Friday, 15 December 2017

'The Problem with Manualized Psychotherapy' #MarkLRuffalo

The Problem with Manualized Psychotherapy

Aaron Beck, M.D., the father of cognitive-behavioral therapy.
“We are what we are because we have been what we have been, and what is needed for solving the problems of human life and motives is not moral estimates but more knowledge.” – Sigmund Freud

Robotics has already been introduced in the field of surgery. It is surmisable that in the not-so-distant future, a robot alone might complete an operation. But could you imagine a robot in the field of psychiatry or psychotherapy? In many ways, being robotic is the opposite of what makes for good therapy.

Yet, we teach our young psychiatrists and psychotherapists to act like “robots” in diagnosing and administering a “treatment plan,” following so-called “evidence-based” therapy manuals to guide treatment. Their patients may seem to get “better,” but usually not for long. Structured, manualized treatment may work in surgery, but, in my opinion, it has no place in psychiatry.

As a psychoanalyst, I have a theoretical disagreement with psychotherapeutic formulations that seek to maximize structure and direction at the expense of autonomy, introspection, and self-exploration. I have found that this preference is shared by a great number of patients seeking psychotherapy. Most have more of an interest in being understood and understanding themselves than in being told what to do or think.

Yet, many therapists begin their work by applying a psychiatric diagnosis and then selecting a “modality” from their repertoire of distinct psychotherapies. This is akin to a physician identifying a lesion and then selecting from a range of medical procedures to ameliorate it. While this approach might work for the patient with a tumor or aortic aneurysm, it doesn’t fit as neatly for the depressed or traumatized patient struggling with deep feelings of guilt and shame. There is no algorithm, no formula, no manual that can begin to account for the complexities and differences of individual human beings.

At its core, this mode of practicing psychotherapy—giving a diagnosis and then selecting from a preset variety of interventions—represents the medicalization of the art of psychotherapy. Needless to say, most psychotherapy interventions arrived at via this process are directive ones—cognitive, behavioral, cognitive-behavioral, dialectical behavioral, etc. The consequences of this medicalization are numerous and include, most significantly, an emphasis on observable “symptoms” rather than on their idiosyncratic, symbolic meaning. Patients are taught their symptoms are mere manifestations of underlying diseases, discounting them of any meaning or importance.

It is now being shown that these directive approaches to psychotherapy may be less effective than previously believed, and that the time-honored psychoanalytic approach may be more effective for many types of patients (Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017).

What is called psychotherapy, of course, is little more than human conversation bound by certain expectations or promises, the most important being privacy of communication. Attempts to explain psychotherapy as a medical “treatment” using neurobiological terms—for instance, trying to explain how psychotherapy may affect the brain—are needlessly reductionistic and contribute to the progressive medicalization of the field. There is no reason to turn to brain science to justify what we have known for thousands of years: conversation bound by certain rules can be a helpful and worthwhile endeavor.

An ethical psychotherapy seeks to support and expand the patient’s personal freedom and self-determination. The therapist should have no interest in controlling the patient, giving advice, or instructing the patient to behave in any particular way. Since the single defining feature of all mental illness is a loss of a sense of control, psychotherapy should focus on reestablishing and expanding the patient’s autonomy and individual responsibility. This approach was first outlined by the psychiatrist Thomas Szasz in his 1965 book The Ethics of Psychoanalysis, and it represents, perhaps, the most significant contribution to the psychoanalytic literature since Freud.

The problem with manualized, directive psychotherapy is that it does just the opposite. It unnecessarily restricts the autonomy of patients in the name of helping them, and in the process, may be doing more harm than good.


Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry. Advance online publication.

Szasz, T. S. (1965). The ethics of psychoanalysis: The theory and method of autonomous psychotherapy. New York: Basic Books.

Wednesday, 13 December 2017

New Year; new directions

Hoping for new beginnings in 2018.  The “year of Chrys” says my son.  Guid stuff 😀

Writing more, a range of outputs, self published.  Short stories.  Fiction faction, some with a sci-fi flavour, space and time.  Letting imagination run.  Putting life experience into different frames, creatively.

Keeping up the mental health engagement but more virtually.  Exploring psychosis in a wider landscape.  The potential and the purpose.  Being kind to myself.  I deserve respect.  Don’t we all?

