Collaborative Possibilities

Social Construction Practices

2008-09-11T14:31:00.000-07:00

I have spent these last few years developing my new website called Social Construction Practices.

Available at http://www.socialconstructionpractices.com

Hope you all enjoy the new site.....

Sociopolitical Activism or Conversational Partnership?

2005-10-09T18:28:00.000-07:00

I know that Narrative and Collaborative Therapists share a lot in common as mentioned in my blog date September 20, 2004. I think that the following statement has put me into a situation in which the client may get oppressed.

Here is the paragraph that I am struggling with from the article http://foucault.info/weblog/000045.html:

"One of the critiques targeted at collaborative therapists is that while they state that they have no particular commitment to a therapeutic direction or intentional agenda, their practice in fact is both deliberate and purposeful. To the extent that collaborative therapists position themselves in a social constructionist epistemology and are dedicated to facilitating the production of multiple voices, they are inevitably motivated to follow one direction more than another in the therapeutic process. From some narrative therapists' points of view, the conversational partner is neither unintentional nor without purpose. Narrative therapists as social activists are also concerned by collaborative therapists' disinterest in acknowledging the sociopolitical discourses that impact and may systematically oppress individuals. Some are concerned that this disinterest invites the potential for therapists to collude with oppressive cultural practices. That is, at best, it restricts the therapist's option to assist the client, and at worst, it adds to the client's oppression. Collaborative therapists respond that, on the contrary, narrative therapists' directive approach and the sociopolitical stance that underpins it may inadvertently push clients toward "alternative stories" that clients feel compelled to agree with, thus potentially producing another form of oppression (C. Smith, personal communication, January 30, 2002). Perhaps these distinctions can provide a note of caution to those narrative therapists who become too pushy pursuing a storyline that is deemed "preferred," while at the same time notifying collaborative therapists to be sensitive to not collude with culturally oppressive practices."

Now that I am cautioned, I am wondering what the area of gray may look like. The dilemma for me is that I may be guilty of taking political activism in the room and at other times I am guilty of remaining a silent while letting the oppression occur.

In response to my thoughts, a colleague wrote:
"I think the scariest thing about what the article says about 'overcoming oppression' was not the call to arms for the soldiers fighting oppression, but the way it critiqued Collaborative Therapy, almost as if were evil for creating a form of therapy that honored the client's own quest to find his own path."

I feel best, as a therapist, about not developing a fight against oppression in which my voice could drown out the client's voice or path. I take an activist stance as a therapist by joining professional organizations but I do not think that it is very honorable to do such in therapy sessions with clients. I may express my thoughts but I would disengage if it does not fit in with the direction that the client wants to take the session.

US teenager's parents sue school over depression screening test

2005-09-30T13:04:00.000-07:00

New York

by Jeanne Lenzer

The parents of an Indiana teenager have filed a suit in a federal court in the state's Northern District, charging that school officials violated their privacy rights and parental rights by subjecting their daughter to a mental health screening examination without their permission.

The suit is seen as significant because President Bush has promoted a controversial plan to encourage widespread mental health screening for people "of all ages" in the United States (BMJ 2004;328;1458). The screening programme at the centre of the legal suit, TeenScreen, was endorsed as a"model" programme by President Bush's NewFreedom Commission on Mental Health.

The complaint, filed on 19 September, charges that in December 2004 Chelsea Rhoades, then a 15 year old student at Penn High School, Mishawaka, was told she had obsessive compulsive disorder and social anxiety disorder after she took the TeenScreen examination. Chelsea has spoken out against the screening and, with her parents, alleges in the complaint that "a majority" of the students "subjected to TeenScreen" with her were also told they had "some mental or psychological disorder."

The Rhoades family charges that TeenScreen test results "are highly subjective" and that "there is a lack of evidence that the screening actually results in a decreased risk of suicide attempts."

On 21 September, just a few days after the Rhoades suit was filed, Rabin Strategic Partners, the public relations firm for TeenScreen, issued a press release with TeenScreen announcing that the Substance Abuse and Mental HealthServices Administration had awarded grants of more than $9.7m (£5.5m; €8.1m) to four states to implement "mental health screenings, using the Columbia University TeenScreen programme."

The programme is currently in use at 424 sites in 43 states, the press release says. The money was made available under the Garrett Lee Smith Memorial Act, which President Bush signed into law in October 2004 to promote programmes to prevent suicide in young people.

Columbia University's TeenScreen, which urges "universal" voluntary screening for all teenagers, has come under fire for offering free cinema passes and other inducements to teenagers in the hope of encouraging them to return parental consent forms (BMJ 2005;331:592 (17Sep)). The programme has also been criticised by the Rutherford Institute, a non-profit civil liberties organisation, for using "passive consent," in which only parents who do not want to have their children screened have to sign a form and send it in to the school. If the school does not receive a form, it is assumed that the parents do not object.

Laurie Flynn, national programme director of TeenScreen, said that only 15% to 20% of schools use passive screening and that the choice to require the active consent of parents was left up to local schools."We name active consent a preferred best practice, we train applicants to use it and we offer templates to assist them in doing so. [But] in some school districts passive consent is the norm for all student health activities," she said.

Michael Wilkes, professor of medicine and director of adolescent medicine at the University of California, Davis, said he was worried about the widespread use of mental health screening among adolescents. "We're way overtreating depression with medications," he said.

"It's often very hard to distinguish [an adolescent] who is truly depressed from a teen who is experiencing developmentally normal cyclic variations in mood. Affect in teens can vary greatly from day to day. A student who didn't get invited to the prom or who broke up with his girlfriend could look depressed one day but not the next. What is needed isn't just more money for screening but money to help teens who want help. What's the point of screening to find a problem if doctors are either unavailable or unable to help?"

President Bush's plan, Achieving the Promise: Transforming Mental Health Care in America, is at

www.mentalhealthcommission.gov/reports/FinalReport/FullReport.htm
http://bmj.bmjjournals.com/cgi/content/full/331/7519/714-a/DC1

APA admits to problem with Big Pharma

2005-08-24T16:35:00.000-07:00

The following is an article from the American Psychiatric Association:

Psychiatric News August 19, 2005Volume 40 Number 16© 2005 American Psychiatric Associationp. 3

From the President

Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly

APA's annual meeting is one of the largest medical meetings in the United States and the largest psychiatric meeting in the world. There is something for everyone at our wonderful meeting, but many have commented to me on the extraordinary presence of the pharmaceutical industry throughout the scientific programs and on the exhibit floor.

