Friday, October 2, 2015

Does Therapy Work for Depression?

The psycho world is abuzz today about Benedict Carey’s New York Times report about the effectiveness of talk therapy.

A recent study—already disputed—suggests that talk therapy is less effective than previously noted in treating depression. In the past such treatment was touted as helping in 30% of cases, now it is seen as helping more like 20%.

By way of comparison, anti-depressant medication provides a benefit in around 25% of cases.

Clarifications are in order here. For the most part, when the researchers are describing talk therapy, they are referring to cognitive-behavioral therapy for depression. Some of them also use a variant on cognitive treatment, called interpersonal therapy. For the most part, they are studying a treatment that can be practiced pretty much the same way by any practitioner.

It makes sense in terms of science. And yet, calling cognitive therapy “talk therapy” is somewhat misleading. It is based more on doing homework assignments and performing mental exercises than it is on a conversation between therapist and patient.

The point needs some emphasis. I consider cognitive treatments a major improvement over psychoanalysis, and I have often reported success stories from such treatments.

And yet, doing therapy by the book does create certain disadvantages. If the therapist is fundamentally disinterested in forging a human connection with his patient, this is not beneficial to depressed patients, in particular.

Keep in mind, depressed patients often feel detached from other people. They feel that they are not worthy of any real relationship. If their therapist refuses to engage them in a conversation, if he does not even try to connect with them, his attitude will reinforce their negative self-judgment and will prove an obstacle to recovery, even with constructive homework exercises.

As it happens, classical psychoanalysis, the kind where the patient lies on the couch and free associates, has always refused to allow patient and analyst to form any real connection. For that reason psychoanalysis has produced far more depression than it has cured.

It is easy to get slightly confused by the new research.  Psychoanalysis has long been called the “talking cure,” and thus is easily confused with “talk therapy.”

The research does not test psychoanalysis, because there is no real reason to do so. Effectively, psychoanalysis has been practiced for over a century now. Everyone knows that it has failed clinically. Its failure laid the groundwork for cognitive therapy and for SSRIs.

To repeat a point I argued at length in my book, The Last Psychoanalyst, namely, when the most influential psychoanalyst since Freud—that being Jacques Lacan—said that the clinical practice of psychoanalysis is a “scam” you do well to pay heed.

Lacan’s minions believe that his perfectly intelligible statement could not have meant what it said or said what it meant. If it did you would not need them to tell you what he meant and what you should think. And yet, they are wrong. Anyone who understands Lacan’s theorizing knows that if his reading of Freud was correct then psychoanalysis as a practice is unsustainable.

In truth, psychoanalysis is moribund in America. It is doing well in France where people do not think of it as a clinical treatment. There they see it more as a pseudo-religion, one that affirms their identity as Frenchmen and Frenchwomen.

The few psychoanalysts who still practice in America tend to present themselves as eclectic. They do a little bit of this and a little bit of that. They do not feel bound by the rules and the Freudian creed. Each one has his own guru, whom no one has ever heard of, but whom they quote as a serious authority.

Scientifically speaking, you cannot run clinical trials using an ill-defined,  eclectic discipline, one that changes in the hands of different practitioners and with different patients. If you were doing science and you had a dozen or two dozen different compounds and decided to call them all the same thing—let’s say: psychoanalysis—and if you then claimed that the clinical results produced by the distribution of these compounds told you something about psychoanalysis, real scientists would laugh at you.

Obviously, it is much easier to do a clinical trial on a medication than it is to do on something as imprecise as therapy. Even where the treatment is performed in roughly the same way by different practitioners, still, it happens that the practitioners are not the same. They have different skill sets, different appearances, different ways of relating, different persuasive abilities, different ages, different genders and different qualifications. I could go on. 

If the effectiveness of therapy with depressed patients in any way involves having a human connection, something that is akin to friendship, then the person of the therapist is not incidental.

Worse yet, if it is true, as the Atlantic reports, that it is becoming more and more difficult to provide good mental health treatment for men, in particular, the reason might be that the profession of psychotherapy has become a woman’s profession. This has caused it to lose prestige, for feeling more like nursing than like doctoring. Worse yet, in many cases its practitioners do not even pretend that it is science. Their minds have been infested with leftist ideology, to the point where they do not even know that they are transmitting an ideology, not helping their patients.

