Before Slow Psychiatry: Drug-centered and Needs-adapted Approaches
A “drug-centered approach” acknowledges that we do not fully understand the causes of peoples’ troubles. We understand more about drug action although our knowledge is certainly incomplete on that subject as well.
A “needs-adapted approach” provides a framework in which we can talk about these drugs, acknowledge the many uncertainties, and support a person in deciding whether to take them. It acknowledges that this is likely to be an ongoing process that may be revisited time and again. It allows for the person’s own values and understanding of the problem to be both recognized and respected and it offers the space for many views to be heard. It allows that what psychiatrists label “symptoms” might not be the most important focus for a person. It gives space for a person to identify what is most important to him and places the discussion of drug treatment or any treatment for that matter within that context. It allows for a physician to be on the team but not necessarily as the leader. There may be discussion of drugs, the brain, what the physician has observed in others in similar situations, and whether there are relevant studies, but it does not require that the physician is the only expert or authority. If there is discussion of brain function and even dysfunction, this in no way precludes a person finding meaning in the experience. It allows for a frank discussion of what psychiatric diagnosis is (a classification system) and is not (a deep understanding of the nature of the problem). And it accepts that all of this occurs in the context of a relationship – usually multiple relationships — that will exert their influences on this process.
I have a longstanding interest in the problems and perils of industrial agriculture and I have often thought there were similarities between that field and the topic under discussion here. Industrial agriculture [like a drug-centered approach in psychiatry] has valued [fast] production and profit above all else. Along the way, we have damaged our environment, our health and our culture. The Slow Food movement arose as a grass roots attempt to recapture our food and the culture attached to food [through thoughtfully working with nature and cooking mindfully] . A Slow Medicine movement has now emerged and [psychiatrist] David Healy has written about this in an elegant blog.
In an earlier blog at MadinAmerica.com, I suggested that psychiatrists have a relatively small part to play in the lives of people who struggle to navigate in this world. I think some colleagues who are generally sympathetic to my views were put off. They thought I went too far in reducing the scope of psychiatry. Was I supporting something along the lines of the 15-minute “med check”? The simple answer to that question is no. In fact, what I think we need is Slow Psychiatry.
While I contend that psychiatry – medicine – can step aside with most people who experience emotional distress, when physicians are involved, these encounters will take time. To reduce emotional distress into small parcels of time and then parse the variety of human experience into rapidly determined and poorly validated diagnoses makes no sense. In addition, it is likely to foster a climate in which we continue to do harm.
Elements in Slow Psychiatry
Carina Håkansson started the Family Care Foundation. Shared among them [her group] is a deep appreciation of the value and importance of social networks in helping to develop understandings of human problems. Diagnosis – and the diagnostic process – is held lightly in these models. The uncertainty many of us find inherent in this work is acknowledged. “Treatment” proceeds from individual/network needs and it remains flexible. The psychotherapeutic attitude is considered at least as important as the technical aspects of the treatment. In keeping with the value placed upon relationships, there is also a recognition of the value of psychological continuity, i.e., to the extent possible the team involved remains constant.
This contrasts with the more traditional medical approach in which there is a focus on the individual who is presumed to be experiencing some sort of psychopathology that the experts will characterize through the evaluative process. Families are a source of further history and support but often are not considered intrinsic to the recovery process. The treatments that are offered are based on this evaluative process whereby a diagnosis is made and treatment recommendations are based on that diagnosis. Treatments are considered in a more technical way and it is often assumed that they work independent of the relationship.
What has been interesting to me is the overlap in values that have been emphasized in other so-called “alternative” approaches. In the past 25 years, the recovery movement has grown in the US. If one goes to SAMSHA, one can find a set of recovery principles that include:
- Hope: expect recovery
- Person-Driven: respect a person’s values and wished
- For some people, reduction of symptoms may not be paramount
- Many pathways: non-linear
- One (or two or three) relapse does not mean one is chronically ill
- Holistic: encompasses all aspects of a person’s life
- Peer Support
- Relational: value of social networks
- Culture: sensitivity to cultural context and diversity
- Address Trauma
- What happened to you vs. what is wrong with you?
- Emphasize strengths
- Individual, family and community all have responsibility
- Respect: community and social acceptance
When I read these, I see an important overlap between the values of need-adapted approaches and the recovery movement. And part of that is embodied in the construction of the sentence – there is an emphasis on values — how one is with a person and his network.
Named to “Best Doctors in America,” Dr. Sandra Steingard is Medical Director at Howard Center, a community mental health center where she has worked for the past 19 years. She is also clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 24 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard is Board Secretary for the Foundation for Excellence in Mental Health Care.
Above are extracts from a longer article published for Foundation for Excellence in Mental Health Care called “Slow Psychiatry: Integrating Need-Adapted Approaches with Drug Centered Pharmacology”, October 15, 2015.
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