Interdisciplinary Review of General, Forensic, Prison and Military Psychiatry and Psychology and the related subjects of Behavior and Law with the occasional notes and comments by Michael Novakhov, M.D. (Mike Nova).
Friday, October 10, 2014
Review: Towards a Hermeneutic Shift in Psychiatry by Pat Bracken, M.D.
TOWARDS HERMENEUTICS. I contend that good psychiatry involves a primary focus on meanings, values and relationships, both in terms of how we help patients as well as identifying from whence their problems arise. This is not to deny ... I do not believe that we will ever be able to explain the meaningful world of human thought, emotion and behaviour reductively, using the "tools of clinical neuroscience".
"I do not believe that we will ever be able to explain the meaningful world of human thought, emotion and behaviour reductively, using the “tools of clinical neuroscience”. This world is simply not located inside the brain.
Pat Bracken in an article in World Psychiatry says psychiatry is in trouble and needs to move from reductionism to hermeneutics. He builds on the .... Responsible clinicians under the Mental Health Act... What place for ...
I know that this might sound odd coming from a critical psychiatrist, but I believe that psychiatry has a future. Furthermore, I maintain that a good deal of psychiatry as practised now is helpful and that many psychiatrists manage to play a positive and therapeutic role in the lives of their patients. However, I also believe that we are at our most helpful when we depart from the current biomedical ideology that has come to dominate in our profession.
We are most helpful when we see ourselves less as technical experts and more like medical facilitators whose job it is to help make sense of states of madness, distress and dislocation. If our profession is to have a positive future, we will need to conceptualise and practice a form of medicine that is not just focused on the brain but one that is able to grapple with the problems of meaning that lie at the heart of most mental health difficulties. In this paper from World Psychiatry, the journal of the World Psychiatry Association, I argue that, as a first step, we need to get beyond the reductionism that currently guides most psychiatric research and education.
Or what is wrong with placebo controlled clinical trials and transparency?
I was in an imaginary meeting with a bunch of Internists and Psychiatrists. We were debating the available and meager literature on the use of trazodone for sleep. We got into one of my favorite topics - the double blind placebo controlled trial and that catch all "Evidence based medicine." The dialogue went something like this: Internist: "The evidence from double blind placebo controlled trials is weak for trazodone....." Me: "Do I need a double blind placebo controlled trial to tell me to prescribe trazodone for sleep?" Internist: "Are you saying you don't need evidence. Oh wait, I was at a conference where the head of the society stood up and and gave evidence that clinical trials have their limitations. Like they are subsequently proven to not be true...." Me: "That is not what I am talking about. I am talking about all of the hype out there that only 40% of people recover from antidepressants or that they are no better than placebo........" Internist: "But you do have the algorithmic approaches that show...." Me: "Yada, yada, yada - for every algorithm, there is somebody with a meta-analysis to show it is wrong. No I am talking about the ridiculous notion that psychiatrists could stay in business or want to stay in business if only 40% of the people they treat got better. If that was true I would have become a recluse 20 years ago and just walked away." General laughter Internist: "I would kill for a 40% response rate for some of the problems that I treat."
And so on........
This informal conversation among colleagues is illustrative of the recent arguments that focus on physicians and generally psychiatrists more than other physicians that treatments are ineffective. They are based on an oversimplified view of placebo controlled clinical trials and conflict of interest. Many times there are no clear points of demarcation between what is a scientific issue (the technical aspects of the clinical trial) and the ethical issue (conflict of interest issues that may compromise the scientific results). You can read all about current technical problems with clinical trials, like the common observation that there is a lack of generalizability to clinical populations compared with the highly selected and trial sample that in the case of psychiatry generally has much milder forms of the illness being studied. Here are a few of the concerns that I don't see being discussed anywhere, especially when it comes to clinical trials of psychiatric interventions:
1. The crude state of clinical trials: Clinical trials in psychiatry are tremendously unsophisticated. The trial result generally depends on rating scale or clinician global rating scale results that grossly oversimplify the condition and measure parameters that are irrelevant in clinical settings. The best example I can think of is depression rating scales that list DSM criteria for depression and then apply a Likert dimension to those symptoms. In clinical practice it is common to see hundreds of patients with the same score on this scale who have a full spectrum of disability from absolutely none to totally disabled. Which population might be more likely to exhibit an antidepressant effect? It is also common to see medically ill patients with insomnia who may score as mildly to moderately depressed who are physically ill and not depressed at all. The same problems exist with clinical trials of schizophrenia, anxiety and Alzheimer's disease. When this weak technology is combined with a selection process that eliminates clinical populations with the most severe illness, it should not be surprising that any treatment being studied has a weak effect.
