{"id":48060,"date":"2014-07-11T08:00:52","date_gmt":"2014-07-11T12:00:52","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=48060"},"modified":"2014-07-11T17:09:44","modified_gmt":"2014-07-11T21:09:44","slug":"the-maual","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/07\/11\/the-maual\/","title":{"rendered":"the manual&#8230;"},"content":{"rendered":"\n<div align=\"justify\" class=\"small\">Back in early May, I was looking into the NIMH ARA funded RAISE study [<a href=\"http:\/\/www.nimh.nih.gov\/health\/topics\/schizophrenia\/raise\/index.shtml\" target=\"_blank\">Recovery After an Initial Schizophrenia Episode<\/a>], an as yet incompleted program being used as a template for a Congressionally mandated SAMHSA block grant allocation of funds to treat these patients:<\/div>\n<ul><span class=\"small\">                <\/p>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/12\/a-fabrication\/\">a fabrication?&hellip; <\/a><\/li>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/14\/where-did-it-go-2\/\">where&rsquo;s the beef?&hellip; <\/a><\/li>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/16\/out-of-the-loop\/\">out of the loop&hellip; <\/a><\/li>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/23\/its-effectiveness\/\">its effectiveness&hellip; <\/a><\/li>\n<p>                <\/span><\/ul>\n<div align=\"justify\" class=\"small\">One component of this RAISE program was something called <a target=\"_blank\" href=\"https:\/\/raiseetp.org\/studymanuals\/IRT%20Complete%20Manual.pdf\">Individualized Resiliency Training<\/a> [IRT], basically designed to teach these patients adaptive skills &#8211; to be &quot;resilient&quot;:&nbsp;                 <\/div>\n<ul>  <span class=\"small\">               <\/p>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/23\/its-effectiveness\/\">its effectiveness&hellip;      <\/a><\/li>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/25\/another-irt-prequel\/\">another IRT prequel&hellip; <br \/>                 <\/a><\/li>\n<li><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/26\/on-irt-some-comments\/\">on IRT, some comments&hellip; <\/a><\/li>\n<p>                 <\/span><\/ul>\n<div align=\"justify\" class=\"small\"> I got a bit diverted by a <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/26\/on-irt-some-comments\/#comment-257940\" target=\"_blank\">comment<\/a>  by Sandra Steingard who brought up a fascinating program from the days right after Thorazine was introduced for the treatment of Schizophrenia in the mid 1950s called <strong><font color=\"#200020\">The Vermont Longitudinal Study of Persons With Severe Mental Illness<\/font><\/strong>  done by Dr. George Brooks and his staff. The patients who were unable to leave the State Hospital after being treated with the newly introduced Thorazine then underwent an extensive psychosocial rehab program &#8211; something along the lines of the therapeutic community model. The combination of medication and this additional treatment was successful in getting these medication-only-treatment-failure cases out of the hospital, and had good results for the long haul. That&#8217;s the subject of these three posts:<\/div>\n<ul>  <span class=\"small\">               <\/p>\n<li><a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/27\/from-before-the-fall\/\" target=\"_blank\">a further comment&hellip;<\/a><\/li>\n<li><a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/29\/not-yet-done\/\" target=\"_blank\">not yet done&hellip; <\/a><\/li>\n<li><a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/31\/fire-in-the-belly\/\" target=\"_blank\">fire in the belly&hellip;<\/a><\/li>\n<p>                 <\/span><\/ul>\n<div align=\"justify\" class=\"small\">I&#8217;m still wandering around with this topic. This post adds a 1963 paper to the mix written by two prominent psychiatrists of the time &#8211; one British [as in Max Hamilton of the Hamilton Depression Rating Scale] and the other from Australia, Anthony Hordern. <em>As you recall. 1963 was the year of the Community Mental Health Act that established public mental health centers in the US as a part of the &quot;deinstitutionalization&quot; process already underway. Enthusiasm for the neuroleptics was high in the US in 1963.<\/em> These authors had a somewhat different take on things [I included my purloined <em>not-very-good<\/em> OCR copy because I think it&#8217;s worth a read if you have any interest in this topic]:<\/div>\n<blockquote>\n<div align=\"center\" class=\"big\"><a target=\"_blank\" href=\"http:\/\/bjp.rcpsych.org\/content\/109\/461\/500\">Drugs and &quot;Moral Treatment&quot;<\/a><\/div>\n<div align=\"center\" class=\"small\">by ANTHONY HORDERN and MAX HAMILTON<\/div>\n<div align=\"center\" class=\"middle\"><strong><font color=\"#0033ff\">The British Journal of Psychiatry<\/font><\/strong>. 1963 109:500-509.