Definition of an Ethical Dilemma:

1. Definition of an Ethical Dilemma: • “a complex situation that will often involve an apparent mental conflict between moral imperatives, in which to obey one would result in transgressing another.” (wikipedia 5/28/12) • “Ethical dilemmas, also known as moral dilemmas, are situations in which there are two choices to be made, neither of which resolves the situation in an ethically acceptable fashion. In such cases, societal and personal ethical guidelines can provide no satisfactory outcome for the chooser.” (http://examples.yourdictionary.com)

2. 2 Key Principles in Medical Ethics • non-maleficence - "first, do no harm" (primum non nocere). • beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)

3. “First, Do No Harm……” ?

4. If we can’t insure no risk of harm from treatment, what can we do? • Aim to overall be doing more good than harm • Attempt to insure that all harm or risk of harm created is truly necessary in order to accomplish what is good • (as in, when a surgeon is careful to use the smallest possible incision.) • Make sure the person being served, to the extent possible, knows and approves of risks being taken

5. Possible causes for bias towards emphasizing benefits over risks: • Desire for Respect • Provider wants to be seen as a professional having a helpful product or service • Wanting to convince consumer to accept services • Financial Incentives • Sometimes because the public pressures the provider to get the consumer to agree to “treatment” • Or provider honestly thinks the treatment is good, • then provider minimizes risk to insure consumer will come to the same conclusion

6. Dialogue: A Key Tool in Approaching Ethical Dilemmas • Creating multiple perspectives • Each informed by the other • Dialogue participants may include: • other professionals • clients and families • The different “parts” of our own mind! • Balanced, sane, living approaches to binds and dilemmas tend to emerge from dialogue

7. Dialogue, unlike fixed rules, leaves things uncertain: • “People wish to be settled; only as far as they are unsettled is there any hope for them.” • RALPH WALDO EMERSON, “Circles,” Essays: First Series, 1841

8. Negative information Positive Information Wise and perspectives on Mind – - a treatment approach in touch a treatment approach with both DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND applied to Balanced Thinking about Treatment Approaches and critical perspectives on

9. How to be an “expert” when one’s area of expertise is too complex to be predictable: • One bad option: insist the topic is simple even when it isn’t • Ignore evidence to the contrary • Use statistical averages even when dealing with individuals • Follow fixed rules even when that isn’t helpful • A better option: • Acknowledge complexity and uncertainty • Look for exceptions that can lead to solutions

10. Medical Model Approach to Psychosis is both “Expert” & Simplistic • professional categorization of certain experiences as “illness • Then disinterest in the particulars of the experience • While attempts are made to suppress the experience with drugs • And criticisms of the approach are defined as “lack of insight into the illness”

11. An example of a “complexity-informed” approach: Open Dialogue • Professionals admit they don’t know what is going on • “That’s what we are here to talk about” • They don’t try to arrive at one certain truth • They aren’t happy unless they have at least a couple possibilities being discussed • They are curious about particulars • About things that might be hard to talk about • They avoid suppressing experiences with drugs • In 2/3 of cases, they got good results without ever using antipsychotics

12. A common [should be horrifying] complaint made by many who recovered: • “In order to recover, • I had to believe the opposite of what the mental health system told me to believe, • and I had to do the opposite of what it told me to do.”

13. One example: 2001 Study on Paxil in Adolescents, by Keller et al. • Journal article reported Paxil was generally well tolerated and effective • But when the study was analyzed it was found that • Paxil had failed to beat placebo on all 8 of the planned measures • So Keller et al reported only on mostly different measures to make Paxil look good • Ratio of self harm & suicidal ideation was 8 for Paxil, 1 for placebo • This fact did not appear in the article

14. A simple formula to make billions • Find a drug that will improve a condition on at least some measure, though only as long as the drug is taken continuously • Design randomized controlled trials large enough to make measurable but possibly slight improvements statistically significant • But small enough that horrible but rarer “side effects” are not statistically significant • Or if cases of a negative effect are still too numerous, break them up into a few different categories so that no individual category shows as statistically significant • Get Approval, Start Marketing! See “Pharmageddon” by David Healy for details on this approach

15. Antidepressants, suicide, & bad science • Robert Gibbons reported • SSRI’s to youth declined by 22% from 2003 to 2005 • Due to black box warnings about suicide • suicide rates in youth rose 14% from 2003 to 2004 • He concluded that reduced prescriptions caused increased suicide • BUT • The decline in SSRI’s to youth in 2003 to 2004 was very slight, most of the decline was 2004-2005 • So the comparison was invalid • When data became available for the full 2003-2005 period, it showed suicide rates fell

16. Excess avoidance of risk is itself risky • Because: • Opportunities are lost • Access to support and resources is diminished • Skills are not developed • Then, when people notice they are “stuck” due to their failure to take risks, they may desperately try taking risks • But taking sudden risks without support, resources, and skills often has poor results • These poor results are then commonly interpreted to be proof that risk taking must be avoided!