2. A weak clinical trials data base: One of the clarion calls of so-called evidence based medicine is the Cochrane Collaboration. I have looked up hundreds of their reviews and the majority of those reviews of both medical and psychiatric studies is: "insufficient results and methodologically unsound". I suppose it is good to have somebody make that statement, but if you have proclaimed that you are an evidence based physician - you have nothing to go on. In fact, at some point you stop going to Cochrane because the results are fairly predictable. Even in the case where you have a result does it apply to the patient you are seeing? I don't see many Cochrane studies depressed patients that have right bundle branch block, ventricular premature contractions, or complex atrial fibrillation - all common patients seen in clinical practice. How many more research papers do I have to read that conclude that "more research is needed" while continued inadequate trials are being published and analyzed by Cochrane? From the current trends and political correctness of evidence based medicine this will go on forever. The practical aspects are the very large costs of trials. That is the real reason that pharmaceutical companies (Big Pharma) sponsor these trials. The political system in the US has decided to farm out clinical trials to private for-profit companies in the exact manner that the US government has farmed out management of the entire health care system. In these systems Big Pharma absorbs a disproportionate amount of criticism relative to managed care companies. Managed care has equated "medically necessary" care with care that can be provided in the form of a pill.
3. The politicalization of clinical trials: No clinical trials of psychiatric medications can be done these days without an eye to the politically relevant dimensions. A new antidepressant needs to get as many FDA approved indications as possible in order to beat the political restrictions of utilization review by managed care companies. That would include indications not only for depression, anxiety, panic, and social anxiety but also chronic pain and possibly attention deficit-hyperactivity disorder (ADHD). The best way to beat utilization review is to have the only FDA approved indication in the class. That is also applied to atypical antipsychotics and that fact seems to escape the critics who focus on the number of prescriptions and what that implies. Physicians are pawns in a game when there are no suitable tolerated medications for bipolar disorder depression and there are atypical antipsychotics for that indication. These current political factors in clinical trials preclude a focus on cognition, functional capacity, and endophenotypes - all potentially much more valuable than a focus on diagnostic criteria or rating scales based on those criteria.
4. A characterization that the average physician is ignorant - at best: Any political movement is associated with ugly rhetoric. There has clearly been an effort to stampede any physicians with reservations about evidence based medicine into a Neanderthalcategory. The irony is that the criticism often comes from sources like managed care companies, medical certification authorities and the press (bloggers) - all entities with their own high levels of conflict of interest. Common rhetoric used against psychiatrists has been: "You just don't want to be measured". If the criticism originates from a government, managed care company or administrative authority there is often the attached explicit threat: "Those days are over!". The obvious implicit observation is that medicine and psychiatry is now being run by people who don't know anything at all about medicine and there is plenty of evidence on this blog to back that up.
Many critics seem to get a lot of mileage out of the position that they seem to be particularly anointed to criticize the field. That seems especially true if they happen to be a physician as in: "My colleagues certainly seem to be a bunch of chumps and therfore can be rejected on a wholesale basis or of course listen to me for enlightenment". I have never witnessed that level of incompetence in any group of physicians where I have practiced across multiple settings.
5. The use of statistics for rhetorical purposes: At this stage after reading research for that past 35 years, I am convinced that you can come up with a meta-analysis that will show whatever you want it to show. Several years ago in the New England Journal of Medicine there was a study that looked at how well meta-analyses predict the results of available large scale clinical trials. That study showed 2/3 times. It is common to see a result and then see a meta-analysis that "disproves" the clinical trials result. Nobody seems very interested in looking in detail at how sound that meta-analysis was.
