Evidence Based Practice in Community Mental Health: Part Two

Looking further at evidence based practice, I want to use professional experience to look at how putting-the-cart-first treatment translates into wasted public dollars and second class services. In this article, I take myself out of the State Hospital, and insert myself thirteen years later in the ranks of the mental health workers.  Not only are we perhaps wrongly trained in the universality of counseling theories (as part 1 on this series suggests,) but additionally we are the rank and file that get hired into local systems that use fidelity measures to promote proven recovery practices.

Much like with economics, it can seem to be widely presumed among administrators that recovery services can only transform via academic trickle down guided by research. I contend that this reductionist view is self-serving to the power structure not taking into consideration the nuances of local culture and recovery itself. In this article—part two, coming at you from my work in Shy Town, Illinois, I am here to reflect opinions of the sometimes underestimated rank and file. While administrators depend on evidence that a practice will work, the potential for doing damage and being wasteful rises exponentially.

I have seen evidence based practices in community mental health perpetuate myths, stigma, unstable relationships, and limit healing.  They may be used to fuel programs that are chasing money and more concerned about silos and statistics than the community.

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Shortcomings of Evidence-Based Practice: Part One | Psych Central Professional

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Source: A Psychotherapist Reflects on Shortcomings of Evidence-Based Practice: Part One | Psych Central Professional

These days, more and more, the concept of evidence based practice is training mental health workers to put the cart before the horse.  Setting up strict fidelity measures to replicate success grossly underestimates the impact of local culture on an individuals’ life. In particular, the widespread practice of CBT for “psychosis” with its set of strict fidelity measures, runs the risk of doing damage in place of really needed work.  Unfortunately, there is rarely longitudinal studies on treatment failures that examine the negative impact of mental health politics and damage that can be done during treatment failures. Often times, big egos and manifest destiny desires of theorists that don’t respect the limits of their work continue to be promoted by administrators. I contend that the cultural art of human connection and the need for psychotherapists to learn more through authentic experiences is not and will never be fully captured in research.

My beef with therapy that follows strict theoretical fidelity measures started twenty-seven years ago when I was first hospitalized at age seventeen for anorexia in Salvador Minuchin’s clinic.  My family was to receive a best practice Structural Family Therapy performed with the highest of fidelity measures with one-way mirrors and expert consultation.  I was expected to gain a half pound a day or my family would be viewed as a failure.  I would later learn that 6000 calories a day would not anatomically gain me a half pound a day.  In therapy I kept making this point but the team was instructed to ignore me when I was oppositional.  In other words, I was to lose my voice in the family system if I behaved that way.  We went through intense and traumatic experiences as a family including my father being encouraged to bully me into eating. While he later did many things that worked, I was not able to conceptualize my rage and started to throw up indiscriminately. I had no idea what we were supposed to do, only that we were failing at an impractical expectation.

In working my way through my Master’s level education I did some extra reading on Salvador Minuchin.  I learned that he was an Argentinian, Israeli Army guy who developed his theory for people of the “slums.” Going after psychosomatic problems like eating disorders and juvenile diabetes was a way for him to penetrate middle class markets and prove that his work was manifest destiny universal.  This way students could learn that they could use his theory with anyone.

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Reconstructing a Culture of Psychosis Across Diagnostic Divides

Perhaps one of the greatest ways to oppress a people is to convince them that they don’t exist.

In America, this is what many people who have experienced psychosis face in standard treatment.  In the absence of a sense of a supportive and functioning self-support community, many who have experienced psychosis don’t feel we belong to a rich, interesting, and meaningful culture.

Consider all the categories that the DSM V has that includes the phenomenon of psychosis. I have collected a rough list below:

Schizophrenia Spectrum and other psychotic disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Delusional Disorder
Shared Psychotic Disorder
 Attenuated psychosis syndrome 
Psychotic Disorder NOS
Schizotypal personality disorder
Psychotic Disorder due to a medical condition (many)
Schizoaffective Disorder
Bipolar with psychotic features
Depression with psychotic features
Disassociative Identity Disorder
All Substance Induced Psychotic Disorders (ten different types)
Dementia of the Alzheimer’s type with early onset with delusions
Dementia of the Alzheimer’s type with late onset with delusions
Vascular Dementia with Delusions
Postpartum psychosis


Above, the construction of tall differentiated towers of illness, often grow taller and more isolated in the current system of care. Most provider-folks who use these words to bill would not want to be faced with the limited life they envision for their clients.

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