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2. Psychosocial Distress Signals and Triggers of Inadequate Allostasis
Outside of the observable signals of mental distress that can be elucidated in the clinical encounter, patients will often report psychosocial distress signals that further damage the quality of their lives. Psychosocial distress signals refer to difficulties in maintaining productive relationships (i.e., at home, at work, or in other social settings). These typically lead to psychological difficulties or the exacerbation of existing psychological problems.
Mary's unhappiness was partly related to being disengaged from her husband and not being able to communicate effectively with him. Also, Mary was working too much, not meeting her deadlines, and perceived by her coworkers and boss as withdrawn and unapproachable. She ruminated excessively and worried about her job and her marriage. Generally she felt unwell.
Mark isolated himself from his peers during his second episode of psychosis, and this isolation continued following treatment. He lost contact with his university friends. Mark remarked on how bored he was, and stated that he didn't do much other than smoke and meet once each week with his ACT team case worker.
Patients with life situations and problems like those of Mark and Mary often report many psychosocial distress signals. The common ones that I've observed in clinical practice include: (1) frequent difficulties at work, problems completing projects on time, delays in getting things done, and so on; (2) boredom, often associated with persistent ruminations and negative thoughts; (3) isolation from others, commonly associated with loneliness; (4) lacking a sense of life purpose; (5) not having close or caring friends and/or a social support system; (6) poor relational skills accompanied by frequent interpersonal conflict and a lack of quality interpersonal connections; and (7) financial problems.
The overarching phenomenon that prevents patients from correcting their psychosocial problems is their inertia in confronting them. Psychosocial problems won't go away by ignoring them, yet patients often erroneously believe that their problems will eventually resolve on their own without any active work or consistent efforts to change things.
Oppressive Forces That Promote Inadequate Allostasis
In addition to the mental and psychosocial distress signals just described, strong oppressive forces may undermine a patient's ability to achieve allostasis. This usually involves some combination of the following four interrelated domains: (1) the dominant mental health system; (2) psychotropic medication; (3) psychiatric diagnoses; and (4) family and friends.
This does not mean that all these domains are "bad" and unhelpful for every patient; rather, I am simply reporting observations and describing how these domains often operate oppressively to the detriment of patients under my care. These domains can weaken a patient's capacities for hope and enthusiasm, and undermine the belief that change is possible, thereby hampering the patient's efforts to reestablish allostasis.
1. The Dominant Mental Health System
I define the dominant mental health system as some combination of inpatient and outpatient medical services involving a psychiatrist, family physician, and other treatment members who have been charged with providing the majority of mental health care to an identified patient. If the dominant mental health system is needed (e.g., suicide prevention), it should only be a short-term commitment. I have concluded that the sooner a patient departs from the system, the better off he/she will be. When patients become more immersed in the dominant mental health system and get committed to it for an extended period, they are typically faced with increasing pushback, oppression, and an overall negativism about their recovery. This becomes particularly evident when patients question their current treatments, become empowered about self-care, seek providers outside the dominant system, and ask about "alternative" forms of treatment.
In Mark's case, he hated being on psychotropic medication and felt that it made him sick and progressively unwell. If Mark should voice his dissatisfaction to the clinicians overseeing his care, it has been my experience that such expressions of disappointment are usually met with oppressive and negative statements like:
"You need treatment for life."
"No other options can help you."
"This is the correct path and you should learn to accept it."
The after-effects of such statements often lead patients like Mark to become agitated, since their individual needs have not been validated, recognized, and/or handled empathetically. As a result, the prescribing clinician usually increases the dose of psychotropic medication or adds other psychotropic medication because he/she believes that Mark's behavior represents not only a lack of insight but also a need for more symptom-suppressive treatment (i.e., additional psychotropic medication).
Mark also participates in ACT, and should he question why he is being forced to take psychotropic medication, the pushback from the ACT team is something akin to: "You need medication for the rest of your life." While there are some very good ACT teams that do more than enforce psychotropic medication compliance and provide compassionate care, many of my patients have not been pleased with their ACT team experiences. Patients have repeatedly told me that their ACT team's focus has primarily been on medication compliance and not on their expressed individual needs. In one study, 4 in 10 patients with psychiatric disorders reported experiencing some form of leverage to adhere to treatment in the preceding 6 months. Medication compliance enforcement pressures may involve the criminal justice system, finances, housing, and outpatient commitment.5 This study also found that patients exposed to the most coercion were more likely to take their medications as prescribed, but had less satisfaction with their treatment.
A more publicized study, the largest randomized trial to date on the subject of compulsory community treatment, compared community treatment orders (CTOs; same as ACT) and Section 17 among patients with psychosis in England.6 The essential differences between patients on CTOs and Section 17 is that those on CTOs have longer periods of compulsory supervision. The results of this study did not show any differences in hospital readmission rates (36% for each group) despite the large differences in compulsory supervision (median 183 days for the CTO group compared with median 8 days for the Section 17 group). The authors of this study concluded: "The evidence is now strong that the use of CTOs does not confer early patient benefits despite substantial curtailment of individual freedoms."
Thus, it appears that forced outpatient treatment (as in CTOs or ACT teams) does little to improve outcomes and, more importantly, compromises patients' civil liberties. When patients like Mark become more unsettled and vocal about the way they wish to be treated, the dominant mental health system often becomes more controlling and oppressive to the point where, not uncommonly, patients lose hope and simply give up (i.e., after experiences that lead to "learned helplessness"). This typically happens over time as the patient's will and action to change are repeatedly ignored and disregarded, thus preventing the patient from receiving personalized care based on mutually respectful, nonjudgmental, and meaningful collaboration that considers each patient's individual symptoms, diagnoses, responses to treatments, and needs for support, encouragement, and competent care so that he/she can recover and live well.