Today we have a large number of questionably valuable clinical indicators or quality care markers that are often based on the political rhetoric of the government and managed care organizations. They may be invalid on the face of it, but there is a second equally important aspect. These same have no valid approach to looking at the statistics of longitudinal data. They will look at clinic results or even results from the same physician and convert them all to a numerator and a denominator. Whether that fraction means anything or not is anybody's guess, but there is an administrator somewhere who will be happy to tell you all about it.
6. False assumptions about the expertise of physicians: Much of the rhetoric above is focused on physicians. Psychiatrists as the most politically disenfranchised group are a frequent target. In the past years we have endured the ideas that medical treatments being prescribed are ineffective and overprescribed. That brings us full circle to the opening imaginary conversation. Physicians are trained to focus on several goals including acute treatment, treatment of chronic problems, and providing care for the dying. The psychiatrists and physicians that I have had the pleasure of working with have been highly effective is achieving those goals. When I look at the modest results of poorly designed clinical trials all I can do is shake my head. I would have quit a long time ago if my diagnostic or treatment capabilities were accurately described in clinical trials and most physicians would have. Informed clinical treatment is a series of often rapid changes in course, rejecting poorly tolerated treatments and looking for things that work better along the way. I can change the course of treatment depicted in a clinical trial in one day. In the trial that result is carried to the end as a failure. How is it that a clinical trial or this evidence would predict my treatment results by mean? If a treatment is ineffective or not tolerated in my practice, I don't stop treatment and call that person an unsuccessful intent-to-treat subject. I work with them to establish effective treatment - often in the same time frame as a clinical trial. Is it quite literally absurd to suggest that clinical trials accurately describe what will happen in clinical practice and yet that is the state of discourse.
7. The false promise of transparency: Anyone who followed politics knows that disclosing potential conflicts of interest is meaningless in the case of politicians. The general idea is that politicians would refrain from either accepting money from sources where they are involved politically or just not be involved in that area of legislation. In reality that does not happen. Sometimes the politicians involved will speak out against any suggestion that there is a connection between the money they receive and their legislative record even when their activities are consistent with a financial conflict of interest. The sunlight of transparency that many of the critics talk about simply legitimizes ongoing involvement in areas of potential conflict of interest. Disclosure is a stamp of approval for involvement. All of that can be researched on Congressional watchdog sites. The new CMS web site that posts payments to doctors is hyped as a way to appease all of the critics who seem clueless about transparency. For an eye opener take a look at their decision point on conflict of interest. much more charitable than the typical blogger, politician or journalist with this disclaimer:
"Sharing information about financial relationships alone is not enough to decide whether they’re beneficial or improper. Just because there are financial ties doesn’t mean that anyone is doing anything wrong. Transparency will shed light on the nature and extent of these financial relationships and will hopefully discourage the development of inappropriate relationships. Given the complexity of disclosure and the importance of discouraging inappropriate relationships without harming beneficial ones, CMS has worked closely with stakeholders to better understand the current scope of the interactions between physicians, teaching hospitals, and industry manufacturers." 8. A lack of appreciation of the regulatory environment: In the rush to condemn Big Pharma and anyone associated with them, critics often have an idealized version of regulation in their minds. If only they had access to all of the clinical trials data to analyze for themselves. They would personally be able to hold Big Pharma's feet to the fire and only allow drugs to be approved that they deemed to be safe and effective. They are smarter and more ethical than anyone doing the actual trials and certainly smarter than the regulators. This at the minimum a failure to recognize that pharmaceutical regulation is after all a political process. Like all politically directed regulation there are broad goals of safety and efficacy but they are relative and the regulatory mandate takes that into account. On this blog I have pointed out several cases of medications that not only I, but the Scientific Committee employed by the FDA recommended but that were Many drugs that I approved as a member of a Pharmacy and Therapeutics Committee(P&T) were expensive but had minimal efficacy. We approved it based on political considerations (small but vocal advocacy group and untreatable illness) rather than pure efficacy or safety considerations. The regulatory environment is currently designed to get promising agents into the hands of clinicians for clinical use. The limited exposure of patients in clinical trials means that rare but serious side effects will not be recognized until post marketing surveillance occurs. Every person taking an FDA approved medication should realize that. The regulatory process is not designed to provide perfect medications because there are none. There is a lot more to say about this subject like a detailed analysis of how the politicalized version about how physicians work and think has nothing to do with the way physicians actually work and think. But for today I am stopping here.
