WHEN TREATMENT MIGHT CAUSE

HARM

Exploring ethical dilemmas related to diagnosis, drugs, and other possibly iatrogenic aspects of mental health care.

Presenters and Overview• Run Unger, LCSW• Pamela Birrell, PhD• Goals of the seminar

• Ethical behavior is not the display of one’s moral rectitude in times of crisis, it is the day-to-day expression of one’s commitment to other persons and the ways in which human being’s relate on one another in daily interactions

ETHICS Philosophy and Practice

What is (are?) Ethics??• 1. ( used with a singular or plural verb ) a system of moral principles: the ethics of a culture.

• 2. the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc.: medical ethics; Christian ethics.

• 3. moral principles, as of an individual: His ethics forbade betrayal of a confidence.

• 4. ( usually used with a singular verb ) that branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.

Ethics and morals•So clearly ethics has to do with doing what it “right”?

•Who is to determine what is right? • Is it the mental health system and the respective codes of ethics?

• Is it our own moral compass?•What about when the ethics code conflicts with moral principles?

•These were questions I began to ask…

And I also began to question things going on around me…•State Hospital•Community mental health—drug cocktails

•Clients being lied to, not respected

•“Ethics” workshops•Need to question the medicalized, paternalistic system that we have inherited

And I saw things that didn’t feel ethical to me…•Ethics Workshops•Parts of the Ethics Codes•Risk management without relationship.

•Let me explain…

Things that aren’t ethical1. “Ethics” Workshops and how ethics has

come to be all about the law and breaking rules and how we can get into trouble

2. The fact the we think that it is possible to be certain about ethic, and finding the “right” answer is more important than careful discussion of assumptions, power and concepts of disorder

3. The lack of questioning of the ethics code itself

4. The fact that ethics is most often thought of as separate from clinical work, almost as an afterthought, rather than the core of clinical work

Here’s what I think…•Ethics must be the core of our work as psychotherapists.

•We have too often been taught that ethics are merely an abstract set of rules that tell us what to do in difficult situations.

•But every moment is the ethical moment, an ethical position is the way we position ourselves with the other. (Birrell, 2006b)

What about risk management?• There is of course a place for risk management, but we must be aware that if it is played out in a manner that only increases the power-over position of the therapist, it can be harmful

• Much (but not all) “risk management” can be avoided by good relationships

Where do we go from here?• Let’s look at how we got to where we are• the western philosophical roots of Ethic Codes,

• And then extrapolate how some other, more modern ideas about ethics might apply to the psychotherapeutic and ethical situation.

• I will also introduce a relational approach to ethics that we will expand on for the rest of the day.

THE VIGNETTEThe classic approach to teaching ethics

Case 4-15: Robert Bumble, Ph.D., began treating a troubled young woman in an office at his home. Dr. Bumble failed to recognize increasing signs of paranoid decompensation in his client until she began to act out destructively in his office. At that point, he attempted to refer her elsewhere, but she reacted with increased paranoia and rage. Dr. Bumble terminated the relationship, or so he thought. The ex-client took an apartment across the street from his home to spy on him, telephoned him at all hours of the day and night with an assortment of complaints and explicit threats, and filed ethical complaints against him. (Koocher and Keith-Spiegel, 1998, p.89)

• This is a typical case study presented as a training model to teach ethics in psychotherapy. In these vignettes, as in much of the writing about ethics, ethical problems are most often presented as separate from clinical work.

You are on the ethics board• What kinds of things do you think about?• How do you come to make decisions about Dr. Bumble?

• The “answer” from the Ethics book:• 2.01 Boundaries of Competence(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

ARTICULATING THE STANDARD APPROACHWhere do Ethics Codes come from, what are their uses, and when we must question them

The View from a Distance: The Standard Approach• What is the basis for this approach?

• In Western philosophical views the basic idea is that we can reason our way to the ethical ideal

• So we talk about “ethical” situations, decide which ethical principle applies, ruminate about what to do, and never question the assumptions underlying the ethical codes.

Characteristics of this View Universal Principles

◦Do no harm, Justice, Respect◦These are good and wonderful principles, but the question is how we apply them

Autonomous self—relationships are not important and total objectivity is possible

Generalized Others in formal relationships In other words, particular situations and people don’t

matter People are therapists or clients

Clinical and ethical issues are separate◦Ethical principles are not integrated into the healing work

A CLOSER LOOKCare Ethics: The Ethic of Dialogue, Care, and Immediacy

A re-framing of the Vignette• Standard vignettes contain the assumptions of the standard approach:

• Individuals are interchangeable (e.g., “clients” and “therapists”)

• Ethics codes are universally applicable

• Ethical situations are separable from the therapeutic context

• What if we look a little closer at how things might actually be happening?

Care Ethics—Noddings, Gilligan Care ethics portrays the moral agent as a

someone who is embedded in webs of relations with others, not autonomous and abstracted.

Care thinking is generally described as narrative, contextual, and particularistic, as opposed to abstract, autonomous and universalistic.

The concept of the “generalized other” is incomprehensible. Instead uses the concept of the “Concrete Other”, arguing that the generalized Other is a stereotyped Other, denying the uniqueness of human life.

• Robert Bumble, Ph.D., was treating a troubled young woman named Angela Jacobs in his office at his home. The relationship between Dr. Bumble and Ms. Jacobs had been uneasy. Dr. Bumble felt that Angela was “putting him through his paces”, as he told his colleagues. He had diagnosed her as Borderline Personality Disorder. During one particular session, Angela started asking questions about his personal life that Dr. Bumble found intrusive. He was somewhat uncomfortable and angry, and it had been a long day in a busy practice. He was tired of dealing with Angela. He fell back on his ethics training about boundary violation and deflected her questions. He then attempted to educate her on the topic of boundaries in psychotherapy.