The U.S. pharmaceutical industry is one of the most profitable industries in the history of the world, averaging a return of 17 percent on revenue over the last quarter century. Drug costs have been the most rapidly rising element in health care spending in recent years. Antidepressant medications rank third in pharmaceutical sales worldwide, with $13.4 billion in sales last year alone. This represents 4.2 percent of all pharmaceutical sales globally. Antipsychotic medications generated $6.5 billion in revenue.

When the profit motive and human good are aligned, it is a "win-win" situation. Pharmaceutical companies have developed and brought to market medications that have transformed the lives of millions of psychiatric patients. The proven effectiveness of antidepressant, mood-stabilizing, and antipsychotic medications has helped sensitize the public to the reality of mental illness and taught them that treatment works. In this way, Big Pharma has helped reduce stigma associated with psychiatric treatment and with psychiatrists. My comments that follow on the pharmaceutical industry and its relationship to psychiatry bear this in mind.

The interests of Big Pharma and psychiatry, however, are often not aligned. The practice of psychiatry and the pharmaceutical industry have different goals and abide by different ethics. Big Pharma is a business, governed by the motive of selling products and making money. The profession of psychiatry aims to provide the highest quality of psychiatric care to persons who suffer from psychiatric conditions. There is widespread concern of the over-medicalization of mental disorders and the overuse of medications. Financial incentives and managed care have contributed to the notion of a "quick fix" by taking a pill and reducing the emphasis on psychotherapy and psychosocial treatments. There is much evidence that there is less psychotherapy provided by psychiatrists than 10 years ago. This is true despite the strong evidence base that many psychotherapies are effective used alone or in combination with medications.

In my last column, I shared with you my experience, and APA's, in responding to the antipsychiatry remarks that Tom Cruise made earlier this summer as he publicized his new movie in a succession of media interviews. One of the charges against psychiatry that was discussed in the resultant media coverage is that many patients are being prescribed the wrong drugs or drugs they don't need. These charges are true, but it is not psychiatry's fault—it is the fault of the broken health care system that the United States appears to be willing to endure. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the biopsychosocial model to become the bio-bio-bio model. In a time of economic constraint, a "pill and an appointment" has dominated treatment. We must work hard to end this situation and get involved in advocacy to reform our health care system from the bottom up.

Furthermore, continuing medical education opportunities sponsored by pharmaceutical companies are often biased toward one product or another, and they are more akin to marketing than CME. APA has strict guidelines for the industry-sponsored symposia presented at our annual meetings; sanctions are applied when our rules are broken. Our guidelines have been held up as a standard for medical meetings in other specialties throughout the country. But there are many grand rounds, evening dinners, and lectures where such standards do not prevail.

Direct marketing to consumers also leads to increased demand for medications and inflates expectations about the benefits of medications. As a profession, we need to be concerned about advertising and the impact it has on the over-medicalization of our field. Of course, what is marketed to consumers are the highest-cost, on-patent products, and the cost of medications is something rarely considered by prescribing clinicians. When doctors don't prescribe cheaper but equally effective drugs, it consumes money that could have been used to provide other psychiatric or medical services.

There are examples of the "ugly" practices that undermine the credibility of our profession. Drug company representatives will be the first to say that it is the doctors who request the fancy dinners, cruises, tickets to athletic events, and so on. But can we really be surprised that several states have passed laws to force disclosure of these gifts? So-called "preceptorships" are another example of the "ugly"; that is, drug companies who pay physicians to allow company reps to sit in on patient sessions allegedly to learn more about care for patients and then advise the doctor on appropriate prescribing.

Drug company representatives bearing gifts are frequent visitors to psychiatrists' offices and consulting rooms. We should have the wisdom and distance to call these gifts what they are—kickbacks and bribes. (For more thoughts on this topic, see Viewpoints on page 33.) If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised.

Here are several suggestions for remedies in our relationship with the industry.
We need to embrace a new professional ethic. The doctor-patient relationship should not be a market-driven phenomenon.

Preceptorships should be considered unethical.

Enticements, gifts, parties, and so on should be reined in because patients must believe that their doctor has their best interests in mind when a prescription is handed to them.

We must re-evaluate single-sponsored medical education events and phase them out in favor of more general support for CME along with a careful policing of these events for bias.

The amount and support received by individual clinicians and researchers from industry should be transparent and the information readily available.

When we attend lectures at annual meetings and other educational events, and read journals and textbooks, we should know very clearly about the industry support given to presenters and authors.

As psychiatrists, we should all be grateful for the modern pharmacopia and the promise of even more improvements in the future. At the same time, however, we must be very mindful that we cannot accept gratuities in the new medical marketplace.

Tom Cruise gets interviewed by Matt Lauer

2005-06-29T13:50:00.000-07:00

Tom Cruise takes on psychiatry during an interview on the Today show.

http://www.msnbc.msn.com/id/8343367#today

Comfortably Numb

2005-06-02T15:52:00.000-07:00

Here is a link to a video that helps us think about the ethics of medicating so many children. I hope that you enjoy it:

http://www.besthorizons.com/

Feel free to send a comment about the video.

DSM IV Disclaimer

2005-05-23T19:37:00.000-07:00

If you have been given a diagnosis by a mental health provider like PTSD, ADHD, Major Depression, Anxiety, Bipolar, etc, etc, etc... Please read this disclaimer since it might be of use to you:

DSM IV Disclaimer

The DSM groups problematic human behaviors into clusters and tries to make sense of them. If you feel some of your behaviors fit the criteria for one of the DSM categories you may find it useful to learn what has been helpful to other people who have struggled with these kinds of behaviors. Or you may not.

The DSM is not without major flaws and the slotting of yourself (or allowing yourself to be slotted) in a DSM category can be harmful, effecting how you think of yourself, how active or passive you are in your life, and what kind of possibilities open up for you to move your life in the direction you want. As you look at the DSM IV please be aware that:

1. The DSM categories are neither scientifically based nor value free. They were created by the consensus of a small group of people – mostly white, upper middle class, American men – and can not help but reflect their values. These may or may not be your values.

