Problems with the Mental Health Paradigm of Victimization - PowerPoint Presentation

Problems with the Mental Health Paradigm of Victimization Diseasifying Victimization Robert Walker, M.S.W., L.C.S.W. University of Kentucky, Department of Behavioral Science and Center on Drug and Alcohol Research

CAVEAT EVERYTHING I WILL BE TALKING ABOUT HAS TO DO WITH CULTURE, NOT INDIVIDUAL ACTIONS OF PERSONS.We are fond of talking incessantly about client culture and its importance. This is all about the culture we have developed over the past three decades and its unintended effects. Every erroneous practice mentioned in this presentation has been committed by me and even promoted by me in earlier years.

What is the mental health paradigm? The science of victimization is relatively new.There was great need to establish the gravity of victimization. Physical injuries were important, but the psychological effects of victimization were far greater. Mental health consequences were one way to show severe negative effects. And, with over 900 diagnoses in DSM-5 virtually all human behavior can be classified.

How victimization changed diagnostics Victimization research informed the mental health world of serious errors.Previously considered psychotic disorders were found to be trauma related and not psychotic at all. A host of disorders found a common root in disturbed arousal systems. Anxiety disorders – including stress related Depression, dysthymia, Personality disorders (Borderline)

What went wrong? A confusion between science and scientism.A little bit of science seems to go a very loooooong way. The evolving science on victimization actually points to growing complexities and away from simple categorizations. The diagnostic framework was simple, sounded sophisticated and ‘scientific’ and became a shorthand for talking about clients.

Did we learn anything useful? Absolutely and still do….To wit, the finding that pregnant women with PTSD have 4-fold greater likelihood of premature delivery and lower birth weight babies. That ‘complex’ PTSD tends to be treatment-refractory using standard approaches. Or, what about all the ACE studies and adult health problems? Powerful science here.

Why should we discard the mental health paradigm? The application of the idea of disorder to victims Criteria for disorders are all over the map The dominance of MH has instilled professional insecurity among advocates and shelter providers It over-simplifies the disturbances of arousal systems and fear states victims experience Labels replace persons with types Making people up – how the popularity of certain disorders leads people to self-identify with them and thus, ‘find’ symptoms that support with the disorder

1. The application of disorder to victims Mental disorders imply diminished capacities – something is ‘wrong’ with the person. In spite of exhaustive effort to rid MH diagnoses of moral judgment, they still carry stigma. Most MH disorders are chronic with episodic remission and relapse. Victimization sequelae are natural, normal reactions to abnormal circumstances – not disorders Some make the argument that we also diagnose those with physical injuries following victimization, but MH diagnoses become diagnoses of persons , not conditions .

Diagnostic identities Disorder types overwhelm other descriptors. Thus, PTSD becomes the meaningful envelop within which people are to be understood. But PTSD includes those who have witnessed one-time tornado events, who have conducted months-long invasions into hostile enemy territory, adults with a variety of childhood events, as well as women living for years with a partner who uses coercive control. Plus, with MH diagnoses there are predisposing factors – that is getting PTSD is not just like getting a bruise or a cut. The victim has something to do with getting the disorder (ETOH, depression, temperament, etc )

2. The criteria for disorders are all over the map PTSD carries 27 separate criteria with diagnosed individuals needing to meet but 9 of them. The range of symptom criteria are everything from sleep disturbance, to fear states, to avoidance behaviors, and cognitive distortions. Many of the symptoms overlap with other disorders – i.e. sleep disturbance, irritable behavior, problems with concentration, negative beliefs about self and the world, etc.

2. The criteria for disorders are all over the map – (cont) A brief excursion through a mental health record will show you how wobbly diagnoses can be. Does she have depression, anxiety disorder, PTSD, or some combination of all three or just two of these? And, among her diagnoses, which is the most important? Diagnoses should discriminate among human conditions – compare the diagnoses of diabetes, or hypertensive disease …… MH diagnoses overlap all over the place.

3. It has instilled professional insecurity among advocates and shelter providers The recognition of mental disorders leads us to believe that the only profession to deal correctly with the mentally disordered are the MH professionals. Not only is the knowledge of the MH professional better, but she/he knows the correct ways of relating to clients. All of this is premised on the idea that MH technologies actually work – and work better than other approaches.