• Angela was indeed “troubled”. She had a history of difficult relationships, never feeling a sense of acceptance and love from others. She felt some hope with Robert Bumble. He had treated her kindly and seemed attentive to her. As her hopes rose, she also felt a sense of rising desperation. What if things weren’t as they seemed? What if this relationship turned out like all the others, with rejection, leaving her more hopeless than before? She tested Robert Bumble. She wanted to know. On the day he gave her the lecture on boundaries, she felt humiliated, lost and angry. However, she could not allow herself to feel the hopelessness—the emotion threatened to swallow her up. Instead, she comforted herself that he really did love her, and if she only was able to stay close to him, things would work out. • (My own extension of Koocher and Keith-Spiegel, 1998, p.89)

THE ETHIC OF RESPONSIBILITY, FACE AND VOICEEmmanuel Levinas

Closer Yet• Care ethics adds an important dimension to how we think about ethics. It begins to question the idea of the autonomous self and speaks about selves-in-relation.

• Yet, there is further we can go. • There is another strand of modern ethical theory that emphasizes not only the importance of the immediate and caring relationships, but also begins to deeply question the nature of the autonomous self and its roots in responsibility to the Other.

Emmanuel Levinas Lithuanian Jew who lost his family in the

Holocaust and was himself a German prisoner of war

Ethics prior to ontology—that is, ethics must be prior to “knowing”

Ethics is situated in an "encounter" with the Other in which the Other cannot become an object of knowledge or experience, but must remain subject. ◦The demand of the Other, according to Levinas is “Do not kill me”—not necessarily in the physical sense, but in the sense of “Allow me to be. Do not make me an object.”

Levinas attempts to undermine Western philosophy and its insensitivity to the Other ◦Characterizes most of Western philosophy as egology, and prefers instead of “love of wisdom”, the “wisdom of love”

“Saying” vs. “Said” ◦The content of speech strives for universality and solidity. Yet, in the failure of that striving, the Saying is revealed - conversations continue and are not discreet exchanges of information.

Totalization• “Totalization“, according to Levinas, occurs whenever I limit the other to a set of rational categories, be they racial, sexual, (diagnostic) or otherwise.

• Indeed, it occurs whenever I already know what the other is about before the other has truly spoken.

• If ethics presupposes the real other person, then such totalization will, in itself, be unethical.

Another go at the vignette• What would the vignette look like from a Levinasian framework?

• Here’s a modest proposal…

Robert Bumble, Ph.D., was treating a troubled young woman named Angela in his office at his home. The relationship between Dr. Bumble and Angela had been uneasy. During one particular session, Angela started asking questions about his personal life that Dr. Bumble found intrusive. He was somewhat uncomfortable and angry, and it had been a long day in a busy practice. He was tired of dealing with Angela. Yet he recognized the total responsibility that he owed her. He knew that he must not “totalize” her, or make her part of his story, as though she was a “type” or class of patient; he must not make their living “saying” into a concrete “said”.

Among other questions, Angela asks, “Are you married?” Robert acknowledges that he does not know where this question comes from, but he recognizes the plea, “Do not kill me” (in other words, “Allow me to be”). Instead of remaining in his safe autonomy, he knows he must risk, open himself to her. He knows he is called into question by her plea. He recognizes his reluctance to engage with her, and his desire to withdraw behind professional boundaries. In this response, he realizes that he is also afraid. He also recognizes that his response must be immediate, honest and authentic, and he answers, “Yes, I am, and this is uncomfortable for me to talk about”.

Angela is frightened by his reply. How is it that Dr. Bumble has feelings like she does? How is it that he is uncomfortable? Angela’s self that is constituted in her responsibility to Robert is mobilized, and she is not sure what to do or say. She wants to totalize him, make him one of the many rejecting figures in her life, but somehow his vulnerability stops her. Nevertheless, she does respond with anger and feels betrayed by him. He acknowledges her feelings of loss and tries to understand them. As he does so, he finds he understands Angela at a much deeper level than her “pathology” and feels that in doing so, his universe is expanded. Angela also, although she is at first frightened, finds that she can expand how she thinks of Robert—not just as a therapist, but as a person.

Listening as an Ethical Act• Although the idea of listening is a very important one in psychotherapy, that listening has not been described in ethical terms.

• Ethical listening has far greater demands on us than simply to “understand” or make sense of another person.

• In fact, in the terms stated above, this is mere “totalization”—taking the Other into our conceptual system rather than allowing our ideas, our epistemology, and even our very selves to be brought into question.

This view of ethics has radical implications for our field• That is what we will be talking about much of today

• What happens if we dare to not just follow “rules”, but to approach each moment as ethical and each person as unique?

RELATIONAL ETHICS

How does this change things?

Stuff that gets left out of traditional approaches to ethics

• We need to begin to question some deep assumptions that we have about what it is to be a person, the workings of POWER in our system, and to let go of “Knowing”

• Facing Suffering• Towards a Relational Ethic

• Mutual Respect and Power-With• Engagement and Suffering-With• Ethics as Uncertainty and Deep Listening

Personhood, Power, and “Knowing”• What persons can say about themselves, the sense of personhood that they can develop, will depend on the stories they can tell, as well as the stories that others are willing to listen to, acknowledge, and accept as viable and true.

• Ethics begins here, with the face-to-face encounter, when we allow or resist our discomfort with uncertainty to influence our encounter with another human being.

Giving an account of oneself…• We can only give an account of who we think we are in relationship, and can only know who we are in relationship.