Thus, many men feel that if they go to therapy they will be encouraged to get in touch with their feminine sides. If not that, they feel that they are being mothered. And for most men, one mother was enough.

If men fear what feminist therapists want to do with them, they have reason to be afraid.

The New York Times has offered a set of characteristics that supposedly define the modern man. One hopes that this is a lame attempt at humor. One suspects that it is not.

Among them are these:

When the modern man buys shoes for his spouse, he doesn’t have to ask her sister for the size. And he knows which brands run big or small.

The modern man makes sure the dishes on the rack have dried completely before putting them away.

The modern man still jots down his grocery list on a piece of scratch paper. The market is no place for his face to be buried in the phone.

Does the modern man have a melon baller? What do you think? How else would the cantaloupe, watermelon and honeydew he serves be so uniformly shaped?

On occasion, the modern man is the little spoon. Some nights, when he is feeling down or vulnerable, he needs an emotional and physical shield.
The modern man has no use for a gun. He doesn’t own one, and he never will.

The modern man cries. He cries often.

If this doesn’t make him depressed, nothing will. Someone who often cries is probably depressed, intractable so. This therapeutically correct version of the modern man represents the latest in metrosexuality. It shows us why men are averse to therapy and also why, when they do go, they are unlikely to sustain any lasting improvement.

The problem is, the modern man is not a man. He is a facsimile, a weak, ineffectual househusband who has good reason to cry, and to cry often. 
If we are talking about cognitive treatment, this also means that the effectiveness of the treatment must depend on how well the patient performs the prescribed exercises. The same applies to 12 step programs, where detractors have often noted that a significant number of participants in these programs tend to drop out and to start drinking again.

If we were evaluating a course of medical treatment-- say antibiotic medication-- and if the patient chose not to complete his treatment, we would not say that the treatment did not work. We would think that the outcome was not relevant.

Also, some versions of cognitive therapy suffer from one of the same problems that doomed psychoanalysis: a failure to consider the patient as a something more than a mind. Patients are social beings. They live in social worlds. If they do not know how to navigate those worlds, if they do not know how to conduct themselves with others, if they do not know how to manage themselves and their lives, if they do not have healthy relationship habits… they are likely to fall back into depression.


KCFleming said...

Wonderful post.
I like best the comparisons between antibiotic non-users and patients noncompliant with CBT.

I myself have some 'salesmanship' capacity to get people to try CBT. But I cannot do it, and I am wholly unsuited to the task.

I do often prescribe books to patients to read on a scheduled basis.
For men, I have them read Marcus Aurelius' Meditations; some have found it quite helpful.
Stoicism seems to me a form of 1st century CBT.
Men seem to like it, much as they avoid the mindfulness-yoga end of things.

Ares Olympus said...

NYT: "The modern man cries. He cries often."

Stuart: If this doesn’t make him depressed, nothing will. Someone who often cries is probably depressed, intractable so.

Hmmm... the statement made me think more of John Boehner's tears. Maybe he was depressed, but it seems more sentimentality than depression.

And sports stars are also allowed to tear up, overwhelmed with emotion, but its more acceptable after a hard fought victory.

Yes, thinking of my own rare moments with crying as an adult, it is more moments of emotional release than sadness, like after a long period of concentrated effort and control where there was actual physical danger especially, and then finally being able to let go of that tension.

It would be interesting to look at where tears are acceptable by gender, like the scene from A league of their own where Tom Hanks says "There's no crying in baseball" after he yells at his player after she missed a play.

Obviously there must be varied social values to tears, and we might imagine children can learn tears will help them get what they want, and some women discover they can hold onto this trait, or like the Baseball movie, as a way of defusing anger of another.

Poet Robert Bly considers grief an important masculine emotion, and perhaps depression arises when there's no way for grief to be expressed?

Oh, of course, the ordinary way many men allow their sadness to come through is through the rituals of alcohol.

But anyway, good to know therapy isn't good for ending depression, and that drugs are better, at least if they haven't been recently bought up by hedge fund billionaires and then the priced jacked up by a factor of 40.

