As I read about historical "scientific" approaches to mental illness, I can't help but reflect on today's practices. For example, Moral Treatment, began in part, as a backlash to the harsh treatments of the time. Pinel and Pussin both believed that people deserved to be treated with kindness. I see similar parallels in today's treatment approaches. On one hand, there is the medical model of diagnosis, and treatment -- with the physician as expert. In many ways, like Benjamin Rush's residents, psychiatrists today are taught to not let their sentiments get in the way, as they know best. Forced treatment happens with regularity. Unfortunately, the "patients" are right much of the time...about the negative effects of their treatments, and are legitimately resistant and noncompliant. Yet, somehow, their perspectives are disregarded, as they are "irrational," and obviously not as smart as the expert psychiatrist. I see recovery and psychiatric survivor movements as a backlash (in part) to this medical model, repeating patterns of the past. (Opposing forces -- Mad Doctors v. Moral Treatment)
It's easy to look back and be critical of the treatments that were considered "cutting edge" at that time -- for example, drowning, spinning, drinking concoctions, bloodletting, flogging. Often people with mental illness experienced these "treatments" negatively, yet these perspectives were disregarded, and "science" prevailed over human experience. Residents were taught to not let their emotions cloud their judgment.
What are we doing today (cite a specific practice or treatment) that YOU think will be criticized harshly when seen through the lens of history, 100 or even 200 years from now? To what degree are we disregarding patient experience now, and why do you think that happens?
Reply to this post and at least 2 of your classmates' replies.
These are questions that we really need to be asking ourselves and it's good practice to try to put my reactions into clear language.
ReplyDeleteI think there are a lot of reasons for why we (professionals and the public at large) continue to disregard the experience of the client. When someone is experiencing mental illness, the common reaction is to assume that they are no longer fit to make decisions and further, that their reactions to the 'real world' are untrustworthy. After all, they're mentally ill, right? They aren't experiencing reality the way a 'normal' person does and therefore professionals need to interpret what the mentally ill client is actually experiencing once that experience has been filtered through some sort of normality. Ugh. It's ugly, it's nasty and dehumanizing. It's really no different than the assumption (which was popularly espoused by doctors just a handful of years ago) that babies don't feel pain. Another reason we continue to disregard the experience of people receiving mental health services is because surely all that training and education that went into creating the specialist must result in some sort of super-human who is better able to judge what is right and necessary. The more years that a person spends becoming educated, the closer to a perfect understanding of the subject they are. Or not ... recent attention to the effectiveness of therapeutic interventions by peer support versus specialists shows that peer support has longer-lasting and more positive results. Why is that? Could it possibly be because the peer support person has shared some of the same experiences and actually listens to the client's reactions and needs? Food for thought.
As for your other question, about what we are doing today that will be harshly criticized by our descendents, our refusal to incorporate the negative therapeutic experiences of people receiving mental health treatment will rightly condemn us as being barbaric. I believe that our ongoing attempts to pigeonhole people into diagnoses rather than taking a holistic view of the individual will also be viewed with disbelief by those who follow us.
(I'm having some difficulty getting this post from my USM-Google account, as I also have a work-Google account and two private accounts. If this shows up oddly, it's Barbara writing here.)
Hi Barbara,
DeleteI agree; there are so many pros and cons of diagnosis and our healthcare and other systems are in lock-step with diagnoses. It can also hamper people's ability to get what they need - can't get a medication (if also have SA DO), special education services would be hampered by SA and ODD/conduct disorder. It's the label that can be detrimental, as well as the financial impact of having or not having a diagnostic label that is also an issue. Thinking back on the history of diagnosis, however, it is so important that we can all speak the same language and our human minds strive to categorize and quantify as decision making tools. Fortunately, many are concerned about this issue and individual providers as well as groups , lawmakers, NGOs, etc. are making an effort to consider ongoing changes in mental health care.
Very profoundly stated Barb. "I believe that our ongoing attempts to pigeonhole people into diagnoses rather than taking a holistic view..." This is what I truly find appalling in our society. That we must put labels on everyone; that everyone must have a diagnosis and once given, no, it cannot be taken away. So if you are bi-polar and you present with headaches, it must be a new symptom of that diagnosis, so let's adjust your meds. It couldn't possibly be something new. You are forever labeled. It's maddening but so much more comforting to the professionals who studied all those years.