• How do we become persons? • How do we give an account of ourselves? • Is this not the heart of ethics? • If we do not allow others to give accounts of themselves, and force our epistemology upon them, have we not committed an ethical breach?

• In the ethical relationship, “knowing” is not about gaining certainty.

• This is the dominant position of positivist science—power, prediction and control.

• The true ethical relation resists rational certainty, and rests on uncertainty and the “perilous adventure of forever insufficient knowers sacrificing their certainty and even their control for understanding.”

Facing Suffering• We have medicalized human suffering, replacing the language of despair and anguish with the language of symptoms and diagnostic criteria.

• Suffering as isolation without meaning• We who are witnesses to suffering of others must make a choice: We must choose whether to be there for them or allow their isolation to continue. It is an ethical choice.

• The goal of therapy is not to preclude or eliminate human suffering, but to take it on in a radically ethical and responsive manner: as a suffering-with which is a “suffering-for” the suffering other.

• When we suffer-with those who are suffering we enter into ethical relationships, responding to them with care and compassion.

• Much of our therapeutic language of “cure” and “symptom reduction” can take us away from suffering-with

We no longer see ethics as a set of rules to follow, but as an attitude and a stance toward the suffering of others.

It is not an attitude of totalizing, controlling, and power-over (be it persons or symptoms); it is a stance of responsibility, of radical altruism or authentic giving in each and every moment.

It is an attitude of respect, engagement and uncertainty.

In contrast to the notion of ethics as known codes and rules, ethical knowledge cannot be known ahead of time; rather ethical knowledge must be developed in relationship

Mutual Respect and Power-With• Mutual respect: Mutuality, mutual empathy, mutual empowerment, mutual responsibility—all add up to mutual respect—seeing the other as worthy of our attention and our regard.

• Mutuality and mutual respect mitigate power’s potential to damage. Mutual respect keeps power in its proper place, with each person able to live within her or his own position of power.

Engagement and Suffering-With Mutual empathy, authenticity, relational

awareness all add up to relational engagement.

To be engaged means to respond to the needs of others. In this moral response, one does not lose oneself, but could be said to find oneself—what one is capable of and the depths one can respond to.

Engagement, as a characteristic of ethical relationships, requires attention to the self, to the other and to the relational space in between.

What about boundaries?? More on that later today…

Ethics as Uncertainty The ethical relation rests, instead, on

uncertainty and the perilous adventure of forever insufficient knowers sacrificing their certainty and even their control for understanding.

Our challenge is living and being comfortable with ambiguity—not only in searching for control.

Relational space is an ambiguous space where certainty does not exist. Our challenge is living and being comfortable with ambiguity—and inviting others to join our web of ethical relations.

We need to practice negative capability

• “I mean Negative Capability, that is, when a man [sic] is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason-

• The ability to contemplate the world without the desire to try and reconcile contradictory aspects or fit it into closed and rational systems.

Discussion: What are the implications of this somewhat radical view of ethics?• Is diagnosis totalization?• How might this play out in clinical practice?

INFORMATION SOURCES THAT ARE HEAVILY BIASED

How can we trust our information?

Where did our thinking come from?• We have begun to see that the quest for being ethical is not just about learning rules, but about beginning to question what we know and how we know it

• We may accept some of the following just because it was taught to us• Diagnoses (even DSM diagnoses) are real things,

scientifically established• We need to work to reduce symptoms that people bring to

us and make them functional again• We need to refer for drug evaluation• We need to accept a subordinate position to psychiatry

Where did our current system come from?• We are taught to accept our current system—DSM, “medications”, “Empirically Supported Therapies”—as the “truth”, scientifically established by objective “experts”

• But just how did we get to our current system?• Is it “true” or perhaps culturally constructed?

Historical Roots of our mental health culture

• 18th century America– no such thing as psychopathology and the idea that there were mental illnesses• There were “lunatics” and people with problems, but

they were not thought of as sick or ill, merely suffering

• In an increasingly complex society, these people became more and more a problem as family and community structures broke down

• At the same time we were becoming a more individualistic culture, and more and more rationalistic, pushing interdependence and non-rational ways of knowing into the background, to be distrusted.

• So now we’ve got the idea that suffering and weird people are sick and defective, and therefore needing to be “fixed”. This is a new idea in the 19th and 20th centuries, one that we take for granted and find hard to think any differently.

More history…

• The rise of the psychiatrist in the 19th century• AMASAII (1844): Association of Medical

Superintendents of American Institutions for the Insane• Campaign to promote their “cures”• Drapetomania• By the beginning of the 20th century, hardly any clearly

defined diseases or known causes• Two Giants of psychiatry

• Freud and Psychoanalysis• Emil Kraeplin– less known, but has had a bigger effect

on the field than Freud

Kraeplin’s Big Idea• Mental illness fall into a small number of discoverable types, and these can be independently identified by studying symptoms, by direct observation of brain diseases, or by discovering etiologies of the illnesses (e.g., genetics).

• Individuals with the same disease, defined by symptoms, were assumed to have the same brain disease.

• Eventually decided on two major psychoses: dementia praecox and Manic-depressive illness, categories still used today.

• So our current ideas of mental health and mental illness are culture bound to our culture, based in social conditions, western ways of looking at things, and a scientific (or perhaps scientistic) individualistic mind set.

So our current system is culture-bound…• We are bound in a culture that is egocentric, largely unaware of the effects of power, and bound by modernist scientific thinking

• The DSM-IV contains a section on “Culture Bound Disorders”, but perhaps they ALL are!

• More about that later…

Is our current system scientific or economic?• I am arguing here that the way we think about mental health and mental illness is largely economically driven rather than scientific.