There's a lot to be depressed about, if you can't afford therapy or drugs, but alcohol is still pretty cheap.

KCFleming said...
This comment has been removed by the author.
KCFleming said...

"good to know therapy isn't good for ending depression, and that drugs are better"
1. For the reasons the post elucidated, that hasn't been demonstrated to satisfaction.
2. The two approaches are not mutually exclusive.

As to men's tears, the key point is not that men might cry, but that the NYTimes says that "the modern man cries often."
That distinction raises the idea of depression, manipulation, or severe immaturity.

Bizzy Brain said... published the article with commentary and retitled it “27 Ways to Be a Gigantic Faggot.” My favorite was, “The modern man has no use for a gun. He doesn’t own one, and he never will.” The article had to be a put on, or the writer believes the modern man should be a total pussy, which is psycho in mind, or perhaps he is a socialist nihilist.

Anonymous said...

Empirical science (physics, chemistry, engineering) shares something in common with moral science (social studies, law, economics): the effort to determine cause(s) and effect(s). Very few people in either discipline are aware of how their own mind is the mechanism that generates both causal ideas and causal uncertainty.

There are studies in the empirical sciences, such as quantum theory, where a statistical model accounts for observations in a predictable enough way, so here we have confidence in the underlying theory. However if the causal mechanisms are too complex, such as the causes of cancer or the outcomes obtain with psychotropic drugs, then there is no compelling reason to have confidence in statistical models, because multiple models can be imposed without obtaining anything other than some numbers that indicate correlation of multiple variables. This is not science, it is evidence of the phrase, "There a lies. Damn lies. And statistics!"

I became involved with men's peer counselling after reading a book, "In the Company of Men," and years later, when I looked for the same book, I learned that the title had been changed to appeal to more women, "Angry Men, Passive Men." I am reading the reviews now on Amazon and it is clear that men find it difficult to relate to each other on an emotional level and particularly men who are doomed to reenact victim, rescuer, perpetrator roles are unlikely to be able to help each other mature beyond such interactions. These are exactly the roles an abused or neglected child must experience.

Hex said...

Stuart Schneiderman said...

Better to take a look at this post, from England: said...

This female-psychoanalyst type male patients "man up" with ease after the feminist hijacking is revealed along with other perverse experiences or perceptions they have had along the way! My take on Boehner, he cried because he saw/experienced the face of all that is good. vs. the evil that runs amok.

Anonymous said...

Mr. Olympian, why do you think cars are evil? Do you not drive? -$$$

Ares Olympus said...

Mr. or Ms. $$$, I did get a driver's license after college, but haven't owned a car for most of my adult life. I've also never owned a car less than 6 years old, and shared my first one with my sister.

I'm pretty lucky that I have cheaper and healthier options most of the time - between a bike, bus, and running.

And yes, needing a 2500-4000lb vehicle to transport myself around does seem like a pretty evil thing, even if sometimes a necessary evil. I accept it's very convenient, a temporary indulgence for a minority of humanity.

As soon as I have evidence we can live in a world of 7 billion drivers acting like Americans, I'll consider my assessment.

It's surprising to me that any poor person would want a car, but it shows how powerful status is, so debt slavery is more attractive.

Anonymous said...

Mr. Olympia: Enough of your lawyering. Do you drive now??? Are you evil? C'mon.Tell the truth, you wanker. It's unnecessary to drive a 2-4K pound car (were you more cultured, you'd go metric), but only if your buy it used? Do you understand the economics of supply chain? Do you understand where things come from, or do you think tomatoes come from grocery stores? Perhaps it's too difficult for you, officially earning your the designation of an idiot. It's pretty easy to understand after all, with effort.

But your inability to separate necessary and optional evils is now evident. What are you going to do when it's not an option for most of humanity? You might just face insanity.

You are evidence you can live in a world of 7 billion people emerging as "Americans". What are you afraid of Ares? Consider as much as you wish. It won't change your mind. You're a believer.

Lots of poor people want cars. They can get around. Maybe you should try living in a low-density country.

And I'm a Mistress, but thank you for your politically correct Mizz. Believe it or not, I am still of child-bearing age, but I assume you don't want me to breed further and pollute the precious planet, populated by people with desires you couldn't possibly understand.