4. It over-simplifies the disturbances of arousal systems and fear states victims experience At the heart of victimization are three major realities: The life history of the person – the early childhood safety and security in development The narrative truth of the person – what her experience feels like and what its facts are The state of her brain/mind interactions – how neurophysiology works for or against her safety interests The state of her brain/mind can be known by paying attention to the person. The narrative truth of the person can be learned with a little patience. The early childhood picture is hard to get at – but listen closely

Arousal Do not be lulled into thinking there is anything simple about this. The brain is a self-organizing cluster of lobes, nuclei, pathways, cells, and chemistry. Once it is out of kilter, it is very difficult to re-balance – but it natively seeks to do this. One overlooked but critical gateway to the brain is through the mind. Listening, caring, appreciating the person can detoxify arousal states.

Arousal Paying attention to the biographical self – the person - re-engages attachment.It connects persons to persons. And re-engaging attachment is associated with moderating arousal states. What is needed is recognition of the person and connection to the rest of the brain. Arousal states can seem to mask the person but focus on persons can help.

What part of the brain do you want to talk to?

5. Labels replace persons with types When using diagnostic labels, we tend to fall into using them as shorthands for persons. No one’s life can be fitted into the box of a diagnosis. The types can be of varying degrees of negativity – i.e., ‘addict’, ‘depressive’, ‘borderline’, ‘agoraphobic’, ‘schizophrenic.’ Watch out for moral dimensions…. We reify diagnoses – make the disorder the thing we focus on. And this can lead to reifying the “patient.” Used often enough, we come to believe that diagnoses are realities, not just ways of grouping behavior into manageable forms.

5. Diagnoses…. We forget that diagnoses come and go. Remember hysteria? The wandering uterus? Multiple Personality Disorder (yes, we’ve kept a part of this – but how different from its original characterization – it’s now just states, not personalities). What happened?

6. Making people up Diagnoses become well-known and “liked”.People begin to self-diagnose and to conform their thoughts, feelings, and actions to fit the diagnoses. It becomes a sort of identity issue. Therapists do the same thing. Staff and participants begin using their diagnoses to get things done with other people – not always to the best ends ……. E.g., one can explain one’s failure by describing clients as having borderline personality disorder.

1. What is to be done? – We may have become overwhelmed by unnecessary complexities.For example, the participant who comes to the center known to have: Major depressive episode Major depressive disorder PTSD Traumatic brain injury Somatic complaints involving GI tract Chronic non-malignant pain Sleep disorder Reality might suggest giving up much of our intellectual architecture around victimization and the clinical language about it. Scrap evidence-based practices.

1. What’s wrong with evidence-based practices? First, the evidence is very weak for most EBPs.Second, the best evidence is from clinical trials which avoid ALL real-world messiness (dual conditions, etc ). Third, almost no one ever reads the evidence – it tends to be taken at face value. From secondary sources – government websites, colleagues, organizations. Fourth, human beings have multiple conditions needing attention – which EBP are you to use? Fifth, every real-world application means modifying the EBP, which eradicates its validity. Ergo, you can’t do EBPs anyway.

2. What is to be done? What you CAN DO is listen to science and listen to the person before you.Listen scientifically. Listen for themes from science. It may be time to return to the basics of getting to know persons rather than treating trauma victims. The three essential practices: Listening to what the person is saying. Demonstrate that you are hearing and understanding what she is saying. Express appreciation for her experiences – validate her personhood

3. What is to be done? Obtain informed consent throughout the intervention. Ask for permission to pursue things. Consent pays attention to persons. Work to maximize safety planning given all the constraints that are in place. Risk-free status is a neurotic illusion – don’t even think about it.

4. What is to be done? Elimination of behaviors that come from intense arousal states is a waste of time and might be harmful. It is hard to know for certain, which behaviors are actually protective from harm . Remember, these behaviors are NORMAL human adaptations to ABNORMAL conditions. Most arousal adaptations will moderate in the absence of harm – thus safety, not symptoms are the issue.

5. What is to be done? Using women’s narratives, search, not for problems but expressions of resilience.Does your center teach staff and participants how to discover resilience? Keep in mind, the diagnostic framework focuses attention on disorders! Resilience is NOT a trait; it is an interaction of behaviors with situations and environments. Does your program model rule conformity or resilience?

5. Compelling compliance vs. inspiring resilience Reduce rules to the absolute bare minimum. Rule-oriented environments convey power and control and authoritarianism. They also induce resistance. They interfere with what should be the real focus of the program. Remember, rules call for more adaptations by participants – the very behavior that is in short supply.