• In fact, the science itself is economically driven.• Economics determines what questions can be asked and what is the nature of the research we can do

Desire for Profit• Economics means that there is a profit motive in what we do and how we think

• On the surface this is so obviously true! We all want to make a living

• But it goes farther than that…

Listening to Prozac• Prozac came on the scene in 1987• As we have seen it was heralded as a new era in mental health care• Listening to Prozac—1993 • Talking Back to Prozac—1994

• Profits from Prozac in 1987 were $800 million • 20 years later ($40 billion!)

Lilly settles Zyprexa Lawsuit for $1.42 billion• January, 2009• Eli Lilly & Co. said Thursday it pleaded guilty to a

charge that it illegally marketed the anti-psychotic drug Zyprexa for an unapproved use, and will pay $1.42 billion to settle civil suits and end the criminal investigation.

• It will pay $800 million to settle civil suits, including $438 million to the federal government and $362 million to states.

• It will pay $615 million to resolve the criminal probe, and plead guilty to a misdemeanor violation of the Food, Drug and Cosmetic Act for promoting Zyprexa as a dementia treatment.

• Eli Lilly reportedly had sales of $4.8 billion of Zyprexa in 2007, and $37 billion since the drug was first introduced, making it one of Eli Lilly’s biggest sellers.

GlaxoSmithKline to Plead Guilty and Pay $3 Billion to Resolve Fraud Allegations and Failure to Report Safety Data• July 2, 2012• Global health care giant GlaxoSmithKline LLC (GSK)

agreed to plead guilty and to pay $3 billion to resolve its criminal and civil liability arising from the company’s unlawful promotion of certain prescription drugs, its failure to report certain safety data, and its civil liability for alleged false price reporting practices, the Justice Department announced today. The resolution is the largest health care fraud settlement in U.S. history and the largest payment ever by a drug company.

• http://www.justice.gov/opa/pr/2012/July/12-civ-842.html• Pharmaceutical giant GlaxoSmithKline reported total

sales of $44 billion for 2011 and generated a net profit of nearly $9 billion in 2011 alone.

Desire for professional dominance• Profit of course overlaps with professional dominance.

• The various mental health professions compete with one another for dominance, economic power, and their way of thinking• Social work• Psychology and counseling• Psychiatry

Psychiatry in the twentieth century and the medical model• Development of the DSM—needed to change it from

Freudian to medical model, to maintain their status as real doctors• Diagnoses as medical diseases, discrete disorders, diseases of

the brain• Was no understanding about biological causes, done for

professional reasons

• APA establishes its own press to tell the story• Funding from pharma to educate doctors• Prestigious organizations began working for pharma, e.g., Duke• NAMI as a reaction to shizophrenogenic mother. Funded by

pharma.

• All of this a reaction to protect professional dominance• None of this had been established scientifically

What about now?• HUGE controversies abound as can be seen from the

debates surrounding the DSM 5.• In 2011, a group of academics wrote an open letter to

the manual task force to protest about some of the proposed changes and the way in which they were being implemented.

• To date, more than 50 international organizations have formally endorsed the letter and have added their own criticisms.

• They include the British Psychological Association, the Danish Psycho logical Society, the Society of Indian Psychologists, the United Kingdom Council for Psychotherapy, Psychology Italy and the Association of Black Psychologists.

DSM 5• The American Psychiatric Association has hired GYMR,

an expensive PR company, to help the organization “execute strategies that include image and alliance building, public education campaigns or media relations to harness the formidable forces of Washington and produce successful results for clients”

• As part of its image-building strategy, the PR company has helped set up a new website, DSM-5 Facts, which claims to “welcome scrutiny, not only of this process but of its results.”

• But Frances one of the developers of the DSM-IV, whom the APA recently tried to brand “a dangerous man”, recently published just a preliminary list of the site’s distortions and falsehoods: “Public Relations Fictions Trying to Hide DSM-5 Facts.”

• http://www.huffingtonpost.com/allen-frances/dsm-5-facts_b_1560994.html

Examples of a public relations firm• GYMR Fiction: "We have extensive data from the field trials that on

average there is a slight decrease in the overall rates of DSM-5 in comparison to DSM-IV disorders."

• DSM-5 Fact: This is simply wrong -- APA has no such data. Except for autism, all of the DSM-5 changes will dramatically raise the rates of mental disorder and mislabel normal people as psychiatrically sick. The field trial provided no data on this crucial question because it made an unforgivable error -- not including head to head prevalence comparisons between DSM-IV and DSM-5. This makes it impossible to estimate how explosive will be the DSM-5 rate jumps. Moreover, false epidemics are often nurtured in the primary care settings that were untested in the DSM-5 field trials.

• GYMR Fiction: The PR claim is that DSM-5 has provided a transparent process.

• DSM-5 Fact: DSM-5 has been peculiarly and self-destructively secretive from its early confidentiality agreements (meant to protect "intellectual property") to its current failure to make public any of the results of its "scientific" reviews. Real science can never be confidential. None of this secrecy makes any sense.

MENTAL HEALTH LANGUAGE AND ETHICSLanguage and culture

Cultural assumptions• Let’s examine the assumptions of our own culture• What do we accept as true that is merely culturally constructed?

Language and reality• Language shapes our thinking• If we think of suffering people as “patients” with “diseases”, we will be motivated to relieve suffering by reducing “symptoms”

• If we think of suffering people as trauma survivors, we will be motivated to uncover the trauma

• If we think of suffering people as fellow human beings with problems in living, and with lives as complex as our own, we will be motivated to be with them without our agenda.

The language of Diagnosis and treatment• Medical language: Treatment, medications, symptoms, disease, etc. (Szasz)

• As we have discovered, this is due to how our particular culture has been trained to think of those who are suffering

• It is because of this language that Muniz was awarded the Nobel Prize in science for the frontal lobotomy

• See Whitaker, Mad in America

Aspects of Culture• The group holds shared perspectives, norms, values, or assumptions that direct the behavior of its members.