The most egregious and dehumanizing form of oppression from the dominant mental health system results when a patient is involuntarily committed, forced to take psychotropic medication, isolated from family and friends, and kept in an unfamiliar environment for several days, weeks, or longer. Such violations of civil liberties can quash a patient's will to get better, or even impair a patient's will to live. Another unfortunate consequence of forced confinement and treatment is that emotional and physical trauma can be associated with such a harrowing experience.
I was once asked by an intern at the college where I work if I would attend a Consent and Capacity Board meeting at a hospital on behalf of her sister, who was diagnosed with schizophrenia and had been held involuntarily in a hospital facility for months. The family and intern wanted me to speak about possible alternative forms of treatment for schizophrenia. The hearing attendees included a lawyer who also happened be a psychiatrist, the patient's treating psychiatrist, family members, me, and members of the hospital administration. The patient was committed and forced to receive psychiatric treatment despite the fact that she had deteriorated while under the care of the hospital. She was kept in a locked unit and had not seen any family members for 6 to 7 months. Her mother was a psychiatric nurse, and despite her pleas at the meeting that the hospitalization and psychotropic medications were making her daughter worse, she was denied any access to her daughter. The hearing determined that this patient needed to be in treatment for another few months despite these pleas. I was never granted the opportunity to speak about possible alternative treatments for schizophrenia. The patient was eventually discharged after having been kept in a locked ward with dangerous criminal justice offenders for about 12 months.
A few years ago, I had a conversation with this patient's sister (the former intern) and was told that the patient is now thriving without any medication, working, and living a normal life. Apparently, upon discharge, the patient's mother slowly tapered her off her psychotropic medications. This was done despite major pronouncements and decrees that her daughter would require psychotropic medication for life. The patient returned to Iran, where extended family could assist in her recovery without threats of hospitalization and forced involuntary commitment.
While this story eventually had a happy ending, many patients I work with feel completely helpless trying to understand and cope with the dominant mental health system that they have been forced to comply with. It takes time, but some of these patients can divorce themselves from this system. Many eventually become healthier and more productive. For some patients, the damage has been too much and continued for too long, making it unlikely that they will sever their connections with the dominant mental health system. For this group of patients, the oppressive forces of the dominant mental health system will always be an obstacle undermining their chances of experiencing meaningful recovery and achieving effectual allostasis.
2. Psychotropic Medication
Psychotropic medications are often touted as correcting some underlying defect or "broken" biology that is adversely affecting a patient's mental state. The most common example is the much-popularized belief that a serotonin deficiency is causal in depression and that augmenting serotonergic neurotransmission will "correct" this "broken" biological system and hasten recovery from depression. Truth be told, there are no convincing data to support this popular belief.7 Psychotropic medications are not disease-modifying interventions when compared with other medications that conventional medicine prescribes for diagnosed diseases or pathologies. More appropriately, psychotropic medications are symptom-modifying interventions that "induce complex, varied, often unpredictable physical and mental states that patients typically experience as global, rather than distinct therapeutic effects and side effects."8 These unpredictable global psychoactive effects (i.e., sedation, psychomotor slowing, activation, and altered sense perception) are often associated with negative outcomes.9
While the judicious use of psychotropic medication can benefit some patients (especially if the number of medications is minimized and treatment is restricted to short-term use only), this is not what I have commonly observed. I have seen numerous patients lose their drive and enthusiasm while on psychotropic medications. Drive and enthusiasm are essential "energetic" components in facilitating recovery. Patients like Mark often have their recoveries impeded by the resulting medication-induced psychoactive effects (e.g., alexithymia, anhedonia, cognitive dysfunction, inertia, and mental fatigue), which thwart their motivational systems. It was apparent that Mark's "energetic" capacities for change were severely limited due to the psychoactive effects of his taking four psychotropic medications daily.
In more extreme cases, patients can become so unaware of these adverse effects that they begin to think that they are functionally improved despite how impaired they have become. Dr. Peter Breggin has referred to this phenomenon as intoxication anosognosia (i.e., medication spellbinding), which has been explained as a failure to perceive that one's irrational, uncharacteristic, and/or dangerous behaviors are being caused by the brain-damaging effects of psychotropic medication, and believing that the medications are helping despite obvious mental deterioration.10 I can recall a patient taking several psychotropic medications who deteriorated mentally over the course of 5 months under my care. She did nothing all day except watch television and listen to music. When I asked the patient about working, socializing, and exercising, she responded: "I am fine and feel well. I just like to relax all day. I like the way medications make me feel." I tried to help this patient for many months but could never provide any form of treatment that was capable of overcoming the demotivating and flattening psychoactive effects of the psychotropic medications that she was taking.
The example cited above demonstrates the ineffectiveness of psychotropic medication in facilitating recovery. When studies have evaluated patients more naturalistically (i.e., in a manner that is similar to office-based or outpatient medicine), the results have shown that the long-term use of psychotropic medication does not lead to recovery and is actually associated with worse outcomes for patients diagnosed with depression, bipolar disorder, and schizophrenia.11–23 For a more thorough review of the literature on the poor long-term outcomes associated with psychotropic medication, the reader is urged to review the work of Whitaker.24,25
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