part four: the answers?…

Posted on Tuesday 8 July 2014

Families that communicate with Double Binds create children who often spend an inordinate amount of time in their lives trying to find solutions to problems that really have no solution [part one: the bind…]. To review the elements of a Double Bind: [1 & 2] Two mutually exclusive commands ["lose weight" and "clean your plate"]; [3] the injunction that you have to act; [4] the prohibition against addressing the impossibility of the situation. What does a "healthy" person do in that circumstance? In the words of the ancients, they "go between the horns." Said in other ways, they deny that [1 & 2] are the only possibilities; they break rules [3] and [4] by talking about the impossibility of the task, that neither action is correct [in this case, "silence is not golden"]. In the real world, the problem needs to be reframed in a more realistic way to look for solutions.

In the case of the challenging/disruptive intellectually impaired child, the Hamlet question, "to prescribe antipsychotics, or not to prescribe antipsychotics" is hardly the right way to formulate the clinical problem. Probably the first order of business is to explore the situation of the specific patient and the specific caregiver and the specific living situation to see if one can figure out what’s so upsetting, what’s wrong? Sometimes it’s something you can’t do anything about, but often it is amenable to change. Mentally retarded people are just like the rest of us – just less able to figure out and communicate what needs to be dealt with. Trying to control behavior with medication if there is ongoing conflict is a dubious enterprise. You end up with a sleepy conflicted person.

The next thing that comes to mind is that such things are rarely acute problems that need to be solved in a single visit. The challenging/disruptive behavior is usually chronic and deserves more than a one-shot decision – so there really is no requirement to act immediately – prescription or otherwise. And as for medication, we really don’t know the answer as to whether psychoactive medications like antipsychotics or anxiolytics are helpful in these situations [part two: the dogma…, part three: the questions…] – when or if to use them. We do know that the Dogma that they are helpful is not based in science.

But we also need to consider the situation I described earlier [part one: the bind…]:
    So you’re a doctor and a parent/caregiver brings a mentally retarded child to see you who is oppositional/challenging/disruptive in the waiting room and in your office. Then you look at the child’s parent/caregiver and you see a person hanging on by a thread, on the edge of tears, spent from dealing with this child. Maybe it’s a Foster Parent, one you already know to be a real trooper, about to give up return the child to DFCS…
This situation is one of the consequences of what’s been wrong in psychiatry and mental health care in general as it has evolved in recent decades. It’s a common problem and what people do has been heavily influenced by the short-session ways of managed care or the pill for every ill meme of the pharmaceutical industry. We ought to be ashamed of ourselves for going along with this superficial approach to something that can be a compelling 24/7 problem for both the patient and the parent/caregivers. In my opinion, this is actually an example of a major failing of our National Mental Health Institute – taking on the real world problems of mental health workers and families with impaired children. A few well designed retrospective and prospective, unbiased studies could provide all the answers needed to give our Double Bound doctor and his patient[s] a path to follow that actually goes somewhere. And this is not just a problem for the biomedical among us. It’s time for the behaviorist or the social worker to get into the act too. Tyrer et al say:
    "Good randomised trials, preferably not funded by the drug industry, are needed to show efficacy. At present there are no randomised trials with adequate numbers that can give definitive advice on the value of any drug group in this population."
While I agree with them, they are still constrained by too limited a question, "to prescribe antipsychotics, or not to prescribe antipsychotics." What is the right thing to do in this situation? Where can the caregiver/parent turn to best approach the problem? What’s wrong with medication? What are the alternatives? I’m no fan of guidelines because they are so vulnerable to bias, but this may well be a situation where a well thought out white paper might really help.

We’re still in the midst of a climate that has been pervasive for much too long – the fantasy that we’re going to knock the ball out of the park, crack the great riddles of the causation of mental illness, figure out the brain. Our National Institute of Mental Health is currently obsessed with discovering new treatments to make up for the deficiencies of the ones we currently have. The solutions remain in the as-yet-unrealized future. Dr. Insel’s NIMH is now saying that future NIMH Clinical Trials will need to contain probes that look for etiological clues – "a focus on learning more about the disorders, as well as the mechanisms of intervention" [time for a sabbatical…].

