Tag Archives: Psychiatric Times

The Good, the Bad and the Ugly of Social Work

By Marvin Ross

Social workers can and do play a significant role in helping the mentally ill to recover when they work with psychiatrists, nurses and occupational therapists. In my personal life, I’ve just witnessed how a knowledgeable and caring social worker can impact recovery from psychosis in an inpatient setting.

Sadly, the training that many social work students (and others like psychologists and counsellors) receive from some institutions does not aid in that role. Susan Inman, the author of After Her Brain Broke, Helping My Daughter Recover Her Sanity, has long complained about the lack of science and medical training for many of these professionals. She said:

Many credentialed mental health clinicians have never received science-based curriculum on severe mental illnesses. Too many are still being trained in the parent blaming theories which contemporary psychiatric approaches to schizophrenia have long since left behind.”

For a number of reasons, I had occasion to look at the mental illness course being taught at McMaster University in Hamilton Ontario and it confirms all that Susan had to say. The course is called “Critical Issues in Mental Health & Addiction: Mad & Critical Disability Studies Perspectives for SW”. Part of the course objective is to:

“explore contributions from critical disability studies, mad studies and the historical influences of sanism and eugenics on contemporary mental health practice. Addiction will also be briefly explored within these contexts.”

Then, this is added

“Throughout the course guest speakers may be invited to share experiences and analyses on course themes from ex-patient, survivor, consumer, service-user, and mad perspectives.”

Nowhere do I see anyone coming who can provide the medical perspective which would include the physiology and treatment of mental illness. Given that McMaster has a world-class medical school and one if its teaching hospitals is a psychiatric facility, this is very troubling. It would be so easy to find a psychiatrist to talk to the class or to take a field trip to the local psychiatric hospital.

One of the readings in the first week is Geppert, C. (2004). The Anti-Psychiatry Movement Is Alive and Well. Psychiatric Times 21(3), 21. Retrieved December 4, 2009”. This article is no longer on the Psychiatric Times website that I could find and the professor referenced it in 2009. It would be nice if the professor asked his students to read something like Psychiatry and Anti-Psychiatry by Dr Allen Frances. There are many comparisons of these two approaches in that article and students should have an opportunity to see both sides.

Another set of readings for this course is by Geoffrey Reaume who is a professor of disability studies at York University in Toronto. His view of Mad Studies can be summed up by a quote he gave to an article on Mad Studies in University Affairs in 2015. He stated that “People with PhDs had oppressed mad people throughout history. I wanted to help liberate this history from the shackles of the medical model.”

Dr Frances had this to say in the article I cited above (for psychologist also read social worker):

Psychiatry is far from perfect, but it remains the most patient-centered and humanistic of all medical specialties and has the lowest rate of malpractice among all specialties.

Psychologists criticize psychiatry for its reliance on a medical model, its terminology, its bio-reductionism, and its excessive use of medication. All of these are legitimate concerns, but psychologists often go equally overboard in the exact opposite direction—espousing an extreme psychosocial reductionism that denies any biological causation or any role for medication, even in the treatment of people with severe mental illness. Psychologists tend to treat milder problems, for which a narrow psychosocial approach makes perfect sense and meds are unnecessary. Their error is to generalize from their experience with the almost well to the needs of the really sick.”

And he added:

For people with severe mental illness (eg, chronic schizophrenia or bipolar disorder), a broad biopsychosocial model is necessary to understand etiology—and medication is usually necessary as part of treatment. Biological reductionism and psychosocial reductionism are at perpetual war with one another and also with simple common sense.”

Another author used quite a bit in this course is Bonnie Burstow of the Ontario Institute for Studies in Education (OISE) at the University of Toronto. Dr Burstow is the creator of a scholarship in Anti-Psychiatry Studies. I’ve done two Huffington Post blogs about Dr Burstow. The first was entitled The Truth Behind U Of T’s Anti-Psychiatry Scholarship and the second was Time For U Of T To Rein In Its Anti-Psychiatry Activist It is worth noting that OISE is a post graduate school on teaching, learning and research. Nothing to do with science or medicine.

In my second Huffington Post blog, I had this to say about Dr Burstow:

Burstow does not believe that the brain is capable of becoming ill, and that therefore mental illness cannot exist. Her doctoral thesis, according to the media spokesperson at her institution, was entitled “Authentic Human Existence: Its Nature, Its Opposite, Its Meaning for Therapy: A Rendering of and a Response to the Position of Jean-Paul Sartre” in 1982 at the University of Toronto.

Dr Burstow is the author of a book called Psychiatry and the Business of Madness which is not one of the readings for this course but exemplifies her position. Blogger, Mark Roseman wrote a very lengthy and detailed critique of this book which is well worth reading.

Roseman defines anti-psychiatry as:

a position that psychiatry is 100% flawed, has no redeeming features, is built on a stack of lies, necessarily does harm to all who encounter it, and must be abolished in its entirety. Moreover, the real proponents of antipsychiatry do not want to seriously engage in discussion with the broader community. They are not interested in critique, or divergent opinions, but only discouraging those seeking treatment, and attracting new followers to their movement.

