Wednesday, November 6, 2013

Making Our Children Conform Using Mental Trickery

Here is an absolutely excellent article by Elizabeth Weil in the New Republic in which she analyzes the increasing use of various therapeutic techniques to get kids to conform to expected classroom behavior. It is a more subtle but insidious form of pathologizing children who are being normal children.  Much of it is predicated on the now well known delayed gratification studies of young children.  You've heard it before--the test child is told not to eat the marshmallow in order to get two marshmallows in a few minutes.

Everyone who has a child with childhood impulses is immediately struck by inner fear.  Is my child the one who can't wait?  What does this mean for her/his future career?

Now this is the basis for all kinds of behavior modification schemes used in schools.  The problems Weil outlines include that (1) we are telling our children they are mentally sick or wrong, and (2) the empirical evidence does does not support the actual interventions being used.

It is yet another case of wanting to believe this is the right way to do things because it sounds good.

Please take a look, it is worth the read.

Wednesday, October 9, 2013

Seeking Safety from Trauma

Over the last decade we have seen a deluge of spilled ink and sermons delivered on the topic of Trauma (capital letter intended).   Therapists and other clinicians are wont to see Trauma as the cause of all mental/emotional distress and disorder.  Payers and regulators want to see Trauma informed care as the standard for all services.

Please don't misunderstand and think I am about to argue against trauma as a factor of etiology.  I am not.  Please do not think I am going argue against trauma sensitive care.  I am not.

I do, however, have to take issue with a number of things.  One of which, I will briefly introduce here, is an intuitive response to emotional trauma (or the vision of Trauma in the mind's eye of the therapist).  I have noticed a tendency among my colleagues to fix Trauma through the exclusive use of invoking Safety (capital letter intended).

What is Safety?  It is a mythical destination we point people to who we believe are wounded by emotional trauma.  In its simplest and cliched manifestation, it is the "safe place" we tell people to go to inside themselves when they are distressed by Traumas past or current.  In its most Utopian manifestation, it is the construction (socially and physically) of a space (or whole communities) designed to remove all sources of trauma and reminders of trauma.  A Safe place is a place where people speak to each other exclusively in soft and supportive tones.  A Safe place has no rules to remind us we are not in control.  In a Safe place no one tells me I am wrong.  A Safe place is a place without "no".

The idea of creating Safety seems to come to some practitioners by intuition and without need for training.  For other practitioners (e.g., Sandra Bloom) it is a treatment model that is bottled, trademarked and sold, but more than that it is a morally driven world view.  It is true by faith and has to be defended against the unbelieving (read: medical model).

Why do we need to create Safety?  Because Trauma doesn't just hurt in the moment, it continues to harm day after day, year after year.  Life's little annoyances and disappointments are more than they are.  They are reminders of the Trauma.  Triggers and re-triggers.  It harms even when the individual has no idea it continues to harm.  Why?  Because the clinician believes.  Sometimes the individual doesn't even know they were Traumatized.  In those cases, the true believing therapist has to help the individual remember . . . (we know where that leads).

That's the reasoning for it.  I can't fault the premise (that psychological trauma hurts), but I doubt the conclusions.

So then, does creating a Safe place help?  I feel the need to ask, if only because so many around me seem to take it on faith.

I haven't come across so much empirical evidence apart from the some apocryphal study about mice and cat hairs.  But maybe this Trauma-Safety dilemma has a corollary in Happiness?  Seeking Happiness for the Sad seems like a very similar impulse to me.  And in that realm I think we do have some evidence that tells us it is a fool's quest.  Turning Sadness into Happiness through the power of affirmations, replacing negative self talk with positive self talk, while intuitively sensible, turns out to be the psychological equivalent of trying to catch a rainbow.  Every time I tell myself I'm beautiful and smart and wonderful, the opposites of those things echo in the mind and I have to increase my affirmations louder and louder to myself, but in the end, affirmations in a vacuum do not lead to Happiness.

