‘Madness’, psychotherapy and medication

Notes from talk delivered 26th February at Open Learning Ireland

Topics

0 – Stats
1 – History of mental illness treatment
2 – Modern ideas about mental illness
3 – Psychiatric / Personality disorders
4 – Diagnosis
5 – Psychiatric Medication
6 – Different types of treatment practitioner
7 – Different types of therapy
8 – How to find low cost treatment
9 – regulatory bodies
10 – low cost counselling services
11 – What psychotherapy is actually like
12 – Mental wellness

Stats

* In Europe, one in five persons will develop a depressive episode during their lifetime
* Mental health problems account for up to 30% of consultations with general
practitioners in Europe
* Depression is a condition that shows a genuine increase. It is also increasingly
affecting adolescents.
– HSE – http://www.healthpromotion.ie/hp-files/docs/HSP00612.pdf

HRB Phone survey
* 10% of Irish people has spoken to doctor about a mental health issue in the last year
– HRB – http://www.hrb.ie/uploads/tx_hrbpublications/HRB_Research_Series_5.pdf

Suicide is the leading cause of death amongst young men in Ireland
(at least one man commits suicide every day)
* men four times more likely to die by suicide (over 80% of all suicide deaths)
* 525 officially recorded in 2011 (increasing year on year) – true figure closer to 600
– RTE News –
http://www.rte.ie/news/2012/0711/328736-recorded-suicides-rose-7-last-year-cso/

* 25% of all disabilities due to mental illness
* 2007 (most recent year available) over 20,000 admissions to psychiatric treatment in Ireland
– of those – Schizophrenia, bi-polar, alcoholism and drug related are overwhelming majority
http://www.dohc.ie/statistics/pdf/stats11_psyc.pdf?direct=1

Over 80% of homeless people (in one survey, of 38 participants)
http://www.drugsandalcohol.ie/19140/
– worth noting that in USA service provision (‘Supplemental security income’) puts people on permanent disability
http://thelastpsychiatrist.com/2010/11/the_terrible_awful_truth_about_1.html

History of treatment and understand of mental illness
– seems like immutable concept

Greeks / Romans
– somatic causation
– humours / emotional illness – humorism / 4 humours
(sanguine (blood), choleric (yellow bile), phlegmatic (phlem) and melancholic (black bile))

Middle ages (in Christian europe, Arab world more civilised – first psychiatric ward, Baghdad beginning of 8th century)
– evil spirits (combined with humours)
– possession
– punishment for sin
– the idiot and the lunatic
– treatment: exorcism, purges, blood letting, whipping, drinking ice water
http://mentalillness.umwblogs.org/middle-ages/
http://www.jstor.org/discover/10.2307/3879623?uid=2&uid=4&sid=21101719523301

Mid 14th century (in UK)
– legal protection for ‘lunatics’ (mentally ill) and ‘congential idiots’ (mentally handicapped)
– family care (in the community) or crown
– trial (inquisition – but not the nasty burny one / more like modern jury) involving community, family and individual
– ‘Unlike today, care in the community was a communal activity that ensured a truly public provision for those who could not look after themselves.’
– Roffe & Roffe, 1995 – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539103/
– Somatic origin, diagnosis (memory, general knowledge and understanding), legal necessity (land and property)

16th century
– Disease model of mental illness emerges
– image – extraction of stone of madness (from late 15th century)
=> equivalent of psychic surgery (also trepanation)
– Differentiation of ‘degree’s of insanity – e.g.: dementia and delirium
http://www.slideshare.net/mikisdad/restraint-to-recovery-asylum-to-acceptance

17th century
– enlightenment / agricultural revolution – control & the state
– confinement of the poor / outsiders
– puritanism / immorality (choice) / spiritual malaise
– homosexuality
– punishment
– entertainment / bedlam – rebuilt bethlehem hospital

18th century
– ‘humane’ treatment
– for profit private madhouses
– moral treatment / friends retreats (Quakers) – farm work

19th century 
Talk therapy and THE BRAIN (Phineas Gage)
– fundamental split between views of the person

– intelligence / immigration / psychometric testing
– ‘mechanical restraints’ (chains, irons etc)

‘hot and cold baths’, ‘bath of surprise’ – calming effect

– subject of medicine

20th Century

– “It was only after the development of the hypodermic
syringe that it was possible to give patients a drug without their consent”
(Thomas Bewley, a History of the Royal College of Psychiatrists)
http://www.rcpsych.ac.uk/files/samplechapter/madnesstomillnessschap.pdf

– eugenics / sterlization
– insulin shock therapy
– ECT – 1938
– pre-frontal lobotomy
– ‘chemical cosh’ – ‘Neuroleptic’ antipsychotics

