These reflections result from my
observations and experiences as a member of Southcentral Counseling Center’s
(SCC) Institutional Discharge Program (IDP) for two years and nine years of
university education including two years of post-graduate study in clinical
psychology. Additionally I have
integrated other sources of information obtained through personal reading and
experience outside of academic and work pursuits. I wish to preface these remarks with a
statement in the hopes of avoiding misinterpretation. The ideas presented here are in no way to be construed as a negative
criticism of current IDP practice and policy.
To the contrary, I have found the IDP team to be dedicated and sincerely
striving to serve a difficult population, despite great odds. In fact, an accurate appreciation of how
hard the IDP team works can only be grasped by being on the team for a period
of time. What is presented here is a
vision, a progressive view, towards the future, building on a foundation
already established, not an attack on the current system. Presented here are not so much answers as
questions in the hope of stimulating creative and open discussion with an eye
towards progress. Mental health services
have progressed a long way in the last hundred years and these services will
naturally continue to progress. We have
a choice: we can facilitate this evolutionary process or resist it.
The current model IDP uses is
largely the medical model. This means
that severe and chronic mental illness is conceived of as a biological brain
disorder and treatment is primarily through medications. Psychiatric stabilization through compliance
with medications is standard practice.
Besides medications, wrap-around case management and skill building
services are offered and provided. For
the record, I wish to be clear, I am not
against the medical model. I have
seen what happens when clients stop taking their medications and severely
decompensate. My main contention is
that the medical model needs to be
integrated into a larger, more integral model. We need to integrate as many useful treatment
modalities as possible, including the medical model and medications. What we are currently doing is simply not
enough for the population we serve. We
see the cycle, of clients decompensating and revolving in and out of
correctional facilities or Alaska Psychiatric Institute (API), repeating
constantly. We see clients in crisis
daily, frequent suicide attempts, two completed suicides in the last two
years. We see clients continuing to
suffer severe symptoms and we hear clients complain about the inadequacy of the
services and the medications we provide.
There is no need for service providers to feel defensive about these
things. The fact is that we do not have
the technology to adequately help all our clients recover. But that fact is also that we are not using
all the technologies available to us now and rely primarily on drugs. If something is not working, we should be
able to seek, with an open mind, creative, innovative, and scientific,
solutions. This is not to say that it is
all bad. We have seen clients make
remarkable progress. Whether this
progress is a result of our efforts or the unique characteristics and strengths
of a particular client, is unknown. I
like to think that it is a synthesis of both.
We all have been trained in certain schools and there tends to be a
resistance to challenging or new ideas.
My hope is that we can release our defense of what we already know in
the hopes of learning something new.
Sometimes our existing reservoir of knowledge can be a block to the new
and progress.
My own bias is the humanistic
model. In short, a humanistic approach
values every human being and sees in every human being a potential for
growth. In other words, given the
optimal environment (or even less than optimal), human beings will develop and
grow throughout their life span. This
evolutionary process is natural and intrinsic.
We cannot make it happen any more than we can make a tree grow. But we can, within limits, provide the
therapeutic atmosphere, the ingredients necessary for the natural developmental
process to proceed. Ideally this is what
parents, and society in general, do for children. If psychological humanism has any merit, then
we can view our clients as valued persons having potential to evolve. The flip side of the coin is that we can also
stunt growth, or prevent growth, by denying the person the necessary elements
that allow the growth process to continue.
Just as if we did not water a plant or provide access to light, the
plant’s intrinsic growth process would be hindered or cease completely.
If our client’s have the potential to develop, then how are we to facilitate this process? How are we going to provide the environment needed for growth? (Later in this paper I will present Dr. Maslow’s model of human development that proposes that certain needs must be satisfied (in hierarchical order) before progression to the next level of growth. I believe this model will be helpful to us in determining how to facilitate our client’s intrinsic potential for growth.) I believe that in the medical model, the idea is that a client first needs to be psychiatrically stable before further progress can be made, and this makes sense. What happens though, is that we fall into a stabilization and maintenance mode. The experience of many mental health professionals, who have been in the field for many years, has led some to the resignation that there is not much more we can do other than a humane maintenance. And this indeed represents significant progress over institutionalization and the deplorable and cruel treatment of the mentally ill over the ages. Granted, for some clients, maintenance may be all we can do. However, a progressive view will seek more than maintenance, despite the history of what we have seen. In fact, our experience that clients do not improve significantly is the challenge to question what we are doing and find out what might work better.
The psychiatric stabilization of
clients through medications works to a degree, but at what cost? We know that psychotropic medications help
our clients because we see what happens when they do not take their medications
consistently. We also see clients who
report and/or demonstrate significant and distressing psychotic symptoms
despite high doses of antipsychotic medications. We also know that clients suffer severe and
dangerous side effects as a direct result of medications prescribed. A brief and simplified review of how
antipsychotic drugs work may be useful and is now presented here.
