Efficacy versus Effectiveness of “Treatment” Issue

“Hello to all following this thread of discussion:

My sense is that psychological problems, specifically of a persistent nature, will always be very unique, and it will always be difficult to translate from a very well conducted research studies of efficacy based model to effectiveness to a specific individual client or clients. One needs to adapt, improvise, and use intuitive clinical judgement ,drawing from a vast array of information sources to address effectively any specific client problem situation to ameliorate personal and associated social distress and hopefully impact functioning outcome in an objective manner….”

” While many published scientific studies are great studies, using the gold standard of experimental designed studies, but they often leave us with possible findings of underlying neurological dysfunctions or speculative genetic markers, or something like that, and while they have the potential for future therapeutic benefits from biological intervention or more investigative research perspectives, but the studies often do not contain any ideas for any current practice implementation, I wish there could be some suggestions, even speculative ones, that could be made after each such studies reported for possible ideas to pursue for clinicians, either for the medication practicing clinicians or for the psychotherapy oriented clinicians to follow in a productive manner in their work with clients.

Speculation and imagination promote research and creativity, and it has a legitimate place in science of mental health.

Let us face, the case study models, possibly supplemented with their own phenomenological reflections, have been in the forefront of theoretical development of psychological models: Freud, Arietti, Piaget, Kohlberg, and others, all used case study models to develop their theories, and we all know their influence in modern psychiatry, psychology, and mental health.

The goal of the Internal Society for Psychological and Social Approaches to Psychosis (ISPS), as I understand, is to highlight the psychological and social approaches to psychoses, which does not necessarily mean negating biological studies and interventions. Often the discussion gets framed in opposing any study report that seems to highlight biological basis of “mental illness.” While there is a legitimate need to advocate for more resource and research funding to funding psycho-social studies and interventions for “mental illness”, one can also attempt to do so by presenting more studies that document effectiveness of psycho-social interventions or innovative ideas either through controlled studies or case reports, and not necessarily focusing on negative biological study findings.

I do share the dismay that many must feel when they see the balance of research funding, federal or otherwise, is so heavily weighted in favor of biological interventions. That’s an area that ISPS and other psychologically minded organizations need to figure out how to redress the balance by representing the psycho-social perspectives in a forceful and productive manner. I sense that a lot of work is cut out for all of us in that area, and each of us need to do our own part individually or through a group process.

Knowledge sharing, open minded dialogue, and communication, and updating one’s skills are all important to this end, and I hope, ISPS will be helpful in that effort.

Thanks for giving me the opportunity to share!”

Extracted from a message posted on a discussion thread of ISPS Listserv!

“Existential perspective” in psychological counseling

Response to a discussion thread on the value of addressing spirituality in counseling in Research Gate

“The reality is that we all live in a world of uncertainty and unknown reality from existential perspectives. Meaning that we cannot predict future events with absolute certainty, and we have no knowledge or verified information as to what happens when we die, as our mind that integrates our conscious information, as a function of body, ceases to exist when our body dies. Many people believe that mind is a part of greater entity, soul, that continues to exist in another form of reality, and they find comfort in the belief of all knowing God, as a Supreme entity . But that is a faith based belief not subject to scientific or clinical investigation, Science, also in a way informs us that with Sun moving at approximately 118 miles per second around the Galactic center takes nearly 240 million years to complete a circle, and that no human being or the human race has ever experienced what the next second of existence of our Sun and the Earth will be. So in a way, it confirms the basic Uncertainty of our living existence. It is in this context that people have come to believe in spiritual values and religious faiths, and they all symbolically address human yearnings to understand and deal with Uncertainties of living.