Late 20th century
– disestablishment of the madhouse / care in the community
=> facilitated by antipsychotics
– group homes / halfway houses / for profit & non-voluntary charity
– multiplicity of perspectives

Mental Illness Today
– massive mental health industry – US centred – controlled by psychiatry and pharmaceutical companies – geared around US insurance system
– psychiatric / neuropsychiatric vs clinical psychology
=> epidemiology and neurochemistry and brain imaging vs experimental research
=> more cynical – dumbest medical graduates vs smartest humanities graduates

– anti psychiatry / expert by experience
– culture & health – situated mind – soma, brain, mind, society, environment
– post-freudian – object relations, systems models, transactional models – meaningful symptoms
(identified patient)

What is mental illness / disorder ?
– harm to self and other
– ‘distortion’ in thinking / reality testing
– anomalous behaviour
– difference that causes dysphoria
– misadaption of individual to society

Psychiatric Disorders
– Schizophrenia (highly heterogeneous)
– positive – delusions, word salad, auditory hallucinations
– negative – catatonia, flat affect, anhedonia, asociality, avolition
– causes – variety of psychosocial factors, genetic propensity

Major Depressive disorder
– low mood, self esteem, anhedonia, energy
– causes – variety of psychosocial factors, genetic propensity

Personality Disorders

– Narcissistic – core deficit in self worth, extreme sensitivity to criticism, excessive feelings of self importance, selfishness, fantasies of success, exploitative, unempathic

– Histrionic – highly emotional, melodramatic, seductiveness, focus on appearance, rapidly changing emotions

– Borderline – lack of certain self, highly volatile emotions, impulsivity, inappropriate anger – strongly polarised and changeable view of others, feeling alone – substance abuse, self harm

– arbitrary distinction
– strongly comorbid (BDP, histrionic, narcissistic)
– dubious utility of diagnosis

But diagnosis is by no means confined to these disorders

Diagnosis
– DSM, ICD
International Statistical Classification of Diseases and Related Health
Problems (World Health Organisation)
The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association)

In DSM-IV, clinical disorders are listed on 3 separate axes

Axis I – principal disorder – ‘what walked in the door’ – e.g.: depression, panic attacks
Axis II – personality disorder or developmental disorder – ‘shaping response’ [Not causing?] e.g.: narcissism, paranoia, mental retardation
Axis III –  relevant medical or neurological problems [NOT TESTED FOR]

Axis IV – major psychosocial stressors e.g.: death of spouse
Axis V Global assessment of level of function [ / conformity]

– straight away we can see conflation of symptom and disorder
– cause and effect – syndromal mental illness
– underlying causes are dimensional and mutifactorial
– geared around diagnosis (rather than treatment) – for insurance
– ‘psychosocial’ factors (i.e.: meaning, only considered as stressors)
– utterly decontextualised

Tested for via tests normalised with diagnosed clients
– tautological

– encroachment of DSM – Oppositional defiant disorder (hostility toward authority figures, angry, spiteful, resentful), conduct disorder (rule breaking, truancy, drug use, vandalism) – selective mutism,  In IV-TR

– DSM-V controversy (finalised last december)
– increasing pathologisation of non-normative behaviours – medicalisation of social / familial problems
– effort to legitimize diagnostic criteria with reference to extremely premature / tautological neuroscientific research
– bereavement no longer excluded in depression diagnosis
– e.g.: hypersexual disorder – distress inducing extreme amount of time devoted to sexual behaviours
– olfactory reference syndrome – excessively preoccupied with body odor
(worth noting halitosis and bo are socially constructed)

Psychiatric Medication

– SSRI’s

  • e.g.:Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Fluoxetine (Prozac, Prozac Weekly, Sarafem)
  • Paroxetine (Paxil, Paxil CR, Pexeva)
  • Sertraline (Zoloft)
  • Fluoxetine combined with the atypical antipsychotic olanzapine (Symbyax)

– relatively benign – work by maintaining levels of serotonin in the synaptic cavity
– sexual dysfunction, increased risk of suicide especially in children / young people
– withdrawal – ‘discontinuation syndrome’ – dizziness, shocks, diarrhea, fatigue, resumed / worsened depression, irritability, gastric distress – similar to withdrawal from MDMA

