studied. The attendees – mostly from northern Europe – include people who have been working for many years in what is more broadly called network approaches. This is all fairly new to me. I am far from an expert, in fact I am not sure I even understand. What seems clear is that this is fundamentally a humane approach to talking to people in distress.  What was wonderful about this meeting is that these individuals seem to practice their ideas in the way they live. They are humane in their interactions with one another. They are respectful of their colleagues. The entire meeting was a reflection of their work and it was profoundly stirring to me.
I want to continue to learn more. I will try to discuss topics of interest as I find the words to articulate them in a manner that seems honest. My colleague, Chris Gordon, used the term “radical humility” to describe the attitude we need to have in our work and I am thinking of that term when I take the bold step of trying to share my experiences here. I want to try and record some of what I have learned. Writing helps me to remember and to think.  I want to share this with those of you who are also curious. I am talking to the “me” of several months ago. I am thinking about what would have made sense to me then.Â
So what are we saying when we talk about dialogue and networks? One concept that was helpful was the notion of crisis perspective vs. illness perspective. When someone calls for help, the team who responds does so quickly. There is an effort to try to understand the crisis from as many perspectives as possible.  Everyone’s experience and perspective is valued and important.Â
What I just wrote is not controversial and I imagine that if I talked about this in most psychiatric circles, no one would object to this. They might even say this is what they are already doing. However, in my current practice, this work is done in the service of classifying symptoms, arriving at a diagnosis, and then developing a treatment recommendation. In Open Dialogue, this work is done because this process in and of itself is what is most helpful.
This is important. Often, what clinicians do in order to do what is considered competent work leads us to have a breach of empathy with our patients. It is often at the point of labeling symptoms that we lose the connection. I have been in this situation and could not think of a way to avoid this. I am now beginning to conceptualize a system in which there are other options.
I hope there will be more to follow. In the spirit of Open Dialogue, there is no conclusion.
Sandra,
Psychiatry is dead.
With any death comes new life.
I’m excited about the transformation, with approaches like Open Dialogue.
I only hope that we don’t miss out on using as many tools as possible that lead to self-empowerment – neurofeedback, mindfulness, nutrition (orthomolecular approach), to name but a few.
I look forward to the day when a person diagnosed with “schizophrenia” is able to decide for *themselves* what approaches/techniques/strategies they would like to use.
And I look forward to a return of the *majority* recovery we had before psychiatric drugs were unleased onto the market and bio-psychiatry had its way with temporarily vulnerable people, in the midst of crisis.
With all the talk about the need for affordable housing, more programs, etc, I look forward to the day when young people get through these episodes, and move past them… build lives, businesses, families – as healthy, inter-dependent, successful adults.
Duane
Duane
oops,
excuse the double-name typo
Duane-
I think a lot about not grabbing on to Open Dialogue as “the next new thing”. I am curious but I could not agree more on the desire that each person can have the opportunity:” to decide for *themselves* what approaches/techniques/strategies they would like to use.”
From what I have learned so far, I believe that the use of Open Dialogue can be a helpful conduit to helping someone make that choice. Many people come to me without a clear notion of what they want. They come to me in distress and this is a way to talk to a person and the people in his/her life about that distress.
Sandra,
You and I don’t always agree, but I have always appreciated your honesty and willingness to listen and *learn* to the readers on this site.
And at the risk of alienating fellow readers who want to see the present system dismantled and rebuilt (something many of us believe *must* happen), I appreciate those qualities in you.
Thank you, doctor.
Duane
I understand.
“Being with” someone is key during an acute crisis.
But, I hope we will begin to look at other approaches that help folks learn to prevent these crises from re-ocurring in their lives.
IMO, the tools involve “self-empowerment” rather than lifetime reliance on *any* paradigm.
We have ex-patients ans survivors on this site. But there are hundreds of thousands of people out there, who have had “breakdowns” as young men and women who we do not hear from.
They are the ones who broke loose from the system, went on to build “lives”… full, meaningful lives, and *never* looked back.
And, I think that for many folks, this may be the best (wisest) approach!
They’re too busy living in the *present* to have much time/energy for the *past*!
Duane
Duane-
I would add that there is another group of people who we do not here from as much here and those are the ones who have had periods of extreme distress, were treated within the current system and had good outcomes. I know that from my daily experiences. It is one of the things I struggle with since I do not know why it is OK to dismiss their experiences.
Sandra,
Re: Good experiences from the current system
Where are they?
They’re not on this site, and they seem pretty hard to find – anywhere.
Oh, sure.
They’re are a few out there who will speak highly of having been locked up and forced to take drugs – but not many.
And when it comes to outpatient psychiatry – even the 15-minute med checks (not by force), there don’t seem to be a lot of people who are pleased with the results.
Consider the fact that 1 in 5 adults in this country are on some form of psychotropic – this means tens of millions.
With those numbers, you would think that at least a million or so would be stepping up to the plate – to let the world know about how much they were helped.
But there doesn’t seem to be a million (which would be a very small percentage).
Could it be that the “treatment” causes more harm than good (at least for the vast majority)?
That’s where I’ve got my money.
IMO, that’s where the smart money is!
Duane
I answer this with some hesitation because I think whatever I say will be discounted or attributed to the power differential I have with my patients. I also can not find the initial thread from which this arose so perhaps I am loosing the train of thought.
All I can tell you is that I have been actively engaging people in conversations about the medications for a long time and more intensively in the past year. Many people I talk to are satisfied with their treatment and do not want to stop taking the medications. Most of them have no interest in websites or blogging. Maybe they are wrong or misguided or they have been mislead into overvaluing the role of medication. But I think that to discount their reality would be another trauma and not dissimilar to discounting the realities of people who report they have recovered without medications (which is what has happened to some people).
Ok, it is annoying when we run out of “reply” buttons in the middle of a thread, but here goes.
Sandy,
In regards to the people who wants to stay on the medications because they feel or believe that it is helping them, I hear you.
However, lets not forget that we know for certain that the medications cause a whole lot of side effects – obesity, diabetes, shrinking brain matter, high blood pressure etc. etc. It is an impressive list of side effects – so even if someone feels that the medications helps them emotionally there is reason to be really cautious with those medications.
Now, that said, I agree with you. If someone feels that the medications really help them, and they prefer this option to other options, then at this time I do not think we should push our agenda on them. While we might not want to “push” our agenda of getting off medications on others, we should however make certain that they are given other options, that they are on the smallest dosage possible, and that the option to taper off the medications are always available to them.
I would much rather that we spend our resources on how to go forward, and the system needs a major overhaul. I wonder how many fewer people would be put on those medications if we had a humanistic system to respond to people in crisis. And, if we offered actual kind and caring help to get their feet under themselves, I wonder if people would be on smaller dosages and stay on the medications for shorter times than what we currently see. I think it is a failure of gigantic proportions of our mental health system that so many people are on those medications – a failure that the leaders of our system must own.
I will also say this to you again, you should be very careful of your own cognitive dissonance. You have a vested interest in believing in the system you represent. If you started to really check in to how many people experienced being harmed by what you represent then I suspect you would have to go through a very dark night of the soul.
Malene
We agree on all points.
“I would add that there is another group of people who we do not here from as much here and those are the ones who have had periods of extreme distress, were treated within the current system and had good outcomes. I know that from my daily experience. It is one of those that I struggle with since I do not know why it is okay to dismiss those people’s experiences.”
What objective criteria are there for this? Psychiatrists are some of the most powerful people on the planet. The possibility of coercion pervades every relationship between a patient and a psychiatrist, its weight being especially felt in the verbal intercourse between the two, and it is whether or not the patient says he is better and at least outwardly professes to be happy with his treatment that is one of, if not the, cardinal criterion for determining improvement.
How do we know that the patient isn’t simply saying what the powerful psychiatrist wants to hear, isn’t telling a judicious lie, which is only beginning to unravel the skein of possible ways in which damage can be mistaken for improvement?
For example, I feel quite confident, based on my interlocutions with my current psychiatrist, that she would say that I had been helped by the drugs she peddles, because quite frankly I say what she wants to hear, cognisant as I am that the wrong words could lead to the deprivation of my liberty. Maybe sometimes this is paranoia, but it is paranoia with more than a grain of truth, given the ubiquity of coercion in the history of psychiatry as well as in the contemporary world.
For many patients, outer (in terms of their verbal communications) and inner submission (in terms of thought and feeling) to authority is like a survival strategy, much as it was for the chattel slave, which is one of many reasons why psychiatric slavery must be abolished and psychiatrists must be forced to compete fairly in the marketplace of ideas and services. Patients must be allowed to speak honestly about their treatment and the profession without fear of reprisal, a fear that may not always be occasioned by the reality of the situation, but is nevertheless perfectly understandable, and reasonable considering the powers the psychiatrist can often use to his/her advantage.
Cledwyn,
I too know of people who have gotten help from the medications. They are people I know well personally and with in confidence, yes, they have gotten help from psychiatry.
It is a lot more complex than just blaming the medications, big pharma and the doctors.
I think the best we can do is keep an attitude of curiosity to find the best ways to move forward and help as many as possible.
I also think the medications should be “last” resort instead as they are now, first resort. The medications should then be in the smallest dose possible, and not necessarily long term.
But before we focus on the medications I think we need to focus on the toxic attitudes we see in psychiatry – the attitudes that allow for coercion and dehumanization.
Malene
Cledwyn & Malene,
I maintain my skepticism about *anyone* being helped by psychiatry via 24 years of having actual proof of good outcomes ONLY for the small minority who escaped or were rescued from psychiatry. On inpatient-locked units, I have witnessed what Dr. Pat Bracken shared in his lecture currently up on this site; that there is no particular therapy/treatment that has proven to be beneficial; the one element that creates a good outcome is the *relationship* between the mental health professional and the patient. Quite honestly, there are precious few beneficial relationships between patients and psychiatrists there! Outpatient psychiatry is predominantly medication check in interviews- 15 minutes or less! Something other than *psychiatry* ALWAYS accounts for good outcomes in my 24 years of clinical experience!
Pat Brackens lecture is about Psychiatry’s CRISIS of LEGITIMACY. Watching this video is an hour well spent. Every facet of the *fraud* perpetrated by this so-called medical speciality is revealed with alacrity, and solid historical social/political relevance.
A lay person can easily point out the fundamental flaw in psychiatry as a medical specialty and booming business. The flaw is in the premise, the medicalization of human mental/emotional/spiritual suffering. The error in the premise appears in ALL the conclusions— from the DSM to the PDR! Only those who are seeking an authority figure to diagnose them with something similar to diabetes or epilepsy; something that is physiological and beyond their control, are *helped* by psychiatry’s fraudulent paradigm of *care*. Dr. Bracken makes this point as he attempts to explain WHY this paradigm has persisted these past 50 years, when there is so much compelling evidence that it is harmful and potentially fatal.
Working very recently with a 40 year old withdrawing from Heroin- on a locked unit because he was status post OD as a suicide attempt, I can tell you there was a big difference between what he believed and wanted and what would be considered *helpful* even by purely medical standards. For the most part, he got what he wanted. His psychiatrist ordered Ativan IM quite liberally along with Clonidine, so he could sleep off the worst of his withdrawal symptoms. Additionally he received the diagnosis Bipolar disorder and the assurance that he was *self medicating* his bipolar symptoms with Heroin! His shrink was more than happy to prescribe drugs that *treat* his bipolar symptoms when Heroin is not avaailable! IF you pause to consider what *psychiatry* had done and was doing for him, it would be hard to conclude he was being helped by psychiatry. BUT, if you asked him. Well, he had more issues with nurses who would not give him Clonidine when his pulse rate was below 50, than he had complaints about his psychiatrist! He was clear about how his Bipolar was the REAL problem! Go figure!
Maybe you will think this an extreme example, but it is fresh in my mind and heartbreaking in terms of all of the purely human stuff that this guy really needed.
I contend that psychiatry id dehumanizing by virtue of its lacking in realizing the human experience as a purely unique and maybe even sacred experience. Psychiatry is dehumanizing in its posture of authority that negates the experience, wishes and basic human needs of a person that they have the legal right to call their *patient*. Psychiatry is dehumanizing in its overzealous assumption of a role in separating people from a *society* that desperately wanted protection from *crazy people*. Psychiatry has built its fortress and its wealth on countless dehumanizing actions, AND by consensus IT formulated a Bible of pathology for every sort of human suffering IT encountered.
I wholeheartedly agree with Dr. Pat Bracken. Psychiatry is facing a LEGITIMACY crisis. In an ideal society, one whose governing and regulating agencies were established for the sole purpose of protecting and caring for us all, Psychiatrists would be facing criminal charges.
I am prepared to enter the witness protection program at a moments notice. 🙂
Re: “toxic” attitudes
Breggin calls psychiatry “toxic” –
http://www.toxicpsychiatry.com/
Warning: He is not concerned about *political correctness* when it comes to the *rat poison* psychiatry calls *medication*.
IMO, we are in the spot we’re in because too many people are not willing to stand up and speak out.
Not because of *black and white thinking* or *political incorrectness*.
1 in 5 adults in this country are taking some form of psychotropic drug (rat poison), and their own doctors have no idea that the drugs are no better than placebo, cause grave harm and according to Marcia Angell, M.D. are are “worse than worthless”…
Do the math.
Duane
P.S.: Is Breggin too “radical” for the politically-correct dialogue? Because, before Robert Whitaker, there was Breggin.
Thank you Cledwyn Bulbs! My first thought was, “if the outcomes are so good why are they still being seen in services???”
Sinead,
There is not doubt in my mind whatsoever that in a Just society every single psychiatrist who has “treated” my son would be facing criminal charges. Every single one lied to me—Mental health so called professionals wonder why I can’t be more ‘respectful’ i.e. just accept what we do don’t question OUR Authority; The current “provider” is either just plain stupid or IDK what. She has ‘no idea’ why I would possibly have any “anger and trust issues” or why my son is absolutely TERRIFIED of going to any kind of medical clinic or hospital. Knowing the absolute power and control they have is THE ONLY reason I do not tell her or the punk psycho pharmacologists at the clinic what the heck I think of them and their lack of respect for my son. I too can be locked up and drugged into a state of disability—
They are not.
Sandy,
you said:
” All I can tell you is that I have been actively engaging people in conversations about the medications for a long time and more intensively in the past year. Many people I talk to are satisfied with their treatment and do not want to stop taking the medications.”
MEDICATIONS ? not DRUGS? Hmmmm guess you have regressed back to the psychiatrist- empowering language??
Well, I’ve been thinking about past and present studies that demonstrate the shrinkage/atrophy/loss of volume due to decreased blood flow? of the frontal lobe, resulting from log term use of neuroleptics and anti-psychotics. You know how critical this area of the brain is for higher executive functioning, right? Well, I wonder if there is any correlation between “satisfaction with *medications* and the length of time the *patient* has been taking neuroleptic drugs? Perhaps it is an effect of longer term neuroleptic drug use?
What if “satisfied with anti-psychotic drugs” is just another iatrogenic –adverse effect of these brain toxins? Well the drug’s so-called efficacy is a matter of disabling the brain, so to speak…. So, the *medicated* patient might not really be competent. or a reliable source on his/her own good??
Could a psychiatrist put her ego aside, and rather than rejoice that her patient is content to be on neuroleptics, employ some critical thinking, and entertain the possibility that THIS- cognitive impairment, is not really such a good thing?
Or perhaps psychiatry will ALWAYS seek to disable the brain in order to cure the mind? Defying true science – is the only way to maintain the authority that would claim a brain- disabled person can attest to the benefits of psych drugs, but a *mentally ill* person’s disabled brain is no judge of what is BEST for the *patient*.
?? what do YOU think???
I was not rejoicing about anything. I was sharing a conundrum and an observation. I do not know if the belief that the drugs are effective are a result taking the drugs. If this is so, why are there people who take them who do not want to continue. Why would one type of attitude be caused by the drug and another attitude reflect the “true” underlying belief. If so, how do we know which attitude is the “true” one?
I just arrived back in the states, having been at the same Open Dialogue conference (and having done trainings in it before).
I will add that the originators of it are very insistent that it not be a technology or a thing, let alone the next new thing. Once it becomes that, it isn’t what it is any more.
On the other hand, it does represent an approach that has brought that area of Finland in 30 years from having the highest rate of “schizophrenia” in the world, to the lowest. They have done careful research to document that, and yet this fact is so startling that mainstream people simply refuse to believe it.
Especially as they are not doing a “thing.” It’s mainly about certain assumptions and very fundamental approaches; things that have always been true, but which have been forgotten since “mental illness” began to be treated with a presumption of underlying biology.
Hi Kermit:))
I suggest that “this fact is so startling that mainstream people simply refuse to believe it,” is because it mean confronting our denial of the unconscious stimulus to our intelligence?
On first sight the systems approach tends to look like its about words & thoughts, in this process of interviewing the family, whether it be with or without the identified patient. Yet the approach comes with decades of research and outcomes that are more about unconscious “affect/emotion” and its autonomic projection which based on a “postural attitude?”
An understanding that unconscious forces drive the family or group projection process, and that an unconscious postural attitude creates a “closed system,” emotional dynamic, just like the closed system of “us vs them,” reactions can’t see our common humanity, because it finds it so painful to let go of an autonomic reaction of “blaming & shaming?”
When systems theory was being developed, it was noted how difficult it was to avoid autonomic reactions that drive the “triangulation” of all group emotional dynamics right down to the need of stabilizing anxiety in a two person relationship.
If we want to open up this closed system reaction of blaming & shaming, in our unconscious projections onto “them,” (psychiatry) we will need to start noticing this unconscious “triangulation” process, which can be seen in black & white ink, right here on these pages? Please consider;
“Triangles
A triangle is a three-person relationship system. It is considered the building block or “molecule” of larger emotional systems because a triangle is the smallest stable relationship system. A two-person system is unstable because it tolerates little tension before involving a third person. A triangle can contain much more tension without involving another person because the tension can shift around three relationships. If the tension is too high for one triangle to contain, it spreads to a series of “interlocking” triangles.
Spreading the tension can stabilize a system, but nothing gets resolved. People’s actions in a triangle reflect their efforts to ensure their emotional attachments to important others, their reactions to too much intensity in the attachments, and their taking sides in the conflicts of others.
Paradoxically, a triangle is more stable than a dyad, but a triangle creates an “odd man out,” which is a very difficult position for individuals to tolerate. Anxiety generated by anticipating or being the odd one out is a potent force in triangles. The patterns in a triangle change with increasing tension. In calm periods, two people are comfortably close “insiders” and the third person is an uncomfortable “outsider.” The insiders actively exclude the outsider and the outsider works to get closer to one of them.
Someone is always uncomfortable in a triangle and pushing for change. The insiders solidify their bond by choosing each other in preference to the less desirable outsider. Someone choosing another person over oneself arouses particularly intense feelings of rejection. If mild to moderate tension develops between the insiders, the most uncomfortable one will move closer to the outsider. One of the original insiders now becomes the new outsider and the original outsider is now an insider. The new outsider will make predictable moves to restore closeness with one of the insiders.”
http://www.thebowencenter.org/pages/concepttri.html
It is highly likely that you will not respond to my comment here, which you “reason” as the right “thing” to do from past experience with me? This is how experience becomes *expectation* and drives behavior at a *physiological* level, even as our conscious mind, pretends it has its reason?
Lets try not to make “things” of each other with thoughtful diagnosis which cannot “feel” its own impulsed motivation within, because of Descartes infamous Error?
Best wishes,
David.
I am in the Cincinnati airport, soon to board to come back from NARPA. I spent two of my three and a half days there there bedridden with the flu, and got little MIA work of any kind done. Just mentioning this because i probably would have responded to this already. Perhaps unadvisedly, I will post whatever I have written when the airplane boards. If I offend, I’ll blame it on traces of the flu.
Funny that you mention Descarte’s folly at the end; it’s what was drifting through my mind while reading the post. Having observed some Open Dialogue sessions up close last week, and done some training in it previously, what comes to mind is that Open Dialogue is about resolutely negating dualism in all its forms. Though it’s nominally about dialogue, its form is really all about creating a field of awareness in which connections form at a very experiential level, and the dialogue arises therefore on a solid (and perhaps improved-upon) ground.
It’s often noted that people leading Open Dialogue sessions “use” a lot of humor. It was my observation that the sessions began with a notable shift into a shared physical/experiential space. This came from the intentionally “open” sense of time; there was simply no hurry to say anything or reach any conclusions. It seemed to me that mutual awareness increased, and that humor percolated up out of that connection. Since the sessions were in Finnish it’s hard for me to know the actual content or how on-task the conversation was, but I was told that the meetings had been very productive.
One of the OD therapists was very proud of having been trained in Sensorimotor Psychotherapy, a modality I favor because of its very careful attention to both somatic and “conscious” experience.
It occurs to me that one of the reasons OD always has two facilitators present is for reasons similar to those you mention, but with a different philosophy underpinning it. With three people, there can be no dualism (so long as there is no “in-group” formation, as you note.) This requires, though, a tremendous tolerance for uncertainty and ambiguity; which is another of OD’s strong foundational principles.
This goes beyond tolerance, etc., and it goes beyond the reflexive understanding of relationship or family therapy. It goes, I think, to being open, on an ongoing basis, to reviewing our understanding how we “know” what we think we know. Does it arise from our somatic/perceptual experience, or vice-versa? Or does it arise in the space between ourselves or others, as some have theorized/philosophized. “Mind” or “consciousness” or “knowing” is always and only something of which there is a shared component; to experience any of them is to imply the actual or potential shared experienced of another. (See Daniel Dennett, or Durkheim).
I think that Open Dialogue is built on such thinking. But when coming at it from a conventional perspective, it just looks like family therapy or the like, and is immediately suspect in the way that such work has come to be held, acculturated as we have become against anything that seems to imply that our families (or other environmental factors) may have had as much a role in our dysfunctions as our reverence for “family values” implicitly suggests they may have in our function.
No one of these ways of seeing the totality of our experience is sufficient. Our bodies and minds are inextricable from each other. Pills DO affect us; the question is how, and what it means, and what they truly suggests they may or may not do for us in our search for a more fulfilled time on earth.
My observation is that a tolerance for ambiguity and uncertainty is the most important thing in all that we discuss here. This is why the “I may disagree with what you say, but will defend to the death your right to say it” principle is so important here. I’m glad you express all that you do.
The airplane is boarding. I look forward to discovering whom I have disgruntled.
“Radical humility” is it! It appears you are on the way there, Sandra, and I so appreciate your courage and willingness to take that humble approach. And you are right that the labeling process itself prevents the necessary attitude – as soon as that process is started, we’ve already lost the humble perspective.
I think Erik Erickson said something to the effect that therapy needs to be reinvented for every person. It sounds like that’s what the Open Dialog folks are all about. I’m very interested to hear both of your experiences and of the reception these ideas receive in your professional community.
Thanks for being willing to “keep your mouth shut and your mind open,” as the saying goes, and sharing your experiences with us. I wish there were more psychiatrists like you – it might give me some hope for the profession yet!
— Steve
Honestly, keeping my mouth shut will one of the big challenges for me! Thank you for you kind words of encouragement.
Amen. You are still here blogging while most of the rest of the psychiatrists seem to have run off with their feelings hurt because they and their ideas were not welcomed with unquestioning arms. I suspect that the ones who stay, like you, are truly searching for better solutions to all of these problems with the present system. Thanks.
Yes, what happened to Dr. Keys and her “bucket metaphor”?
Dr. Keys has been enjoying the summer and changes that have come with leaving her practice of psychiatry. She looks forward to writing more, last we spoke.
Thanks for your comments.
Second what Steve said.
Ditto.
Duane
“Often, what clinicians do in order to do what is considered competent work leads us to have a breach of empathy with our patients”
Psychiatry’s empathy breach:
http://www.madinamerica.com/forums/topic/is-psychiatry-totalitarian/page/2/
Sandra
I appreciate your open approach and your excitemet of discovery. As a counselor in community mental health, I have noticed that most psychiatrists are only interested in listening to a patient’s narrative/story until they hear enough symptoms to make a diagnosis and then medicate; and then its ALL about the medications. We all should know the tragedy of this model.
In opposition to this approach, for me the narrative is so critically important because it hopefully will begin to explain what experiences in that person’s life gave rise to their particular symptoms of extreme psychological distress. If I can’t figure it out, then I haven’t asked the right questions or created a safe enough environment for the person to tell me.
I believe part of our work in helping people is trying to create conditions for that person to figure out how the particular events in their life are directly connected to the emergence of their syptoms of distress; something that any human being might experience under similar circumstances. Often understanding these connections can be one of the first steps in the healing process.
I look forward to learning more about the Open Dialogue treatment model in the coming period.
Richard
From what you write and from what I understand so far, your approach overlaps with Open Dialogue. One very nice aspect of Tornio is how deeply embedded this is in thier entire system of care.
“What seems clear is that this is fundamentally a humane approach to talking to people in distress.”
Talking to people can only ever be “framed” as a “therapy”. The people that talk, can only ever be “framed” as “clinicians” and “patients”.
But what two humans talking to each other and helping to work through problems will never be, is something “medical” in nature.
Therefore the ubiquitous medicalizing language that plagues even this, is nothing but an affectation, and bound to get in the way of progress.
Anonymous-
As I said, I am addressing this to the “me” of a few months ago. I think it is important to bridge a gap by using the language that people in the medical system use. But I have no doubt that there is better langugae for this. I did find my colleagues in Tornio to have a distinctly non-medical tone but you may not have had the same impression.
I know. I’m just sayin’. In general.
Thanks.
“Open dialogue”— a “treatment”? Pretty funny when you think about it. When I engage the *inmates* at work in humanistic dialogue, they usually tell me it is like a break from treatment!
RE: your *link*to views and visuals on psychiatry, and those who earn a salary working on a locked unit. I just want to share that after experiencing the entire thread, I am convinced that I earned my salary on night shift Saturday!
Thanks!
Sinead
Dr. Steingard,
Bravo, and welcome to what might end up being an interesting journey for you.
You mentioned the fundamental difference between listening to a person’s story to diagnose and treat symptoms vs. what you saw in Finland. To listen to someone in order to diagnose and treat them creates an “other” that is diminished. IE, you are here because you are less than me, you are sick and have less value. I am the almighty, the one in power, the healthy one that can fix you.
Where as talking with someone about their crisis just to talk to them communicates “I am here because I care about you. We are in this together. We are all uniquely human”. Talking with someone just to talk to them also necessitates listening to them about how they like to feel better. Which means finding a way through the wilderness must be collaborative.
In the current psychiatric system the worst problem is not medications, although I tend to think medications pose a big problem. The worst problem is the attitude that is trained into the professionals for years; it is an attitude which is largely now unconscious because it has never been challenged. when we train people to “be objective” we also train them to “objectify”. Apart from the fact that no one is truly “objective”, it is nonsense to begin with. If we look at little deeper at the attitudes I refer to though I think we can trace it back to some experiences on behalf of the staff.
Dealing with people in crisis is often very difficult. It can be scary and overwhelming. It includes dealing with strong emotions on the part of the person in crisis, and strong emotions in others have a tendency to stir strong emotions in ourselves. So what emotions do the staff often feel?
Fear?
Overwhelm?
Maybe even disgust?
Powerlessness?
Irritation / annoyance?
How is the staff trained to handle these emotions? Can you see how these emotions play into a staff meeting conversation? When the staff discusses the apparent “sick” behavior of a patient – what feelings are underneath all the dehumanizing talk?
Is it the patients fault that the staff feel those emotions? How can a therapeutic environment be created when the staff feels emotions like the ones above?
In how many million little ways do staff in current psychiatric hospitals display attitudes that are inherently dehumanizing? Monday or Tuesday when you return to work how many times do you see someone dehumanize a patient? How often do you feel the stirrings of fear or other emotions that push you towards dehumanizing the person in front of you?
It is ingrained in the system, deeply ingrained.
Malene
Thank you, Malene. One person from the group from Tornio said that she never liked to have meetings that did not include the person in distress and his family or other support system. She alluded to attitudes arising among the staff that were not helpful. They clearly have what we would call a person centered approach and it runs very deep.
Dr. Steingard,
This little comment rushed me quickly in to reality – the reality of how distorted psychiatry as it works right now has gotten.
When I was in junior high we sometimes got together and gossiped, you are not that much older than me, I bet your remember it. Us girls, whispering, talking, giggling. The girls I hung with were by and large very sweet and we didn’t go down the mean paths. I remember how we also often talked about how it “wasn’t really ok to talk about others when they weren’t there”. There was usually someone who were willing to stand up for someone else who wasn’t present. As I said, the girls I hung with really had good hearts. Remember those conversations?
How on earth can we hope to be of help to someone in distress if we talk about them about their backs? How can we keep trust intact? How can we collaborate on finding best solutions? How can staff meetings, or meetings without the person we are trying to help ever be anything other than an insult, demeaning and dehumanizing?
Can you mention just one positive thing that comes from talking about someone in distress behind their back? Actually, let me rephrase that, can you mention just one positive thing that comes from talking about anyone behind their back? Why should it be different when talking about a person in distress.
No, Dr. Steingard, this is exactly why we need drastic changes, a revolution.
And the staff? The staff needs the training and the ongoing support so they have the tools to continue to see those they are helping as first of all human beings – human beings who might not be so hard to understand.
