Tuesday, November 27, 2012

Undue faith in evidence based treatment may lead to commitment orders

In a recent edition of  Huffpo, Marvin Ross takes on the recovery movement, in his blog post entitled For Some with Mental Illness, There is No Recovery.

Mental health advocate Lembi Buchanan of Victoria, B.C. released a new report called Emergence of the Recovery Movement: Are medications taking a back seat to recovery? She points out that the popular recovery model threatens to take centre stage at the expense of the urgent needs of the people diagnosed with severe and persistent mental illnesses such as schizophrenia and bipolar disorder. What sounds like a logical approach to the treatment of mental illness, recovery, is actually regressive because it does not focus on the evidence-based neuroscience of these brain disorders.

Read more here

Mr. Ross's complaint about the recovery movement, is that "They reject the emphasis of the biomedical model of mental illness. Instead, they believe the patient is the expert on treatment rather than the doctor and that there is no need for clinical evaluation or evidence-based treatment. This model does not accommodate the needs of individuals with severe mental illness (3 per cent of the population) who may lack insight into their illness and are unable to make appropriate treatment choices."

Dr. Mark Ragins, Medical Director, MHALA Village, stepped up to the plate with a detailed critique of Marvin Ross's post.
Your argument is irrational: Because some people don't recover, the recovery movement should be stopped.

No approach to anything requires a 100% success to be implemented. At best pills help about 70-80% of the time and we don't urge stopping them because some people don't respond to them. Not everyone learns in school, some people can't read and some people can't see or hear TV. That doesn't mean schools, books, and TV shouldn't be widespread.

There are some people for whom the recovery model seems a bad idea - people who are repetitively seriously dangerous, predatory people, people with severe brain damage or mental incapacity, and people incapable of any human relationships. This is a very different group and a much smaller group than the group this article discusses - people who don't believe they have a biochemical illness, "lacking insight," and people who won't do what other people want them to do, "noncompliant". Those two sets of people are failures of our existing medical system, not the recovery model. I spend my life focusing on working with precisely those people (low insight and compliance) in a recovery program and we have very high success rates including reductions of over 70% in homelessness, jailings, and hospitalizations, increases in independent hosing, family reunification, and working along with very low dropout rates. Those people (low insight and compliance) are the main group of people who will benefit from more recovery based programs, not a reason not to use recovery.

Misleading assertion 1: The recovery movement neglects people with severe mental illnesses. The core focus of the recovery movement is people with severe mental illnesses. It is people who have suffered the most loss and suffering in their lives who most need a person centered approach instead of an illness centered approach. For them mental illness is not just a medical condition needing medical care, it is a profoundly destructive experience needing recovery. Recovery is for people who don't respond to just treatment alone, not for people who respond very well to treatment first. The vast majority of the recovery based strategies are specifically directed towards people with severe mental illnesses including - outreach and engagement, trauma sensitive inpatient treatment, housing first, harm reduction, motivational interviewing, integrated substance abuse treatment, supported housing, employment, and education, skills training and psychosocial rehabilitation, clubhouses, self help and consumer staff, building protective factors and resiliency, and strengthening families.

Misleading assertion 3: Recovery is anti-medication. Many people use medications as part of their recoveries, but they have a choice just like people with physical illnesses. If you have high blood pressure you may want to use pills, at least for awhile, and/or you may want to exercise or diet, or you may want to live with your condition and its risk of stroke and heart attacks because of side effects, or even just because you don't like doctors. In contrast, anyone who doesn’t agree to take psychiatric meds "they "need for the rest of their lives" is labeled as "noncompliant" and shunned in our current system. Recovery favors a collaborative, goal driven, client driven approach to "using" medications, instead of a professionally driven, compliance based, symptom reduction based approach to "taking" medications. Many people who don't agree they have a mental illness and don't like following orders, can find their way to using medications to improve their lives if they have a psychiatrist willing to collaborate with them. In many cases it is the system that needs to be committed to helping the person more than the person needs to be committed to working with the system. Recovery is an improvement in accessibility and customer service. Dropouts go way down.

