The more we think of a persistent problem, the worse it may become!

The Law of Exercise states that more we practice or engage in a habit, the stronger it becomes. This may apply to our repeated “attention” to our “psychological problems and mood,” which may unwittingly feed into strengthening these the problem associated behavioral habits and mood, and the underlying “neural networks in our brain” that support these behaviors and the moods, following the dynamics of brain-behavior interaction that we know. In the process of trying to “understand” or find “cure” and trying to “eliminate” these bothersome behaviors and mood from our life, we may neglect the use of our inherent “adaptive” thinking and capacity for coping, which otherwise may be used to displace such “troubling and persistent” negative mood and behavior.

Our approach to dealing with psychological problems, which are considered to be a part of “deficit” behavior syndrome, accompanied with personal distress feelings, and at times evoking social distress (negative reactions of “significant others” in one’s life,) typically may involve our targeted attention to the problem, understanding the dynamics of it , thinking about what may have caused it, and revisiting the experience and associated memories. Through this self-reflection, we may attempt to generate ideas how best to “eliminate” or manage such “deficit” behavior syndrome using our own knowledge base, and the information gathered from various media sources and social and family contacts.

When experiencing a lack of progress, we may seek professional help from medical service community, family physicians or psychiatrists, and psychological counseling either on our own initiative or at the request of “significant others” in our life (e.g., family member, friend, or any other caring member in our community network) The psychiatric community -psychotherapist-counselors and medication practitioners (psychiatrists)- also target their assessment and intervention at our “deficit syndromes” which are supposed to be causing our “personal distress.” For many of us, we have active ongoing productive day life, such as work, family, social life, recreational activities or hobbies, and active involvement in religious practice or community activities, which help us to divert our mind, from being preoccupied with our problem behaviors. Given that level of engagement in productive activities and family-social support, we are also able to utilize the benefit of medication treatment (from anxiety or mood stabilization medication) or from counseling and psychotherapy. The positive medication effect, when experienced, allows us to stabilize our mood, and think adaptively and help us to stimulate our redirection capacity to engage in positive behavior activities in our life and ignore or suppress our negative behavior traits. Similarly psychotherapy and counseling helps us to internalize experiences from therapy sessions to change our thinking and behavior outside the therapy to effect productive changes in our life, and consequently reduce associated personal distress. As a result, we may be able to move on with our daily productive life as we are able to rediscover our ability to redirect away from preoccupation with “deficit” behavior syndrome, or learn to think differently in dealing with emergence of negative behavior habits that causes distress in us. In the process, we are able to restore some sort of balance to our personal life.

But for many of us, who may continue to exhibit “negative behavior syndromes and mood,” either periodically or on a continuing basis in spite of our repeated personal attempts to eliminate or reduce the “negative behaviors associated feelings with “internal reflections,” or with intervention of psychiatric support services, including medication and or psychological counseling, this kind of repeated attention to one’s personal problems may unwittingly strengthen the negative behavior traits or feelings that we want to eliminate or reduce. This is consistent with the Law of Exercise, as repeated attention to the problem, and repeatedly revisiting the “negative behavior issues” and their dynamics, or thinking about or reflecting on them, or having our “well meaning” care givers (e.g., family or mental health clinicians) focusing on them in our interactions, all of which may have unintended “iatrogenic” effects, reinforcing the maladaptive behavior habits and associated feelings. This may also promote one’s continued identification with the “illness persona,” that we may adopt for us, complicating any potential benefit from medication or psychotherapy treatment. In the process of paying attention to “negative behavioral symptoms” we may also lose touch with awareness of our inherent capabilities and in our ability to utilize our “dormant intact” thinking and reasoning to help us in coping and managing our “negative behavior syndromes,” and dealing adaptively with our present life circumstances.

We may have heard many times in our life the value of positive thinking, and belief in one’s inner capacity for growth and change, but we may not be consciously aware how engagement in “positive” behaviors and feelings displace “negative” behaviors and feelings automatically, as only one of its kind can be experienced at a time, lessening the frequency of one over the other. This will require us to actively re-direct ourselves to our inner strengths and positive traits and feelings and able to see a situation so to speak as “ glass half full as opposed to glass half empty.” This level of thinking may also require us to evaluate our expectation of change in a realistic framework, and to focus on the present moment of our living existence, focusing on “What” one is doing now, and not on “Why” what one is doing, as “Why” may lead to many innumerable speculative causes and interpretations, and in the process, we may find ourselves repeatedly “visiting” our negative thoughts and feelings, reinforcing their influence and presence In our life, as the Law of Exercise dictates, fulfilling the dictum, “The more you think of your problem, the worse it becomes.” As human beings, we are all processing information within and from outside our social and physical environment and our adaptive behaviors to specific situations are guided by this process. Finding a balance between relying on our inner strengths and abilities, and seeking external professional services and supportive social contacts, when appropriate, is challenge to all of us.

