Education

Coaching vs Parenting Or Home Depot and Recovery

While reading an academic paper it made me smile when I came across this line:

“…coaching teams function like the Home Depot motto: “You can do it. We can help.

That is a wonderful reminder of how ACT clinicians ought to see their role in working with clients!

The line is from a paper titled The Work of Recovery on Two Assertive Community Treatment Teams by Salyers et al.  In it they explore how to best measure recovery orientation. Looking at two Indiana ACT teams and using observational measures and interviews over time, they identified “Recovery Critical Ingredients” in four areas: Environment, Team Structure, Staff Attitudes and Process of Working with Consumers (see table below or click to view online).

Recovery Critical Ingredients Table 1

In visiting the teams they found thatDespite teams’ similarities in baseline fidelity to the ACT model, we experienced many differences between the teams during our visits – both teams were meeting similar ACT model standards, but were approaching the work very differently.”

Some recovery measures are more objective, such as rating the environment looking for such features as “Open waiting area, posters about recovery, posted team mission included recovery” versus  “Separate waiting area and bathrooms, several signs with rules posted.”  More challenging to quantify are Staff Attitudes, which included looking at components of Positive view of Consumers, Positive expectations of consumers and Strengths-based Language.

They note that Concepts of risk and trust appeared central to treatment decisions and differentiated two distinct models of recovery work: coaching and parenting. Coaching teams have high trust in consumers’ ability to self-manage and view the risks as low” noting that “ The majority of consumers on coaching teams would manage their own medications and receive more intensive monitoring if repeatedly demonstrating need. This approach seems closely related to staff beliefs that consumers are “like us” in fundamental ways and should be afforded the greatest freedoms possible. As in Davidson’s view, coaching teams function like the Home Depot motto: “You can do it. We can help.”

So, should all teams be striving to become more coaching/recovery-oriented? The answer isn’t as clear as one might think.

“It may be easy to see these programs as though one team is “good” and the other ”bad,” particularly in light of recovery concepts. But both teams expressed feelings of genuine concern and care for the consumers and took pleasure in positive events in consumers’ lives. And, there were some downsides to the coaching approach. The team’s hands-off approach may foster independence quickly, but at least one consumer reported that the process was too fast — the team believed the consumer was more ready than he did. Differences in staff and consumer expectations of need are common, even in teams that are actively trying to be more consumer-directed. Another difficulty was that the team struggled with maintaining fidelity to the ACT model over time. At the time of our follow-up visit, the team was in danger of being de-certified for infrequent consumer contacts. Although the less frequent contacts could reflect staff vacancies, it is also possible that the initial coaching drifted into a mild form of neglect with the team not intervening enough, perhaps in service of the recovery ideal.” 

I’ve touched on this issue in previous blogs – in Tough Gig I expressed my view that Perhaps the most important role of the team leader is to set the underlying direction for the team.  Is our team focused on long term recovery or are we more focused on medication treatment and stabilization?”  In the blog Forcing Treatment and addressing the issue of outpatient commitment I wroteI believe forced treatment is of value. I don’t believe my conviction in any way diminishes my firm belief in recovery principles and client-centeredness. At times it’s the illness, not the individual that’s making the decision to refuse treatment. The goal of forcing treatment is to allow the individual to find their healthy, true voice”.

Consider using Salyer’s paper for a team education session to look at how your team operates.  Maybe put out questions such as

  • Are we maintaining our recovery orientation?
  • Are we too assertive?
  • Does everyone on the team have to be of the same mindset?

I think leadership has to bring a recovery-orientation to the team, not as a mandate but as a guiding principle.  Otherwise teams can fall into the trap of becoming mobile medication clinics.  Medication is unquestionably necessary – if someone is psychotic they can’t really engage in meaningful work – but medication should never be an end in itself. (see my blog Ultimat-hmms?)

As always thank you for your time.  Happy Holidays!

Shalom Coodin MD FRCPC

November 29, 2017

Coexist

 

Train ’em and Pay ’em

Can mental health consumers act as teachers for mental health professionals? Should they? If so do they have the pedagogical skills to be educators?

In a 2014 paper titled Consumer involvement in the tertiary-level education of mental health professionals: A systematic review the authors look at the research on this. Interestingly the first citation is of a Judy Chamberlain paper – (see my recent post).