All human beings, therapists and clients, have this existential uncertainty, and therapist should engage in discussion of these issues, if and when they surface in communication, highlighting Existential Mystery, and affirming some sense of connection for clients to the rest of the human race. This acknowledgement and respect of different peoples beliefs in faiths and religious or spiritual values, help the therapeutic dialogue to move on to what the present issues of coping with one’s psychological issues or problems are, but also help therapist to stimulate and explore client’s intact capacity for adaptive reasoning and thinking, fostering in client a sense of well being and how to use positive re directional strategies and engagement in “positively valued” activities to desist from engaging in “negatively valued” activities. We have outlined some of the strategies in our recently published collaborative book: Mind Stimulation Therapy: Cognitive Intervention for Persons with Schizophrenia (Ahmed and Boisvert). I have also started a Blog on existential thoughts and perspectives.
See www.existentialperspectives.wordpress.com

So my take on this issue is when religious faiths and spiritual beliefs are brought into therapeutic dialogue, one needs to affirm the universality of such faiths in the context of coping with Uncertainties of living, and acknowledging acceptance of the Universal Mystery as part of our living existence, while mindful that rational discourse on the issue is not possible, but symbolic interpretations are. Use the discussion as long as it promotes client’s well being, reducing client’s stress and agitation and increasing his sense of contentment and motivation for productive change. Here clinical judgment needs to come into play as to determining how far to go.”

An hypothetical origin of delusional beliefs in schizophrenia

Response to a discussion thread in Research Gate:

“Delusional beliefs, I believe. originate from incessant preoccupation with inner world of fantasy (above and beyond norm) in response to dealing with “uncertainties” of living experience and exacerbated by possibly “perceived real or imagined traumas” and to “ward off” what one perceives “ego dystonic” thoughts and impulses, which do not match one’s concept of a “perfect self,” (“who does not do any wrong, does not have any “evil thoughts,” and knows everything there is to know, so no need to verify or validate one’s thoughts through interpersonal communication). This gives one a sense of “existential certainty and control” by being the “creator of one’s own world,” At some point, one perceives that it is difficult to expunge these “ego dystonic” thoughts and impulses, which are often related to sexual and aggressive fantasies or impulses, associated with transition to adulthood. Then they attribute the presence of the intrusions of these thoughts and impulses to outside agents and not to oneself, often taking the form of paranoid thoughts coming from outside and being tormented in the process, without acknowledging that the “self” as the originator of such thoughts. This splitting of the mind (a la Bleuler), so to speak occurs, and preference to the “inner world of ruminations and fantasy” become so pronounced that distinction between fantasy and social world may have been lost, so no longer one is able to move consciously from one to another as most people are able to do,because of their continued active involvement in social world. Also, because of repeated visitations to these experiences, by Law of Exercise, the delusional beliefs become entrenched in one’s daily life, as behavioral habits, with possible underlying neural networks supporting them. By trying to expunge intrusion of the “unwanted thoughts and impulses,” they become more pronounced and dominant by the “failure experiences.” In that frame of mind, it is more adaptive and comfortable to say “somebody else is having these thoughts and beliefs, not me.” There could be vulnerability to personal stress tolerance and some level of atypical information processing along with possible “negative” life experiences, a combination of biological vulnerability and social and psychological factors that may promote this kind of “atypical personal adaptation” to coping with everyday life experiences.

Besides being influenced somewhat by Freud’c conceptualization of “psychotic defense” and Bleuler’s and Arieti’s concepts of schizophrenia, I was greatly influenced by reading Joseph Lyons’ brief article, The Psychology of Angels (1958, Forum), which was given to me by supervisor, Donald Derozier, while I was an Intern at Wnnebago State Hospital some 45 years ago, along with my own personal phenomenological reflections on the issue.”


Atypical Thinking Psychosis for Schizophrenia

“I have been reading with interest the discussion thread on the ISPS Listserv our commentary published in the Lancet Psychiatry titled An Alternative name for schizophrenia (Ahmed, Bursztajn, Abramson, and Nisenbaumm volume 1, Issue 4, 2014). I am taking the liberty of sharing my personal thoughts and opinions without consulting with other authors who participated with me in the response article to Bill George and Aadt Klijn. In expressing my thoughts and opinions, I am not presuming more knowledge than others, just contributing to the collaborative dialogue process on this complicated psychiatric diagnosis.

