Great thought-provoking post, Sera. You raised many important points, mainly the double-edge sword of a what can happen as a result of a diagnosis, including being shut out of employment, housing, and educational opportunities. To me, the most disturbing aspect is not so much the well-documented failings of DJT, but the fact that so many of our citizens were willing to vote for him (and continue to support him) in spite of all that he has said and done. I watched some historic coverage of the Democratic National Convention from 1924 in NYC where a significant arm of the DNC was headed by full-fledged KKK members who wanted to influence the choice of the Party’s candidate that year. Their choice was a well-known DNC member with close ties to the KKK and they wanted to vote down the alternative candidate. Anyway, the run off between these candidates was so contentious, they eventually went with a relative unknown who ended up being trounced in the general election by Coolidge. The KKK used these events as a rationale to beef up their national image, which included a march on Washington DC a couple of years later by 50,000 bona fide, card carrying members of the KKK! They were in full garb, including robes and hoods, marching down Pennsylvania Avenue. My point is that this country has a large segment that fully supports DJT and he has understood this from the very beginning. To me, coupled with general voter apathy in the general election (almost half of eligible voters did not vote), DJT speaks to a very large constituency in our country that has existed from the outset. And, because he took full advantage, including the use of the MAGA slogan, this reveals a sense of savvy on his part that completely belies most people’s notion of what is meant by the word “crazy.” So, as one of your commenters said, DJT is “crazy like a fox.” My only creative addition to that would be a “crazy like a fox in a red power tie.”
Sadly, therapists are not very good at appraising client progress. Lambert and the work of many others has brought these limitations to light. Hubble, Duncan, and Miller have developed several really good process oriented assessments (outcome rating scale, session rating scale) that are not expensive or cumbersome to administer, many of which take less than a minute to complete. But, it gives the therapist immediate feedback on their performance from the perspective of the client, a perspective that is often ignored or at least under appreciated. The OQ and YOQ instruments are excellent but the downside is that they are proprietary and costly.
To Steve, Sera and others who have commented. First, thank you for weighing in! I admit to being a complete novice at writing for this kind of venue. I had no idea what to expect and it has been a learning experience. The MiA community is clearly a tight-knit and committed group, something that I admire. I also know I have many blind spots. But, I would add that many commenters have made, in some cases, sweeping generalizations about my background that are far from the truth. No essay can be comprehensive enough to cover all of the bases or perspectives. I will certainly endeavor to think long and hard about the points made during this extended discussion and I sincerely hope others will extend to me the same courtesy.
My interest is writing for Mad in America is based primarily on my immense respect for the work of Bob Whitaker. I have read his work for years and believe that he has called attention to injustices perpetrated by the pharmaceutical industry that has no interest in policing itself. So, he has been an unwelcome whistle blower to many. But to countless others, he has been an amazing advocate.
You make some pretty hefty assumptions about me and my background. You have no clue about who I am yet you make several claims about how I don’t know the other side of equation. How can you possibly know this? I am fine with you disagreeing with the points I raised, but I have no earthy idea why you have to resort to personal insults, especially when you began your response by admitting that you incorrectly attributed some of the comments to me that were offered by others. By the way, I was not referring to zero suicide or DBT. I was suggesting you look into the Means Matter program first developed by a woman named Cathy Barber and her colleague, Elaine Frank, who is credited with developing the CALM program.
Sera, thank you for reading the article. I certainly don’t vouch for all of the prevention programs that are part of a national data base, nor did I mean to imply I vetted them fully, only that it is a source of information for individuals who wish to examine their utility for particular community needs. With respect to the means restriction literature, it is a well-established public health approach to preventing death by suicide. I acknowledge that it is not a “one size fits all” approach, but again, depending on the needs of a particular culture or community, it has been shown to be an effective adjunctive intervention as part of comprehensive suicide prevention efforts. For example, as part of the CAMS model, lethal means restriction is but one aspect of stabilization (safety) planning. Means restriction was never meant to be a “stand alone” intervention. I urge you to look deeper into the lethal means restriction paradigm, given that your comments suggest you might have a somewhat limited appreciation of the approach.