2. Diagnosis suppresses the uniqueness of the individual. To fit yourself into a DSM category it is necessary to take a very simplified look at a complex life, highlighting some events and ignoring others. The parts of you that are excluded from the picture are probably at least as important as the parts that are included.

3. The DSM is deficit focused. It focuses on what you’re not doing well rather then what you are doing well. Putting too much focus on what you’re not doing well runs the very real risk of the problem becoming an even bigger part of your life, increasing its influence over the way you understand your self and further reducing the possible pathways to change.

4. The DSM supports a medical model of psychology in which the psychologist or psychiatrist is an expert on you. He/she tells you what is wrong with you and then tells you what to do to set it right. In fact no one, outside yourself, can fully understand you or your problems. There is no expert who can tell, with any validity, what caused your current behaviors or problems, what they mean, what needs to be done or how it will unfold or turnout. Clinicians can help you clarify your own knowledge and they can offer you their expertise, i.e. thoughts from their own lives, from working with others with similar struggles and from reading they have done. It is up to you to decide what is helpful and what isn’t.

5. The DSM focuses on the individual not the environment. The DSM views problems as residing within the individual. Thinking of problems this way leads to certain pathways forward and away from others. It’s also possible to see problems as residing within the family, within a system (school, government, etc) and/or within culture.

Lynn Hoffman: From Systems to Stories

2005-03-28T22:47:00.000-08:00

The following is the personal experience I had in meeting Lynn Hoffman (See footnotes for more information about Lynn Hoffman):

Lynn came to Seattle for a conference and our first meeting was a memorable one for me. She went around all the tables of people (approx 100) and started shaking every persons hand individually. I was sitting at a table in the middle of the room. I was thinking to myself, "Is she going to recognize my name from the listserve I am on with her?" I went to a Supersonics basketball game the night before and was still wired from all the hype. That may explain what happened next. She came to me and I looked her in the eye and started shaking her hand. She looked at me in amazement and said "what a reverberation." I guess she felt an electrical current flow through her veins and told everyone about the experience. I started shaking uncontrollably (faking it) and we started our face-to-face encounter with shocking results.

After shaking everyones hand, she started to discuss the importance of connection and how we should all touch our clients like putting fingers together. I thought to myself, maybe I can master the electrical current that flowed through our first physical connection and do a natural form of Electroconvulsive Therapy (ECT). I may have to think about that possibility further someday.

I met with Lynn again at the first break. She said,"So you are the blowtorch!" I said "yes" not knowing if she was referring to the passion of my posts on the listserve we are both on or our first physical encounter. She then told me of her meeting with Bradford Keeney in Lousiana and how he was shaking when she went to connect with him and he had an elegant explanation of coming back from an experience from some tribal people.

Lynn had a wonderful way of bringing people together. She asked a person in front of her if he ever had the honor of meeting the "blowtorch." That was endearing.

The best thing about Lynn's workshop was that she brought us in connection with each other. I got to know the people at my table and I experienced that it was due to her spirit of opening herself up to us in a very genuine way. Actually, I would have to say that I experienced Lynn as the most genuine presenter that I have ever met. I am not talking about what she said or did. I am talking about how people started to feel in her presence. I thought to myself this genuineness is what is missing in our world today.

Footnotes:
http://www.amazon.com/exec/obidos/ASIN/0393703800/102-4998218-6252940

http://www.california.com/~rathbone/reflecting.htm

Motivational Interviewing

2005-02-27T21:15:00.000-08:00

I attended an eight hour training to learn about Motivational Interviewing. Here are some of my thoughts about the training:

The story that was told about Motivational Interviewing is that it started in the substance abuse field with people who were called resistant to change.They have six stages for readiness for change which are precontemplation, contemplation, preparation, action, maintenance, and relapse. The precontemplation stage is supposed to be those who are in "denial" or do not think that they have a problem. I guess a lot of therapists were complaining that their clients were not motivated to meeting their treatment goals so along came an answer to resistant clients. How to motivate clients to participate in therapy is exactly what it is.

The presenters taught us that the therapist is supposed to develop a bag of tricks to move the client up the stages to maintenance. What I perceive that they have done is incorporate the CBT, SFT, and Collaborative ideas for an agenda of guiding the client to what they call true and appropriate behavior. They have scaling questions and reflective listening along with an agenda towards "right" behavior set forth by the therapist expert knowledge about how life is meant to be lived.

Link:
http://www.motivationalinterview.org/

Suicide

2005-02-07T15:50:00.000-08:00

Has suicidal behavior always been seen as a mental health issue? One of the ethical obligations is that a mental health counselor is to put up barriers to prevent people from committing suicide. These barriers may involve involuntary hospitalization. Failure to make attempts to save the client from killing him/herself may result in lawsuits and removal of the mental health counselors license priviledges. It is apparent that western society values life and condems death. Other cultures have perceived suicidal behavior as an honorable act such as killing yourself because you have dishonored your family so it gives them a chance to die with their honor. Such behaviors today have been severely criticisized by our western culture. It was a surprise to me to read a psychiatrist by the name of Dr. Thomas Szasz write about his perspective on suicidal behavior and how the mental health intentions to treat sucide as a medical problem may be erroneous. Dr. Szasz writes:

Not long ago the right-thinking person believed that masturbation, oral sex, homosexuality, and other "unnatural acts" were medical problems whose solution was delegated to doctors. It took us a surprisingly long time to take these behaviors back from physicians, accept them comfortably, and speak about them calmly. Perhaps the time is ripe to rethink our attitude toward suicide and its relation to the medical profession, accept suicide comfortably, and speak about it calmly. To accomplish this, we must demedicalize and destigmatize voluntary death and accept it as a behavior that has always been and will always be a part of the human condition. Wanting to die or killing oneself is sometimes blameworthy, sometimes praiseworthy, and sometimes neither; it is not a disease; it cannot be a bona fide medical treatment; and it can never justify deprivation of liberty.

