Monday, July 20, 2015

Psychiatry and Its Discontents

Let’s keep in mind, every advance in psychiatric medication over the past five decades or so has been touted as a godsend. In many cases these medications have worked wonders. No one who works with seriously mentally ill people wants to go back to the time when they were not available.

Many of the most important medications were prescribed for psychotic states, states that today’s psychiatry would consider to be brain diseases. From Thorazine to Haldol to Clozaril psychiatry has provided far better treatments for people with psychotic conditions.

It has also provided excellent care for people with bipolar disorder-- considered, as I understand it, as a metabolic disturbance.

Of course, with Valium, first, and then with Prozac and the SSRIs psychiatry has offered up a slew of new medications for conditions that, if they are biological at all, are considered to be part of everyday life. Some recent research has suggested that the conditions that produce depression cause biochemical brain anomalies, and not vice versa. I report the findings, but I am not competent to judge them.

When Prozac was mass marketed its success was predicated on the failure of traditional models of talk therapy. These latter were often based on psychoanalysis and often promoted the value of insight and awareness and understanding.

Since that time, cognitive and behavioral treatments have become more available and have been recognized as more effective than the insight based treatments.

I mention this to point out that when one talks about psychotherapy, one needs to be clear what kind of psychotherapy one is talking about. Between cognitive treatments and psychodynamic psychotherapy there is an abyss. One does best not to confuse them.

According to Dr. Richard Friedman psychopharmaceutical research has not made very many advances lately. It has not been offering very many new and effective treatments:

AMERICAN psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.

With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.

Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.

Friedman bemoans the fact that psychotherapy has gone out style. He says that this is happening at a time when psychotherapy—we do not know here what kind—has been shown to be effective in treating depression and anxiety disorders. This is undoubtedly true, though it applies primarily to cognitive and behavioral therapies.

In Friedman’s words:

First, psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses like major depression and anxiety disorders; second, a majority of Americans clearly prefer psychotherapy to taking medication. 

He might have mentioned that a clear majority of people in Great Britain also prefer psychotherapy to pills, and that they also prefer it to psychodynamic psychotherapy. I posted about this last year. Link here.

It is true, as Friedman adds, that it is cheaper and faster to give a pill than to deliver psychotherapy. For my part I would ask how many of today’s psychiatrists and psychologists know how to provide cognitive therapy? Is the psychiatric profession teaching young residents how to perform cognitive therapy? In some places, notably Payne Whitney, where Friedman practices, they do provide instruction in Marsha Linehan’s cognitive approach to borderline personality disorder, but I suspect that most American psychiatric residents do not receive such training.

And yet, cognitive and behavioral therapists do not provide insight or self-understanding. I disagree with Friedman when he says:

There is often no substitute for the self-understanding that comes with therapy. Sure, as a psychiatrist, I can quell a patient’s anxiety, improve mood and clear psychosis with the right medication. But there is no pill — and probably never will be — for any number of painful and disruptive emotional problems we are heir to, like narcissistic rage and paralyzing ambivalence, to name just two.

I do not agree that narcissistic and rage and paralyzing ambivalence vanish when a patient has attained to self-understanding. What is called self-understanding has always involved finding a convenient narrative that pretends to explain your problems, but that, more significantly, provides you with access to a group of people that believes in the same "truth."

In the past, the narrative would have involved the Oedipus complex. Today’s therapists are likely to tell you that you are a narcissist with control issues. (I expect some gratitude for having saved you years on the couch.)

The point is, such insights do not tell you anything about your problems and do not tell you have to solve them. The only way to get over an inability to make decisions is to make decisions. Knowing why you can't make decisions will not get you any closer to that goal. Self-understanding provides you with a narrative you can believe in and that will make you feel like you belong to a group filled with like-minded people.

Finally, Friedman references a study that shows how PTSD can be treated with psychotherapy. As always, one study does not a spring make, but we will take it at face value.

Here Friedman describes it:

Dr. John C. Markowitz, a professor of clinical psychiatry at Columbia University, recently showed for the first time that PTSD is treatable with a psychotherapy that does not involve exposure. Dr. Markowitz and his colleagues randomly assigned a group of patients with PTSD to one of three treatments: prolonged exposure, relaxation therapy and interpersonal psychotherapy, which focuses on patients’ emotional responses to interpersonal relationships and helps them to solve problems and improve these relationships. His federally funded study, published in May’s American Journal of Psychiatry, reported that the response rate to interpersonal therapy (63 percent) was comparable to that of exposure therapy (47 percent).