Malene
Malene,
Once again, thank you for your thoughts on this. Is it never OK to have a conversation when someone is not there? In my personal life, I have found that it is helpful to have “safe places” where I can talk about my thoughts and feelings about relationships.
BTW- if you want to address me by name, it is fine if you use my first name. It seems strange that I would address you by your first name but you would address me as doctor.
Sandy
Ok, then, Sandy it is.
I should give fair warning, I am no less opinionated when using first names. We can blame it on my grandmother – among the first few women in her country to ever demand equality. She was a significant role model in my life.
I think there is a huge difference between talking to a trusted friend about someone,and what happens in “clinical meetings”.
For instance, my best friend works with autistic children. She often talks to me about feeling heart broken when a teenager struggles to communicate. In this situation we are talking about her heart break – about how she is impacted. We are not talking about what is wrong with the teenager she is trying to help, rather about how she handles her own sadness at seeing suffering.
I wish that is what would be going on during various staff meetings etc. But truth is, it isn’t. Diagnosis are discussed, what is wrong with a person, and most importantly, what the clinical setting can do to control this person – now that is all discussed. When a staff member refers to something wrong with the person in distress the staff member is not ever encouraged to look at their own emotions – the person in distress has a diagnosis and what is wrong with that person is fair game to discuss.
None of this is the least bit helpful. None of it fosters a therapeutic environment. It doesn’t foster caring, concern, humanity or dignity.
Besides, how can a person in distress ever truly get better if they are not 100% involved in the process?
Malene
“One person from the group from Tornio said that she never liked to have meetings that did not include the person in distress and his family or other support system.”
That is one of my too many complaints – I call it “displacement of self”. I have been routinely “kicked out” of my own life. When people have “meetings” about me and I am not allowed to participate, it just isn’t possible for me to be considerate of “them” … “doing their jobs”.
I once became so frustrated from standing alone in a lobby while more than a dozen people (including my own family) sat in a room – discussing me at length. I eventually opened the door and walked in (no doubt, seen as a “bad” and “pathological” behavior) and they were not pleased with that. I must have “broken a rule” and disrupted the formality and structure of policy, practice and procedure. To this very day, there are plenty of people who will not ever apologize to me or admit any wrong-doing and in addition to that, the double-standard will still apply: I’ll be “nailed to a cross” for every of my own “wrong-doings” – but not ever them. (scapegoat syndrome)
In one hospitalization, I knew that I only really needed at that very moment to be held. Not a hug – I needed to be held. I communicated that and then had to endure the mockery and taunt from one of the nurses and even her punishment (ordering an injection) when I panicked and couldn’t choose between getting to group on time and not being late or using the bathroom. Instead of seeing that I was in a moment of crisis (which is NOT ALLOWED) and needed real care and support, I was PUNISHED.
That hospital has posted signs all over the place that “assaulting a staff member of the hospital is a FELONY”. Let me tell this whole world something: do not think for one minute that a staff member would NOT intentionally provoke a patient that they don’t like into striking out. I saw that “law” as absolute abuse of power and extremely dangerous for very many people. The burden of abuse I had to put up with from that nurse will always fall entirely on ME. It should be on my “criminal” (medical) record somewhere to guarantee that if in any event I am to return to any psyche ward, that it NEVER BE the one where the sinister nurse works.
Distress? Then steer far away from hospitals who declare that striking a staff member is a “felony”.
mjk-
These are very powerful and important comments. When I try to explain this to my colleagues, I would like to use this and some of the other comments above to help to illustrate why what we do when we think we are helping can be so destructive. I am sorry for how you have suffered.
Here is what I see as a “tip-off”: “In one hospitalization, I knew that I only really needed at that very moment to be held. Not a hug – I needed to be held.” (is that what a straight jacket is for?)
How awkward and … “pathetic”? Had I embarrassed somebody and revealed the “stunted growth” of Americans, where “strangers” are so icky? EWW, I’m not touching YOU.
That was in 2007 – I was 31 years old. My “no PC” (physical contact) training began in my first hospitalization in 1991 when I was only 15 years old. Things have not changed.
When I think of this – “What seems clear is that this is fundamentally a humane approach to talking to people in distress. What was wonderful about this meeting is that these individuals seem to practice their ideas in the way they live. They are humane in their interactions with one another.”, I have to really wonder if I had expressed my need to be held (comforted and consoled) with those people, would it have been granted and given without the other person feeling ALIEN about it?
Not that I should have to explain to justify why needing to being held was so NORMAL but wait a minute, DO I actually have to explain it? In fact, I do think so.
I put a belligerent, drunk homeless woman to sleep when “staff” (volunteer) could not handle the situation. I got down on my knees beside her, I touched her. I spoke to her. She told me “I love you, I love you” and she went to sleep. She woke up a short while later and I immediately ran to her side, again, and put her right back to sleep.
I have the love of a woman that 99% of people would laugh at, devalue, mock or even ridicule. But every time I think of her, I’m pained and joyed. She’s on my heart and in my mind for all of ever. No professional that I know of could have cared for her and handled the situation as effectively as I did.
I CARED about her.
mjk, I am so sorry for what you went through. I am sure it is hard to convey the horror in words. Like you, I think touch, to be held. Comfort and love must have a place in clinical settings. We know already how important, vital a component of health it is. Infants die without it for crying out loud. Yet, we are scared, more so in this country than in many other countries.
I think, there are a lot of steps we need to take before that kind of healing will be available in clinical settings.
But you are right, we all crave it. It is normal. For people to not have been able to respond appropriately to your very human need is horrible.
I am sorry.
Malene
I bring it up because it is crucial when the very essence of ‘being’ goes beyond language and talking. Sometimes, we have that need to hear the right words. Sometimes, the *inner* world is literally falling apart and no word is able to do what contact CAN.
I’ll give another brief example: I was struck and bed ridden with an intense vision. I cried out for it to stop. A man knew enough to tend to me by placing his fingers on my temples. It gave me relief. You see, in that instance – to have spoken to me would have agitated me, especially if someone decided to say “call an ambulance” or deemed it some “psychotic episode”. The man did the exact right thing.
And in case anybody’s wondering what the vision was – it was the Earth caving in with bubbles rising up from very, very deep. I’ve since learned those are called “sink holes”.
And thank you Malene and Sandy, for your acknowledgments.
Malene-
I ran out of reply buttons above. I think I understand what you are saying about the distinction between personal conversations and clinical meetings and I expect no lightening up on your critical thinking (in the sense of incisive) when you comment here.
I do want to think more about this for personal reasons. I had the sense that the Finns have this sense of respect on many settings. It seems to be a case where culture influences practice whihc influences culture. Maybe I need to apply this outside of work.
Hi Malene, I really think these comments expressed by you and particularly mjk’s clear articulation of deeper needs and the emotional projection process which denies them, are crucial to our self-understanding and what we need to see about the Pride/Shame foundations of society, which prevents progress in mental health care.
I hope & pray that any so-called professional reading this thread, is able to let go their habitual intellectual posture & *feel* the primary process reality of human need, in this wonderful articulation of the power of *touch*
I share a similar timeline with mjk, regards 2007, which was my 1st & only sectioning, when an “as if” intellectual posture of “I know & you don’t,” triggered a reaction in young psychiatrist who ran out of ideas, when I challenged his presumption of a disease process in my experience of what is labeled bipolar type 1 disorder.
This clear statement by mjk is very powerful & people to pause % feel their resistance to it, through a consensus norm of “I think therefore I’m so identified with my thoughts that can’t feel my own body, its sensations of primary process need, & and the reality of *presence*
IMO Even the cognitively articulate on our side of the us vs them fence, do not want to acknowledge a primary process reality which makes a mockery of the minds sense of superiority? Descartes error has caused a fundamental mind-body split in Western societies, that founded on a Caucasian NEED to feel superior, IMO.
I resonate completely with mjk’s statement & give an example of it from my own experience;
“Sometimes, the *inner* world is literally falling apart and no word is able to do what contact CAN.” From my own experience;
““All behavior is communication,” springs to mind now as I walk towards the city center and the old “That Dam” stupa. Old and crumbling, I gaze on the conical structure and try to sense its deeper symbolic meaning, its unspoken voice as an expression of metaphor and the projection of unseen processes.
Behavior built this monument, yet something deeper and unseen informed its shape. Like the behaviors of psychosis and the unseen, hidden thermo-dynamic processes that drive the motor movement patterns of behavior.
A scene from 2007 springs to mind as I muse before the wisdom of this ancient monument, a hospital room and a beautiful young woman. She was on the bed as I entered the room, legs drawn up tight, her arms warped around her knees, rocking backwards and forwards, and quietly sobbing.
Alone, frightened and abandoned, her face was a mask of tragic loss and the deep sorrow of a harsh biting reality, “what love, what empathy, what understanding?” It was a gut wrenching scene to behold because she could have so easily been my lost daughter, perfect age. I sat beside her, putting my arm around her shoulder enjoining the movement, an unconscious prompting about need?
She turned towards me burying her face in my shoulder and allowed me to embrace her and power the rocking motion. It was probably about fifteen minutes before I’d felt the solid heaviness of her secure slumber and lowered both our bodies down onto the mattress. I remember thinking that if nurse Ratchet had re-entered the room right then there would be a fearful misperception, in that loss of sensitive awareness which tends to fuel the denial of our mechanical, “stand apart” cognition. As it was, I quietly left the room thinking about the generational transmission of emotional affects, my Grandmother, my Mother, my lost Daughter and Monica McGoldrick’s profound statement, “loss is the pivotal human experience.” A daughter may have helped to heal a generational wound which powers the emotional cut-off reactions within my family tree. “The ghost in our emotional systems machine?” Strangely there is always a song with poignant lyrics which come to mind at moments like these. Do you get that unconscious, and implicit inner self, messing with your mind too?”
http://www.born2psychosis.blogspot.com/p/chp-4.html
Professionals, please note that I did not say a single word to this girl, I did not ask any questions, I simply allowed my body & the power of presence to inform my movements?
Warm regards,
David Bates.
Yes, but they also mentioned that if they have meetings without “the person” present, the focus of the discussion is on the people who are present and what is up for them, not what they speculate might be up for anyone else.
That this conversation takes place is, I think, a product of the fundamental understanding that “the problem” exists between people, not within any one person. So it’s not germane to speculate on what is going on inside anyone, present or not, and to focus on what is going on between people who are present. Or, I suppose, if someone is not, to focus on your end of it.
I think this can be a legitimate and productive thing to do, not least because it is a step away from assuming that the person MUST be present because they ARE the problem. It is possible for people to have realizations about their own end of things that might never have if the other person whom they have presumed to be the problem is always present.
“Yes, but they also mentioned that if they have meetings without “the person” present, the focus of the discussion is on the people who are present and what is up for them, not what they speculate might be up for anyone else.”
The “meeting” is informed on the health care side with a knowledge of emotional dynamics which operate unconsciously? The meeting is designed to address these unconscious dynamics which remain “hidden,” without training and much practice in this method?
Questions are formulated to elicit predictable answers, which tease a more “open” attitude to one’s own experience? The “meeting” is based on decades of research into the nuclear family? Example:
“Nuclear Family Emotional System
The concept of the nuclear family emotional system describes four basic relationship patterns that govern where problems develop in a family. People’s attitudes and beliefs about relationships play a role in the patterns, but the forces primarily driving them are part of the emotional system. The patterns operate in intact, single-parent, step-parent, and other nuclear family configurations.
Clinical problems or symptoms usually develop during periods of heightened and prolonged family tension. The level of tension depends on the stress a family encounters, how a family adapts to the stress, and on a family’s connection with extended family and social networks. Tension increases the activity of one or more of the four relationship patterns. Where symptoms develop depends on which patterns are most active. The higher the tension, the more chance that symptoms will be severe and that several people will be symptomatic.”
http://www.thebowencenter.org/pages/conceptnf.html
Warm regards,
David Bates.
I think you’ve pointed out something here that is very important. The fact is, the staff that have direct patient contact on locked wards have little or no training about dealing with their feelings. In my institution we taek just about anyone who comes in off the street to be Behavioral Health Workers! The nurses are not much better in the education and training. Let’s face it, the medical professions are sadly lacking in education in the Humanities; most of what they get is science and more science. Even the psychiatrists have no background in Humanities unless they went to one of the few med schools who demand some education in this, there are a few but not many.
I, as a survivor working in the same hospital I was locked up in, often have an me versus them mentality when viewing the other staff on the units. What you make me realize this morning is that some of their awful treatment of patients stems from having absolutely no exposure or training about how to deal with your own, personal feelings when you have to deal with someone else experiencing strong emotions. Thanks for this very important insight.
“What was wonderful about this meeting is that these individuals seem to practice their ideas in the way they live”
This seems a pretty important observation Sandy and is related to several of the comments. People want to be treated with dignity, respect, basic human compassion. Hopefully this is the way people live their lives as well. When we put on a different persona to “help others” we have to stop and question. There should be no need of such a persona. We just need to be one person offering help, support, etc. to another. Period. No lables, no psycho-babble, no power differentials, or need for ego-stroking, etc.
Thanks for this update.
Re: “no psycho-babble”
Ha!
We agree,
Duane
Hi Sandy,
This is good news that I hope it will resonate well with your professional colleagues at home, although I’m surprised that you find this “family systems” approach to be something new?
Does this suggest a to narrow focus in psychiatric training, which has convinced itself of disease processes, involved in emotional suffering, while *proudly* dismissing alternative views? IMO There is a Pride/Shame axis to individual & societal function, which we chose to remain in denial of? As you write;
“This is all fairly new to me. I am far from an expert, in fact I am not sure I even understand. What seems clear is that this is fundamentally a humane approach to talking to people in distress.”
Open dialogue, is based on the “Milan Family Therapy” approach, which like all family therapy, views the family as an interactive “emotional system” which cannot be analyzed or “fixed” with standard cause & effect logic. The basic premise is that the individual within the family has become the “identified patient,” to contain “emotional anxiety,” within the family group?
In the theory, there is no such thing as a perfectly stable “dyad” (two person emotional relationship) with a third person becoming involved to strengthen the dyad. Two become strong at the expense of the third, by projecting a Strong/Weak, Pride/Shame emotional need onto the “pitiful” other. Typically, parents can share an affirming emotional connection through their joint concern over a “sick” child. Its an emotional “bonding,” issue for the parents, acting at an unconscious level of emotional motivation. The child gets caught up in a “double bind,” unable to defend themselves, because their survival is dependent on parental support.
For those in our survivor community who resonate with this subjective notion of “double bind,” dammed if you strike back at parental behavior, and dammed if you don’t. There is a physiological foundation to the double bind, as explained here;
“Bull discovered that the emotion of anger involves a fundamental split. There was, on the one hand, a primary compulsion to attack, as observed in tensing of the back, arms and fists (as if preparing to hit). However, there was also a strong secondary component of tensing the jaw, forearm and hand.
When Bull studied the patterns of elation, triumph and joy, she observed that these positive affects, did not have an inhibitory component; they were experienced as pure action. Subjects feeling joy reported an expanded sensation in their chests, which they experienced as buoyant, and which was associated with free deep breathing. The observation of postural changes included a lifting of the head and an extension of the spine. These closely meshed behaviors and sensations facilitated the freer breathing.
Understanding the contradictory basis of the negative emotions, and their structural contrast to the positive ones, is revealing in the quest for wholeness. All the negative emotions studied were comprised of two “conflicting impulses,” one propelling action and the other inhibiting (thwarting) that action. (p, 333)
In addition, when a subject was “locked” into joy by hypnotic suggestion, a contrasting mood (eg, depression, anger or sadness) could not be produced unless the joy “posture” was first released. The opposite was also true; when sadness or depression was suggested, it was not possible to feel joy unless that postural set was fist changed. (p, 334)
A direct and effective way of changing one’s functional competency and mood is through altering one’s postural set and thence changing pro-prioceptive and kinesthetic feedback to the brain. Hence, the awareness of bodily sensations is critical in changing functional and emotional states. (p, 337)”
Excerpts from “In an Unspoken Voice” by Peter Levine PhD.
In the “open dialogue” approach, I suggest that it this this unconscious “postural set,” that is freed up by encouraging the *strong* in the family group to let go of their *bonding* need of projection onto the *weaker* ones? Traditionally the family systems approach encourages the opening up of a system that has become to closed, through this unconscious projection process, which revolves around an axis of Strong/Weak, Pride/Shame. For interested in the history of this systems approach, largely developed in America;
“History and theoretical frameworks:
Family therapy as a distinct professional practice within Western cultures can be argued to have had its origins in the social work movements of the 19th century in England and the United States.[1] As a branch of psychotherapy, its roots can be traced somewhat later to the early 20th century with the emergence of the child guidance movement and marriage counseling.[2] The formal development of family therapy dates to the 1940s and early 1950s with the founding in 1942 of the American Association of Marriage Counselors (the precursor of the AAMFT), and through the work of various independent clinicians and groups – in England (John Bowlby at the Tavistock Clinic), the US (John Elderkin Bell, Nathan Ackerman, Christian Midelfort, Theodore Lidz, Lyman Wynne, Murray Bowen, Carl Whitaker, Virginia Satir), and Hungary (D.L.P. Liebermann) – who began seeing family members together for observation or therapy sessions.[1][3] There was initially a strong influence from psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry, and later from learning theory and behavior therapy – and significantly, these clinicians began to articulate various theories about the nature and functioning of the family as an entity that was more than a mere aggregation of individuals.
The movement received an important boost in the mid-1950s through the work of anthropologist Gregory Bateson and colleagues – Jay Haley, Donald D. Jackson, John Weakland, William Fry, and later, Virginia Satir, Paul Watzlawick and others – at Palo Alto in the US, who introduced ideas from cybernetics and general systems theory into social psychology and psychotherapy, focusing in particular on the role of communication (see Bateson Project). This approach eschewed the traditional focus on individual psychology and historical factors – that involve so-called linear causation and content – and emphasized instead feedback and homeostatic mechanisms and “rules” in here-and-now interactions – so-called circular causation and process – that were thought to maintain or exacerbate problems, whatever the original cause(s).[4][5] (See also systems psychology and systemic therapy.) This group was also influenced significantly by the work of US psychiatrist, hypnotherapist, and brief therapist, Milton H. Erickson – especially his innovative use of strategies for change, such as paradoxical directives (see also Reverse psychology). The members of the Bateson Project (like the founders of a number of other schools of family therapy, including Carl Whitaker, Murray Bowen, and Ivan BöszörmĂ©nyi-Nagy) had a particular interest in the possible psychosocial causes and treatment of schizophrenia, especially in terms of the putative “meaning” and “function” of signs and symptoms within the family system. The research of psychiatrists and psychoanalysts Lyman Wynne and Theodore Lidz on communication deviance and roles (e.g., pseudo-mutuality, pseudo-hostility, schism and skew) in families of schizophrenics also became influential with systems-communications-oriented theorists and therapists.
A related theme, applying to dysfunction and psychopathology more generally, was that of the “identified patient” or “presenting problem” as a manifestation of or surrogate for the family’s, or even society’s, problems. (See also double bind; family nexus.)
By the mid-1960s, a number of distinct schools of family therapy had emerged. From those groups that were most strongly influenced by cybernetics and systems theory, there came MRI Brief Therapy, and slightly later, strategic therapy, Salvador Minuchin’s Structural Family Therapy and the Milan systems model. Partly in reaction to some aspects of these systemic models, came the experiential approaches of Virginia Satir and Carl Whitaker, which downplayed theoretical constructs, and emphasized subjective experience and unexpressed feelings (including the subconscious), authentic communication, spontaneity, creativity, total therapist engagement, and often included the extended family. Concurrently and somewhat independently, there emerged the various intergenerational therapies of Murray Bowen, Ivan BöszörmĂ©nyi-Nagy, James Framo, and Norman Paul, which present different theories about the intergenerational transmission of health and dysfunction, but which all deal usually with at least three generations of a family (in person or conceptually), either directly in therapy sessions, or via “homework”, “journeys home”, etc.
Psychodynamic family therapy – which, more than any other school of family therapy, deals directly with individual psychology and the unconscious in the context of current relationships – continued to develop through a number of groups that were influenced by the ideas and methods of Nathan Ackerman, and also by the British School of Object Relations and John Bowlby’s work on attachment. Multiple-family group therapy, a precursor of psychoeducational family intervention, emerged, in part, as a pragmatic alternative form of intervention – especially as an adjunct to the treatment of serious mental disorders with a significant biological basis, such as schizophrenia – and represented something of a conceptual challenge to some of the “systemic” (and thus potentially “family-blaming”) paradigms of pathogenesis that were implicit in many of the dominant models of family therapy. The late-1960s and early-1970s saw the development of network therapy (which bears some resemblance to traditional practices such as Ho’oponopono) by Ross Speck and Carolyn Attneave, and the emergence of behavioral marital therapy (renamed behavioral couples therapy in the 1990s; see also relationship counseling) and behavioral family therapy as models in their own right.
By the late-1970s, the weight of clinical experience – especially in relation to the treatment of serious mental disorders – had led to some revision of a number of the original models and a moderation of some of the earlier stridency and theoretical purism. There were the beginnings of a general softening of the strict demarcations between schools, with moves toward rapprochement, integration, and eclecticism – although there was, nevertheless, some hardening of positions within some schools. These trends were reflected in and influenced by lively debates within the field and critiques from various sources, including feminism and post-modernism, that reflected in part the cultural and political tenor of the times, and which foreshadowed the emergence (in the 1980s and 1990s) of the various “post-systems” constructivist and social constructionist approaches. While there was still debate within the field about whether, or to what degree, the systemic-constructivist and medical-biological paradigms were necessarily antithetical to each other (see also Anti-psychiatry; Biopsychosocial model), there was a growing willingness and tendency on the part of family therapists to work in multi-modal clinical partnerships with other members of the helping and medical professions.
From the mid-1980s to the present, the field has been marked by a diversity of approaches that partly reflect the original schools, but which also draw on other theories and methods from individual psychotherapy and elsewhere – these approaches and sources include: brief therapy, structural therapy, constructivist approaches (e.g., Milan systems, post-Milan/collaborative/conversational, reflective), solution-focused therapy, narrative therapy, a range of cognitive and behavioral approaches, psychodynamic and object relations approaches, attachment and Emotionally Focused Therapy, intergenerational approaches, network therapy, and multisystemic therapy (MST). Multicultural, intercultural, and integrative approaches are being developed. Many practitioners claim to be “eclectic,” using techniques from several areas, depending upon their own inclinations and/or the needs of the client(s), and there is a growing movement toward a single “generic” family therapy that seeks to incorporate the best of the accumulated knowledge in the field and which can be adapted to many different contexts; however, there are still a significant number of therapists who adhere more or less strictly to a particular, or limited number of, approach(es).”
http://en.wikipedia.org/wiki/Family_therapy
I apologize to you Sandy & to readers, for this long, long response, yet I’m passionate about trying to shed light on this alternative *emotional systems* view of so-called mental illness. My own recovery journey has involved an understanding of emotional systems theory and practice, through my own training, and then a further understanding and experiential integration of the *physiological* foundations of our emotionally charged subjective experience.
Warm regards,
David Bates.
If the usual “black & white” critics would like to have a shot at me, to fill their need of *Pride* in their ability to function, we can actually explore the interactive dynamics of *emotional systems* right here on MIA?
Just as we did here, for anyone interested in peering beneath their own, *intellectual posturing?*
“What I’m trying to “tease out” here is our emotional functionality beneath our cause & effect reasoning? I’m doing that by becoming the *identified patient* in this group dynamic? My aim is to try to highlight the emotional nature of so-called *mental illness.* Hence my suggestion that repeated confirmation statements about our *ideological* stance are not really productive, in helping us to help each other?”
http://www.madinamerica.com/2012/08/collusion-and-control-the-reality-of-mental-ilness/
Do we want to discuss the reality of mental illness, here on MIA, or do we just want to point the finger of blame at “them,” in our endless Pride/Shame, emotional games?
Regards,
David.
Matthew,
I’ve had comments deleted for length and repeating myself.
Why are others, allowed to daily post almost 6000 words of slabs of text here, almost always mentioning this “Murray Bowen” person?
First of all, please report posts you feel an inappropriate to me directly, rather than in a comment.
David’s posts, while lengthy, do not contain incivility or personal attacks that I have noticed. You have been moderated for repeated posting for the purpose of changing/challenging/influencing a specific individual. His 6000 words are part of a general dialogue and not directed AT anybody here.
David,
I noticed that you said something directed to me above, and I wanted to answer you. I am really sorry to say this, but your replies are usually so long, verbose and confusing that I am lost early on in the writing, and skip what you have to say. I think that is sad, because I suspect you have something valuable to say, I am just not quite sure what. I would really recommend you start to edit yourself a bit, and consider how to get your thoughts across with clarity.
Malene
Hi Malene,
I understand what your saying and realize that my comments are far to long for many people. My explanation, is a sincere attempt to get well researched references of an alternative explanation to the disease model of mental illness, up here for people to access if they wish.
I don’t expect people to read through and grasp these explanations in one bite, and I do realize that my approach will offend many, as I go against a consensus expectation here. Yet I’m confident in my research & long experience and believe that as time passes, more people will start to read these references and take them more seriously.
I’m not well educated in classic terms and do so obviously struggle with the writing, yet as time goes by I think more people will make the effort to read between the lines, to see what I’m trying to say.
Best wishes,
David.
David,
Thank you for this history of the development of these ideas. I have written elsewhere (“In praise of families”), why I personally turned away from some types of family treatment and more towards psychoeducational approaches. When a person is in distress, everyone around her is in distress. To say to a mother, in that instance, “I know why your child is suffereing. It has to do with how you treated her when she was young”, struck me as cruel. This is not what happens in Open Dialgogue or the other network approaches, as I understand them. They seem to be neutral on causation. They just want to coneect and understand. This position of humility,i.e., not entering te situation as experts, seems important. Psychiatrists are not the only ones who can use their theories in a way that is hurtful.
Dear Sandra, I keep pointing out this *phenomena* of how we all take from other people’s comments what we need to justify our current intellectual posture, with a pre-conceived *expectation*? Can you say why you make the assumption that I’m promoting older ideas that “blame” anyone in my comment above, and why you don’t address the excerpts from Levine, I included about the physiological foundations of emotion?
You write;
“It has to do with how you treated her when she was young”, struck me as cruel. This is not what happens in Open Dialgogue or the other network approaches, as I understand them.”
During my own training in family therapy approaches, this was often the *reaction* of women in our group, particularly towards Murray Bowen and his apparently, cold non-feeling logic.
Elsewhere I’ve suggested that much of our *reasoning* is based on reactions rather than an insightful intelligence which finds it hard *pause* and *feel* the impulse to thinking. I posted the reference to Nina Bull’s research to highlight these unconscious physiological reactions, which we tend to rationalize, as an after the fact intellectual interpretation of our feelings, our emotional guidance system.
Its interesting to note what Bull’s research discovered about *postural sets* while reading the ideology of “us vs them,” here on MIA. IMO It is this *postural set* described above which is responsible for our *ideology* of “us vs them,” yet in a consensus normality of *I think therefore I am* we dare not examine this *physiological* stimulation of our thinking, because it would lead us into examining the evolved nature of the human mind?
Above I wrote;
“Open dialogue, is based on the “Milan Family Therapy” approach, which like all family therapy, views the family as an interactive “emotional system” which cannot be analyzed or “fixed” with standard cause & effect logic. The basic premise is that the individual within the family has become the “identified patient,” to contain “emotional anxiety,” within the family group?”
I’m not suggesting for a minute that we have not moved on from the 1950’s, and that the theory and methodology has not been refined and improved. Please read the note below, taken from the “Open Dialogue” five year outcomes study, which explains the origins of the approach.
“Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies
Note: Circular questioning is a specific way of interviewing the family first introduced by the *Milan systemic group* (Selvini-Palazzoli et al., 1980). In the questions, differences are highlighted by, for example, asking one family member to evaluate a relation of two others after the crisis occurred. Another form of asking of differences is to ask to rate who is most concerned, who is the second most concerned, and who is third most concerned.”
http://www.iarecovery.org/documents/open-dialogue-finland-outcomes.pdf
Perhaps we can continue a discussion about our tendency for reactive, and assumptive reasoning here? Perhaps we can learn to ask questions like they do in Finland, instead of jumping to assumptions, about others, their intentions and their meaning?
Regards,
David.
David,
I am so sorry. That comment was more about me and my own reasons for not being more attuned to how family theory has evolved. It was intended to be more self reflective than reactive.
Hey Sandy,
I too ran out of reply buttons above. I think language is a direct reflection of attitude. We can’t hide our attitude, no matter how hard we try to be “objective”. Currently the pathologizing attitudes are trained into practitioners. They are encouraged.
Here are a couple of examples that I have observed during my own work in a half way house for people in crisis. I worked there for about one year. I was never able to subscribe to the attitudes towards those we were trying to help, and I lost the job.
I remember one time I came in to work with a shift change happening. A new person in the house was immediately described as “so borderline, really be careful with her she will split the whole house up.” The more experienced staff member who described this one person in this way did it with an eye roll. A discussion ensued about how to keep this person under control, and what was generally wrong with this person. I hadn’t even met the person yet when this happened.
During another situation a woman was assigned primarily to me. As I read through her charts release papers from the hospital I read that she “had presented as dramatic and histrionic”. When I spoke with the person she spoke of heart break, and emotions she simple wasn’t equipped to handle. Given her situation, the emotions were not that hard to understand.