While it’s important to research how to best involve consumers in teaching perhaps it’s time to, as a certain footwear company recommends, just do it!

First we have to recognise the value of lived experiences. On the issue of what we call patients (yes, I am a physician and I still use this term to remind me of my role) I’m increasingly comfortable with the title of Expert By Experience (see my blog I Got A Name on this)   Consumer, client and patient all have validity.  But when a patient asks what I think they should do – whether it’s to use or not use a medication for example, or to try returning to work – usually, before me answering, I’ll point out that my patient is truly the expert. They’ve lived with depression, PTSD, anxiety, psychosis, addiction or all of the above.

It’s well past time for psychiatry residency programs to have included consumers as instructors.  I suggest a plan on how to do this.  Step 1 – Pay Them!  I don’t work pro bono, why would we ask consumers to do so? Step 2 – Train Them!  One of the fallacies in Medicine is that by virtue of going through medical school and then a residency that you automatically acquire teaching skills along the way.  That ain’t necessarily so.  I don’t really know if I’m any good as a teacher – I certainly would have valued learning more about how to be a better teacher.  Medical schools have increasingly recognized this, offering teaching faculty training in how to be better educators.Apple

Just being a mental health consumer or expert by experience doesn’t necessarily make one a good teacher. There are individuals who are better able to articulate and communicate than others.   We need to invite, entice and did I mention PAY those consumers and involve them in ongoing training, not one-off seminars.

I have no doubt that there are such individuals out there because I’ve met them.  We psychiatrists may not like all of what they have to say but that can make for more interesting conversations.

Can those with the most severe, disabling illnesses – ACT clients – be part of this? Yes, I think there are some.  And ACT clinicians, who know their clients so well, would be a great resource for identifying individuals who might take on the role of becoming educators.

It’s way past time.  As I near the end of my career I’m saddened to see so little having been achieved in my community on this.  Maybe the next generation.

Shalom Coodin MD FRCPC

Lobotomy Retro

In the April 16, 2017  New York Times online (free access) is an 11 minute video and article titled The Quest for a Psychiatric Cure, looking at the use of lobotomy.  Lobotomy FreemanWhile many of us know of the history its always jarring; what psychiatrists thought of as an effective treatment in retrospect turns out to be unthinkable!Lobotomy 1

It’s easy to focus on Walter Freeman and his freewheeling lobotomy road tours.  But in order to understand the history one needs to remember the context of the times.

Dr. Heinz Lehman, a Canadian psychiatrist, is remembered for having brought chlorpromazine (Thorazine in the US, Largactil in Canada) to clinical use.  In 1985 he gave a talk on The Introduction of Chlorpromazine to North America (which is well worth reading and maybe using for an ACT education session)

A somewhat long excerpt:

“I should perhaps give some sort of a feel of what things were like in the 1950s, just immediately preceding and immediately following the discovery and introduction of the psychotropic drugs. I was working at the Douglas Hospital in Montreal. It was a small hospital – not small in the number of patients, we had some 1500 or 1600 – but we had very few physicians and very few nurses, one registered nurse for 600 or 700 male patients; the others were all untrained personnel.

It was pretty horrible to work under those conditions: I felt the only way to keep morale up in the 1940s with the few doctors we had then – most had gone to war – was to do some sort of research. So I did all kinds of things, always convinced that psychotic conditions and the major affective disorders differed in principle from neurotic and personality disorders, and they, I was convinced had some sort of a biological substrate. So I kept experimenting with all kinds of drugs, for instance, large doses, very large doses of caffeine, I remember, in one or two stuporous catatonic schizophrenics – of course, with no results…  We experimented with an extract of the pituitary gland, which we thought might have some effect on psychiatric conditions. So I gave it to some of my schizophrenic patients. We kept good records of our patients then – actually daily progress notes – and there was suddenly, on October 16, you see a very long note, describing a miraculous, very dramatic improvement, almost overnight, from one day to the next: the patient was lucid, cooperative, rational, he had a different posture – it was dramatic…  So we had great hopes for this “extract 47,” until we found out, within a week or so, what had really happened: this extract had a high alcohol content! It just shows you that even with the best efforts and looking at all kinds of different criteria, whether they are rating scales or other criteria, one has to be very skeptical, before one accepts even dramatic results as being promising or novel treatments.

