Treatment as Usual

I am a member in a work group that is developing national guidelines for treatment of conduct disorder. It is most interesting although bothersome work. Hundreds, thousands of scientific articles have been written about conduct disorder. We are reviewing evidence base for treatment recommendations in a most rigorous way. There are a number of high profile approaches for prevention or treatment of conduct disorders, as there are for other mental disorders. But when you really start to critically review the evidence of their superiority, it is not only revealed that the developers of a method always get better results that subsequent independent research teams, but also that research on complex psychosocial interventions is too often inconclusive. Carrying out a randomized controlled study – the golden standard for obtaining solid evidence – evaluating a long-term and complex psychosocial intervention is most complicated a task. One problem is, what to choose as control intervention. That will often be treatment as usual, TAU. I have now found out that TAU is quite an excellent treatment, in conduct disorder and many other conditions. Particularly Swedish TAU seems good. I assume that Finnish TAU resembles that in Sweden.

But seriously, treatment as usual need not be something small and insignificant. Treatment as usual often combines elements of various specific treatments, flexibly according to the needs of the patient. There are highly skilled professionals working in Finnish adolescent mental health services, with positive attitude towards continuously developing their competencies. But it is very Finnish to invalidate one’s own work: This is just… I am only… Of course I am not formally qualified as… We really appreciate formal qualifications in Finland. There are always more formal qualifications that are still lacking. It is known that in patients randomized to waiting list, not even natural improvement may take place, due to the painful knowledge of being in the waiting list and getting nothing. I wonder if some patients unnecessarily get that painful feeling when the skilled professionals invalidate themselves and the treatment they give.

The need of psychiatric help seems to be all increasing, at least increasing numbers of referrals across psychiatric services suggest so. Public discussion is also concerned that people don’t get enough help. Many seem to think that only those who are taken to inpatient care are getting treatment. Sad stories are portrayed where not being admitted to hospital is presented as culmination on injustice. On the other hand, de-institutionalization has long been seen one of the greatest development of Western psychiatry. Psychiatric hospitalization has been portrayed as the evil, unjust isolation of the mentally ill from the society, destructive solution for everyday disputes where one is being scapegoated and punished with hospitalization because of breaking social norms. Obviously the tide is turning in this matter.

I had thought of making independently some exercises on pointé shoes before the start of the fall term ballet classes. But then I was not that disciplined. I managed to make myself believe that after the very hard exercising in the spring, some rest was good and my acquired skills might actually consolidate during resting period. But unfortunately they didn’t. However, I have improved some stretches. One can always improve and do better! Now, more exercise…