4.3 Severe Mental Illness in Urban Context Samenvatting Week 5
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Course
4.3C Severe Mental Illness In The Urban Context
Institution
Erasmus Universiteit Rotterdam (EUR)
Samenvatting van alle te lezen literatuur van week 5 en colleges van het vak 4.3 Severe Mental Illness in Urban Context van de master Klinische Psychologie aan de Erasmus Universiteit Rotterdam (EUR). Behaald tentamencijfer: 8.0. Literatuur is in het Nederlands samengevat en colleges zijn voornamel...
WEEK 5: Reflection on the role of the psychologist
Lecture 9 (video lecture); Reflection on the role of the psychologist
Evidence-based practice (EBP)
Based on the fundamental principle that people have
the right to the best possible care.
One of the components is evidence based treatments,
which are based on research.
EBP is not the same as EBT EBT is part of EBP
it’s a part of it, but more components are important. However, in practice we rely mostly on EBTs.
You as clinical professional are just as much part of EBP clinical reflexivity as imperative for good
practice. Your role is to balance difference sorts of information, either based on science, experience or
ethical considerations.
Ethics of clinical practice
Evidence-based practice (EBP) > Evidence-based treatment (EBT)
“The APA Task Force defined EBP as “the integration of the best available research with characteristics,
culture, and preferences (APA Task Force 2006, p. 273)”. (Duncan & Reese, 2013, p. 980)
“Practitioners must use their clinical judgment and expertise to determine how to implement, and if
necessary, modify a given approach for a particular client, in a particular circumstance, at a particular time.”
(Duncan & Reese, 2013, p. 983)
You as a professional have to make a translation of universal knowledge to a particular patient, which is
called dissemination. That translation is not one-to-one. It’s not just just the transference from science to
practice, but it also involves a translation in which you as a psychologist play a vital part.
Ethics and evidence-based medicine (EBM)
EBM starts from a moral position, based on values (Gupta, 2009, p. 280-282):
o Health is a good that we should pursue
o If we should pursue health, then we should pursue the most effective means of pursuing health
o We should pursue evidence-based practice
this is the core of the buildup of evidence based medicine. This stems from utilitarian ethics.
Utilitarian ethics (greatest happiness for the greatest number allocation of means) rather than
Deontological ethics (meet needs of every individual in the best possible way). In EBM we rely more on
utilitarian ethics.
“This is not to say that deontological and virtue ethics commitments are dismissed (in evidence based
medicine); however, the central purpose of EBM practice is not to foster our virtues or enhance our actions
or duties towards patients.” (Gupta, 2009, p. 281)
Ethics and evidence based practice in psychiatry
“EBM’s approach to decision making gives researchers, first and foremost, the authority to define what
constitutes improved health or decreased harm to health. It is researchers who typically choose the
outcomes under investigation in medical research, and it is these outcomes that EBM seeks to achieve.”
(Gupta, 2009, p. 281). This means that what we define as health is in hand of the researchers.
The core task in psychiatric EBP is to ‘determine who can be thought of legitimately as having a psychiatric
disorder. This task requires that psychiatrists possess shared and objective standards of what constitutes a
psychiatric disorder.’ (Gupta, 2009, p. 277-278). For this purpose we need shared and objective standards.
Two problems (Gupta, 2009, p. 277-278):
o “They rely primarily on self-reporting of symptoms. Apart from observing patients’ behaviors,
there are few objective methods of assessing most psychiatric disorders, […which] increases the
likelihood that psychiatric diagnoses contain value judgments—rather than scientific judgments—
about what is normal and what is abnormal” By our aim in psychiatry to adhere objective
standards, we actually open the door to value judgements.
o “How to draw the line between normal and abnormal in domains that exist along a continuum and
where the range of normal is wide”
Domains of medical ethics
, 2
Ethics of clinical practice
Foucault: The Birth of the Clinic (1963/1986)
o Power explained via the panopticon architectural design as a sort
of metaphor (Jeremy Bentham). The middle is the surveillance
tower and no matter where you are in the building, you can see this
tower. However, when inside the building you can’t see if there is
someone in the tower. This makes you feel like at every moment
you are being watched. This creates the opportunity to being
watched without knowing if you are actually being watched.
Because of the knowledge that you may be watched at all times you
know that there may be punishment if they don’t behave/adhere to
rules. This surveillance tower and this design makes is possible to
register all behaviors of everyone in the system.
Prison
Schools
Psychiatric hospitals
o Discipline via surveillance & registration. Why is this relevant for us? He uses this idea as a
metaphor for how psychiatrics work. He calls this the power of analysis.
o ‘The power of analysis’
‘Identification’ in dichotomy (e.g., normal/abnormal) every individual is marked by
dichotomoy (= individualisation).
o This identification based on dichotomoy is a basis for exclusion (e.g. you need to be hospitalized or
go to prison, it’s about putting people aside and in a place where they are not completely
autonomous anymore ) Collective system (every person who identifies as ‘normal’ substantiates
the dichotomy normal/abnormal) Internalising effect on people who will be called normal or
abnormal and will wonder where they belong in this dichotomy. By calling yourself normal you sort
of allow that other people can be called abnormal. Everyone is a part of this system of identification
and exclusion.
Dichotomies and ethical differentiation
Dichotomies are quite present in our psychiatric realm
“The language of clinical psychology remains the language of medicine and pathology – what may be called
the language of the illness ideology.
o Terms such as symptom, disorder, pathology, illness, diagnosis, treatment, doctor, patient, clinical
and clinician are [used].
o These terms emphasize abnormality over normality, maladjustment over adjustment, and sickness
over health. Differentiation, abnormal over normal, sick over health. What we call
normal/abnormal depends on the time in which we live (time-specific)
o They promote the dichotomy between normal and abnormal behaviors, clinical and nonclinical
problems, and clinical and nonclinical populations. differentiation (time-specific)
o They situate the locus of human adjustment and maladjustment inside the person rather than in the
person’s interactions with the environment, or in sociocultural values and sociocultural forces such
as prejudice and opposition. identification on basis of dichotomy (individual-level)
o Finally, these terms portray the person who is seeking help as passive victims of intrapsychic and
biological forces beyond their direct control who therefore should be passive recipients of a
expert’s ‘care and cure’.” exclusion (dependence)
This leads to people feeling like experts and feeling OK to take over autonomy from others. This puts people
in different positions in a hierarchy.
The case of ‘difficult patients’
“The fact that current treatments are not a good fit for these patients was seen as a major problem. Some
participants [health care professionals, FT] stated that they believed that these patients would cease to be
“difficult” if they could participate in a program designed to meet their needs. Participants partly blamed the
lack of suitable treatments on the poor [unidimensional, FT] diagnosis of these patients (its
unidimensional). They also criticized the term “difficult patients” because it may invoke half-hearted care, or
what participants termed “pampering and dithering,” (Koekoek et al., 2009, p. 696)
The use of the term difficult patient the attempt of care changes
Identification by health care professionals shapes approach
Treatment resistance
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