Could the quest for Safety be a similar fairy tale?  A nagging doubt tells me so.   The fact that no one questions it, makes me worry all the more.
  • Focusing so exclusively on Safety paradoxically highlights an individual's vulnerability.
  • Focusing so exclusively on past Trauma reifies victimhood and takes the person out of the here and now.
  • By focusing on victimhood we take away a person's agency.
  • By focusing on the past we can't change, we forget the here and now where a person actually does have the power to change things.
  • By externalizing cause and effect we have taken all control away from the person.
Considering these things, is it any wonder that we see so many people taking part in this therapeutic approach sink deeper and deeper into dysfunction?

Monday, September 9, 2013

Autism's Tipping Point

Besides being an expert at neuroscience, to the benefit of the greater good neuroskeptic also dabbles in cultural criticism of science and healthcare with an eye toward empirical observation of the ethnocultural processes of those areas.  A bit of armchair social science, but well done.

His latest piece on the phenomenal growth of autism:

Many have observed the unnatural increase in autism over recent years.  In the midst of this apparent epidemic, news stories push "autism awareness" and "promising findings" about the cause(s) of autism.

Among practitioners, among psychiatric naysayers, among the small community of social scientists who make medicine, psychiatry and science their field of study, there has been much conjecture about the sociocultural factors behind the growth.  The usual conclusion based on observation and/or conjecture, is that the incidence of the underlying condition has probably not changed dramatically, but instead we are seeing an expanding practical definition of autism as interpreted by clinicians in the field.  You can add to this the fact of heightened awareness of the diagnosis resulting in people (clinicians, parents, teachers, etc.) seeing it where they didn't see it before (rightly or wrongly).  This, in the context of a loosely defined spectrum disorder that (like all mental health diagnoses) is determined by a check list of behavioral signs and indicators allowing for broad differences of interpretation and understanding.

Sadly the places and people with money to pay for research don't seem particularly interested in putting resources into resolving this question.

Lucky for us we have a guerrilla social science researcher in neuroskeptic who counted the number of research papers (via PubMed) on the subject of autism, relative to several other disorders.  He found that autism research has increased eight fold in 12 years, about twice the rate of ADHD (the next highest growth disorder) and maybe 4x (about) the growth of schizophrenia research.  It is hugely out of proportion to the 4% growth in science (as a whole) per year.

I might take it a step further and just state what has been clear over the last 150 years or so of psychology and psychiatry--the field, popular and professional, is driven by fads.

Monday, August 12, 2013

Peers of the Mental Health Realm

The last decade has seen a flood of peer counselors in the public mental health system in the U.S., the basic idea modeled, if loosely, on the the practice of recovered addicts becoming counselors in the alcohol and other drug (AOD) treatment field.  In mental health it has the added gain of making public mental health treatment a more humane and understanding place.  Psychiatric survivor activists have long called for this move.  If services are provided by counselors who have themselves experienced mental health problems and have been on the receiving end of services, then services will inevitably be rendered in a more sensitive and user-friendly manner.

These things are true as intended, but I feel the need to point out there is also a dark tangled mass of contradictions, uncertainty, and politics that inhabit the practice of peer counseling like a hidden cyst threatening to break open and poison the entire initiative.  As always, I find myself the voice of doom and gloom in the fantasy land of Mental Health where fake positivism, false prophets, and general quackery goes hand in hand with unicorns, pixies, and evidence base practices.

Peer counselors come to the public mental health field like faerie-activists waving their magic "recovery" wands.  They go to the dark places of mental health--think Shutter Island, Sucker Punch, One Who Flew Over the Cuckoo's Nest, and hundred other examples--and these peers turn the dark places into sunlit gardens of recovery with doors broken open to let the sunlight in and to let the inmates out to discover they were never mentally ill to begin with--it was all a lie made up by psychiatry and Big Pharma.

The only thing is, it’s just another lie really.  Let me give you a smattering.

1. Peers do not necessarily have special insight into the experience of individual mental health system users.

Mental health peers are self defined.  It has to be so for simple legal reasons.  A prospective employer is not permitted to ask about an applicant’s disability.  It is contingent upon the applicant to decide if she or he is or is not a mental health peer.

In the AOD field, addiction disorders are a straightforward set of behavioral categories that are bound by a single phenomenon: addiction.  Straightforward, relative to mental health anyway.  By contrast, mental health disorders cover so vast an array of human behavior patterns so as to be absurd.  What does it mean to be a mental health peer?  Does someone who experienced adult attention deficit have some kind of special insight into what it’s like to experience schizophrenia?  Or vice versa?  If that seems like a stretch, it’s because it is.

