What does Best Practices really mean when it comes to Mental Health treatment?
I have experienced heartache, grief, hallucinations, and the chaos of my mismanaged altered state on my personal and academic life as a student. I think all too often people forget that those living with a mental health disorder, diagnosis, or issue with their health are unique and singular in the expression and needs as individuals, and people ingratiated into a large system of care. We all require different forms of treatment, support, and often help. This is why I will never understand why there are so many niches and cliques out there championing mental health reform yet disabling the voices of people with different sets of needs, opinions, and ideas on how to advance the discourse further. Our voices are diverse and should be diverse. Our voices should reflect our needs as professionals and consumers.
Only when needs are truly articulated will professionals, and peers alike, reform the system progressively. It is up to all of us, to be clear about our needs, and throw our support to ongoing research to drive the discourse of mental health for all people needing understanding forward (Speed, 2006). This is why I believe, and still do, in bridging the gaps not only in academia, but among the prosumer, peer, and professional community of all people interested in improving the mental health system, with or without a diagnosis, requiring medication or just a supportive friend. Our voices must be as diverse as possible, instead focused on the agents which limit and marginalise us further away from our goals and dreams of tomorrow (Relojo, 2018).
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 (Mangnall & Yurkovich, 2008). There must be a decisive change in their treatment pathway and course of therapy. This course of action takes place when we continue the same treatment and wait for progress or halt care in favour of a more restricted treatment setting e.g., in patient or more intense treatment milieu, continues to a big source of conflict in the mental health community (Form, 2012). 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 hospitalised 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 hospitalisation 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-centred, 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 scepticism 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, a ‘third wave’ behaviour therapy approach with a supposedly ‘expanded perspective on how to guide clients to skilfully 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 (e.g., Hayes et al., 2006), who experience affective dysregulation from a new or existing anxiety, posttraumatic stress disorder (PTSD), depression diagnosis and/or deep interpersonal conflict (Boltivets & Relojo, 2019). 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 diffusion; being present; and self as context. When all of these targeted modalities are mobilised 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 behaviours (Caleb et al., 2019). 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 behaviour (Schoendorff & Steinwachs, 2012). This chain reaction yield, what ACT terms, the behavioural 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 minimise 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 utilised 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 (Gagani et al., 2016). The next wheel I like to suggest isn’t so inventive is active cognitive diffusion (Dobrev, 2001). Even more problematic, cognitive diffusion, 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, contextualising the self in more meaningful and meaning- laden terms is what we are already doing as therapists (Kuha et al., 2018). 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.