Life is not a randomized double blind controlled clinical trial and that is generally a good thing.
On August 15, 2014, McGill-Queens University Press published Psychiatry Disrupted: Theorizing Resistance and Crafting the (R)evolution. The work is a collection of papers by various authors, edited by Bonnie Burstow, Brenda A. LeFrançois, and Shaindl Diamond. There is a Foreword by Paula Caplan, and a Preface by Kate Millett.
It is no secret that there is growing opposition to psychiatry. No longer marginalized and ignored, as in former decades, anti-psychiatry writers are proclaiming psychiatry’s spurious and destructive nature in a wide range of venues. Even the mainstream media is taking tentative steps in our direction.
But there is also a growing awareness within our movement that speaking out against psychiatry’s abuses is not enough. Increasingly, we are hearing the question: what can we do about it? And in this respect, Psychiatry Disruptedis timely and welcome. This book does indeed criticize psychiatry, but it goes beyond criticism, and addresses the crucially important question: what can we do to stop it?
Here are the titles and authors of the fourteen chapters, with a quote from each one:
1. Impassioned Praxis: An Introduction to Theorizing Resistance to Psychiatry, by Bonnie Burstow and Brenda LeFrançois
“Children are being massively over-drugged as a result of the complex relationships between pharmaceutical companies vested capitalist interests and child psychiatry’s subsequently entwined influence over parents, carers, and other professionals working with children (such as within social work, nursing, and education).”
2. Becoming Perpetrator: How I came to Accept Restraining and Confining Disabled Aboriginal Children, by Chris Chapman
“And what held all the violence, care, and rationalization at the treatment centre together as sensible, but which has no secure foundation, is the myth of achieving an enduring state of normalcy, free from emotional discomfort, even in the face of violence and oppression. The children and staff were both disciplined toward this imaginary state, parallel to one another, but distinctly. Following restraints, we ‘debrief’ new staff to help them feel at peace with perpetrating these forms of violence; and then we ‘processed’ with the child who had just been restrained, requiring them to accept ‘full responsibility’ for having individually caused the entire situation (see Jenkins 1990).”
3. The Withering Away of Psychiatry: An Attrition Model for Antipsychiatry, by Bonnie Burstow
“The power of psychiatry, its continual growth, its ever more tenacious entrenchment in the state is a brutal reality and not one for which we bear responsibility. I would like to suggest, however, that antipsychiatry is also floundering because it has no model or models to guide its action.”
4. Psychology Politics Resistance: Theoretical Practice in Manchester, by Ian Parker
“Women are expected to be as busy ministering to the needs of others in their workplace as they are at home, and the ‘emotional labour’ they undertake leads to deeper and more draining forms of alienation. Women, and the men who learn from them how to behave nicely to customers and clients at work, are thus expected to engage more fully in their work and the stage is set for more pressure and more personal breakdowns for those who are eventually unable to cope.”
5. From Subservience to Resistance: Nursing versus Psychiatry, by Simon Adam
“Why is it that despite the obvious ethical violations psychiatry commits, nurses remain silent? What are the institutional conditions under which this silence comes to be?”
6. Developing Partnerships to Resist Psychiatry within Academia, by Peter Beresford and Robert Menzies
“When it comes to psychiatry and mental ‘health,’ the vision advanced by the champions of biogenetic psychiatry and new realist mental health is abidingly neoliberal. The new discourse constructs a psychiatric subject who stands in contrast to the robust, autonomous, trustworthy, self-governing citizen of the liberal dream. This psychiatrically outcast subject is an alien, an object of sympathy, and/or derision (or simply an object), a victim of a ‘broken brain’ (Andreasen 1985), a being to be spoken and written about (but who cannot take part in the dialogue herself), and above all else, ‘a problem’ (DuBois 2005) to be risk-monitored and rehabilitated through the application of law, science, and technology.”