<\/div>\n<div align=\"center\" class=\"middle\">[<a href=\"http:\/\/1boringoldman.com\/index.php\/drugs-and-moral-treatment\/\" target=\"_blank\">OCR version<\/a><a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/images\/drugs-moral.pdf\"><\/a>]<\/div>\n<p>                <\/p>\n<div align=\"justify\">The advent of the phenothiazines as a treatment for chronic schizophrenics has been enthusiastically hailed as a great advance, but the history of medicine teaches that the enthusiasm with which a new treatment is greeted is not necessarily a measure of its efficacy, and this is as true of psychiatry as of other branches of medicine. In general, the results obtained with the phenothiazines have not bettered the results of those pioneers who introduced &quot;moral treatment&quot; over a century ago. The present-day equivalent of &quot;moral treatment&quot; has also achieved good results, and its supporters are not over-enthusiastic about the value of the phenothiazines. This review has attempted to bring some sort of order in the conflicting reports and an examination of the work done to combine these two forms of treatment has shown that their role is not yet established. Many more investigations will have to be made to establish the value, indications, and inter-relationship of the various treatments available for the mental hospital chronic patient.<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">By the time I came along [1974], &quot;deinstitutionalization&quot; was something of a done deal. The megalithics State Hospitals had emptied out and closed their doors. Central State was replaced by a Regional Hospital System in Georgia, but beds were disappearing at what seemed like an alarming rate. So it was the <em><strong><font color=\"#200020\">Era of the Revolving Door<\/font><\/strong><\/em>. Patients were admitted to the hospital and back out in a matter of days. It was called &quot;Stabilization&quot; which essentially relied on neuroleptic medications. The hospitals were brief custodial medication units. There were an increasing number of &quot;street people&quot; &#8211; many with chronic psychotic illness &#8211; and there was a migration of these patients to the urban centers, often given a bus ticket by the rural sheriffs to get them out of the small towns. The system that relied essentially on medication and brief custodial hospitalization sure didn&#8217;t look very effective to me. It wasn&#8217;t pretty, and was a striking contrast to the formal lectures about community treatment given to students in training. I personally never saw an effort like that described in the Vermont study, or like some of those &quot;moral treatments&quot; mentioned in the Hordern and Hamilton <em><strong><font color=\"#200020\">Drugs and &quot;Moral Treatment&quot;<\/font><\/strong><\/em> article. I just saw <em><strong><font color=\"#200020\">Drugs and More Drugs<\/font><\/strong><\/em>.<\/div>\n<p>        <\/p>\n<div align=\"justify\" class=\"small\">While the RAISE study and the recent plan to implement something like it in the States through dedicated Block Grants even before the RAISE results are in seems more rushed and driven by the availability of funding than one might like, that&#8217;s the way things work in the real world. The ARA stimulus money becomes available &#8211; jump on it. The SAMHSA Block Grant money comes along &#8211; grab it. In this world, you take advantage of any breaks that come your way. The thing that worries me isn&#8217;t that, it&#8217;s specific &#8211; it&#8217;s the  <a target=\"_blank\" href=\"https:\/\/raiseetp.org\/studymanuals\/IRT%20Complete%20Manual.pdf\">Individualized Resiliency Training<\/a> [IRT] aspect of the program. I had my say about that earlier [from <a href=\"http:\/\/1boringoldman.com\/index.php\/2014\/05\/26\/on-irt-some-comments\/\" target=\"_blank\">on IRT, some comments&hellip;<\/a>]:<\/div>\n<ol>\n<div align=\"justify\" class=\"small\">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 &ndash; 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\" class=\"small\">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&rsquo;s nothing we know about Schizophrenia  that&rsquo;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\" class=\"small\">I won&rsquo;t go on and on here. I expect I&rsquo;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&rsquo;t feel like something new is that it&rsquo;s about <em>training<\/em>  the patients, yet it&rsquo;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&rsquo;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\" class=\"small\">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&rsquo;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 [<em>and the opportunity<\/em>] to engage their patients, and learn with them what might move  things along a helpful path&hellip; <\/div>\n<\/ol>\n<div align=\"justify\" class=\"small\">As I gave this manual a second chance and read it again, it became clearer to me what bothers me about it. It&#8217;s <em>strategic<\/em>. People with paranoid trends [these patents] see through strategies and are suspicious of their indirectness independent of the content. If implemented as it is, they will feel &quot;talked at&quot; rather than helped. So I hope Dr. Steingard is right, &quot;<em>many  well meaning and caring people will use the manual but end up not   following it to the T.