Friday, August 14, 2020

Comments by Marcello Maviglia

Showing 27 of 27 comments.

  • Thanks for the excellent article about recovery. As a psychiatrist who has embraced the concept for quite some time and has been mentored by peer specialists I deeply appreciate it. Stressing the social determinants of health in the process of recovery is essential both at a policy level and on the ground.
    However, I would like to stress a fundamental issues which as professionals often we tend to neglect. in our work in the field of recovery, we should always try our best to to involve individuals with “lived experience”(individuals who are managing their recovery and are willing to help others).Speaking about recovery without their involvement and necessary lead could translate our efforts into the typical hierarchical academic approach which would minimize the concept of recovery as a “consumer lead process” and which has been correctly criticized by the recovery movement multiple times. Thanks again for your efforts in illustrating and making more popular the principles of recovery.

  • Anomie, I wish we could have more time and space for this conversation. I believe that a sound strategy is needed to change things. Also, I agree about the distress experienced by Drs and I already expressed my criticism about corporate medicine both in the article and some of the posts. The limitations of the medical model have been challenged by a substantial number of professionals in the field of medicine and mental health. I spent years working on these issues with my mentors in the public health field( these were professional from different social, racial and educational backgrounds). Also, not all the Drs are the same: we come from different experiences, racial and social backgrounds, social classes and family histories. In fact, some of us are struggling with emotional distress and /or have loved ones struggling with it.

  • Reply to Steve McCrea

    Hi Steve, I do not think it is a disrespectful question. It is a challenging one, which would require a live conversation.
    In addressing the first part of your question” What do you see as non-biological psychiatry?”, this is my response:
    Instead of psychiatry or behavioral health I do focus on “physical and psychological wellbeing” (as suggested in the recovery literature), which includes the social determinants of health (embracing also psychosocial trauma, and Historical Trauma of the Indigenous people), so essential to the understanding of emotional and physical distress. Moreover, focusing on “physical and psychological wellbeing” highlights the ability of individuals to attain a good quality of life no matter what the alleged diagnoses may be and departs from the concept of psychiatric diagnoses as chronic disorders.
    In terms of the role that doctors play within this frame, I can identify at least three aspects:
    Coordination and integration of care within his /her own practice among the social, physical and psychological aspects of health. Psychiatrists should function more as primary care physicians and focus on those comorbidities which are common to individuals in a state of prolonged emotional distress.
    In this frame, the Dr.’s role includes the discrimination between physically induced emotional states (i.e. thyroid disorders, brain lesions, and traumatic injuries), substance abuse, and emotional distress due to psychosocial factors.

    Since psychiatric medications will unfortunately continue to play a major role in clinical practice, the responsibility of a medical doctor in this area can be twofold: providing alternatives to psychiatric medication whenever is possible, and helping individuals who want to withdraw from psychiatric medications with proper recovery –based approaches , which would include the support of peer specialists.

    Much more can and should be said, but this could be best accomplished thru a different format than posting. But, please, let’s continue the dialogue if you feel is worthwhile.

  • Reply to Berzerk:

    Thanks for your comment.
    It is true that cannabis comes in many shapes and forms. Its injudicious use, especially when it is adulterated with other substances ,which is often the case, can indeed cause problems.
    I was referring to the judicious and therapeutic use of marijuana in my earlier comment.
    in reality, there is no proof that cannabis used in moderation causes brain damage.

    The majority of the official studies ,which for the most part have been conducted with the intent of showing that cannabis is noxious, have serious methodological problems. Therefore there is a real need for more independent and unbiased studies.

    However, there is plenty of reliable literature and individual narratives showing the benefits from appropriate use of cannabis for PTSD, ANXIETY CHRONIC PAIN and other conditions. There is indeed some evidence that there could be short term effects on cognitive functions especially if the use is inappropriate, but no long-term chronic problems have been clearly demonstrate with judicious and moderate use.
    Of course, I would never suggest its use in people who have experienced episodes of psychosis or other conditions in which its use could be potentially damaging( this si a very complex area), even though the data on this aspect are not totally clear.

  • Hi Sam, in reality the influence of big pharma cannot be discounted. Ideology is created by power and money. Since the times of the Flexner report medicine has been controlled by corporate interests. The book Rockefeller Medicine Men: Medicine and Capitalism in America , by E. Richard Brown, illustrates this issue vey eloquently. Gramsci used to refer to the same process as hegemony to explain the role of powerful entities in the control of the production and reproduction of knowledge. In the brief article I clearly stated the recent attempts by the corporate giant Sanofi to control the process of medical education in Italy, like it is happening in the rest of the world. I agree that In this context psychiatrists have the responsibility to raise their voice nd fight. It does not happen with the necessary emphasis since the so called biological psychiatry is the dominant thinking in the field. Therefore , it would be naïve to underestimate the power of Big Pharma in all field of medicine and not just psychiatry.
    I believe that action requires concrete planning on what is doable. I am ready to listen to your alternative views to the current system including those which contemplate the total disappearance of psychiatry. Thanks.