Oban 22 July 2017 on way to Isle of Coll

Monday, 11 December 2017

when trust becomes fractured; from mischief to malevolence

The last couple of years have been very interesting, since coming through another psychosis after a complete physical and mental breakdown, following years of campaigning and no justice:

End of July 2015 my body rebelled at the stress I'd been under, attending various events and meetings to speak out with survivor carer voice about the locked seclusion room human rights abuses in the Stratheden IPCU February 2012.  I'd been continually bullied and silenced by various people, sometimes assaulted, badmouthed, threatened.  Raised many complaints to statutory agencies with very little positive outcome.  They defended the bad or poor practice of their staff and did their best to vilify me.

The psychosis I experienced following the breakdown was an escape, also an acute reaction to what my body was going through and I ended up with a bladder prolapse which I didn't get diagnosed until the March 2016.  Wasn't strong enough mentally to face what I thought was cancer treatment, it looked like a tumour.  I decided instead to get fit, went back to swimming and the gym, eventually took up cycling because of having to get rid of the car, couldn't afford to run it.  Being a carer activist and campaigner is costly. 

During my psychosis from August 2015 I began to engage virtually with a clinical friend, sharing experiences, someone who I thought would understand my psychosis.  At some point I will write in more detail about these exchanges which became something of a counter-transference in psychoanalytic terms.  [thanks to History Beyond Trauma for helping me make sense of it]  The virtual reality engagement was both enjoyable and confusing, words without context can seem like double entendres, which actually helped me get stronger although it may have had the opposite effect.  But I've always liked a challenge.

The thing about quips or jokes, on paper or in person, is that they are not always funny when it's a serious situation and there is a risk of hurt or misunderstanding.  The joker in the pack is a wild card, tricky.

We used to play cards a lot when the boys were young, the Pairs game when I was pregnant with my youngest son, I remember us at Rigside all sitting down to play this, on the carpet, I could hardly get up again when nearly 9mths gone.  Other card games included Cheat, Snap, Happy Families, Trump, Solitaire, Pontoon (21).  We enjoyed the play and trying to win, being very competitive in our family!  We play to win, it's not just about taking part.  

I found that last psychosis or altered mind state experience to be unsettling and enjoyable, at the same time.  The challenge was to reframe the shifting perceptions, to see them as something positive, an enhancement, and make the best of it, going with the flow.

For example, I thought, on occasion, that I was being watched and framed this as a bodyguard looking out for my welfare, protecting, and I felt safer.  In psychosis, in my experience, it's like the outside world is coming in to my space, or I'm more aware of others, being there, around and about.  I'm usually a sensitive person anyway, in terms of others, and in a psychosis it's just more so.  The main thing was to get a good night's sleep and I got this sorted by twice taking one Lorazepam to regulate it, making my bedroom a place for sleep, no TV or books or any other stimulation, apart from my thoughts and imaginings, in dreams and upon waking.

[to be continued]

Wednesday, 6 December 2017

I have a need to know that my son's suffering was not in vain; that my whistleblowing has led to improvements for others.

Addendum to Email sent yesterday to Paul Gray, Director-General Health and Social Care/Chief Executive of the NHS, and Others, requesting information about healthcare improvements for patients and carers accessing Stratheden Hospital, Fife:

"To add.

I have a need to know that the human rights abuses of my son in Stratheden IPCU/Ward 4 February 2012, physically, mentally and sexually, were not in vain.  That his suffering has helped others.

I also want to know that my whistleblowing, and the bullying and silencing by others, that I've had to contend with since 2012, on speaking out about psychiatric human rights abuses, has led to improvements for other patients in Stratheden Hospital, and for other unwaged Carer Mothers like me.

It's not been easy speaking out and getting bullied, sometimes assaulted by others because of their own pain.  In fact it's been very hard to survive it.  The isolation.  The blaming, in reports, in words, face to face, behind my back.  Getting financially poorer in the process.  While others retire early on their big pensions, compared to my basic State pension and no Carers Allowance or benefits.


20 questions on clinical effectiveness at Stratheden Hospital 18 July 2012

I was raking back Emails yesterday and came upon this one from 18 July 2012, sent to Graham Buchanan, at that point Manager of Playfield Institute and Lead on Clinical Effectiveness at Stratheden Hospital, NHS Fife:

Strapline: 20 questions on clinical effectiveness at Stratheden Hospital 

"Dear Graham

As the lead on Clinical Effectiveness at Stratheden Hospital I have 20 questions about the effectiveness of clinical practice in wards at Stratheden Hospital that I would like you to consider and give a response to:

  1. How do you ensure that nurses take time to engage with patients, listen to them and establish relationships with them?  Please detail the procedures, training, systems.
  2. What processes are in place to measure the effectiveness of the nurse/patient relationship?  Please list the processes, how often they are implemented, outcomes.
  3. Have you asked patients/carers/family members for feedback on their experiences of inpatient care at Stratheden Hospital?  Please give statistics, outcomes.
  4. What is the best approach for a nurse to take when working with a patient experiencing mental distress?  Please explain and give reasons.
  5. Are there any alternatives to psychiatric drugs for patients in mental distress?  Please list alternatives.
  6. Do you have systems that give opportunities for patients/carers/family members to feedback on their experience of how patients were treated when in distress in acute wards?  Please send me the forms, procedures and outcomes.
  7. When is the use of force justified in the treatment of mentally distressed patients in Stratheden Hospital?  Please give details, examples, outcomes.
  8. When is it considered appropriate to bring in a police presence to psychiatric wards?  Please list the reasons.
  9. How do patients feel/react to police presence in psychiatric wards?  Please give feedback responses and statistical evidence.
  10. What are the reasons for patients absconding and the measures in place for limiting this?  Please detail reasons, procedures, outcomes.
  11. When is restraint used in the wards?  Please give details of situations, circumstances and any available statistics on use of restraint.
  12. How many patients have been injured by the use of restraint?  Please give statistics (I know there was one death in 1994, Shaun Martin).
  13. How do you ensure that the use of restraint is monitored closely and effectively?  Please give policies, procedures, training details.
  14. What feedback do you have from patients who have been restrained?  Please give information about this - how the patient felt, did it hinder their recovery or trust in staff etc.
  15. How do you ensure that bullying and intimidation does not happen in psychiatric wards, by staff to patients/carers, by patients to patients?  Please describe training, systems, procedures.
  16. How do you respond to allegations of bullying and intimidation, from patients or carers/family members?  Please give details, examples.
  17. What are the incidence rates of self harm by patients in wards and how do nurses minimise the risks of self harm?  Please give statistics, procedures, training details.
  18. Why have patients been driven to self harm while in wards?  Please give patient feedback details (I know of one patient breaking his own hand because he was intimidated, distressed and cornered by 3 male nurses in a room at the back of Lomond Ward)
  19. How many patients have attempted suicide while in the ward?  Please give details - by which means, which ward, outcome etc.
  20. How many patients on discharge have completed suicide?  Please give statistics (I know of one, Audrey Evans who was discharged on 31 March 2012)

I look forward to receiving a response to my questions. 

Regards, Chrys" 


Link to NHS Fife FOI Request Response which had very little information contained within. For example:

"We have no specific procedures or systems relating to this point"

"We have no specific processes in place that provide such a measure at this point in time."

"We have no collated feedback or statistical data relating to this point."


Following the abuse of my son in the locked seclusion room of Stratheden IPCU February 2012 and Scottish Government awarding £4.4million to NHS Fife to build a new IPCU, I believe that there have been improvements in the treatment of mentally distressed patients at Stratheden, in respect of safety and protection from physical, mental and sexual abuse, although I have no proof or evidence of this.  So I have written to Paul Gray, Director-General Health and Social Care/Chief Executive of the NHS, asking for evidence:

"Dear Mr Gray
Geoff Huggins, Scottish Parliament

Please find forwarded Email 6 June 2012, from Geoff Huggins, copied to others in Scottish Government, plus my previous responses.
Can you please let me know if "recording of use of seclusion, incidents etc. to track change over time in terms of the patient safety agenda" has happened since my son was abused in the locked seclusion room of Stratheden IPCU nearly 6 years ago? 

I would like details of this and the Scottish patient safety agenda, in respect of restraint, seclusion, abusive incidents, human rights issues of locked-in patients.  How this has improved since 2012, how patients and carers are being listened to now, we weren't back then.  And any other information that would help me to understand how things may have, hopefully have, improved for people experiencing mental distress or psychosis and entering Stratheden Hospital voluntarily as a patient, to be supported through psychosis and extreme emotional distress.

I would also like to know how unwaged Carers are being better supported than I was in 2012 after whistleblowing about the locked seclusion room's human rights abuses: no toilet, no light, no water, locked up for hours in the dark, unobserved.  Physical, mental and sexual abuse by Nurses, invading bodies, face down restraint in faeces and urine, as ways of "managing" locked-in seclusion room patients who have shouted for the toilet but not been heard because staff were down the corridor in their staff room, out of hearing and out of sight.  Resulting in glandular infections and series of verrucas, broken hand still needing treatment after psychiatric discharge.  I had to listen to the flashbacks from the abuse for years, my son lives with me.  We got no other support apart from occasional psychiatrist appointments.  Abandoned by community MH services, despite completing a Carer Assessment form.  Unpopular for speaking out about psychiatric abuse and neglect.