We did all kinds of other things. I injected sulphur in oil which was painful and caused a fever; I injected typhoid antitoxin intravenously which produced pyrexia in schizophrenic patients. Nothing helped; I even injected turpentine into the abdominal muscles which produced – and was supposed to produce – a huge sterile abscess and marked leucocytosis. Of course, that abscess had to be opened in the operating room under sterile conditions. None of this had any effects, but all of this had been proposed in, mostly, European work as being of help in schizophrenia. The best results I could obtain were with prolonged sleep, which Klaesi had introduced in the 1920s, but that was quite a dangerous procedure, because it often led to pneumonia and we did not have penicillin in those days. All this led to a lot of frustration but no discouragement. I kept on looking for something.”

I’ve read this article a number of times over the years and always end up humbled.  How, as a committed, caring mental health professional do you go to work every day in a hospital where there’s “one registered nurse for 600 or 700 male patients”.  How unimaginable to be one of the 700 patients suffering in such a place. Many ACT clients would have been in such settings.

Psychiatrists want to help and we are all too often faced with problems for which we do not have effective treatments.  This leaves us vulnerable to forgetting that critically important insight made by historian Leland Bell and which I blogged about 3 years ago in Cycling History.  Bell wrote how

” … institutional psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability.  A new therapy is introduced with great excitement and enthusiasm.  Sophisticated, detailed reports verify its effectiveness and show remarkable cure and improvement ratios.  This excitement and interest soon fade.  Follow-up studies and additional research challenge the initial reports and reveal that the therapy has limited applications, that it should be given only a modest place in psychiatry’s armamentarium.   Even the most dramatic therapeutics have followed this cycle of hope and disillusionment.”

These days there seems to be a lot of buzz around ketamine, an anesthetic used in veterinary medicine which may have benefit in treating refractory depression.  Authors of a recent JAMA review note that “Even these data are limited by the fact that most of those studies evaluated efficacy only during the first week following a single infusion of ketamine,” the authors caution.

It’s not that I doubt that ketamine, or deep brain stimulation or other ‘cutting edge’ treatments are of benefit.  I just think we should approach new treatments with a certain mindfulness (mindfulness is big these days), always keeping Bell’s words in the back of our minds.

Thanks for taking the time to read my musings.

Shalom Coodin

 

Remembering Judi

A week before the tragedy of 9/11 I attended the First International Congress on Reducing Stigma and Discrimination because of Schizophrenia held in Leipzig Germany.  At that conference I met Judi Chamberlin (click to read Wikipedia entry), an outspoken advocate of patients’ judi-chamberlinrights and a fierce critic of psychiatric labeling, of forced hospitalization and compulsory treatment.  I got to spend a bit of time with Judi and enjoyed hearing her thoughts.

Judi Chamberlin died in 2010 but her book On Our Own is still available. She didn’t pull her punches. In the introduction she writes:

George Orwell would find the language of the psychiatric system an instructive example of his profound understanding of how words can be used to transform and distort. Just as Big Brother uses benign words to mask totalitarianism, so does psychiatry use words like “help” and “treatment” to disguise coercion. “Help,” in the common sense meaning of the word, must flow from an individual perception of what is needed. There are many things that can be done to a person against his or her will; helping is simply not one of them.

I do not see psychiatry as a tool of social control; I see it as the area of medicine that deals with the most complex part of the body – 100 billion neurons with 100 trillion connections.  I also think it’s worth going back to the ideas Judi Chamberlin articulated; the need for persons with mental health issues to advocate for change, the importance of protecting the rights of individuals who may find themselves disempowered, the need for those granted power – especially psychiatrists – to always be aware of how they exercise iton-our-own. I still remain an advocate for forcing medication treatment(click to view previous blogs on this) in certain situations.

Listening to critics and critiques of what we do is of indisputable value.  Without reminders as to the dangers of labeling people (please consider reading my blog on APA -Best/Worst) , of the inherent trauma in what we must do at times, such as involuntary hospitalization, we lose a valuable perspective.

Mental health clinicians should come back to these periodically.  How about ACT teams have one education session per year to look at Judi Chamberlin’s criticisms of the mental health system?

