Mental Health: Pharmacotherapy and Talk Therapy I

Mental Health and the Brain:
A Discussion
Fall, 2008

 

Pharmacotherapy and Talk Therapy I

Our seventh session and resulting on-line forum discussion considered issues of genetics and development in mental health in the context of our earlier discussions of the brain. This week, we will move on to begin to think about existing forms of mental health therapy in that context.

Readings for this week

Resource pages for experiential therapy (on-line and Word file)

Relevant recent materials elsewhere

 

Where we've been ...

"if our mental life is solely the result of our physical brains and the interactions between the neurons/dominoes inside of them then I don't see how we can continue to believe that we have "free-will." ... MartinBayer

"As I try to review the observations and decide what is least wrong, I find myself faced with two stories. The first story attempts to explain all of our human intricacies, tendencies and abilities in terms of the intimidating complexity of the nervous system. The other story attempts to explain all our human intricacies, tendencies and abilities in terms of the intimidating complexity of the nervous system PLUS add on an immaterial self to the top of that which no one can really observe or say anything about. All other things being equal, why would I choose to believe that I have this immaterial self that is also interacting with my already bogglingly complex nervous system?" ... ryan g

"what I was suggesting was not simply that there are two stories that explain things equally well but rather we have two stories which attempt to explain the same thing to different degrees of success. Chemicals react in a specific way, they don't get to pick how they react. They respond to other chemicals in a determined way, and that is quite simply the whole story of a material brain. That does NOT explain our experience of free-will. So, I agree with you the immaterial self is a "posit" that we can't prove by pointing to some material thingy but it is a necessary one to explain our experience. " ... MartinBayer

"In appealing to the storyteller as a vehicle for reshaping meaning, is that not an act of free will? Is that not the very point of “creating meaning” that we have the capacity, the ability, the possibility, if not always the tools, to craft a new story?" ... Sophie F

"Can we perhaps find a more nuanced approach, one that will help people understand the gene story in a way that doesn’t ignore its power, while at the same time doesn’t promote false views of us as helpless automons condemned to march haplessly along a pre-determined path? ...adiflesher

" I'm worried that if we start making excuses for people based on their genes that people will be able to get away with anything." ... Ljones

"By targeting genes that influence detrimental behavior, we can at least give a genetically predisposed individual a small advantage in avoiding detrimental behavior." ... Paul B

"where does this sort of thing stop? What sorts of behaviors amount to things that make us unique and different, and what are pathologies?" ... ysilverman

" I believe that nature IS nurture and vice versa. One does not exist in isolation with out the other." ... akerle

"The model you have proposed (the interaction between genes and environment being dynamic and interactive) seems to be much more useful and makes more sense. The effect of nature/nurture on behavior seems like the perfect place to implement another "loop model." ... ryan g

"It would seem there is a tendency to view genes as a sort of "lowest common denominator" for explaining choices and behavior, when if fact, genes serve to make the story more complex, and indeed, more interesting." ... mstokes

"Perhaps I always thought of genes affecting an individual more physiologically that mentally or emotionally. And perhaps I believe that nurture is more important than nature, and this is incredibly shocking to me because I am a die-hard biology major and am writing a genetics thesis. So I’ll just stop here and try to figure out more ..." .... llamprou

"It is more “natural” for me to see the correlation between one’s environment and behavior rather than one’s genes and behavior, so I suppose I was clarifying for myself that the role of genes is something important to be taken into consideration." ... Sophie F

Pharmacotherapy discussion take off points

http://www.youtube.com/watch?v=v-GWXCZK5Dw

http://www.youtube.com/watch?v=yeq4gSfMXdo&NR=1

As for the drugs, there is no great mystery about the efficacy of antidepressants. We have access to the results of large-scale trials whose protocols were published in advance and whose data have been analyzed openly at every stage. Study after study shows a response rate on the order of 50 percent to 60 percent, where the response to a placebo pill is 35 percent to 40 percent. In general, most of the positive change occurs in the sicker patients. The more stringent the study, the more robust the outcome.


Just because it feels like, just because it sounds like, just because soaring drug company profits and obnoxious direct to consumer advertising seem to indicate that everyone around us is popping pills like mad doesn’t mean that they are doing so. Nor does it mean that we’re in the grip of some new, previously unheard-of, and uniquely epoch-defining social phenomenon.

 

People have been unofficially drugging themselves for as long as they’ve had the capability to do so. They smoked cigarettes to boost their concentration. They drank cocktails with lunch and dinner — and more — to deal with anxiety and despair. Prior to the modern era of F.D.A.-regulated prescribing practices, they slugged down untold quantities of tonics and bromides.


…perhaps most troubling, is the implication that a recent major loss makes it more likely that the person’s depressive symptoms will follow a benign and limited course, and therefore do not need medical treatment. This has never been demonstrated, to my knowledge, in any well-designed studies. And what has been demonstrated, in a study by Dr. Sidney Zisook, is that antidepressants may help patients with major depressive symptoms occurring just after the death of a loved one.