Link to Szasz paper:
http://www.szasz.com/iol2.html

AAMFT on Homosexual Marriage

2005-01-25T22:19:00.000-08:00

The American Association of Marriage and Family Therapy has made a statement on Homosexual Marriage. Here is a quote from their statement:

Research indicates that gay men and lesbian women who have come to terms with their homosexuality, and who function effectively sexually and socially, suffer no more emotional or mental distress than comparable heterosexual men and women. Further, coupled homosexuals and heterosexuals do not differ in terms of psychological adjustment, love for their partners, relationship satisfaction, or on those variables that improve or detract from relationship satisfaction or stability. Personal and relational adjustment and satisfaction of gay men and lesbians is positively related to public disclosure of sexual orientation, perceived social support, and lack of discrimination experiences. Although specific research on the effects of prohibitions on legally sanctioned same sex unions for gays or lesbians has yet to be conducted, the absence of opportunity for most lesbians and gays to look forward to marriage or legally sanctioned same sex unions, and to have their love relationships treated on an equal social and legal basis, likely creates a sense of stigma known to be deleterious to all people.
Research studies have found few if any differences between gay men, lesbians, and heterosexuals in their parenting styles, skills, and experiences. Further, there is conclusive evidence that children raised by gay men and lesbians do not experience unfavorable outcomes compared with children raised by heterosexual parents. Studies have demonstrated that children raised in lesbian families are no different from other children in terms of short term and long term emotional well being, occurrence of psychiatric illness, gender role behavior, gender identity, intelligence, and pro-social behavior. The preponderance of the data on gay and lesbian parenting, however, comes from lesbian versus gay male families. In addition, there are a number of design and sampling limitations in the available research on gay male and lesbian parenting. Nonetheless, the uniformity of the results of these studies, showing few if any differences between heterosexual and homosexual families and outcomes for children in them, suggests that the effects of such limitations is probably small.

For more information go to:
http://www.aamft.org/about/marriage_politics_statement.asp

Postmodern Therapies PMTH News

2005-01-10T16:09:00.000-08:00

This blog is mainly for students and professional practitioners. It has been two years since the last update of Postmodern Therapies News.

Lois Shawver reports the various articles in this issue of PMTH NEWS are:
1) PMTH NEWS (an article about PMTH NEWS)
2) PMTH as a Textbook
3) PMTH as Graduate Student Instruction
4) We Call it PMTH 2
5) Who Was Involved in the Course
6) Interview with Andy (my interview of Andy Lock, the man who made this course possible and who, for your interest, taught a course in this program during the same time with our own Tom Strong).
7) What the Teachers Said about the Experience of the Course (includes articles by Lynn Hoffman, Val Lewis and Brent Dean Robbins tell about their experience. I tell about my experience in planning the course, etc., elsewhere.
8) What is PMTH?
9) Course Assignments
10) Postmodern Therapy (by Wendy Williams - a student) an account of our conversation on PMTH on this topic
11) First Therapy Sessions: What PMTH Therapists Think (by Mark Murphy - a student account. click through to read this article)
12) Assignment Two: Interview
13) Reflections: Karin Taverniers Perspective (by Mark Murphy)
14) Reflections on Karin Taverniers Perspective (by Wendy Williams)
15) Karin Taverniers Reflections on Reflections (by Karin Taverniers)
16) The Third Assignment
17) Wendy Williams Reflections on Professional Development (of therapists)
18) Mark Murphy's Reflections on Professional Development (of therapists)
19) Lois Shawver's Reflections on the PMTH 2 Course
20) It's Been a Long Time

I hope that you all may enjoy the PMTH News.

PMTH NEWS Link: http://www.california.com/~rathbone/pmth.htm

Taking a break...

2004-12-14T20:30:00.000-08:00

I am going to take the month of December off from blogging. There is simply too much to do for the rest of the year. I hope you all have a happy new year. I hope you can find some of my previous blogs of interest to you.
Take care,
Brian

Penetration

2004-11-21T21:05:00.000-08:00

I mentioned on a different blog about the New Freedom Act and how it aims to test all children attending school for mental illness. There is a concept that the government calls Penetration. Penetration is about the Community Mental Health Agencies attempting to recruit more children to receive mental health services by expert observation and coercion. The Community Mental Health Agencies get funded for how many children who are deemed to be "in need" of mental health services actually receive those services. Therefore, there is pressure for these agencies to enroll children into their services. This can lead to pressuring parents to get their children enrolled in services. This forced service doctrine can have some detrimental effects. The parents can be coerced by the schools and agencies to get served. This mental health system still believes in denial and resistance while using some forceful techniques to sweep parents and their children up in the the medical model that dominates our society. Any alternative approach may be viewed as disatrous to the funding of the Community Mental Health Agencies. I strongly encourage parents to actively scrutinze the system and get to really know your rights. The Community Mental Health Agencies may get offended and add pressure but ultimately you still have a lot of control over what happens with your child.

Chocolate Cake

2004-11-12T09:06:00.000-08:00

The name of this blog is Chocolate Cake due to the perks that psychiatrists get from the pharmaceutical companies. I noticed this beautiful chocolate cake, along with a wonderful spread of food, for the psychiatrist from a pharmaceutical representative this has been a continous perk. I told the psychiatrists nurse that I was amazed that they all were not overweight from getting so much food. The nurse informed me that it was an agency rule that they could only get a pharmaceutical buffet two times per month, otherwise they would be eating very good lunches all the time. Once in awhile, the rest of the staff gets a meal deal along with a lecture on some sort of topic related to the pharmaceutical companies agenda. I am sure that they have done studies on how to get people to use their product and meals seem to be a good way to package it. However they do not stop with food. They have fancy ink pens, clipboards, tissue, clocks, and even soap. Our offices are filled with medication paraphenillia. So the next time you visit your local psychiatrist you might take a look around his office and ask him how the perks influences his choices of medication that you get prescribed.

New Freedom?

2004-10-28T21:09:00.000-07:00

Given the spirit of the election being less than a week, I thought that it would be appropriate to discuss President Bush's New Freedom Initiative. It is told that this initiative has been developed so that all children will be screened for mental illness through their schools. I became aware of this proposal when the story came out from a British journal. Just how can this New Freedom Initiative really about being free?

