Friday, 19 October 2007

Soulful Psychiatry

My team practices pretty eclectic psychiatry.

This week alone we've worked in people's homes, on the streets as we've gone for walks, in a garden centre, in a cafe, in a pub and on one lady's garden path. Heck, 3 patients were even seen in an out-patient clinic :-)

All of this was purposeful. Whether it was one lady's anxiety and phobia necessitating walking to her garden's gate and being there 'til distress diminished, or a social phobia and sitting in a cafe with the hustle and bustle or wanting to get back "to normal" after a bereavement and bimble about looking for bedding plants, we're in the business of alleviating distress and working with patient's problems in a way that fits with them. Everyone's different, after all.

Too, medication's just part of the solution. Seeing a bereaved gentleman at his home with his son yesterday evening the nurse and I were struck by his progress over the last few weeks which I attribute wholly to the support (and CBT principles) his community nurse* proffered.

The medication he has of olanzapine 5mg (used as a treatment for his bipolar disorder in the past and his son's at present) was reintroduced when sleep got worse (down to 2 to 3 hours), Activities of Daily Living became increasingly impaired, anxiety rose (so he'd not leave the house) and thoughts became more disturbed with negative ruminations. A month on and things hadn't changed but he then was less chaotic in his thoughts and could work with the nurse to effect practical behavioural change and spend hours with her doing this work.

Which is good, because he's now dramatically better.

But what got him better, to my mind, was the nursing input and the medication. The medication afforded enough resilience, cohesion and alleviation of distress to engage in the somewhat cognitive and mostly behavioural work, the medication wasn't a cure and didn't effect the change itself.

Working with people at their pace, introducing nursing when there's a window of opportinuty and they're ready for it, use of medication at the lowest doses, treatment in the community at the most suitable location, work with the patient and family, use of different modalities as interventions, as I started off saying I'd like to think we're a team with a pretty eclectic approach.

I was dipping in to Bob's blog and reading about Soulful Psychiatry. The language used by Dr Roberts sounds appealing. I'm not sure who Dr Roberts is, she's not listed as a medic. Some themes espoused sound appealing. The antipsychiatry and antidrugs does not sound appealing. As Bob himselves says, he's spent ages on in-patient wards and now his mix of medication and removing stress has thankfully kept him well for ages. What are your thoughts on talk of things like Soulful Psychiatry? So much mumbo jumbo? Dangerous anti-psychaitry propaganda that's increasing the stigma of psychiatry? Maligning mental health care making it less accessible by people who could benefit from it? Or it it useful in highlighting elements that can be introduced in to main stream mental health clinical practice?

* I used to call them CPNs (Community Psychiatric Nurses) but nowadays there's a vogue for them to be CMHNs (Community Mental Health Nurses) for reasons I can't quite fathom, so I largely eschew.


Jan said...

"Soulful psychiatry" (that is, the phrase itslelf, not what's described on the websites listed) sounds like the sort of idyll, or even ideal, that I'd like to see. We all need these things to aspire to.

In crises I've experienced I've used meds to get me in a position where I had enough wits about me to give serious time and proper consideration (and action) to what needed to be done to look at the underlying causes of my problems, and to develop ways of living post-crisis. Sounds like the sort of approach you're advocating.

In practical terms, medication is a short-cut to getting to the sort of state where I'm fit to tackle the rest of the shit, and as such, useful. But never an end in itself, which is, unfortunately, the way many psychiatrists behave.

Regarding the statement "useful in highlighting elements that can be introuduced in to main stream mental health clinical practice", well, absolutely. In a world of infinite resources, maybe those ideals could become the mainstream. But in harsh reality, in a world of rationed resources, in light of clinicians' urges to respond and relieve distress, medication is useful tool. There are no magic bullets, and in the society we live in today many of the people who seek help from the team I work for seem to believe that we can solve their problems with a pill. It isn't just traditional institutonal psychiatry that has medication as its foremost option.

