New Freedom?

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

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?

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

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