What does best practices mean when it comes to Mental Health treatment?

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As a psychotherapist, one of the most troubling aspects of providing safe, patient focused, effective therapy for patients in radically altered states is balancing the benefits of continuing with ongoing treatment due to increasing concerns of risk of harm from their compromised or shifting mental status. Let me be perfectly clear here, I truly believe some people have spiritual emergencies which can be treated with psychotherapy without medication and even with the support of a peer who has similar lived experience in the community without forced treatment. I am also a seasoned mental health therapist who knows when someone is an acute psychiatric crisis running the risk of self-harm or exacting harm to others as a direct or indirect result of their weakened mental status. There must be a decisive change in their treatment pathway and course of therapy. This line of when to continue the same treatment and wait for progress, or halt care in favor of a more restricted treatment setting e.g. in patient or more intense treatment meliu, continues to a big source of conflict in the mental health community. Practitioners are plagued with patient complaints, family petitions, and court orders which further complicate the provision of psychotherapy. In the end, most patients want the least restrictive and intrusive course of treatment available and rightfully so. 

The line I am referring to has been and continues to be outlined by the letter of the law and mental health laws in the US. These laws, for better or worse, make it as clear as day when someone is at immediate risk of serious harm to himself or others.  Upon crossing this metaphysical line in the clinical realm, these folks at risk of immediate harm need to be hospitalized and or assessed for further risk of harm. There really is no grey area here. To do otherwise is negligence. Of course, sometimes someone can be at risk of harming themselves, having a spiritual emergency, and still not require in-patient hospitalization or a psychiatric evaluation and observation. It doesn’t matter, though. When the risk is this high, we simply shouldn’t be gambling with life. Self-harm is the act of deliberately inflicting pain and damage to your own body. Think about it: as therapists, we assess risk all the time. If we are doing our jobs right and are truly person-centered, we should be using every technique in our toolkit to treat our patients where they are at regardless of how society views mental health diagnosis. Again, it doesn’t matter what the world believes a psychiatric label means in the context of providing therapy, what works and is the right fit for our clients in the context of their disorder and circumstance. However, somewhere along the way these new hot emerging trends in psychotherapy and peer work are being thrown around. They are the ‘in’ therapies, the hot new miracle modalities which are going to bring about better outcomes and are more humane.

I have made no secret about my skepticism in the clinical value of new research in mental health in the last decade. I am just not certain we are targeting the right areas or bodies of underdeveloped research and moving forward in the important or needed areas to truly impact mental health as a discourse or field of enquiry. ACT (Acceptance and Commitment Therapy) and other hot interventions like dialogical therapies, while sharing some commonalities, also share what has truly become a cancer in mental health research. This cancer, located at the metaphysical polarities of the clinical spectrum for accepted, empirical, and ‘evidence-based’ research, continues to eat away, and carve out the discourse of mental health treatment from within. Therapists are all talking about ACT (Acceptance and Commitment Therapy). ACT is a ‘third wave’ behavior therapy approach with a supposedly ‘expanded perspective on how to guide clients to skillfully self-regulate emotional distress and conflicting states of mind’, or at least, that is what all the literature suggests this new so called approach to same age old problematic experiences therapists encounter when treating their patients.

These are patients, according to the literature on ACT, who experience affective dysregulation from a new or existing anxiety, PTSD, depression diagnosis and/or deep interpersonal conflict. The theory behind ACT is a framework which posits through the application of a traditional mindfulness exercises and intensive psychotherapy targeting specific cognitive processes, the patient will experience relief through acceptance of private experiences; active cognitive defusion; being present; and self as context. When all of these targeted modalities are mobilized in the course of psychotherapy, patients supposedly become more flexible in their interpersonal kinship networks, and other interactions in their professional work and personal lives. Building upon the assumption that firstly, a positive increase in prosocial interactions will result in the cultivation of value-based behaviors. ACT theoretical underpinnings go a layer deeper. The literature suggests this algorithm for conducting therapy will yield further patient insight into their own personal set of values, developing a stronger commitment to positive action and behavior. This chain reaction yields, what ACT terms, the behavioral and cognitive activation which contributes to the success of patients experiencing therapeutic gains in the course of their treatment.

The framework of ACT builds upon basic mindfulness. While I doubt many therapists would minimize the importance of patients understanding basic mindfulness or even a nuanced deep and complex awareness of self-awareness tools, the use and validity of research confirming this existing modality is already widely accepted and utilized across the board by therapists in mental health. So, what’s really new then? Self-acceptance? I haven’t met a social worker, psychologist or psychiatrist that hasn’t, in the course of treating anxiety, depression, and PTSD, forgotten to teach self-acceptance strategies when the opportunity presented itself in the course of their patients’ treatment. The next wheel I like to suggest isn’t so inventive is active cognitive defusion. Even more problematic, cognitive defusion, which has patients confront or raise problematic areas of their dysfunction or conflict without affective state escalation or agitation isn’t even accepted as completely effective in treating the symptoms of these disorders.