DeleteI have to agree here. When I open people, mostly kids in my private practice, insurance requires me to assign a diagnosis on the first visit. I struggle with this, however the only way to get paid and provide treatment is to diagnose a child with mental illness. Is a child who is reacting to a life transition really mentally ill? How can anyone feel good about this labeling? I often see kids who are struggling with peer and/or academic demands. Instead of just helping them learn skills, I have to label them as ill. Breaks my heart. This is a barrier for so many families who bring their child to me for help, but refuse diagnosis. Even though I agree, my hands are tied and unless a family can pay it of pocket, diagnosis is the only way to get reimbursed. I am not disputing all diagnosis, some are very appropriate and warranted.
DeleteI think we will be criticized for our lack of health support for all people in regards to our health care system creating ineffective methods like the 15 minute window a PCP has to see a patient. I think we have gone backwards from the days a doctor would go to someone's home, get to know the family and the person. A 15 minute window is ridiculous, because this does not give a doctor enough time to really listen to the patient and his or her concerns, nor does it give a doctor enough time to think holistically about a patient and his or her symptoms. Doctors are humans too, and I am sure there are times in that 15 minute window of seeing a patient where the doctor may be thinking of all the paperwork that must be done or getting ready to transition out of the office to meet the next patient.This answer ties into the second question of disregarding the patient's experience. A doctor has a 15 minute window and a patient comes in with symptoms of schizophrenia. The doctor was aware of this DX. However, because there is the cultural and social view of people with MI not being rational or able to think on their own, added to the small 15 minute window of care, this could create less compassion toward a discussion about the negative side effects of the drugs compared to the positive ones due to the rush of the appointment and the outlook of a person with MI. There are many more ways a person with MI receives assistance, but I think of our PCP care and how that effects someone without a MI DX. Therefore, I can only imagine the care for someone with a MI in this method of treatment.
ReplyDeleteKelly, great post. I agree that it is hard to get a feel for a patient is such a small window. I sometimes think that maybe this is one of the reasons we have such a rampant pill problem here in Maine. seriously, how is anyone supposed to get a real feel for what a patient needs in a 15 minute window. when we are rushed we look for the quickest way to address the problem, usually prescriptions. with a 15 minute window it becomes wash, rinse, repeat, to deal with as many patients as possible in as little time as possible.
DeleteGreat point Kelly. It is so frustrating knowing physicians are only allowing 15 for medical treatment. how can one trust thier doctor knowing that thier treatment is a cookie cutter approach where everyone is treated the same and not individualized considering everyone is different and respond differently to treatment.
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DeleteI agree, Kelley, that a 15 minute time frame does not leave alot of time to accomplish much and for someone who really needs time to feel comfortable in order to discuss what they're experiencing, 15 minutes would not even begin to cover it! I know that I have felt rushed or like I was taking too much of the Doctors time before and its very frustating! I can only imagine how frustrating and depleating it can be for someone who has a mental illness or has limited funds or transportation to make it to a provider but not have enough time to achieve anything.
ReplyDeleteI think (hope) that when we look back through the lens of history that we recognize the disservice and maltreatment we have given to those with mental and substance disorders. I think we have improved since the days of instutionalization, but not enough, as today institutions are now jails. We need to realize that jailing people with these disorders is not helpful or rehabiltative. This is not the place for them and they have no chance of overcoming their illness and becoming members of society being locked in jail. Locking up the mentally ill needs to stop and programs need to be put in place to humanely treat and rehabilitate these individuals so that they can lead a life they deserver to live. I think one reason this is happening today is because WE ARE disregarding the patient experience, it is obvious by the thousands of people who are incarcertated. I think it is easier to disregard the patient experience, what do they know anyway, they have a mental illness, must be what the providers think. They deserve more than that, and are aware, how can they not be, they are living this experience. I hope that this maltreatment and incarceration epidemic will soon change and we start to effectively care for these individuals who deserve more than what they are receiving.