17. Examples of excess risk avoidance by mental health professionals: • Excess reliance on medications • Which may work short term, with long term problems • Excess use of forced treatment • Which increases control in the short term • But traumatizes people & leads to more mental health problems later, • and increased avoidance of the mental health system • Fear of even talking to people with psychosis about their experiences, beyond assessment • To avoid perceived risk of “making the delusions worse”

18. Switching from Risk Avoidance to Impulsive Risk Taking • When risks are taken by professionals who have been avoiding risks, they are often taken too impulsively • Like when a person who has been on high medication for a long time wants to try less medication, the person might be encouraged to cut the dosage too dramatically, without providing adequate support and skills • When this fails, the failure is seen as proving the need to avoid risk taking

19. More problems to start with, but better long term…. Progress Works better in short term, but…… Time People encountering trauma, & our mental health system, tend to evaluate based on short term results that may be misleading

20. Graph as printed in “Anatomy of an Epidemic” by Robert Whitaker

21. Problem in accountability • Professionals are typically held accountable for supporting inappropriate risk taking in the short term • But not held accountable for supporting even very serious long term risk taking • So supporting going off a medication that is providing short term stability may be seen as excessively risky • While the danger of encouraging staying on a medication that could lead to medical complications and eventual death may not even be considered an issue worthy of discussion

22. Staying within one’s scope of practice, without also empowering people to make informed choices • If problems are not clearly primarily medical, then medical practitioners should not be treated as unquestioned authorities about the imposition of medical treatments • We can question the dominance of medical viewpoints • Without claiming authority ourselves • Better to emphasize the diversity of viewpoints • And the existence of individual choice

23. “I am referring you for an evaluation by a psychiatrist” • This is often seen by the psychiatrist as an indication that you think medication is indicated • If you don’t intend it that way, tell the psychiatrist • Realistically, people should be warned that psychiatrists are likely to prescribe if someone goes to them, and that • They don’t have to take this as an indication that they definitely “really need” the drugs • They should know that taking drugs is one option among many • They should have access to other options

24. What’s causing these difficult experiences? Therapist: We can diagnose you with the illness called ________________because you have these difficult experiences. Therapist: These difficult experiences are being caused by your illness, which is ___________ Client: How do you know that I definitely have an illness called ___________________? Problems occur when a “diagnosis” is used as an explanation for the problem

25. Are they “symptoms” or reactions meant to serve a purpose? • If they are “symptoms” then we want to get rid of them • If they are about some part of us trying to solve a problem, we might • Become curious about what the issue or problem is • Get thoughtful about whether the problem really is important or solvable • If it does seem solvable, work out a plan to address it • Or notice that it isn’t solvable, and make a decision to let go

26. A better approach • At least be curious about the possibility that “symptoms” may have a purpose • For example • Grandiose “delusions” could be a last ditch attempt to preserve self esteem • Relentless self criticism could be an effort to ward off failure by attacking personal flaws • Homicidal ideation may represent a need to find a way to be less dominated by or oppressed by the target person • Or by whatever the target person represents

27. Evidence of biological causality is commonly exaggerated • Such as • Evidence of a genetic contribution • Brain differences • That only exist “on average” • That appear to at times be caused by mental events • Better biological understandings of the brain appreciate how important aspects of brain chemistry and even brain structure emerge out of interactions, • or out of relationships

28. Excessively biological beliefs induce passivity in consumers • With the exception, of course, that people are then more likely to seek medical treatments • Or to abuse substances! • These beliefs also cause • A reduced interest in psychological approaches • A reduced curiosity about connections between mental health problems and life events • A reduced sense of responsibility for behavior and for recovery • Induced helplessness • which can amplify helplessness which resulted from past traumatic experiences

29. The extreme version of the “Medical Model” tries to relieve shame & blame, but it goes too far: A better model: “You aren’t to blame for falling into this problematic pattern, you didn’t know how to anticipate it, but with effort and with help you may learn to get out of it” Shame and Blame model: “you must have chosen to become like this and you could chose to get over it if you want to – pull yourself up by your bootstraps” Medical model: “You have a brain disease and/or a biochemical imbalance: you aren’t responsible, your thoughts & decisions played no role in this”

30. Other problems when biological evidence is exaggerated: • Family and friends lose curiosity and empathy • Stigma goes up • At least for more serious diagnoses like schizophrenia • Medication is commonly over-emphasized • While caution about medication induced harm is reduced • An internal “civil war” is commonly amplified • While attempts at peacemaking and integration are reduced

31. A vicious circle caused by the brain disease theory of schizophrenia Slide by Paris Williams, author of “Rethinking Madness”

32. Ideas about “Illness” Also Create Other Kinds of Vicious Circles Myth: Excess anxiety and depression are the result of “biochemical imbalances” that aren’t related to life circumstances and interpretations of them Myth: The best approach to such illnesses is to avoid thinking about their meaning and to take drugs to make them go away Fact: When people avoid thinking about negative feelings and disrupt those emotional states with drugs, the connection with life circumstances becomes obscured while “relapses” into the emotional state become common

