“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)

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.)

“First, Do No Harm……”

?

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

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

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

“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

Positive Information

and perspectives on

a treatment approach

WiseMind –in touch

with both

Negative information

-a treatment approach

and critical perspectives on

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

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”

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

“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.”

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

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

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

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!

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”

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

Pro

gre

ss

TimePeople encountering trauma, & our mental health system, tend to evaluate based on short term results that may be misleading

Works better in short term, but……

More pro

blems to st

art with

,

but bette

r long te

rm…

.

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

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

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

What’s causing 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 ___________________?

Therapist: We can diagnose you with the illness called ________________because you have these difficult experiences.

Problems occur when a “diagnosis” is used as an explanation for the problem

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

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

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

◦ 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

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”

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”

The extreme version of the “Medical Model” tries to relieve shame & blame, but it goes too far:

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

Slide by Paris Williams, author of “Rethinking Madness”

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

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

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”

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

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.

Chart by Robert Whitaker

Chart by Robert Whitaker

Chart by Robert Whitaker, from Anatomy of an Epidemic

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!

“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.

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)

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

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?

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

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

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

Slide from presentation by Dr Warren Larkin & Pauline Callcott

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

Don’t want to either◦ “Blame the victim” or◦ Induce passivity & irresponsibility

Focus on responsibility in the present◦ “Restoring the right to be socially sanctioned” –

Alberto Ferguson To restore a sense of full humanity

◦ There must be a sense of personal responsibility for choices made

Many fixed boundaries are seen to serve professionals more than treatment

What would work better?◦ Flexible, personalized boundaries

Meeting needs of both helper & person to be helped Awareness of the needs behind the boundary is

crucial

Being transparent about our obligations to others

When there is a conflict between client needs & our other obligations, two options:◦ Advocating for system change to reduce conflict◦ Looking for ways to meet client and system needs

at the same time Being cautious about the rewards offered to

us for defending the status quo◦ We need to balance that with supporting healthy

challenges to that status quo

If it’s the professional◦ Disrespect of consumer autonomy and needs can

result If it’s the consumer

◦ Professionals might side with the consumer’s conscious self in trying to “get rid of” experiences that might better be integrated

What is the alternative?◦ A collaborative, dialogical, long term focus

Identify one or more things want to change about how you practice based on what you heard today◦ What problems will you be trying to address by

making these changes?◦ What problems might be created if you go too far

with these changes And how might you notice if you are going too far, or

not far enough? In general, share your hopes and fears about

confronting the issues discussed today

But these same professionals often refrain from offering information about hazards. The overall effect is like a one way valve, the information that is given is all biased in one direction…….

List things you might notice if your client is getting information that is biased pro-drug◦ From you or otherwise

List things you might notice if client is getting information that is biased against drugs◦ Again, from you or otherwise

Identify which types of issues on either list you have the hardest time addressing with clients, and why

What other questions do you have about informed consent issues?