ReplyDeleteJessica - what a great post! I have also been hearing some unbelievable stats about the level of MI for individuals who are in the DOC system. A fellow student is a social worker in Cumberland County Jail and he talks about how many people are going through withdrawal and benefit from some simple meds (anxiety). Also, it seems when they get out of jail, individuals are not set up with the right supports to manage their symptoms so they do not end right back in jail again. I wonder what we might learn from Canada and English (and probably other countries as well) as I have read that their recidivism rates are lower and they have some successful rehabilitation programs. I visited a facility in England where people were being trained for community vocations (with day work pass privileges during their sentence) and some people shared that they had missed this during their teenage years.
DeleteKelly, that is a great idea to look to other countries or places that are having success in the decrease of turn over for people with MI and substance abuse in the jail systems. As America, I think we are pretty amazing, but not amazing enough to know we know it all. Looking to other methods is a wise thought. The fact that England has a vocational training program is excellent instead of letting an inmate leave without assisting in resume building or experience. My thought is that person would be homeless and get back into the criminal life again. It is great that now many schools in Maine are providing vocational experience for the teens that don't fit the educational mold of schooling and do better with hands on specific training.
DeleteJessica, I agree with you entirely. there used to be a time when the MI were institutionalized and treated (albeit, most people would agree the methods were barbaric at best; lobotomy, shock treatment, etc.) Now it seems the MI are incarcerated and lost to the system to be released at a later date to commit the same crime again and be re-incarcerated (quite a vicious cycle) If there were proper institutions set up using more modern practices many of these offenders could be treated and released as a functioning member of society able to live a life they deserve.
DeleteIn viewing the Bellevue film and in my role as in-home family therapist, I still often see providers (and school) strongly advocating for medication for youths and adults, despite concerns (i.e., side effects, not wanting to be on meds). We are only beginning to understand the long term effects of some meds, and new ones are marketed every day. I believe this will be looked upon harshly in the future. Also, our national health care crisis I believe will also be looked upon as inhumane, as it already does to our citizens and those in other countries. Having a business background myself, I wonder how me might even balance our cultural foundation (independence, competition) with the needs of the many. It is also worth considering how oversight is handled - at insurance companies, federal & state Medicare and Medicaid, etc. Lawmakers, journalism and the legal field help to reveal fiduciary practices and abuses, though sometimes the lag time on immoral dealings is significant. On the bright side, information sharing seems to be at its highest ever and people are less constrained in talking about taboos (like MI), so that is one silver lining to where we are today.
ReplyDeletefollow up: why does the medication issue happen; some factors might be trusting the all knowing medical expert, not considering other systemic factors for behavior (family, peers, prosocial activities?), less evidence in literature for some holistic treatment approaches, no insurance coverage for various non-med treatments, wanting a quick fix for Sx....the list could go on.
DeleteI agree Kelly. We as a health care system tend to not help educate the client, maybe even ourselves, about the cultural impact toward MI, medications and how we view humanity. I think you hit right on it when you shared that most people receiving assistance do not realize that their perceptions, family, peers and leisure activities really do affect their functioning. The Wellness Model is such a great tool and I hope to use this in my counseling future. I am sure you are well aware of this model! It is such a great educational tool and extremely holistic. I think that health insurance providers are recognizing that leisure and social interactions are important and implement them in "prevention" tools. As a Recreation Therapist that has been a selling point for my profession as it parallels with health insurance expectations of prevention. Lastly, I think the biggest emotional reaction I felt from reading what you wrote was when you referenced America's idea of competence and independence and how that causes major issues with people who are DX with a disability or MI. Heck, I don't even think it fits the mold for people who do not have a DX, yet it is what we are molded to strive for. There have been countless times during my counseling courses where I have realized and was somewhat burdened by the fact that we Westerners are more individual based and less collective based. I wished so much that this was not the case. My faith is hugely collective, but my society is not. I feel this is a major reason why so many people who acquire a MI or disability go through anxiety and depression (at least one of the major factors)
DeleteKelly, I was an HCT BHP before being a HCT Clinician. It would kill me to sit with other clinicians, before I had my own cases, and listen to them advocate for medication! They would literally sit inside a home full of chaos, soda/junk food, violent TV shows and video games, no physical outlet, and not speak to the environment or the yelling and screaming. I was horrified. From that point on I have made it a point to include a self-care goal on every treatment plan I write.