Please note, this is one of the series of blog postings by Mohiuddin Ahmed, under the blog tittle of reflectionsandthoughts.wordpress.com, created in 2014. Any unauthorized use and/or duplication of this material without express and written permission from this blog’s author is strictly prohibited. Excerpts and links can be used provided full and clear credit is given to Mohiuddin Ahmed and reflectionsandthouights.wordpress.com with appropriate and specific direction to the original content.

Medication for Severe and Persistent Mental Illness

Excerpt from a write-up draft on medication practice for severely and persistently mentally ill patients:

I have been a practicing clinical psychologist in inpatient, outpatient, and nursing home settings, and I have had extensive experience with clients of all ages receiving psychotropic medications over the past 40 plus years.  More recently, I was involved in a collaborative long-term outcome study in clinical practice involving an atypical antipsychotic medication for hospitalized discharged patient. This and my other experiences highlighted several issues that are worth considering.

·         Many clients seem to have a carryover of their psychotropic medication treatment from previous providers, with added additional medication regimen to their historical medication treatment, while there appears to be no significant change of report of their “psychiatric symptoms” over the years. This appears to be true for psychiatric patients in long-term care facilities as well as in nursing homes.

·         In a long term study of discharged hospitalized patients over a 11-year period that I was involved in, the subjects (10) in the study continued to have an average of 4 psychiatric medications, and often two atypicals in their regimen, and there was no report of improved functional outcome in terms of subjective symptom ratings or participation in vocational program related activities. For sixty percent of the clients, for whom Clinical Global Ratings and BPRS were obtained, (since data on others were not collected by providers in spite of repeated requests), no changes in the positive direction was noted. However, in the initial 1-year follow-up study for the same 10 subjects, significant improvements were noted in clinical symptom functioning and functional outcome measures (e.g. vocational status).  This brings up the issue that initial positive response to this particular atypical med may plateau within a year, and further improvement is questionable. More importantly, continued involvement in this medication, and other medications regimen may have contributed to a compromised metabolic functioning, which is often reported in the literature.

·         This could be a common issue to many psychiatric treatments, whereby initial medication treatment may show initial positive response, but the efficacy beyond a certain time period may be questionable.  But who can really challenge this intuitive assumption, as I am not aware of any specific study or protocol in real life clinical practice to document objective changes in functioning, other than reliance primarily on subjective impressions of care providers, and documentation of clinical record maintained by service providers following some specific guidelines, which may not necessary capture the functional improvement in an objective manner. Often assessment procedures, such as Global Assessment Functioning (GAF) which is often used  by the prescribing clinician and the Team, without necessarily using an objective benchmark of progress, is often influenced by the desire to satisfy the funding criteria, and may reflect the subjective bias of the Team to justify progress independent of any objective criteria.  Additionally, any assessment of progress as a result of specific medication treatment or psychotherapy may be compromised and confounded by the addition of community service and other support program in the mix, which may not have been present before.

·         Often improvement in functioning in terms of adherence to medication, case management service, and continued placement in a community alternative, may be primarily related to medication effect on agitation and anxiety control, rather than reduction or elimination of targeted psychiatric symptoms, (e.g., subjective experience of hallucinations or delusions). The reduction in agitation experience and normalization of the “vegetative sigs” (e.g., sleeping, eating, activity level) due to medication effect, nevertheless allows patients to be more amenable for re-direction to positively valued activities and support from the available care givers. In addition, the availability of increased community services and support,  and personal care assistance (e.g., case management, supervised living support, transportation to community programs, etc) is a crucial element for patients being maintained in the community alternative with a “higher level of functioning,” so drug treatment targeted at the so called “psychiatric symptoms”  alone could not be cited as a major factor.

·         Besides, one gets the impression that as the targeted psychiatric symptoms continue to persist in spite of best efforts, and given the limitation in clinical research, clients often are prescribed more medications than perhaps necessary in the belief that somehow the added medication regimen will contribute to symptom relief or remission, where in fact, the primary effect, and a necessary one is the “calming effect” (e.g., agitation control) of the medication effect. My question is: “Does a client need for ”agitation control”, four and more medications, or one or two perhaps will do the necessary trick?” I don’t get a sense this has been addressed in the field.