I have seen first-hand, both experienced and inexperienced therapists clumsily use this technique, and sessions collapse shortly after as their patients unravel, become irritated, and begin to flood with emotion and negative sense memory. So, if this technique is so delicate and difficult to apply in practice, why incorporate it into this already complex and overly technical so-called ACT paradigm. I am assuming, much of this has to do with the assumption that ACT-trained therapists will go through rigorous training and attend every webinar possible throughout their careers and tenure or practicing ACT. The final two underpinnings are in my opinion, the basic skills taught in social work 101. Maybe I am missing something here? Or, just maybe, contextualizing the self in more meaningful and meaning-laden terms is what we are already doing as therapists. So many of these so called new and exciting modalities we chit-chat about at the water cooler and gloat about to our colleagues should already be in our tool kit for practicing psychotherapy.

Yet, when you break these new therapies down to their core theoretical underpinnings, they are no different, new or unique than what we already do as therapists. Unless you are grossly incompetent or were trained 50 years ago, who are these webinars and conferences for anyway? I just don’t get this hot fuss going around the practitioner community. Let me put it into greater context if it isn’t clear. I just read another training is being offered, this one called: ‘Making meaning from visions and voices: Supporting altered states’ in NYC.  The theory behind this training is to provide therapy and services for patients and peers which support their so-called altered states and understand that in some cases these seemingly difficult spaces for patients can be beneficial and powerfully creative having the potential to yield insight into their condition or particular circumstances. The training flyer makes it clear too that for some folks these situations can be quite disturbing and dangerous.

I seem to be unclear as to what’s new here in terms of practicing person-centered therapy. Are training like this one and so many offered out there truly for the public and not geared or targeting clinicians at all? If so, which I believe, they should be targeting the public. They need to be clear that this is for the general public and everyone can benefit from attending. Otherwise, clinicians like myself will find themselves sitting at the same round table discussing the same techniques and theories from graduate school. Maybe I am a brilliant clinician, or just maybe, I’ve taken the time to truly be person-centered, read a diagnosis for what it is, and apply my existing and ever broadening skill set to my patients and experience good outcomes without calling upon the buzz of a new acronym or miracle modality. I get it, we all do it, and want to talk about our skills in broad colorful strokes of positive regard, but we therapists should also be a little humbler and learn our craft from the moment we commit to the helping process. Instead, we blame our shortcomings and inability to successfully treat our patients on our incomplete education of new terminology and the next, ‘in’ therapy.

The acuity and esoteric nature of these hot, miracle modalities continue to overshadow what we practitioners are setting out to do. Instead of practitioners learning a vast, eclectic and broad skill set to treat all diagnosable or treatable conditions, the task at hand has become estranged from healing and the helping process. Alas, clinicians are boxed into a small physiological space for learning new research and identifying gaps in current mental health trends and community-based needs. In a sense, these mental health clinician-crats (and those that decide what techniques are in, and which are out ) are ruling out and marginalizing hope and healing for a segment of the population which could benefit and stand to profit from advancing research forward across the board and not limiting future data collection to the in treatments and those practiced by those with more influence in the field than intellectual credence.

Stigma is not just real – but is covert, overt and insidious. I have experienced it first-hand. The public really needs to understand mental health diagnoses for what they are and not label and ridicule people with psychiatric disabilities. However, we really truly do need to do some homework and conduct new and authentic valid research before saying this or that therapy is going to change the way we practice in this field. Otherwise, you are just offering vapid and vacuous CEU (continuing education units) and mis-calibrating the message to those in the field that we really need to revamp the manner in which we practice and provide the work that truly be done for our patients or peers. In terms of peer professionals, your self-awareness and insight into your disorder should be advancing research. Maybe the misperception or misunderstanding of what is really ‘new’ is my own. I really haven’t met too many people who have my particular diagnosis of schizophrenia and practice psychotherapy. But other people have had similar symptoms and have gone ahead and become practitioners too. 

Maybe these people I am referencing have never vocalized their lived experience due to the same stigma I just talked about. If this is true, then I suggest you need to be more open about your lived experience. As far as I am concerned, if you aren’t furthering the work that needs to be done, then you shouldn’t be in this profession which exists to help others. If you are holding back knowledge that can benefit others, why and how could you possibly profess to be helping them?

