Helping consumers add years to their lives, VII: More implications for treatment and training

This is the seventh in a series of blogs and the third that will address replacing the current disease model of serious mental illness with other treatment models, particularly one linked to ACEs (Adverse Childhood Experiences) and rooted in individuals’ traumatic life experiences. This blog will focus on the nuts and bolts of replacing the disease model, viz., on underlying values and practice principles; on several treatment models; and on the training of helpers.

My principal objection to the disease model is its reliance for treatment on psychoactive medications, particularly the atypical neuroleptics, that have been documented to shorten the lives of those prescribed them by as many as 25 years, and that appear to be iatrogenic, i.e., to exacerbate and even to cause the symptoms they’re supposed to relieve.

The disease model has also served to invalidate the use and the effectiveness of psychosocial treatment interventions, particularly those that impart life skills crucial to rehabilitation, an approach that has left most behavioral health practitioners untrained and ill-equipped to make use of them. Despite what I just wrote, I will not argue against the possibility that many individuals who have psychotic experiences do have some sort of biological vulnerability that undermines their resilience in highly stressful circumstances. I also won’t argue that trauma is the only way to understand why these individuals have the experiences they do, even though the great majority of persons with serious mental illnesses have been victims of trauma.

Cause is not crucial here; more importantly, how are folks to be helped and who is to help them?

Practice principles

Prospective treatment models will be described below; but discussion of specific treatment approaches must be preceded by consideration of underlying practice principles and values. Listed immediately below are those I consider crucial:

1. First and foremost, treatment and helpers must do no harm. In practical terms, that means that if neuroleptic medications are to be prescribed, those prescribing must use the lowest possible dose for the shortest possible time and must adhere scrupulously to proactive protective protocols, such as the Metabolic Syndrome Monitoring Protocol.
    
2. Secondly, helpers must have the capacity for empathy, which is key to helping. I have long fantasized about an empathy test that helpers would have to pass before entering the mental health field. Such tests do exist … just Google “empathy test”, but I’m sure no one has yet to correlate a score on such a test with an individual’s effectiveness in helping others.
    
3. Third, helpers must be committed to promote what I term “consumer liberation” via a practice which emphasizes hope, seeks to heal trauma and works to re-socialize those who have been alienated from or pushed out of their natural communities.
    
4. Fourth, helpers must conduct holistic assessments that bridge the mind-body divide and focus on individuals’ strengths. These assessments must view psychotic episodes as transitional life experiences, not as evidence of characterological defects.
    
5. Finally, helpers must assist those they are helping to develop their own treatment goals. Individual treatment goals should point toward protection of his/her self-identity, pursuit of community re-integration, and pursuit of opportunities to work for a living. Helpers must also be trained to provide treatment that promotes individual acquisition of emotional regulation and relationship skills.

These skills are taught in Linehan’s “Social Skills Training,” a six-month long, multi-module training program. (This program was originally developed by Linehan for use with women who have been diagnosed with borderline personality disorder and are suicidal. We used it for years with great and documented success with persons with serious mental illnesses and impulse control disorders. More on this below.)

Treatment models

Trauma-based: In previous blogs (specifically, Part V and Part VI), I’ve suggested a treatment model linked to ACEs and rooted in trauma theory and treatment practice. Admittedly, there is no demonstrated link between ACEs and psychosis among adolescents and adults, though there appears to be a link between ACEs and chronic physical diseases.

Yet, persons abused as children often exhibit behavior considered disordered and anti-social as adolescents and adults. Further, the co-morbidity between trauma and emotional disorders and psychosis is high, with several studies evidencing rates of emotional, physical and sexual abuse among adults in the public mental health system in excess of fifty percent.

I’m also partial to a trauma-based treatment model because of its compatibility with a psychoeducational treatment approach: it’s much less damaging to individuals’ sense of self–worth to tell them that the psychotic episodes they’ve undergone are consequent to their life experiences and not because of a genetic or neurological defect. Life skills training is also particularly apt here. I’ve been trained in Linehan’s DBT, a key component of which is Skills Training that is conducted primarily in group settings, but can also be used in individual sessions.

