on IRT, some comments…

Posted on Monday 26 May 2014

I recognize that in the last post [another IRT prequel…], I’ve stepped out of the general frame of Evidence-Based Medicine in that it’s the experience of a single clinician with a small number of cases. While it’s reinforced by my own teachers and patients, and from reading the writings of a lot of clinicians [Eugene Bleuler, Viktor Tausk, Kurt Schneider, John Cameron, Harry Stack Sullivan, Frieda Fromm-Reichmann, Otto Will, etc]. I acknowledge that it is a collection of opinions and observations rather than scientifically validated data – hard facts. I make no apology about that. I’m mentioning it just so you’ll know that I know I’m doing that generalizing-from-small-numbers thing that people like to criticize. I can’t think of any other way to express what bothers me when I read the Individual Resiliency Training [IRT] Manual. I expect I’ll continue in this vain in this post too.

Anticipating my negative reaction to the IRT  manual, Dr. Sandra Steingard who is more familiar with the RAISE program than I had this to say in her comment to its effectiveness…:
    I suspect the manualized approaches will be very helpful for some but not all and just getting the person into the room is a huge challenge… However, these manuals contain some useful guidelines on how to talk to people about psychosis other than just encouraging them to take their medications. .. Even if we hire more people to do the work, we need to give them some idea of what to do once they have their job and these manuals can help with that. In my experience, DBT worked that way. At first it was applied rather rigidly but now many of the concepts have worked their way into many aspects of what we do and the tools we try to give people to help them recover. However, if this increases resources and attention, I think that many well meaning and caring people will use the manual but end up not following it to the T; some of them are bound to look up and see the human being sitting in the room.
Which I agree with and would suggest the authors put verbatim at the beginning of the manual itself. I’m sure there’s no manual on the planet written in this structured, recipe-like fashion that I would personally like. It’s just not my style, so I’ll lay off on that score as a personal conflict of interest of my own. Drs. George Dawson and Bernard Carroll also had some useful comments. Said Carroll:
    I agree with George Dawson. This Individualized Resilience Training [IRT] looks like a dressed-up, manualized version of training for coping skills plus supportive-psychoeducational therapy, plus case management. What’s remarkable is that it is presented as something new. …the description smacks of armchair planning of services for nice clients by nice mental health administrators. Will they do a demonstration trial within the Los Angeles County jail?
I sent the IRT Manual to Dr. Pat Bracken of the Critical Psychiatry Network who is in West Cork, Ireland. He responded:
    I’d be surprised if there were any consumers [service-users] involved in this. Its language and orientation is far from the material produced by consumer-led organisations such as the Icarus Project. It is very much a product of the ‘technological’ mind-set that dominates psychiatry and psychology. The assumption is that mental health problems can be analysed in the same idiom we use to analyse endocrine or cardiology problems. Even ‘fun’ is a technical issue here, patients will receive education on the ‘three stages of fun’ The writers of the manual are very much the ‘experts’. This is the starting point. The patient is rendered passive in this move. They are to come to sessions to be ‘trained’ as though they have little to contribute themselves. There is no ‘critical thinking’ in operation, no questioning of assumptions about the nature of psychosis, the limitations of medications, the questionable expertise of psychiatry etc. It is very confident in its message: ‘we know how to teach you about resilience’. There is no room for uncertainty here. In my experience, this is simply inadequate. It is much better to start with doubt, with questions, with openness. This allows the very many patients who are struggling to make sense out of their psychotic experience to make contact and to engage. The IRT approach will chase people who are questioning away. There is no mention of ‘culture’ in this document, no acknowledgment that religion, spirituality, creativity etc are often bound up with psychotic experience… Again, this is inadequate. I hope these comments make sense! They are initial observations after a quick read through. I don’t think I could face really reading the whole thing carefully!
I really appreciate his response. I obviously picked Dr. Bracken because his sensibilities are close to my own. I’m not trying to hide behind him. I just know him to be someone who can articulate things with refreshing clarity. He didn’t disappoint.