I also remember some situations where someone was referred to as “floridly psychotic”, or “so manic it took three of us to keep up”.
If I were to interpret those ways of talking about people in distress. I think the person who referred to someone as “extremely borderline” was frustrated, maybe even angry and certainly overwhelmed.
I think the heartbroken person was met with irritation or annoyance. There certainly wasn’t much patience with her heart break.
The person referred to as psychotic was often a little scary to be around, and if not scary then certainly so difficult to follow that it felt confusing trying to help him or her. An experience of helplessness or frustration because this person keeps not getting better is also common and will reveal itself in the language.
These are the staff emotions – yet, not one single staff meeting were dedicated to help the staff get a better grip on their reactions. Is it the person in distress’s fault or responsibility how staff reacts to them? How is this way to talk about people better than the meanest girls gossiping in junior high?
Were these ways of talking about someone in distress objective? Professional? Helpful? I am sorry, but this is what happens during staff meetings and it should be stopped.
It is much different when my girlfriend and I share how someone we tried to help touched us, or how difficult we find it to some times be a good helper. “I had a tough day today”. “I wish I did this better”. “It is hard for me to watch xyz”. Is different from the examples above.
As far as the ingrained attitudes you saw in Finland? Well, I was raised in Scandinavia and very humanistic and socialistic attitudes are common. In spite of that, there is plenty of dehumanizing behaviors going on over there as well. In the mental health field it takes really excellent training and ongoing support not to fall prey to the difficulty of the job.
In the US, we have the movements from Diana Fosha and Sue Johnson offering some alternatives at least within psychology. We need to focus on humanism and attachment theory.
Malene
Malene,
The language staff uses to describe a “patient” is the clinical psychiatric lexicon that clearly delineates the patient from the caregiver. The patient is labeled with terms (created and used by the *experts*) that absolve the caregiver of any personal responsibility for problems caused by *borderlines* and *manic/psychotics*. The language sets the stage for depersonalization by staff and the dehumanizing manner in which staff may describe or define a *patient*. IF one becomes fluent in this language and can rattle off the text book meanings of each term… you can be 100% assured that there will be no *open dialogue* initiated by THAT staff. Be it during change of shift report, or so-called collaborative- multidisciplinary *treatment team* meetings, the clinical language will provide a barrier and a shield that eliminates any sort of dialogue from happening!
Being the change I want to see, I have developed these strategies:
1) When I give report, I forego the clinical descriptions and talk about very specific things I have learned about the *person* who is stuck with having us care for him/her.
Preface to strategy #2:
I have recently returned to a locked unit after 2 years of few time constraints to inhibit researching and networking to get a better handle on *psychiatry*. Shocked and awed by the ongoing *ignorance* of front line staff with regard to the biochemical causes for severe mental states/major mental illness AND even greater ignorance regarding the brain altering actions of psychotropic drugs, adverse reactions and withdrawal syndromes;– in shock and awe, I have found creative ways of teaching to prevent me from screaming out :”HOW IS IT POSSIBLE YOU DON’T KNOW THESE THINGS”
2) When a person is admitted with the classic: “Off his/her meds” — I supply the physiological explanation for the *symptoms* that led to the admission. I say in a very matter of fact tone- ” Jim Bob is experiencing an episode of dopamine flooding due to the increased number of D2 receptors created by his long term ingestion (by prescription) of Haldol . Sans Haldol (his choice) he is suffering severe withdrawal.” I have provided pertinent articles, scientific citations to explain this: “Wow! how can that be?” phenomenon that happenes every single time I mention these medical facts on a *medicaal/psychiatric unit* THIS is generating some very interesting *open dialogue* between/ amongst clinical disciplines on my unit 🙂
3) When I receive report, I always strike up a conversation. “Borderline” references used to just make my skin crawl, but now I pull up a stored audio memory of Madonna’s song “You keep on pushing my love over the borderline..” and then I very sincerely ask for details about the “gamey” “splitting” “upping the ante” *behaviors* — and I ignore the “rolling of the eyes” of the reporter. “Can you give me a little more info about Loopty Lou ? Can you please just tell me what happened?”
WHEN a staff reporter starts to talk about what actually happened, and I am wearing my real, true affect of concern, amazing things happen. Something like an *open dialogue* starts to flow. The staff reporter shows affect, too! and seeks validation or *help*. Other staff hearing the report join in and share their feelings of helplessness, overwhelm or frank intolerance. WE start to talk about human dynamics and suddenly the clinical terms fall out of the discussion– probably because they held no real meaning in the first place.
The only way I can envision changing the dynamic you describe, Malene, is by initiating real humanistic dialogue, or inserting it into the process. If this catches on I envision my mental health professional co-workers/colleagues coming to the realizations that I experienced as visceral reactions before becoming educated about the uselessness of psychiatric language and the real harm caused by hospitalizing people who are NOT medically sick, or mentally incompetent.
Open dialogue evokes self reflection and even confrontation with our own weaknesses and misunderstanding. Rattling off clinical terms and psycho-slang is a shield for those who can’t bear the thought of commonality between themselves and people wearing the label, mental patient.
I predict that some psychiatrists will advertise *open dialogue* as their treatment modality du jour. However, I am confident that service users will be able to tell the difference between *live* and *memorex*. 🙂
The ultimate test: Can a psychiatrist dump the lingo and the authority he has come to regard as close to divine? Can the doctor see himself as an equal, NOT the expert,which is requisite for true open dialogue to occur?
We shall see what we shall see!
“I supply the physiological explanation for the *symptoms* that led to the admission. I say in a very matter of fact tone- ” Jim Bob is experiencing an episode of dopamine flooding due to the increased number of D2 receptors created by his long term ingestion (by prescription) of Haldol . Sans Haldol (his choice) he is suffering severe withdrawal.””
This is a very disappointing load of quackery to be reading from you.
If I was ever your captive detainee, and you ever DARED reduce my experience to some pathetic guesswork “episode of dopamine flooding”, I’d probably wish I could sue you, but like most captives, I’d probably be powerless to sue you, because you’re free to theorize about quack pat biological explanations for people’s distress.
Oh, did you get that everyone? Whatever thoughts are going through your mind, and then you’re hospitalized? Sinead’s answer? “Dopamine flooding”.
How do you justify feeding your mouth by taking away the freedom of innocent people?
Anonymous,
I am placing ** around absurd terms.
I would hope that you might consider:
1) I am addressing *professionals* who automatically link OFF MEDS with PROOF of needing MEDS and MORE MEDS. Anyone who presents with a *diagnosis* a severe mental state and has stopped taking *meds* is automatically viewed as a validation for both *diagnosis * and *meds* by whatever means necessary!
2) I have to acknowledge my audience. Where they are in the dark cave is just something I have to accept IF I want to strike a match there.
3) The reality that psychiatric *treatment* causes harm is NEVER a consideration on a locked unit. (and in lots of other *treatment* settings as well).
4) Scientific evidence supports: A) the brain responds to dopamine blocking drugs by making more dopamine receptors. B) When the dopamine blocker is suddenly removed, there will be a sudden increase in dopamine C) Insomnia is a sure bet…. D) Consistent with *patient* reports: “Haven’t slept in … several days!”
5) SO… there is science/medical evidence here for the adverse effects of neuroleptics and atypical antipsychotic drugs. There is an opportunity to begin the discussion of CAUSING harm, There is an opportunity, then, to impact the *cause/effect* thinking that is so engrained on these units.
Though you tend to immediately grab on to a biochemical explanation for a state of mind, which I do not ascribe to either, you COULD go to the next level and realize that I am working as an advocate for *patients* to be viewed as the people they are and with professionals who don’t know what they are doing!
You asked me:
“How do you justify feeding your mouth by taking away the freedom of innocent people?”
I have yet to exercise the only ‘power’ I actually have to take away another’s freedom while earning my paycheck.I have yet to initiate either restraint or seclusion for a *patient*. I earn my salary adhering to my own (higher than the my professional code) of morals and ethics where people are being deprived of their human rights and inherent dignity. You are well aware, I am certain.; that for all the righteous indignation and cries for justice on this site and all over the world from psychiatric survivors and their allies, PEOPLE ARE STILL BEING LOCKED UP AND FORCED TO ENDURE HARMFUL *treatments*.
I have a pass that grants me admission to these units, as an employee who will absolutely NEVER endorse or condone the practices you know very well. This is my personal contribution to the cause, and I am in it for the long haul.
I may be crazy for taking this job, but I am NOT stupid!!
xo,
Sinead
“4) Scientific evidence supports: A) the brain responds to dopamine blocking drugs by making more dopamine receptors. B) When the dopamine blocker is suddenly removed, there will be a sudden increase in dopamine C) Insomnia is a sure bet…. D) Consistent with *patient* reports: “Haven’t slept in … several days!””
Not sleeping, is not the reason stated for committing somebody. There has to be someone who doesn’t like the content of the person’s thoughts.
Nobody can prove any “dopamine flooding” is the cause of the prohibited thoughts.
I see how you view your job, you’re better than most, but the way I play it, is I boycott earning any money from people’s detention, don’t set foot in an evil place, and I’m happy that way.
Hey Sinead,
I really appreciate the work you are doing. Unfortunately, I lost the job i had, and am not in a position to do what you are doing, but I am thrilled to learn that there are people like you out there.
I wish when they committed me on a 72 hour hold that one time, I really wish I had met someone like you. The story might have had a different ending if I had.
You are right of course, the staff needs to learn to do things differently. The attitudes that we hear during staff meetings / change of shift meetings are trained in to the staff, and can be trained out of them. I just think it will take a lot before that happens.
You are right, it keeps intact a power structure, based on the fears of staff.
As far as the “he/she is so borderline and will do xyz”, I am not sure it would have worked where I was at to ask the reporter to describe in detail why they were to say that. I remember some conversations with a reporter taking a lot of apparent joy in describing what they would refer to as “borderline behaviors”, and actually sounding like the gossiping neighbors or junior high girls back stabbing others. I am not sure how that trap could be avoided. I could imagine a conversation about why we staff found this person difficult to work with, and how that impacted us would work. I can also imagine a conversation about what we think the person in crisis genuinely needed and how we could best provide it would work.
Either way, it all comes back to attitudes, the use of language and finding ways to approach those who needs a bit of help from a kind, caring and respectful place.
Malene
Why do merely wish for a nicer person on the other side of the table during the time you lose your freedom?
Why do you even accept the very notion of being imprisoned “for your own good”?
Hey Anonymous,
Well, I was asking for help at that moment. I shouldn’t have been committed, and if the person I had spoken to had any kind of ethics, I wouldn’t have been. So right there, if the person in front of me had been “real”, things would have worked out better.
That doesn’t change the fact that I did ask for help. Instead of help I got dehumanization, degradation and a ridiculous and irresponsible amount of medications. I will never forgive the corrupt hospital system for kicking me while I was down. But I did want a kind and understanding person to listen to me. That would have been “help”.
Malene
Why do you even accept the very notion of being imprisoned “for your own good”?
?? What NOTION?? It’s the LAW!
ACCEPTING *that* is crucial !
Maybe there is some measure of personal pride in defying an unjust LAW. But defying it is a personal choice to risk the consequences… no matter the specific law, no matter the innocence of the one negatively impacted by it. In the case of involuntary commitment statutes, there is a very real possibility that the dire consequences will far exceed the personal benefit of pointing out the injustice of the law !
I want to change this reality, not become another failure statistic. There are countless minds that must be changed, IF this law is to be justly abolished. I can’t help worrying that when you instigate out right rebellion at the point of confrontation with this law as a *detainee*, you are actually fueling the mindset that defends this law!
I hear what you are saying and know how easily *report* can become gossip and even demoralizing judgments of others, staff and *patients* alike. My learning curve on this very important aspect of language as attitude reflector, has cost me a job or two. Years into the learning curve now, I am finding that the discussion, if it is to be helpful, and IF it is to be based on solid knowledge; IT, the discussion must be redirected to:1) The fact that behavior happens in a context— not a vacuum. and 2) The context is both within and external to the person acting out. The progress, or help, depends on gaining this information and developing insights regarding how to assist the person to regain and maintain control. Maintaining a non triggering environment on a locked unit is virtually impossible. Teaching another person how to regain control involves developing a connection to her and THAT means that at some point we *staff* need to talk in ways that allow us to connect to what is basic and human in us all. At the very least, we *staff* cannot deny that unless or until the *patient* trusts us, there will be no progress at all. Who would trust people who gossip behind their back and reduce their suffering to hideous terms ? These are the points I am pondering as I look for opportunities to create possibilities for *staff* to achieve a human victory with a *difficult* to deal with person in crisis. When such a victory is achieved, it is no different for the *staff* than it was for you or MJK , or David Bates. THAT moment of knowing we helped someone with our very lives , our own personal humanity is extremely profound and reinforcing for the development everyone working with people in crisis needs to maintain momentum and conviction… and most of all, hope.
You see? Our failures are valuable lessons. Our community is key to our advancing— we are always working “together”. I deeply appreciate your courageous front line work and on line sharing!
Dear Dr. Steingard,
The 17th International Conference on the Treatment of Psychosis was hosted by ISPS, “an international organization promoting psychotherapy and psychological treatments for persons with schizophrenia and other psychotic conditions.”
http://www.isps.org/index.php
I noticed the 18th ISPS conference is listed as:
‘Best practice in the psychological therapies for psychosis: A contemporary and global perspective.’ A conference for all mental health practitioners
As a mental health advocate, it seems like a lot of time and effort is spent on what appaears to be a constant battle between only two main perspectives of mental health care: psychiatrists and the advancement of medication management v. psychologists and the promotion of talk therapy.
The many other alternatives and evidence-based treatment options seem to be ignored.
I appreciate reading Duane’s comment:
“I only hope that we don’t miss out on using as many tools as possible that lead to self-empowerment – neurofeedback, mindfulness, nutrition (orthomolecular approach), to name but a few.”
What are your thoughts about the benefits of Functional Medicine for the treatment of psychosis?
Here is a link to The Institute of Functional Medicine:
http://www.functionalmedicine.org/themovement/international-movement/
“The Institute for Functional Medicine is the global leader in functional medicine education. We are a nonprofit organization dedicated to serving the highest expression of individual health through widespread adoption of functional medicine as the standard of care.
Together, we can change the way we do medicine, and the medicine we do. You can join the movement in several ways and help us move toward a higher standard of health care.”
In general, do you feel Best Practice Assessment is being used in most cases of psychosis?
Here is a link to the British Medical Journal’s published guidelines for Best Practice Assessment of psychosis:
http://psychoticdisorders.wordpress.com/bmj-best-practice-assessment-of-psychosis/
BMJ: helping doctors make better decisions
Step-by-step diagnostic approach
The evaluation of the acutely psychotic patient includes a thorough history and physical examination, as well as laboratory tests. Based on the initial findings, further diagnostic tests may be warranted.
Organic causes must be considered and excluded before the psychosis is attributed to a primary psychotic disorder.
The most common cause of acute psychosis is drug toxicity from recreational, prescription, or OTC drugs.
Patients with structural brain conditions, or toxic or metabolic process presenting with psychosis, usually have other physical manifestations that are readily detectable by history, neurological examination, or routine laboratory tests.
Brain imaging is reserved for patients with specific indications, such as head trauma or focal neurological signs. The routine use of such imaging is unlikely to reveal an underlying organic cause and is not recommended.
Kind Regards,
Maria Mangicaro
Re : BEST practice.
It is outrageous that MEDICINE has established guidelines that:
A) Call for hospitalization on a locked psychiatric unit via involuntary commitment, as a first line treatment for someone presenting in the emergency department with *psychosis*.
2) It is outrageous that first line treatment IS neuroleptic or anti-psychotic drugs, administered either WITHOUT complete informed consent of the *psychotic* person and/or his parent/significant other OR by FORCE.
3) The medical screening process for physiological causes does NOT precede the *first line treatment*; nor is carried out as any other pre-admission screening for physiological illness occurs.
It is a very simple process to rule/out organic, physiological disease causes for psychosis, as it is easy to determine via toxicology, what *drugs* could be a probable cause.
I appreciate much of what you are proposing, but when you fail to address that discrimination against psychotic people as *patients* in doctor’s offices or emergency rooms as the MAIN problem, as the *cause* for the unjust and detrimental way these people are *treated* by MEDICINE, well, i have to think that you are just trying to tap a market for what you have to sell.
MEDICINE does not treat psychotic people as *medical patients* are routinely treated. MEDICINE fails to respect these people, their experiences and just can’t help usurping authority over their lives via violating their autonomy and right to *correct medical intervention*.
Maybe you are not directly involved in signing involuntary commitments and writing orders for Haldol in the ED, BUT, if you aren’t addressing this, and working to change it, I really can’t buy into your paradigm of *alternative* care. Surely you know that those most in need of alternatives are least likely to be granted the opportunity to make this choice by, MEDICINE!
Sinead,
I appologize if my post has offended you.
I am employed as a cashier at a retail store, so no I am not involved in signing involuntary commitments.
In the past I have been perscribed Haldol and I know what it feels like to suffer severe parkinsonslike-syndrome from not being perscribed Cogentin along with it.
I do not have anything to sell to those suffering from symptoms of mental illness.
I volunteer my time to several nonprofits concerned with mental health issues.
The reason why I support the use of Best Practice Assessment of Psychosis is because I was misdiagnosed in 1996 as having bipolar disorder. Below is a link to a narrative that was published in the JoPM that explains my past experience.
One of my goals as a mental health advocate is to call awareness of underlying medical conditions and substances that can induce psychosis and be misdiagnosed as bipolar disorder/schizophrenia, this is why I support the benefits of Functional Medicine/Integrative Psychiatry and Orthomolecular concepts.
I have met a number of other individuals who have been misdiagnosed. It is especially sad when an antidepressant or anothe medication induces psychosis and a person commits a horrific crime.
New Jersey officials reported a tragic filicide-suicide involving a 33-year-old mother who admitted to a 911 operator that she was currently being prescribed the anti-depressant Prozac.
On August 23, 2012 Police found the body of 2-year-old Zahree Thomas after his mother, Chevonne Thomas, placed a rambling, sometimes incoherent call to 911. Thomas openly admitted to the dispatchers that she had stabbed her son and in a gruesome discovery the toddler’s head was found in the freezer.
During the 911 call the dispatcher apparently recognized Chevonne’s apathetic tone and bizarre behavior may have been a result of taking a prescription medication and the operator asked if she was taking any. Chevonne acknowledged that she was on the anti-depressant Prozac but didn’t take it that day.
She could have been suffering a substance-induced psychosis from Prozac. I urge mental health advocates to start working towards a best practice standard of assessing psychotic states to rule out underlying cuases, including medication-induced psychosis.
Kind Regards,
Maria Mangicaro
http://www.jopm.org/perspective/narratives/2011/03/28/psychosis-possibly-linked-to-an-occupational-disease-an-e-patient%E2%80%99s-participatory-approach-to-consideration-of-etiologic-factors/
Hi Maria,
My response to your first posted comment on this blog was an attempt on my part to provide a realistic context for *the treatment of psychosis*. You say you’ve read Mad in America, but haven’t read Anatomy of an Epidemic? I think that when you do read Bob Whitaker’s most recent education manual for mental health professionals (my reference) you will see that the background for the current *harmful approaches from psychiatry* are rooted in disregard of the people who experience severe mental states; it is a paradigm of biological causes that are , 1) Without scientific evidence, that; 2)Have led to the dehumanizing of people- citing broken, damaged brains as disorders causing psychosis and other symptoms of so-called mental illness and 3) Justifying the harmful *medical interventions* that are currently thriving as *first line treatment for psychosis*.
My response provided very basic background, a context, that I urge you to study, especially since you want to create value as a mental health advocate. I am not personally offended by your comments here, but very concerned about a tendency exemplified by psychiatry, to propagate theories and promote treatments for conditions that are 1) Not very well understood and 2) Are NOT medical, physiological— in the vast majority of cases.
Of course, you are correct in pointing out that there are a few known physiological causes. My comment was focused on the fact that the screening process for these is very simple and NEVER done as a rule/out protocol BEFORE people are unjustly committed to a locked unit and/or forced to take neuroleptic drugs!
Yes, you are so right that psychiatric drugs can and often DO cause the very symptoms they have been advertised as treatment for…BUT, unless you realize what lies beneath the failure of our medical model for psychiatry– being NON-MEDICAL in every conceivable way; that it is a basic issue of discrimination against the people who exhibit symptoms labeled *mental illness* that *they* have been exploited for profit, or at the very least, invalidated as human beings with inherent basic rights.
I urge you NOT to get drawn into *alternative* treatment promotion UNTIL you have a firm grasp of the background laid out in Anatomy of an Epidemic. When mental health professionals are STILL struggling to come to grips with the reality of the unjust, inhumane treatment of people labeled with various forms *mental illness*, it stands to reason that the public is still easy prey for more of the same. Education is our only weapon against this. Welcome to MIA!!! Thank you for taking the time to respond to my comment, and please believe that I am not personally offended by anything you shared as a concerned, mental health advocate.
Best!
Sinead
Sinead,
I am really enjoying this exchange and I am very glad when I can have a welcoming conversation on this site. Thank you for your courtesy.
I have not read Anatomy because it it not in my local library system yet. I’m on a low budget and don’t spend a lot of money on books.
I have seen Robert Whitaker lecture in the past and have watched all of his lectures that are available online.
I think his C-Span discussion on Anatomy of an Epidemic is excellent.
If you have not seen this presentation, it is a bit long but well worth watching.
http://www.c-spanvideo.org/program/293935-1
Mr. Whitaker provides a concise outline of the research used in his book regarding the treatment of psychosis and shares the conclusions he has come to along his “intellectual path” of discovery.
Ironically, the conclusions he has come to regarding the treatment of psychosis along his “intellectual path”, relate closely to those I have formed from my not-so intellectual, sometimes psychotic, very grateful for restored sanity path.
My desire to help others and become an advocate did lead me to coursework that I thought would be helpful including, sociology, public justice, medical ethics, abnormal psychology, Constitutional law and some training in complimentary therapies.
Mr. Whitaker makes his C-Span concluding statements very clear.
My interpretation (summarized) of his his beliefs regarding the treatment of psychosis are:
– the research supports short term efficacy of antipsychotics and long-term chronicity
– the comparison research from 1945-55 involved treating psychotic episodes with hospitalizations that lasted between 12 months and five years.
– his book is not a medical advice book and does not encourage patients to go off of medications (although some psychiatric patients have gone off medications after reading Anatomy)
– he believes psychiatric medications have a place in mental health care
– Anatomy of an Epidemic does not take an anti-medication position and is in fact a “pro-med”, best use practice
– when considering psychotic patients, some will do better off meds, while others do better on meds
– he believes the psychophramacology paradigm is a failed revolution
– psychotic episodes have flu-like characteristics of coming and going on their own, treatment with medication is the best approach to quickly stabilize
– his appeal is to create a national discussion that incorporates the long-term data
Earlier this year, Jason Russell, the creator of “Kony 2012” suffered from “reactive psychosis” resulting in a bizarre incident in San Diego that ended with police transporting him to a mental-health facility.
TMZ posted the video and described him as “not your average crazy person”. This video demonstrates an important aspect of psychosis, that it can come on quickly and change how others perceive you permanently.
If this is what having a bout of the flu was like, I would sure want a flu shot.
http://www.youtube.com/watch?v=yGiR2TmeNYc
If I has the opportunity to ask Robert Whitaker two questions in an interview it would be:
If you experienced a first time psychotic episode, what treatment, if any, would you choose? and why?
What do you think of the BMJ’s guidelines for Best Practice Assessment of Psychosis?
I would love to know his answers.
Thank you for your comment. The answer to your first question is that I was not aware of this organization so I can not say much other than to reiterate my belief (as expressed in a some earlier blogs) that nutrition is critical to good health and that we spend a considerable amount of time and energy repairing problems brought on by unhealthly lifestyles.
Regarding best practices: I do not disagree with the BMJ excerpt you posted here. I do not agree with the focus on using medications early in first episode psychosis.
Dear Dr. Steingard,
Thank you for your response.
Functional Medicine/Integrative Psychiatry/Orthomolecular concepts involve testing for and treating underlying medical conditions/detoxing. It basically supports the BMJ’s Best Practice guidelines.
I have read Mad in America, but I have not read Anatomy of an Epidemic. In Robert Whitaker’s C-Span discussion, linked below he clearly states:
– his findings support short term efficacy of antipsychotic medications and long-term chronicity
– he believes psychiatric medications have a place
– Anatomy of an Epidemic does not take an anti-medication position and is in fact a “pro-med”, best use practice
– when considering psychotic patients, some will do better off medications
http://www.c-spanvideo.org/program/293935-1
Do you disagree with the conclusions Robert Whitaker sets forth?
I agree that Anatomy of an Epidemic is neither a pro or anti medication book. What I think are his major points – and I will focus here on the neuroleptics because that is my major area of interest and what I have reviewed personally in some detail – is that we do not have adequate information about the long term outcomes for people who are prescribed neurolpetics. What data exist suggest that there are people who may do better in the long term without them. Furthermore, he argues that this data is not promoted adequately and that the notion that all people who have experienced psychosis need to be on medication indefinitely is also not supported by data.
I have reviewed the data on the short term efficacy of these drugs and although I do believe they can be effective for some people, they are as a group not nearly as effective as one might be led to believe by the way in which these drugs are promoted.
I read in your comments elsewhere that you have some personal experience with these drugs. I deeply respect your willingness to engage in conversation on this site. As you know if you read what I write, I continue to prescribe these drugs but I try to be very cautious and I try to be as open as I can with my patients about what I know and – as importantly – what I do not know.
As you also know, there is no controversy about many of the serious side effects associated with these drugs. Therefore, if there are ways to help people recover without them, I believe I have an imperative to look into those approaches.
Sandy,
I’ve been mulling over this statement in your comment/response to Maria:
” As you know if you read what I write, I continue to prescribe these drugs but I try to be very cautious and I try to be as open as I can with my patients about what I know and – as importantly – what I do not know.”
I see this as an example of your employing *theories* as a basis for your interventions. ??
Earlier you commented:
” Psychiatrists are not the only ones who can use their theories in a way that is hurtful.”
Regarding your own writing here, I feel an urgency to point out that you seem to be discounting two important factual points:
1) Psychiatrists are the ONLY ones in the mental health field who CAN cause true, physiological/emotional/spiritual harm with the actions they CAN take on their *theories*. Psychiatrists wield the prescribing pen; the commitment to involuntary *mistreatment* and forced drugging pen. There is a big difference between “hurting someone’s feelings” and “destroying someone’s life”.
2) You have consistently cited Anatomy of an Epidemic as a “neither a pro or anti medication” book, while failing to comment on the this book being the first strongly referenced, clear exposure of the “lie(s) behind the biomedical model of psychiatry” . So while you are quick to point out that an investigative journalist is NOT assuming the role of the MD, you avoid commenting on being one of the MDs who has and “still does” prescribe drugs for *non-existent* bio-chemical disorders of the brain.
Yes, you do have your theories. And surely many of us do as well, but your unique position of power to cause harm via the authority by which you CAN act on your theories, places you in a very separate, unique category.
Open dialogue takes place on a level “playing field”, so to speak. The very real and present barrier for psychiatrists to utilize this very human form of understanding seeking exchange, IMO, is their inability to see themselves as *non experts* with no *special powers of authority*. And this extends to the confrontation with who they are in the scenario that has produced very formidable psychiatric survivor/ service user groups. IF psychiatrists want to engage in open dialogue HERE,I believe it is imperative for them to demonstrate the most basic of human traits: acknowledgement of error, remorse and dedication to repairing the damage caused to millions of people, a growing number of whom are children.
Sandy, you and other psychiatrists who present yourselves here, have inspired the following analogy :
I see: MIA blogging psychiatrists are like beach balls thrown into a pool, where psychiatric- survivor/reform groups are like heavy objets that have migrated down to the bottom of the pool, forming a new floor/foundation. Many attempts are made to push the beach balls down to the new floor, foundation. Some of the” balls” claim they want to be part of that newly forming floor/foundation– but something about their basic nature, causes them to pop up to the surface, again and again! I assume that the beach balls float because they are full of air; that so long as the air (could be hot?) remains inside the balls, they will keep popping up to the surface!
Holding on to false beliefs regarding their participation in widespread deceit (based on theories upon which they have reached consensus)(despite lack of scientific evidence) and perpetuation of their expert,- take- the -lead- on the surface of the pool- status; many psychiatrists cannot fully engage in open dialogue. And they won’t be able to do this, I maintain, until they release all of the” hot air ” that keeps them at a great distance from those who will succeed in alleviating the suffering caused by psychiatry and establishing something like a new world order of basic humanism where open dialogue is just “what WE DO”!
In my 24 years of associating with psychiatrists, I know only one who has said: “I made a terrible mistake.” or “This *medication* is harming my patient”. This one psychiatrist was in agony over these realizations. I hardly wanted to bash him for his errors. And he is my actual proof that beach balls can make their way to the bottom of the pool and become part of the movement for change!
Here at the bottom, we like to keep it real 🙂
Thanks,
Sinead
Maria-
I also want to add that your summary of Anatomy (in one of these comments) is incredibly articulate and clear in my opinion. Perhaps we can get Bob to provide an answer to your questions.