33. But don’t ignore biology • Biological stressors can perhaps increase overall stress load • Contributing to psychological problems • Some examples • Problems in utero • Childhood infections and immune system response • Dietary factors including • Omega 3 deficiency • Gluten intolerance • Unfavorable intestinal bacteria • Psychosocial stresses can also create biological differences • Though these may be reversible with corrective experiences

34. Be vigilant for possible role of past trauma, but don’t assume it • Be aware that there may be a variety of pathways to problems that look the same • With what we recognize as trauma being only one pathway • Also be aware that even when traumatic experience has occurred • Responses to similar traumas may be very different in different people • And may change over time, • as new experiences provide new perspectives • An individualized approach reduces harm from treatments that “don’t fit”

35. An option: The Distress Model • Or something similar called the Normalizing Model • Can integrate biological information about possible causes of, and results of, distressing events • While also incorporating elements that are much broader • Distress is often between people, and not just inside them • Also, distress is often about the need for social change • And not just a signal to be eliminated

36. Role Play: Ethically Informed Dialogue about Defining the Problem • Joe has been very depressed for 2 years, • He’s been unable to work more than 10 hours a week at his job which involves selling an insurance product he believes is not very valuable, but which sells well and pays a good commission. • He thinks about changing careers but his wife thinks this is way too risky. • He “hears” 2 voices (not “through his ears”, but in his head) • one of which tells him he is worthless and should work harder, and • one which tells him he can have a great life but has to reject everything and everyone he knows in order to have it • He has been on a variety of medications that overall didn’t do much, and • He has been in therapy for a year with no significant improvement. • Joe is coming to you to ask for clarification about his diagnosis, • so he will know what is wrong with him and what to do.

37. Chart by Robert Whitaker

38. Chart by Robert Whitaker

39. Chart by Robert Whitaker, from Anatomy of an Epidemic

41. Informed Consent: What should people be told? • Ideally, prescribers would be making complete, balanced information available • Verbally & in written form • But the rest of us can’t just use the excuse it “isn’t our job” if prescribers don’t accurately inform • Our clients rely on us to help them navigate the mental health system • If we know they are relying on misinformation • We should at least be offering to help them become informed • While being cautious not to act like medical experts!

42. An overview of what I want my clients to know about starting any psychiatric medication: • “There’s lots I don’t know about how this drug you are considering will affect you, but I can tell you that: • The drug will not simply correct a specific “biochemical imbalance” • It will create what could be called a “drugged state” and then either this drugged state or the placebo effect may be likely to give you some relief in the short term • But in the long term, there is a large risk that the use of the drug will interfere with resolving the issue • And also there is the risk of various side effects, including possibly permanent neurological changes, and dependency problems.

43. Hope, and Informed Consent • One thing that motivates practitioners to tip toward pro-drug information is a desire to offer hope • Hope is very helpful in reducing distress in the present • And can amplify the placebo effect • While providing negative information can create a nocebo effect! • But long term damage can result from a failure to be objective • If we want to support the placebo effect, better to support something more benign (like exercise)

44. Informed Consent shouldn’t stop once a person is on drugs • People should often be monitored for adverse effects • It may not be our job to monitor, but we might need to advocate for getting it done • Sometimes neither the consumer nor the prescriber consider the possibility that new problems emerging may be drug related • Without attention to this possibility, a “prescription cascade” is likely to ensue

45. Susan has been on a few different antidepressants for past 8 months and an antipsychotic (Abilify) for depression for 3 months • She is doing more poorly than when she started medication • Though there had initially been some improvement when starting the each antidepressant • It faded after a couple months • The restlessness in particular didn’t exist before Abilify was begun 3 months ago • She now reports being very restless and irritable • The restlessness increased dramatically when she tried stopping the Abilify for a week • What sort of treatment induced harm do you think she might be experiencing? • How would you want to bring these issues up with Susan? • How would you want to bring these issues up with the prescriber, assuming you are not the prescriber?

46. Supporting choice, including help in reducing or coming off drugs • You will want to encourage: • A broad understanding of psychological problems • Understanding of, and access to, non-drug ways to address problems • Thoughtful attitude, awareness of risks both ways • Empowered dialogue with prescriber • Once a reduction is underway • Offer assistance with emergent problems • Consider possibility problems may be temporary withdrawal effects • See going back up in dose as one option • Not the first option to take

47. Excess risk avoidance in therapy • Areas avoided too much may include: • Difficult subjects in general • Past Trauma • Discussing evidence that supports a suspect belief • Fear of appearing to collude • Discussing evidence that contradicts a belief • Fear of confrontation • Noticing one’s common humanity with the person who has psychosis • Because that would connect one to one’s own vulnerability and insecurity

48. Dependency and Therapy • Problems can occur if: • Too much dependence • Too little dependence • These problems relate to our own expectations for ourselves • When our expectations for ourselves are balanced and realistic, we are more likely to create balanced levels of dependence VS independence in our clients

49. Slide from presentation by Dr Warren Larkin & Pauline Callcott

50. Other Risks from Coercive Treatment • Damaging person’s relationship with mental health system • Creating either • Too much rebellion & disengagement, or • Too much compliance • Possible unjustified infringement on liberty • Possibly imposing a treatment which is actually more harmful than helpful