– antipsychotics/ neuroleptics
e.g.: Haloperidol / Halidol, Clozapine, Zotepine
– side effects
– with ordinary pharmaceutical side effects can often be listed which occur in a tiny proportion of users – for some side effects, and in some dosages neuroleptics inevitably cause them
– structural brain changes – loss of grey matter, brain shrinkage, decreased neuronal density
-memory, attention, appetite / major weight gain / diabetes (through insulin level)
– permanent central nervous system damage tardive dyskinesia – twitchy uncontrollable facial and other bodily movements
– increased risk of stroke
– restless movements – akinesthesia
– withdrawal – high rate of recidivism – in addition to psychosis,
– mechanism of action – blocking dopaminergic (and in case of atypicals) additionally serotonergic
– Abusive use common – residential care in dementia, mentally handicapped, prisoners (USA juvenile detention, foster homes (more than half) – anywhere with socially beneficial sedative effects
http://healthland.time.com/2011/05/26/why-children-and-the-elderly-are-so-drugged-up-on-antipsychotics/

– interaction with nicotine
– may help offset some of the working memory / attentional deficits
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2702723/

Efficacy – dubious – control rather than cure – cochrane reports (schizophrenia, bipolar)
– WHO studies – outcomes better in African nations (prior to antipsychotic use) –
– huge issues in pharmaceutical industry funded studies – discontinuation of medication (prior), very high drop out rates etc
– atypicals do not as promised as reduced side effects

Psychiatrist / Psychotherapist / Clinical Psychologist / Counsellor
– Psychiatrist – a doctor with postdoctoral qualification in psychiatry
– focused traditional on neurochemistry / prescription
– may / may not have psychotheraputic training

Clinical Psychologist
– Psychology graduate with post graduate PHD in clinical psychology
– focus on disorder, assessment, research based efficacy, cognitive methodologies

Psychotherapist
– Psychology graduate with post graduate qualification in psychotherapy
– talk therapy

Counsellor
– Diploma / degree level in psychotherapy / counselling
– emotional difficulties – personality disorders
– talk therapy

Types of therapy

Psychoanalysis
– object relations, family systems, gestalt, existential
Cognitive Behavioural Therapy / Rational Emotive Behaviour Therapy
Person Centred Therapy
Body Work
Art based therapies

– different therapies differ in their ‘way of being, way of intervening, way of understanding’
– way of understanding – origins and meaning of symptoms
– way of intervening – treatment
– way of being – how therapist relates to client
– efficacies similar

3 major – approaches distinct
=> CBT – cognitive distortions, homework, new strategies, alter conditioning
– computational metaphor
– therapist engaged helper
=> Psychoanalysis – ‘depth work’ focus on defences, impact (CT) of client, understanding roots of distress, insight and reparative reparenting
– forces metaphor
– therapist passive listener
=> Person Centred – client directed open conversation, focus is on emotions
– growth metaphor
– congruence, empathy, unconditional positive regard
=> Bodywork – hands on massage, breathing techniques (holotrophic breathing)
– In practice – most modern therapy is -> Integrative

What is therapy like

50 – 60 minute session, weekly
6 or more sessions
Just 2 (unless group therapy)
Therapist doesn’t want to trick you
There is no couch
Empathic conversation (possibly with homework)
You do the talking
Interventions are minimal and targeted
Good therapist – will never tell you what to do

Finding a cheap CERTIFIED therapist
– statutory regulation does not exist yet – pending
– Certification bodies –
Irish Association for counselling & psychotherapy (IACP),
Irish Association for Humanistic and Integrative Psychotherapy (IAHIP),
Psychological Society of Ireland (PSI)
The Association for Psychoanalysis and Psychotherapy in Ireland (APPI)
The Irish Association for Cognitive Analytical Therapy (ICAT )

Low Cost

– low cost counselling services (10 – 40 euro)
– services attached to colleges that teach

– Village Counselling Service – Killinarden, Tallaght
(limited sessions)
– Liberties Counselling Service (services liberties only)
– Tivoli Institute – city centre and Dun Laoghaire (15 – 25 euro, no waiting list)
– PCI College (10 – 25)

Finding an experienced therapist
– directories
– cost

Making a choice
– browsing is OK!

Wellness
– proactively looking after yourself
– positive psychology movement
– physical activity, social status, sociability, existential meaning

Research shows
– diminishing returns of wealth over ‘baseline’ (in US 75k) – in other words, you will be happier
– Social skills
– not intelligence (over 120 IQ) or
– not having children
– being female (especially in youth)
– being married
– being emotionally stable
– healthy strong social relationships
– meaning – derived from work or group affiliation
– practicing mindfulness
– learned optimism

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  1. […] the festival I prepared a talk on ‘Madness, Pyschotherapy & Medication’ (slides and notes). Delivering this talk, and discussing the issues raised with attendees, helped focus my mind on […]

  2. […] the festival I prepared a talk on ‘Madness, Pyschotherapy & Medication’ (slides and notes). Delivering this talk, and discussing the issues raised with attendees, helped focus my mind on […]



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