Regarding your last points, beginning with “people basically being happy to be locked up and become powerless,” I honestly have no idea what you are referring to here. I made no such comment or claim, either in my article or in my follow-up comments. On the contrary, I emphasized how I fully advocate for a client’s right to self-determination, not only for those who can provide legal consent, but notably for children and adolescents who only have the right to assent to treatment. As for your remark about my “privilege” and “power”, I fully admit that as a Caucasian male I do, in fact, have power and privilege, but I have committed my life’s work to using it in a manner that uplifts and honors others to the best of my ability. I certainly have my failings both as a human and as a professional, but I have never taken power or privilege lightly.
Stephen, I do feel fortunate to be surrounded by open minded, smart, and compassionate learners. Their core values include a sense of duty to advocate for their clients first and foremost and to value a client’s right to self-determination. Yet, I am also familiar with the circumstances you described, having spent a great deal of my early career in state institutions and hospitals. Those experiences led me to make a major change in my career direction, the one I am in currently. I recall several formative experiences while working hospitals and correctional units that were awakenings for me. One time, when I was working as a Psych Tech, the Unit Manager called a meeting of the Techs and coached us on how to write our notes in a manner that would satisfy the care managers from insurance companies to authorize more bed days. It was sickening. Another time, when working at a correctional unit, the superintendent said the “inmates did not deserve any treatment and should be locked up for the rest of their lives.” He was referring to 14 and 15 year old boys. It was at that moment that I knew I had to get out or risk becoming institutionalized myself.
John, you are correct. I’d suggest looking into the work of Elaine Frank (Counseling on Access to Lethal Means; CALM) and Cathy Barber (Means Matter). Elaine developed a program in New Hampshire and has teamed up with Cathy and some other people on this public health approach to suicide prevention. I mentioned some of this work in the article (IDF, Lubin et al., 2010). Feel free to email me and I can send you more information and references. Here is a link to a more recent summary. https://disastermilitarymedicine.biomedcentral.com/articles/10.1186/s40696-015-0007-y
We have used this approach in spirit, in many of our programs. Montana happens to be one example where the approach is used often, notably on American Indian Reservations. Consult the work of Stephanie Ironshooter, Erin Butts, and Don Wetzel Jr. All 3 work for the Office of Public Instruction (OPI).
Based on your comment here, I’m sure you would be intrigued by the Youth Voice Project that is geared to address the very problems and injustices you highlighted. As adults, we regularly fail to consider the perspectives of youth, which truly imperils effective clinical practice. As just one example, we might get full informed consent to treat youth under the age of 18 without fully honoring the child’s need and right to provide informed assent. In fact, though children have less legal standing, we need to go the extra mile to ensure that their assent in respected and honored and that their viewpoints are seen as primary as we go about the task of providing care. This is true in research as well and must be addressed clearly as part of any approved empirical protocol.
Okay Steve, I definitely agree that power dynamics are always a relevant consideration, whether we are talking about parents and children, school administrators and students, or clinicians and patients. One of the most gut wrenching aspects of 13RW were the rape scenes. I just had an email exchange with one of my colleagues who correctly pointed out that for those who have been subjected to ACEs, their risk of suicide increases cumulatively, with each additional ACE. For instance, my colleague reminded me that for a child or adolescent with an ACE score of 7, their risk of suicide is 51 times greater compared to youth with a zero on ACEs. The scene where the counselor turns the tables on Hannah and essentially blames her for the trauma is abhorrent and a sharp reminder of exactly what NOT to do as a clinician. It is a cautionary tale that should remind us all about the horrific impact of trauma, up to and including suicide. Honestly, those scenes and issues were the real story behind 13RW in my opinion. But, I do not think that the scene was representative of what most counselors would do in that instance. I have spent my career surrounded by caring and effective professionals who are advocates first, the second priority of which is to expedite referrals for effective clinical care for their legitimate ailments, especially those who have been subjected to the injustice of trauma. I fear that scenes like that might create a chilling effect on help seeking of any kind, something that I believe would be harmful.