I agree with them all. The only thing I would add is that the Individual Resiliency Training [IRT] Manual didn’t seem to me to be written with the target population in mind. They address the topics of people recovering from psychosis, but they don’t seem to know them very well. That’s why I wrote another IRT prequel… first. This is a population of patients that often don’t know what they want, where they’re headed. So starting the sessions asking them about their goals is ill advised ["That’s what I am, a blank page"]. The authors of the manual obviously are the ones with the goals. Trying to tease those goals out of the patients can reproduce a problem rather than solve it – the author’s intent. It’s a strategy, and strategies are particularly virulent here. The patients pick up on being subtly lead somewhere, often don’t intuit where, and become mistrustful [paranoid]. So with this, of all groups, communications need to be clear, direct, and honest. The basic rules "never ask a question the patient can’t know the answer to" and "don’t use questions to make statements" both apply. And then there’s the Ambivalence thing. Questions are for exploring.

Speaking of honesty, again  with this, of all groups, "honesty is the  best  only policy." For example, on page 181 under Summary Points for – What is psychosis?, the manual includes:

  • Scientists believe psychosis is caused by a chemical imbalance in the brain.
  • Both stress and biology contribute to psychotic symptoms.
  • Biological factors contribute to this chemical imbalance in the brain.
I doubt the authors really know that, or even believe it. I expect the motive in putting it there is to simplify things for the patient. But there’s nothing we know about Schizophrenia that’s "dumb." The Manual is filled with pseudo-expertise and, as Dr. Bracken rightly says, "It is much better to start with doubt, with questions, with openness." And when he says "questions," he means the explorative kind.

I won’t go on and on here. I expect I’ve really already said what I wanted to say in another IRT prequel…. I think the reason this doesn’t feel like something new is that it’s about training the patients, yet it’s not informed by the patients themselves or what we know about them. What would be new would be to organize this around learning together rather than how to train them. I agree with Dr. Steingard that these clinicians need something to go on, but I think we’d be much more effective if we tried to train the clinicians in the ways of these specific patients. The manual may offer a road-map to some of the areas in need of exploration [and some of the examples are useful]. But if the point is to teach the clinicians to do their jobs ["many well meaning and caring people will use the manual but end up not following it to the T"] and the hope is that "some of them are bound to look up and see the human being sitting in the room," why not start there in the first place?

This RAISE program is a good idea. It gives these patients some time to work with clinicians who can get to know them. The clinicians aren’t "dumb" either. We need to support them not as trainers with a training manual, but as people who have been given the tools to engage their patients, and learn with them what might move things along a helpful path…
    May 26, 2014 | 1:10 PM

    Well put. This is why – at least in my mind this is how I imagine it – in our clinic I want to try to start with network meetings modeled after Open Dialogue and reflecting therapies. Everyone is brought in and we start with just trying to have everyone give voice to the problem. Them telling us rather than us telling them. I find it fascinating to know that the innovative rehab program introduced by George Brooks at Vermont State Hospital in the 1950’s, which was the basis of Courtenay Harding’s ground breaking long term study in the 80’s (2/3’s living full lives in the community, 50% on no medications, another 25% using them intermittently), was predicated on a non-hierarchical approach. Brooks brought in the patients and asked them what THEY needed in order to be able to be well enough to leave the hospital.
    I know I am saying mixed things – honestly I am trying to work this all out for myself and I appreciate your help here – but the technical approach of IRT can be brought in or put on the menu of things to consider. I just do not want to dismiss it. I have known people who have made use of cognitive techniques and if there is a way to enhance that individual trial and error approach, I do not want to ignore it. I am also interested in cognitive enhancement therapy.
    But in my notion of how to go about this, we will embrace the uncertainty and heterogeneity inherent in these problems.
    Alas, we are living in a world where these words are heretical.

    May 26, 2014 | 1:36 PM

    Thanks Sandra,

    I hope it helps. For the record, I left out a piece of Dr. Bracken’s response because I thought you might mention it.

    I would contrast this with the approach to the treatment of psychosis developed in Finland under the heading ‘open dialogue.’. This works to draw out the expertise of the patient and his/her social network. Professional expertise, diagnoses and anti-psychotic drugs are deliberately ‘held back’ to allow this to happen.