Once a year for close to 10 years, I taught 20 to 25 clinical staff members at FEGS in New York City how to utilize Linehan’s skills training manual in a 20-hour course I had developed for that purpose. Once the course was completed, they would proceed to teach the skills to clients in the agency’s clinics, day treatment, and psychosocial clubs. Many of these clients had serious emotional disorders and many suffered from trauma sequelae. Attendance at the weekly training sessions conducted by the clinical staff was usually good and participants enthusiastic. Most persons who took the classes reported that they used what they learned day-to-day.

In sum, DBT appears well-suited to a trauma-based treatment model. It also serves to illustrate the flexibility of the trauma model, i.e., that the model can accommodate various treatment approaches and be individualized to conform to the unique and idiosyncratic life experiences of the persons to whom it may be applied. Conversely, it may not work so well and thus should not be applied to persons who have had no serious abuse in their lives; which indicates the need for various treatment models.

Soteria: Soteria House, established in the mid-1970s, by the late Leonard Mosher and colleagues in northern California, serves as the international model for mental health practitioners seeking to help persons experiencing their first psychotic episode.

As I wrote in Part V, Soteria House was the scaled-down and relatively short-lived American version of R.D. Laing’s Philadelphia Association, where staff was trained “to be with” rather than “treat” residents cycling through the various stages of their psychoses. This approach was rooted in two assumptions:

• That psychoses were transitional and valid life experiences and that if those who experienced them were left undisturbed (i.e., unmedicated), they would be able to work through them, wiser for having done so.
   
• That those affected by psychosis knew how they could best be helped and could effectively communicate their needs, provided their helpers actually listened to them.

In sum, this approach avoided “treatment” in the conventional sense and instead utilized empathic helpers to support, validate and accompany psychotic clients through their episodes.

The first Soteria residents were individuals experiencing first-time psychotic episodes. Later, following political squabbles with the National Institutes of Mental Health, Soteria was obliged to admit all comers, which served to confound the outcome data being collected on first-time psychosis clients, cast doubt on Soteria’s ultimate effectiveness, and hasten its closure in the early 1980s.

Regardless, the basic idea of the Soteria experiment, viz., that persons who had psychotic experiences could be helped without medication, has endured.

Within the past decide, members of the International Network Toward Alternatives and Recovery (INTAR), have extensively discussed how to operationalize the Soteria ideal with “first break” individuals. Much of this information can be obtained via INTAR’s website (cf. www.intar.org).

In sum, a growing number of helpers appear to be exploring alternatives to the disease/medical model which will allow persons experiencing their first psychotic break to be helped before long-term neuroleptic medication maintenance has distorted the psychotic process they are going through and blocked their recovery.

Interpersonal Psychotherapy: For want of a better term, I’ve appropriated the one Harry Stack Sullivan used to describe his work with persons diagnosed with schizophrenia. Sullivan was a groundbreaking psychiatrist who, during the 1920s to 1940s, was responsible for moving the treatment of schizophrenia within the purview of psychoanalysis, influencing along the way many notable psychoanalysts, including Frieda Fromm-Reichmann. Significantly, he re-framed schizophrenia as a “problem in living,” traceable to a person’s disturbed childhood relationships.

As I wrote in Part VI in the series, when I entered the field in the mid-1970s , psychoanalytic approaches with persons with serious disorders were in disrepute—too lengthy, too costly, with results “documented” in a few case reports rather than controlled studies. In the ensuing years, the disease model became pre-eminent in defining serious mental illness and determining its treatment.

Yet, the notion of intensive psychotherapy to treat persons with schizophrenia persisted. Daniel Mackler’s 2008 documentary film, Take These Broken Wings, makes clear that psychotherapy for persons who have experienced psychosis is actively practiced today. Mackler is a practicing psychotherapist who, during his film, interviews several colleagues who have continued the work of Stack Sullivan and Fromm-Reichmann.