• Information about the group is handed down through the generations of its members.

• The group has a common language, dialect, or set of terms.

• The perspectives and practices of the group are widely shared by its members.

• Members of the group react emotionally when the perspectives or practices of the group are not upheld.

How the Mental Health System operates as a culture • The group holds shared perspectives, norms, values, or assumptions that direct the behavior of its members.• Professional Ethics Codes• Modernist Science• Mental illness located in the individual• Brain disorders

• Information about the group is handed down through the generations of its members.• Medical schools, programs in psychology

• The group has a common language, dialect, or set of terms.• The DSM, statistics

• The perspectives and practices of the group are widely shared by its members.

• Members of the group react emotionally when the perspectives or practices of the group are not upheld.• Reactions to the anti-psychiatry and critical

psychiatry movements

An example of cultural construction—PTSD • Civil War—Soldier’s Heart• WWI—shell shock

• http://www.youtube.com/watch?v=mhlfmY_hdiI• WW II: Battle Fatigue• Trauma in the DSM I and II• PTSD as a Vietnam War Syndrome in the DSM-III• Political reasons

• Changing views and cultural assumptions• “PTSD” and healing from trauma looks different in different cultures, e.g., Sri Lanka

MEDICATION USEShort term gains, long term damage?

• Benzodiazapenes• Antidepressants (WHY are they called that?)

• Antipsychotics (WHY are they called that?)

Benzos The toxic effects of the BZs in general can be divided into several somewhat overlapping categories:

(1) Inducing sedation (tranquility) or hypnosis (sleep), which is indistinguishable from a toxic effect except in degree;(2) Cognitive dysfunction, ranging from short-term memory impairment and confusion to delirium;(3) Disinhibition -- including extreme agitation, psychosis, paranoia, and depression, sometimes with violence toward self or others;(4) Withdrawal, from anxiety and insomnia after routine use to psychosis and seizures after the abrupt termination of long-term, larger doses;(5) Rebound, an aspect of withdrawal, in which the individual develops anxiety, insomnia, or other serious emotional reactions that are more intense than before drug treatment began. (6) Habituation and addiction

Chart by Robert Whitaker, from Anatomy of an Epidemic

Long term effects• Cognitive Problems (Barker, et al., 2004)• Moderate-to-large weighted effect sizes were found for all cognitive

domains suggesting that long-term benzodiazepine users were significantly impaired, compared with controls, in all of the areas that were assessed.• Sensory processing• Nonverbal memory• Speed of processing• Attention/concentration• General intelligence• Working memory• Psychomotor speed• Visuospatial• Problem solving• Verbal memory• Motor control/performance• Verbal reasoning

More effects• Chronic benzodiazepine usage can cause both

depression and 'emotional anaesthesia', and can aggravate depression and provoke suicide.

• Because of the slow elimination of many of the benzodiazepines, cumulation may occur on repeated dosage and may lead to excessive sedation with impaired psychomotor performance, ataxia, dysarthria, motor inco-ordination, diplopia, muscle weakness, vertigo, poor memory and concentration, and mental confusion.• http://www.benzosupport.org/adverse__effects_of_prolonged__be

nzo_use.htm

Antidepressants• Tardive dysphoria• Antidepressant induced mania• SSRI-induced apathy• Direct toxic effects on the brain

Are Antidepressants DepressogenicOver the Long-Term?• “Antidepressant drugs in depression might be beneficial in the short term, but worsen the progression of the disease in the long term, by increasing the biochemical vulnerability to depression . . . Use of antidepressant drugs may propel the illness to a more malignant and treatment unresponsive course.”

--Giovanni Fava, Psychotherapy and Psychosomatics, 1995

Tardive Dysphoria“A chronic and treatment-resistant depressive state is proposed to occur in individuals who are exposed to potent antagonists of serotonin reuptake pumps (i.e. SSRIs) for prolonged time periods. Due to the delay in the onset of this chronic depressive state, it is labeled tardive dysphoria. Tardive dysphoria manifests as a chronic dysphoric state that is initially transiently relieved by -- but ultimately becomes unresponsive to -- antidepressant medication. Serotonergic antidepressants may be of particular importance in the development of tardive dysphoria.”-- Rif El-Mallakh, 2011

Source: El-Mallakh, R. “Tardive dysphoria: The role of long-term antidepressant use in inducing chronic depression.Medical Hypotheses 76 (2011): 769-773.

SSRI induced apathy• “You know I used to become unglued whenever the

neighborhood kids would ride their bikes through my lawn. Since I’ve been taking Prozac I just don’t give a shit. Tell the little bastards to come on. I tell you, Prozac is great.”

• An amotivational, or apathy, syndrome has been reported in a number of patients receiving SSRI treatment over the last decade. This adverse effect has been noted to be dose-dependent and reversible, but is often unrecognized. This phenomenon has caused significant negative consequences for adults as well as social and academic difficulties in adolescents.

Toxic effects• The Serotonin Syndrome is a potentially lethal condition caused by excessive serotonergic activity and is diagnosed by the presence of at least 3 of 10 symptoms: mental status changes (confusion, hypomania), agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever.• Source: Journal of Clinical Psychiatry

Why do we call them antidepressants?• In a recent article (Antonuccio and Healy, 2012), the authors suggest to be called an antidepressant, the medications • should be superior to placebo, • should offer a risk/benefit balance that exceeds that of alternative treatments,

• should not increase suicidality, • should not increase anxiety and agitation, • should not interfere with sexual functioning, and

• should not increase depression chronicity.