Hi Maria:))You bring up a fundamental issue above, about our “intellectual” assumptions of a disease process in mental illness, particularly the analogy of flu like symptoms in psychotic behavior? You write;
“Earlier this year, Jason Russell, the creator of “Kony 2012″ suffered from “reactive psychosis” resulting in a bizarre incident in San Diego that ended with police transporting him to a mental-health facility.
TMZ posted the video and described him as “not your average crazy person”. This video demonstrates an important aspect of psychosis, that it can come on quickly and change how others perceive you permanently.
– psychotic episodes have flu-like characteristics of coming and going on their own, treatment with medication is the best approach to quickly stabilize”
This “as if” assumption in comparing psychosis to a viral infection, goes to the heart of our common need for easily digested plausible explanations which both self-sooth & appease the consensus norm of expectation need?
Later in this thread I’ve re-posted a poem about toxic shame & with a suggestion taken from family and emotional systems theory, that society works like an extended family, and revolves around an axis of Strong/Weak, Pride/Shame, as a direct expression of our internal guidance system, the autonomic nervous system.
I’ve been loath to use the Jason Russell, footage in my comments here so far, understanding how sensitive American society is to any description of human behavior, with somehow insults a faith in God, by suggesting we are in fact a human-animal.
There are other clips of Jason’s behavior that day, which are longer than the one you point readers towards, and I suggest that watching his movements closely, without a perceived “concept-cognitive construct” of assumed illness, what we see is the naked ape, acting out? Please consider an approach to understanding the human condition which is not based on tribal attachment beliefs, and does include every member of our human species?
http://en.wikipedia.org/wiki/The_Naked_Ape
Also, if people watch the TMZ video clip and the comments of others, about Jason’s behavior, this Weak/Strong, Pride?Shame axis of emotional projection in our behavioral responses, can clearly be seen in the emotionally adolescent “reactions,” which pretend to be slick, sassy reasoning?
IMHO. INSTINCT lies at the root of so-called mental illness and in psychosis what we see is a misunderstood attempt by the brain/nervous systems to re-condition through new experience, the connections within the brain stem which have conditioned a response to threat, which was once external and has become “internalized,” through the now popular “neurons which fire together wire together?”
Obviously its a more complex process than I describe, yet our unique susceptibility to trauma and its internal mechanisms are increasingly being understood, as the root cause of much human dysfunction. The trauma reaction of nervous systems function is also applicable to an organismic response to invasion from without, such as infection. Gulf war syndrome, is a classic case of such nervous systems reaction to infectious invasion?
Warm wishes,
David Bates.
David,
Jason Russell’s wife said a contributing factor to the brief reactive psychosis was dehydration. Dehydration can cause psychosis.
This “as if” assumption in comparing psychosis to a viral infection came from Robert Whitaker, not me.
Does anyone know if Robert Whitaker has ever taken a course in Abnormal Psychology?
Or what degrees he holds? and from where?
David,
In your opinion, what can society do to prevent tragedies like that of Chevonne Thomas?
Police found the body of 2-year-old Zahree Thomas after his mother, Chevonne, placed a rambling, sometimes incoherent call to 911. Thomas openly admitted to the dispatchers that she had stabbed her son and in a gruesome discovery the toddler’s head was found in the freezer.
She admitted to the 911 operator that she was on Prozac before killing herself.
http://isepp.wordpress.com/2012/08/24/cases-of-filicide-do-911-operators-easily-recognize-medication-induced-psychosis/
For those interested in exploring the myth of our so-called intelligence, with its blind faith in cause & effect mechanical analysis, I highly recommend Teresa Brennan’s articulation of “The Transmission of Affect.” Please consider;
“The idea that one can soak up someone else’s depression or anxiety or sense the tension in a room is familiar. Indeed, phrases that capture this notion abound in the popular vernacular: “negative energy,” “dumping,” “you could cut the tension with a knife.” The Transmission of Affect deals with the belief that the emotions and energies of one person or group can be absorbed by or can enter directly into another.The ability to borrow or share states of mind, once historically and culturally assumed, is now pathologized, as Teresa Brennan shows in relation to affective transfer in psychiatric clinics and the prevalence of psychogenic illness in contemporary life. To neglect the mechanism by which affect is transmitted, the author claims, has serious consequences for science and medical research. Brennan’s theory of affect is based on constant communication between individuals and their physical and social environments. Her important book details the relationships among affect, energy, and “new maladies of the soul,” including attention deficit disorder, chronic fatigue syndrome, codependency, and fibromyalgia.”
Review:
“Brennan challenges what she views as a uniquely Western myth, that individuals are discrete and self-contained, with affect driven primarily from endogenous sources. Instead, she argues, humans absorb emotions that originate from others and that influence their very physiology and experience. This argument challenges the boundaries that are often assumed to exist between the self and the environment, between subject and object.”-R. Compton, Haverford College, Choice, September 2004
“It is truly exciting to read something so far beyond the usual scholarly projects: the scope of this highly original book is quite revolutionary and the erudition and historical research by which Teresa Brennan advances her argument are impressive.”-Linda MartĂn Alcoff, Syracuse University
“The Transmission of Affect is subtle, innovative, and trenchant. It provokes fresh questions about the relations of mind and body and it proposes original answers. Teresa Brennan’s charged and lucid prose makes us understand our experiences in new ways.”-Gillian Beer, author of Darwin’s Plots: Evolutionary Narrative in Darwin, George Eliot, and Nineteenth-Century Fiction
“In this rich and provocative book, Teresa Brennan has developed an alternative theory of affects that challenges any notion of self-contained individuals. Her theory of the transmission of affect insists on a constant communication between individuals and their environments, with social pressure acting at the intersection of the social and the material to bring together mind and matter through energetics. A well-thought-out and clearly argued treatise that gives credence to some popular ideas about energy, The Transmission of Affect will shake up many of the ideas that are in vogue in the academic establishment-part of the reason that it is such an exciting book.”-Kelly Oliver, Stony Brook University, author of Witnessing: Beyond Recognition”
http://www.amazon.com/The-Transmission-Affect-Teresa-Brennan/dp/0801488621
From a chapter entitled, “The Sealing of the Heart;”
“The notion that free-flowing anxiety are in the air, and more prone to descend on the anxious, has been expressed in the vocabulary of doubt and guilt and despair. The earliest Western records of the transmission of affect (excluding the Homeric record, which makes them monitions or energies from the gods) make them demons or deadly sins.”
This book is a brilliant alternative view of emotional suffering, which puts the heart and not the head, at center of our individual experience and our group behaviors. I’ve expressed elsewhere that I think its time to accept what is now staring us in the face, about the chemical reality within? That changing our metaphors of self-definition, from external object orientation to internal chemical functioning, will allow us to “sense,” of what we truly are, and explain the extraordinary sensitivity of experience, in so-called, mental illness.
IMO We are not separate from the Universe, we are the Universe observing itself and acting upon itself? Such a notion of chemical metaphor, is captured brilliantly by the author of “A Brave New World,” Aldous Huxley;
“Nothing in our everyday experience gives us any reason for supposing that water is made up of hydrogen and oxygen; and yet when we subject water to certain rather drastic treatments, the nature of its constituent elements becomes manifest. Similarly, nothing in our everyday experience gives us much reason for supposing that the mind of the average sensual man has, as one of its constituents, something resembling, or identical with, the Reality substantial to the manifold world; and yet, when that mind is subjected to drastic treatments, the divine element, of which it is in part at least composed, becomes manifest.”
It is this change in metaphors of self-definition and understanding, which has allowed me to make sense of those overwhelming experiences of oneness, I go through during 40 days & 40 nights of a euphoric psychosis, as I continue to practice sensing my reality within.
Warm Regards,
David Bates.
Hi David,
Of course you would have the human knowledge of human existence, references to reinforce what I am experiencing in the *trenches*. I am bringing my awareness of *oneness of self/universe/other* via my affect into a very convoluted arena, where it is so dark, one could not see her own hand in front of her face! My own understanding of the transformations I am witnessing merge from my study and practice of Nichiren Buddhism. However, after studying your posts on Chrys’s recent blog on “us v. them” – I feel that my dance background, training in body work and practicing/teaching Peter Levine’s instructive exercises, have prefaced my current appreciation for the power of affect.
Before I recognized how my own affect could function as a defusing/disarming catalyst, I knew well how deeply I was impacted by the affect of the major authority figures on psychiatric units. My visceral reactions to their affect(s) led me to an understanding of the root cause for “us v. them” thinking. It is a strong and urgent need to separate one’s self from an evil too horrible to name. BUT… Once you give IT a name, THAT deep personally threatening fear goes away.
Words from thoughts formed out of a real and present danger; perceived threats to the integrity of our psyche FEEL like shields of self preservation. These words spring from impulse, not reason, and they draw a very clear distinction between *us and them*. WE are safe with these words that place the threat outside of ourselves.
BUT our TRUE self is never really in danger, only the small minded ego-self, the animal self is really being threatened. (Right?)
What then is our TRUE self? You describe the feeling awareness of it very beautifully. I hope the words inspire the action required to experience the truth of what you have shared.
Cheers!
Sinead
Hi Sinead, re the trenches and those awful moments when the human distress alarm goes off, in another and we all react? An interesting review of Brennan’s book;
“The animal of ourselves is secretly captured, driven and dictated to by the bio-chemical, emotional, conceptual and social ropes which bind us to our communities and our lives. There is something in the thick of the air which is not pure idealism or voluntary metaphor, but palpably reaches into us and calls us out with its physical inter-penetration, transcending our merely conceptual placements as to where we begin and end; we are not contained individuals but already and always entrammeled, beyond ourselves in the endless repercussions of things. If there is no other or ideal space than this one in which we live, where would we get our freedom from? We are led by mobs and hysteria, by the continuities of language and information, by images and news media and myth and pictures of emotion which conjure emotion; there is no escape; we are the place we are in.”
http://www.amazon.com/The-Transmission-Affect-Teresa-Brennan/product-reviews/0801488621/ref=dp_top_cm_cr_acr_txt?ie=UTF8&showViewpoints=1
For those readers interested in the power of word/symbols to affect us within;
“The power of words is bound up with the images they evoke, and is quite independent of their real significance. Words whose sense is the most illdefined are sometimes those that possess the most influence. Such, for example, are the terms democracy, socialism, equality, liberty, etc., whose meaning is so vague that bulky volumes do not suffice to precisely fix it. Yet it is certain that a truly magical power is attached to those short syllables…‎ (p, 54.)”
I think others where you work, Sinead are affected by the essence of your true-self and your growing ability to find that space beneath all conscious communication. What is the essence of light, or a flower, or the affective essence of a truly heartfelt smile;
“The Buddha is said to have given a “silent sermon” once during which he held up a flower and gazed at it. After a while, one of those present, a monk called Mahakasyapa, began to smile.
He is said to have been the only one who had understood the sermon. According to legend, that smile (that is to say, *realization*) was handed down by twenty eight successive masters and much later became the origin of Zen.”
Excerpts from “A NEW EARTH” by Eckhart Tolle.
Best wishes,
David.
David,
Thanks for the “goose bumps”! Always appreciate feeling more alive as I head back into the trenches with– my flower?
xoxo,
Sinead
Thank you, David, MY FLOWER !!
Is what I think best captures what I experienced when reading your response above…
WORDS— and beyond !!!
In any case, I hardly go into the trenches alone… anymore
*:-)
Sinead
Hey Sinead,
Ran out of reply buttons above, but I wanted to reply to your comment about involuntary commitment being the law.
Yes, it is the law, and in the absolute most extreme cases it makes sense. Violence to self or others, or the inability to care for the most basic of ones own needs can necessitate involuntary commitment. The problem is that the law as it currently exists is very easy to take advantage of. It gives an inordinate amount of power to people that we know are already dehumanizing those they should be caring for.
In my case, yes, there was enough suicidal intent to warrant a 72 hour hold. However; I took myself to the hospital and asked for help. This means that they should not have utilized a 72 hour hold. I was also out of the most acute suicidal tendency within about 50 hours and should have been let go at that point, I was not. In fact, I had to get the lawyers involved to get them to rethink the idea of extending with a 2 week hold.
This is the only time in my life when i honestly believe that the fact I had insurance was not in my favor. Had i not had insurance and thus a way to pay for the hold I would have been out of there in 24 hours; 12 if they were busy.
So, Yes, it is the law. It is a law that is all too often abused by those in power. For that reason it is a law that needs to be changed.
Malene
Malene,
I totally agree that this LAw needs to be changed. It is outrageous that it became LAw in the first place, BUT, my point is that when someone chooses to make a case for this law being unjust, while facing the enactment of said unjust law, the consequences are nasty. For all of the reasons you and Anonymous site. this LAW becomes a weapon wielded by a certain brand of authority who gets pleasure from flexing its muscle.
I wish that just saying this out loud was all it took. I wish that when I first challenged a psychiatrist issuing a section 12 the result had reflected the truth of the matter. That’s NOT how it went. Instead, I was “put in my place”, which didn’t set well with me, so I went further to suggest the obvious: “You seem to be viewing a medical decision as a means for settling some personal grudge you have .” Prefaced by, “With all due respects”… The psychiatrist maintained a perfectly neutral affect and said, in a gentle tone; “You seem to be over-identifying with the patient, which happens frequently with new staff. You won’t last long here if you can’t separate yourself from the patient’s personal drama and see the BIG PICTURE.”
There it is!
Malene, I have witnessed your perfectly reasonable recounting of your encounter with the *law* countless times. Yes, insurance plays a role, but over all the power trip thing is very sensitive to being challenged. The more a patient or I challenge IT, the more power is exerted over the patient… and me , too, for that matter.
I keep in mind that it is not just knowing when to engage in battle, but knowing what is and is NOT a battlefield. Or at least, I know when the playing field is not level….
“Yes, it is the law, and in the absolute most extreme cases it makes sense. Violence to self or others, or the inability to care for the most basic of ones own needs can necessitate involuntary commitment. ”
This is the ‘other people’ deserve forced psychiatry but not me argument.
Violence to others is a police matter, violence to self is something violent hypocrites use to selectively justify ripping freedom away from certain self-harmers and not others.
You’re allowed to stuff your face with fast food and give yourself a heart attack, but if you ever dare take to your wrist with a knife, you’re going to lose your freedom.
Society only pretends to care about freedom, and society only pretends to care about protecting some people from themselves in some instances and not others.
It would be better if the busy bodies would just let people alone.
Anonymous,
you said: “Society only pretends to care about freedom, and society only pretends to care about protecting some people from themselves in some instances and not others.”
In my idealistic day dreams, I address *society*… a large diverse group of people who have the attention span of a knat ( ? sp? small insect) on a good day. I see occasional flickers of recognition that the topic *human rights* should be attended to, BUT… that look is quickly dissolved into helplessness, a shoulder shrug and “That really sucks!”caps off the interaction.” WELL!– you may need an up close personal experience to light a fire under your apathetic butts!” That’s about when I become the target of verbal abuse … and remind myself that SOCIETY is made up of individual people whose thoughts, ideas and major concerns are unknown to me unless I connect on a one to one basis and ASK some questions.
One thing I do know for sure about the individuals in “our society”. They do not believe that have any power to directly influence or redress any grievance they may have regarding human rights. In other words, SOCIETY, a collective term for enfeebled individuals here, does not view itself as FREE or powerful.
I’m working on ideal one to one and small group discussions in close proximity to the unjust incarceration of innocent people. Hoping for a ripple effect…
Anonymous, I couldn’t disagree more. While I believe that I strictly speaking should not have been committed, the fact that it happened is the least of my complaints. If I had received help after I was committed then I would have been ok with it. I do believe that acutely suicidal people should be helped not to do the act. Most acutely suicidal people usually think better of their plans after a relatively short time frame. They want to get away from the pain. Help then should consist of some way to get the pain under control. Stopping the self destruction is a valid concern.
No, I have been around enough people in distress to know that there are a few extreme situations where taking away a person’s self determination briefly will help them find the strength to rebuild after the crisis is better managed.
The problem is that we do not offer valid help after the 72 hour hold has been initiated, in fact the help we offer does more damage, and is managed by power hungry people without the right training.
Malene
You couldn’t disagree more. Fine. If you want your freedom taken away, go lobby for “Malene’s Law”, and make sure it only applies to YOU personally. Not anyone else.
If it stands a chance of ensnaring me, I’m against such a law.
I own my body, and unless I’ve committed a crime, I deserve freedom. As does everybody.
Real supporters of human rights don’t make exceptions. All humans deserve human rights at all times.
What you seem to be saying is, distressed humans don’t deserve their freedom, and by extension, that all people should be forced to live in fear of the “people from the government who are here to help us”.
“Stopping the self destruction is a valid concern. ”
It may be a valid concern but it is not a valid reason for a set of laws to take away their freedom.
And I note, there are many self-destructive behaviors, such as eating too much, that you’re prepared to allow adults the freedom to indulge in, with forcing you definition of so called “help” on them.
Using government force to “help” people is a recipe for destroyed lives.
Dear Anonymous,
Your thinking about “human rights,” looks spot on, at first sight. There is a lot about life which “should be” right. Yet does this rational reasoning serve an inner purpose which is not easy to see?
We all tend to think in idealized terms about how life should be, and hopefully will be in the future, yet how do we in so-called 1st world societies explain higher recovery rates in countries which have less “human rights?”
Our mechanically minded cause & effect logic, usually assumes its because of “lack” of access to medications? Yet these countries where recovery rates are higher also lack a welfare system of state support, which allows individuals & families to avoid “responsibility,” for their survival?
I know you don’t like me mentioning Murray Bowen, yet please consider this explanation about how society “functions”;
“After the mid 1960’s there was more evidence of an even lower level of societal functioning. There was more feeling-oriented action and less long-term principle planning, more “rights” thinking than “responsibility” thinking. The overall pattern was closer to that of a family with a problem child, giving into emotional demands, hoping the problem would go away.” _Murray Bowen.
Murray Bowen’s seminal ideas, inform much of the ground for the systemic approach which Sandra is reporting on here, and which Robert likes to quote in a meta-analysis, cause & effect approach, to analyzing mental health. A cause & effect approach which works fine if we’re analyzing a machine, yet gets nowhere near understanding the systemic interactions of our body/brain, or the systemic emotional interactions of group dynamics.
IMO What we all avoid in our “intellectual” rationalizations, is the reality of how we actually function, with far more unconscious reaction stimulating our so-called reasoning, than we care to admit?
Your “should be” idealizations are great, and I agree completely with your sentiments, yet suggest that what these idealized fantasies are largely self-stimulated to avoid, is the reality within, as we project an emotional need onto the world out there?
Perhaps you might care to read this comment & tell me what you think?
“What I’m saying, is about our common tendency to look at the world, and think that we really do perceive what is going on out there, and why society functions the way it does?
Yet consider the role of *unconscious* motivations, and ask yourself if perhaps there is a system within, which creates the so-called *system* we observe, without sensing how each of us functions, on an unconscious level? Consider;
“The subconscious, the other 90% of the mind, is responsible for a variety of functions, such as the physiology of the autonomic nervous system, our dynamism or energy, and our *habitual patterns*.
I think these unconscious habitual patterns create the system, we call society, and we are all far less self-aware than we admit to? Keeping a focus on *them* serves the useful purpose of avoiding our own internal motivation?
Its the *realization* of our common humanity, in the way we all function, that I think is required to change *the system.*”
http://www.madinamerica.com/2012/08/rxisk-stories-azathioprine-withdrawal/#comment-15371
Best wishes,
David.
Sure, the all powerful psychiatrists doesnt like to have their power questioned. Certainly; I as someone who has been in the system am easy to discredit. So might you be if you are not busy kissing up to the right *sses.
Does that mean we should give up on the fight?
I dont think so.
Malene
Malene,
I have been discredited on many levels over the past 24 years and as I mentioned earlier, lost a few jobs over being outspoken and proactive. I have no talent or skill for flattery or kissing up. I am even less inclined to aide in a CYA episode. I’ve worn a target in enemy territory for being a *whistle blower*. I was recruited for my current inpatient/locked unit job after nearly two years of being black listed in the field.
Every day I take full stock of the dangerous territory I breech, and know that I will probably never feel that my job is secure— especially if I continue to uphold my professional standards and code of ethics. So, I am no better or worse off than anyone in our current economy– employment wise.
If I gave the impression that I am giving up the fight or suggesting it is not worthwhile, then I want to correct your impression. I actually believe this is the most important battle of our lifetime and that is precisely why it must be won. I reject tactics that have led to countless defeats— for the same reasons. That’s all. Just like there is wisdom and knowledge reflected in a decision NOT to administer toxic treatments, so I believe that employing self restraint requires wisdom, knowledge and tons of experience.
It’s almost as if you have a double job. You must wwalk with the people in your care, and you have to educate most of the rest of the staff. Hard, hard work. I suspect that the second is much more difficult than the first. Perhaps it’s a matter of building bridges, not that you have to accept the ways of those on the other “side” of the chasm, but so that some common ground might be built so that all of you can stand comfortably in the same place and when they are not threatened or fearful they can listen to what you say and see what you do. As long as they are fearful of you they cannot and never will learn from you. I salute you in your endeavor because I know how difficult it is to show people that they have nothing to fear. Yikes, Anonymous will probably be after me for all of this but I think it’s true. The other staffs’ fear is partly what makes them hold so tightly onto all of their psychiatric jargon, useless labels, and authoritarian attitudes. I want to fight them in oiutright battles but I know that this will not lead to much progress.
Could this be similar to what David is always talking about?
Stephen,
Please forgive me for possibly getting you into more hot water,,, BUT, you are expressing realizations that gave me goose bumps for the second time today as I revisit our *open dialogue* here. The first goose bump reaction did happen to occur when I was reading David’s response to me above–.
Yeah— this stuff is more visceral than cerebral and FEAR itself is the strongest catalyst for so much sub and/or unconscious impulses to affect expression and action. sometime I think that the more we focus on just overcoming the fears we can name, the more we will become aware of those that plague us anonymously. (no reference to our dear friend here, intended).
I was working night shift with two MHC’s a few years back. All three of us women, but the MHCs were both young enough to be my daughters. One particular (15 y.o.) patient was evoking fear responses from one of these young women while evoking a steady flow maternal nurturing responses in me. My plan to set a tone for day shift where this young man would greet the day in a place of warmth, acceptance and care involved my waking him fully after vital signs assessments to offer him a tui na back massage — which he often requested to help him fall asleep, but also provided a sense of grounding and safety for him as well. One of the young women began to interject what she interpreted as “the treatment team’s” strict guidelines for minimizing “rewards” for this kid due to his episodes of acting out– property, not people destruction, but none the less scary because he was 6″1″. (same height as my own adult son) I am, according to my son “5 foot nothing – just shy of 100lbs)— the least intimidating presence with absolutely no skill or desire to develop skills in limit setting… etc. You get the picture. My *staff* obviously was more focused on my physical appearance than spiritual strength?—- even knowing I had a solid track record for kids NOT needing restraint of any kind when I was in charge. So, here I was assuming T., the young MHC would just TRUST me and I was becoming irritable with her challenging my plan to create a safe unit for day shift. MY plan was to create a safe feeling for the most *disruptive* (in THEIR eyes) patient. Perfect sense. Nope! T. continued to challenge until she began to slip in little threats, like,
“I will need to inform the team leader and nurse manager if you don’t follow the *treatment* plan”.
I pondered the whole situation and said to her: “I am going to carry out what I believe will be the best intervention for our patient. His safety and feeling of being cared for is my focus, but I know it will benefit ALL— so here it is :first, the patient, then the unit, followed by the staff… etc” My priorities– logic, reasoning all spelled out in WORDS with the goal of easing the edge off of this MHCs attitude of challenging me as the charge nurse. She said :
“Yep, you are in charge all right. It’s YOUR license. So, go ahead and do whatever you want.”
That was not the response I was going for. I am always uncomfortable with lack of unity amongst front line staff. but, the more WORDS I used, the more entrenched she became, and I realize I was just going to be following HER directive, that is :go ahead and do whatever I wanted”
Intervention/ back massage TLC etc, worked like a charm. Everyone seemed happy on day shift as well, but T. had placed a complaint call about me to the “brass”— and let me know on her way off the unit at the end of our shift.
The “brass” is currently a colleague and back then my strongest supporter/advocate in the nursing scheme of things. He urged me to talk it out with T. and invite him in of that didn’t work.
So–I had an opportunity a few nights later. Me and T. on a quiet night. I started the discussion with wanting to understand what exactly about my intervention plan was causing her so much anxiety.We went back and forth with superficial stuff and political roles on the unit and suddenly she just said :
“That kid scares the hell out of me. I did not want him awake when just the three of us women were here. ”
Mind you we were not without immediate back up… can;’t provided details or I will give too much info about ‘where this took place” BUT , still I started to notice T.’s affect… more than I thought about the WORDS she used.
She was scared, no doubt. So , then I asked if she had cause to feel that I was jeopardizing her safety; that I was not confident in my own practice and relationship with this kid. Ego stuff, Right? but my ego touched off this— the crux of the matter:
T. said: “The way you show caring for some of these really rough kids makes me feel bad–(inadequate). I guess I really do’t’ feel “unsafe” when you are in charge, but you do have a way of making me feel terrible about myself… even for being afraid- even when there is good reason because a kid has acted out violently— you still make me feel bad for having the fear in the first place .”
I felt terrible. I could sense her suffering and see it all over her face. I don’t really SEE myself as some special entity as far as kids go, BUT I do sometimes get irked when I demonstrate confidence that is REAL and get reactions that make it seem that something is WRONG with me, or that I don;t GET IT. I will always— continue when I KNOW that my plan is best for the *patient*… and ALWAYS have and will say:”I am taking FULL responsibility”
I told T. that we could learn from this— I wanted to show attentiveness to her “feelings”– and wanted her to feel comfortable saying “I am scared of this kid”. That matters to m,. and it isn’t up to me to talk her out of it… but realize that the goal is for her to overcome the fear. Genuinely. THEN, regarding the way my caring about a kid she felt negative towards, I shared an experience from my early days as an ICU nurse when I failed to live up to my own standards of compassion, and became physically sick at the sight of a patient’s head injury. IShe was very supportive around this being a universal reaction- potential— even nurses have their *weakness*.. BUT,” NO !”… I replied this is about how I FELT about ME… I could not accept my response… and went on to say that this episode had happened when I was about her age; that I have seen the story change in my mind over time to being a learning experience of my own humanity… humility..
“I know how it feels, T.”, I said, ” to realize you aren’t as good as you believe you are or should be. It’s OK. ”
Since then, I have placed more emphasis on the affect my co-workers are showing—-attuning to it… feeling it myself. I am less critical and judgmental about staff as individuals and more aware of my influence over creating an environment where they—-where WE all can be steadily growing and improving.
THIS story could have been a very descriptive narrative about the challenge of working with “untrained people” who cause trouble for anyone who actually DOES care about the patients. Maybe it would have led to my UNJUSTLY being disciplined for being a “good nurse”— or how “bad kids” just wreck a unit and threaten the safety of staff— because STAFF won’t own their own FEAR and work to overcome IT, instead of the easier route of “Blaming the patient” for scaring the crap out of them.” You see what i mean…?
IF we can sustain engagement with each other—- we WILL find the place of increasing our understanding of each other and ourselves— WORDS are our tools, but affect awareness and recognition and all the sub/unconscious underpinnings are the horizon… our “collective” evolutionary challenge?
Welcome aboard!
xo,
Sinead
Anonymous… since you point out:
Not sleeping, is not the reason stated for committing somebody. There has to be someone who doesn’t like the content of the person’s thoughts.
Nobody can prove any “dopamine flooding” is the cause of the prohibited thoughts.
I see how you view your job, you’re better than most, but the way I play it, is I boycott earning any money from people’s detention, don’t set foot in an evil place, and I’m happy that way.
I just want to reiterate that I am not debating the relevance of your more sophisticated understanding, I work with THREE people who have your level of knowledge and passion for protecting the rights and freedoms of ALL people- unjustly incarcerated under false pretenses, suffering harm … The majority of staff I encounter believe they have the job dialed in, and aren’t even interested in who blew the whistle on what type of disturbing thoughts the person was having– or if this is right or wrong in theory or practice. Focusing on sleep deprivation ties into the major complaint or uncomfortable precipitating factor for most of this type of admission. It is important, I feel, to highlight a good reason why MORE Haldol, for example is a POOR choice; Haldol is more like a silver bullet than a *magic* one. Or pointing out that the “more sedating drug, Thorazine” is even worse… and there are better ways to promote sleep, rest and the real need to talk to this person about every decision he has made, most importantly discontinuing his Haldol! From there, we would begin the journey of learning the person’s story from him. FIRST, I began to call attention to the ‘lies’ about the wonder drugs themselves.
Am I really earning money from people’s detention? Most of the people I meet are ambivalent about being detained, that’s for sure. Would I be working with any of these people if they weren’t detained? No. Because I would not be meeting them, because they are, in fact, detained. If I quit my job today, these people and a steady stream of others will continue to be detained. I will have my ticket out of this “evil place” and will not receive anymore tainted money. Will you respect me more for making this decision? How long before you wonder if I ever think about the people still suffering there? One minute would be longer than the time that passed before I thought of them.
“Would I be working with any of these people if they weren’t detained? No.”
