another IRT prequel…

Posted on Sunday 25 May 2014

re·cov·er·y    []
n. pl. re·cov·er·ies

  1. The act, process, duration, or an instance of recovering.
  2. A return to a normal condition.
  3. Something gained or restored in recovering.
  4. The act of obtaining usable substances from unusable sources.

In its effectiveness… I was fretting about the Individual Resiliency Training [IRT] that is part of the RAISE ETP Project. It’s a structured program for patients and families following the first episode of psychosis. Unlike the other things I write about here, I thought it was well-meaning and some people have obviously put a lot of thought into writing it. I’ve mused about what bothered me so much about it. The most obvious thing might be more about me than the point of the manual. I find myself put off when approached with that much structure – it feels distancing. It’s like talking to a drug rep who has something to sell, some direction he wants to take me in, and I feel like I’m talking to an background agenda rather than a person. But that might also be something I’ve learned about this particular group of patients, they’re always looking for the hidden meaning behind the words, even in very clear communications. And a lot of the modules have that feel – strategizing to get the patient to think some certain way. And strategies breed paranoia in this group. But that’s not all that bothers me.

Just like the word Resilience, I have some difficulty with the word recovery. I get that it means not psychotic anymore. But it implies that the patient used to be fine, normal, and then psychosis came, and the goal is to get back to fine again. I’ve seen a lot of these patients and had the privilege to follow a few for a long time [one mentioned in 1. from n equals one. [and 2. from n equals one, 3. from n equals one, etc]. When I’ve gotten to hear about the patient’s experience before the overt psychosis, things may have looked fine, but they weren’t at all fine inside. And with the families, there has always been a background worry, some kind of special vigilance for this particular child – not fine. Bleuler talked about that a hundred years ago, calling it the Schizoid Personality. It’s the thing Professor McGorry and others want to be able to identify – a pre·psychotic syndrome that could be treated before the outbreak of psychosis. I agree with their premise, but I don’t think we yet know how to do that. So I’m not arguing with the word recovery itself, but with the idea that there’s been a stable place to recover to. I see the psychosis as just the outward manifestation of an ongoing condition. And my best success has come when the patient can look back on those earlier days and address them as part of the problem.

What are those qualities that are often seen before and after a psychotic episode? Bleuler described them as shy people who replaced interpersonal experience with other pursuits, and were uncharacteristically explosive when frustrated. These patients often describe a predominant feeling of inner tension and "not fitting in" that has always been present. Their intuitive compass isn’t pointed by positive emotions, or directed by desires, but is rather driven by worries and towards ways to achieve tension reduction. They may edit the school paper or be a head cheerleader, but there’s no joy in the enterprise, just relief when it’s over. And identity formation, the task of adolescence, may be remarkably stunted. The patient above was in her senior year of college about to graduate Magna Cum Laude with a Liberal Arts degree, but had no idea what came next. The family sent one of her siblings on a visit to help her. Her sister got a legal pad and pencil and asked her to write down all the things she had been interested in or had thought about doing. The patient-to-be was paralyzed, thinking, "That’s what I am, a blank page." That was two years before her first psychotic episode. Three of Bleuler’s diagnostic "A-s" are almost always there before there are any signs of psychosis: Anhedonia, the absence of pleasurable emotion; Ambivalence, problems resolving conflicting emotions; and Abstraction, problems seeing the abstract meanings – sticking to the literal. Knowing in a felt way what you want is required for that intuitive compass I mentioned, and these patients to a greater or lesser degree just don’t seen to have such a mechanism in place. You will recognize that this paragraph might fill the bill for the "negative symptoms" we often read about – the ones medication doesn’t seem to help. If you look carefully, this stuff is there before the psychotic episode, though it may be well concealed.

The topic is the RAISE  Individual Resiliency Training [IRT] modules. They are trying to design a program that will help the patient manage or even make progress in these areas, to recognize the earliest signs of an impending psychotic episode, and to live more pleasure-driven and fulfilling lives. So what are the stressors that predispose to psychosis? It’s not just any old stress. It’s things in their areas of vulnerability – situations that require understanding abstract meanings or things that can only be resolved with emotional intuition. From my experience, emotionally ambiguous situations with other people top the list. And learning to recognize the signs of impending psychosis is hard work, because the signs invariably feel ego-syntonic – an integral part of personal experience. The patient I’m referring to came in one day several years down the road and announced her discovery. Whenever something in nature felt like it carried a special meaning for her – specifically for her – she was in trouble. For some of us, the thought, "It’s a beautiful day and that means I’m going to have an absolutely great day today!" might occur as a benign happy thought. But for her, it meant get on the phone [and she was absolutely right about that]. The reason I say "emotionally ambiguous situations with other people top the list" is that when we went back over the lead in to either psychotic episodes or "near misses" with this and other patients, that’s what we usually found.

Well, I didn’t quite make it to the Individual Resiliency Training [IRT] modules and what bothers me about them, but I’m a lot closer than when I started. I expect I’ll finally get there next time around…
    May 26, 2014 | 8:36 AM

    Thanks for your comments. There’s a lot for me to reflect on there. It’s really refreshing read what you have learned from years of carefully looking at the experiences of people and their difficulties and problems. It sure makes a change from what I see so much of these days in psychology and psychiatry, which is generally statistical distributions of various scores on abstract scales completely detached from individual experience.

    May 26, 2014 | 11:17 AM

    I agree, Adam. I think a lot these days about how we can balance these two things – empiric data with individual based observation and experience. I am just now re-reading Jaakko Siekkula and Tom Erik Arnkil’s book “Dialogical Meetings in Social Networks”. What continues to be appealing to me in this work is the ongoing interchange between the experience of the clinicians (and individual and families) and revisions to both practice and theory. One informs the other and nothing is really static – at least that is how I read it. (in addition, I just like the values and attitudes inherent to this type of approach).
    I think Mickey is getting at a question that is broader than this one topic – can we mannualize everything we do? How do we balance accountability and quality control with the great unknowns of what we do? I have observed and experienced the problems in going too far in either direction but I do not have a solution.

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