7. “We Do Not Want to Be Split Up From Our Family”: Group Home Tenants Amidst Land Use Conflict, by Chava Finkler
“Language that emphasizes dependence as a prominent psychiatric survivor trait reflects an outlook based on the privilege of able-bodiedness and wealth.”
8. Disability Divisions, Definitions, and Disablism: When Resisting Psychiatry is Oppressive, by A. J. Withers
“Another reason that psychiatrized people resist inclusion within the disability label is the view that disability is permanent.”
9. Convention on the Rights of Persons with Disabilities and Liberation from Psychiatric Oppression, by Tina Minkowitz
“The recognition of forced and non-consensual psychiatric interventions as torture represents in itself a step towards reparation of the harm done by these acts of violence.”
10. Deeply Engaged Relationships: Alliance between Mental Health Workers and Psychiatric Survivors in the UK, by Mick McKeown, Mark Cresswell, and Helen Spandler
“After all, the survivor movement has a noble history of its own in providing a persuasive, reasoned, and moral critique of bio-psychiatry and an equally compelling vision for change. These kinds of discussions, debates, and alliances are happening in various contexts internationally.”
11. Trans Jeopardy/Trans Resistance: Shaindl Diamond Interviews Ambrose Kirby, by Ambrose Kirby
“But the point is that people are still being directed to go through the hoops of psychiatrists to get access to medical transition. And it’s clear that psychiatry is holding onto the right to classify and determine the best course of action for us.”
12. Taking it Public: Use Art to Make Healing a Public Narrative, by Rosemary Barnes and Susan Schellenberg
“Equating emotional pain to mental illness functions to suppress other possibilities, other meanings, and other stories for naming and responding to such pain.”
13. Feminist Resistance against the Medicalization of Humanity: Integrating Knowledge about Psychiatric Oppression and Marginalized People, by Shaindl Diamond
“As institutional psychiatry grows in power, more and more people are coming into contact with the psychiatric system and are being labeled and subjected to different types of psychiatric intervention.”
14. Sly Normality: Between Quiescence and Revolt, by China Mills
“Pretending to be normal – mimicking – seems to emerge in the stories of those who have survived the psychiatric system as a tactic, a strategy of deception that enables some freedoms, at a cost.”
Psychiatry Disruptedis a compelling, thought-provoking volume for anyone interested in this field. Please read and pass on.
Host: Forensic Technology Center of Excellence | Type: Classroom | Description: The goal of this workshop is to enhance forensic science practitioner’s knowledge and understanding capabilities of the most prominent 3D crime scene scanning technologies with established forensic applications. The target attendees for the event are those with crime scene investigation experience and have or, will have input, on agency instrument assessments and implementation. Forensic laboratory practitioners with crime scene, crash scene, and/or fatality investigation experience, forensic engineers, technical managers and/or crime laboratory directors are also welcome to apply. Topics discussed will include:Scope and utility of multiple 3D scanning instruments.. (Leica ScanStation C10/Faro Focus)Strengths and limitations of each instrument.Evaluation based on practitioner needs.Strategies for adoption and implementation.
The National Institute of Justice (NIJ) and Bureau of Justice Statistics (BJS) are launching a collaborative Data Visualization Challenge in support of theU.S. Department of Justice (USDOJ) Digital Strategy. This Challenge seeks data visualizations capable of expanding the use and understanding of publicly available criminal justice data. This is a two-phase Challenge. Successful Phase I (Ideation) contestants will move to Phase II (Creation). Twenty-five thousand dollars in prize money will be awarded to winners of the Creation phase of the competition. | Applications Due: Jan 30 2015
Annotation: Final Report and Findings of the Safe School Initiative: Implications for the Prevention of School Attacks in the United States, 2004
Abstract: This report presents findings from a study of school-based attacks that was conducted by the U.S. Secret Service's National Threat Assessment Center and the U.S. Department of Education's Safe and Drug-Free Schools Program.