As a social worker, I sit on a vast, layered, and profoundly broader body of knowledge, theoretical understanding and foundation of information than some other more narrow-focused disciplines out there in mental health. This is why I believe it is up to social workers, prosumers (people with lived experience and professional training) and other more ornate backgrounds and experiences to jettison research into the next era. In order to truly help people, the mental health community needs to better define what “help” means for people with a mental health disorder. We work in a multidisciplinary field rife with different approaches and different languages all targeting the same issue, treating mental illness or mitigating the impact of the disorder by providing a service to people in the public mental health system. Maybe this is the problem. By in large, practitioners are working in isolation at the micro level within a larger system of care. This is a bit counterintuitive to reform an already mixed up way of managing the entire way we do things in mental health.

In the end, there are so many different perspectives on what constitutes best practice in mental health treatment. So, what is and is not best practice will continue to be hotly contested until the structure of the system is changed as well as what the system defines as common indicators of progress and what a good outcome is and is not. Thinking about progress is critical for both consumers and practitioners, as well as researchers and those with a vested interest in creating space in the field for creative pathways to empowering people with a diagnosis to be motivated in their recovery and truly track in their own terms, their success in treatment.

I am very serious about the set of propositions I am laying out here. This is part of a restatement of claims I have made before, but this article needs to signal a giant tectonic shift in how we do things in our field. 

So, who really is charged with appraising the clinical value of our research these days? Who is really validating the claims researchers are making? Scholarly work, studies, published papers – all of these outlets and mediums for disseminating good information in our field have bias. We must accept and own these biases. Peer-reviewed work, blinded, however we tell ourselves our work is pure, intellectually and ethically solvent, needs to be overhauled if not torn down at the very ground floor we built the discourse on before we can call ourselves truly unbiased, and platonic in our commitment to unassailable research in mental health. Let’s be totally honest here.

Endorsement of peer work in academia is as rife with political intrigue and back door funneling of money and funding as the White House. The difference with academia is that we refuse to talk about it. And there are no television dramas depicting our ethical and moral battles in the wings of institutions and library halls. Similar to the perseverance of our patients, we must redirect the very meaning-making and re-target the areas of research which aren’t talked about: the missing or underdeveloped areas of research which continue to confound and contest the very bodies of knowledge we hold as truly incontestable. Well, if we are really being honest about what we do in mental health, we would do just that. No modality, no study, no manuscript for submission is truly above reproach. There are taboo areas of how we do things as researchers that are problematic. 

If we do not overhaul and turn academia, pedagogy and practice on its head sooner rather than later we are headed for disaster. I would hazard to say the destruction of this field as we know it as an accepted discourse of intellectual enquiry. So, before it is too late, ask questions, continue to go against the current, until the very armamentarium of new research moves with us towards a brighter, healthier vistas of tomorrow. 

In therapeutic settings, therapists monitor the progress of their patients. This is done in several ways, depending on the type of therapy (for example, the modality, setting and treatment milieu) and needs to also be taught to consumers of treatment, so both practitioner and patient can work more closely and in greater clinical harmony. For most therapists, in private practice, or in the public mental health system, there are already methods of tracking progress, without using complex, cumbersome, and expensive treatment modalities to implement and train staff. But, ultimately, these measures, are clumsy and at times, disorganized approach to tracking recovery, and its converse, the over-intellectualized, ornate, and highly prescribed new, hip, modalities, which are so difficult to train with enough latitude to reach the mass base of practitioners, that identifying a common language to measure client and collateral reporting during interdisciplinary meetings, or even indiscipline collaboration becomes impossible and presents yet another impasse to treatment. 

The DSM-5, and other manuals, research, can only provide generic research for diagnosis, Meaning, research and prognosis is measured in broad strokes, and is based on studies, populations, circumstances, but is limited in its ability to truly put numbers and language around a person-centered prognosis for people with a mental health disorder. This is a problem for people who want to know what’s ahead, plan for it, and what to expect, in their own terms, while living out their life with a diagnosis. Underneath diagnosis, and even less researched, is rate-of-recovery, and the speed (duration of illness and the symptoms) of a person to experience progress and relief from their symptoms. I recommend, without further delay, immediate research and studies charged with the measurement of recovery, in very real terms, that truly allows patients and practitioners to know what to expect, when to expect it, and plan ahead so problems can be addressed before they occur.

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  • Article By :
    J. Peters writes on his lived experience, and also brings his story into his work. J blogs daily on his site mentalhealthaffairs.blog and for other sites around the United States and Europe, bringing his passion for mental health to consumers everywhere.

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