In my mind, any “diagnosis” physical or psychological, has connotative and denotative functions. Connotative function for a defined “illness” describes the atypical condition requiring special attention by “society” in terms “treatment or intervention” and denotative function describes the naming of the condition. Societies, in general, to its own ability level and there level of functioning, allocate resource commitment to conditions that are defined as “atypical functioning” (illness) and to people afflicted with the said illness.

We hope all “illnesses” are transitory or best managed by interventions that optimize functioning without any “disability,” so no diagnosis will attain any “negative stigma” or connotation of association with “persistent disability.” Everybody will be blended into the general population due to built-in interventions as part of normalization process. In that setting, any atypical condition or associated “disabled functioning” are compensated by technological advances or social attitude or a combination of both. But the current reality is different, as we all know.

For persons diagnosed with current psychiatric terminology of schizophrenia, there is a legitimate dissatisfaction that schizophrenia name has acquired a negative connotation by implying an associated persistent functional impairment, which is always not the case. And we applaud the current movement to explore how best to eliminate or reduce negative stigma associated with schizophrenia. Considering the complexity of diagnostic change, and implications what such change will mean in terms of how medical and psychological services are funded, specifically in this country (United States)that I am most familiar with , and how the proposed change will also impact societal service programs including “entitlements” that are tied to specific diagnostic categories, any change that is initiated becomes complicated. One also needs to acknowledge the reality of the level of “incomplete” and evolving knowledge base about complicated “atypical conditions” such as schizophrenia. Therefore, any change will be incremental and will require time. Hopefully the current dialogue through ISPS and other forums will provide incentive to this dynamic process of incremental change in a positive direction, somehow accommodating all the stakeholders involved to a degree of consensus .

Having said that, I will like to present some opinions and ideas related to the specific issues raised by Bill George through his communication to Margreet on the ISPS-International Forum.

Atypical thinking, we believe is shared by many creative people and other non-clinical populations as well as, and by many people who are currently diagnosed as having schizophrenia . So psychosis is not necessarily embedded in the concept of Atypical Thinking.
in our proposed formulation, we retained the concept of psychosis to provide a historical continuity, and delineated six core elements (incorporating historical and DSM criteria) that we believe contribute to impairments in adaptive functioning, involving personal as well as social distress (with consideration for at risk behaviors) that elicit special attention to a person’s functioning.
The rating scales for each of the dimensions in our proposal were designed to capture changes and improvement in functioning. One can be open to change to the Level Ratings from 1-3 to 0-3 ratings, 0=Not Significant, 1=Mild, 2= Moderate, 3= Severe and persistent, to acknowledge partial-to-full recovery on the functional behavior dimensions specified .

Given this framework, a person diagnosed with Atypical Thinking Psychosis may move from different dimension ratings, even to a level of rating 0 for all six dimensions, signifying “full recovery. ” More importantly this definition, identifying specific dimension ratings may lend to more targeted research in biological as well as in psycho-social interventions, in conjunction with providing more impetus to a progressive movements in resource allocation, societal attitude change, and normalizing integration of people with “schizophrenia. ”

The name change that we propose, is in line with the de-stigmatization movement that Bill George as a consumer and others are involved, and it should not only focus on reducing or eliminating stigma associated with the name of schizophrenia, but also highlight changes in the connotative function that the denotative name of schizophrenia implies, and hopefully, whatever new named is agreed upon, it will delineate a path to a fuller recovery.

I believe this commentary, like others, is just a part of an ongoing dialogue process, hopefully drawing attention from different “stakeholders” (e.g., consumers, service providers, researchers, public and private funding agencies, social service systems etc.) to address the issue of concern that so many people are raising from different directions. ”