The world net daily (1) wrote:
The president's commission found that "despite their prevalence, mental disorders often go undiagnosed" and recommended comprehensive mental health screening for "consumers of all ages," including preschool children. According to the commission, "Each year, young children are expelled from preschools and childcare facilities for severely disruptive behaviours and emotional disorders." Schools, wrote the commission, are in a "key position" to screen the 52 million students and 6 million adults who work at the schools.

I have been seeing a lot of bumper stickers on cars with the slogan "Freedom is not Free" and I would like to agree as I think that this New Freedom Initiative is a prime example. In the recent years, I have heard many stories about teachers coercing students to get on medications so they can control their classrooms against deviant behaviors from children. The use of medication is instituted instead of considering that the child's problems may have resulted from classroom size or the teachers inability to control the class by means of effective discipline. I believe that mandatory testing of children for mental illness which has not met validity or reliability standards could be the start of a forced medicating of our children.

I have written this blog without the intention to sway any voters on November 2nd because I do not know where John Kerry stands on this issue. I thought that it would be appropriate for us to realize what has been happening to our liberties from a mental health perpective.

Footnote

1) http://www.worldnetdaily.com/news/article.asp?ARTICLE_ID=39078

Client Voice

2004-10-21T14:20:00.000-07:00

What does listening to client voice really mean? Some would say that it means they can let therapists know what symptoms, behaviors, and cognitions they are experiencing. This type of client voice guides the thinking of therapists into diagnostic labeling and exploration of irrational thinking errors. Thus, appropriate medication will be prescribed and thinking errors will be addressed. Another way to work with client voice is to focus on working together by engaging in a conversation that sets the tone for client voice to enter front stage. The therapist can explore (with the client's voice in the process to help guide what is discussed) what is wanted in therapy, what the client's thoughts are about change, and where the therapeutic interaction goes.

In order to explore these diverse utilizations of client voice, I will compare and contrast Cognitive Behavioral Therapy (CBT) to Solution Focused Therapy (SFT). The direction of therapeutic conversation and the intention are clearly different.

The crux of the CBT approach is perceiving the client as a cognitively distorted entity with irrational thought processes. The therapist carefully listens to the client and then makes an assessment about the errors in the client's thinking. Given this perspective, the therapist is put into an expert position to properly teach the client a new set of rational thinking skills that lead to appropriate behaviors. The client must conform to the therapists instruction and not resist.
The appearance of someone being resistant to CBT generates a confrontation that leads the CBT therapist towards diagnosing some kind of personality disorder. The personality disorder label often serves a function of drastically limiting the client's voice to a sound of a pin hitting the floor.

In contrast, the SFT approach perceives the client as a capable human being whose voice must be heard in order to get what they want out of the service. The therapist takes a non-expert position in the therapy room that invites curious questions. The client leads the therapist to the goal of treatment, how far they have come to that goal, and what is needed to take small steps towards the goal. The therapist may process with the client their thoughts about the client voiced story. However, the most important part of this therapy is to listen to the client voice while continously asking series of curious strength based questions that lead the client to the goals that they seek from therapy. Thus, resistant clients become very rare given that their voice is honored and the therapy becomes a mutual partnership between therapist and client. Since the focus is solely on what the client wants to work on, the use of diagnostic labels are rendered unnecessary.

According to best practice standards, it would appear that a mixture of SFT and CBT may be necessary for optimum positive outcomes. I am afraid that this mixture may lead to relative confusion on part of the client and therapist interaction with each other. How can a therapist switch from viewing the client's problem as an irrational thinking error and then suddenly switch to believe that the client can voice important rational thinking towards their goal? There seems to be a mixed message to the client and therapy becomes cluttered. Maybe taking an initial SFT perspective in therapy and then switching to a CBT perspective when SFT does not work? This answer may lead the client to believe that they are failing the therapist since the process was started with strength based inquiry and led to distorted thinking error teaching which may take the wind right out of the client voice sail. A better solution may be for the SFT therapist to refer to a CBT therapist and vice versa. Acknowledging that each therapists have distinctly different styles that may be useful for a different array of clientele.

In conclusion, honoring client voice may mean different things to different therapeutic approaches. I used SFT and CBT as an example to start defining the differences in approach in hopes that clients, students and professionals will be educated enough to ask well informed questions about the type of therapy that they are seeking, receiving, learning or providing. Thus, client voice can assist in the venture towards increased possibilities of quality mental health service.

Best Practice: Harmful to Consumers?

2004-10-14T08:27:00.000-07:00

There has been some interesting responses to the statement that I have made on the "Cognitive Behavioral Therapy: Best Practice?" blog that goes as follows: "Cognitive-Behavioral Therapy and its proponents claims of being a superior method indicates a very dubious plan that may be harmful to many consumers." The main question that I have been confronted with is: How can Cognitive-Behavioral Therapy (CBT) be harmful to anyone?

I believe that the damage has more to do with the "Best Practice" idea than CBT. The idea of consumers being forced into having no options for treatment is flawed and possibly fatal. This forced method monopoly will have the effect of being harmful to some consumers while useful to others. Not everyone can be helped with CBT even though it can be a useful approach. It is harmful when managed care companies dictate a cost effective CBT treatment to consumers when it does not work for some of them. Limiting consumer choices to treatment is not a good idea as far as I am concerned.

By trying to demonstrate CBT's superiority, researchers take positions such as this one:

For global functioning as measured by the Global Assessment Scale(GAS), clients in the CBT group showed a significant improvement in mental functioning compared to standard therapy. (1)

Now, I have no idea what they mean by Standard Therapy. I have never heard of a model or therapy called Standard. Somehow this is rarely questioned.

Here is a sample of some interesting questions along with my attempts at answering them that were brought up from a listserve:

Question: What evidence do you have that insurance companies only cover CBT?

My Answer: A huge majority of managed care insurance companies require a diagnosis and a treatment plan. CBT claims to treat diagnoses. The treatment plans are designed with objectives that should be measureable in a way that satisfies CBT style interventions. There has been absolutely no evidence that diagnosing and developing treatment plans reflect better outcomes in therapy. Here is a quote from a September 2, 2002 Washington Post article (2):

What will be the ultimate effect of managed care's push for quantifiable, short-term results and the mental health profession's struggle to meet patients' needs? Psychotherapies that may be as effective as CT but take longer and have little if any data to show they work will be screened out, says Lloyd Sederer, who worked on managed care issues at APA before becoming New York City's commissioner for mental hygiene.