Shalom Coodin MD FRCPC

 

Ultimat-hmms?

When do you “draw the line” in working with a client?  Is there a time when ACT clinicians have to put out a “you must – or else!” statement?

I think there are rare occasions where an ultimatum is understandable.  Mostly in my experience it’s been related to concerns of violence towards the team or others.

In a 1990 paper  titled The Use of Ultimatums in Psychiatric Care (Click to view) Dr Schwartz looks at this thorny issue.  While not directly addressing ACT I think the issues are very pertinent.

I believe in the use of contingencies but as Schwartz points out:

“The threat to end treatment is not just another contingency in the context of ongoing treatment.  When we make that threat, we invoke the final contingency available when all the usual contingencies we employ have failed.  At that moment we issue an ultimatum: “Either you do as I say [enter an alcohol treatment program, take this medicine, come to sessions regularly] or I will not work with you”.  Only the language of ultimatums captures the unique power of this moment…”

He goes on:

“An ultimatum can be very powerful indeed, but the particular nature of its power must be appreciated.  Often it represents an abuse of power or a disregard of responsibility.  Yet it may be the only way out of meaningless or harmful treatment.”

Schwartz then lays out 7 principles for consideration.  The first is, beyond ethical issues a reminder as to practicality.

“An ultimatum controls the psychiatrist’s future behavior and limits the range of responses to the patient”. ultimatum-cartoon

Ain’t that the truth – the ultimatum restricts the one putting it out there leaving them little choice as to what path to take next.  And using an ultimatum doesn’t exactly invite a collective problem solving approach now does it?

Another point:

“Do not neglect the potential gain in therapeutic alliance that comes from trusting the patient unless the trust is proven to be misplaced.”

I especially admire Schwartz’s sixth point:

“Be wary of institutional pressures to trust conventional wisdom over the patient’s understanding of his own needs”. 

Read the whole article.  Even better – present it to the team to read it together as part of an educational session.  Open it up for discussion. And let me know what you think.

Thanks again for stopping by.

Shalom Coodin

Seeing Everything

Nothing about me without me!

This idea of NAMWM should be a basic right for all users of health care including ACT clients.  But how to put it into practice? And how might NAMWM affect what clinicians record and  what clients get to read?

I have an interest in EMRs – electronic medical records – having been involved pts-logowith the design of the PACTwise database over many years.  I have some questions including this partial list:

  • Should EMRs incorporate ways for clients to access information?
  • Is it necessarily good for clients to see everything recorded?
  • Are there times when information should be withheld?
  • Will knowing clients are able to read what clinicians are writing change the way clinicians record information?
  • Are there differences between the clients and information recorded in an ACT program versus for example an oncology clinic?
  • Should clients have a way to record their own observations in the EMR?

Let me take these on one at a time.

Should EMRs incorporate ways for clients to access information?

Yes, yes, yes.  The courts in both Canada and the US have decided the issue – patients (clients) can request and must be provided with copies of their medical information.

Is it necessarily good for clients to see everything recorded?

Maybe not but the alternative – paternalistically protecting patients is probably worse in my opinion. In a 2010 report to the British parliament titled Equity and excellence: Liberating the NHS the authors note that “We want the principle of “shared decision-making” to become the norm: no decision about me without me. International evidence shows that involving patients in their care and treatment improves their health outcomes, boosts their satisfaction with services received, and increases not just their knowledge and understanding of their health status but also their adherence to a chosen treatment.”

Are there times when information should be  withheld? 

Maybe.  I do think there are occasions where clinicians should be able to record things that perhaps aren’t immediately shared with a client.  This violates the principle of NAMWM and maybe feels like a bit of a shaky answer on my part.  I’m open to discussion and need to think this one through more.

Will knowing clients are able to read what clinicians are writing change the way clinicians record information? 

Yes, probably.  Is that a bad thing? Probably not.  If I knew patients were reading my notes I’d likely be more careful, not in a politically correct way but in a more “sensitive to the effect of my words” way.  I think I can adjust.

Are there differences between the clients and information recorded in an ACT program versus in an oncology clinic? 

No.  To treat mental health clients as ‘different’ is to add to the longstanding stigma around mental health and mental illness.

Should clients have a way to record their own observations in the EMR?