Zarathustra said...

I think it's certainly true that some people in psychosis view their experiences as meaningful in a creative or spiritual way, and I suppose in that context "soulful psychiatry" might help them to express that. Whether that means they should stop taking the meds and start doing meditation and Bach Flower remedies instead is another matter entirely.

I did hear of a woman with bipolar disorder who was instructed by her Wiccan psychotherapist to stop taking her meds so that she could change over to addressing her illness through visualisation techniques. Apparently the results were predictably horrendous.

Oh, the CPN/CMHN thing. I think it's because somebody decided we should refer to ourselves as mental health nurses rather than psychiatric nurses - something to do with emphasising that we also promote good mental health as well as treat mental illness. Admittedly I don't know any CPNs who are involved in turning clients into Nietzschean supermen, but there you go.

Spiritual Emergency said...

... was dipping in to Bob's blog and reading about Soulful Psychiatry. The language used by Dr Roberts sounds appealing. I'm not sure who Dr Roberts is, she's not listed as a medic. Some themes espoused sound appealing. The antipsychiatry and antidrugs does not sound appealing.

Something to keep in mind...

"...85% of our clients (all diagnosed as severely schizophrenic) at the Diabasis center not only improved, with no medications, but most went on growing after leaving us."

Source: John Weir Perry & Diabasis

Like Maureen Roberts, Perry was a Jungian trained psychiatrist. He was of the opinion that schizophrenia was an attempt by the psyche to self-heal. Perry found that individuals undergoing an acute schizophrenic break could move through the process in about six weeks, at which point it would come to a natural conclusion. [Ref: Mental Breakdown as Healing]

If someone is producting recovery rates in the range of 85% without relying on medication, I would think that's someone we should be willing to learn from. We are perfectly aware, after all, that numerous individuals are not med-compliant whereas the medications themselves come with a host of side-effects that range from various unpleasantries to death.

It's worth noting that Jaakko Seikkula, a clinicial psychologist currently practicing in Finland who is not Jungian oriented, is also producing similar rates of recovery: Between 1981-1998, he worked as a clinical psychologist at the Keropudas hospital in Finland where he and colleagues developed a highly successful approach for working with psychosis known as Open Dialogue Treatment (OPT). The approach de-emphasizes the use of drugs and focuses instead on developing a social network of family and helpers and involving the patient in all treatment decisions. Ongoing research shows that over 80% of those treated with the approach return to work and over 75% show no residual signs of psychosis. Official government statistics comparing 22 health districts in Finland found that Dr. Seikulla's district was the only one not to have any new chronic hospital patients in a two year period and led the National Research and Development Center for Welfare and Health to award a prize for "over ten years ongoing development of psychiatric care".

Source: Open Dialogue Treatment

I'm not aware of any other programs currently operating in North America or Europe that can offer recovery rates in those ranges. If you are, please do share the information.

Medication or non-medication should not be the issue. The real question is, are people getting better? Are they recovering? And if so, how are they doing so?

My own schizophrenic break occurred almost five years ago. The "psychotic" stage lasted approximately six weeks. It was preceded by a prodromal phase of roughly ten months when I was getting a "little odd". Because I did not know that what I was experiencing was considered to be psychosis, I did not go to the hospital. Because I did not go to the hospital, I did not receive any form of medication. I have now been working for more than four years; my relationships are stable; my cognitive abilities appear to be fine and I have yet to be hospitalized, medicated, or even receive any degree of formal therapy. The clinicians I found most helpful in the aftermath of my crisis however were the Jungians.

Those who are interested can read a brief summary of my experience here: Story as a Vehicle of Healing

These links may also be informative:

- Schizophrenia & Hope

- Voices of Recovery


Spiritual Emergency said...

zarathrusta: Admittedly I don't know any CPNs who are involved in turning clients into Nietzschean supermen, but there you go...

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