The article continues to state:

Therapists feel they are being railroaded into a single school of therapeutic thinking -- the one supported by managed care companies, which care less about patients than about holding costs down.

If you happen to read the whole article, you will find that CBT is only compared to psychoanalysis. Where are the other treatments and why do they get excluded? Perhaps, politics?

It appears to me that CBT has developed itself in relation to the DSM diagnoses and then measures its relative strength, given its reality, to a Standard Therapy (whatever that seems to be). Could their position of superiority (Best Practice) be more vague and erroneous?

Question: Why do you believe CBT is so connected to the medical model? I think CBT can be practiced without any reference to biology.

My Answer: CBT treats DSM diagnostic labels that are believed to have biological origins. You can look up NAMI, a political organization that lobbies for the medical model, in order to see what treatment it recommends for people. (3)

Question: Are you familiar with any of the literature or research as to why CBT should be best practice?

My Answer: Yes, I am. I am glad you asked. Here is a couple of paragraphs from a paper by Scott Miller, Mark Hubble, & Barry Duncan called "No MoreBells or Whistles" (4):

The only problem is that there is not a single shred of evidence to support such claims. In fact, there is not any evidence that brief therapy is actually briefer than existing therapeutic approaches. Rather, the research clearly indicates that most therapy is of relatively short duration and always has been regardless of the treatment model employed. The average client of any therapy, for example only attends five or six sessions! Similarly, there is no evidence that brief therapy results in more single session cures. Once again, the research indicates that a single session is the modal number of sessions for all clients in therapy regardless of the treatment model employed. Finally, there is absolutely no evidence that brief therapy results in more effortless, reliable or even enduring change than "longer term" treatment. Indeed, available data suggest that brief therapy achieves roughly the same results as the traditional approaches they are supposed to replace. In short, whatever differences the experts may believe exist between brief and traditional therapy, there simply isn't a difference in terms of outcome.

Why then do the developers of treatment models spend so much time and effort highlighting the differences between their respective approaches when no empirical support exists for such differences? One possibility is that advocates for the various models are trying to influence and impress their primary consumers; not clients, but other therapists. After all, therapists are the ones most likely to be interested in one theory or another, to use the various models to conceptualize and organize their clinical work and to buy professional books and attend training workshops. From a marketing point of view, proponents of brief therapy should be considered especially skilled salespeople since they have successfully convinced large numbers of clinicians to buy a model that produces essentially the same results as other models presently in use. How could such a large segment of practicing clinicians be sold such a bill of goods?

In closing, I do believe that CBT can be a useful approach to therapy but should not take a superior stance to therapy. It is the "Best Practice" idea that needs to be further scrutinized because there is nothing more dangerous than an idea when it is the only one you have.

Footnotes:

1) http://www.joannabriggs.edu.au/best_practice

2) http://www.washingtonpost.com

3) http://www.nami.org/

4) http://www.talkingcure.com/reference2.htm

Mental Illness: The Scientifically Based Political Story

2004-10-07T08:50:00.000-07:00

Categorizing symptoms and behaviors into diagnostic labels called mental illnesses can have serious implications for the lives of millions of people. Political powers want people to know about mental illness and the serious effects it has on our health. Scientific studies are being generated to inform best practices that will ensure appropriate procedures.

When a person is diagnosed with a mental illness the treatment that is scientifically recommended is to take a medication, correct irrational thoughts, and receive psychoeducation about how to become more functional. There have been numerous cases where this scientifically based approach has worked by relieving the symptoms and behaviors that brought people into services. However, what about the consequences of this one-size-fits-all approach as to how we story our problems? What if a person does not want to experience the side effects of medication? What if a person does not accept that their thoughts are irrational? What if a person does not want to live their life based on what they are told is functional in our western mainstream society? The answer, from those who propose this one-size-fits-all approach, is that it is ethically sound to do the following: A)Teach people how the benefits of the medication outweigh the negative side effects; B) Reinforce that personal problems are organic in nature; C) Confront people about how their thinking has become more irrational based on the fact of disagreement; D) Diagnose people with personality disorders based upon their refusal for trying to be "functional" within the western mainstream definition of the term.

Now these practices are being seriously questioned even by those who have constructed the story. Studies have been conducted considering brain wave activity (1). What most psychiatrists won't tell you is that our brain wave activity may change given the stories, not irrational thoughts, that we develop about our lives. It is a fictional story that we can separate our brain organ from other parts of our body, environment and spirit .

Some experts have gone as far as to say that the DSM is only useful to have fun playing diagnosing games at dinner parties (2). Given that the mental illness story has been determined to be invalid and unreliable, it appears that it would put the scientific studies of mental illness into the category of fictionally based political story telling. How can people scientifically prove a fictional story?

A lot of times, the medical model story actually makes the symptom or behaviors worse. When it gets worse the medical model story may get stronger as the symptoms and behaviors worsen. The reason the story is maintained, regardless the damage done, appears to be political motivated.

For further reading about this issue, I highly recommend the article called "Is Diagnosis A Disaster?: A Constructionist Trialogue" (3).

Footnotes:

1) http://www.corante.com/brainwaves/20030401.shtml#30168

2) http://www.newtherapist.com/dinner12.html

3) http://www.brieftherapynetwork.com/trialogue.htm

Third Party Invasions Into Private Conversations - Revisited

2004-09-30T07:21:00.000-07:00

There was a comment from an anonymous NY Clinician concerning my statement about “available to make decisions about loans for your house…(1)” That prompted me to ask myself, “Where did I get that idea? Then, I remembered that I was listening to a internet radio show with the host, John A. Riolo PhD (2), on the Psychjourney website (3).

I listened to his program with his guest, Susan Frager (4), called “Managing Managed Care.” During the program, John asked, “Say you want to buy a house. Most people need to buy a house. They need to get life insurance to cover the mortgage. The bank expects it. I’m wondering. I do not know of a particular case. But I am sure there are certain situations. Where if you go apply for life insurance to cover your mortgage and you have a diagnosis, that is not exactly real, you may be denied that life insurance and the mortgage company may not want to cover your mortgage. I am guessing at that. I honestly do not know of a particular case but is it a plausible situation?” Susan replied, “I do not know about the house part. Being that I just bought a house and nobody asked me about life insurance. But certainly life insurance companies will deny you or increase your premium and reduce your benefits.”

