How Not to Treat Psychiatric Disorders

Erica Komisar’s Wall Street Journal op-ed starts out well-- until it goes completely off the rails.

She opens by suggesting that psychiatric medication is overprescribed. This is very likely true, though I am hardly qualified to venture a guess about the issue.

You’ve probably heard that anxiety and depression are “brain disorders” that must be treated with psychotropic medication. That’s closer to a pharmacological marketing slogan than settled science. These conditions, along with ADHD and addiction, result from trauma, loss, psychosocial stressors and failed relationships. Even when there is a genetic proclivity to severe mental illness, such as bipolar disorder and schizophrenia, the environment plays a central part in triggering the disease.

Besides, some of what are gingerly called mental illnesses are really physiological conditions. One understands these days that bipolar disorder is a metabolic disturbance and that schizophrenia among other psychoses is a brain disease.

Komisar does not seem to care about the importance of medication in these cases, so she defaults to something called environmental stresses. In truth, some of the most important improvements in psychiatric treatment over the past decades have involved the discovery and prescription of new medications.

Everybody knows this. It is not a secret. It does not obviate the fact that some of these medicines are overprescribed, and that even internists prescribe them, but to dismiss them out of hand for as much is irresponsible.

More important is the fact that neither Komisar nor I, not being physicians, has any real business offering advice on medications. 

And there are mental disorders like depression or anxiety. Why has it happened that the nation and much of the world has embraced medication as a treatment option for these conditions.

The simple and easy answer is-- that talk therapy, especially the kind promoted by psycho analysts like Komisar, does not and never has worked as treatment.

Since I used to practice psycho analysis, I have some basic knowledge of these facts. My own psycho analyst, Jacques Lacan-- a leader in the field-- once opined in a public lecture that if someone gets better doing analysis, it is a fortunate accident, but not something that we can attribute to analysis. In 1977-- which is a long time ago-- Lacan declared that psycho analytic practice was a scam and that analysts’ words are so much bullshit. 

I have reported all of this elsewhere, some of it decades ago. And I am certainly not alone in pointing this out. Those who undertake classical analysis often do so for reasons that have nothing to do with treatment.

So, psychiatrists overprescribe medication because most talk therapies have been largely ineffective. That is the truth. Those who have a longer memory recall that when Prozac was introduced a few decades ago, the press was filled with stories of patients who had spent decades on the couch exploring their childhood fantasies-- without any change in their depressive conditions. With Prozac they showed marked improvement. 

So, the over prescription of psychiatric medication is a symptom of the fact that most long term psycho analytically inspired talk therapy is simply not effective. In truth, most psycho analytically trained therapists do not practice it any more at all.

Besides, there are certainly not enough psycho analysts around to treat the patients that Komisar wants to send to them. Her view is retrograde and absurd:

Medication can be a godsend in the right context. But it is risky and should be offered only after nonmedical options, such as psychoanalysis, have been exhausted. Why is therapy instead often a last resort for patients? In part because it is uncomfortable. Some patients temporarily become more symptomatic when they expose themselves to the origins of their pain. This temporary pain is necessary for long-term relief, but it’s easier to numb with pills.

Yes, indeed. Psycho analysis is going to offer you more pain. It will teach you to feel your pain and suffering. As for the notion of the root causes, psycho analysis has a hokey theory about that, but no one really believes that gaining insight into an origin changes much of anything about the pain.

And then there is the simple fact that, for example, the National Health Service in Great Britain and certain American insurers will no longer pay for long term psycho analysis. They will only pay for cognitive and behavioral treatments.

To that Komisar takes exception, trotting out an old slander that had been floating through the psycho world for decades.

She writes this:

Therapy is also expensive. Even if a patient does get a referral to a therapist, it will likely be a cognitive behavioral therapist who focuses on symptom relief rather than the underlying causes. The rise in CBT therapy came out of insurance companies’ demand for a short-term solution to the expensive problem of treating mental health. CBT has an important role to play in treating some obsessive disorders and post-traumatic stress disorder, and with patients who are extremely nonverbal and lack the capacity for deep introspection. But it’s being used as a go-to therapy for anxiety and depression, moving patients further from the root causes of the illness.

The reason that patients are more likely to seek out cognitive and behavioral treatments is that they are more effective. Many studies over many decades have demonstrated the point. They work where psycho analysis does not work. 

Cognitive and behavioral treatments were invented by psychiatrists like Aaron Beck who wanted to offer their patients a treatment that was more, not less effective. Since the treatment was short term, it could be provided to more patients than could psycho analysis, especially when we are talking about the kind that involves four hourly sessions a week for multiple years.

The notion of root causes is simply a lie. You can learn all you want about what may or may not be the root causes of your illness, but insight and understanding, in themselves, produce no therapeutic benefit. The idea of root causes is a relic for a past age when psycho analysis was the only treatment in town and where it needed to rationalize its treatment failures.

Komisar’s notion that we should try psycho analysis before prescribing medication is irresponsible. It is even more irresponsible since we know that the treatment she proposes takes years. How many years of suffering should we ask patients to endure? When she argues that it is good to feel pain is she not exposing the inconvenient fact that psycho analysis does not help anyone to get better.

Besides, among the more effective contemporary treatments for depression is aerobic exercise. About it, Komisar has nothing to say. Mountains of research data has shown it to be far more effective than psycho analysis, and of comparable benefit to pills. And then there are yoga and meditation, also effective treatments for anxiety. About them Komisar has nothing to say. And let us not forget the various forms of counseling, counseling that involves directly conversing with patients, that has also been shown to be effective. Since psycho analysis basically allows the patient to talk to walls, it does not produce the positive benefits that require social interaction.

So, she directs Journal readers to a treatment modality that does not work and either downplays or ignores treatments that are effective. Even if psychiatric medication is overprescribed, that does not mean that physicians should refrain from offering it until a patient has undergone eight years of psycho analysis. And, for all her presumed concern about treatment, Komisar either slanders or ignores treatments that work.

The Wall Street Journal should know better than to publish such nonsense.