{"id":46563,"date":"2014-05-26T12:22:34","date_gmt":"2014-05-26T16:22:34","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=46563"},"modified":"2014-05-26T13:45:39","modified_gmt":"2014-05-26T17:45:39","slug":"on-irt-some-comments","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/05\/26\/on-irt-some-comments\/","title":{"rendered":"on IRT, some comments&#8230;"},"content":{"rendered":"\n<p align=\"justify\" class=\"small\"><em>I recognize that in the last post [<a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/25\/another-irt-prequel\/\">another IRT prequel&hellip;<\/a>], I&#8217;ve stepped out of the general frame of Evidence-Based Medicine in that it&#8217;s the experience of a single clinician with a small number of cases. While it&#8217;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 &#8211; hard facts. I make no apology about that. I&#8217;m mentioning it just so you&#8217;ll know that I know I&#8217;m doing that generalizing-from-small-numbers thing that people like to criticize. I can&#8217;t think of any other way to express what bothers me when I read the <a href=\"https:\/\/raiseetp.org\/studymanuals\/IRT%20Complete%20Manual.pdf\" target=\"_blank\">Individual Resiliency Training<\/a> [IRT] Manual. I expect I&#8217;ll continue in this vain in this post too.<\/em>         <\/p>\n<div align=\"justify\">Anticipating my negative reaction to the <a href=\"https:\/\/raiseetp.org\/studymanuals\/IRT%20Complete%20Manual.pdf\" target=\"_blank\">IRT&nbsp; manual<\/a>, Dr. Sandra Steingard who is more familiar with the RAISE program than I had this to say in her <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/23\/its-effectiveness\/#comment-257909\" target=\"_blank\">comment<\/a> to <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/23\/its-effectiveness\/\">its effectiveness&hellip;<\/a>:<\/div>\n<ul>\n<div align=\"justify\" class=\"small\">  <font color=\"#200020\">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&#8230;  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.<\/font><\/div>\n<\/ul>\n<div align=\"justify\">Which I agree with and would suggest the authors put verbatim at the beginning of the manual itself. I&#8217;m sure there&#8217;s no manual on the planet written in this structured, recipe-like fashion that I would personally like. It&#8217;s just not my style, so I&#8217;ll lay off on that score as a personal conflict of interest of my own. Drs. <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/23\/its-effectiveness\/#comment-257879\" target=\"_blank\">George Dawson<\/a> and <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/23\/its-effectiveness\/#comment-257887\" target=\"_blank\">Bernard Carroll<\/a> also had some useful comments. Said Carroll:<\/div>\n<ul>\n<div align=\"justify\" class=\"small\"><font color=\"#200020\">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&rsquo;s remarkable is that it is presented as something new. &#8230;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?<\/font><\/div>\n<\/ul>\n<div align=\"justify\">I sent the IRT Manual to <a target=\"_blank\" href=\"http:\/\/pb.rcpsych.org\/content\/32\/6\/240\">Dr. Pat Bracken<\/a> of the Critical Psychiatry Network who is in West Cork, Ireland. He responded:<\/div>\n<ul>\n<div align=\"justify\" class=\"small\"><font color=\"#200020\">I&rsquo;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 <a target=\"_blank\" href=\"(http:\/\/www.theicarusproject.net\/\">Icarus Project<\/a>. It is very much a product of the &lsquo;technological&rsquo; 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 &lsquo;fun&rsquo; is a technical issue here, patients will receive education on the &lsquo;three stages of fun&rsquo; The writers of the manual are very much the &lsquo;experts&rsquo;. This is the starting point. The patient is rendered passive in this move. They are to come to sessions to be &lsquo;trained&rsquo; as though they have little to contribute themselves. There is no &lsquo;critical thinking&rsquo; 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: &lsquo;we know how to teach you about resilience&rsquo;. 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 &lsquo;culture&rsquo; in this document, no acknowledgment that religion, spirituality, creativity etc are often bound up with psychotic experience&#8230; Again, this is inadequate. I hope these comments make sense! They are initial observations after a quick read through. I don&rsquo;t think I could face really reading the whole thing carefully!<\/font><\/div>\n<\/ul>\n<div align=\"justify\">I really appreciate his response. I obviously picked Dr. Bracken because his sensibilities are close to my own. I&#8217;m not trying to hide behind him. I just know him to be someone who can articulate things with refreshing clarity. He didn&#8217;t disappoint.    <\/div>\n<p align=\"justify\">I agree with them all. The only thing I would add is that the <a href=\"https:\/\/raiseetp.org\/studymanuals\/IRT%20Complete%20Manual.pdf\" target=\"_blank\">Individual Resiliency Training<\/a> [IRT] Manual didn&#8217;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&#8217;t seem to know them very well. That&#8217;s why I wrote <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/25\/another-irt-prequel\/\">another IRT prequel&hellip;<\/a> first. This is a population of patients that often don&#8217;t know what they want, where they&#8217;re headed. So starting the sessions asking them about their goals is ill advised [&quot;<em>That&rsquo;s what I am, a blank page<\/em>&quot;]. 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 &#8211; the author&#8217;s intent. It&#8217;s a strategy, and strategies are particularly virulent here. The patients pick up on being subtly lead somewhere, often don&#8217;t intuit where, and become mistrustful [paranoid]. So with this, of all groups, communications need to be clear, direct, and honest. The basic rules &quot;<em>never ask a question the patient can&#8217;t know the answer to<\/em>&quot; and &quot;<em>don&#8217;t use questions to make statements<\/em>&quot; both apply. And then there&#8217;s the <em>Ambivalence<\/em> thing. Questions are for exploring. <\/p>\n<div align=\"justify\">Speaking of honesty, again&nbsp; with this, of all groups, &quot;<em>honesty is the&nbsp;<strike> best&nbsp;<\/strike> only policy<\/em>.&quot; For example, on page 181 under <em><strong><font color=\"#200020\">Summary Points for &#8211; What is psychosis?<\/font><\/strong><\/em>, the manual includes:<\/div>\n<ul><span class=\"small\">    <\/p>\n<li>\n<div><font color=\"#200020\">Scientists believe psychosis is caused by a chemical imbalance in the brain.<\/font><\/div>\n<\/li>\n<li>\n<div><font color=\"#200020\"> Both stress and biology contribute to psychotic symptoms.<\/font><\/div>\n<\/li>\n<li>\n<div><font color=\"#200020\"> Biological factors contribute to this chemical imbalance in the brain.<\/font><\/div>\n<\/li>\n<p>   <\/span><\/ul>\n<div align=\"justify\">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&#8217;s nothing we know about Schizophrenia that&#8217;s &quot;<em>dumb<\/em>.&quot; The Manual is filled with pseudo-expertise and, as Dr. Bracken rightly says, &quot;<em>It is much better to start with doubt, with questions, with openness<\/em>.&quot; And when he says &quot;<em>questions<\/em>,&quot; he means the explorative kind.<\/div>\n<p align=\"justify\">I won&#8217;t go on and on here. I expect I&#8217;ve really already said what I wanted to say in <em><a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/25\/another-irt-prequel\/\">another IRT prequel&hellip;<\/a><\/em>. I think the reason this doesn&#8217;t feel like something new is that it&#8217;s about <em>training<\/em> the patients, yet it&#8217;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 <em>train<\/em> them. I agree with Dr. Steingard that these clinicians need something to go on, but I think we&#8217;d be much more effective if we tried to <em>train<\/em> 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 [&quot;<em>many  well meaning and caring people will use the manual but end up not   following it to the T&quot;<\/em>] and the hope is that &quot;<em>some of them are bound to look up and see the   human being sitting in the room<\/em>,&quot; why not start there in the first place? <\/p>\n<div align=\"justify\">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&#8217;t &quot;<em>dumb<\/em>&quot; 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&#8230; <\/div>\n","protected":false},"excerpt":{"rendered":"<p>I recognize that in the last post [another IRT prequel&hellip;], I&#8217;ve stepped out of the general frame of Evidence-Based Medicine in that it&#8217;s the experience of a single clinician with a small number of cases. While it&#8217;s reinforced by my own teachers and patients, and from reading the writings of a lot of clinicians [Eugene [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-46563","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/46563","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=46563"}],"version-history":[{"count":30,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/46563\/revisions"}],"predecessor-version":[{"id":46595,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/46563\/revisions\/46595"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=46563"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=46563"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=46563"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}