Brain research has been growing at
an extraordinary rate. We are constantly
learning more about how the brain works, and new drugs are being introduced all
the time. But there is still much more
that we don't know, than we know, about the brain. Antipsychotic medications (neuroleptics,
psychotropics) do not heal the schizophrenic.
They only help control her or his symptoms and often at the cost of
serious and dangerous side affects, which require additional medications. Antipsychotic medications were discovered by
accident. They were first used as
anesthetics and anesthesiologists observed their calming affect on
patients. They were originally though of
as major tranquilizers (i.e. Thorazine).
Most antipsychotic drugs work at the synapse to block dopamine
uptake. Dopamine is a neurotransmitter
(there may be hundreds of neurotransmitters, more are being discovered all the
time). The synapse is the gap between
two neurons (there are at least 100 billion synaptic gaps in a human
brain). When neurons communicate with
each other, a chemically induced electrical signal (action potential) travels
along the long tail (axon) of the pre-synaptic neuron. When this electrical signal reaches the end
of the axon, chemical messengers (neurotransmitters) are secreted and move
across the synaptic gap and bind to receptors on the post-synaptic neuron,
which may or may not, depending on various factors (like second messengers),
cause an electrical signal to proceed in the post-synaptic neuron, causing the
secretion of neurotransmitters to the next neuron and so forth. Most antipsychotic drugs attach to the
post-synaptic receptors that bind the neurotransmitter dopamine and thus
prevent dopamine from reaching the post-synaptic neuron. In preventing the dopamine from getting to
the post-synaptic neuron, antipsychotic drugs interfere with neuronal activity
that depends on dopamine. This action
reduces the symptoms of hallucinations and delusions in some psychotic
patients. The prevention of dopamine
uptake is also directly responsible for the side effects clients
experience. And there are other drugs
that target different neurotransmitters.
Now tinkering with the neurotransmitters
has had some success in reducing psychotic symptoms and we can hope for better
drugs in the future. One of the common
consequences of these drugs is sedation and we see these sedative effects in
our clients frequently. The real
problem, as I see it, is that one of the effects of these drugs is a loss of
motivation and thus a suppression of the natural growth process. There are other factors that interfere with
this process also, as we will see, but one of the consequences of psychotropic
drugs is increased avolition. Avolition
is one of the negative symptoms of schizophrenia according to the DSM-IV. So on the one hand the use of these drugs
provides some relief from symptoms in some clients, at the same time we
increase avolition resulting in clients that are sedated and lacking motivation
to change and grow. It is like treating
a cancer patient for pain but not doing anything about the cancer. We do need to ameliorate the cancer victim’s
discomfort but we also need to treat the cancer in the hope of recovery. It is the same way with schizophrenia and
other psychotic disorders. We do need to
ameliorate client's symptoms, but we also need to address the whole person and
facilitate growth and development. We
need to treat the symptoms and the disease. Treating the symptoms alone is not enough.
I believe it is possible that if we
integrate a variety treatment modalities, conventional and non-conventional,
then the need for psychiatric stability through drugs may be decreased. Psychiatric stability may be achieved with
lower doses and thus decrease sedative effects and increase motivation. Many of our clients do not receive or
participate in basic self-care activities recognized to be beneficial for everyone. Some of these factors include, but are not
limited to, healthy diet (including health supplements like vitamins and
minerals, therapeutic amounts of clean water), exercise, proper medical care
(including dental care), and proper amounts of quality sleep. Many of our clients are obese (sometimes a
medication side effect), have poor diets, never exercise, and/or sleep too
little, too poorly, or too much. The
lack of these basic self-care needs can only add to the difficulties our
clients experience and hinder their growth and recovery. Again, if these basic needs were being met,
we might see an increase in psychiatric stability that permits lower does of
antipsychotic drugs, resulting in less severe side effects, less sedation, and
more motivation towards health and progress towards realizing client identified
goals.
As mentioned above, Abraham
Maslow’s hierarchy of needs provides a model for human development that may be
helpful to us in conceptualizing how to provide the therapeutic environment in
which clients may grow and move forward. This hierarchy of needs is often diagramed as
a pyramid with lower needs at the bottom and progressing upward as a person
develops towards her or his full potential.