• Since “antidepressants” do all of that and since many of the “side effects’ have larger effects than the antidepressant effect size, to call them antidepressants makes sense from a marketing view but not a scientific one.

• How about…• Anti-aphrodisiacs, • Agitation enhancers, • Insomnia inducers, • Suicidality inducers, • Mania stimulators, or • Gas busters.

• Language again…

The Evidence for Antipsychotics• Short-term Use

• The medications reduce target symptoms of a disorder better than placebo in six-week trials.

• Long-term Use• In relapse studies, those withdrawn from the medications

relapse at a higher rate than those maintained on the medications.

• Why do we call them anti-psychotics?

What’s Missing From the Evidence Base?A. It does not provide evidence that antipsychotics improve the long-term course of schizophrenia and other psychotic disorders, particularly in regard to functional outcomes.B. The relapse studies may reflect risks associated with drug withdrawal, rather than just the return of the natural course of the disorder.

Assessing Long-Term Outcomes• “After fifty years of neuroleptics, are we able to answer the following simple question: Are neuroleptics effective in treating schizophrenia? [There is] no compelling evidence on the matter, when ‘long-term’ is considered.”

• And:• “If we wish to base psychiatry on evidence-based medicine, we run a genuine risk in taking a close look at what has long been considered fact.”• --Emmanuel Stip, European Psychiatry (2002)

The First Hint of a Paradox• NIMH’s First Followup Study (1967):• At the end of one year, patients who were treated with placebo upon initial hospitalization “were less likely to be rehospitalized than those who received any of the three active phenothiazines.”

• Source: Schooler, C. “One year after discharge.” Am J of Psychiatry 123 (1967):986-95.

Clinicians’ Perceptions• Patients were returning with great frequency, which was dubbed the “revolving door syndrome.”• Relapse during drug administration “is greater in severity than when no drugs are given.”• If patients relapse after quitting antipsychotics, symptoms tend to “persist and intensify.”Source: Gardos, G. “Maintenance antipsychotic therapy: is the cure worse than the disease?” American Journal of Psychiatry 135 (1978: 1321-4.

Loren Mosher’s Soteria Project• Results:• At end of two years, the Soteria patients had “lower psychopathology scores, fewer [hospital] readmissions, and better global adjustment.”

• In terms of antipsychotic use, 42% had never been exposed to the drugs, 39% had used them temporarily, and 19% had used them regularly throughout the two year followup.• Source: Bola, J. “Treatment of acute psychosis without

neuroleptics.” J Nerv Ment Disease 191 (2003):219-29.

• Loren Mosher’s Conclusion• “Contrary to popular views, minimal use of antipsychotic medications combined with specially designed psychosocial intervention for patients newly identified with schizophrenia spectrum disorder is not harmful but appears to be advantageous. We think the balance of risks and benefits associated with the common practice of medicating nearly all early episodes of psychosis should be re-examined.”

Summary of the first 25 YearsOutcome studies led researchers to worry hat antipsychotics might make people more biologically vulnerable to psychosis over the long-term, and thus increase the chronicity o the disorder.In 1978, Jonathan Cole wrote a provocative article titled: “Is the Cure Worse than th Disease?”

The Dopamine Supersensitivity Theory“Neuroleptics can produce a dopamine supersensitivity that leads to both dyskinetic and psychotic symptoms . . .An implication is that the tendency toward psychotic relapse in a patient who has developed such supersensitivity is determined by more than just the normal course of the illness.”

• Guy Chouinard and Barry Jones, McGill University• Source: Chouinard, G. “Neuroleptic-induced

supersensitivity psychosis,” Am J Psychiatry 135 (1978): 1409-10; and “Neuroleptic-induced supersensitivity psychosis,” Am J Psychiatry 137 (1980): 16-20.

Study of Tardive PsychosisIn 1982, Chouinard and Jones reported that 30% of the 216 schizophrenia outpatients they studied showed sign of tardive psychosis, which meant their psychosis was becoming chronic. When this happens, they wrote, “the illness appears worse” than ever before.“New schizophrenic symptoms of greater symptoms will appear.”

• Source: Chouinard, C. “Neuroleptic-induced supersensitivity psychosis, the ‘Hump Course,’ and tardive dyskinesia.” J Clin Psychopharmacology 2 (1982):143-44.

• Also, Chouinard, C. “Severe cases of neuroleptic-induced supersensitivity psychosis,” Schiz Res 5 (1991):21-33.

Reviewing the Evidence for the Dopamine-Supersensitivity TheoryLonger-term studies in the 1970s showed higher relapse rates for drug-exposed patients.• A biological explanation for this paradoxical result was proposed and assessed in a study of schizophrenia patients.• Animal models further refined understanding of drug induced dopamine supersensitivity and researchers at University of Toronto concluded that this was why the medications failed over time.

Nancy Andreasen’s MRI Study• In 2003, Andreasen reported that schizophrenia was a “progressive neurodevelopmental disorder” characterized by “progressive reduction in frontal white matter volume.” This decline in brain volumes was seen in MRI imaging tests.• Source: Ho, B. “Progressive structural brain abnormalities

and their relationship to clinical outcome.” Arch Gen Psych 60 (2003):585-94.

In 2003 and 2005, Andreasen reported that this brain shrinkage was associated with a worsening of negative symptoms, increased functional impairment, and, after five years, cognitive decline.

Source: Ho, B. “Progressive structural brain abnormalities and their relationship to clinical outcome.” Arch Gen Psych 60 (2003):585-94. Andreasen, N. “Longitudinal changes in neurocognition during the first decade of schizophrenia illness.” International Congress on Schizophrenia Research (2005):348.