Thank you Richard. I am about halfway through the piece and I certainly see merit in many of your arguments. I have been a direct witness to some of the injustices you highlight, especially earlier in my career. However, in the rural communities in which I have lived and worked for the last 25 years, the most common occurrence is a virtual dearth of providers or hospitals. There are also major problems with access due to other barriers (transportation, lack of qualified providers, no insurance, skepticism of professional healthcare, geographic distance). So, as least in my experience, we have several forces working against us in our attempts to bring effective clinical care to the children and families who live in remote areas. However, we are a persistent bunch and remain committed to serving individuals who would otherwise not be seen at all.
Steve, I can say with confidence that the training programs in Psychology with which I have been associated are not beholden to the medical model or biological psychiatry, nor are any of my students. You used a single anecdote from one exchange to argue how there is a complete disconnect between providers and consumers. I certainly acknowledge how big pharma and the medical establishment has had undue influence over mental health and psychology in particular for decades. In fact, I require that all of my students read Brett Deacon’s (2013) article: The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. It appeared in Clinical Psychology Review. It provides an excellent summary of the failure of the medical model. My students are bright, critical thinkers, capable of sifting through the literature in search of effective ways of helping others. Moreover, they are not satisfied with overly simplified (and wrong) assumptions about the nature and treatment of mental health impairments. They are committed to addressing the multifactorial issues that come up in day to day practice, including the why and how associated with suicide prevention. As for me, I am committed to science and practice of effective psychotherapy and yes, I favor third wave interventions (CBT, DBT, ACT), but that does not suggest a blind loyalty to these approaches. Indeed, as we saw in the Treatment of Adolescent Depression Study (TADS), CBT was not that effective. Consequently, we learned that some of the modular aspects of this particular CBT program were weak or implemented poorly. These “lessons” from the literature are then taken into account when serving clients. So, the commitment here is not a robotic allegiance to a particular paradigm, but to providing compassionate, effective clinical care for the individuals and families we serve.
Thank you for sharing your experience. You raised many important issues. In fact, you should know that interventions like CAMS are designed to target “life experiences behind those feelings.”
Great thought-provoking post, Sera. You raised many important points, mainly the double-edge sword of a what can happen as a result of a diagnosis, including being shut out of employment, housing, and educational opportunities. To me, the most disturbing aspect is not so much the well-documented failings of DJT, but the fact that so many of our citizens were willing to vote for him (and continue to support him) in spite of all that he has said and done. I watched some historic coverage of the Democratic National Convention from 1924 in NYC where a significant arm of the DNC was headed by full-fledged KKK members who wanted to influence the choice of the Party’s candidate that year. Their choice was a well-known DNC member with close ties to the KKK and they wanted to vote down the alternative candidate. Anyway, the run off between these candidates was so contentious, they eventually went with a relative unknown who ended up being trounced in the general election by Coolidge. The KKK used these events as a rationale to beef up their national image, which included a march on Washington DC a couple of years later by 50,000 bona fide, card carrying members of the KKK! They were in full garb, including robes and hoods, marching down Pennsylvania Avenue. My point is that this country has a large segment that fully supports DJT and he has understood this from the very beginning. To me, coupled with general voter apathy in the general election (almost half of eligible voters did not vote), DJT speaks to a very large constituency in our country that has existed from the outset. And, because he took full advantage, including the use of the MAGA slogan, this reveals a sense of savvy on his part that completely belies most people’s notion of what is meant by the word “crazy.” So, as one of your commenters said, DJT is “crazy like a fox.” My only creative addition to that would be a “crazy like a fox in a red power tie.”
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I just ran across this blog that offers some good insights: http://www.betterevaluation.org/en/blog/best_practices_arent
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Sadly, therapists are not very good at appraising client progress. Lambert and the work of many others has brought these limitations to light. Hubble, Duncan, and Miller have developed several really good process oriented assessments (outcome rating scale, session rating scale) that are not expensive or cumbersome to administer, many of which take less than a minute to complete. But, it gives the therapist immediate feedback on their performance from the perspective of the client, a perspective that is often ignored or at least under appreciated. The OQ and YOQ instruments are excellent but the downside is that they are proprietary and costly.