<\/em>&quot; The principles in the <strong><font color=\"#200020\">Vermont Study<\/font><\/strong> and the <em><strong><font color=\"#200020\">Drugs and &quot;Moral Treatment&quot;<\/font><\/strong><\/em> article would be a useful guide to its rewriting&#8230;<\/div>\n<hr width=\"500\" size=\"1\" \/>\n<div align=\"justify\" class=\"small\"><strong><font color=\"#200020\">An Aside<\/font><\/strong>: Discussions of this topic this often deteriorate into Either\/Or [&quot;Moral Treatment&quot; vs Drugs] and tend to become contentious. The &quot;Moral Treatment&quot; advocates are characterized as trying to <em>love people into health<\/em> and in turn become self-righteous accusers. Those advocating Drug treatment are seen as controlling and ignoring the patient&#8217;s humanity while seeing their opponents as naive. I tend to see window-shades coming down when such arguments get going and become uncontrollably sleepy. I think that&#8217;s a developed somnabulism after twenty-five or thirty years of hearing those arguments go nowhere. I&#8217;m a <em>Both person<\/em>. Without the neuroleptics, we had huge &quot;snake pits.&quot; Without &quot;Moral Treatment,&quot; we had a different kind of chronic problem with mental patients living under bridges and in prisons. So I&#8217;m a <em>careful-and-wary-use-of-existing-medications<\/em> person and also a <em>moral-treatment-is-the-way-to-go<\/em> person who is in that dualistic position for life and will likely ignore invitations to change my mind. And while the below [from <em><strong><font color=\"#200020\">Drugs and &quot;Moral Treatment&quot;<\/font><\/strong><\/em>] was written in 1963 about a previous era, it could&#8217;ve equally been written in the present about the contemporary past:  <\/div>\n<ul>\n<div align=\"center\" class=\"small\"><strong><font color=\"#200020\">Moral Treatment in Decline: The Rise of Custodialism<\/font><\/strong> <\/div>\n<p>  <\/p>\n<div align=\"justify\" class=\"small\"><font color=\"#200020\">Many   authors have discussed the slow attrition of &quot;moral treatment&quot;,   attributing its decline to such general factors as increasing   urbanization, mass immigration, increase in the size of mental hospitals   and, in psychiatry itself, to a mechanistic approach patterned on the   discoveries in cellular pathology made by Virchow and Van Gicson. In   addition, towards the end of the nineteenth century, the development  of  Kraepelin&#8217;s comprehensive nosological system led to a preoccupation   with patterns of disease or constellations of pathological entities   while mental hospital inmates were regarded as of little interest and of   only minor importance as individuals. Whatever the reason, the  mentally  ill were regarded as suffering from incurable degenerative  diseases and  were locked away in huge human warehouses which, of  necessity, began to  be organized on custodial lines. Conditions  worsened towards the end of  the nineteenth century, and as late as  Meyer&#8217;s early days at Kankakee, a  vigorous search for specific  causative agents or noxae, adequate to  account for the various  manifestations of mental illness, was stall in  progress. In the general  climate of enthusiasm which surrounded this  quest for specific etiological factors the lessons of the past were  forgotten or ignored,  and only painfully and slowly did academic  psychiatry, through  Bleuler, Freud and Meyer, return to consider the  claims of individual  patients.<\/font><\/div>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Back in early May, I was looking into the NIMH ARA funded RAISE study [Recovery After an Initial Schizophrenia Episode], an as yet incompleted program being used as a template for a Congressionally mandated SAMHSA block grant allocation of funds to treat these patients: a fabrication?&hellip; where&rsquo;s the beef?&hellip; out of the loop&hellip; its effectiveness&hellip; [&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-48060","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/48060","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=48060"}],"version-history":[{"count":43,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/48060\/revisions"}],"predecessor-version":[{"id":48112,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/48060\/revisions\/48112"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=48060"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=48060"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=48060"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}