Yes.  To create a portal to an EMR for clients by which they can read and access information in their record while denying them a chance to input anything seems misguided, giving an implicit message of “you can look but not touch!”  Clients should have ways to add their thoughts.  The goal need not be to turn the EMR into a kind of Facebook page with ongoing dialogues.  There can be a middle ground allowing clients to flag information they want to comment on without this leading to clinicians having to revise their observations and assessments.

Kevin, Roman and I will be at the OAA Act III – Beyond the Standards OAA International ACT Conference in Niagara Falls October 26-28, 2016.  If you’re OAA Logothere have a look for the PACTwise table and stop by.  We’d be delighted to meet you and hear your thoughts about EMRs, about ACT, about making things better.

If you haven’t registered for the OAA conference just click the logo at right to get the conference brochure.

Shalom Coodin

Down On The Farm

Recently I was listening to an interview on CBC radio – the Canadian equivalent of NPR – with Kay Parley. (Click image below to view the CBC website). At age 93 Kay recounts her experience of being admitted to a psychiatric hospital as a young woman – the same hospital where her father was a patient and where her grandfather had been treated.  While the webpage plays up the LSD treatment piece,Kay Parley Interview this is really an aside.  The more interesting elements of Kay Parley’s story, for me at least, were around her recovery journey and her discussion of how important certain professionals were.  She talks of how valuable it was to have recreation therapists who engaged her in tasks and of how important working on the hospital farm was for many patients.

I’ve met older psychiatrists who also spoke with real appreciation of the value of the farm work that went on years ago in the large psych hospitals of years ago.

Meaningful work is tremendously important for most of us including persons with severe and persistent mental illness.  At the same time I have very mixed feelings about the history of work in the asylums for which patients were rarely adequately paid.Farm work 1929

In teaching psych history I ask trainees to consider the case scenario below.  It could also be used for an ACT teaching session, maybe facilitated by the vocational specialist on the team.

Consider listening to the Kay Parley interview – it’s really quite interesting.

Shalom Coodin


Case Scenario:  It’s 1930.  Dr. David Young, medical superintendent of the Manitoba Asylum ( or insert name of large hospital in your area) has died and you’ve been asked to take over the role.

One of your first challenges is to make a decision around the Asylum’s farm facility.  For years patients have performed a variety of  tasks and such activity has always been considered therapeutic.

Several labour unions have threatened to protest in front of your office and to launch legal action unless you put a stop to the practice of making patients do unpaid work.  While you point out that patients are never forced to perform work, the union reps are unmoved.  You’ve appealed to the provincial/state government for funds to pay patients and this request has been repeatedly rejected.  (Keep in mind it is the Great Depression with roughly 30% unemployment across the country)

How would you address this?

Some additional questions to ask might include:

  • If rehabilitation is important isn’t it reasonable to press patients to work?
  • If lack of motivation is a symptom of schizophrenia might patients benefit from being encouraged to work?
  • What is the difference between rehabilitation and recovery?

 

 

Horror, guns, mental illness.

I have no special knowledge about what happened in Orlando this past weekend in which 50 innocent people were murdered and a greater number wounded.  It is unimaginably horrific.  There are no words.

I do not in any way mean to suggest that the Orlando killer was mentally ill.  This may have been just an act of evil.

The subject of severe mental illness and violence is a perennial one.  ACT clinicians know some of the issues, which are complex.  Consider reading  Metzl and MacLeish’s  Mental Illness, Mass Shootings, and the Politics of American Firearms in the American Journal of Public Health (2015 February).  The authors review the literature and

“critically addressed 4 central assumptions that frequently arise in the aftermath of mass shootings:

(1) Mental illness causes gun violence,

(2) Psychiatric diagnosis can predict gun crime before it happens,

(3) US mass shootings teach us to fear mentally ill loners, and

(4) Because of the complex psychiatric histories of mass shooters, gun control “won’t prevent” another Tucson, Aurora, or Newtown.”

The authors note that “… in the real world, these persons [persons with mental illness] are far more likely to be assaulted by others or shot by the police than to commit violent crime themselves. In this sense, persons with mental illness might well have more to fear from “us” than we do from “them.” And blaming persons with mental disorders for gun crime overlooks the threats posed to society by a much larger population—the sane.”