The course does discuss medication but this is the description of that:

The Biological Mind: What are some of the critiques of the role of medication and the psychopharmaceutical industrial complex? How does neoliberalism matter in mental health? How do we think critically about suicide and self-harm?”

Here is the recommended reading:

Cohen, D. (2009). Needed: Critical thinking about psychiatric medications. Social Work in Mental Health, 7(1-3), 42-61.

Medawar, C. & Hardon, A. (2004). Sedative hell. In Medicines Out of Control? Antidepressants and the Conspiracy of Goodwill (pp. 11-27). N.P., Netherlands: Aksant.

Whitaker, R. (2001). Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. Cambridge, Massachusetts: Perseus-p.3-19.

White, J., Marsh, I., Kral, M. J., & Morris, J. (Eds.). (2015). Critical Suicidology: Transforming Suicide Research and Prevention for the 21st Century. UBC Press. – Introduction

The titles give it all away. Whitaker, of course is an infamous anti-medication proponent and I have critiqued his views a number of times as have others more qualified that I am as in the debate between Whitaker and Dr Allen. The teaching of anti-psychiatry did not include anything pro-psychiatry and the discussion of medication contained no information on the benefits of medication. Should students not be given an opportunity to see the other side? McMaster and its teaching hospital has many first rate psychiatrists well versed in their specialties. I’ve observed the near miraculous results that properly prescribed medications can have on severe psychosis. Neoliberalism did not come up once.

The bottom line is that no one who graduates from this course will be capable of working in a psychiatric setting with patients. Hopefully, none of them will. The effective social worker I cited at the outset is a graduate of another university.

 

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On ECT and The Variability of Bodily Experience

By Marvin Ross

ECT or shock therapy has to be the most contentious treatment in all of medicine, in part, due to its depiction in films which is highly negative. My initial view of it was coloured by my favourite aunt when I was a kid. She had what in those days (1950s or 1960s) was a nervous breakdown. Her husband had died and then her brother (my father) died suddenly of a heart attack.

One of her symptoms was unusual pains in her chest and back for which no organic cause could be found so her physician nephew had her admitted to a private sanitarium rather than the infamous Toronto Hospital for the Insane at 999 Queen St W ( actually the Ontario Hospital and now the Center for Addiction and Mental Health). She underwent a series of ECT treatments and was eventually discharged.

After discharge, she confessed to me that after each treatment, the staff asked her how she felt and if she was still experiencing the pains. She told me that if she said yes, she got more shocks so she told them she was fine, the pain had gone away and she was discharged. But, she told me, she still had the pains. I can’t recall how long after but she died of a stroke. I’ve always wondered if they had missed atherosclerosis as diagnostic skills were quite primitive in those days as was treatment for heart and stroke compared to today.

Fast forward to the late 1990s and I was a regular visitor to the psych unit at our local hospital. One of the patients was a young mother with schizophrenia who, I was told, attempted to kill herself and her young children. She was getting ECT. A few months later, I was picking up a coffee at the hospital snack bar when an attractive woman said hello to me.

“You don’t recognize me, do you” she said.

“I’m so and so and this is the new me post ECT. I was discharged, I feel really well and I’m here for an outpatient visit with my psychiatrist”

Psychiatric Times just ran an interview with the author of a new book called Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy by Jonathan Sadowsky, PhD. The one question he was asked that I found very interesting was this:

“Patients have both attested to damage it has done and expressed gratitude for the relief and hope it can provide.” How do you explain this seemingly paradoxical disparity in the experiences and opinions of patients?

The answer was what I have tried to say about medical treatments and recovery in schizophrenia in general but not as elegantly as this author. This is what he had to say:

“The human body is not a mass-produced machine, where given inputs such as therapies produce automatic and predictable results. Most clinicians and lay people know this but often act as if they don’t. One result of this mechanistic conception is resistance to the variability of bodily experience. But this variability is easy to show.”

And so, some people do well and others do not just as some drugs work well for some people and in others not only don’t work but have horrific side effects. We are all different and good clinicians have to recognize (and do) that trial and error is required to find the correct treatment for any given individual.

In a recently released study out of the Karolinska Institute in Sweden, it was found that there is considerable variability in the efficacy of anti-psychotics to prevent relapses in patients with schizophrenia. This study involved 29,823 patients aged 16 to 64 years with a median follow-up of 6.9 years. It was also a naturalistic study where each patient served as his/her own control to avoid selection bias. Long-term injectable antipsychotics, paliperidone and zuclopenthixol and the oral clozapine had the lowest risk of rehospitalization.

Going back to ECT, another recent study found that remission rates for patients with severe mood disorder are lower among those who have had ECT as inpatients. Earlier studies had shown that ECT leads to better remission rates in people with major depressive disorder and results in reduced mortality.

The bottom line is that despite the bad press that ECT and other treatments may have in the media or among the general population, many will experience positive outcomes. Keep an open mind.