Imagine, if you will, a world in which medical peers--people who have experienced medical problems and have received medical treatment in their lifetimes--replace nurses in your doctor’s clinic.  Will a medical peer who has experienced medical treatment for eczema have some special understanding, gleaned from experience, into the medical needs of a patient with necrotizing fasciitis?  Sound preposterous?  Why then is the idea of mental health peers any less preposterous?

2. In mental health, recovery is a word without meaning.

One of the basic rationalizations for peer counselors is that a peer is a living example of recovery, a person with a mental health condition who has persevered, and met their therapeutic goals, and now can work productively as a peer counselor.

It stands to reason.  This rationale works very well in AOD services where peer counselors are the norm.  In that field, peer counselors have beat their addiction--they are in recovery--and they can help other addicts on the path to recovery through the wisdom of their experience.

Okay, that’s all well and good.  But.  In the AOD field, recovery is black and white.  You are either using, or you aren’t.  Recovery is tested and assured by urinalysis.

If you think mental health has a standard of recovery, you are mistaken.  Recovery, like the peer identity itself, is entirely self defined.  Anyone, and I mean anyone, can walk through the door and proclaim they are a peer and they are in recovery.  There is no testing and such claims are accepted at face value, at least at time of hire.  This literally true.

Sadly, I have seen peer counselors (and therapists and psychiatrists for that matter) with untreated axis II disorders do great harm.

3. The sudden, poorly thought-out growth in peer services is driven by feel-good politics.

This true statement does not discount the possibility of benefit from having peers working in the system, but, it does tell us something about the process that led to the current situation and can illuminate how preventable problems were allowed to fester.  The peer counselor initiative may have a grassroots origin in the consumer/survivor movement, but it came to fruition because of state legislatures and state level department heads made the decision that peer delivered services is a good thing and made it so through law and regulation that, if not mandates, at least incentivises the practice in many states.

System changes driven at the state level are seldom well considered.

4.  And it is powered by cost cutting.

Medicaid reimbursement for services delivered by a peer counselor is considerably less than reimbursement for services provided by bachelors and masters level clinicians.  This impacts state budgets.

Need I say more?

Sunday, February 24, 2013

The Folly of DID

Not that I've been there myself, but I understand if you travel through England you might come across some of these apparent medieval towers or castles in various states of ruin.

Except that they aren't medieval and they aren't ruins.  They were built to look like ruins.  Many of them were constructed in the 18th and 19th centuries by persons with excess wealth and imagination.  A little bit of deception for someone's amusement.  They refer to them with the term folly.

That brings us to Dissociative Identity Disorder, AKA multiple personalities . . .

I just came across this good review of the DID controversy by Dr. August Piper:

The Persistence of Folly: A Critical Examination of Dissociative Identity Disorder. Part I. The Excesses of an Improbable Concept

Here is an excerpt:

With the recent appearance of several critical articles and books, the concepts of dissociative amnesia and dissociative identity disorder (DID) have suffered some significant wounds (1–5). Between 1993 and 1998, the principal dissociative disorders organization lost nearly one-half of its members (1). In 1998, Dissociation, the journal of the dissociative disorders field, ceased publication. A paper published in 2000 examined the weaknesses in the dissociative amnesia construct (6). Various dissociative disorder units in Canada and the US (for example, in Manitoba, Illinois, Pennsylvania, and Texas) have been closed down. US appellate courts have repeatedly refused to accept dissociative amnesia as a valid entity (6), and several ardent defenders of dissociative disorders faced criminal sanctions, malpractice lawsuits, and other serious legal difficulties.

Nevertheless, despite the significant harm these concepts have wrought in North America, some Canadian and US practitioners continue to support, and practise according to, dissociative disorder concepts (7–9). Further, these North American countries export the concepts. In India, for example, the cinema has influenced the production of dissociative signs (10), and 4 recent papers demonstrate a recurring interest in spreading awareness of DID to other countries (11–14).

and on it goes.

Like the follies built by the idle rich of the romantic period, DID is not simply wrong, it is a fantasy people want to believe and proliferate.