That’s the key phrase.
Language such as “working with” when used in relation to a party who had choice in the matter, irks me.
I’m sure a lot of anti death penalty advocates would love to counsel and outreach and smooth the way for death row inmates, cook them a nice last meal, look into their eyes while the life drains out of them in the death chamber, but the way I look at it, most of them don’t take a job on payroll in the execution system.
Like I said you’re better than most, you’re hardly evil, but meh, I like it when people value voluntarism and voluntary interaction.
Anonymous,
Well, it irks me that you would assume I use language like, “work with” in a context of coercion. True, the majority of people detained where I work feel that they had no choice in the matter, but I don’t presume that they have to “work with me” just because they are detainees. I will not administer medications via any route to a person who is refusing them; regardless of physician orders or court commitment/Rogers. I evoke the ANA code of ethics for nurses with specific emphasis on the lack of evidence for calling neuroleptics *effective treatment* for a non medical phenomenon. I respect autonomy as a basic human right. “Working with” means collaborative problem solving with a person who is seeking his/her freedom.
I was recruited to role model humanistic, trauma informed care- on the units (3); to assist and educate nurse educators who have envisioned a *recovery model* . Some days it feels like a long shot— like when I had to say to my ‘bosses” . “Recovery in the true sense is about overcoming the harm done by psychiatric treatment. There is no such thing as a disordered brain or “mental illness”– the biomedical paradigm is an outright lie.”
I create documentaries of this surreal job during my one hour commute. The facial expression on my colleague’s face when I handed her back the power point she had used to orient new nurses, explaining my corrections is “priceless”. By the time we got to the “brain” slide— straight out of a NAMI pamphlet, she was in tears. She has since read the supporting literature and I have empathized from the depths of my being. I know, too well how it feels to discover the truth and then try to unravel and understand the betrayal. I will take my come uppin’s for being ignorant, but I won’t become arrogant and self righteous around my peers when I witness their anguish.
In the trenches, Anonymous, the microcosm of our sick society has built up a resistance to truth that seems to replicate as quickly as malignant cancer. I did not return because I want to comfort the innocent victims of unjust incarceration and forced drugging. I agreed to perform a professional service that is either a daunting challenge or a crap shoot. (depending on the what I put into my daily documentary). BUT it is the work that reflects the value I can create; my livelihood. I also voluntarily support activism on the community level and network with therapists and social workers who are struggling to protect kids in foster care and our public schools from the “Biederman net”.
I meet amazing people on locked units— people of all ages that I feel fortunate to have encountered. The first kid I went to the mat for just started her freshman year , with a scholarship for writing. According to a prominent young psychiatrist, who will not remain nameless, I promise, this young woman belonged in a state hospital, and that is where she was headed … for medication noncompliance and no insight into her mental illness; a danger to self and others, whose parents could not contain– detain? FOR her own safety. She is one a several who wanted to work with me while being detained against her will. AND that was before I KNEW what a sham psychiatry is!
What really irks me is how hard it is to just tell the truth— how many hoops I have to jump through and rehearsals of bad news I have to do JUST to talk about the OBVIOUS to highly educated professionals. That’s WORK and if I didn’t believe it is my mission to accomplish, you couldn’t pay me enough to do it!
Sinead-
You have been fairly critical of me at times but I sometimes think about who I would want as my advocate if I were to land on a locked psychiatric ward and I must admit, I would likely choose you.
Good luck with your work.
Sandy
Sandy,
What a team we would make… whatever our roles and wherever the setting!!!
Thanks for this deeply meaningful compliment
*;-)
Sinead
I commented on your last post on page one of the responses here. I think it fits here too. Despite what anyone may say here about my response, I commend you for what you’re accomplishing for I know that the way you walk with the people on those locked units is appreciated by those you travel with. You are making the human connection from wich all other things flow. Without that connection nothing can be done, no matter who well intentioned it may be. Most of the conventional staff are not making any real human connections.
I think that some people here believe that working on the locked units is a walk in the park and that we go home in the evenings counting all of the big bucks we’ve made that day and feeling very proud of ourselves. In reality, much of what we witness rips our hearts out or puts such big holes in them that they will never be filled. But we can’t leave people to those fearful and ignorant staff who most of the time don’t even realize that they’re wrecking trauma and havoc on people, all done in the name of the best practices of care! Very few peers ever come back to work in hospitals and locked units, probably because true peer work is almost impossible to carry out in these places. Perhaps they can’t stand being reminded constantly of their own time spent in such places. But I’m reminded of one of the mottos of I think it’s the Marines: “You never leave a wounded comrade on the battlefield.” Perhaps this is why a few of us return. I don’t know.
“I think that some people here believe that working on the locked units is a walk in the park and that we go home in the evenings counting all of the big bucks we’ve made that day and feeling very proud of ourselves. ”
I never said this with relation to “peers” who do this.
There are psychiatric nurses etc who are very proud of themselves. Whether they find it a walk in the park, I could not care less.
The folding of psychiatric survivors into paid employees in mental hospitals is a co opting coup for psychiatry.
There are all sorts of rationalizations.
We are going to have to agree to disagree.
And, Stephen… we can’t continue to do this work ALONE, isolated and struggling to heal from what is now being called, “vicarious trauma”… but really is another chapter David Bates has been kind enough to write for us…HERE!
And rather than going down with the ship.. how ’bout we build some kind of flyin’ contraption??
xo,
Sinead
Sinead
I have great respect for the work you are doing. I have worked in a community mental health clinic for 19 yrs as a counselor. This is an area of work close to the trenches in which you are imbedded; though not nearly as intense. Almost every day you have to walk that fine line challenging Biological Psychiatry and their disease model with both staff and clients and at the same time try not lose your mind and/or your job. This is not easy to do. You are have educated yourself well and have great courage. If I ever entered such a facility I would want you there to support and protect me.
Anonymous, I respect your unrelenting criticism and analysis of Biological Psychiatry; I always look forward to your take on blog submissions. In this case I believe your criticisms of Sinead are overly harsh and mispalaced. Many people who end up in locked units in my area are there with some amount of choice; they frequently ask to be hospitalized and know ahead of time it will be locked. They first went to a crisis center for an evaluation in desperate need of help, most often suicidal. It is also true that some are there completely against their will.
I don’t believe that Sinead is a person that will give up or back down from her principles. She is taking great risks with her aggressive defense of patients and her attempts to educate staff. If she were to be fired (and that is very likely given the strength of Biological Psychiatry at this time) she will not go down without a fight. This will draw a powerful line among staff and force many to choose sides and grapple with their own conscience; patients will also ask why she disappeared. We need some people working on the front lines like this. There is no victory without risk.
Richard
Thanks Richard,,, and I would add,
There is no “i” in TEAM…!!
for the longest time, I felt like the “i” stood for isolated— where there is not even another soul to form a duo… the “i” that made the “i”-dea of a team for the work we do “I-mpossible”!
Who knew?
The “i”-nternet could be so “i”-nspiring an all of us “i’s” so “i”-nnovative!!
I very much appreciative our “team” here!!
Sinead
I just found your latest post in our conversation. What you said reminds me of one of the first things I was taught in chaplaincy training, and it showed up again in peer training. One of the most important things that a person can do is ask this question of people who oppose you or whom you oppose: “Help me to understand why you feel the way you do>” If it’s asked in a genuine manner with the attitude of really wanting to learn from and undersand that person you have problems with, it often opens doors in ways you never imagined. It helps to build that bridge across the chasm and it prepares the “safe groud” that both groups can come together on. I have the feeling that this is much of what you do.
I wish we could clone you because we could use a dozen of you where I work. Thanks for responding.
One of my big problems with where I work is that now I’m on the staff and rub shoulders with some of the very people who tried to coerce me or who threatened to call security on me every time I didn’t jump when they thought that I should. The old feelings are still there about them being the “enemy” and it’s extremely difficult for me to work towards a different understanding of them. It doesn’t help when those very people come up to me and act as if we’re now the biggest bosom buddies that ever existed. They’ve conveniently forgotten the fact that they didn’t always treat me with dignity and respect and like a regular human being but they expect me to put that all behind me and let bygones be bygones. Hmmmmmmm……….
Stephen,
I found a YouTube link to this documentary created in MA. and used extensively in restraint reduction/elimination training . I have witnessed some transformations in staff who were strong proponents of the therapeutic value of “force” and threat of force. The ultimate teacher, the equalizer… when all else fails, such are the rationalizations of those who have become completely disconnected to the deeper awareness we have of what it feels like to be violated. Perhaps, it is a shield, used to prevent the conscious memory of that feeling, or the fear of having it. The task at hand is not easy. It is difficult to know what sort of stimuli will penetrate the walls built up by suppressing this fear. As a teacher, I try to come up with as many different venues , as I can to share a message that is difficult for most of my audience to hear. This documentary,like any on this subject, carries the warning of being very disturbing. Guess what? THAT is precisely what drew the audience I most wanted to reach into the conference room for the showing of this video/documentary/training film. They were lured in by the disclaimer! Not so tough after watching the film.
I think you are amazingly courageous to challenge yourself to work on a unit where you have experienced so much humiliation and degradation. Perhaps because you showed up with the capabilities you obviously have, this reinforced to your ‘enemy’ that they are justified –“Look!, Stephen is cured- and WE helped!” Of course if you had sunk deeper into despair, these same people would no doubt absolve themselves of responsibility and pat each other on the back for trying so hard….”poor, Stephen…”
There are peer specialists in the video who speak very candidly about their experiences being restrained. Maybe your co-workers will hear something that leads them down a different path on a journey of understanding .
I really admire how you are walking into the lions den. Though you may not be aware day to day of the growth you are achieving, I bet you will see the cumulative effect of conquering your own fear in order to help your comrades still in captivity. You could just let it be known that your appearance on this unit it not about wanting to connect with and thank people who treated you with disrespect and degradation, BUT to be the light and warmth you were seeking when locked up with them.
Wait a minute! IF your presence is a beacon for another *patient*, then there is something profoundly valuable about your initial experience being locked in with bullies. And if even a horrible experience like that can become the catalyst for all of the good you are doing…., then ,in effect, we all could say thank you to whatever the adversity that caused us to awaken to our own humanity. That’s an enlightened view of things… and NOT a suggestion that you party/celebrate with this group until they have completed sensitivity training. 🙂
http://youtu.be/Z0iqYGE01-Q
Here is the link to the sensitivity training I had in mind when I started this response to your comment…
May the Force be with you!! or at least, not AGAINST you!
xo.
Sinead
Hi Sandra!!!
just to say it was great to meet!. I am back at work and reminded every day about the importance of taking a stance and try to find out every day what is now “the best” to do.
Met a little girl yesterday together with her parents. She has after ONE meeting with professionela, as we are called, got a very severe psychiatric diagnosis. That is what is needed to focus on, as I think. The far too fast assumptions about other peoples way of behaving, feeling and thinking.
So we have to keep up the work and try to make it more humanistic and including. No matter if calling it the one or the other method. That struck me during days and nights in Findland, the, as it seemed need from so many participants to get a “solution”, a method, a certificate and so on.
I know it is necessary maybe to have some method to hold on to, but it may never be, in away which takes away the focus from the people we meet in every day work.
once again, great to meet. Take care.
Carina
Carina-
Thank you so much for reading and commenting! Your perspective and comments are invaluable to me and everyone else here. I tried to tread so lightly on the notion of method and to focus on attitude and perspective because I did take away that this is the most important thing. The challenge is how to convey that attitude. Most people think they are being humane. However, I continue to believe that there is something fundamentally different about what you and your colleagues are doing.
To anyone who reads this – please read Carina’s blogs! She is an important voice in this discussion!
Carina – send my regards to your your colleagues and please keep contributing here!!!
Sandy
To others: Please check out Carina’s blogs on this website:
http://www.madinamerica.com/author/chakansson/
I just ordered your book!!
Thanks a lot!!!! and also for reminding me how to use words like human and humanistic. It takes too much time at the moment to express waht it means to me, but I will come back to it. Love, Carina
This is in response to Sinead latest to Sandy, which is hard to link to since we ran out of “reply to”, but it had to do with the unique position of psychiatrists in that they can prescribe drugs and make commitment (sanctioning) decisions.
We need to start a thread or forum on the following:
-Where should people go when they are interested in receiving help for problems of living?
-What training, if any, is necessary for those in a “helping” role?
-What reimbursement structure, if any, makes sense in these instances?
-How will everyone know that the process/relationship was beneficial to the person seeking help?
Maybe this is being discussed in Laura Delano’s forum, but I think we need to start discussions on these very basic concepts.
Sinead – I guess you are – like me – a psychiatric nurse and therefore, like me, have inside knowledge of cases so grotesque they defy belief. What baffles me is that you can work on a locked unit where it’s patently obvious that coercion is used, perhaps even on a daily basis, and yet be exempted from taking part in the execution of decisions to employ coercion.
But let that be. This discussion has brought up very many very interesting points, some of which I feel a need to contest, some of which I’d like to endorse or simply ask for more elaboration thereof. I’m not aquainted with American practice but I assure you that in the civilized countries of Europe, involuntary commitment is not first line treatment for people presenting with psychosis. The majority of people presenting with mild symptoms of psychosis would not be able to get admitted even if they wanted to – and often they do want to. The countries I know of have strict guidelines for the use of involuntary commitment, which always entail a requirement to document that stringent efforts have been made to secure the patients’ compliance, before any form of compulsion is considered.
Likewise with medication. Although it is true that medication is the first choice treatment for psychoses deemed severe enough to warrant admission, there is generally only one exception to the rule that coercion can only be considered after all other avenues have been exhausted. The exception is where a patient is already under a court order to receive medical treatment for his condition.
And medical screening processes for physiological causes certainly do precede any treatment in Europe, at least inasfar as it is possible to gain the patient’s consent to these processes. (In the case of ‘swingdoor patients’ a recent screening process from an earlier admission might be considered up to date enough. )
I would also contest that it necessarily is a simple matter in every case to rule out organic/toxicologisk causes as the primary ætiology. It is very common to see a developing schizophrenia masked by a chronic use of cannabis, where many years may go by before it is possible with any confidence to reach a diagnosis.
As to the question of whether coercion is intrinsically bad, I do have to admit that after 25 years in the service I no longer (it would be an emotionally impossible thing to do) ask this question every time I make use of it. I only ask if it is the least evil of the available alternatives. As recently as today I have used coercion – it was a very quick and undramatic process where as much dignity and respect as such a situation allows was preserved, the goal being simply to ensure the patient was not suffering certain kinds of side effects as a result of his treatment. Contrary to what some believe using coercion is never pleasant for the staff, nor does it satisfy power lusts or any other kinds of deviant psychological or physical needs. True professional satisfaction comes alone from using ones skills to garner trust and form therapeutic alliances with one’s patients.
Most professionals are used to being demonized of course, and don’t last long in the profession if they can’t take it with a smile. What really left a lasting impression on me as a newly educated nurse, determined to be the best and wisest, with a real commitment to listen to patients needs, and act solely in their interests, was a psychotic man who resisted all my attempts to reach out to him and refused both general care and dialogue as well as the offered medical treatment, and who by utilizing all his patient rights to have the proposed treatment reviewed by the independent patient counselling body, managed to delay the start of treatment by four weeks, in which time he became more and more chaotic, but finally after being treated coercively, recovered his composure and was able and willing to enter into dialogue again, and showed a personality and humour which before had been completely absent. This man then suddenly said to me one day in the course of breakfast: “What the hell took you so long getting round to getting me medicated?” It turned out that this was all he’d been waitng for; he both expected and wanted it, but in his psychosis, whether by command of voices, or by dint of some delusional system, he was committed to strive in the very opposite direction. The decision to treat had to be ours, and had we not taken that responsibility upon us we would have seriously let him down.
So even though the principle of the least invasive intervention for me is sacred, I now know that the field I am in is a field of the most amazing paradoxes, where weak or no intervention actually can be less respectful and in a sense more invasive than intervention where coercion is necessary, and it can certainly be more negligent.
I think the comments and questions I have about Open Dialogue (the subject of this blog after all) I’ll make in a new reply, to avoid this already long piece getting even longer. But I’d like to say one last thing about science concerning knowledge and hypothesis. The dopamine hypothesis remains that. It is not knowledge and professionals with respect for their science and profession do not pretend it is. The same applies to the much more popular ‘knowledge’ which is getting bandied about everywhere; I’m referring to the discovery, some believe, that the brain reacts to treatment with dopamine blocking neuroleptic medicine, by sprouting more D2 receptors in an attempt to compensate, and this is what acounts for people becoming psychotic when they come off the meds (in contrast to the much more simple and obvious explanation which is that it was the medicine which was holding psychosis at bay.) This new ‘dopamine theory’ interesting as it is, is by no means established fact. It is, just as the old dopamine theory only a hypothesis. Please remember this.
Hello Colin,
Just out of curiosity, did I notice misspellings that indicated that you are from Denmark? I think I did.
First of all, let me say with 100% certainty, the use of coercion is always and inherently traumatic, disrespectful and wrong. That is not to say that there might not be some extreme examples of when it is necessary, but those examples have to be extreme.
I also think it has to be seen as an inherent failure of the care takers when and if coercion is used.That means if you use coercion then you have failed in your duty to that human being, and you should be doing some soul searching to find out what you could have done better.
I would highly recommend that you spend some time reflecting on your own emotions each time you felt that coercion was necessary, because you were an acting participant and your emotions would necessarily play a role in the situation. Now, if the person mentioned above knew with certainty that you would never have the power to medicate him against his will, and you managed to establish a connection with him, do you think that the power plays and interactions would have been different?
Secondly, your attitude that “hey, we have to be used to be demonized” is also inherently disrespectful and dehumanizing. It completely disregards why those you are trying to help might feel upset enough with you to “demonize” you. I suspect they sometimes have good reason to be very upset with you. If you ignore that then you abuse your power. I would suggest you find some humility – in all the power you, have are still fallible, and you make mistakes. When you have power over others then those mistakes have a exponentially bigger impact.
Thirdly, you claim that there is no power hunger at play when you choose to use coercion. I still hold that there is a huge power differential inherent in the relationship. Just the fact that you are capable of using coercion if you deem it necessary shows the inherent power differential. Please do not fool yourself into thinking that human beings are not apt to sometimes take advantage of the power they have. They might not do it out of a perverse desire for power – for instance I think fear is a much more common reason why nurses like yourself sometimes abuse their power. That said, the second someone has all the power in a relationship is the second someone sometimes will abuse that power. It is just human nature.
Finally Colin, be careful that your humanity is not trained out of you. I suspect you are on the wrong track – the track that sometimes, maybe unknowingly, dehumanize those you are trying to help. Denmark has a proud heritage in the humanities, tap in to it. Tap further into the humanistic currents in psychology. There is no excuse for the obvious disrespect shown above to those you are trying to help.
Malene
Well said, Malene.
I will add that the dopamine hypothesis has been fairly well discredited (if you haven’t read Anatomy of an Epidemic yet, you need to – the studies are there), and even some mainstream psychiatrists have recently come out in the national media and acknowledged that “things just aren’t that simple.”
As to the increase in dopamine receptors with antipsychotic use, yes, that is also a theory, but a theory with a lot more science to back it up. Starting with animal models, the observed response is well documented. It is also very well studied in the field of addiction medicine, where changes in receptor densities have been found to correlate with the development of tolerance as well as with extended withdrawal processes that last many weeks or months longer than the actual removal of the drug from the person’s body. It’s been particularly clear in studies of withdrawal from benzodiazepines that anxiety attacks became MUCH WORSE than baseline during the withdrawal process on the average.
Given this, I don’t see why it’s far fetched to say that withdrawal from antipsychotics can cause a temporary increase in psychotic symptoms, even if you do believe the dopamine theory. It seems just as well supported as the idea that going off medication brings back the original symptoms, which is also, in your own words, just a theory.
As a fellow scientist by training, I am sure you would agree with me that a theory is only as good as it is able to predict future events and allow us to predictably influence them. The litmus test of the “dopamine theory” does not really rest on whether or not dopamine imbalance is involved in psychosis, or whether there is an increase in dopamine receptors with long term use. The test is whether or not intervening with antipsychotics produces the expected results. In the short term, there is no denying that it can reduce psychotic symptoms dramatically. But long-term outcomes, from Soteria House to the Harrow study to Open Dialog, appear to suggest that this short-term benefit can be deceptive, and that other non-medical or limited-use approaches result in much better long-term outcomes. That should be enough to convince anyone that the idea of using lifetime antipsychotic prescriptions as the preferred “treatment” for “schizophrenia” is not scientifically supported.
Add in the radical concept that it may, in fact, be the patients themselves that are being “demonized” and that their resistance to medication may be, in many or even most cases, very well-founded and rational, and the idea of forcibly medicating someone beyond anything but the most severe immediate crisis situation (and even then, only after everything else has been attempted) seems pretty oppressive.
—- Steve
Thanks Steve,
As I was mulling over this thread again, I should add a comment about the difference between the US system and the Danish system – if indeed I am correct that this this guy is Danish, I would almost stake money on it though.
The big difference lies in – money. In the US working nurses are often upper middle class, and doctors are relatively rich. Hospitals and insurance companies all need to make money, they need to turn a profit. Of course treatment decisions are influenced by this gluttony of money in the US.
In Denmark nurses makes solid money, and so do the doctors, but they don’t get rich. The hospitals are all state run, which means they have zero financial incentive to hold on to people.
In the US hospitals have financial incentive to hold on to those with insurance, and no financial incentive to hold on to those without insurance, lets not pretend that this isnt a consideration. On top of that doctors sometimes gets additional financial incentives to prescribe certain medications.
Now, in the US multi-medication cocktails are extremely common. For instance, six years ago i was held on a 72 hour hold. This was the one and only time in my life I was hospitalized, and it was for suicidality – not psychosis. I was prescribed an SSRI, a benzodiazepine, risperdal, seroquel, lyrica plus one other anti convulsant I forgot the name of. I had never before taken psychiatric meds and _never_ ised recreational drugs. I was prescribed all medications in relatively high dosages. For instance, they tried to increase seroquel to 600 mg, although I completely refused that, so they lowered it to 300 mg.
Most people even over here would agree that this is ridiculous, but it is not that uncommon over here. I suspect these medications are not handed out like candy in Denmark. I suspect this for two reasons: I respect and know intimately the inherent common sense of the Danish soul, and the doctors do not have a financial incentive to medicate in to oblivion. The doctors over here do have financial incentive to medicate irresponsibly.
All of this said, the clear and obvious disrespect Colin showed for the people he is trying to help was like nails on chalk board for me. Even more so due to the just as obvious ignorance to the fact that he was extremely disrespectful. Breathtakingly disrespectful. Colin, you have a long path in front of you – that is if you don’t run screaming away from this site. I suspect some of the survivors here will make mince meat of you.
Malene
“Given this, I don’t see why it’s far fetched to say that withdrawal from antipsychotics can cause a temporary increase in psychotic symptoms, even if you do believe the dopamine theory.”
Well, you can’t both have your cake and eat it. If you’re saying that it’s true that antipsychotic medication causes increase in D2 receptors and this accounts for the return of even stronger psychotic symptoms on withdrawal, then you’re also saying that excess dopamine activity in some part of the brain is intrinsically bound up with psychotic symptoms, which in essence is what the original dopamine hypothesis says. “Things just aren’t that simple” is an excellent starting point, since the brain IS complex, but I know of nobody who can think without one, so it’s a fair guess that seriously disturbed thought processes might be a manifestation of ‘faulty wiring’ in the brain. What constitutes ‘seriously disturbed thought processes’ and who has the authority to define which thought processes are and which are not ‘seriously disturbed’ is of course another matter, as is the question of whether the ‘faulty wiring’ is caused exclusively by genetic factors, exclusively by environmental factors, or a combination of the two, or indeed some as yet unknown third and fourth factors.
The addictive properties of benzodiazepines are of course well known, and they are on their way out in mainstream psychiatry. But that’s a completely different discussion.
Hi Malene . . . “did I notice misspellings” . . Well observed . . indeed you did although I have to say to my shame that I am English! Du har sikkert ogsĂĄ danske rødder med et navn som Malene.
“the use of coercion is always . . .wrong. [but] there might be some extreme examples of when it is necessary” Need any more be said? War is wrong but can be unavoidable.
That said is it then necessarily true that use of coercion “has to be seen as an inherent failure of the care takers “? Naturally none of us are perfect nor would we want to be, so of course a basic and vital component of any suitable training for this kind of work, has to be development of an acute awareness of the meanings, uses and effects of the interpersonal psychodynamics which inevitably attain to this work, the most important part of which is communication under sometimes very bizarre or difficult circumstances, where the patient experiences those who try to help as enemies and torturers. Our ‘soul-searching’ is therefore done on a systematic and regular basis with both group and individual supervision and counselling, and when finances permit it subscription to courses aimed at upgrading our skills and knowledge. I doubt if we ever find ourselves in a situation where we think that what we have done couldn’t have been done better in some way, big or small.
When I mention that most professionals are used to being demonized I was thinking more of the times when I’ve been accused of being in league with Satan, being a mass rapist who every time he is on night duty has his way with all the women patients, of working for Mossad and so on and so on. It is not in my opinion inherently disrespectful to shrug one’s shoulders and accept that this is part of the job
You are undoubtedly on to something when you begin to talk of fear as a background for abuse of power, but this is a huge and complex subject and to be able to talk authoritatively about it you need to have insight both into individual human psychology in extremely stressful situations, and a comprehensive understanding of the bigger picture in which large organisations operate, including the very real dangers inherent in the work. I have been battered several times but thankfully not as seriously as one or two of my colleagues who came close to losing their lives and were forced to retire with PTSD. Here the tendency is anything but to shrug one’s shoulders and accept it as part of the job. One makes individual decisions to err on the side of safety, and sharing these decisions leads to policy and finally a culture which puts safety first above all else. This can unfortunately lead to a quite restrictive environment which a psychotic but non dangerous patient with no insigt into the background for the culture, will inevitably find both absurd, demoralizing and intrusive.
Thanks for reminding me not to let my humanity be trained out of me. I certainly won’t let that happen; if there’s any one thing I am a little bit proud of it is my humanity which I guard jealously! As for yourself well it’s shame you lost your job at the halfway house. I mean if I’m trained wrongly, and I’m doing the wrong things and harming the people I’m trying to help, and need the right training to do it properly, then who is going to help me? I need a demonstration of someone who is doing it right. Who is it who is in possession of the truth and can show all of us in the dark the light? When are they coming my way, and where are the successful cures of people I once regarded as hopeless? So I hope you’ll get back on the right track again soon and perhaps be my beacon of light.
ps I have no problem with people making mincemeat of me. It happens every day. If someone’s got something concrete to offer me which will help me help my patients then my arms are wide open. If they’re just intellectually huffing and puffing, but in reality have no credible alternatives to offer then I pass them by, because I know they’re not the ones I can depend on to come and relieve me on the front line when the going gets tough, and I need a bit of support.
Re: “The use of coercion is always wrong [but] there might be some extreme examples of when it is necessary.”
Comment:
It is NEVER necessary unless a person is given “due process” – legal *proof* that a person is an *imminent* threat – an attorney with alternatives, non-drug options, presented as options to forced psychiatry
And the “necessity” is not comparable to war. Nothing compares to war. Including the sacrifice many make to prevent situations like (unconstitutional) forced psychiatric treatment.
Alternatives? –
http://discoverandrecover.wordpress.com
Duane
I understand you are from Denmark?
It makes no difference.
“Constitutional” rights are universal.
Natural law is not complicated.
Human beings have inherent rights.
Including the right to life, liberty and property.
These rights cannot be taken away, without “due process” of law.
Forced psychiatric treatment that ignores this Natural Law is destructive to the spirit and inhumane.
Duane
Oops,
My apolgies, you said you are ‘English’.
Duane
Hey Duane,
I remember a woman a few years back who spent a lot of time talking with her voices. She lived on the street and her whole existence was preoccupied with the voices. She often was unable to find food for herself, and by the time she was put on a 72 hour hold followed by a 2 week hold her clothes had rotted off her body so that her privates were showing. Never mind the indecency – it was cold out. Something she seemed to not even really notice.
There were resources available in the community for homeless people that would give her access to food, shelter and clothing, but she was too far gone to take advantage of those resources.
Now, I hear you – force is wrong. Even worse, what we had to offer this woman after using force sucked fish.
The woman in question clearly met a legal definition of “severe mental illness”, in that this definition specifically stipulates a person who is unable to provide food, clothing or shelter for themselves.
The reason that I can accept the use of force in such an extreme example is because I think it is just as wrong to ignore this level of suffering. I am the type of person that if I see a wounded animal on the side of the street i stop. Even if I just see a lost dog I stop. I cant live with myself if I ignore it. If I come across someone on a highway that has a flat tire I stop my car and ask if I can help. I can’t turn away from a woman who stands around talking to the voices, with her privates showing, and unable to realize how hungry she is because of how loudly the voices are screaming. I am sorry, I cant ignore the suffering.
Now, I think we need plenty of non-coercive options. I think the options we currently have are horrific. I think our current systems should be trashed so we can start over. If we do it right, then maybe we wouldn’t have to use coercion in above mentioned example. If we do it right maybe she would have never gotten so far out to start with.
But, in examples that are this extreme I will rather show my caring and do something – even if initially that something is not what the person claims they want, than I will ignore someone who so clearly needs help.