*******************************************
Don’t get me wrong; we have very effective and safe treatments for a broad array of psychiatric disorders. But in everyday clinical practice, we have little ability to predict which specific treatment will work best for you.


rarely does an antidepressant medication far exceed the placebo in effectiveness.


As biological psychiatry defines more and more human variation as abnormal, and as the choice of prescriptions grows, the result will be an increasing standardization of behaviors and feelings, and a reduction in freedom, as biological psychiatry inexorably circumscribes ever more tightly the range of acceptable emotions and actions.


Discovering that I had a recognized syndrome brought my parents tremendous relief. The news was comforting to me too. All I had to do, I thought, was pop a few pills and I’d be as focused and success-driven as everyone else in my school. I’d be normal.


******************************************
Calls for increased funding for pediatric psychopharmacology research are ubiquitous within the child mental-health community. The pharmaceutical industry, which now sees a children's market large enough to justify the expense, is funding several large studies, hoping to obtain FDA approval for the tested drugs.

On the other hand, studies on psychosocial interventions provide no similar profit-driven initiative for investigation. The much lower funding for this kind of research comes primarily from government. However, with the profit-motive incentive to develop new drugs and the real-life pressures to medicate children these days, there is ever-increasing pressure to medicate.

When all you've got is a hammer, everything starts to look like a nail.


The fact is, we’re not allowed to prescribe placebos in our practices, and we have patients coming to us and banging down our doors because they are miserable,” says Carlat. “We can’t offer them a sugar pill, but we can offer an antidepressant even if its effect is 80 percent sugar pill. A lot of our patients are getting better. That’s why we prescribe antidepressants even in the face of this recurrent data.”


In 2001, Americans spent more than $12 billion on antidepressant medications, the equivalent of $43.85 for every man, woman, and child in the country.

…by insisting that disorders like depression and anxiety are primarily caused by malfunctioning brains, the proponents and practitioners of biological psychiatry ignore clear evidence about the psychological and social factors equally at the core of human emotions. There is a great loss in that. As ever-increasing numbers of Americans take psychotropic pills, we all begin to believe that more and more of our feelings—sadness, shyness, anger—are illegitimate and abnormal and require biological intervention to correct.


Diagnostic and Statistical Manual of Mental Disorders, or DSM, has been revised three times since 1953—in 1969, in 1987, and in 1994. The 1953 and 1969 editions offered classifications that accorded with the psychodynamic model prevalent at their time, when conditions warranting treatment were understood to be disorders of the mind. Then, in 1987, the language abruptly shifted, and diseases of the brain became the new currency. Whereas in 1953, the DSM had named 60 psychiatric disorders, the current DSM describes over 350 diagnoses. Surely, a 480 percent increase in identifiable psychiatric abnormalities cannot have resulted solely from dispassionate scientific discovery.

 

Comments

adiflesher's picture

Better model of health

I have really enjoyed the dialogue in the forumthis week and it has me thinking a great deal about all the issues raised.

 

Martin’s comment about distribution of resourcesreally made me think a great deal about the question of health and MentalHealth about what the most effective ways to enhance it in society are.

 

In general, my sense is that our system stillrelies too heavily on a band-aid model of medicine. For example, we invest aton as a society in good surgical and pharmacological remedies for heartdisease.  But heart disease in the ratesthat we are seeing it in the United States is really a combined problem ofdiet, exercise and stress.

 

If we were really serious about health shouldn’twe try to find ways to keep people from getting heart disease in the firstplace?

 

The other thought that comes to mind is the close correlationbetween physical health and mental health. Very often when we are dealing withphysical ailments we are really dealing with underlying mental causes.  For example a person who is suffering fromheart disease, might be very obese.  The obesitymight be related to an unresolved conflict between their story-teller and theirunconscious – that keeps them, despite the advice of friends and family anddespite their own better intentions from being able to help themselves. In thiscase the physical illness is just a symptom of the underlying unresolvedconflict.  

akerle's picture

I will not disagree that

I will not disagree that pharmacotherpay is a hugely useful and important aspect of the mental health industry. But I do sometimes wonder if, at this point, we are using a 'sledgehammer instead of a needle'. This is not to trivialise the overwhelming nature of mental illness, but I think that we may sometimes be using medications based on a very simple cause and effect principal. As ryan said " Pill X affects structure Y which is responsible for symptom Z". I'm not sure that the brain, as nuanced and complex as it is, can really handle this kind of treatment. There are so many variables. I think the issue is not pharmacotherapy per se, because as we have seen it can be immensely useful- especially in conjunction with talk therapy, but the lack of knowledge on the nuances of the brain. The saturating effects of drugs do not replicate the brain's natural functions and for that reason can have drastic side effects, sometimes worse than the original symptoms. If the drugs really did work all the time without any side effects perhaps pharmacology would not be such an issue. Time, research, trial and error- perhaps those things are MORE important and tenable than a complete re vamp of the medical industry. 
llamprou's picture

Thoughts

Hello All,

I have not had a very healthy weekend andmaybe forced to miss tonight’s discussion but I wanted to let you all know howI felt about last week.

