I continue to be amazed, professionally, by the overlay of needless suffering people with psychiatric illnesses go through on top of that they must endure from their conditions. Much of this comes from the central conflict both within the mental health field and in the zeitgeist between the “minders” and the “brainers”, which Followers know I’ve written various takes on.

As a recent example, a therapist friend of mine recently sent me a posting from a Rogerian therapy mailing list to which he belongs. Rogerian therapy, also called client-centered, was pioneered by humanistic psychologist Carl Rogers and is based on the primacy of active empathic listening on the part of the therapist. The implicit theory behind it is that the experience on the part of the client of “unconditional positive regard” will heal all ills. A prime directive is that the therapist be non-directive.

In the one-paragraph email message forwarded to me, the Rogerian therapist described the somnolence his client (who had had a history of a psychotic break several years before which had required hospitalization but had been stable since on medication) was experiencing, leaps to the conclusion that it is caused by the medication, and is so concerned by this trumped-up evil that he considers abandoning his non-directive stance and suggesting his client stop the medication.

In my response, which I allowed my friend on the listserv to post to the group, I said that I was amazed the poster had managed to raise as many red flags as he had in one brief paragraph — the automatic assumption that it was the medication, lack of plans on the part of the therapist to collaborate with the prescribing physician, his failure to evaluate the possibility that the client’s stability since such a severe episode of psychosis probably depended upon the medication. It worried me that the therapist’s PDR was so outdated that he admitted he had not been able to find the medications his client was taking to read up on them before deciding to advise his client to discontinue them. I was bothered that the therapist sought consultation about his clinical dilemma from a mailing list where he was likely to get only similar anti-medication biases.

I mentioned that, before medical school, I had trained and practiced in a Rogerian model; passionately so. But I had found it “hopelessly inadequate” (yes, I know, an inflammatory comment) to deal with patients with the major mental illnesses I sought to treat, who I am emphatically convinced need — but need, no matter how unconditional, much more than — empathy and positive regard. (Courts have agreed, by the way, for what it’s worth. No matter how non-medical [or anti-medical] the biases of a given therapist are, s/he is considered liable for failing to raise the issue of medication with a patient who has a degree of psychiatric distress more likely to respond to the addition of drugs than solely to the techniques advocated by the therapist.)

As expected, there was a firestorm of backlash from the members of the listserv. They were convinced my friend was a traitor for sharing the message with me, that I might be a traitor for abandoning my Rogerian roots but that it was more likely that I had never ‘gotten it’ in the first place. It was clear that I could not stand the pain of ‘sitting with’ clients in severe distress and was resorting to medications to salve my own distress. Really. I wasn’t offended, but mightily saddened. For the sloppy thinking and intolerance of these supposedly intelligent and well-meaning people… and for the spectre of the numbers of unsuspecting clients placing themselves in their and similar hands.

This all came back to me when Alwin Hawkins (who undeservedly described himself thusly: “think Drew Carey without the keen fashion sense and subtle wit”), gently suggesting it’s more up my alley than his (he’s a veteran critical care nurse in a coronary care unit), pointed me to this British Medical Journal editorial.

Improving outcomes in depression

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Around 450 million people worldwide have mental or psychosocial problems, but most of those who turn to health services for help will not be correctly diagnosed or will not get the right treatment. Even those whose problems are recognised may not receive adequate care. In a World Health Organization study of psychological disorders in general health care carried out in 14 countries around the world patients with major depression were as likely to be treated with sedatives as with antidepressants, although antidepressants were associated with more favourable outcomes at three month follow up. This benefit had dissipated by follow up at 12 months; but patients had only been taking drug treatment for a mean of 11 weeks, with a quarter of them doing so for less than a month. About two thirds of patients whose illnesses were recognised and treated with drugs still had a diagnosis of mental illness at follow up one year later, and in nearly a half the diagnosis was still major depression. Indeed, there are no observational studies of routine care for patients with major depression in the United Kingdom or in the United States that have found most patients to be receiving care consistent with evidence based guidelines.