This is an FOI request.
Yours sincerely,

Chrys Muirhead (Mrs)"

Email from Geoff Huggins, Scottish Government, to me 6 June 2012, in response to an Email I sent him about the abuse of my son in Stratheden IPCU Feb12:

Monday, 4 December 2017

Campaigners Marion Brown & Ann Kelly beg MSPs to tackle 'health scandal' of prescription pill harm @HMcardleHT

Campaigners Marion Brown and Ann Kelly beg MSPs to tackle 'health scandal' of prescription pill harm

Exclusive by Helen McArdle Health Correspondent, Herald Scotland

Ann Kelly (left) and Marion Brown, who are campaigning on behalf of patients harmed by prescription drug dependence and withdrawal (Picture by John Young /
Ann Kelly (left) and Marion Brown, who are campaigning on behalf of patients harmed by prescription drug dependence and withdrawal (Picture by John Young / 

CAMPAIGNERS will this week issue a heartfelt plea to MSPs to make Scotland a trailblazer in the fight against prescription pill harm. 

Patients have revealed shocking accounts of being crippled and traumatised by withdrawal from mood-altering drugs as part of a petition calling for recognition of and dedicated support for people suffering pharmaceutical dependence.

It is due to be considered at Holyrood on Thursday and has won backing from mental health charities, psychiatrists, the BMA and MPs on Westminster's All-Party Parliamentary Group for Prescribed Drug Dependence, who warned that medics are too often "unaware of the severity and duration of withdrawal symptoms" and issue patients with "inappropriate new diagnoses instead".

Scottish mental health charity, SAMH, said its own research indicated that "around half of GPs" were unfamiliar with guidance that patients with mild to moderate depression should initially be offered therapy, self-help or physical activity instead of antidepressants. 

One patient from Fife who was prescribed Diazepam for three months to treat panic attacks said she had developed feelings of terror and "burning skin, internal vibrations and feelings of extreme electrical shock throughout my body" despite tapering the dose slowly over 10 months.

She added: "Addiction services I've been referred to are of no help as they specialise in drug misuse and not prescription drug dependence."

Another woman told how withdrawal from antidepressants left her with "terrible panic and inner turmoil on a scale I had never encountered before", eventually leading to a suicide attempt.

It comes as a record number of Scots are being prescribed antidepressants and antipsychotics. Recent research by the University of Roehampton estimated that, while some patients do benefit, there were more than 770,000 patients taking antidepressants unnecessarily in England alone. 

Dr Des Spence, a Maryhill GP who has called for a public inquiry into pharmaceutical addiction describes it as "a disgrace, a scandal, and the biggest public health issue of our time". 

He said patients were dying from unintentional overdoses and that he encountered patients "all the time" harmed by prescription drugs. 

He said: "From a public health perspective, it's really under the radar. It's a real burning issue. It's affecting a lot of communities right across Scotland, right across the Central Belt." 

He said there was "very limited long-term data on antidepressant use" despite patients being prescribed high doses for decades amid assurances it would be safe. 

He added that the profession exacerbated the problem by being overly defensive. "There's a lack of recognition, a lack of acceptance, about the problems these drugs have created," he said.

Half of all suicides in Scotland between 2009 and 2015 involved individuals prescribed antidepressants in the 12 months to their death. 

While some will have been depressed, many patients are prescribed the pills for other conditions - such as anxiety - and clinical trials have long highlighted that the risk of suicide spikes as patients undergo withdrawal. 

Marion Brown, a psychotherapist from Helensburgh who brought the petition, said doctors "simply do not believe what patients are experiencing", yet patients are repeatedly told to go back to their GP. 

She said: "Patients come to be seen as ‘difficult’, ‘heart-sink’, ‘complex’ patients, coming back complaining of multiple apparently unrelated symptoms and, in due course, become categorised as displaying ‘medically unexplained symptoms'." 

She added that the number of patients being labelled with MUS was growing in primary care. 

Ann Kelly, the patient whose own ordeal with antidepressants inspired Mrs Brown to pursue the campaign, said her GP had encouraged her to try alleviating symptoms with anti-seizure medication, painkillers, acceptance therapy or a "combination of all three". 

She added: "All of which are nothing more than an attempt to cover up neurological damage from antidepressants. Why this is acceptable? I believe this to be one of the biggest scandals in modern medicine."

Siobhan Miller - The Ramblin' Rover (Quay Sessions)

Published on Feb 22, 2017

Gorgeous uplifting Scottish folk song originally by Silly Wizard.

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