  • Hi Rosalee D,
    Thanks for your thoughts. It is essential that mental health professionals listen to individual stories. Your comment about” having been harmed by psychiatry” it is certainly something I cannot neglect in my response. Your points about the harm created by the medical model and the need for a social model “that acknowledges many varied psychosocial determinants” are crucial to the understanding of emotional distress as part of the individual existential experience which can be managed and overcome.
    The role of the mental health professional is to listen, learn from individuals in emotional distress and from those with “lived experience”. Moreover, medical school and residencies curricula should include mentorship modules where persons with “lived experience” provide their feedback to medical students and residents.

  • Thanks Sam, your questions are well taken and I do not take them as confrontational, but legitimate. Please, allow me to clarify some aspects of my thinking, which I feel essential. Today, unfortunately, the biological model dominates. In reality there is no proof of any concrete brain abnormalities for any of the psychiatric diagnosis. Therefore, to talk about mental illness is not accurate. We should be talking about emotional distress and challenges or difficulties (I am borrowing language used by individuals with “lived experience”) instead of symptoms and diagnosis.
    In regards to the use of diagnosis, both in the private and public system it is virtually impossible to omit their utilization. However, it is imperative to engage the individual, often with the assistance of a peer specialist, in a dialogue about the fact that emotional distress is not forever, that there many possible solution to the current problems, that instead of diagnosis and symptoms we should focus on addressing difficulties, and attaining goals. It is in this context that I am using the word “Recovery”.
    By Recovery I do not mean medical recovery but existential recovery, often defined by the peers, like( paraphrasing) “a self-directed process, not focused on symptoms and diagnoses but on overcoming obstacles and difficulties with the goal of realizing individual aspirations, goals and dreams and attaining a good quality of life”

  • Anomie, I thank you for the question. As general rule, it is pivotal that people are always offered alternatives to meds. There are other modalities that people could and should consider. The recovery field offers a variety of possibilities. I like to emphasize that Peer Specialists are essential, in my view, in identifying appropriate alternatives. However, If the individual decides to take medications, it necessary to emphasize that there are not sufficient data for their utilization in the long run and that it is extremely important to build a strong self driven-recovery oriented support system.In this vein, the possibility of judicious withdrawal from medications should be explored with everybody who is and has been on medication. All this is also consistent with freedom of choice and should not be neglected.
    But in reality, what I am saying should not sound odd because is backed up by data( often published by MIA and the MAD affiliates) ,which indicate that the long term use of medications is not helpful and that the building of a strong psychosocial support system is highly therapeutic. In this frame, I was just reflecting on your nickname” Anomie”( breakdown of social bonds,social isolation) which I think is a clever way to summarize the genesis of emotional distress and hopefully to find a solution. Ciao for now.

  • thanks for the inquiry . As a psychiatrist, of course I prescribed and prescribe psychotropics drugs. Many individual come to me already on psychotropics. But I consider a essential part of my role was to communicate the limitations of the utilization of psychiatric medications, assisting people with alternatives and helping them to get off medications, while involving peer specialists to help me in the process. In regards to cannabis, I found that lot of individuals in treatment are getting cannabis cards and are trying to get off opioids and psychotropics utilizing cannabinoids and cannabis. I am not imposing cannabis or cannabinoids on anybody, but I respect their choice, while providing some assistance. I simply listen and work with those individuals who make that choice. PS: In the book I ask cogent questions about the use of cannabis. I do not promote it as treatment for psychiatric illness, but I highlight the need for more unbiased research on the topic.

  • Hi Sam , thanks for the legitimate criticism and the tone which allow me to engage in a constructive dialogue.
    Firstly, I wanted to make a disclaimer about the use of ” MAD” in the title. It is referred to the MAD sites and affiliates. In fact, the goal of the article is to try and unify the efforts of all MAD affiliates to collaborate towards the goals which I describe in the article.
    But first, we need to develop an agenda hinging around some of the themes I am proposing . but not limited to them. The format could be similar focus groups and he participation of people with lived experience essential. But this will have to be decide in the course of our meetings.
    Also, this effort will not see me being in charge, but being based on the principles of recovery and social justice, will emphasize the role of individuals with lived experience, peer specialists, and people with solid knowledge in recovery. Personally, I am not advocating for the medical model to be the leading force in this effort. I was fortunate in my professional development to be mentored by people with lived experience and peer specialists for more than 15 years. This process , still in progress, has made me aware that as a Doctor I had lot to learn that listening to the people in recovery, to their issues and, at times to their anger, was part of my job if I wanted to be part of the solution. Also,I became painfully aware of the limits of the medical model. Of course I still fail…. that is I why I need the ongoing mentorship of people with lived experience.
    Your questions regarding what I am doing to get the people involved is pivotal. Currently, in my work in the States.I try as much as I can to support the ‘building” of recovery networks under the leadership of local recovery experts, mainly Peer Specialists. Also, I am trying to apply strategies to provide individuals with alternatives to psychiatric medications. This includes the possibility of withdrawing from them with the support recovery oriented approaches( peer specialists). I am also involved with the Center For Native American Health in Albuquerque NM. This has provided me with lot of insights regarding the meaning of community as a powerful asset towards recovery and regarding the importance of culture and social determinants of health.
    In terms of my efforts with MAD In Italy, I have tried