• In 2011, Andreasen reported that this shrinkage was drug-related. Use of the old neuroleptics, the atypical antipsychotics, and clozapine were all “associated with smaller brain tissue volumes,” with decreases in both white and grey matter.

• The severity of illness and substance abuse had “minimal or no effect’” on brain volumes.• Ho, B. “Long-term antipsychotic treatment and brain

volumes.” Arch Gen Psychiatry 68 (2011):128-37.

Nancy Andreasen, former editor of the American Journal of Psychiatry, on antipsychotics:

• “What exactly do these drugs do? They block basal ganglia activity. The prefrontal cortex doesn’t get the input it needs and is being shut down by drugs. That reduces psychotic symptoms. It also causes the prefrontal cortex to slowly atrophy.”

--New York Times, September 16, 2008

WHO Cross-Cultural Studies, 1970s/1980sIn both studies, which measured outcomes at the end of two years and five years, the patients in the three developing countries had a “considerably better course and outcome.”•The WHO researchers concluded that “being in a developed country was a strong predictor of not attaining a complete remission.”• They also found that “an exceptionally good social outcome characterized the patients” in developing countries.

Source: Jablensky, A. “Schizophrenia, manifestations, incidence and course in different cultures.” Psychological Medicine 20, monograph (1992):1-95.

WHO Findings, ContinuedMedication usage:16% of patients in the developing countries were regularly maintained on antipsychotics, versus 61% of the patients in rich countries.15-year to 20-year followup:The “outcome differential” held up for “general clinical state, symptomatology, disability, and social functioning.” In the developing countries, 53% of schizophrenia patients were “never psychotic” anymore, and 73% were employed.

Source: Jablensky, A. “Schizophrenia, manifestations, incidence and course in different cultures.” Psychological Medicine 20, monograph (1992):1-95. See table on page 64 for medication usage. For followup, see Hopper, K. “Revisiting the developed versus developing country distinction in course and outcome in schizophrenia.” Schizophrenia Bulletin 26 (2000):835-46.

Summary of Cross-Cultural StudiesWith Medication as a Variable1) In 1970s and 1980s, WHO investigators found that outcomes were significantly better in developing countries, where only 16% were regularly maintained on antipsychotics.2) In recent global Eli Lilly Study, where all patients are maintained on antipsychotics, patients in developing countries do not have better functional outcomes than patients in developed countries.

PSYCHOTHERAPYPitfalls and assumptions

What are the iatrogenic effects of therapy?• Where have you seen this? • What are the “dangers” of therapy?

Dimidjian and Hollon, 2010• If psychotherapy is powerful enough to do good, it may be powerful enough to do harm. Although it is now well established that most psychotherapies provide benefit, recent discussions have raised concerns about examples of psychotherapies that may do harm.

Lillienfeld, 2007• Critical incident stress debriefing: Heightened risk for PTSD

symptoms• Scared Straight interventions: Exacerbation of conduct

problems• Facilitated communication: False accusations of child abuse

against family members• Attachment therapies (e.g., rebirthing): Death and serious

injury to children• Recovered-memory techniques: Production of false

memories of traumas• Dissociative identity disorder-oriented therapy: Induction

of "alter" personalities• Grief counseling for individuals with normal bereavement

reactions: Increases depressive symptoms• Expressive-experiential therapies (e.g., Gestalt):

Exacerbation of painful emotions• Boot-camp interventions for conduct disorder:

Exacerbation of conduct problems• DARE programs: Increased intake of alcohol and other

substances

What do these therapies have in common?• Critical incident stress debriefing: Heightened risk for PTSD

symptoms• Scared Straight interventions: Exacerbation of conduct problems• Facilitated communication: False accusations of child abuse against

family members• Attachment therapies (e.g., rebirthing): Death and serious injury

to children• Recovered-memory techniques: Production of false memories of

traumas• Dissociative identity disorder-oriented therapy: Induction of

"alter" personalities• Grief counseling for individuals with normal bereavement

reactions: Increases depressive symptoms• Expressive-experiential therapies (e.g., Gestalt): Exacerbation of

painful emotions• Boot-camp interventions for conduct disorder: Exacerbation of

conduct problems• DARE programs: Increased intake of alcohol and other substances

When therapy seems to be making things worse• This can often happen in “trauma” treatment• As the person begins to remember and reframe their experience, there can be grief and anxiety and increased dissociation

• Informed consent—is it truly possible?• We can begin to panic• We can begin to feel hopeless and outside our comfort zone and maybe even our competence

• It is times like this when we disconnect from clients and retreat into professional demeanor.

Dependence or Attachment?• Case 3-25: Ida Demeaner had been in psychotherapy

with Manny Continua, Psy.D., weekly for 6 years. Ida had successfully dealt with the issues that first brought her to treatment, but had become very dependent on her sessions with Dr. Continua. While there had been no real change in Ms. Demeaner’s emotional status for at least 4 years (aside from the increasing attachment to him), Dr. Continua made little effort to move toward termination. His philosophy is, “If the client thinks she need to see me, then she does.” (Koocher and Keith-Spiegel, 1998, p.73)• “Dr. Continua has a conceptualization of psychotherapy that

suggests the potential for endless therapy….He may have fostered her dependency and actually be perpetuating her “need” for treatment.”

A re-telling of the vignette• Ida Demeaner had been in psychotherapy with Manny Continua, Psy.D., weekly for 6 years. Ida had made strides in dealing with the issues that had brought her to treatment, especially the panic and anxiety that had kept her from leaving the house. As the anxiety lessened, also began to experience the emptiness and loneliness in her life. In connecting with Manny, she began to realize that she had never felt a true connection and the sense of safety that she experienced with him.