The terms used here are Maslow’s. The first, most basic needs are
physiological: air, water, food, shelter, sleep, etc. Higher needs of love, esteem and
self-actualization will not mean much to a person who is starving. So these physiological needs must be met before
a person can progress. Assuming that the
basic physiological needs are met, the next level of needs is described as
safety and security needs. These needs
are usually present in children rather than adults. These safety needs are generally met through
limits, consistency, fairness, routine, and a fairly predictable world. If these needs are consistently met for a
period of time, the person develops so that safety and security are longer
crucial needs (they have been met) and the person grows into the next level of
needs, love and belongingness. At this
level a person’s needs shifts towards the interpersonal and relationship,
giving and receiving love and affection, trusting the other, and a social
belonging. Assuming the needs of love
and belonging are met, the next needs to emerge are esteem needs, both
self-esteem (confidence, competence, mastery, adequacy, achievement,
independence, freedom, etc.) and esteem from others (prestige, recognition,
acceptance, attention, status, reputation, appreciation, etc.). Finally Maslow describes the “growth” needs
leading to self-actualization (or reaching ones full human potential). It is beyond the scope of this paper to
describe this mature process. The point
of outlining Maslow’s theory is to provide a conceptual foundation for serving
our clients with better outcomes. If our
clients evolve to the point of self-actualization needs, they will no longer
need our services.
Do our clients have their
physiological needs met? For the most
part yes, but there are frequent exceptions.
Many of our clients are often homeless and shelter is a basic
physiological need. The issues of
housing, or lack of housing, not to mention quality of housing, are major
pieces to the puzzle of poor outcomes with our clients. If these needs are not met, then we can have
little hope that the natural evolutionary process will unfold. In terms of empathy, can we see our client’s
world from their eyes? What is it
like? Imagine being tortured by
frightening and disabling psychotic symptoms, sedated and confused by
medications to the point where you cannot communicate clearly (i.e., your
speech is slurred and people assume you are intoxicated), abject poverty,
marginalized and stigmatized by society, isolation, lack of interpersonal
relationships and support group, serious physical health problems, chemical dependence,
fear, and on top of all this you are homeless and it is 20 degrees below
zero. Imagine how stressful it would be
for we who are relatively mentally healthy to be homeless and how difficult it
would be to develop our human potential under these conditions. The cards are really stacked against our
clients in so many ways and we need to change our approach if we wish to see
better outcomes.
Those of us who work in the field
know how complicated and difficult the housing issue is. We have seen clients evicted over and over
again because of their behaviors.
Clients are even banned from the homeless shelters. There are some that prefer a behavioral
approach and see homelessness as a natural consequence of behaviors and as a
way to modify client’s behavior so that they can retain housing. My view is that homelessness does not help
the client and it is not the atmosphere our clients need in order to grow.
Besides homelessness, there is the
issue of quality of housing. Many of our
clients live in housing that would frighten and/or disgust most of us to live
in. This situation arises because many
clients have a tendency to burn their residential bridges and run out of viable
options. However, at the point of being
redundant, I maintain that we must see that our client’s physiological needs,
including shelter, be met before significant progress can take place.
The next needs to be met in order
to provide the therapeutic climate required for recovery are safety and
security. This ties into the quality of
housing issue because some of our client’s housing situations are far from safe
and secure. Safety issues are further
complicated for clients who suffer from paranoia. What might be considered relatively safe for
a healthy person may feel very unsafe to the paranoid schizophrenic. So the question arises, how can we provide a
therapeutic atmosphere for our clients such that their needs for safety and
security are met? This is not an easy
question to answer because it is not enough to provide for this need while they
are with us, which might be from a few minutes to a few hours in a day. This is a 24 hours per day, seven days per
week need. How can our client’s need for
safety and security can be met full time without institutionalization, and with
respect for the “least restrictive environment” philosophy? Here is an opportunity for creative problem
solving and innovation. As mentioned
above, these needs can be met through the stability provided by limits,
consistency, fairness, routine, and a fairly predictable world.
The establishment of a “clubhouse”
for our clients could go a long way towards realizing some of these goals. Currently, IDP clients who come to the Tudor
facility on a daily basis attend medication clinic and have the option of
participating in one or two groups. Most
of the day clients have nowhere to go and nothing to do. They congregate outside the building and
smoke cigarettes or sit around in the upstairs reception room, or disperse
throughout the city on foot or by bus.
Our clients need a safe, clean, and secure place to call their own,
where they belong, without the stigma and victimization they generally
experience with nowhere to go and nothing to do. This clubhouse would be a place for client’s
to go and socialize, build relationships, perhaps have access to games (pool,
Ping-Pong, board games), materials for artwork, writing, and playing musical
instruments, inexpensive but nutritious food, coffee or tea, water, music,
television, resources, telephone, the Internet, and counseling as needed. This clubhouse might be open for most of the
day and evening and provide transportation to various outings and home at
night. This clubhouse would be
maintained by clients with staff help and have an informal structure as compared
to the Day Rehab Program. I vigorously
encourage SCC to consider the establishment of such a safe place, perhaps
funded by a grant or Recovery by Choice funds.