    I would also contrast the IRT approach with that of the Hearing Voices Network. Again, this is about allowing a different sort of knowledge and expertise to emerge around psychotic experience.

    Steve Lucas
    May 26, 2014 | 3:02 PM

    One of the many problems of looking in from the outside is a lack of expertise or the ability to verbalize a sense that something is wrong. Following the discussion and having glanced at the IRT material I feel this best covers the issues I could not put my finger on.

    So much of life today is set in some type of manual format. We start here, make this statement, get this response, and then move on to the next step. I frustrate salespeople because I often know more about what they are selling and how to sell it than they do. Tell a person you want to bottom line a deal and they are left speechless since they have not moved through all their steps.

    I also appreciate the focus on the patient. Patients are smart. They often know what is wrong, and also know how to manipulate the system to achieve their desired response. Family and friends also, when being honest, can give important insight into a person’s state of mind.

    This is again way beyond my expertise, but I do find it “fascinating.”

    Steve Lucas

    May 27, 2014 | 1:50 PM

    I agree with practically everything said in this thread so far. Just want to add that treating “resilience”as a thing, as an individual quality, is problematic. We narrative therapists think that it is more useful to think in terms of relational processes than in terms of individual qualities. What IRT deals with as resilience, we would unpack as a whole network of relationships of reciprocal support—family relationships, educational relationships, financial relationships, social relationships, etc. People labled as resilient, in my experience, invariably participate in richer relationship networks and have historically experienced more support than people labeled as something other than resilient. Focusing on resilience as an individual genetic or intrapsychic attribute is a political act in that it directs attention toward personal, individual responsibility and away from collective community responsibility.

    May 27, 2014 | 7:27 PM

    It seems to me this is another one of those patronizing top-down approaches that undermines anyone who already has the capacity for autonomy. In addition:

    For example, on page 181 under Summary Points for – What is psychosis?, the manual includes:

    – Scientists believe psychosis is caused by a chemical imbalance in the brain.
    – Both stress and biology contribute to psychotic symptoms.
    – Biological factors contribute to this chemical imbalance in the brain.

    What the heck is the “chemical imbalance theory” doing in this current project from NIMH?

    Some people just cannot let go of their unfounded beliefs.

    May 27, 2014 | 7:38 PM

    It’s not a belief, Alto, it’s a script intended to get people to behave a certain way.

    May 29, 2014 | 5:07 PM

    That makes it a lie and a manipulation, Steve. Is this a good foundation for a therapeutic relationship? Is this something that should be “manualized”?

    May 31, 2014 | 5:49 PM

    From: [altostrata]
    Subject: Inappropriate language in RAISE project IRT manual
    Date: May 31, 2014 2:48:08 PM PDT
    To: nimhinfo@nih.gov

    Please forward this note to Thomas Insel and Pamela Hyde, SAMHSA Administrator, regarding the RAISE project.

    I am deeply appalled that the Individual Resiliency Training manual included in this project and funded by US taxpayers instructs mental health staff to explain psychosis to patients in these deceitful terms (as quoted and discussed by retired psychiatrist Mickey Nardo here http://1boringoldman.com/index.php/2014/05/26/on-irt-some-comments/):

    For example, on page 181 under Summary Points for – What is psychosis?, the manual includes:
    • Scientists believe psychosis is caused by a chemical imbalance in the brain.
    • Both stress and biology contribute to psychotic symptoms.
    • Biological factors contribute to this chemical imbalance in the brain.

    The “chemical imbalance” theory is groundless and has been utilized only to persuade patients they have an intrinsic biological disorder that must be treated by drugs forever. It’s a disgrace that this dishonest manipulation appears in a manual intended to improve treatment for psychotic patients. Is this any way to establish a trusting therapeutic relationship?

    NIMH and SAMHSA should not be devoting any effort to promulgate this misinformation. Whoever reviewed and approved this material should be fired.



    May 31, 2014 | 8:03 PM


    More power to you.

    I mean this in the good way it is used, not the insulting one.

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