Report comment
To Steve, Sera and others who have commented. First, thank you for weighing in! I admit to being a complete novice at writing for this kind of venue. I had no idea what to expect and it has been a learning experience. The MiA community is clearly a tight-knit and committed group, something that I admire. I also know I have many blind spots. But, I would add that many commenters have made, in some cases, sweeping generalizations about my background that are far from the truth. No essay can be comprehensive enough to cover all of the bases or perspectives. I will certainly endeavor to think long and hard about the points made during this extended discussion and I sincerely hope others will extend to me the same courtesy.
Report comment
My interest is writing for Mad in America is based primarily on my immense respect for the work of Bob Whitaker. I have read his work for years and believe that he has called attention to injustices perpetrated by the pharmaceutical industry that has no interest in policing itself. So, he has been an unwelcome whistle blower to many. But to countless others, he has been an amazing advocate.
Report comment
You make some pretty hefty assumptions about me and my background. You have no clue about who I am yet you make several claims about how I don’t know the other side of equation. How can you possibly know this? I am fine with you disagreeing with the points I raised, but I have no earthy idea why you have to resort to personal insults, especially when you began your response by admitting that you incorrectly attributed some of the comments to me that were offered by others. By the way, I was not referring to zero suicide or DBT. I was suggesting you look into the Means Matter program first developed by a woman named Cathy Barber and her colleague, Elaine Frank, who is credited with developing the CALM program.
Report comment
Sera, thank you for reading the article. I certainly don’t vouch for all of the prevention programs that are part of a national data base, nor did I mean to imply I vetted them fully, only that it is a source of information for individuals who wish to examine their utility for particular community needs. With respect to the means restriction literature, it is a well-established public health approach to preventing death by suicide. I acknowledge that it is not a “one size fits all” approach, but again, depending on the needs of a particular culture or community, it has been shown to be an effective adjunctive intervention as part of comprehensive suicide prevention efforts. For example, as part of the CAMS model, lethal means restriction is but one aspect of stabilization (safety) planning. Means restriction was never meant to be a “stand alone” intervention. I urge you to look deeper into the lethal means restriction paradigm, given that your comments suggest you might have a somewhat limited appreciation of the approach.
Regarding your last points, beginning with “people basically being happy to be locked up and become powerless,” I honestly have no idea what you are referring to here. I made no such comment or claim, either in my article or in my follow-up comments. On the contrary, I emphasized how I fully advocate for a client’s right to self-determination, not only for those who can provide legal consent, but notably for children and adolescents who only have the right to assent to treatment. As for your remark about my “privilege” and “power”, I fully admit that as a Caucasian male I do, in fact, have power and privilege, but I have committed my life’s work to using it in a manner that uplifts and honors others to the best of my ability. I certainly have my failings both as a human and as a professional, but I have never taken power or privilege lightly.
Report comment
Stephen, I do feel fortunate to be surrounded by open minded, smart, and compassionate learners. Their core values include a sense of duty to advocate for their clients first and foremost and to value a client’s right to self-determination. Yet, I am also familiar with the circumstances you described, having spent a great deal of my early career in state institutions and hospitals. Those experiences led me to make a major change in my career direction, the one I am in currently. I recall several formative experiences while working hospitals and correctional units that were awakenings for me. One time, when I was working as a Psych Tech, the Unit Manager called a meeting of the Techs and coached us on how to write our notes in a manner that would satisfy the care managers from insurance companies to authorize more bed days. It was sickening. Another time, when working at a correctional unit, the superintendent said the “inmates did not deserve any treatment and should be locked up for the rest of their lives.” He was referring to 14 and 15 year old boys. It was at that moment that I knew I had to get out or risk becoming institutionalized myself.
Report comment
John, you are correct. I’d suggest looking into the work of Elaine Frank (Counseling on Access to Lethal Means; CALM) and Cathy Barber (Means Matter). Elaine developed a program in New Hampshire and has teamed up with Cathy and some other people on this public health approach to suicide prevention. I mentioned some of this work in the article (IDF, Lubin et al., 2010). Feel free to email me and I can send you more information and references. Here is a link to a more recent summary. https://disastermilitarymedicine.biomedcentral.com/articles/10.1186/s40696-015-0007-y
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http://www.youthvoiceproject.com/
We have used this approach in spirit, in many of our programs. Montana happens to be one example where the approach is used often, notably on American Indian Reservations. Consult the work of Stephanie Ironshooter, Erin Butts, and Don Wetzel Jr. All 3 work for the Office of Public Instruction (OPI).