But what about the treatments we’re currently using? One would have to have been in a prolonged coma state not to know that many of our current practices and beliefs about psychoactive medications have been heavily shaped by influences that don’t have to do with patient care – the profit motives of PHARMA, the cost-cutting motives of third party carriers. Medical science has been clearly twisted to serve both masters. It seems to me that the onus falls on the National Institute of Mental Health [and our professional organizations] to investigate problems like the one addressed in Tyrer et al’s editorial. It’s time to stop simply decrying over-prescribing, and provide some solid evidence-based science to the practitioners who sit in their offices seeing patients.

Writing a prescription may well be the solution to the physician’s discomfort at being in a Double Bind in a given session. In fact it probably will solve the problem of that moment. But a frank discussion of the downside of that option, at least long term, might be a much more effective use of the time and open the door to a more productive approach. It may well turn out that there are situations where the use of medication may be medically sound rather than just a momentary solution, but that’s the kind of thing that requires solid research with follow-up, and right now it’s just not available. The pharmaceutical companies can’t be expected to do this kind of study. That’s why we have a publicly funded NIMH, to help us answer this kind of everyday question. The answers? Not yet…
    Bernard Carroll
    July 8, 2014 | 9:22 AM

    A key perspective is that the drugs can do the most good in the context of wrap-around psychiatric services. For most long term problems they are not magic wands or magic bullets, effective as the sole intervention. As early as the 1950s studies were conducted to document the interactions between psychosocial interventions and drug interventions in patients with chronic psychosis. Through the late1980s this understanding was just part of the grounding of psychiatric management. Managed care changed the landscape, so that now public sector patients are more likely than private sector patients to receive comprehensive psychiatric services.

    In the early 1980s academic inpatient psychiatry units here in the U.S. had an average length of stay of 5-6 weeks. Today it is 2-4 days and the numbers of beds have been sharply reduced. Germany, on the other hand, still has an LOS around 7 weeks, yet their national expenditure on health is lower than in the U.S. Go figure. Here, the administrative pressure fed into the ramped up promotional talk of PhRMA to get us to where we are today.

    July 9, 2014 | 12:45 AM

    One of the primary problems is that for all the proclamations of “Think about the children!” in our culture, our jobs, or schools, and our schedules, our programming is antithetical to troubled children, the elderly, the disabled…

    If we want to help troubled children so that they can overcome, recover, and thrive; then we’re going to need to pay for it and train adults how to deal with children. U.S. mainstream culture is often focused on the needs of children in technocratic ways that only serve to objectify children. Too many adults in the U.S. do not know how to communicate appropriately with children, and to communicate to a child that they are “broken” is to drive a stake through their hearts and minds.

    It’s obvious that appropriate early intervention costs less and benefits more than drugging and/or waiting for the bottom to fall out. The drugging of children right now, as widespread and routine as it is; is absolutely wicked to me, and damaging in ways that we may never fully comprehend. It should be stopped— very carefully.

    I just discovered that the baclofen I’ve been taking for three years for muscle spasm, has caused agnosia, depersonalization, sensory distortion, increased spasm and pain, taste perversion, somnolence, and so on; so I am rejoicing, though the state I was in before I regained attunement may have been a clue into what it’s like to suffer from the kinds of “ADHD” that makes it impossible for some sufferers to hold a job, do okay in school, stay out of trouble. It was profound. I’m not opposed to any medication, but it should be used carefully, sparingly, and very consciously for all parties concerned.

    Ninety-five percent of my awful night MS pains have disappeared, I’m in full remission and have discontinued the baclofen and oxycodone. I could be angry or feeling any number of emotions, but I’m not; because I already learned the lessons of poly-pharmacy from psyche drugs and great resources like this one. Guess I was thinking that MS is a bona fide neurological disorder— but like a wise old friend of mine says, “Forgetting is part of learning.”

    All kinds of drugs can cause psychiatric symptoms, at this point, I think psychiatrists and anyone who prescribes psyche medications should be obligated to review all the medications a client is taking. And for children, psychiatrists should be absolutely forbidden to prescribe drugs before having some rigorous studies done that include watching parents interact with their children, and spending time with a child in various environments. Home nursing programs that educate new parents in their homes, could be expanded to include specialists who know how to reach children with various deficits.

    As a nanny, I’ve worked closely with a couple of special needs children. Learning the basket hold (with layers of soft pillows and bedding helped) kept one of my charges from tearing up our house and hurting herself or others. One must absolutely get to know a child— any child— and have their respect before attempting to alter their behavior. It takes time, access, and flexible structure.

Sorry, the comment form is closed at this time.