Brent Robbins on Children on Antipsychotics
On the future of mental health
Posted Mar 09, 2016
The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
EM: You are the co-editor of Drugging Our Children: How Profiteers are Pushing Antipsychotics on Our Youngest and What We Can Do to Stop It. Can you give us the headlines of your findings and conclusions?
BR: The book is looking specifically at the over-use of antipsychotic drugs with young people, but it also speaks to a broader concern with the fact that child psychiatry, and psychiatry in general, has been driven by market forces more than medical research.
The book examines the scientific evidence, and finds that there does not seem to be an empirical justification for prescribing antipsychotic medications to children; in fact, on the contrary, there are many reasons why many alternative treatments should be considered first, not least of all because of the very high risk of side effects from this class of medications. For example, children placed on antipsychotic drugs are put at higher risk of potentially irreversible motor disorders, obesity, and diabetes, to name a few. In addition, we do not fully understand the long-term consequences of these drugs, and there is a compelling body of evidence that suggests these drugs might more likely produce long-term disability rather than prevent it.
Despite the research evidence that should dissuade physicians from prescribing antipsychotics for treatment of children, we have seen shockingly high increases in the prescription of these medications both in children and for treatment of the elderly. We show how these trends are driven primarily by the massive marketing dollars invested by the pharmaceutical companies who manufacture these drugs.
The book also contains a legal argument from an attorney, Jim Gottstein, who argues that clinicians who encounter children on these medications have an ethical responsibility to inform the parents and/or guardians of the risks of these medications. Clinicians who are not medical doctors can recommend that the parents seek a second opinion, and refer the parents to someone with expertise in the children’s issues. The clinician might consider a referral to an M.D. who may be able to offer alternative, safer treatments.
Finally, the book outlines and describes alternative treatments for children that have demonstrated effectiveness in addressing the kind of problem-behaviors that are increasingly targeted with anti-psychotics. The implication is that non-medical, alternative treatments, that are free of medical side effects, should be, at the very least, attempted prior to considering more invasive medical interventions.
EM: You were the chair of a panel called "The DSM-5 Controversy” at a recent American Psychological Association annual convention. Can you help lay readers understand those controversies a bit?
BR: The DSM-5 is the diagnostic manual that is produced by the American Psychiatric Association, and it is used by clinicians to diagnosis people with various categories of mental illness. The “controversy” refers to the fact that there is a growing concern that the diagnostic categories in the DSM-5 are not based on good science. The categories seem to lack reliability and validity. They lack reliability in that the same individual is likely to get diagnosed differently and inconsistently if they were to visit different clinicians. A good diagnostic instrument would, on the contrary, lead to precision in diagnosis. The DSM-5 diagnostic categories, in most cases, are far below minimal expectations for reliability.
The issue of validity is a concern that the DSM-5 diagnostic categories are often treated as if they point to underlying mental illnesses. But, in fact, we do not see evidence for this. Rather, DSM-5 diagnoses are descriptions of symptoms that often happen together, but they are not themselves an explanation for the symptoms that are being described.
There are many reasons to be concerned about this beyond scientific concerns. The weakness of the DSM-5 has real implications for real lives. Because the instrument lacks scientific reliability and validity, many people get diagnoses and get put on medications when they don’t merit a diagnosis and do not need the treatment. This puts the individual at risk of side effects from unnecessary treatment, and it takes resources away from individuals who really do need the treatment.
Clearly, there is a pressing need to develop alternatives to the failed DSM approach to diagnosis. I think a growing chorus of professional clinicians today agree that the DSM is a failed system, but there is still a lack of clarity or agreement about a way forward toward a viable alternative.
EM: You have a special interest in existential thought. How might an individual in distress use the ideas of existentialism to help him or her reduce that distress?
BR: From an existential perspective, suffering and anxiety are part of the human condition. If we were to completely free ourselves from suffering and anxiety, we would in a sense become either beasts or gods, or in any case, something more or less than human.
Often, when a person is in a lot of distress, especially when anxiety is the root of the distress, the suffering is amplified when the person attempts to avoid or flee from the anxiety. So, from an existential perspective, I encourage people to move toward, rather than away, from their anxiety, anguish, sadness, and other painful emotions. Our emotions are meaningful, and if we pay attention to them, and learn how to give voice to them, they can be a powerful source of insight and wisdom. By rightly viewing our painful emotions as a resource of meaning, and by turning toward them with the intent to understanding them and with the expectation of gaining wisdom about life choices, the suffering suddenly becomes much more bearable.
EM: You teach a course called Happiness, Well-Being, and Human Strengths. What do you see as some of our core human strengths?
BR: Humanistic and positive psychology approaches are bringing back an appreciation for virtue theory. The Ancient Greco-Roman approach to ethics was based less on a process of developing moral codes, and more focused on what kind of character strengths a person needs in order to live a truly excellent and fulfilling life. The development of a virtue theory for our contemporary age is an important project, though one that is still very much in its infancy. We need to do a lot more research before I could very confidently answer this question. Nevertheless, I can offer some observations based on what we do know at this point.
Aristotle’s theory of virtue had a central place for the character strength he called phronesis, which we can roughly translate as “practical wisdom.” A person may have a lot of character strengths, but without phronesis, the strengths will never live up to their potential to become virtues, because they will lack the guidance of practice wisdom. It is practical wisdom that tells us when and how to use our character strengths and when and how not to use them. Practical wisdom develops through a process of maturation and life experience, matched with ongoing efforts to reflect on ourselves and to intentionally learn new, more virtuous habits over time.
I think there is also a lot to be gained by looking at the cardinal virtues, especially as they were developed by Thomas Aquinas. The four cardinal virtues are prudence, justice, temperance, and fortitude. While some of the language may seem antiquated, I would argue that these virtues maintain their relevance, and would be an excellent foundation for a contemporary psychology of virtue.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
BR: The first thing I would suggest is that the person examine whether or not they are maintaining adequate, basic self-care. Are they engaged in exercise at least 30 minutes for at least 5 times per week? Are they getting sufficient sleep on a nightly basis? Are they eating a balanced, nutritional diet? Are they making time for social connection and for recreation?
Once the basics are down, I would inquire into the quality of current relationships with important people in their lives. If those relationships are distressed, then the individual will be distressed. Working on the relationships with other people who are important to us is one of the most effective ways to truly address problems that are directly causing much distress. Relationships, in addition, also provide us with coping resources to better manage other stressors outside of those relationships. Marriage, family or couples therapy can often be a way to help a relationship past a difficult transition phase.
I would inquire into the person’s current working conditions, or other environmental stressors, and I would encourage them to consider ways that they can better manage their work environment, or change it, in order to increase their coping resources and reduce distress.
Finally, I would invite them to reflect on their emotions relevant to their distress, and to begin to unpack the meaning of those emotions. I would encourage the person to use that understanding as a source of inner wisdom and guidance to resolve their current problems.
Dr. Robbins is Chair of the Department of Humanities & Human Sciences, Associate Professor of Psychology, and Chair of Graduate Council at Point Park University in Pittsburgh, PA. He has a Ph.D. in Clinical Psychology from Duquesne University. He is a Past President of Society for Humanistic Psychology, Division 32 of the American Psychological Association.
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at email@example.com, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
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