·         The other question I have, do many psychiatric treatments, including psychotherapy, have ongoing benefits following stabilization of symptoms or initial treatment effects? What is evidence or rationale for continued medication treatment or for long-term psychotherapy involvement, other than perception of care givers, even at times against the subjective negative impressions of the subjects that it may not be helpful? Many patients I encountered in inpatient, outpatient, nursing home settings, report of many years of involvement in psychiatric medication treatment and involvement in psychotherapy without any appreciable benefits.

·         However,  a case can be made that any intervention to be effective, specifically for  long-term and severely mentally ill or “compromised functioning” individuals, should be built into client’s ongoing therapeutic milieu to provide a supportive and therapeutic psychological environment to maximize functioning, with the evidence that in the absence or withdrawal of a specific support or intervention, client’s functioning may negatively affected.

·         More recently, I have had a personal involvement with a family member who went into severe depression with psychotic features. This family member is  in his early 70’s, and after several hospitalizations and various medication treatments without any positive benefits, responded positively to ECT. He started slowly regaining his functioning, from an extremely “regressed level” characterized by severe weight loss, anxiety, tremors, paranoid ideation, inability to participate in self-care,  and following discharge, as he regained his functioning further, he took himself off on his own , in consultation with his treating psychiatrist,  of all medications and follow-up ECT treatment, and in the process recovered fully his functioning to his pre-morbid level, without showing any residual symptoms whatsoever. The case illustrates the success of maintaining “recovery” without continued involvement in any medication and psychotherapy follow-up involvement, relying solely on one’s resiliency and positive outlook.

·         In psychological disorder, importance of motivation, self-reliance, identification with normalization experience are often considered to be important indicators of progress and recovery process. In that context, how does indefinite medication treatment or involvement psychotherapy promote this sense of independence and self reliance, besides having to deal with continued side effects of potent psychiatric medications? Might not supervised drug holidays, with re-involvement in medication or therapy regimen in presence of relapse, and provision of withdrawal of medications, once self-reliance and recovery is established, with supportive environment is preferable to ensuring “risk management” and quality of life issues? Of course, this will entail reconceptualization of maintenance support and recovery, and a greater emphasis on assessment of functioning, with or without any treatment intervention. This process, I believe, not only promotes and ensures highest possible quality of life for clients, but also may save enormous cost involved in treating clients with “unnecessary medications” and all other “costs” associated in dealing  with the “iotregenic” effects of treatment interventions.

·         My sense is that when health care industry operates like a free market economy, whereby any “disability” is viewed as a source of income to providers, then marketing a product is no different than marketing or enlisting support of consumers to buy into a service product. In this scenario,  the balance between the notion of what is “medically necessary” or clinically beneficial and what is profitable to the providers may get blurred. Consequently, the medical-health care cost will continue to spiral as there is no regulatory limit that can be imposed, just like in a free market economy driven by innovations of product and demand, where the “demand” can be marketed through advertisements- appealing to individual unique likes and needs. I get a sense we are going in the same direction with our health care needs, and the mental health service industry is no different.

·          I don’t have any answers in raising these issues, I am just clarifying what I see happening in the health care field. While I applaud our social value of commitment to compensate for “disabled” functioning of our individual members, and support the “creativity” process involved through research and new interventions to maximize functioning, of a disabled and health compromised individual, but I am appalled at the lack of ensuring any objective criteria to evaluate positive outcome analysis for any “interventions” for the reasons cited above.”

Mind-Body Relationship

Mind-Body, Brain-Behavior are two sides of the same coin, and one can chose one perspective over the other, but changes in one correlates with changes in the other. I don’t see  real conflicts between medical intervention perspective and psychological-social intervention perspective, unless one blindly promotes one to the exclusion of the other. Whatever one thinks, psychological behavior have underlying correlations in brain activities,  and changes in the brain affects overt behaviors. Please see this month’s article in Scientific American by Grabiel and Smith  that outlines how all “behavioral habits” have demonstrated neural networks supporting them (of course based on animal studies, which has implications for humans, and it makes perfectly sense).