  • Hi Dr. Francisco, I read with the utmost interest your study. First of all congratulations!
    The review the study has triggered in my mind the following observations/questions , which I would like to share with you and the site members:
    -You stated that…. almost 500 people were invited to participate in the program. Three-hundred-fifty accepted (70%). Do you have any feedback about the main reason(s) as why 25% did not accept? This could be extremely important data to develop insight about consumer’s engagement in withdrawal practices.( It looks like you are reporting some of the reasons for about 50 participants).
    – You stated that..None of the 350 people in the program needed to be admitted to the hospital as a result of withdrawal or relapse symptoms. To me this is impressive, and I feel it would be beneficial to know about what contributed to the high retention rate, high level of functioning, and stability of these consumers.
    – Your cost saving figures do not include savings from prevention of episodes of inpatient care. That would be a very valuable piece of information, needless to say. Can you elaborate on that?
    – Also you referred to the need to….Facilitate coordination with professionals, family members, and caregivers. Can you be more specific on how you accomplished that? This is a very important aspect without question.
    – I TOTALLY AGREE WHEN YOU SAY” Maybe we should ask the patients what their needs are and what they would choose to do.. Indeed this should be common practice… Also , I would speculate that including in the process Peer Specialists, could benefit the path of withdrawal in many ways, including symptoms management, and relationship building at different levels.
    Thanks you ! Marcello Maviglia,MD,MPH, Albuquerque, NM

  • Thanks Pacific for expanding on the meaning of moral improvement Model. I had to make sure, since the adjective “moral” has been used in different contexts in behavioral health.
    In reality, when I learned about the model ,years ago, as a psychotherapy framework, I had my doubts due to the fact that the definitions of morality , moral development, and moral improvement, are very subjective and bound to cultural, social and class issues. Therefore, I do not agree with the approach.
    In my view, real Recovery happens when the individual experiencing psychological distress drives his/ her own efforts and decides, at time with assistance, where to go with it.
    Thanks for your insights.

  • Thank Alex! If can join the site Mad In Italy and then sent us your SPILL/ ARTICLE about the topic you would like to address regarding emotional distress/ mental health to [email protected], we will translate it and also provide the original version in English. Best, Marcello

  • Hi,

    I agree that is very challenging to get off neuroleptics, but it is possible, as shown by multiple positive experiences, which I have personally witnessed , heard , and read about. THX!

  • Hi Alex, your questions are well taken. I hope you will continue to challenge every clinician who claims knowledge in the field of Recovery.
    Indeed, for a clinician is not easy to truly respect the independence of individuals with “lived experience” and Peer Specialists, without assuming the role of the “expert”.
    In this vein, I believe that the process may require that the clinician would accept the role of mentee under the guidance of a seasoned peer specialist. or “individual with lived experience”; learning about the wisdom and nuances of Recovery is not intuitive for clinicians. When I perceived my inadequacies, I decided that to foster my knowledge in the field of Recovery, I should seek assistance from Peer specialists. One of my most valuable mentors of many years has been a very knowledgeable Peer Specialist here in New Mexico, Donald Hume, who has been extremely kind and patient to correct my bias and misperceptions in the area of Recovery. For several years , we have met on a daily basis to discuss issues related to individuals with emotional distress , mental health and Recovery strategies and policies. I am very thankful to him for his assistance in this journey, which will never stop since I am aware that it may easily reverse to the narrow logic of the medical model. The clinician cannot be “in charge” of the path to Recovery , since it would be against the principles and the spirit of Recovery itself, which is a self driven process. But, as you stated, this is a real complex topic which cannot be delved into, in one sitting and in few messages.
    Anyhow, if you agree, I would like to invite you ,in the near future, to write your thoughts on this subject on Mad In Italy. This would be of great help for our readers , who may need more clarity on the subject.
    Your challenging and insightful comments are always welcome. Please let me know. Thanks. Marcello