As a Canadian, where handgun ownership is rare, I’ve felt a certain distance from what goes on south of the border.  Yet the issue is one Canadians must confront as well.  Last month Justice Eric Macklin concluded that 23 y/o Matthew de Grood who in April 2013 went to a house party in Calgary and stabbed to death five young people – “was experiencing a psychotic episode at the time of the slayings.” And “that at the time he caused their deaths, was suffering from a mental disorder that rendered him incapable of appreciating or knowing that his actions were wrong” and concluded that “… Matthew de Grood committed the acts that resulted in the deaths of these five individuals, but he is not criminally responsible for those deaths on account of mental disorder.”

Does mental illness cause violence? Yes, but there’s far more to it. And is ease of access to guns the determining factor? It’s a factor but there’s far more to it!

Metzl and MacLeish conclude that:

… gun violence in all its forms has a social context, and that context is not something that “mental illness” can describe nor that mental health practitioners can be expected to address in isolation.

My heart goes out to all those affected by violence.

Shalom Coodin

June 12, 2016

 

 

 

Spring Has Sprung – And Fall Is Coming!

Spring has sprung but October will be here soon and with it the Ontario ACT Association’s biannual conference happening October 26-28, in Niagara Falls, Ontario. They recently posted a call for workshop and poster proposals for ACTT III Beyond the Standards.

There aren’t enough ACT-specific events out there and this conference is a rare opportunity.  The location is ideal for those on both sides of the falls to attend. Bonus is that an American dollar gets you $1.30 worth of Loonies (yes, that really is how we refer to the Canadian dollar coin).  Add visiting a few of the wineries in the Niagara area and you have a perfect conference/holiday combo.

Even better than just attending consider submitting a poster or workshop proposal (click to view the pdf for workshop and poster submissions).  Maybe have a look at my Aug 2014 blog titled Measuring Up.

My favorite ACT ethics article-see Bill’s Barbeque – is by two Ontarian ACT physician researchers (at least they were in 2006).  I still think teams should use this article once a year – take just a few of the case scenarios and add/embellish based on your team’s experiences.

OAA LogoFinally, kudos to the OAA for their tag line which, to my mind captures some of the essence of ACT work : “If we can, we must.” 

Maybe see you in the fall.

Shalom Coodin

Relativity Risk

Professor David Nutt, a British mental health researcher, surveyed addiction experts for their views on the risks of various drugs.  Dividing the issue into personal risk (i.e. harm to self) and social risk (harm to others), they assembled the results into a paper published in The Lancet in 2010.  The graphs below summarize the results.

Nutt - Mean Harm graph
Drug Harm Graph 1

Examining such a subject shouldn’t be a big deal right? Well, Dr Nutt’s Wikipedia entry notes that:

“…Nutt published a controversial study on the harms of drug use in The Lancet. Eventually, this led to his dismissal from his position in the Advisory Council on the Misuse of Drugs (ACMD)…  Subsequently, Nutt and a number of his colleagues who had subsequently resigned from the ACMD founded the Independent Scientific Committee on Drugs. “

The Guardian newspaper published an article on the work titled Alcohol ‘more harmful than heroin or crack’.

Professor Nutt challenged conventional thinking in pointing out that:

“We saw no clear distinction between socially acceptable and illicit substances. The fact that the two most widely used legal drugs lie in the upper half of the ranking of harm is surely important information that should be taken into account in public debate on illegal drug use. Discussions based on a formal assessment of harm rather than on prejudice and assumptions might help society to engage in a more rational debate about the relative risks and harms of drugs”

Others have replicated Nutt’s survey and come up with their own graphs that differ slightly.  A Scottish group did a similar survey and their graph looks like this:

Drug Harm Graph

Dr. Nutt has been an outspoken advocate for medicalizing drugs of abuse. In a blog entry a few years ago he writes:

“I strongly believe that we should focus on public health approaches to the drug problem, and decriminalise the possession of drugs for personal use, for the following simple reason;- If users are addicted then they are ill, and criminal sanctions are an inappropriate way to deal with an illness.”

How should this information affect and inform how ACT clinicians approach their clients?  Will  ACT teams in the future be providing certain clients with methadone? With needles for injection drug users?  Should they? If they did would they risk consequences such as losing funding?

What do you think?

Shalom Coodin MD