• Since she had never realized this connection and safety she became dependent on her sessions, not knowing if such connection was possible with anyone else. When Manny mentioned the lack of social connections in her life and tried to urge her to connect with others in her life, Ida felt criticized and abandoned and often ended up cutting herself. While there had been no visible change in Ida’s emotional status for at least 4 years, Dr. Continua realized the time and care it took to successfully heal the kind of isolation that Ida had grown up with. He therefore made little effort to move toward termination. His philosophy is, “I respect the client’s attachment, along with her needs and deep loneliness . If the client thinks she need to see me, I respect her knowledge of her own needs.”

How to best avoid harm• Client as expert• Making our own agendas for therapy secondary to ethical listening

• It is important to know what you are doing, but can we really know?—respecting our limits while trusting our humanness

• We are often taught to treat “disorders” rather than people

• Back to the case of Angela and Robert.

BOUNDARIESProtection or punishment?

• There is a quietly ferocious struggle going on for the soul of psychotherapy and counseling, manifesting in many ways – regulation, training, evidence-based practice – but ultimately about the tension between spontaneity and control.• Nick Totton• http://www.therapytoday.net/article/15/54/categories/

• And a fight to maintain each profession’s status in the marketplace...

What do we mean by boundaries?• Boundary issues mostly refer to the therapist's self-disclosure, touch, exchange of gifts, bartering and fees, length and location of sessions and contact outside the office (Guthiel & Gabbard, 1993).

• Boundary crossing in psychotherapy is an elusive term and refers to any deviation from traditional analytic and risk management practices, i.e., the strict, 'only in the office,' emotionally distant forms of therapy (Lazarus & Zur, 2002).

• Do you agree or disagree?

Would you do any of the following? Why or why not?• Walk with an agoraphobic client to an open space

outside the office or fly with a fear-of-flying client on an airplane as part of an exposure or in vivo intervention.?

• Working with children: leave the office for walks with them and or perhaps attend school plays in which they are performing, provide snacks and drinks, play cards and exchange small gifts and photos.

• Self-disclosure as a way of modeling, offering an alternative perspective, exemplifying cognitive flexibility, creating authentic connections, increase therapeutic alliance or leveling the playing field.

• Joining an anorexic or bulimic client for a lunch or for a family dinner.

• Go on a home visit to an ailing, bedridden or dying client. • Accompany a fearful client to a medically crucial but

dreaded medical procedure. • Escort a client to visit a gravesite or a place that held

special meaning for the client and their deceased loved one in order to facilitate the grief process.

• Join an addict at a first 12-step meeting.

The shadow side of boundariesWhat I have come to understand about these boundaries is that: • like all man-made fences, they are artificial and arbitrary. They “fence in” and “fence out,” serving to exclude certain groups, certain movements, and certain behaviors. They can be constructed, heightened or lowered, moved, or taken down at any time. (The confusion expressed in recent years by many psychologists regarding what is and is not allowed and what is or is not an ethical violation serves as a constant reminder, and a clear demonstration, of this artificial quality);• while it is argued that boundaries exist for the purpose of protecting patients from exploitation due to the supposed power of the therapist, the real and much grander reason for building these fences is to establish practitioners, and the profession itself, as an elite and potent force;• these fences are not built to control therapists’ power but rather to establish and embellish the impression that the people who are qualified to assume the role of psychotherapist are so powerful as to be able to exert a dangerous, Svengali-like, influence.•What do you think?

Therapy and boundaries• Therapy is as much about questioning boundaries as it is about asserting them; as much about supporting clients to break out of the rules as it is about teaching them to observe the rules.

• For some clients at some times, it is crucial to know that the therapist will act within a defined frame.

• For others, or for the same clients at other times, it is equally crucial that the therapist dances outside the frame, and that a trust can be established which is based on authenticity rather than predictability.

Or are they about ‘defensive practice’?• Therapy based on authenticity may reasonably be

characterized as ‘undefensive practice’, as opposed to the ‘defensive practice’ which is becoming more and more the norm of contemporary therapy.

• Undefensive practitioners are vulnerable to misunderstanding, and indeed, if not sufficiently self-monitoring, to misbehavior; but defensive practitioners, in the extreme, neither like nor trust their clients – they see them as a potential threat, a danger to be negotiated.

• On one level this threat is to the practitioner’s standing and income, should a complaint be made; but more deeply, one feels that the real threat is to the practitioner’s insecure self-image and self-esteem. Their internal critic is projected out into their clients, who are then mistrusted and feared.

Thought about boundaries and relationship• Every therapeutic relationship needs to be a

relationship: a place where two subjectivities meet, with all the difficulty and painfulness this implies, but also with a developing willingness and capacity to tolerate the other person’s otherness.

• For a therapist to hold careful boundaries because they believe they must, or because they are afraid of the uncontrollability of closeness, cripples the potential for relatedness.

• But for a therapist to hold such boundaries as an honoring of the client’s woundedness is itself relational. The only valid generalization about relationships is that they are each unique; and therapists are artisans of relationship, co-creating one-off works with their clients.

The opposite of boundaries• What is the opposite of being boundaried? One answer is ‘unboundaried’; another is ‘boundless’.

• Undefensive practice draws on a sense of boundlessness – abundance, space, attention and care. In contact with abundance, the therapist can afford to be generous on many levels, which communicates the experience of abundance to the client, perhaps allowing them to relax about life and its challenges.

• A practitioner who cannot offer her clients boundaries is dangerous. But a practitioner who cannot offer her clients boundlessness is useless.

WHO DO WE SERVE?

Ego or superego?

Do we know the reasons we do things?• Is informed consent possible?

• Network will be san1• ID will be L88888888• Pin will be chipmunk2012