The Politics of Psychosis: Advance in Treatment?‏

[sophia-sadek.livejournal.com]

My first introduction to the concept of therapeutic communities for the treatment of extreme mental states was mention of a project in California called Soteria House. It was only open for a relatively brief time period before losing its funding. Thomas Szasz criticized the concept in a book called Antipsychiatry: Quackery Squared in which he focuses on the work of R. D. Liang and the therapeutic community of Kingsley Hall. His objections concentrated more on specific abuses of Liang and colleagues than on the validity of the treatment model.

In a collection of articles on therapeutic community treatment experiences, I was struck by the following case study:

Beate, who had already lived for almost 2 years in the therapeutic community within the therapeutic community, in the face of overwhelming feelings of guilt, had reacted psychotically. She had been hospitalized on a ward whose chief psychiatrist was very opposed to any psychotherapy with patients diagnosed with schizophrenia and followed a strictly pharmacological regime. After three days the acute psychotic reaction had subsided and Beate became increasingly aware of the conflicting situation she was in. The situation deteriorated when Beate identified with the community and attacked the psychiatrist, who diagnosed this as a sign of another impending psychotic reaction. He urged her not to return to the community. Her psychotherapist, with whom Beate kept contact, informed her social worker in charge of the flat she lived in the community within the community. She asked for an appointment with the psychiatrist and succeeded in establishing a dialogue by outlining to him the personality growth process Beate had undergone, over the last two years. She also pointed that the present situation, where Beate took one parent's side and nevertheless felt torn apart between different parents, resembled very much her infantile situation. Beate herself kept negotiating about the amount of medication she felt necessary for her condition, which was considerably lower e.g. 5 mg instead of 20 mg Zyprexa that her psychiatrist wanted to prescribe.

- Andreas von Wallenberg Pachaly in John Gale, et al Therapeutic Communities for Psychosis, Routledge, N.Y. 2008

This example reveals some of the deficiencies of the bio-chemical paradigm and those who practice based on it. The patient felt she knew what dosage of drugs was suited to her. The psychiatrist prescribed a dosage in line with the standards of his training. One of the differences in psychiatric practice centers on the sensitivity of the psychiatrist to feedback from the patient. Some psychiatrists are comfortable with reasonable requests for what is called self-titration on the part of the patient. This psychiatrist seems to have felt challenged by the patient's desire for self-control.

Another deficiency can be seen in the way that the psychiatrist attempted to control the patient's life choices. The text says that the psychiatrist "urged" the patient to not return to her community, but in reality he may have prevented that return by refusing to discharge the patient. The use of a diagnosis of a pending psychotic break is a power tool that can drive a patient up the wall. It takes a great deal of self-control to not get angry and frustrated in such a circumstance.

Some may argue that the psychiatrist is "old school" and that changes have been made. Yes, changes are being made, but old school psychiatry is the prevailing method of treatment in much of the Western world. Beate was very fortunate to live in a region where support for patients against old school abuses exists. She could have wound up heavily drugged for life.

In a discussion of the treatment method of therapeutic communities, one of our students described his personal experience with a variety of psychiatric facilities in California over a decade ago. He encountered therapeutic methods in one out of four facilities, three of which were private and one public. The public facility and two of the private facilities provided no therapeutic treatment. As far as he could tell, they relied solely on drugs. Although advances have been made in psychiatric treatment, the successes of those advancements have yet to be recognized by public health advocates. They are overwhelmed by proponents of a crude bio-chemical paradigm and the economic interests that depend on public acquiescence in that paradigm.

There seems to be a great deal of political opposition to discussing mental health treatment methods. It is as if there is only one politically correct way to view mental health issues. Anything that confronts that monolithic paradigm is considered outside the domain of public discussion. Failure to kowtow to the party line results in censorship.

What can be done to increase the pace of reform to improve the quality of care for people who suffer from extreme mental states?

Links: Thomas Szasz on R. D. Liang. John Gale, et al on Therapeutic Communities for Psychosis.

Comments

[underlankers.livejournal.com]

Oh, goodie, another Psychiatry is the Antichrist post:

[sophia-sadek.livejournal.com]

That image is soooo gay!