On Lieberman’s statement the schizophrenia is a brain disorder prompting dialogue in ISPS 

 The question is what level and intensity of intervention one chooses to follow or wants to  investigate through research projects, and what kind or outcome measures one needs to pay attention to justify a specific type of intervention. In this context, mental illnesses, such as schizophrenia, are behavior illnesses (e.g., behaviors that cause personal and or social distress, and  are viewed as “maladaptive” by social norms).  Both biological and psycho-social interventions could be effective, but not yet found to be universally effective, as such, schizophrenia and similar challenging mental health problems  are labeled as “severe and persistent mental illnesses,” needing development of more advances in mental health technology in both fronts. The other issue is that pursuing one level of intervention, biological or psycho-social intervention,( such as changing one’s thinking through therapy intervention, or   milieu support by modifying social environment, such as re-engineering) one may still raise ethical issues of compromising “self determination,” “individual choices,” promoting  negative effects of over-reliance on “external” intervention, biological or social or  otherwise, on the individuals, as each of one of us consciously experience the uniqueness of our living identity and want to figure out ourselves to make the best of our living existence. Personal and social ethical issues must be confronted in pursuing either of the perspectives to the exclusion of others, as both are theoretically valid perspectives to bring about changes in an ideal or controlled experimental situation. But the reality is complex, and we need and use and have made advances in the use of  both interventions, biological and psycho-social, and our human civilizations are built on those advances.  My final comment relates to politics of mental health or politics of any other economic activity.  Mental health service delivery, like any other health service or service oriented industries, is driven by professional identity, our vested interests,  and economic motivation, as such , at times objectivity may be lost in advocating one type of service over the other. Open communication and consumer awareness and choices will determine what make sense. In this sense, this kind of reflective thinking and dialogue is helpful. .

 Response to an ISPS member:

For a while, I was thinking that I was “whistling in the wind” as I thought that my post got lost in the commotion of dialogue on issues and strategies that are still in an evolving process, and the “exact science” is not there yet, and perhaps will never be, due to unique individual conscious existence. It is nice to have a belief in “certified defined approach” to give us a sense of certainty of knowledge, but clinical challenge and reality of dealing with individual cases is quite different, as we all may know.  As I have said in my original note, mind-body/brain-behavior are two sides of the same coin. The issue is what perspective one chooses to emphasize, and how much one pays attention to one over the other.  But also what  kind of outcome data, including client satisfaction, (a  subjective individual and collective dimension of experience used now in all business and service industry), personal and social distress criteria, and involvement in “productive day routine” (a criterion of social adaptation),  are included, taking into account iatrogenic effects of any intervention, medical or psycho-social. Personally, because of my training and professional identity I emphasize  psycho-social approaches, but have appreciation of biological interventions in mental o physical illnesses, but I am also keenly aware of  limits of both psycho-social and biological interventions. I understand from advocacy and funding or politics of mental health issue, “limits” are not what people want to convey for either of the approaches, and we may be caught up in this.

  Previous response  on the same issue:

Mind and body in a way are two sides of a coin, so to speak. All our psychological processes and behavioral manifestations, including hallucinations and delusions, are accompanied by underlying corresponding neurological activities of the brain. Given the advance in brain functioning assessment instruments, we will always find psychological processes and activities reflected in our brain functioning for both typical and atypical behaviors. In that sense, all behavior and psychological activities, normal or atypical dysfunctions, related to what I believe the information processing system, will be reflected in our typical or atypical brain activities and functioning. The progress in behavior science will be related to therapeutic intervention at behavioral, social, and cultural level, as well as due to increased understanding how best to direct intervention at specific brain activity sites through medication or other invasive intervention. It will always be a question of value, which is one preferable, and what is consistent with personal and social values and norms for the day. One needs to pay attention to judicious use of balance between biological and psychological interventions, as both, seemingly coming from different directions, but with the same goal and end:, that is to reduce personal and social distress and optimize one’ adaptive functioning. It is an exciting time for brain-behavior scientists, as correlation between behavior and brain activities are being increasingly possible to be identified, give support to a particular theoretical model or clinical intervention, recognizing that its value will always be time limited with advancement of human knowledge and change of social values of the day.

Hello THE PSYCHOLOGY WORLD

Here, my psychology friends and professional colleagues, and I will be posting our thoughts and communication that pertain to  mental health and behavior issues from psychology perspectives.  We may cite correspondences, reflections and thoughts on various subject matters. We will refine the site as we go along. All postings will be  by invitation only, and need to be cleared  by site administrator, Mohiuddin Ahmed, Ph. D.

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