5. Compelling compliance vs. inspiring resilience MORE critically for staff, rules and program standards create a focus of attention . Staff begin to think more about what participants have NOT done or what they have violated instead of listening to plans and solutions. Staff are negatively affected by rules imposed on participants. They begin to feel helpless and victimized by participant failures. Powerlessness among staff is a communicable disease ………. To other staff and to participants. Powerlessness is a virus.

5. The search for resilience One must probe for it - it is hard to discover. One must search over and over for it. “Talk about times you’ve pulled through……” “How have you bounced back from problems?” “Who leans on you in life? Why do they do that?” AND, does the program interact with participants in such as way as to increase their likeability? Confrontation brings out less likeability in people. Focusing on problems begs defensiveness – another unlikeability trait.

6. What is to be done FOR YOU Develop a sense of professional identity around the practices of shelter and safety planning . This has become a professional practice in the same way that other helping professions have arisen. Safety planning is a mindset, a skill set, and a practice with its own ethical dimensions. View safety planning as if you were conducting an orchestra; you aren’t making the music, but it wouldn’t happen without you. Being available as one human to another may be the essence of the itnervention . Work cooperatively with imperfections . Among the automatic thoughts that flow from the MH paradigm is a belief in becoming healthy – getting rid of disorders. Imperfection/disorder is the default setting for most of the people we serve. In fact, most people (you included) are quite imperfect!

Some take-away ideas

Celebrate the uniqueness of each individual life We are all embedded in our narratives.For most people, their stories make up their lives. The standard assessment approach is categorical – looking for check-listed problems to make sure the assessment met criteria. Our human service culture segments lives into categories of problems rather than asking us to understand persons.

A way out of this mess The thread of meaning of every life is discoverable by careful listening.The pseudoscience of diagnoses conceals personhood. We can facilitate people inventing their own solutions if we can come to know the person. But we have to resist the growing trend toward fake science and the bureaucratic mandates. Mandates can be complied with on paper, but if enacted, the results are far from ethical or helpful.

Ethics – a discarded concept? Contemporary American thinking is utilitarian and consequentialist. That is, things are deemed ‘good’ if they worked for the majority of persons. So, an intervention is ethically employed if most people (somewhere in the literature) benefitted from it. But the ethical core of social work and other related professions is NOT utilitarian – it is deontological. This means following Kant’s idea that no person must be seen as means to an end but must be seen as an end unto herself. That ethical stance places personhood as the central focus – not disorders, or EBPs or segmented problems. Just the person.

And personhood means…. Uniqueness……Biological uniquenessSocial uniqueness Life stage uniqueness Psychological uniqueness

Don’t forget uniqueness: It starts with every human brain There are at least 40,000 major pathways for neural connectivity in the human brain. Think of the number possible variations that can occur among 40,000 connections…..

This is the basic roadmap of connectivity But remember the difference between a street map of a city with the actual flow of traffic. Now, imagine that the ‘neural cars’ can create new streets.

Remember neural density – so which neurons do you want to medicate?

The only gateway into this uniqueness is Through the person.Every interaction stimulates a radical response from neurons and neuronal pathways. When we ask the person to tell us their lives, their brains have to begin forming the associational complexes that give us responses. Each act of responding builds new connectivity and novel combinations of neural pathways. We can do this in ways that stimulate growth and strength in critical areas of the brain or we can rely on simplistic well-tread pathways.

Self-organizing complexity: How brains actually work We all make up grand patterns out of small things. Great complexity can arise from the simplest of initial conditions. Each pattern is unique. Same for each brain.

Self organization MEANS uniqueness: Examples Human gaitFingerprintsDNA Voice tone Perception of colors Eye iris formation Blood vessel array Sentence structure Now, with all of that, why would we think that a simplistic term like depression would say much that is meaningful about a person?

More take-aways We have fallen prey to pseudoscience – to scientism and over confidence in empirical science on human beings.This scientism has led us into depersonalization of those whom we serve. There is a pathway out of this mess and it is painfully easy. Listen to persons, discard diagnoses and all their implications for interventions. Appreciate uniqueness: Listen to persons, try to understand, convey appreciation for their experiences and ask what they can do – how we can help.

Last take-aways By setting aside the MH paradigm, you have the opportunity to create a new paradigm for safety work. Think about what you do in safety planning….. Who else can do this? Who else WILL do this? Do you really think the MH professions can attend to this? Keep complexity in the back of your mind – but just to keep you humble, not to keep you paralyzed. Minimize rules. Try to make your program a background for persons , not the foreground to which they must adapt.