[telemann.livejournal.com]

What makes it gay? (Besides that wandering Satan hand, which is up to no good! Or should I say, down to no good!)

[sophia-sadek.livejournal.com]

Ohhhh! I thought that was Peter. My bad.

[telemann.livejournal.com]

Your double entendre was really bad, but that's precisely why I LOVED it.

[dexeron.livejournal.com]

Satan! Stop giftwrapping Jesus and go walk the dog like I asked!

[mahnmut.livejournal.com]

Sorry, this post has nothing to do with politics whatsoever. You have 1 hour to amend that or it'll be removed.

[sophia-sadek.livejournal.com]

So, mental health treatment is not a public policy issue?

[mahnmut.livejournal.com]

The way you've made the post, no. You've been consistently drifting away from politics and into psychiatric topics. I'd suggest you post these in a community dedicated to psychiatry and post political stuff here. Or at least connect this to politics somehow. Deal?

50 minutes, by the way.

[sophia-sadek.livejournal.com]

Is that adequate?

[mahnmut.livejournal.com]

Yes, thank you.

[malasadas.livejournal.com]

There seems to be a great deal of political opposition to discussing mental health treatment methods.

Requires actual evidence of the tools of politics being used to oppose discussion of mental health treatement methods.

By the way, people waving their hands dismissively at the way you frame things is not politics.

Failure to kowtow to the party line results in censorship.

And yet, here you are.

[sophia-sadek.livejournal.com]

In public policy debates, patient rights advocates typically get short shrift. The opinions of "experts" are granted greater attention. Although that is not overt censorship, it comes across as censorship to people who are allowed to speak out but are unduly ignored.

[malasadas.livejournal.com]

patient rights advocates typically get short shrift

It would be lovely if you would ever substantiate this sort of accusation -- and I mean beyond anecdata.

it comes across as censorship to people who are allowed to speak out but are unduly ignored.


"Unduly ignored" is a judgement call. Such statements, if they are to be taken seriously, should actually justify why such speech is due attention. For example: Pamela Gellar has many vocal opinions on Islam. Those opinions are, however, worthless in the context of an informed debate and SHOULD be ignored. Alas, they are not.

[sophia-sadek.livejournal.com]

I have cited a significant body of patients' rights and health care advocacy literature in past postings. You may feel that people who complain about psychiatric abuse should be ignored. Their abusers thank you for that support.

[malasadas.livejournal.com]

No, you cite anecdotes and a circular rotation of the few critics you rely almost entirely upon. That's not the same as a substantiated argument by any stretch.

Their abusers thank you for that support

Gosh, I cannot imagine why I am disinclined to take your claims seriously. By the way, "you may feel" is yet another example of you using weasel words to reach a conclusion without actually bothering with the fuss of arguing for that conclusion. It is your main rhetorical tool.

[sophia-sadek.livejournal.com]

Anecdotes can mislead, but they can also elucidate. We can learn more from examples than we can from digested statistics, especially when it comes to determining exactly where a mechanism is broken. A statistical analysis can be used more effectively to gloss over gross injustices than to understand and correct them.

Of course, the number of critics is few. The majority are the people being criticized. A good psychiatrist is difficult to come by. Bad ones are a dime a dozen.

[malasadas.livejournal.com]

PART 1:

And there's your glibness again.

Alright, I will give you a substantive reply even though I have rarely ever seen you respect one:

Is psychiatry making mistakes? Has it made mistakes in the past?

Of course it is and it has. That is the nature of every scientific and medical endeavor. However, psychiatry has a great set of methodological tools at its disposal to self correct and to refine both its understanding of what it seeks to treat and how it goes about that treatment. Those tools are things that you appear to distinctly lack.

I'll offer you an example from outside of psychiatric practice: cancer treatment. When the combination of early antibiotics and anesthesia made modern surgery possible, surgeons eventually became the kings of cancer treatment. It made absolute sense to the paradigm of the day -- when the body is literally being eaten up by a tumorous mass, you cut out the tumor. When it was clear that many tumors were not gotten completely out by surgary or the cancer came back, it made sense to cut further and deeper into the body. Eventually, this led to the paradigm of radical surgery for cancer, where the surgeons would see the ultimate tool of their craft as cutting out more and more tissue regardless of how far into cancer development the patient was.