Afterwards, I went to the interview program that John had with guest, Michael Freeny (5), called “How Private Are Your Records.” During the program, Michael stated, “Its how your medical record link up with other elements of your life and the impact that has on, for example, things that you think would be pretty unusual. Like, getting a loan, getting a credit rating, getting into college, getting a job. Things that you would think your medical record would not even be a component of it.”

I would like to thank the NY Clinician for bringing this issue to the forefront in genuine hopes of increasing our understanding. I appreciate how the NY Clinician’s comment enabled a chance at dialogical collaboration in hopes of increasing all of our possibilities for ongoing understanding of what is happening to privacy in the mental health field. This shows the true spirit of this weblog called “Collaborative Possibilities.”

Footnotes:

1) Refer to blog on September 22, 2004

2) http://www.moosemeals.com/labyrinth.htm

3) http://www.psychjourney.com/

4) http://www.otr-therapy.com/

5) http://www.clinicalceu.com/

The Medical Model Monopoly

2004-09-23T15:27:00.000-07:00

I am going to be very critical of the Medical Model (1) and their attempts at domination within the mental health field. I do believe that medications and diagnosis may be one appropriate way consumers want to go when it comes to treatment. However, I think that what is more appropriate is getting accurate information to the public as a form of informed consent. In my opinion, the Medical Model's attempts at domination in order to monopolize mental health as "their way is best practice" has to be confronted.

I constantly get bombarded with fear tactics when I go to ethics courses that are mandated to keep my licensure. A better suited title for these ethics courses should be called "How to cover your ass when sued." I keep hearing the ridiculous catch phrases of the day which include: "Best Practices and Standards of Care." Then comes the scare tactics about how lawsuits are on the increase. Instead of learning from the lawsuits in order for the profession to change and grow, we learn, "Document, document, document." You will be safe, as long as you follow the Medical Model procedure and document it well. It does not matter if the client has been harmed as long as you have documented what you did and most of all "Cover your ass." Your license to practice will be revoked if you do not follow the Medical Model Monopoly with the appropriate documentation. In other words, using a Star Trek "Borg" analogy, "You will be assimilated, resistance is futile."

The Medical Model's attempts at holding mental health hostage will be discussed further in the upcoming blogs. Due to time constraints, I have to start writing one blog per week. I look forward to continuing to spread the awareness about what I perceive as happening within the mental health field. Feel free to write your comments about any of these blogs. Thank you for reading.

(1) Refer to blog on September 15, 2004

Third Party Invasions Into Private Conversations

2004-09-22T14:15:00.000-07:00

There was a day in which counselors/consumers were protected by priviledged confidentiality. Now that is all starting to change.

At first, I thought the change was very good idea for society in some cases. For instance, having the duty to warn if someone states that they are out to kill someone or reporting child abuse/neglect.

Now comes the extreme invasion of privacy disguised as a consumer protection law. This new law is called The Health Insurance Portability and Accountability Act of 1996 (HIPAA). I believed HIPAA was designed to allow for electronic billing to be more accessible with your informed consent. Most people believed that it adds more protection to their privacy. What is not commonly known is that HIPAA has opened the floodgates for the invasion of your privacy. Insurance companies can get your mental health diagnosis. Then your information is available to make decisions about loans for your house or ability to get affordable life insurance. Those were just a couple of examples about the devastating effects this invasion to your privacy could be.

I will include some links that you can explore for a more detailed picture of your privacy rights being invaded.

The National Coalition of Mental Health Professionals and Consumers, Inc.

The Myth of Confidentiality

HIPAA applauded for mandating uniform electronic transmissions, but raises privacy and security concerns

The War On Mental Health: Outcome Research

2004-09-21T09:22:00.000-07:00

Third party payers of your mental health needs are demanding that there are good outcomes in mental health counseling. This all makes sense. You should get good quality services when you go to a mental health counselor. However, their approach to quality research and sound information appears to be highly flawed with a definite agenda in mind. The Medical Model (1) ,with all its money, is attempting to limit the legitimate choices of what therapy consumers receive. The Medical Model is attempting to justify that medications and Cognitive Behavioral Therapy (2) combined is the best approach to your mental health.

I received a newsletter in the mail that was sent from the Washington State Department of Health (WSDH). The WSDH is the entity that licenses all the mental health disciplines. In this newsletter, the following was stated:

Avoiding the Medical Model

Faced with the complexities of informed consent, standard of care, note taking, etc., some therapists have tried to opt out of these requirements by simply taking the position that they do not believe in, or endorse the medical model, and therefore they should not be held to it. This has the same effectiveness as reporting to the Internal Revenue service that you do not believe that the tax laws are valid, and that you should not have to comply with them. The medical model will generally be imposed with or without your agreement.
Brandt Caudill Jr., Clinical Social Work Federation Newsletter, November 2003.

It appears that the mental health field has gone to war over research protocal for informed best practice. It is time for the heroes to emerge in order to start leveling the battlefield. There is a book available called "The Heroic Client: Doing Client-Directed, Outcome-Informed Therapy"(3) that confronts false claims in the mental health field. The authors of this book have websites that you may want to explore (4) and (5). This grassroots organization seek to take back the field of mental health and finally give the consumers a voice along with truly ethical work with mental health counselors.

Footnotes:
(1) refer to September 15, 2004 blog

(2) refer to September 16, 2004 blog

(3) http://www.amazon.com/exec/obidos/ASIN/0787972401/qid=1095789424/sr=ka-3/ref=pd_ka_3/002-1802842-2709649

(4) http://www.talkingcure.com/

(5) http://www.heroicagencies.org/

Therapies of Social Construction (Postmodern Therapies)

2004-09-20T10:50:00.000-07:00

I guess you could look at the Medical Model (1) and Individualized Therapies (2) as a first wave in mental health. Family Systems Therapies (3) can be viewed as a second wave. It appears that consumers are rarely informed about a third wave of mental health counseling. This third wave I refer to is Postmodern Therapies as described by Lois Shawver (4).