Misleading assertion 4: Recovery eliminates involuntary treatment. Most people in the recovery movement believe that involuntary treatment is occasionally absolutely necessary. However, most people presently treated involuntarily today, could and should be more humanely and effectively treated in voluntary, trauma informed, welcoming, accepting crisis programs that include consumer staff. It only looks like we have too few involuntary treatment resources because we have almost no recovery based voluntary treatment resources. None of the horror stories of desperate people being turned away by hospitals included those people being offered anything else as a meaningful alternative. Involuntary treatment, even when it is effective and necessary, is a violation of human rights, usually highly traumatizing, and destructive of relationships with the mental health system overall. So we shouldn't use it for social disruption, poverty and homelessness, avoiding responsibility, or frustration by staff and family that someone is not doing what they're told to do. There should be highly restrictive usage. Also having coercive power over someone else is corrupting and damaging to the staff, family, and society that uses it. Locked hospitals have a way of becoming dehumanized, burned out, hopeless places for everyone involved. Recovery programs have higher staff morale and hopefulness.

Irrational conclusion: Because we can find a heartwarming story of someone's recovery that included involuntary treatment and medications, the present system is working and should be defended against the threat of the recovery movement.

Our present system is not "all bad" nor are the people working in it evil and unhelpful. Sometimes recovery does result from our current efforts. Everything we're doing doesn't need to be changed. (Sometimes recovery results from placebo too.) That doesn't mean we should stop trying to improve things. We all deserve a better approach and system to work with. The recovery movement has developed better approaches and continues to learn and implement new strategies.

The recovery movement is actively fighting for positive reforms. Please join us.

Mark Ragins, MD
Medical Director, MHALA Village

novabird Lover of Life, Radical Centrist comments:  My daughter literally lost everything as untreated schizophrenia ravaged her mind over a period of years. She ended up sleeping on the streets because she was in psychosis and all of the women's shelters kicked her out because her behavior was so out of control. She was in full blown psychosis for many months, a fact that was well known to the police department as she kept breaking the law. The police took her to the emergency room many times and the hospital repeatedly refused to admit her or treat her due to the fact that she has extreme lack of insight.

I went to a judge and got a court order and she finally got admitted and put on the anti-psychotic drugs she so very desperately needed. And she has continued to stabilize since that time.

You say that involuntary treatment is a "violation of human rights, usually highly traumatizing, and destructive of relationships with the mental health system overall". And yet evidence based science tells us that the earlier the person can be treated with anti-psychotics, the better their chances for recovery.

Are you OK with the massive and permanent losses my daughter suffered due to the fact that she has extreme lack of insight and the local hospital saw fit to not provide the involuntary medical treatment she so very desperately needed? That is not a rhetorical question by the way. I would sincerely like an answer.

MarkRagins replies: 1) Was your daughter offered any meaningful assistance in the community that accepted her as she was, psychotic, and tried to form a relationship with her and help her with her goals, even if they were irrational - for example, housing first, voluntary crisis housing, peer outreach and support, quality of life community policing, drop-in-serivces, charity, benifits assistance? If not, I'm not "OK" with that.

2) After all of that and more is tried and failed and if there is acute danger (and I assume there was since the judge granted your order), I'm "OK" with involuntary treatment even with it's massive downsides, if it's trauma sensitive and used to engage in voluntary recovery-based services before discharge,

3) What family services and supports were you offered to you?

BTW It's hard to distinguish between correlation and cause in early intervention studies. Many people who take a long time to engage in treatment have significant risk factors that impact their outcomes in additon to not taking meds. Many places are now using intensive psychosoical interventions with first break psychosis instead of jumping straight to meds to build relationships and coping skills and avoid antagonizing people. Also it's unclear whether meds themselves may have long term negative effects.

I hope, in addition to stabilizing, your daughter is now recovering.

Mark Ragins


  1. Re: Psychopharmacological Approach....
    Aka, "Evidenced-Based Treatment"

    What "Evidence?"
    Biopsychiatry has no Evidence!

    ... What a joke!


    1. I didn't put my usual "quotation" marks around this word, mainly because I deliberately decided not to editorialize this particular post.

    2. Re: Quotation marks

      I'm a long-time reader, Rossa.
      I understand where you were coming from.

      Thanks for the post.
      It was a good one.



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