The bulk of Take These Broken Wings, however, is taken up with the stories of two remarkable women who entered the mental health system just prior to its de-institutionalization.

• The first is Joanne Greenberg, the author of, among other books, I Never Promised You a Rose Garden. She chronicles for the camera her journey from psychosis, through the perils of treatment in large and de-humanizing institutions, to personal liberation and her identity as a professional writer. She recounts that to survive, she resisted being labeled ‘mentally ill’, and, fortunately, through several hospitalizations, encountered helpers who listened to her and validated her.
   
• The second is Catherine Penney, who, by the film’s end, is married and working as a registered nurse in California, helping persons very much like herself. Penney’s journey was arduous: For several years, she maintained total silence through long hospitalizations to protect her sense of self. But, like Greenberg, Penney was lucky enough to be assigned to a dedicated psychiatrist and psychotherapist early on. The two, working for eight years, enabled Ms. Penney to regain her speech and emerge better prepared to deal with her “problems in living.”

Unlike the persons I referred to earlier in this discussion, these two women were not abused in childhood, although the impersonal institutional “treatment” they were subjected to as adults could be considered abusive and most certainly was oppressive. Further, they were prescribed for the first several years of their psychoses the neuroleptic medications available at the time, first and foremost thorazine. Accordingly, the two treatment models described above, even had they existed at the time, would not have been appropriate to help them. Rather were they helped by kind, empathic therapists, who worked with them to safeguard and preserve their very personal self-identities.

Training

Whichever model or approach is used, those who use it will have to be trained to do so. Immediately below are listed training principles and practices which I believe would be facilitative.

• First and foremost, mental health practitioners and the individuals they are there to help should be trained together. If you look at the first in this series of blogs (actually an article summarizing the results of the joint training integral to our Intensive Collaborative Case Management Project and Study), I go to some length describing the eight-session training program that was attended by both program case managers and supervisory staff and selected clients. We were training case managers and clients to work together as primary health care advocates.
  
  
  While the case managers were initially somewhat uncomfortable, the presence of the clients, most of whom were outspoken and asked many questions, heightened the focus of the case managers, allowed them to see the clients in a different light, i.e., as fellow students, and promoted what we were most looking for, the formation of collaborative relationships.
  
  Most readers might think joint training is wildly impractical, but do it any way because it works!
   
• Second, and this applies both to training content as well as to fostering a needed awareness, the history of mental health and its evolution to the present day must be taught. I’m partial to a deconstructionist, analytical approach here, because a mere chronologiocal recounting won’t get across to trainees the choices, some good, most detrimental, that were made on behalf of those presumably being helped. I remember when I first read Michel Foucault and learned the origin and evolution of Europe’s “ship of fools”: in the Middle Ages and into the Enlightenment, the ships of fools plied Europe’s rivers first carrying lepers then madmen between riverside cities, where they offloaded those who had died and took on board new passengers. Always the outsiders.
  
  In fact, I would recommend as a basic text at the start of this history course Foucault’s History of Madness, first published in France in 1961, later in the U.S. in 1964, most recently in second edition in 2006.
  
  To bring trainees up to the present, I would teach what I outlined in Part VI, viz., the history of mental health, system and treatment, since the end of World War II, its period of most rapid change. Two texts I would recommend here, both because of the high quality of their contents as well as their polemics are Bob Whitaker’s recent publications, Anatomy of an Epidemic and Mad in America.
   
• Since I entered Hunter’s doctoral program in 1984 and heard the dean of the school, the late Harold Lewis, speak of the “reflective practitioner”, i.e., a person who always examined in great detail what she/he was about to do or what she/he had done, I have been a great partisan of that notion. Less than 10 years later, when I developed the training curricula for the Intensive Case Management Training Program at Hunter and taught prospective case managers the fundamental case management functions, I always emphasized that monitoring, case management’s QI function, began with self: what did I do that did or didn’t work?
  