Publication date: November–December 2014 Source:Journal of Criminal Justice, Volume 42, Issue 6 Author(s): Joseph A. Schwartz , Kevin M. Beaver Purpose Failing to deal with missing data patterns effectively may result in biased parameter estimates and ultimately may produce inaccurate results and conclusions. The vast majority of criminological research has addressed this issue with listwise deletion (LD) and multiple imputation (MI) techniques. Identifying the specific covariates that directly contribute to patterns of missingness is highly important in deciding which technique to use. One of the more surprising omissions from the identified list of covariates is the potential role of genetic influences in the development of missingness. Methods The current study addresses this gap in the literature by estimating genetic (A), shared environmental (C), and the nonshared environmental (E) influences on missingness across measures of delinquency and self-control within a longitudinal sample of twin and sibling pairs. Results The results indicated that genetic influences explain a significant portion of the variance in missing values related to both delinquency and self-control. Conclusions Current methodological techniques aimed at addressing missing data should be amended to take genetic influences into account. Such modifications and the implications of the findings for future research are discussed.
Publication date: November–December 2014 Source:Journal of Criminal Justice, Volume 42, Issue 6 Author(s): J.C. Barnes , Brian B. Boutwell , Kevin M. Beaver , Chris L. Gibson , John P. Wright Purpose Many criminological scholars explore the social causes of crime while giving little consideration to the possibility that genetic factors underlie the observed associations. Indeed, the standard social science method (SSSM) assumes genetic influences do not confound the association between X and Y. Yet, a nascent stream of evidence has questioned the validity of this approach by revealing many criminological variables are at least partially affected by genetic influences. As a result, a substantial proportion of the literature may be misspecified due to uncontrolled genetic factors. No effort has been made to directly estimate the extent to which genetic confounding has biased the associations presented in criminological studies. Methods The present study seeks to address this issue by drawing on simulated datasets. Results/Conclusions Results suggest genetic confounding may account for a negligible portion of the relationship between X and Y when their correlation (r yx) is larger than the correlation between genetic factors and Y (i.e., r yx > r yg). Genetic confounding appears to be much more problematic when the correlation between X and Y is in the moderate-to-small range (e.g., r yx =.20) and the genetic effect is in the moderate-to-large range (e.g., r yg ≥.30).
Publication date: November–December 2014 Source:Journal of Criminal Justice, Volume 42, Issue 6 Author(s): Benjamin Steiner , H. Daniel Butler , Jared M. Ellison Purpose Inmate rule violations or “misconducts” reflect offending within a prison, and this study involved a systematic review of studies of the causes/correlates of inmate misconduct published between 1980 and 2013. Methods An exhaustive search of relevant high impact journals yielded 98 studies of causes/correlates of inmates misconduct published between 1980 and 2013. The final models from these studies were examined to assess the impact of the predictor variables on misconduct. Results Findings revealed that predictor variables reflecting inmates’ background characteristics (e.g., age, prior record), their institutional routines and experiences (e.g., prior misconducts), and prison characteristics (e.g., security level) all impact misconduct. Conclusions Researchers should apply general theories of crime and deviance (e.g., control) that can incorporate all of the empirically relevant inmate and prison characteristics to the study of offending in prison (misconduct). Researchers should also examine the sources of variability in the effects of predictor variables across studies.
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The ruling, on a 2012 episode in which a prisoner was hog-tied, highlights the infrequency of strong punishments for guards and the pace of investigations at a jail that has come under heavy federal scrutiny.
Chikungunya fever is a debilitating but rarely fatal disease that is being seen with increasing frequency in travelers returning to the United States from affected regions. In addition, the mosquito vectors for this virus are widespread within U.S. borders. Clinicians thus must be aware of the presentation, diagnosis, and management of this emerging infection.
The streets where homelessness, abuse and mental illness meet Mail & Guardian Online The researchers believe the figure is likely to be higher because “many might not have remembered the diagnosis or might not have been able to access services (and therefore have not received a diagnosis)”. ... which examined the “health and wellbeing ...