My only question here is how a focus on “patients’ emotional responses to interpersonal relationships… helps them to solve problems and improve these relationships?”

Unfortunately, this standard definition of interpersonal therapy is not rigorous. If it means that you should focus first on your emotions, the technique will most likely come up short. It will cause you to introspect, thus to detach from real life situations. As I have often documented on this blog, introspection is largely a waste of effort. See yesterday’s post on anxiety.

If, however, the treatment begins with a focus on real world situations and problems and reads emotion as one among many indicators that help to guide you toward an effective approach to the situation, it would be more closely akin to coaching.


Pogo: I never said I was a diplomat said...

I seriously love this blog. Just started reading your book as a result.

I am an internist and work with chronic pain patients.

Your insights have been invaluable to me and, consequently, to my patients.

Stuart Schneiderman said...

Thank you... much appreciated!!

Ares Olympus said...

re: I do not agree that narcissistic and rage and paralyzing ambivalence vanish when a patient has attained to self-understanding. What is called self-understanding has always involved finding a convenient narrative that pretends to explain your problems, but that, more significantly, provides you with access to a group of people that believes in the same "truth."
re: In the past, the narrative would have involved the Oedipus complex. Today’s therapists are likely to tell you that you are a narcissist with control issues. (I expect some gratitude for having saved you years on the couch.)

I think about Mr. Househusband in the previous blog, with the liberated wife here. How could a therapist (or psychotherapist) help liberate an abused househusband? How would a therapist "treat" his sensitive complacency if he was say only concerned his wife's behavior would harm their children?

How do therapists deal with a patient who wants nothing for himself, just wants the best for his children?

If "self-understanding" always reduces to a narrative that pretends to explain, what else is there besides a narrative? Is there any narrative besides blame?

One blogger I like, John Michael Greer, had a saying "Knowing many stories is wisdom. Knowing no stories is ignorance. Knowing only one story is death."

The "explanation" of this "narrative" is that there are many points of view, and wisdom comes from weighing them against each other. Refusing to be reflective at all perhaps doesn't "shutdown" our story telling, it just makes us ignorant about what beliefs are behind our judgements and assumptions. But the biggest problems may come when we PRETEND there is only one right answer that must be right for everyone, and stand for that no matter how much it would seem inferior to other answers.

So the value of a therapist in my mind would be to help verbalize what assumptions a patient is making and hint at possible blind spots, and reflect what those assumptions look like from the outside. This might be hard I admit. Perhaps some therapists are better than others? Perhaps most people would be terrible therapists, even if they spent a lifetime of study?

So instead perhaps Valium or Prozac or some other medication will magically make his worrisome concerns over negative affects of his wife's choices on the children go away?

Or then again, perhaps a Life Coach would do better, and when advice is requested he could tell a patient to "experiment" saying "no" to his wife sometimes, on small things just for practice, and see what happens? That might be a stretch, or not.

Or maybe a combination of drugs and expert advice, so many ways to offer hope, assuming we even know what outcome is optimal.

Anonymous said...

This is a biographical article about Marsha Linehan:

Here is an introduction to Dialectal Behavior Therapy (DBT):

Mindfulness and tolerance of whatever state of mind arises or does not arise are the essence of any meditation practice. Here they are called aspects of cognitive therapy.

Acceptance and gradual change is the pattern experienced by a well-parented child.

These therapists have a lot more mindfulness practice to do if they think the labels applied to suffering persons (disorders, disease, etc.) are aids to self acceptance. I can tell you from personal experience such labels are nothing but stigmatizing judgments imposed by others who are not aware of how their mind generates judgments.

Stuart Schneiderman said...

Of course, I have previously written about Linehan... see this post from May:

Anonymous said...

Regarding the prior article, where the young man could not beat depression via professional success as a performer and via compliance with the advice of mental health experts, the reasons for such failure are described by Alice Miller in The Drama of the Gifted Child. Neither success nor compliance with the expectations of others can substitute for the painful loss of love as a child. In fact if one had not been loved and accepted as they are as a child, and instead had to perform for the sake of others, to be and become what others need and want from the child, then the young man's strategy for "beating depression" (residual pain) is nothing but a reenactment of submission to the demands of others to be a successful performer and comply with the diktats of some external authority figures. One can enjoy success and relationships in the presence for what they are, but one cannot fill a whole in the soul by playing roles in life which continue to operate primarily as substitute gratifications.

The practice of Zen Buddhism appears to be the operative foundation of DBT.

Anonymous said...

Errors in comment above. Last sentence change presence -> present and whole -> hole.

Zen Buddhism teaches the Four Noble Truths and the Path of Right Action.