After many years of working in the mental health field, I have come to appreciate the many ways that we can story our problems and develop our solutions. Social Constructionism is about how we story the world we live in. Social Construction Therapies work with the clients to explore stories that may have a better fit for them and their lives.

These models include Solution Focused Brief Therapy (5) , Narrative Therapy (6) , and Collaborative Therapy (7). Harlene Anderson has a wonderful paper that compares and contrasts these three models (8).

These models reflect my work better than that of the first two waves of mental health counseling. However, consumers are rarely aware of any differences in how therapy can be conducted.

Footnotes:
(1) Refer to September 15, 2004 blog

(2) Refer to September 16, 2004 blog

(3) Refer to September 17, 2004 blog

(4) http://www.newtherapist.com/lois6.html

(5) http://apt.rcpsych.org/cgi/content/full/8/2/149

(6) http://www.massey.ac.nz/~alock/virtual/narrativ.htm

(7) http://www.harleneanderson.org/writings/postmoderncollaborativeapproach.htm

(8) http://www.harleneanderson.org/writings/postmoderntherapieschapter.htm

Family Systems Perspective

2004-09-17T13:23:00.000-07:00

I made a startling discovery as I continued my studies in college about the different approaches to counseling. I wanted to make sure that I would be able to work in the in the counseling field so I decided to take some substance abuse courses. I wanted to become a substance abuse counselor if I was not accepted into graduate school. I was exposed to the Family Systems Perspective during one of the substance abuse courses. Later, I was accepted into a very good graduate program and received my Master's degree in Marriage and Family Therapy that taught me the Family Systems Perspective.

This perspective viewed individual behavior and emotional symptoms in relation to the family interactional patterns as well as a larger context. No longer was an individuals symptoms viewed as only existing within the individuals cognitions, emotions, and behaviors viewed in isolation. The Family Systems Perspective brought forth another world view as to how to approach human problems such as mental illness, marital, children, and family problems.

Click on this link (1) for more information about the Family Systems Perspective. Also, the different Family Systems models include Structural Family Therapy (2) , Bowenian Family Therapy (3), Strategic Family Therapy (4), and the Satir Model Family Therapy (5) .

Footnotes:
(1) http://www.aamft.org/faqs/index_nm.asp

(2) http://ccp.colstate.edu/balt/Structural%20MFT_files/frame.htm

(3) http://www.psychpage.com/learning/library/counseling/bowen.html

(4) http://www.psychpage.com/learning/library/counseling/strategic.html

(5) http://satircentresingapore.tripod.com/

Cognitive Behavioral Therapy: Best Practice?

2004-09-16T09:20:00.000-07:00

When a student learns to become a mental health counselor, he/she has to study many different models of therapy. When I was a student, I remember watching a 1950's study called "The three approaches to Gloria." Gloria was a woman looking for counseling and volunteered to be interviewed by the three dominant therapy models at the time which were: Client-Centered Therapy (1) , Gestalt Therapy (2), and Rational-Emotive Behavior Therapy (3). Many therapy models have been developed since the Gloria interviews.

The Medical Model folk have been working diligently to corner the market of mental health. They have funded many studies to show that Cognitive-Behavioral Therapy (4) has the cornerstone of effectiveness. They are actively lobbying the government, insurance companies, and managed care to try to demonstrate the need for everyone to be treated with Cognitive-Behavioral Therapy. Cognitive-Behavioral Therapy and its proponents claims of being a superior method indicates a very dubious plan that may be harmful to many consumers.

I will introduce to you many other effective models and approaches to therapy that may be just as well, if not better, suited to meet your needs. Consumer awareness, consumer voice, and appropriate outcome information needs to come to the forefront before we are led into a direction that may be disastrous for many consumers.

Footnotes:
(1) http://world.std.com/~mbr2/cct.html

(2) http://www.aagt.org/html/chapter.HTM

(3) http://www.rebt.org/

(4) http://www.nacbt.org/whatiscbt.htm

The Famous Medical Model

2004-09-15T10:22:00.000-07:00

I am almost certain that most of you have heard about the Medical Model. The Medical Model is famous for the invention of the Diagnostic and Statistical Manual (DSM) that is currently available in its fourth revision. The DSM is where you find the famous diagnoses such as Major Depressive Disorder, Social Anxiety Disorder, Bipolar Disorder, Schizophrenia etc... The Medical Model is based on the theory that problems which bring you to therapy are organic in nature. Thus, our environment along with our genetic make up can trigger our brain chemicals to get out of balance which create symptoms that, when clustered together, become mental disorders. The idea is to treat those consumers who have to get those brain chemicals back into balance in order to be in normal working condition which means the reduction of symptomology.

Out of the five major mental health professions (Psychiatry, Psychology, Social Work, Mental Health Counseling, and Marriage and Family Therapy), the psychiatrist is the only professional that can prescribe (psychotropic) medications for DSM disorders. Recently, psychologists have been lobbying for prescription rights and have been able to prescribe these medications in some areas of the United States.

Pharmaceutical Companies have been developing famous medications such as Prozac, Zoloft, and Ritalin. The popularity of these medications have grown over the years and many of them are now household names. The pharmaceutical companies, psychiatrists, and the other mental health professions have gone to many lengths to convince the public of the truth about the legitimacy of the Medical Model. Upcoming blogs will explore these claims , introduce other possibilities, and discuss the politics within the mental health professional discipline.

Background of Collaborative Possibilities

2004-09-14T22:02:00.000-07:00

I am really excited to introduce the inspiration behind the creation of this weblog. I have a deep passion for giving service to people who have psychological and/or interactional difficulties in their lives that lead them to get help from outside professionals. There are many success stories that come from relationships with professionals who seek to help others in psychological and interactional pain. However, I believe that there has been a lack of informed consent to the consumer of these professional services that has led to consumer detriment. As a Licensed Mental Health Counselor, I would like to inform the consumer of the political implications towards how they are treated within the mental health system. I want to assist in creating an atmosphere that would inform more thought towards how mental health is viewed in our culture and to deepen our explorations to further the possibilities of really getting the genuinely effective/ethical services that all consumers of mental health deserve. With your awareness and voice, the services by mental health providers can be even better than ever before. I look forward to taking this journey with you all.