  Ten years subsequent, I was trained in DBT and I learned skills that completed me as a practitioner. As I determined after a time, “mindfulness meditation” was the most strategic of those skills, since it taught me, after daily practice for an extended period of time, how to “be in the moment;” “be non-judgmental;” and, crucially, “to be accepting,” that this moment, this very moment, was “perfect.” How very Zen Buddhist. How very effective!
  
  Accordingly, I would recommend that all trainees be taught, at the least, this DBT skill. They will become more aware of self and others and their careerist impulses—which I have come to view as characteristic of the “helping” professions in this country—will be offset by their commitment to their mission.
   
• Finally, in a summary potpourri, I would give trainees thorough overviews of trauma, oppression and resilience, all of which are beginning to be taught with some frequency in professional schools and knowledge of which is clinically and historically critical for good practice. Ditto the numerous other issues which I have raised throughout these blogs, I through VII.

Thank you all. My next blog will finally be devoted to JOBS and will be my final blog before my summer recess.

References

1. The ACEs Study: For a fuller exposition of facts and analysis, log on to https://www.cdc.gov/ace/findings.htm. For an illustration of ACE’s applicability to standard medical practice, c.f. the article in the March 21, 2011, edition of The New Yorker, “The Poverty Clinic,” by Paul Tough.
    
2. Carney, J., “Outpatient DBT Treatment for Forensic Clients,” Currents, NASW< NYC Chapter, Vol. 8, #5, February/March, 2004
    
3. Carney, J., et al, “Utilizing Dialectical Behavior Therapy To Treat Impulsive Aggression in Forensic Clients with Serious Mental Illnesses In an Outpatient Clinic,” unpublished manuscript, 1999
    
4. Evans, F. Barton, Harry Stack Sullivan: Interpersonal Theory and Psychotherapy, Rutledge, London and New York, 1996
    
5. Foucault, M., History of Madness, Routledge, New York, 2006
    
6. Fromm-Reichmann, Frieda, “The Psychotherapy of Schizophrenia,” a lecture, 1954. For a copy and further information, log onto https://ajp.psychiatryonline.org/cgi.
    
7. Greenberg, J., I Never Promised You a Rose Garden, Signet Books, New York, 1964
    
8. Laing, R.D., The Politics of Experience, Pantheon Books, New York, 1967
    
9. Linehan, M., Skills Training Manual for Treating Borderline Personality Disorder, Guilford, New York, 1993. For further information about DBT, log onto www.behaviortech.com
    
10. Mackler, D., Take These Broken Wings, a documentary film, 2008. For further information and to obtain a copy, log onto www.iraresoul.com
    and www.isps-us.org
     
11. Mosher, L.R., Hendrix, V., Soteria: Through Madness to Deliverance, Xlibris Corp., 2004
     
12. Shulman, L., The Skills of Helping Individuals, Families, Groups & Communities, 4th edition, Peacock, Itasca, Ill., 1999
     
13. Soteria Models: Further information can be found at the ff. websites:
    www.Soteria-Alaska.com
    www.ciompi.com/en/soteria.html (Berne, Switzerland)
    www.soterianetwork.org/uk
     
14. Werner, E., Smith, R., Overcoming the Odds: High Risk Children from Birth to Adulthood, Cornell U. Press, Ithaca & London, 1992
     
15. Whitaker, R, Anatomy of an Epidemic: The Hidden Damage of Psychiatric Drugs, Crown Publishing Group, New York, 2010 & Mad In America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill, Basic Books, 2010

More on "Helping consumers add years to their lives"

• Helping consumers add years to their lives (Part VI): The Implications of ACEs and a Trauma-based Treatment Model
   
• Helping consumers add years to their lives (Part V): Replacing the Disease/Biological Model with ACEs
   
• Helping consumers add years to their lives (Part IV): The Beginning of the End of Institutionalized Housing in New York City
   
• Helping consumers add years to their lives (Part III): Psychoactive Drug Dependence & Harm Reduction
   
• Helping consumers add years to their lives (Part II): The metabolic syndrome monitoring protocol and other tools
   
• Helping consumers add years to their lives (Part I): Training case managers and clients to be partners in primary healthcare advocacy