So, you are right, we have rights. Coercion is wrong. I agree. But, I think there are extreme examples of human beings who so clearly needs help, even if initially they are unable to accept the help. I am not prepared to ignore their need either.
As for above mentioned woman, she was on a 2 week hold in a hospital and was force medicated. Then she came to the half way house I worked for an additional 2 weeks. During the two weeks in our house she did not express not wanting the medications. After that I don’t know what happened to her. When she left our house she was still officially homeless although we had hooked her up with some community resources. When she left she seemed able to feed herself, realize if she was hungry and perform daily actions related to hygiene. She was also able to hold a conversation that included thinking about the future and taking care of herself. I think a lot more should have been done for her – in fact, I think we should have had the mandate and resources to make certain we got her permanent shelter as well as someone to make certain she continued to make certain she could feed herself.
Again, i dont like our current options in this situation. I dont like the medications. I hate the hospitals. The half way house were I worked was only marginally better. I will even say that the people who decided to hold the woman in question might have been more upset about the indecency and nudity than motivated by a sincere wish to help her. It was a conservative community, those old church bitties got an eyeful.
Still, could there be a place were we can meet? I will rather use some force than I will ignore the suffering of above mentioned individual – is that a point of view you can relate to or respect? Or, do you think I should be willing to just turn a blind eye and drive on?
Malene
Malene-
In an ideal world, what would you have wanted to do for this woman?
Malene,
Each one of these cases needs to be heard in court, because they are each unique. (with a lawyer, representing the person).
Before anyone is put in a “hospital” for their “own good,” the facts of the case need to be sorted through, and the best interest of the person whose freedom hangs in the balance need to be considered.
If these basic freedoms do not apply to the most vulnerable, then they apply to none of us.
Anyone is a do-gooder away from being forced to undergo brutality, in the guise of “wanting to help.”
If a person cannot take care of themselves, a judge/jury might consider a non-profit – three hots and a cot, until someone could be seen bt a doctor, arrangements made for long-term place to live – least restrictive, most therapeutic environment – not an expensive, dangerous psychiatric ward!
Duane
Well – like it or not coercion is a fact of life. We meet it both in psychiatry and in a thousand other situations in life having nothing whatever to do with psychiatry. So NEVER is a very unrealistically categorical stance to take if left unqualified.
I’m not quite sure what you mean by “due process” but something along the lines of the protocols required to be adhered to by a police officer making an arrest is my guess.
Life and liberty I go along with as inherent human rights but property? That’s a weird assertion I’ve never read in any book on philosophy, and sounds especially weird in the world’s most supreme capitalist state where the doctrine that rights to property are not inherent but have to be earned is almost religion.
Anyhow whatever the case what has it to do with psychiatry? Are psychiatrists now beginning to take people’s property as well as their lives and liberty over there?
Hey Sandy
You asked: “in an ideal world what would I have liked to do for the woman talking to her voices”.
In an ideal world, I do not think her situation would have ever gotten so far out. In an ideal world there would have been people involved in her life, whom she trusted, that could have prevented this ever coming to that point.
I think it was a lack of people whom she trusted that made her completely withdraw. In an ideal world she would have been offered qualified help by kind and respectful helpers well before it came to the point it did.
If she refused the help then I could imagine one or two people getting assigned to go by her daily hang out spots on an every day basis making sure she had food and clothing. Making sure to take her to shelter again and again until it sunk in to her clouded self that there were options she could rely on. Then I think she would have started to take advantage of those options on an ongoing basis and help could then become many faceted. No force would be needed then. She wasn’t self destructive just lost in a world of voices.
So far I have never met a human being who didnt want or long for kindness and caring when things are difficult. If they are shown that kindness, caring, non-judgmentalism and respect then I would hazard the opinion that 99.9999% of people will want to take advantage of assistance. The problem is that
the system is inherently judgmental and disrespectful.
I have a question for you too Sandy. Let’s say that by some miracle we managed to completely reform the system. In the new system there were probably not nearly the need for psychiatrists with an MD because lets just say that 1/100 the amount of medications would be prescribed. Which means only 1 in 100 psychiatrists remained. Would you be willing to take a drastic pay cut to remain working in the industry but not as an MD? or would you leave the industry and use your MD in a different capacity?If you would not be willing to take a drastic pay cut, can you see how that sets you up to maintain status quo?
When I refer to a drastic paycut then I can tell you that in this area people working in the mental health field without an MD typically makes from $12-$30 an hour.
Malene
Once again, we are in agreement. We have a new program now – staffed with peers and professionals – that goes out to where people are to try and engage and thereby avoid the kind of situation you have described. I am not sure there is a need for psychiatry. I undoubtedly will never convince you that I have little stake in maintaining the status quo but I understand your point.
Hey Duane,
I think we essentially agree. It should be exceedingly difficult to rob someone of their freedom based on “mental illness”. Judges should be involved, I can easily agree with that. I think there are situations when decisions have to be made quickly and we might not be able to get someone to a judge instantly, but in principle I completely agree with you. I also agree that we should have good options available when we decide to force someone into treatment. Options that are not currently available. Our current hospitals are not valid options.
Malene
Colin,
The phrase “life, liberty and property” dates back to the writings of philosopher John Locke – one of many Jefferson drew upon for inspiration. It is the essense of our common law, our Constitution.
You seem to take the loss of freedom very lightly. I do not. We’re opposites – to say the least!
Duane
You say that coercion is never pleasant for the staff. I wholeheartedly disagree. Some people derive a lot of pleasure from controlling and punishing people, and it is natural that this particular species of human would gravitate towards the jobs that offer them scope to exercise their will to control and punish.
Also, whether or not a psychiatrist or his/her subordinates derives pleasure from coercing and meting out punishment to a patient is contingent upon the character of the relationship. If there is enmity between the two, then the one who has powers that he/she can use to his/her advantage in the struggle might derive pleasure where otherwise he/she wouldn’t.
Your argument on this issue is transparent propaganda that makes me think that, well, you would say that wouldn’t you, I mean, after all, in order to adapt to your environment properly, you need to be constantly inventing casuistries to pacify your conscience and to think well of your actions, casusitries that have come to seem like self-evident truths to those who profit emotionally, psychologically and materially from them.
By the way, I also don’t believe that there is anything psychologically deviant about the lust for power.
To paraphrase Jeffrey Schaler from a recent debate about coercion on Cato Unbound, there is no postscript to the Bill of Rights stating “for mentally healthy people only”, just like there is no postscript stating that it should be left to the discretion of delusional psychiatrists (or to use your terminology, people who do what they do and think what they think by dint of some ‘delusional system’) who should be free and who should be allowed to own their own bodies.
You say that, as a budding coercer, you were determined to do what is in the best interests of the patient. If that was what really motivated you, you would have quit, having long since realised that you are simply not at liberty to act always in the patient’s best interests, because it is the interests of the state, of society, of the family, as well as the economic interests of the institution, that prevail where coercion is being used, which is an elephant in the room ignored because acknowledgement of its existence would be less emotionally and psychologically rewarding for the kind of tyrant who likes to delude himself that he is the benefactor of those whom he tyrannizes.
What you have not given us evidence of is why that gentleman underwent a change. Maybe it was because he recognised he was in a situation where he had no recourse to help whatsoever, so he changed his strategy, fully cognisant that more resistence to the busybodies who wouldn’t stop pestering the poor, hapless sod, would be an exercise in futility. Maybe this realization of the futility of resistence was the causative factor in this change of behaviour after all.
There are two kinds of human beings in this world. The first are easily susceptible to despair and fear in the face of insuperable opposition and do whatever they have to do to rid themselves of such intolerable sensations; the second, are like springs, in that the harder you push them, the harder they come back at you.
Whenever there is a discussion of the use of coercion in psychiatry by proponents of it, such considerations are conveniently ignored, and the change in a patients behaviour is wrongly attributed to the ‘treatment’ of that person’s illness, and the role of force in rendering the individual more manueuverable to behavioural change is consigned to oblivion.
I think the gentleman whose story you have given a biased account of is of that kind, but even if he wasn’t, even if he was grateful from the bottom of his heart, doesn’t make the act of pharmacologic-biological rape any the less despicable, especially when it clearly traumatises so many people and has biological and existential repercussions worse than the victim who experiences literal rape could ever dream of.
“You say that, as a budding coercer, you were determined…”
Now I know that this is a serious discussion, but I just had to point out this particularly clever phrase. A budding coercer. That’s good stuff Cledwyn. You’re an excellent writer and know how to turn a phrase.
We’re over a 100 comments on this one! This always happens when my friend Batesy is involved.
Gee David:)) is that a compliment, or am I wishfully thinking?
I note that on this thread, there is a turning towards real conversations about real-life situations & our actions & reactions, which is taking us beyond simple confirmation statements about our “us & them.” ideology.
I also note the reluctance of the more credentialed “intellectuals” to get involved in these more “real” conversations? I suggest this is NOT because of a superior education and therefore autonomic assumption of high ranking status, but FEAR of exposure, in their lack of self-awareness?
Something to do with the Western world’s practiced mythology about its superior intellect?
Of coarse I’m being deliberately provocative, hoping some bright shinny, educated intellect, might choose to debate me on the *cause* of mental illness?
Be well my friend,
Batesy.
Hey, Batsey!
You provocative dog, you! Just so you know, I am a “credentialed intellectual” (Masters in Education, BA in Chemistry, history as a counselor/therapist, MH professional, including 9 horrible months doing evaluations for “involuntary detention”), and love the ‘real’ conversations. But I do agree, there are actually a lot more professionals out there who are sympathetic to these ideas but are afraid to speak up for fear of being attacked. I was never one, but I have been attacked or ostracized or simply marginalized for my views. The oppression does not only exist for the recipients of “mental health treatment.” There is plenty of oppression for any provider who strays from the prescribed path!
— Steve
It IS a compliment David. More often than not when you offer your thoughts, ideas, insights, feelings, the responses are numerous. Some agree, some disagree but I think it helps the discussion. I’m afraid of being exposed for my lack of self-awareness all the time, especially with women. Let’s say you’re chatting up a nice young lady and at some point in the conversation (at least my conversations) she says, “You don’t know how you’re coming off do you?” To which I say, “No, no I don’t. Please, enlighten, hold on, let me order another round.” It’s a typical Friday night for me Batsey, so I’m not afraid to admit it.
Hi Colin,
Thank you for stepping up to the plate! I am a psychiatric nurse by default. I shunned psych as a nursing student, and like most of my peers in the early ’70’s, I could not take it seriously— as a legitimate medical specialty. 14 years into my nursing career, a combination of pediatrics and ICU/CCU, I was drawn to a different sort of pediatric setting, a Residential Treatment Center for Adolescent boys with “behavioral/emotional dysregulation”. It was located in a rural area, next door to a wild life preserve. A 45 bed, open dormitory in three separate buildings plus a school ‘house’ 1/2 mile from the campus. I accepted a position there in 1988 to work as a pediatric nurse managing the health care needs of a robustly healthy population. This very humanistic, enriching environment with “no locks” and no restraint/seclusion was transformed by 1989 into a ‘psychiatric treatment facility” for the same population! Why? History marks that year as “Day One”, a year after Prozac hit the market in the U.S. and inspired an explosion of *off label* prescribing of *magic bullets* for kids. So… long story short, having grown very fond of the *not acceptable to the mainstream* youth, I followed them into psychiatry. To keep my job, I needed to complete hours of inservice education (quite a joke in retrospect) to learn how youth could be diagnosed and medicated to prevent the ruination of their futures, which slowly became painted as the horrible consequences of “untreated mental illness”. So, I learned to talk like you to ‘fit in’ when I did my nursing internship at Johns Hopkins. I learned all the psychobabble and pseudo-medical/psych talk required of a pediatric psychiatric nurse. How else could we medicalize childhood and adolescent development? For nearly ten years, I worked with great anticipation of validation for drugging kids. At Hopkins I worked Child Psych. No mechanical restraints there; against the law to restrain a kid under 12 years old in 4 points. In the early 90’s we held kids, like they were ‘our’ kids– close enough to us (nursing staff) to create a strong connection through which our calm vibes would flow naturally into their overly stimulated little bodies. The goal was clearly to help then regain control, to provide warmth and safety for them in every possible way. Drugs were administered to kids as young as 3 years old— on a wing and a prayer that the *inservice education* by renowned psychiatrists on staff was true; that we were saving these kids from a lifetime of failure and hopelessness.
During my 2 year vacation from the field, when I learned the truth about psychiatric drugs, thinking of these little guys, trying to recall as many of the hundreds I met that first year, I began the process healing from my collusion in this *authorized*by the profession we esteem so highly in America- child abuse. Before the healing came the intense sadness and self loathing. After having achieved expertise in critical nursing through rigorous study, I swallowed hook, line and sinker all of the *weird science* I was being spoon fed regularly. I still do not forgive myself for *trusting* physicians carte blanche. I had never done so before.
I have worked in many different psychiatric settings over the past 24 years. Well over half of those years on locked inpatient units. I have never initiated a restraint, and managed to avoid administering chemical restraints as I would immediately assume the role of managing the emotional melt downs of all of the other patients on the unit. However, I have to tell you that I only witnessed a few *grotesque* take downs. These few incidents are burned into my memory. They were the fuel for my ceaseless efforts to prevent them. Early on, I began to develop my own practice. It was/is the direct opposite of the way I was trained. I spend almost no time in the nurses station. I am eager to meet and talk with the “patients”, wanting to learn something about them that connects us. I opted out of being assigned: therapeutic” group” leader, instead, I would initiate activities from a 1:1 encounter, that invariably drew other kids in. Art, music, dance and improv games were possibilities, but I was open to whatever could be improvised on the unit to the specification of one of our creative kids. My practice seemed to have an effect on the whole unit. Rarely were there outbursts, stand offs or any of the precipitants to restraint and seclusion when I worked. Despite their rigidity and suspicion of my ‘work’, I drew in a few nurses and many of the MHC’s. The hard part was documenting what we were doing in psychobabble , or staying under the radar! By 2003, the restraint reduction/elimination initiative by our state Department of Mental Health legitimized much of my practice and my methods were suddenly defined by neuroscience discoveries as, Trauma Informed Care. I was doing quite well as a nursing leader until I began to network with leaders in cognitive remediation at Kings College London and an eating disorder guru on the West coast; doing fabulous until I began to have evidenced based data to prove that the remaining coercive practices going on routinely were violations of our DMH licensing policies.
I will say with 100% conviction that coercion and force are NEVER therapeutic; that they ALWAYS create a tear in the fabric of a therapeutic bond/ relationship AND, furthermore, I view ALL coercive tactics and use of force as barbaric, animalistic— devoid of humanism and reason. I find that my position on this remains steadfast, the one consistent thread or theme in my 24 year psychiatric nursing practice, because I had total aversion to the *method* when first introduced to it via the required “safe use of restraints” training I endured in 1994.
As a direct result of my never really learning how to direct or participate in a restraint, I have been shunned by fellow staff and really demonized by young “patients”. In other words, I ride the emotional waves kids act out, and I have often absorbed the bitter, anger and rage both kids and young adults feel on an inpatient unit. The verbal assaults were formidable, though more educational for me in terms of where the kid had been and what parts of his/her story could not be told. I don’t ‘ignore’ and ‘depersonalize” verbal attacks, I see/feel the pain behind them and I want to know “why” and how I can help the *patient* realize their inherent value that remains pure and intact no matter what… which is why, it is natural for me to view *patients* on a locked unit as *innocent prisoners* of an unjust society, where their introduction to injustice most often happened with those they wanted to trust the most — or needed to trust in order to feel secure and safe from the “rest of the world”.
I can stay in the ring and spew psychiatric terminology with you. (ask Anonymous, if you doubt my capacity to put the evil spin on a natural phenomenon). But, I would not be answering your questions about how I could not be a part of grotesque episodes happening on a daily basis all around me. Want to see how naturally and beautifully human psychiatric “patients” are, Colin? Observe what happens when a regular, sincere, caring human being is in their midst. I am by far, not the only professional in this category. I have learned and still learn from other regular folks who wear the mask of a mental health professional in order to infiltrate the hideous units where something called psychiatry is highly esteemed as a medical specialty!
There is something perceivably different about those who rationalize their use of coercion and force. I saw it during my first restraint training. They become fixated on the means for protection they must have in order to be amongst the totally insane. They master restraint, take downs and holds like they are the most important skill for their profession. They make fun of the squeamish and consider themselves to be brave and bold as protectors of ‘us’… And they become hostile when a little runt like me is in charge and makes them ‘back off’— all the way off the unit sometimes, when they are flexing their muscles and provoking — restraint scenarios. They hope, I get the clear sense sometimes, that I will be beaten to a pulp– maybe that they will have the opportunity to abandon me? I am 100% up front about not participating in holds and restraints for the purpose of administering drugs that accompany a court commitment, nor will I administer the drugs under these conditions. This is the most grotesque scenario where I currently work, but hardly a daily occurrence. Most RNs on this unit share your perspective, but are becoming more curious and attentive to my reasoning, which although it is rooted in not violating another human being, it is strengthened, I feel, by the reality of the damage caused by perturbing neurotransmitter pathways in the brain and the potentially life threatening adverse reactions that… do occur from time to time.
I have conducted Trauma Informed care classes for staff who wear hostile, mocking expressions for the entire 2-3 hours. Invariably one will ask me: “Have you eve been hit, attacked…etc.?” When I say , “No”, the smirking begins, and I hear; “Then you don’t really understand what you’re talking about”. I think this is a strange response. Let’s say you did not want to be attacked by ‘patients’ on a locked unit. Let’s say that was the goal of training. Wouldn’t you want a staff who hadn’t been attacked to teach you? Go figure!
Lastly, the dopamine/psychosis connection. We know how neuroleptics work in the brain and the changes they cause. I know that a first episode psychosis is vastly different than an ‘off meds’ episode. I’ve seen plenty of both! Subtle, yet profound- the difference, once perceived opens the way for any and all means for preventing the use of these drugs… , IMO. When you try to understand their short term efficacy, or the gratitude of a court committed patient who can no longer avoid the drugs, you cannot factor out where you are when you see these phenomenon. You must never forget that being detained against your will on a locked unit; losing all reference points for your identity and sense of purpose—- produces its own changes over time. Some patients will comply to get their ticket out of that hell, and others surrender to it. If you don’t get the chance to see these patients back in their natural habitats, or check in with them over the years they will be kept on these drugs, you will never get a true sense of what it is you are really doing when you think that these drugs must be given, by whatever means is needed because they are ‘wonder drugs”.
“Skepticism is the chastity of the intellect!” — (unknown)
Curiosity, *Compassion and Courage are fundamental.
True compassion entails sharing in the suffering of another… which, of course is the opposite of the condescending , patronizing attitude of the typical *expert* in the field of psychiatry 🙂
Hope you pick up the gauntlet and debate Batesy on the “cause of mental illness”.
Best,
Sinead
Batesy and Sinead, haven’t we had this disucssion on the causes of so-called mental illness already? A couple times no?
Many on MIA take (more or less) the view that there’s no such thing as “mental” illness as “mental” is a construct or metaphor, not an actual organ. No one on this site, that I’m aware of is promoting, Brain Illnesses. You have to go to NAMI, TAC and the APA for that non-sense. Again, more or less the Szaszian view. Spring Fever = Mental Illness. The Spring can not rightly be said to have a fever anymore than Mental can be ill.
Different words have been thrown out that more accurately reflect what has been mis-labeled mental illness. Problems of living, problems/challenges of life, distress, extreme states of distress, etc.
Yours and Davids call is for us to consider the underlying connections between the unconscious, reptillian vagal systems and emotions and it’s interesting stuff.
We need to consider it, along with our cognitions, as well as environnment including trauma, toxins, substance abuse, family dynamics, traditions, mores, cultural norms, religious traditions, etc. etc. etc.
We’re very complex and I think the consensus on MIA is that we won’t be reduced to low Serotonin or out of control Dopamine.
-D
Sinead – thanks for your very illuminating reply. I should like to work with you sometime. I suppose that your colleagues sometimes feel you get a free ride when it comes to what they see as the necessary dirty work. I assume nevertheless they could depend on you in a truly critical situation, (a colleague or another patient was getting strangled or threatened with a knife for example). I hate using coercion but I do it nonetheless, and I’d be out of a job in no time if I tried to do what you do, and nor would I accept that one of my colleagues opted out except on the grounds of their own injuries or frailty. But unwillingness to lose my job isn’t the only reason of course, I do accept that it is necessary sometimes. I think I can deduce from your insert that your clientele are kids and young adults only. These can of course be pretty hefty, but there may be some difference when it comes to adults, which is my clientele. And because we’re a combined acute/assessment/treatment department many with unknown histories and backgrounds get admitted, not even necessarily mentally ill, perhaps with long criminal records, coming sometimes directly from prison, or the street, sometimes they are foreigners with no command of either English or Danish, sometimes they are in a state of delirium and therefore totally uncommunicable with. They may be people with a history of intellectualis inferioritas or control problems because of previous head injury and at the same time intoxicated to the eyeballs and thus completely out of control. You don’t know what they may have in their pockets of weapons, drugs, syringes or alcohol. If there’s good reason to suspect they might have such things, and they won’t surrender them voluntarily, then force may be the only option.
I should of course qualify the use of the word coercion which I know conjures up any number of terrible scenarios in people’s imaginations, but when a coercion situation goes after the book which it does in the majority of cases, it’s usually pretty undramatic. Personnel assemble in a number which signifies clearly to the patient that the situation is unwinnable for him through the use of force, a doctor then states the requirements and informs the patient of his rights to contest the decision legally afterwards, and he is given a couple of minutes to digest this and decide what to do. If he decides to use violence he will be quickly overpowered, and with minimun risk of injury. But usually the explosiveness of the situation fizzles out, the patient aquiesces (not consents obviously) and tensions subside.
This won’t happen with someone who is violently delirious, and unaware of what’s around him and simply lashes out at anything that moves within the periphery of his vision, as well of course at things that are not there. This is a medical emergency which strictly speaking ought not really have anything to do with psychiatry, and the only thing to do is use physical restraint so that tranquillizers can be administered as quickly as possible. I know you know all this Sinead, but I include it for the sake of readers who might not know it. The point is that in DK at least, these patients get admitted to psychiatric departments because these are the only departments authorized to use restraint.
I recall once a patient who I had a good rapport with (so I thought) who suddenly attacked me after we had been singing together in the common room. He told me at the time that it was a particular Donovan song he couldn’t accept me singing, but later he told me that he periodically had a need to rediscover the boundaries of his own being, and getting himself into these physical constraint situations was the only way he knew how to do this, and indeed it turned out he had done this several times before. I was amazed to say the least. Had I but known this beforehand and had you availalable with your massge therapy perhaps this episode could have been pre-empted? Then again perhaps not – who knows. Our physiotherapists specialize in helping people in psychosis to ‘ground’ through use of massage, but it’s not a cure-all unfortunately.
Colin,
I would love the opportunity to work with you. I think your learning curve would be greatly enhanced by actual experience that proves how off the mark your assumptions about me are. 🙂
I am currently rotating between three units: adolescent, adult and older adult. I often get my assignment to the adolescent unit because so many staff beg not to be assigned there! My deep compassion for kids leads me to do whatever I can to protect them from staff who do not like smart-assed kids! I have not perceived any difference in my effect on the tone of a unit. Regardless of variances in age groups, and acuity- the result is the same. I am perceived as the “patients’ ” ally. Which is an accurate perception. It may ruffle a few feathers amongst staff, but it is a breath of fresh air for the “patients”.
The culture of care is the MO of an inpatient unit. Most, if not all inpatient psychiatric units ARE expressions of a culture of fear-based discrimination and rationalization for the use of force. The violence imperative is the primary defense mechanism employed by the creators of these cages, called *psychiatric treatment units*.
It is my belief that one who has a deep awareness of his disdain or disregard for another will feel a need to protect himself in some way from that “other”. Why? Surely there is reason to fear the ‘other’ may act out the animosity he is suppressing internally. Hardly anyone acknowledges or owns his own negative feelings, displacing them is the way to peace of mind and personal security. Therefore, you and your colleagues will continue to be trained and to ready yourselves to deal with *attacks* and *resistance* to what you want to administer as treatment to inmates*. You will justify and rationalize this until you are able to get a grip on the reality of:
1) Your own internal motivations being the major influence over the *violence* around you.
2) The true nature of the *locked unit*… what it is, what it means, what is says about human beings.
Astounding as it may seem, the “patients” on these units are far more sensitive to the realities I mentioned as 1) & 2)— and knowing they have no voice; no power; no hope of support, they do one of three things:
1)Fight— and get restrained
2)Try to escape— even if it means complying with *being drugged*
3) Freeze—- get stuck in the vortex of hell.
The only real difference between you and I is a very BIG one. I have always been skeptical of psychiatry. I have not always had the ammunition to fight against the inhumanity of it, but I certainly never bought it. Without even realizing it, you speak the lexicon of this pseudo medical specialty and with all of the authority your license grants you , you enforce it!
There is a saying that if one spends all his time in an out house, he will become comfortable with the smell. To apply this as a metaphor for your take on your role as a psychiatric nurse, I would say that you have not employed much critical thinking to what you do and why you are doing it— or rather, you have not stepped away from the stench of the profession and breathed in the air of truth. A truth so simple that lay people, even high school kids “get it”… and some even pity those of you who don’t know how ridiculous your theories and practices really are. A metaphor for this phenomenon would be the reaction of Americans to Clint Eastwood’s dramatic performance at the Republican National Convention. (A Hollywood legend talking to an empty chair where imaginary “President Obama” was sitting.) WE do all we can to keep from letting Clint Eastwood know how crazy he looked…. pity and silence…
You can only justify the use of force in your professional role to others who need to have validation for their use of force.
And BTW, I always respond to my co-workers in trouble. I can’t be initiated into the gang approach to dealing with a person in crisis, but I have often diffused the crisis by being the ‘thing’ that grabs the attention of the person suffering… just long enough for him to begin to think rationally again. And other times, i come into a situation to relieve the staff who is perpetuating the standoff… provoking the patient.
Just about anything CAN be used as a weapon. Don’t be surprised that your quest to remove all potential weapons and to be hypervigilant for them, doesn’t just perpetuate the *weapon wielding* … Rather than worrying about what weapon a patient might be concealing, you ought to ask yourself why a patient would feel the need to have/use a weapon while being “held against his will” in your *treatment setting*.
Cheers!
Sinead
Sinead – I hold no assumptions about you just as I hold none about anyone else I don’t know personally, except for the one assumption I did mention in my last post. Perhaps I ought to revise that one however.
Once again I do appreciate your thoughts even if they can seem a little abstruse for me, and rather seem to – in a slightly arrogant holier than thou attitude – only draw esoteric circles around the concrete issues I’ve been bringing up instead of addressing them head on.
People on this site on the other hand are certainly not withholden when it comes to flaunting their prejudices about me; for one who has only just recently discovered the site and been commenting – I think in a decent, sober and respectful way – just a short while, I have to admit I find the vitriol pretty overwhelming and distasteful already, although of course I can only blame myself. I knew full well what I was letting myself in for when I stuck my head into the lion’s den. I’m chastized for abusing my patients, although none her really know anything about that, and the abuse I’ve already received here certainly isn’t going to convince me that the ideas being promoted by the site are worth considering in any depth. So perhaps it is already time for me to be on my way.
That’s a great pity really because even though I don’t and will never buy the lock stock and barrell hopelessly unnuanced “Psychiatry is all wrong – dismantle it now” slogan, I am dissatisfied with psychiatry as it is and am on the lookout for credible ideas for reform and alternatives. But I don’t think any longer I’m going to find any here, though actually the reason this blog did interest me (we’ve strayed far from the subject – a bit disrespecfully of the author perhaps?) – was that it was about Open Dialogue, which seems to me to be one of the most promising projects launched in the last quarter century. I have for many years now had a fruitful working co-operation with the Fountain House movement which pre-dates Open Dialogue by more than half a century, and like Open Dialogue has stood the test of time and achieved impressive results. It is not however and never could be a replacement for mainstream psychiatry, nor has it ever promoted itself as such.
If psychiatry is going to change then people like you and I have to meet somewhere neutral where we can exchange ideas in a slander free zone, and accept that we won’t always agree on everything. You have criticized but not slandered me and I appreciate that. I am pragmatic and doubt if I ever will be absolutist like you, but I imagine we can agree that reducing coercion in psychiatry to the absolute minimum must be a goal we should wholeheartedly commit ourselves to. (which I am already)
Best wishes Colin
Colin-
Thank you for reading my blog. I understand what you are saying. I wanted you to know that there were quite a few people at the conference from Denmark. Perhaps you can connect with them. The meeting is scheduled to be held there in 2014.
Colin, Your writing horrifies me. I love Danish common sense, love and revere it. It seems that this common sense has turned to darkness, violence and cruelty in psychiatric units. I also happen to know that the patients in your units of horror over there have even fewer legal options of recourse than we do over here.
You claim that faced with overwhelming odds most people aquiesce and no actual violence ensues. You describe this as “non-dramatic”. I am very certain that inside the victim of this show of force it is a deeply traumatizing and dramatic experience. One that you clearly have zero understanding or compassion for. I would also expect that after your locked unit have abused your power against someone so aggrievously this person is not likely to ever show any type of trust in any of you, and a million times more likely to want a violent revenge – thus perpetuating the violence. And frankly, using that type of coercion, you deserve to have your ass kicked.