Report comment
Based on your comment here, I’m sure you would be intrigued by the Youth Voice Project that is geared to address the very problems and injustices you highlighted. As adults, we regularly fail to consider the perspectives of youth, which truly imperils effective clinical practice. As just one example, we might get full informed consent to treat youth under the age of 18 without fully honoring the child’s need and right to provide informed assent. In fact, though children have less legal standing, we need to go the extra mile to ensure that their assent in respected and honored and that their viewpoints are seen as primary as we go about the task of providing care. This is true in research as well and must be addressed clearly as part of any approved empirical protocol.
Report comment
Okay Steve, I definitely agree that power dynamics are always a relevant consideration, whether we are talking about parents and children, school administrators and students, or clinicians and patients. One of the most gut wrenching aspects of 13RW were the rape scenes. I just had an email exchange with one of my colleagues who correctly pointed out that for those who have been subjected to ACEs, their risk of suicide increases cumulatively, with each additional ACE. For instance, my colleague reminded me that for a child or adolescent with an ACE score of 7, their risk of suicide is 51 times greater compared to youth with a zero on ACEs. The scene where the counselor turns the tables on Hannah and essentially blames her for the trauma is abhorrent and a sharp reminder of exactly what NOT to do as a clinician. It is a cautionary tale that should remind us all about the horrific impact of trauma, up to and including suicide. Honestly, those scenes and issues were the real story behind 13RW in my opinion. But, I do not think that the scene was representative of what most counselors would do in that instance. I have spent my career surrounded by caring and effective professionals who are advocates first, the second priority of which is to expedite referrals for effective clinical care for their legitimate ailments, especially those who have been subjected to the injustice of trauma. I fear that scenes like that might create a chilling effect on help seeking of any kind, something that I believe would be harmful.
Report comment
Thank you Richard. I am about halfway through the piece and I certainly see merit in many of your arguments. I have been a direct witness to some of the injustices you highlight, especially earlier in my career. However, in the rural communities in which I have lived and worked for the last 25 years, the most common occurrence is a virtual dearth of providers or hospitals. There are also major problems with access due to other barriers (transportation, lack of qualified providers, no insurance, skepticism of professional healthcare, geographic distance). So, as least in my experience, we have several forces working against us in our attempts to bring effective clinical care to the children and families who live in remote areas. However, we are a persistent bunch and remain committed to serving individuals who would otherwise not be seen at all.
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BTW, most of what I said in my previous response was intended for Richard, not necessarily Steve.
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Steve, I can say with confidence that the training programs in Psychology with which I have been associated are not beholden to the medical model or biological psychiatry, nor are any of my students. You used a single anecdote from one exchange to argue how there is a complete disconnect between providers and consumers. I certainly acknowledge how big pharma and the medical establishment has had undue influence over mental health and psychology in particular for decades. In fact, I require that all of my students read Brett Deacon’s (2013) article: The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. It appeared in Clinical Psychology Review. It provides an excellent summary of the failure of the medical model. My students are bright, critical thinkers, capable of sifting through the literature in search of effective ways of helping others. Moreover, they are not satisfied with overly simplified (and wrong) assumptions about the nature and treatment of mental health impairments. They are committed to addressing the multifactorial issues that come up in day to day practice, including the why and how associated with suicide prevention. As for me, I am committed to science and practice of effective psychotherapy and yes, I favor third wave interventions (CBT, DBT, ACT), but that does not suggest a blind loyalty to these approaches. Indeed, as we saw in the Treatment of Adolescent Depression Study (TADS), CBT was not that effective. Consequently, we learned that some of the modular aspects of this particular CBT program were weak or implemented poorly. These “lessons” from the literature are then taken into account when serving clients. So, the commitment here is not a robotic allegiance to a particular paradigm, but to providing compassionate, effective clinical care for the individuals and families we serve.
Report comment
Sam,
Thank you for sharing your experience. You raised many important issues. In fact, you should know that interventions like CAMS are designed to target “life experiences behind those feelings.”
Report comment