DeleteI think when society looks back at the way we treat patients today they will criticize the practice of online treatment. Even treatment that involves Skype, Facetime, etc. only gives the practitioner a limited look at the patient. A lot can be said and inferred from body language and a patients demeanor. Now don't get me wrong, online treatment does have its uses; patient snowed in, car problems, unforeseen circumstances that prevent a patient from coming to the office. These online services should not be used as the only way for a patient and practitioner to meet.
ReplyDeleteThere is too much depersonalization when there is no direct interaction, which may lead to the patient not "clicking" with the practitioner or the practitioner not forming the bond with the patient that is often needed to find the best treatment plan possible.
I too am concerned about online treatment for emotional and psychiatric issues. My first concern centers around ethics and confidentiality; how does the client know the practitioner is not only qualified but is keeping the information confidential (i.e. is that practitioner alone - how can the client know?) Even though it can have its uses for those in rural areas that might otherwise not receive treatment, it is fairly impersonal. I liken it to psychics performing readings over the telephone. Even supposing such a thing could be done in person (I'm not sure I'm a believer), how could it be done remotely? Where's the bond, the connection? Practitioners rely a lot on visual clues and voice inflections; without that, it may be like half a conversation. Only time will tell if they will be truly effective I guess.
DeleteWow, I had never thought about this. Partly because I do not use online treatment and as far as I know it is not allowed by most insurances. But, you are totally right and I as well hope this is criticized. I hope it never evolves into a common practice. We all know that the success of therapy depends on the alliance and relationship between provider and practitioner. It is hard to imagine having a genuine, working relationship formed through the internet. I try to stay away from email communication with parents, aside from scheduling or quick questions.
Deletelooking back 100 hundred years from now I think we are going to criticize how our primary care providers are treating mental illness using the medical model. Mental illness is being numbed by medication without even getting to the root of the problem or even understanding what may be causing the problem. It is scary knowing how easy it is to complete a questionnaire about yourself or your child and walk out with a diagnosis of ADHD with medication. Mental Illness should be treated by multiple providers in making sure the best treatment is being offered. A hundred years from mental illness will only be treated by specialists and not just your medical Dr.
ReplyDeleteI hope that in 100-200 years that when society looks back, they'll be appalled by our propensity to label everyone and how quick we are to diagnose every tick as a syndrome or disease. Many of our brilliant ancestors who brought medical and scientific advances, art, philosophy, and more to us would have been put on medications because they acted erratically. The incidence of diagnosing ADHD in children increased 24% from 2001-2010 according to one study: (http://www.amren.com/news/2013/01/adhd-in-kids-jumps-24-percent-in-a-decade-study-shows/). Another study shows a 228% increase in bi-polar disorder diagnoses between 2006-2011, a span of just five years! (http://www.timeslive.co.za/thetimes/2013/09/05/bipolar-disorder-cases-show-staggering-increase). What's worse is that along with these increases in diagnoses are of course, increases in medicated persons. While I am confident some of this is quite necessary, I do not believe that slapping labels, following by medicating is the correct way to manage every itch or tick we have. Competent and compassionate care could alleviate some of this along with, dare I say it, better parenting and educators who can deal with kids being kids and parents instilling some discipline so they sit and listen (re: ADHD). On the bi-polar side, wow, 228% increase in 5 years. Can this be true and real?
ReplyDeleteOne area I think we will criticized for in 100 years is lack of holistic mental health care and over reliance on medication. We do not rely enough on what our bodies naturally need to be healthy and string; healthy diets (free from dye, GMO's and other artificial ingredients), sleep, rest, relaxation, and EXERCISE. Giving medication to young children, before trying other treatment approaches will most certainly be criticized. I can see it now, "there was a time when children were medicated so they could sit in class for 6 hours at 5 years of age".
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