You might have forced a person to aquiesce, but that does not mean you have broken the person. In some cases I have no doubt you do break a persons resistance completely. This person will never again be the same of course. It is their sense of self you break.
You mentioned that a couple of your co-workers have ended up with PTSD through working on the psychiatric units. I wonder how many patients have ended up with PTSD by being unlucky enough to be put there. I suspect hundreds if not thousands – just based on what you tell us.
So, when you describe your fear of the patients I tend to think of this as I think of sharks. People are terrified of sharks. There are almost 400 shark species, only three of them really attack humans – but people are terrified of all sharks. There are approximately 10-12 shark attacks world wide a year. Yet humans kill thousands of sharks every year. We are the aggressors against the sharks, they are the ones who should be afraid.
In much the same way you and your fellow nurses are the agressors on the locked units. Sometimes your aggression comes full circle and patients answer in kind. Surprising, huh? That doesnt change the fact that the aggression and cruelty starts with you. For each nurse with PTSD there are most likely 300 patients with PTSD. So, yea, I am more interested in seeing protection for the 300. I am more interested in the well being of the 300.
Colin, naeste gang du faar en roevfuld haaber jeg at du kan huske at du har fuldt ud fortjent den. Og hvis den roevfuld goer at du ikke laengere kan arbejde paa et psychiatrisk hospital saa har de i det mindste slaabbet af med en til voldelig roev.
Malene
Malene,
I believe that your clearly articulated explanation for the behaviors that characterize a locked psychiatric unit bring us back to one fundamental issue or question:
What is *mental illness*?
So long as there are psychiatrists and psychiatric nurses who view *mental illness* as the malady that incapacitates to the extreme opposite end of the spectrum of human traits, it won’t matter how clearly these “professionals'” transgressions are cited, “they” will defend their degradation of the *mentally ill* as the “dirty work” that someone has to do to spare normal people the burden of dealing with them. “They” will insist they are heroes and superior in many ways to those of us who feel compassion and try to empathize from our own humanity.
Unless nurses like Colin change their view of what *mental illness* is, and seriously scrutinize their own aversion to the *mentally ill*, they will not be phased in the least by the harsh admonishments that Colin had already blown off as being “demonized”, which he blows off as an “occupational hazard”.
Colin does not question the propaganda psychiatry has masterfully infused into Western culture and he has not found cause to ponder the implications of his failure to do so. Laziness, apathy, or cowardice– any or all of these accounts for merely accepting the teachings of psychiatry. But only if one can become blind and deaf to the pain and the needs of the “patients’ themselves, is it possible for a nurse or a doctor to continue on rationalizing their inhumane posturing against the human rights of the *mentally ill*. This is a deadly combination– blind allegiance to unproven doctrines and lack of empathy for those entrusted to your care.
I have not responded to criticize your beautifully written admonishment of mercy. I am sharing what I am reminded of whenever I unlock the doors of any one of the three units I now work on; it is this:
There is a fine line separating the mental incapacitation of the patients and the staff. If not for the power wielded by the staff , both groups would find common ground and infinitely expand each other’s humanity. The power is based on an evil, erroneous doctrine. When that has been exposed and then disposed of, we can get about the task of becoming fully human. And, the term *mentally ill* will fall out of our consciousness. Without the evil doctrine, it, the term *mentally ill* has NO power, and no meaning.
Malene – I liked you when I read your previous post but that was one of the most violent and hateful things anyone has ever said to me. Shame on you.
Colin,
I simply reflected the violence you described right back at you. You didnt like the mirror I held up?
There are a lot of people on this site who have been the victims of abuse at hospital locked wards, and we generally have very little respect for those who wants to perpetuate the violence.
Now, I get it. You have no comprehension that what you represent is wrong. You are arrogantly certain of yourself that you are doing nothing wrong. You have never stopped to truly, genuinely consider how many people find their personhood, their sense of self destroyed on your locked ward.
Your lack of awareness does not excuse the daily engagement in violence that you so easily describe. Your description of a “non-dramatic” altercation where someone is forced to acquiesce based on a superior show of force made me nauseated in it’s inherent violence. You described it as non-dramatic. I saw deep violence – the kind of violence that destroys a persons sense of self. I was further horrified by the fact that you didnt even consider the harm such a use of force would cause.
So, no, I feel no shame for holding up the mirror for you. The aggression that is cruel and unusual is the one you have described engaging in. The fact that you have gotten to the place where you take it for granted is horrifying.
I love the Danish common sense, but i am also aware that DK have a few stains on their conscience. The ease with which they discriminate against foreigners is one such stain. Clearly, the way locked psychiatric units functions is another.
I doubt you will find anyone here sympathetic to your point of view though. If you want people clapping their cute little hands at your ability to handle all these terrible patients you might want to reconsider if this is the place for you.
Malene
Sinead,
I love your writing and your insight. You have so much more patience than I do. You also have an ability to simultaneously express your disgust with violence in psychiatry without letting your anger in the way. I admire that.
Malene
Malene – it’s a distorted mirror you hold up. I neither like nor am proud of having to use restraint, and usually feel that I’m lacking something when my communication skills fail to resolve a situation in a more professionally satisfactory way. But coercion is there on a daily basis in lieu of the fact that the door is nearly always locked, and sometimes it’s locked because a judge has ordered it to be locked, so it’s not as if I have any influence whatever over the situation. The only thing I can do is quit the job, (which I’m not going to do) but if I and all my colleagues did that, where would the patients be then? Are you and all your likeminded ready and willing with your alternative to take over and assume responsibility? I seriously doubt you have anything near the competence needed.
I can reassure you that had you been in DK when you were in distress, and admitted to my department it would have been on a voluntary basis only, if indeed you had been admitted at all. At most you would have been offered (not forced to take) an Oxapax (benzo) and 100 – 200 mg Seroquel, daily within the first 72 hours. Unless your condition deteriorated you would almost certainly have been quickly discharged, perhaps even the next day. Grade 3 close observation probably would not have been instigated at all and grade 2 would most likely have been concluded within the first four hours. We would have taken contact to and consulted your relatives only to the extent you yourself gave consent. Only in the event that you attacked a member of staff or another patient, started vandalizing the surroundings, set fire to something, abused the telephone to ring false alarms or terrorize persons known or otherwise, repeatedly ignored the smoking restrictions, or seriously threatened to harm yourself would you have been subject to any restraint, and the restraint employed would be considered and measured to meet just the need and avoid excess. (It would by no means automatically involve harnesses and syringes, but but even minor restrictions would give you the right to consult a patient counsellor and lodge an appeal to the patient complaints body.) The door to the outside world would be opened to you as soon as we could ascertain the risk of doing so was defendably low. At any time we would attempt to meet your needs for contact and communication, although we might discourage long drawn out nocturnal discussions which could mean you were deprived of sleep, which we regard as an important healing factor.
That’s how the Danish common sense would have reacted to a case like yours; like you I’m a subscriber and find it hard to see how it could be much more reasonable. You might find this hard to believe but sometimes we have to use coercion to get people out of the place, who no longer really need us, but would prefer to stay longer.
Colin,
You claim that you have been unfairly judged, although the only thing you have been judged based on is what you have told us yourself. The violence you have described engaging in at a Danish locked unit is horrifying to many of us. A number of us here have walked away from locked wards feeling deeply scarred from the experience. In my case – I have described it as being “kicked while I was down”.
I will never, ever forgive them as they stood in a circle, giving me an ultimatum that terrified, humiliated, and dehumanized me out of my mind. It is 6 years ago, and I can still start to shake in terror when I remember that moment. it took a few years to move out of the thinking that i deserved the cruelty perpetrated by “psychiatric nurses”, now, I am just angry. You don’t like the anger? It is an anger that was started by nurses who felt justified in using non-dramatic coercion.
The anger you hear from me is the anger of someone whose sense of self was hurt doing exactly the type of “non-dramatic” coercion you referred to. Now, I tell you point blank i was damaged in that interaction. You can choose to invalidate that story, I am sure you have a vested interest in not hearing about the damage. But let me be clear, I am sure that by far most of the people you have used “non-dramatic” coercion with feel deeply violated, just as I did. This is not to mention the violation of those you have to physically subdue – I am sure their experience of violation is comparable to rape.
Now, I would like you to consider for just 2 minutes the pain of each of those people. Pain that you took part in perpetrating.
You come in to this site defending “treatments” that do more harm than good. Then you claim that no one else can do it as well as what you do. And then you get surprised when someone gets pissed at hearing the arrogance.
If you truly want to learn something better then I suggest you work hard to learn non-violent ways to interact with your patients, instead of defending the violence. There are quite a few options on the market today that does not propose to work through violence.
As far as the treatment protocol that you outlined for me, I highly doubt I would have been hospitalized in DK. If I had been, there would have been no financial reward in trying to keep me, and I would have been released fairly soon, as you mentioned. I believe that prescribing seroquel to me was then and remains now deeply irresponsible. I have several very high risk factors for diabetes already. Seroquel for any amount of time would almost guarantee that I got diabetes. That is irresponsible to prescribe based on a one time emotional breakdown – even if that break down is extreme. Have an emotional break down – go to the hospital and add diabetes to the mix – not right. Now, the doctors failed to inform me of the risk of diabetes as they prescribed several medications that would easily cause it. They prescribed the medications knowing of the risk factors I had for diabetes.
I could maybe imagine a benzo and an ssri, given that I have zero history of substance dependency.
Ultimately, I needed a bit of kindness and some understanding that I had just experienced something I was not equipped to handle. Nothing more and nothing less. I didn’t need the dehumanization. I didnt need the coercion. I didnt need the fear tactics. I didnt need the medications. I needed one human being to sit down next to me and express kindness. Not one single person in the 72 hours I was there had the inclination to offer that kindness. They had time for coercion. They had time to force horrific amounts of medications down my throat, they did not have even 30 minutes for kindness.
So, really Colin, consider the violation of your “non-dramatic coercion”. Consider how many people still start to tear up 5 or 10 years after you have used it and forgotten all about it – because for you, hey, its just in a days work. For the people you did it too, it is a horrific violation of personhood.
Malene
“Not one single person in the 72 hours I was there had the inclination to offer that kindness. They had time for coercion. They had time to force horrific amounts of medications down my throat, they did not have even 30 minutes for kindness. ”
Sheesh! OK Malene that makes me angry too. I’m stumped. Don’t know what to say other than that I don’t believe it would have happened to you in DK. If it did I’d have been there protesting with you. I apologize on behalf of my profession.
I think the risk of diabetes with taking 4 -500 mg Seroquel over three days is effectively zero, but in any case as I say, no-one here would have forced you to take it anyway.
“If you truly want to learn something better then I suggest you work hard to learn non-violent ways to interact with your patients, instead of defending the violence. ”
I couldn’t agree more and of course I already have worked hard at learning non confrontational conflict management. 99 times out of a hundred I succeed too, there’s just the odd occasion when no-one seems to have the skill to solve a problem without the use of force. When I mention that coercion is a daily affair on my department I don’t mean that there are violent episodes every day, where we force medicin down people’s throats and strap them to beds. I just mean that the door is locked for a proportion of the patients who have been sectioned under psykiatriloven and this is something we always have to keep in mind even though everything is peaceful on the department. Sometimes six months goes by without a single case of belt restraint, and the average number of days in total annually, adding together all days for all patients using this form of restraint is about 25. Every kind of coercion used is registered and submitted to a national board for review and statistical analysis. This year for some reason has been a bit of a freak year where the number of belt days already is up over 80. But our ambition is always to reduce this number.
I found your last reply. Thank you so much for the link. I am a struggling Buddhist, not a very good one, but I too see my experiences as a patient on the locked unit as valuable and a positive thing. It taught me so many, many things. My roommate was one of my fellow prisoners on the unit but spent more time there than I did. I got out, got a job and then an apartment so that he would have a place of sanctuary to come to when he was freed. When we were on the unit we were the “organizers” of impromptu events like you speak of. We always sat at the same table in the dining room and most of the time it was surrounded with people sitting with us to listen to my roommate play the guitar. They came and went at will but all knew that they were welcome at our table, as long as you were respectful to everyone else. Some of the patients who never talked to anyone would come and sit and watch and listen, often reaching out to touch his or my hand (which was forbidden, no physical contact!!!!) I remember one afternoon when those of us at the table began making noises in rhythm, each person choosing a different thing to add to what suddenly became an orchestral event. In a few minutes almost the entire 30 people of the unit were gathered in the dining room; some added their own noise and some danced and some made singing. It was all spontaneous and at that moment we were all connected into something that became greater than any one of us. It was absolutely wonderful and amazing. And then the nurses came stomping down the hall and demanded to know what we thought we were doing. Without thinking I piped up and yelled, “we’re having a spiritual experience!” They yelled, “You need to stop this right now!” I yelled, “Why? What are we doing wrong? We’re all making music together!” They headed off back down the hall to call security. Anyway, I often think of myself as something along the lines of the French Resistance. Anonymous couldn’t resonate with my metaphor but that’s how I see myself and the work I do. I had to go sit through the training for restraining people and at the end I stood up and stated that I would never lay a hand on one of the patients on the units. The administrator asked why and I said if a peer worker ever involved themselves in something like that they would have no credibility and should quit their job immediately since they would no longer be a peer. The person looked at me silently and then agreed that I was not to be involved in restraining people. A very small victory but a victory nonetheless. Anyway, thanks. As Dr. Spock says: Live long and prosper!
The post above is directed to Sinead. Thanks
Stephen,
Although my ‘people’ (the nurses) were the ones who rained on your parade, I relate so strongly to the spiritual experience you were part of and, as a matter of fact, some of “my people” rained on a few of my parades as well. So, here we are “us v them” representatives, but clearly on the same side of what is humanistic and the same team regarding what is therapeutic!
I imagine from your perspectives, having experienced coercion and restraint from ‘both sides, now” you would be the perfect witness, embedded reporter, to uncover the effects of creating a *culture* of coercion and force. The *enforcers* seem pretty clueless regarding their role in permeating the environment with vibes that are triggering for most everyone who would be detained in this *culture of coercion and force*.
During some restraint trainings, staff are asked to volunteer to be restrained — to have the experience, and thus develop some sensitivity to the traumatic effects of the restraint. Ideally, ALL staff should have this experience, and especially those who are identified as frequently involved in restraints. I would like to go a step further, in terms of sensitivity training fro staff on locked units ; like to admit all staff TO a locked unit for 72 hours! I suspect there would be a shift in terms of understanding WHO is evoking the fear responses that most often lead to restraint. Perhaps there may even be a serious movement to rid our society of these ‘cages’?
My Buddhist practice, Nichiren buddhism, has been the guiding light for my professional development. I met the woman who introduced me to this practice at the center where I was catapulted into psychiatric nursing. It has often occurred to me, believing in Buddhist doctrines that discount the possibility of random, accidental coincidences, that my bodhisattva practice is being the wacko nurse who maintains hope at the epicenter of human darkness.
Congratulations on your victory. I know only too well how difficult it is to present a convincing ethical argument to management staff & administrators on a locked unit. The problem seems to be one of inability to get the basic “first do no harm” principle and apply it universally ! The ‘us v. them’ mentality, I contend was created by and is perpetuated by psychiatry’s experts. AND, still “they” wonder why anyone would turn on or against them??
If you are in the market for a low key, under the radar spiritual experience, I have a suggestion. I have initiated a “1,000 Crane” project on both the adult and adolescent units where I work. I am providing the origami paper and the direct, demonstration instruction for folding cranes. I ask the participants to put their initials on the underside of one of the wings. After the 1,000 crane is folded ALL participants will get their “wish”… according to my broader definition of this Japanese custom. I make the mobiles and have to hang them inside the nursing station, but they are visible from the unit. Of course, the 1,000 may not be reached before some participants are discharged, BUT I remind them all that WE share equally in the victory that each of us has contributed to.
Folding origami cranes is also my *coping skill*. I will fold them and give them out sitting in the community area of the unit whenever there just seems to be no way to escape the *insanity* of the staff.
Shhh-h-h… when you want to have the most profound effect on those around you…be very, very quiet!!
xo,
:-0
Sinead
Hi David:))
I guess it comes down to trying to tease out actual physiological function, beneath our tendency to cling to cognition. IMHO. Not until we accept the distancing from our own reality, inherent in thought, will we see the paradigm shift we are all longing for.
I believe that there has been a necessary denial of the body, in western societies in our advancing of intelligence & civilization, which has brought many benefits while at the very same time, pushing us towards catastrophe, (climate change).
I believe there has been a basic-assumption that our “thinking-mind” world-view can override the primary process reality of the body and its survival needs. Paradoxically, the western mind seeks to exert supremacy over the very physiological vitality which ensures its survival. Best exampled by people like Ken Wilber, and the “big mind” theories which drive notions of a wished for Ascension?
IMHO. Its a basic denial of our own instinctive nature which ties us, not from above, but below, to the reality of a manifest cosmic nature, as we observe the world and cosmos, out there. For me, what we’re going through right now, is our coming of age century, as a species.
This is the reason I suggest the community is involved in a “human meaning” campaign, as much as it is a human rights campaign. With the rise of super-technologies we now have the power to take human potential further, by undermining age-old taken for granted assumptions about “rank & status,” and dominance hierarchies of societal structures..
As we type these symbols on a computer and flash feedback signals of action-reaction creativity to each other, the world is changing, as this mass-communication device overturns an old-world, taken for granted order of priesthood reverence, in the daily life of the average citizen.
Yet just as in individual life, real change will only be recognized in hindsight. I do believe that beyond the headline debate, the hierarchical position of psychiatry in mental health, is being undermined as we speak. I think we tend not to see real evolution/revolution though, because instinct (a dirty word for some) keeps our attention, to narrowly focused.
A tip for those Friday nights David:)) Learn to speak with your eyes and your smile, and she will be putty in your hands? Or from a Buddhist perspective, find the gap between the spark of impulsed feeling & that magnificent eternal flame, of your mind?
Best wishes,
Batesy.
David Ross, Dah-ling, of course you are correct when you say:
[Batesy and Sinead], haven’t we had this disucssion on the causes of so-called mental illness already? A couple times…?
The next level would be to debate with someone who is so confident in their “theories” of the “cause” of mental illness that they wield power and influence to coerce, force or simply encourage a person to *comply with psychiatric treatment*. This interests me because it changes the dynamic from: what do you think? to what do you believe so strongly that you will risk another’s health or life in order to administer the *treatment* for “mental illness” ?
I want to witness the process of ownership of a belief system that allows for, condones and perpetuates the negation of the inherent dignity in the lives of others; assigns them a label that assures no one in a position of power and influence will either believe or trust them. I am very curious about the unconscious underpinnings of this *practice* …
In other words, I’d like to witness the debate that should have taken place 30 years ago … or at the very least participate in an open dialogue where there is an undeniable common denominator and a quest for a greater understanding of our shared humanity- and our autonomic nervous system ……
I propose we title this debate: “In search of the missing link”
Sinead, I do believe you’ve used the first Zsa Zsa reference on MIA! Congrats.
I think I understand what you’re saying about the debate now. I’m not sure we have any typical MIA bloggers that would fit the bill but perhaps a debate like this could be arranged.
You know, just brainstorming here, Bob has traveled all over the world talking abot Anatomy of an Epidemic and he’s had many many conversations with those who disagree with parts/all of his book. Some of those folks would definitely meet the criteria you describe above. I wonder if Bob could find the time to turn the many conversations he’s had into a book. A kind of “On the Road with Anatomy: Conversations & Musings”
Hmm.
D.R., M.Ed LPCC,
What if? … someone right here on this thread on this blog – right now, just tells us what causes “mental illness”—precisely WHAT about the cause of *mental illness* is *treated* by a psychiatrist or by the currently embraced paradigm –biomedical psychiatry??
Can you cure an *illness* without knowing the cause? Treat symptoms of unknown etiology with toxic drugs whose adverse effects just might be worse than the symptoms???
How come only those brave souls who stopped taking their psych meds and stopped seeing their psychiatrist were CURED—?? People who STOP the treatment that was prescribed for their DIAGNOSIS of lifetime severe mental illness… NO LONGER have the damn illness when they STOP the freakin’ treatment!!!
Calling on the super intellects to explain this paradox
!!!
YET… Where are the CURED amongst the drug taking patients of psychiatrists??? Seen any?, KNOW any??
We have to “tease out the barrier” to confronting a very, very important bit of info—
Looking for people with lots of initials after their names… if they don’t have MD or RN already. And let’s add another point for dialogue…
What “causes full recovery” from a “diagnosed” chronic/ severe mental illness?
Somehow, the really well credentialed, full contact-actively practicing psychiatry experts, avoid delving into the heart of the matter… or are just petrified that our own David Bates may make them look foolish?
Happy Saturday night, Dah-ling ~~~ !!
I can’t answer as part of the “super intellects”
I can say that I like what David Cohen and Joanna Moncrieff have said about this topic. It seems very honest, accurate and straightforward to explain.
There is no illness to treat. So let’s get that out of the way. What’s treated is problems of living. How are they treated? Sometimes with drugs. Is this unusual in our culture? Nope. Lot’s of people use drugs to “deal” with problems of life/living. Most of those drugs have far fewer brain damaging effects than so-called “psychotropic medications.” I think we do need to make room for the possibility that a percentage of people taking drugs of any kind will come to believe, truly believe, that they “do better” on the drugs than off. Sometimes this belief is false, temporary or ill-informed, but it’s not uncommon. I’m not sure who among the super intellectuals you mean, but these are my thoughts.
Hi David,
Here it is:
“There is no illness to treat. So let’s get that out of the way”
That is the PERFECT thesis statement for the dialogue/debate!!! THANK YOU!
David Bates is looking for the proponents of “mental disease” and their allies to step into the ring, or up to the plate AND tease out the underpinnings for this *theory-belief-model*
Actually this could be an invitation to open dialogue practice for our reporter from the front lines of this model, and/or Colin the psychiatric nurse who ventured in here due to his curiosity about open dialogue!!
Or, it could be that I want to see this happen? want to see the theory of open dialogue come to life!
If wishes were horses….??
Thanks D.R. for the perfect beginning to a thrilling adventure!!
and… Thanks David Bates for indulging me!
xo,
Sinead “Gabor”(?)
Hi David:))
In your orthodox belief system, do you recognize any paradox in your “idolization,” of Robert, as part of your “unconscious” attachment needs, and Mosses advise not to worship idols? Or from an Eastern perspective “if you meet the Buddha on the road, kill him?”
Can you say why you have been so quick to suggest a closing down of debate & a restriction of topics like religion, which does after all, question the existential nature of our human experience, and for many here parallels the mystical experiences in their psychotic process.
Is there a desire for self-awareness which may improve social function, counteracted by an unconscious appeasement of attachment needs, based on the “patriarchal” structure of a particular tribal view of our existential reality? Is there a need to “please & appease,” a taken for granted structure which thwarts your own unique individuality? Its a tough call for us all, in our need for both belonging & individuality.
How much of our social behavior is taken for granted, with but the merest of knowledge about the internal stimulation of our behavioral responses? While looking “out there,” how much do we each understand about how our perceptions are created from within?
http://www.scribd.com/doc/4387656/The-Brain-Nervous-System-and-Behavior
Be well, my friend,
Batesy.
Great question Batesy. I admit my view may seem a bit strange, even to myself! There’s nothing in my life more important than my faith. I have a feeling that there are many here on MIA that feel the same way. Within different faith traditions are tenants and principles that those in that faith believe. Very strongly in most cases. To think we could have a debate between those traditions here, via this medium, when so much emotion and cognition is involved, seems impossible and therefore counter-productive. For example, some faith traditions teach that there is only one true and legitimate faith tradition and all others are untruth and idolatry. Now how exactly are those people going to truly have a constructive debate here? I’m not saying it’s impossible, but I think it’s far more likely that people become upset and the exchanges aren’t helpful.
Personally I will tell you, that as you mention above, an individual’s faith is at the heart of living in this world. I can’t think of a more important conversation that needs to be had. These conversations do happen in different forums (face-to-face typically) regularly. I’m just hesitant that MIA is the right forum, but I should have clarified that religion IS the right topic!!! So, I can understand why I came off as confusing. Sorry about that.
Hi David:)) As you say;
“Now how exactly are those people going to truly have a constructive debate here? I’m not saying it’s impossible, but I think it’s far more likely that people become upset and the exchanges aren’t helpful.”
Is there a basic-assumption in this view that the internet platform works with the same proximity of face to face dialogue?
IMO This platform provides a mechanism of distance from the “visceral” impact of face to face confrontation, with “time” and staying in the conversation, providing an opportunity for the kind of “open” dialogue which is very difficult in close proximity, on such highly charged emotional issues.
The difficulty lies in the emotional energy required to keep a conversation going over time, when natural arousal cycles will dilute interest, and the unconscious needs of established homeostatic responses will impose a tried and tested *expectation,* like our assumptions that highly charged emotional issues are best avoided, to maintain a comfortable status-qua.
IMO There is enough experience within the community to tease out the *functional* realities which keep us all stuck in a preference for intellectual posturing and self-preservation needs, as we *project* the system within onto the so-called system, of the world out there.
IMO Its not the world out there which needs re-organizing, like rearranging the deck chairs on the titanic, its a more fundamental reorganizing of the world within, with realization of what we are, not who we are?
In this 21st century A.D. are these old-world dependencies of a projected attachment need, “as if my father is in heaven,” really going to meet the challenge of global warming? Are we or are not part of a global community now?
I don’t expect the conversations to take place anytime soon, as the physiological agenda of self-preservation need, maintains a typical group hierarchy of intellectual assumptions, which are prompted more unconsciously than the majority wish to explore.
In the meantime I’ll keep trying to point out the difference between intellectual assumptions and actual function, as we scan comments looking for emotive resources to fuel our projection needs?
Warm regards,
David.
In response to Steve, and the comment, “But I do agree, there are actually a lot more professionals out there who are sympathetic to these ideas but are afraid to speak up for fear of being attacked.” I re-post my suggestion that society operates like an extended family, and that fear of SHAME dominates our actions and reactions to each other, at an unconscious level of actual functioning?
Toxic Drugs or Toxic Shame? – The Parental Nature of Society?
Murray Bowen tells us that society operates just like a family? John Bradshaw in his brilliant “Healing the Shame that Binds You,” explains how shame is used to shape the family & society, by its ability to suppress and even crush, the natural energies of interest & excitement, of curiosity and wonder?
It begins around 18 months of age, as parental adoration and encouragement turn to admonishment and the restriction of innate affect/emotion? Shame has been long recognized as the *binding* emotion which allows society to function in an orderly hierarchical fashion of perceived rank & status.
This is perhaps the unconscious motivation in our drive for *diagnosis,* the ranking of another as inferior, or as described by Donald Nathanson, the Pride/Shame axis of all human relationships?
Can the good Doctor in his need for the pride of deference, as Michael Cornwall points out, be sure that a motivation of good intention, is not driven by an unconscious need, in this Pride/Shame axis of human relationship? Is our current debate here on MIA inhibited by our *objective* analysis, with a lack of awareness, or discussion about *unconscious* motivation? Please consider the effects of Toxic Shame and its shaping of Western Society?
“My Name Is Toxic Shame
I was there at your conception
In the epinephrine of your mother’s shame
You felt me in the fluid of your mother’s womb
I came upon you before you could speak
Before you understood
Before you had any way of knowing
I came upon you when you were learning to walk
When you were unprotected and exposed
When you were vulnerable and needy
Before you had any boundaries
MY NAME IS TOXIC SHAME
I came upon you when you were magical
Before you could know I was there
I severed your soul
I pierced you to the core
I brought you feelings of being flawed and defective
I brought you feelings of distrust, ugliness, stupidity, doubt
worthlessness, inferiority, and unworthiness
I made you feel different
I told you there was something wrong with you
I soiled your Godlikeness
MY NAME IS TOXIC SHAME
I existed before conscience
Before guilt
Before morality
I am the master emotion
I am the internal voice that whispers words of condemnation
I am the internal shudder that courses through you without any
mental preparation
MY NAME IS TOXIC SHAME
I live in secrecy
In the deep moist banks of darkness
depression and despair
Always I sneak up on you I catch you off guard I come through
the back door
Uninvited unwanted
The first to arrive
I was there at the beginning of time
With Father Adam, Mother Eve
Brother Cain
I was at the Tower of Babel the Slaughter of the Innocents
MY NAME IS TOXIC SHAME
I come from “shameless” caretakers, abandonment, ridicule,
abuse, neglect – perfectionistic systems
I am empowered by the shocking intensity of a parent’s rage
The cruel remarks of siblings
The jeering humiliation of other children
The awkward reflection in the mirrors
The touch that feels icky and frightening
The slap, the pinch, the jerk that ruptures trust
I am intensified by
A racist, sexist culture
The righteous condemnation of religious bigots
The fears and pressures of schooling
The hypocrisy of politicians
The multigenerational shame of dysfunctional
family systems
MY NAME IS TOXIC SHAME
I can transform a woman person, a Jewish person, a black
person, a gay person, an oriental person, a precious child into
A bitch, a kike, a nigger, a bull dyke, a faggot, a chink, a selfish
little bastard
I bring pain that is chronic
A pain that will not go away
I am the hunter that stalks you night and day
Every day everywhere
I have no boundaries
You try to hide from me
But you cannot
Because I live inside of you
I make you feel hopeless
Like there is no way out
MY NAME IS TOXIC SHAME
My pain is so unbearable that you must pass me on to others
through control, perfectionism, contempt, criticism, blame,
envy, judgment, power, and rage
My pain is so intense
You must cover me up with addictions, rigid roles, reenactment,
and unconscious ego defenses.