In my opinion, resources would be better spent and help more clients by
providing a clubhouse, then say hiring an individual attendants for a
particular clients 24 hours per day.
Assuming we can provide for our
client’s physiological and safety needs (and that is a big assumption), the
next needs are for love and belonging.
Many of our clients have stories of abuse, neglect, and rejection in
childhood. And the cycle of abuse,
victimization, and rejection continues throughout their lives. Many have no family system or support in
place. Most of our clients have poor
interpersonal skills and have a difficult time maintaining healthy
relationships. Many of our clients have
Axis II personality disorders, which own symptoms that derail just about any
relationship. For many of our clients,
their best chance at meeting these needs are through the therapeutic
relationship with mental health service providers. Here, I believe, is where the Rogerian
approach is appropriate and if properly performed will lead to positive
outcomes. In short, Carl Rogers’
research states that three things are necessary to create a therapeutic
relationship: (1) Congruence or authenticity (being real, no pretense), (2)
Empathy, or empathic listening (not sympathy, the client feels heard and
understood), and (3) unconditional positive regard towards the client. The formula appears deceptively simple and it
is easy to remember, but very difficult to do.
In fact Rogers stated that if you approach therapy this way, the
therapeutic relationship will not only benefit the client, but the therapist
herself or himself will be changed significantly. How many of us are willing to risk this
change in ourselves? One of the barriers
to the love and belongingness needs being met through the clinical therapeutic
relationship is staff turnover. Building
relationships with our clients takes time and often by the time a relationship
is beginning to be established it is ended for one reason or another. One IDP client told me, “I’ve been here
longer than anyone on the staff. It’s
confusing, you keep having all these new people.” Needless to say, building relationships with
the population we serve is difficult and slow work and it requires certain
skills and characteristics of staff, some of which cannot be taught.
If we were able to facilitate the
development of our clients through these first three levels of needs, with
these needs being met, consistently, over a period of time, I believe our
clients would no longer need the intensive services provided by IDP. For the most part, they would be able live
independently in the community and continue their development without much
professional help. To provide the level
of services suggested here would be very expensive. It would be more expensive, however, to not
provide these services because the costs of stabilization and maintenance would
continue indefinitely, whereas the costs to facilitate natural growth would be
temporary.
Earlier in this paper I spoke of an
“integral” approach to therapy. This
means combining as many useful therapies or interventions as possible. Insights from all the schools of psychology
may be applied as appropriate for each client including psychoanalytic
psychology, ego psychology, self psychology, behavioral psychology, humanistic
psychology, cognitive psychology, existential psychology, Gestalt psychology,
the bio-psycho-social model, motivational interviewing, health psychology,
neuro psychology, systems theories, social psychology, abnormal psychology,
physiological psychology, transpersonal psychology and lots more. An integral approach will also try to
integrate anything that is useful outside of the field of psychology, such as
medicine, chemistry, biology, history, art, literature, music, mathematics,
physics and lots more. Already mentioned
are basic self-care factors such as diet, exercise, and sleep. There are also may other interventions that
may be beneficial. Examples include,
massage therapy, bodywork, acupuncture, yoga, magnetic therapies,
neuro-linguistic programming, new sound and light therapies (binaural
technology), and spiritual disciplines.
Whether you consider spirituality to be relevant or not, many of our
clients have spiritual issues that are sometimes ignored as “delusional
religious ideation.” But if we are to
treat the whole person we need to acknowledge all areas of being human,
especially if they have value to the client.
Clinical pluralism is necessary in this post-modern period.
I believe that an integral approach to serving our clients will eventually become the norm. I have no idea how long it will take before this is so. One of the limitations with the current system is the lack of resources for research, both reviewing current research and performing our own studies. Few staff will even feel like the have the time it takes to read this paper. There continues to be a dichotomy between the academic world of research and the practical world of clinical work. IDP and SCC have the opportunity to innovate improvements in mental health services that are cutting edge, groundbreaking, and boundary pushing. We can think outside the box. We have the opportunity to initiate improvements that not only will impact our clients and the agency, but also have historical ramifications worldwide in terms of the progression and evolution of mental health services. If we do make changes, we should try to document these changes and demonstrate, if possible, outcomes. Future funding for services is likely to be outcome-based. If we can demonstrate positive outcomes, funding will be available. I hope these ideas promote dialogue. I am not an expert and I am not insisting that I am right. These notions have been buzzing around in my mind for some time and I felt the need to communicate them and put them on paper. Thank you for taking the time to read this. Any questions, comments, suggestions, criticisms are welcome. Hopefully this will become a collaborative and collective project.