Social Construction Practices

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?

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

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

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

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

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

Comfortably Numb

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

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.