My pain is so intense
That you must numb out and no longer feel me.
I convinced you that I am gone – that I do not exist –
you experience absence and emptiness.
MY NAME IS TOXIC SHAME
I am the core of co-dependency
I am spiritual bankruptcy
The logic of absurdity
The repetition compulsion
I am crime, violence, incest, rape
I am the voracious hole that fuels all addictions
I am instability and lust
I am Ahaverus the Wandering Jew, Wagner’s Flying Dutchman,
Dostoyevski’s underground man, Kierkegaard’s seducer,
Goethe’s Faust
I twist who you are into what you do and have
I murder your soul and you pass me on for generations
MY NAME IS TOXIC SHAME” _Leo Booth/John Bradshaw.
http://www.goddirect.org/mindemtn/writings/january/toxshame.htm
Warm regards,
David Bates.
Good ol’ Freud! Haven’t heard from him for a while. Does this have anything to do with The Battle of the Trees?
Colin,,
If you don’t mind my asking, how long have you been practicing psychiatric nursing ?
Freud uncovered more than a few universal human traits and characterisitcs that resonate with Buddhist philosophy…
The Buddha would label “Toxic Shame” as the karma created by degrading the fundamental dignity inherent in all life. Or rather, “Slander of the True Law”.
Shakyamuni Buddha predicted (485 BC), that by 2,000 years following his passing there would not be a single human being alive on the planet who had not formed karma for “Slandering the Law of Life”…
Another spin on what the poem David shared… and another way of explaining this universal TRUTH!… Everyone suffers this ‘condition”… everyone, without a single exception!!
The most fortunate, then, would be those who realize this and make causes from THIS moment to honor the dignity of life that is inherent in all living beings and the environment. Fortunate are those who know how to *change their destiny*…. through their own efforts, of course, and by their own choice!
About 25 years. I did once flirt with Buddhism though I can’t say I know that much about it. I kept the vegetarianism though.
I wonder, Colin, if you practice any medical or surgical specialties in nursing after graduation? Or did you go straight to psychiatry?
Above you said that you have made no assumptions about me, but yet I detected your view of my posts as “holier than thou and self-righteous’ before you made a passing, casual reference to my tone? I have worked with so may nurses who sought to “train” out of the very aspects of my basic nature and character that have allowed me to connect with ‘patients’ and see them through to recovery ( from the trauma of psychiatric treatment ). At the very least, I remain a pacifist who is routinely under the microscope by fellow nurses, who see me as either a freak or a traitor.) You seem to fit into that group of critics, though you are using the very best internet/on-line form etiquette!
If your interest in open dialogue is as sincere as you have stated, then I welcome you to what IT is. Fully engaging with other human beings is key, and if you are defensive and self absorbed, as would be the case when you are prepared to exit when unpleasant things are said to you or about you, well then, you’ve missed the point. Open dialogue is not a conversation that you entertain based on your personal preferences, but the SPACE between human beings that can be filled with new understandings for all invested in the goal of reaching them. So, it is about transcending the small, ego-bound self, and going through the fire, so to speak to reach a goal that will expand your life. IF you are not able to believe and respect another’s perception— even if the perception is of you, then you will not get the benefit of participating in open dialogue.
I think many psychiatric professionals are viewing “open dialogue” as a new technique they can master and add to their “tool kits”. When engaged with “patients” using their new technique, they will maintain their professional boundaries and sense of themselves as expert authority. This is always a risk— and I think it comes from the adherence to the doctrines that define *mental illness* and view “patients” as a problem to solve using that model. You should read the recovery stories on this site to assist you in the discovery of mental/emotional/spiritual wellness — the possibilities when the biomedical model of psychiatry is obliterated. Pow!! then, WOW!!
I view Buddhism as a philosophy based on teachings that do not stray from natural laws, common sense and everyday experience. Buddhism describes life itself and the living beings who share the experience due to their causal relationships with each other. The difficulty many Westerners have with Buddhist concepts are due mostly to the lacking in a hierarchy or ranking of superior/inferior amongst us, and that living in a web of interconnectedness, we cannot take any action that does not simultaneously effect ourselves. The implications of “self harm” resound in every act of coercion, force, violence and killing, the ultimate grave offense that taints one’s own life throughout future existences. Buddhism holds the highest regard for the dignity and the sanctity of life— the essence we each share. So, those who have many prejudices and “reasons” for actions that violate the dignity or the rights of others , will struggle through many agonizing ordeals in order to free themselves from these delusions. That is to say; Buddhism is not a romanticized world view, it is a practice for purifying and perfecting one’s life. I practice Nichiren Buddhism, based on the Lotus Sutra.
If you are so inclined, you can investigate this practice, which is the means for comprehending difficult to believe and understand doctrines.
I asked about your resume in nursing, because I believe that unless you have had years of experience learning what it means to put your ‘feelings’ and personal comfort aside in order to care for critically, or seriously ill people, you can’t see how ‘by the book’ psychiatric nursing is the antithesis of nursing practice itself. I continue to be shocked by the degree to which psychiatric nurses defer or default to their comfort level and artfully employ “psychobabble” to justify what can only be called, failure to perceive the basic human needs in their patients. Psychiatric nurses are the WORST nurses. They give NURSING a bad name, IMO. Why? Because they are about upholding the *doctrine* at the expense of the patient– and there is no parallel to this mindset in any other specialty of nursing! I still wonder how a nurse can buy into interventions that disconnect them from the feelings thoughts and wishes of their patients. Psychiatric nurses pride themselves on having achieved this disconnect. Psych nurses call it, ” maintaining professional boundaries” and claim it is ‘therapeutic”. Well that is only possible IF they totally tune out the patient’s response!! And they do, right? It is the “behavior” they want to see,; what THEY have decided is BEST for the patient that drives your separating yourself from the hard to miss suffering this disconnect causes your patient! IF the patient complies and behaves as you wish, THEN you may connect— just a little, but never in a personal way!!
I wince when I hear you describe your practice. I feel queasy because it does not resonate with the Florence Nightingale oath or even the code of ethics nurses are bound by (at least in the U.S.) — it does not reflect attention to Maslow’s -BASIC human needs model; IT does not focus on what you give of yourself to patients, but what you take from patients.
Psychiatric nurses give “drugs”; enforce “rules” and enforce consequences, all the while robbing their patient’s of their individuality, their inherent unique dignity. THIS is not what I had in mind when i went into nursing. IT is not what I believe nursing education/training is about— and I make it a point to BE a REAL nurse in every psychiatric setting I walk into!
I have practiced in psychiatric settings for 24 years and medical/surgical adult and pediatric settings for 14 years. I am guessing that I am your senior in terms of years of nursing experience? If not, then,Ii am not admonishing you as a senior nurse, but as a colleague who values the art of nursing practice and “first do no harm” applies to us- RNs in spades!!
Hint: IF you discount the voice of your patient when he/she says you are causing harm, you are not practicing nursing, IMO. Since the doctrines of psychiatry grant you permission to do this; and tell you that the voice of the patient IS the disease… you have become all the more disconnected from your patients, and all the more adept in carrying out interventions that any REAL nurse would question, or like me, out right refuse to carry out!!
I could assemble a team to relieve you and your colleagues of duty in your “hospital” (using the term loosley)– the condition would be that you NOT intervene or interfere when we start doing the *impossible* !!!
Sinead – yes I think you’re right that psychiatric nursing is not “real” nursing á la Florence. It’s more of an art really, and being artful probably isn’t too wild an exaggeration, which isn’t to say it’s about being dishonest. You certainly have to give a lot of yourself IMO to do it well, but in an artful way where humour, compassion and empathy aren’t necessarily worn on the sleeve and trumpeted about, but nevetheless are in place, and allowed to shine through naturally in whatever way the developing relation between nurse and patient allows, to lighten burdens and lend authenticity, without compromising professionalism. As you yourself have discovered connecting with patients is what it’s all about, but if the connection occurs completely on the patient’s terms then you really haven’t done him any good as a rule and may even have done harm.
Maslow and basic needs are all given proper attention in my experience. Perhaps I’m just lucky to be on an excellent department. In DK psychiatric nurses learn to equate the psychodynamics of relations with treatment possibilities, and use the relationship to confer ego support. For me the great attraction and why I love psychiatric nursing is the paradoxes it throws up, and that I have to relearn my psychical juggling skills every day, because there’s always something new. So in that way yes, I do truly get a lot of personal satisfaction out of it, and it’s not as if I “take something” from the patients in doing so. On the contrary I would say it’s greatly to the benefit of my patients that I take something from the relationship too, because that gives authenticity, and offers precisely the opportunity to prepare oneself for the real world of real relations.
I daresay you could relieve me and my colleagues. It wouldn’t be too difficult. The thing is the first day when you unlocked the door you would lose the first six patients and the next six would soon apply for discharge or transfer when they found out they weren’t going to get any medicine. So I guess the remaining four wouldn’t be too much of a handful. I don’t know what you’d do when an alarm sounded for aid on another department, (we don’t have any ‘security’ we manage these things ourselves) but as you say that wouldn’t be for me to interfere with.
Hi Colin:)) If you can step back from your reactive “impulse” and re-read your own comment here, you may come to see how you demonstrated this blaming & shaming reaction perfectly?
My comments here on MIA are an attempt to show people their own reactive behaviors, in black & white, and your assistance is much appreciated.
Reason? Or Reaction, Colin? Please think about it?
Warm wishes,
David.
Sure David. It was reaction. Well considered reaction nonetheless and maybe not a reaction to what you might be thinking it was. I happen to have an interest in ancient Welsh and Celtic legends and poetry, and couldn’t help noticing the the format of Bradshaw and Booth’s poem – it’s Cad Goddeu (The Battle of the Trees) and Hanes Taliesin but with a different and very Freudian content. I’ve no idea why Bradshaw and Booth might try to synthesize these two things since there’s no obvious connection. But then again the Battle of the Trees is very mystical and open to just about any interpretation. The best I know of is found in the remarkable work by Robert Graves “The White Goddess”.
I am by the way a closet admirer of Freud, but please don’t tell anyone.
Cheers – Colin
Hi Colin, you say its a well reasoned reaction to my comment above, as you type;
“Good ol’ Freud! Haven’t heard from him for a while. Does this have anything to do with The Battle of the Trees?”
Yet you don’t seem to address me at all, as you project this emotional association?
No comment about my introduction to the poem and my thoughts about the parental nature of society, or what I’m trying to suggest with this?
Please tell other readers, what you expected to communicate with this response, other than your internal emotional-intellectual state? As you say;
“I’ve no idea why Bradshaw and Booth might try to synthesize these two things since there’s no obvious connection.”
Perhaps because they didn’t Colin, and your emotive associations and reaction, was simply the need, of an unconscious emotional projection? A need to feel proud of your own functioning?
Hence, no real attempt at perceiving my intentions or initiating a real conversation? Are you sure, you managed to stand back far enough, as you highlighted the emotive associations in your second response here?
In previous threads I’ve pointed out how we *scan,* rather than read and digest, looking for emotional resources to fuel our unconscious projection needs, suggesting this happens unconsciously, at the millisecond speeds of auto nervous system reaction. Perhaps you can give a “well considered reaction nonetheless,” to these thoughts?
Best wishes
David.
Sorry to barge in, but there are no reply buttons for Colin’s last response to me.
Hello again, Colin,
I , too, admire Dr. Freud. I particularly admire hm for coming out of the closet with all of the strange paradoxes he discovered in his own psyche. I trust you have a copy of his “Basic Writings”? The best explanation for your affinity for psychiatry and your love of psychiatric nursing are to be found in this excellent work by Dr, Freud 🙂 Coming out of the closet is a thrilling adventure, IMO. I hope you choose the adventure!
I wonder why you equate connecting with and respecting the individual who has lost all rights to his/her autonomy (my practice) as a non-therapeutic relationship due to its being on “the patient’s own terms”? (your conclusion) These are MY terms, Colin, based on my own standards and values. You see, I could not possibly know if or how I was violating another person’s innate sense of himself if I had no real sense of who he is. It sounds to me as though you operate on many assumptions about a *patient*. Is that based on the presenting symptoms of a specific psychiatric disorder? Or is it simply based on your own beliefs of what would be best for a patient acting in a certain way? I will challenge you a bit on your subtle assertion of authority.
What sort of information do you gather from your professional stance that leads you to believe you are well versed on the best approach with a patient? Do you realize that the degree to which you separate yourself from another human being effects the other’s level of comfort in expressing himself to you? (The greater the distance, the less security, ergo, paucity of content, sorry to say)
Perhaps you have never considered how you might be more of a director than a facilitator of healing? The messages you send out resemble those of an emotionally distant parent. Clearly the rewards for compliance are to be found in your approval, but your approval is ‘professionally derived’ so it does little to support the ego of the person. It does develop the ego identity of a patient, which is more or less the goal of psychiatry. Your professional boundaries make it so! Tell me when you are not helping the person to know there is a difference between “the patient’ and ‘the nurse”?
I can’t help thinking that you need to be in a position of authority and control. You can’t possibly know what my ‘team’ and I would do as the new staff on your unit, because you have no experience with a paradigm that does not focus on differentiating the nurse and patient into separate roles, that are far from equal! YET, there you go telling me what will happen and what I won’t be able to count on for support! I get the sense you did so with alacrity, which is fine, except you really don’t have a clue about the changes in dynamics that would occur when “authority over and control of people” are not the impetus for interactions. If you could realize that you know nothing about my practice, then you would be naturally curious about my approach to relieving you and your staff of duty. No curiosity? More evidence then, of your claiming to know what you cannot possibly know. This is the consistency of your practice, I’m afraid.
Although you did not directly answer my question about having (at least 5 years) experience in medical/surgical nursing, I think I can safely infer that you went straight into psychiatry. Again, I wonder if you can appreciate the significance of what you do not know? The thing is, I am very well versed in the theory and practice of psychiatric nursing, and have heard many of the same reasons for ‘loving it’ that you shared. Obviously this all works well for you. but there is a huge deficit on the patient end of the story. The conclusion matches the error in your premise. I hope you will read a few of the stories on this site that come from the people who are fully functioning and contributing to society BECAUSE they were able to heal from the traumatizing effects of psychiatric treatment!
And, Colin, after you have read at least one of these stories, I challenge you to share from your casebook. I’d like to hear about a full recovery from severe mental illness a la Colin’s artistry as a psychiatric nurse. In the end, results are everything!
Cheers!
Sinead
“Yet you don’t seem to address me at all, as you project this emotional association?” (apropos blaming and shaming)
You’re right David it was an egotistical little sidekick on my part where I engrossed myself in one little aspect of your post, without really stopping to consider whether it might be something which interested you too, quite blithely skipping over the issue you wanted to talk about. The blaming and shaming of me is quite appropriate.
And I hope you won’t take it personally but I won’t pick up the cue on this one since in times past I’ve had my fill of discussions on Freudian guilt, and it’s role in the formation and extension of social repression and status formation. It’s great stuff, and I adhere to the Marcusian school of thought 99%, but I can’t manage any more of it.
Cheers Colin
Hey Sandy!
I am almost certain you have expressed your interest in, study of, and appreciation for “cognitive science”. I assumed then, that you would make the connection between “cognitive impairment” that is proven to be an adverse effect of neuroleptic drugs, and “deficits in self awareness “. There is little doubt that long term use of these drugs produces the “once thought to be” prognostic decline in cognitive function of schizophrenia. Another example of “The Drugs Done It”— which Anatomy of an Epidemic exposes. How, then, can you NOT consider the self reports of neuroleptic fed patients to be “questionable”??? Surely, you have no problem saying that the “mentally ill” are not reliable in their assessment of their “wellness”.
Way back… on a thread that has no more reply buttons you responded to my comment that suggested another reason for your satisfied customer- “self reports” ,by saying:
” Why would one type of attitude be caused by the drug and another attitude reflect the “true” underlying belief. If so, how do we know which attitude is the “true” one?”
Sandy..” attitude” and” beliefs” are NOT the operative words in my challenge to your own statements about patient satisfaction with DRUGS you prescribe. Scientific evidence and the inferences that can accurately be made are the topics I broached with you, and for a very good reason. I am trying to encourage you to be consistent. IF you want to use biomedical treatments, then at least stay within the paradigm of science when you assess their efficacy!
IF your patients on neuroleptics are reporting that the drugs are just the thing they need… how confident are you that they are NOT cognitively impaired because of the drugs??
By the same token, how can you assume that a person who has difficulty attending to her hygiene and living space IS “impaired” when she tells you that she is NOT mentally ill?
You ask “How do WE know which attitude is the true one?” Well,who is WE? You and the patient? You and a colleague?, You and a family member? YOU & ME???
I am more interested in what is known; what can be known and who is most effected by false assumptions.
Neuroleptic and anti-psychotic drugs cause atrophy in an area of the brain KNOWN to be crucial to higher executive thinking, planning. reflecting and abstracting. The part one would need in order to figure out how well one was getting along…. compared to what one hoped to achieve– thought was possible, believed himself capable of…(collaborative brain functions– multiple- neuro nets connectors for: short and long term memory, attention, comparison of information from stored data ) Abstract reasoning is a cognitive function dependent upon neurological development and the functionality of that developed neuro network.
The longer a person stays on neuroleptics or “anti-psychotic” drugs the more concrete their thinking becomes. COGNITIVE SCIENCE can tell us WHY that happens., but has very little to say about “attitudes” and “beliefs”.
Call me old fashioned, but I think that there should be some way to assess psychiatrists for competency in basic science. Had this been achieved, I believe there would never have been a biomedical model of psychiatry or a field called, psychopharmacology!
Cheers!
Sinead
Hi Sinead
I think it’s time to wrap this up since I’m beginning to feel a little impolite about hijacking Sandras blog, and there’s a risk from now on that we’ll just start circling around the same themes in a futile way.
Yes I went straight into psych. It’s what interested me from the start, general nursing did not. But I spent several years as more or less untrained nursing assistent looking after the physically handicapped so I understand what you’re talking about.
“you equate connecting with and respecting the individual who has lost all rights to his/her autonomy (my practice) as a non-therapeutic relationship due to its being on “the patient’s own terms”? “
is not what I said Sinead. In DK people are fairly passionate about equality and they naturally extend this passion to the workplace where status is often hard to discern because they work hard to flatten out hierarchy, and make it possible for the employee to chat with his boss on very level terms. It’s not that people forget that status exists, but they insist on the distinction between equality in status and equality in rights and dignity. The same is true in the nurse patient relationship. These two parties cannot be equal in status and it would be false to pretend they can. A patient’s terms might begin as an insistence on equal status. The nurses job is then tactfully and humanely to maintain the difference in status (reality orientation) whilst simultaneously supporting the process towards equality in self esteem, which is what will most benefit the patient and realise the goal of winning back his autonomy. IMO this is the most professional way of handling things and the way that brings best results.
Many thanks for your engagement in this discussion with me. I hope others got something out of it. – Colin
I know that I certainly did. Very interesting……..As a former patient, after reading all of this, my personal preference for a nurse would be Sinead. I think she absolutely “get’s it.” My feeling is that she’s not there to get her ego stroked for being such a great and wonderful person. She’s there because she realizes that there is absolutely no difference between herself and the person she’s ministering to, the person often referred to as the patient. There are no walls, no psychobabble, no warm fuzzies, no “us” vs. “Them,” no patient and no nurse. She is simply witnessing to the fact that the two are one and the same. What animates the supposed patient is the same thing that animates her and she bows down and reveres and witnesses to this fact. I would much rather have her walk with me in my “journey on a locked unit” for she is the one who could actually feel my pain. And then she would do her damndest to do something about it!
I have to go now and learn how to fold paper cranes!
Stephen – your choice would not disappoint or offend me. Absolutely OK. In DK nurses learn that the various ego supporting techniques can be seen as lying on a continuum where the two poles can be thought of as representing paternal and maternal principles. The maternal tend to be nurturing and protective and are most valuable usually at the beginning of an admission, whilst the paternal typically come into play later where there is a need to find suitable challenging tasks which will help the ego recover the strength and elasticity it will need when the patient returns to society at large.
A good nurse needs to be conversant with both principles and able to move between them as necessary, but individuals have their preferences naturally and – not surprisingly – male nurses often gravitate towards the paternal end while female gravitate towards the maternal. Classically, Sinead is obviously more comfortable with the maternal, whilst I tend to gravitate towards the paternal.
Colin,
I see you are still holding true to your perception of your disocourse on “our differences” as nurses on locked units?
You did write:
” Sinead – I hold no assumptions about you just as I hold none about anyone else…”
But the I revisit this blog and read you ‘last’ comment:
.
” Classically, Sinead is obviously more comfortable with the maternal, whilst I tend to gravitate towards the paternal.”
Not for the sake of argument, but purely for clarity, I must correct your ‘latest; assumption. My practice is based on 24 years of both education and experience in psychiatric nursing. My conclusions include disbelief in the basis for psychiatric diagnosis, as there is no scientific evidence for it; and opposition to ‘classical’ psychiatric treatment as it is far more harmful than it is ever beneficial. Would you say that my foundation for my practice reflects ‘maternal’ qualities? Are strict, authoritarian control freaks ‘paternal’ by nature? These are the inferences I make from your comment above.
My practice of nursing on locked units is not motivated by a need to nurture and protect people whose freedom has been taken from them. My practice is inspired by the positive outcomes I continually witness, that are the product of connecting with and relating to ‘inmates’ of psychiatry as human beings in distress. Apparently you would view these very people as ‘patients of psychiatry’.
Interesting that you make your claim to understanding Stephen’s preference for a nurse , (Stephen is someone with lived experience on a locked unit); that you analyze and define his choice in such a Patriarchal manner… almost as though you are fully displaying your admiration for Dr. Freud?
Vive le difference!!!
Sandy, I hope there’s another installment of your experiences in Finland coming. I’d like to read about what you saw there, how the conference was conducted, etc.
Colin-
Thank you for reading my blog. I understand what you are saying. I wanted you to know that there were quite a few people at the conference from Denmark. Perhaps you can connect with them. The meeting is scheduled to be held there in 2014.
All being well I’ll be there. Look forward to seeing you – Colin
Sandy,
Thank you for sharing and for continually creating a space in your blog to hold that uncertainty and ambiguity Kermit mentioned. I also think this is one of the real merits of OD that need not be contained, nor can be, to any particular tradition, therapy or approach.
It it the work of deeply connecting with each other, bringing an attitude of curiosity and “don’t know mind” to a crisis or challenging situation, attuning to our own voice and recognizing our perceptual limitations while welcoming a layered understand and the importance of emergent meaning making. For me, meditation, anchoring in the body, deep listening, and “keeping my mouth shut” (as someone so succinctly put it) are helpful in the process. I like the concept of radical humility and would also add to that the efficacious medicine of tension-breaking, self-effacing humor and radical unselfed love (born of an unwillingness to create the artificial and damaging distinction between “self” and “other.”
I am excited about the possibilities of seeing more Open Dialogue in the U.S., but worry that we mystify this approach too much. It is a time-honored, compassionate approach to healing suffering and community that many have modeled so beautifully throughout history. And an approach that each of us has the potential to practice, given enough wise friends to remind us of its importance.
Thank you for being one of those wise friends.
Thanks, Jennifer. That is very kind and generous.
You make an interesting point about mystifying Open Dialogue. I am trying to be careful about not going beyond what I know. One thing that seems to be important is that they have been able to collect data that suggest that we can wait before we start medications and that people can recover. There may be other ways to achieve recovery. Some of these other approaches may overlap. In fact, the Finns talk about the work being context dependent and the work may vary depending on the context.
This is an excellent point Sandy! What makes OD so important in this space and time is its remarkable evidence base and decades-long track record. We are in an era where “fact” battle with “facts” and it is necessary to bolster time-honored wisdom with data. Makes me wiggle a bit, but it is likely necessary to to halt rampant overprescribing and bring us back to a state where the artful practice of medicine and consideration of many pathways to healing can become again the stand of care. Which requires the same ability to tolerate ambiguity and uncertainty that OD requires.
There are so many doctors, like you and others on this forum, who are practicing this art, I believe, but need more protections and encouragement to do so.
And as for mystifying OD, I don’t feel that you are at all doing so, I think it is a tendency for perhaps us lay people or policy makers to do so, to think we need mirror replicas of an Open Dialogue program here in the U.S., which may prevent its principles and approach from becoming widely available b/c there are so many institutional hurdles in our current system.
Perhaps that is what OD practioners mean by context dependent. Sounds like even they are able to operate outside the conventions of the rest of Finland, thanks to geography and other factors.
Thank you for sharing!
Hi Sinead
Ah! Well perhaps after all your assumptions about me and my practice and motivations, I daresay I still owe you one or two. Yes, I see from your misreading of my comments that you are unfamiliar with the Scandinavian school of psychiatric nursing care, perhaps even with the general concept of ego supporting and ego rebuilding nursing care. What a pity the excellent work by the Norwegian nurse Liv Strand Fra kaos mod samling, mestring og helhed (From chaos toward containment (or collectedness), competence(coping) and wholeness ) is not available in English. I would certainly be looking for a nurse of this calibre of professionalism and depth of understanding, if ever I became mentally ill.
all the best
Colin
Message to: Sandra Steingard, M.D.
Posted on http://www.MadinAmerica.com
Date: 10/10/12
Subject Matter:
1. Clarity of interpreting the data presented in “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America” and “Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill”
2. Support for individuals suffering from symptoms of psychosis/mania to have access to Integrative Psychiatry and Functional Medicine.
Dr. Steingard, although I have not read the book “Anatomy of an Epidemic”, I have listened to all of Robert Whitaker’s lectures and interviews available online that discuss his work.
On Sept. 5 you stated that my “summary of Anatomy (in one of these comments) is incredibly articulate and clear in my opinion. Perhaps we can get Bob to provide an answer to your questions.”
Pasted below are some of the email exchanges that I have had with Bob over the past three years.
I am of the belief that Bob’s work involving the mismanagement of psychotic/manic symptoms points to a large majority of individuals labeled with psychotic disorders/schizophrenia/bipolar disorder as individuals who are in fact misdiagnosed and mistreated.
I also am of the belief that Bob’s research on psychotic disorders points to Integrative Psychiatry/Functional Medicine as providing a best-practice standard of care for patients suffering from symptoms of mania/psychosis.
Below are 4 email responses from Bob that I would like you to consider:
1. APA seems to embrace psychotherapy/cognitive therapy Thu, May 10, 2012 4:01 am
Hi Maria,
I was speaking to a group of primary care physicians yesterday, and this very point came up. And that is, in the past, the first thing doctors did when presented with someone with psychiatric symptoms was think of possible physical causes (thyroid, vitamin and mineral deficiencies,), and of course environmental toxins.
And your letter does highlight part of the problem, which is that those against the drug model usually have their own horse they want to ride, which is talk therapy, or some other form of therapy.
But you are right–I think nutrition, environmental toxins, lack of sleep, other medications, etc., should be seen as possible culprits for psychosis (whenever someone presents with such.)
All the best,
Bob
2. Integrative Psychiatry/Medicine Thu, Oct 6, 2011 8:49 am
HI Maria,
Thank you for this.
I am very much looking forward to Dr. Shannon’s presentation. I also think that your story illustrates that when someone experiences a manic or psychotic episode, the first thing doctors should look for are agents (such as chemical exposure, psychoactive drugs–illicit or licit) that could have triggered such episodes.
I hope that integrative psychiatry becomes the future.
Bob
3. Article: After Soteria House Shooting Victim Dies, Questions Remain July 24 2011
Hi Maria,
What happened at Soteria is such a tragedy. What the article didn’t state is that the woman who was killed was one of the home’s real success stories. She had gotten off medications and was doing so well. Her death is so heartbreaking.
Regarding your other point here, well, I think all of psychiatry needs to think about this point, which is that many things can induce psychosis, including other medications, and thus they avoid seeing psychosis as necessarily a sign of mental illness. Physicians a century ago regularly thought that psychosis could result from poisoning, other diseases, etc.
I recently was at an event where one of the psychiatrists said that he believed that 80% of those diagnosed with schizophrenia in recent years had been doing illicit drugs before they had their psychotic break.
all the best,
Bob
4. Talk by e-Patient Dave from the Society of Participatory Medicine Wed, Jul 6, 2011 10:52 am
Hi Maria,
It was nice to meet Dr. Sinaikin there, and all in all, the conference was decent, and actually not too radical.
I’m sorry to hear that ICSPP didn’t show much interest in Dr. Kohl’s presentation.
And I agree with you on this–many, many things can induce psychosis (illicit drugs, lack of sleep, physical illnesses, etc.), and it’s a mistake to lump psychosis into one large cagtegory.
I think the old adage of doctors needing to take a detailed case history (which is a form of participatory medicine) needs to be recalled and reintegrated into practice.
Psychosis is just a symptom of something amiss, and often, not a disease unto itself.
Thanks for this link. I’ll check it out.
Bob