When Dr. Farber began experimenting with chemotherapy treatments, it was seen as an absurd innovation to give patients doses of effective poisons to treat cancer. But over time, with experiments and results, it was finally demonstrated that in early treatment of say, breast cancer, it was not necessary to remove an entire breats, half the lymphatic system and deep parts of chest cavity -- you could treat with smaller, precise surgeries and a course of chemotherapy and be as successful as the radical surgeries of the 1940s and 1950s. What happened next was a reflection of the surgeon's problems -- chemotherapists worked from the assumption that if a little chemotherapy was effective, then more would be even more effective and they advocated for harsher and harsher regimens, basically bringing their patients to the brink of death from the chemo.

But they had the same problem as the radical surgeons. Eventually, the data and studies demonstrated that they were overprescribing the very harsh regimens and that there is a fast diminishing return on high dose chemotherapy depending upon the stage of the cancer and the type of cancer that it is, which has lead the field to more and more study of how intensely diverse and differentiated cancer actually is.

There's a key to this: observation, discovery, study, refinement, study, refinement, new discovery, and so on.

[malasadas.livejournal.com]

PART 2:

So the same thing applies to psychiatry. My mother's aunt suffered from bipolar disorder. She was treated originally with a very harsh regimen of electroconvulsive therapy, a regimen that would not be repeated today as they have discovered how the high voltage shocks of the 1940s and 1950s were unduly damaging. You would call her a "victim of psychiatry" but she was not. She was a victim of her time, much the way that people who died of appendicitis before surgery were victims of theirs.

Now I would consider it a safe bet that the field is over impressed with medication simply because the increased understanding of brain chemistry and the biological bases for behavior are easily channeled into same trends that impact most medical fields. But psychiatry is in possession of powerful methodological tools that will correct that over time as both knowledge and data lead it to new directions. It has already done that in most respects over the decades in ways you refuse to recognize but which, nevertheless, are there for anyone not willing to be misled by your constant comparisons to the most of the field as tantamount to torturers and nazis. And you offer NOTHING in its place. You hint at and provide anecdata of cases outside the statistical averages of treated populations, but you have no actual explanation for them that you are willing to share. You hint at things and avoid direct explanations. There is no reason for anyone here to believe that you possess ANY methodology whatsoever, and without that, there is no way to evaluate the validity of your huge claims. Case studies allow us to see the shades and nuances when theoretical models are applied to individuals, but without any thereotical models, cases cannot tell us that, so any compendium of your contributions on the subject of psychiatry to this forum will find it both quantitatively AND qualitatively deficient.

A good psychiatrist is difficult to come by. Bad ones are a dime a dozen

Your posts need more trite aphorisms the same way Washington, D.C. needs more tobacco lobbyists.

[dwer.livejournal.com]

there you go again.

[sophia-sadek.livejournal.com]

You forgot the Reagan icon.

[root-fu.livejournal.com]

I agree with you.

I've heard decent things about this book: Bad Pharma: How drug companies mislead doctors and harm patients (http://www.amazon.co.uk/dp/0007350740/ref=nosim?tag=bs0b-21) which I would guess could go some ways towards substantiating some of the points you've made on a broader and more defined scale.

Hopefully, people will catch on eventually.

[sophia-sadek.livejournal.com]

It is too new for any library in my area, but I will check out his previous work, Bad Science.

Psychiatry is more susceptible to pharmaceutical proselytizing because of its special ability to use force and coercion to achieve its ends. This does not mean that general practice is immune. David Healy's work details how statins are over-prescribed due to pharmaceutical guidelines and disease mongering on the part of pharmaceutical manufacturers.

[underlankers.livejournal.com]

Yes, we should all fear the Sumerian Space Lizardmen Jewish Uncles peeling potatoes in nuclear reactors.

[root-fu.livejournal.com]

:T