I will be the first to admit that Ibelieve talk therapy in conjunction with other forms of therapy and even solois extremely beneficial. However, I do wholeheartedly agree with Martin thatpeople in today’s society have begun to depend upon talk therapy so completelythat often times they are no longer capable of thinking about issues andproblems by themselves and coming to productive and coherent solutions. I alsobelieve that in the past the ability for members of a family to talk aboutissues, problems and concerns created a strong foundation for familial supportand development.

In regards to Yona’s comment that alarger portion of the human population have ‘underlying problems that can behelped through therapy’, I do not disagree, people are bound to have problems,and a lot of those problems can be helped using talk therapy but those problemscan also be helped through individual contemplation and analysis. Human beingsare engineered survivors, and if all therapists were to disappear – at least inthe past – it wouldn’t be the end of the human race, as we know it. I also amuneasy about the comparison between a yearly physical and mental health care.If I were to tell a physician that my entire body hurt, that I had horriblecoughing fits, that I was out of breath after walking up a stair case, but thatI also smoked like a chimney, drank like a fish and ate only trans-fats, hewould wonder why I hadn’t put two and two together. I feel like it is the samewith a surplus of talk therapy, people complain about unhealthy relationships,estranged familial relationships, and everything else under the sun. If thosepeople sat down and thought about their relationships and why they had reachedthe states they had, I am pretty sure they would be able to reach somesemi-decent conclusions and then proceed to take reasonably well-plannedactions. I do fear that in constantly asking for mediation in our lives the daywill come when we no longer know what is good for us, what we can handle, whatwe can’t and what we simply don’t want to.

I do feel as though at least in thiscountry, medication is over-prescribed and certain problems can be handledwithout popping several pills. However, I also know first hand that sometimesmedication is absolutely the fastest and most effective way to bring a personback from a place they really do not want to be. I believe that the phrase ‘everythingin moderation’ really applies here.

I will certainly write more later, butunfortunately I feel physically exhausted from just sitting up at the computer.Hope you all have a great class!

ysilverman's picture

Hmmm ... The doctor might

Hmmm ... The doctor might very well ask you to put two and two together.

But it has been shown time and time again that quitting smoking, quitting drinking, and changing eating habits are extremely difficult to do without medical/social/psychological support. It's a lot easier to pinpoint our bad habits on our own (I smoke, I drink, I eat too much, I eat too little, I do heroin, I'm afraid of commitment, I need tons of structure or I fall apart, I chafe under structure, etc.) than it is to implement change on our own. Would you suggest to the person you described above that she not seek out medical care, because with contemplation, she could figure out what her problems were? Just because she recognizes her culpability doesn't mean there are no current heart/lung/liver problems that need to be addressed, nor does it mean she is easily able to make those necessary changes. 

I think you are probably right -- we aren't as clueless to the machinations of our mind as we sometimes imagine/present ourselves to be. But I think a lot of times we are clueless as to how we can exact change, and that is where professional help can be of use to most people, I believe.

adiflesher's picture

Next generation of therapies?

I think that Ryan raises a really good point.Its interesting to ask the question - "Howdoes a given therapy affect the Brain." But we should not get caught in thetrap of assuming that tracing physical correlates is going to reveal the "real"nature of Mental Health and illness.  Asyou said we can assume that every experience has physical correlates in thebrain - and that every experience changes the brain.   So we can ask other questions:

 

Forexample how does meditation or prayer affect the brain?

Howdoes diet affect the brain?

Howdoes playing piano affect the brain?

 

But to really be effective in mental healthwe are always going to be forced back to dealing with both the brain and thesubjective experience of the story teller.

 

As for what this suggests for next generationof therapies - we should always be curious about how small changes in the braincan cause significant changes in the storyteller.  See this fascinatingarticle regarding how ovarian cysts were shown to cause schizophrenic symptomsin young women.

 

But we should remember that while a troubledstoryteller may be caused by an ovarian cyst, a bump to the head, a stroke, theloss of a loved one, abuse, or a host of other causes - that originate in thesocial or physical world - the story-teller is on some level what makes usuniquely human. 

 

To really define mental health and mentalillness - I think we have to continue talking about the storyteller even incases like my father's where the root cause of the illness could be clearlytraced to a very clearly identified problem with a brain structure.

kmanning's picture

Brain chemicals and the story teller

I have been puzzling over many of the same issues Ryan brings up. I feel that a lot of what I have learned so far this semester has led me to feel that though we aren't even close to understanding all the complex functions of the brain, all of who we are is in indeed created and maintained by the structure of our brains. For a long time I have struggled to place the story teller; to really understand how it functions and how to comprehend it. We refer to it and utilize it in class as an autonomous part of us that picks and chooses from different signals from the unconscious to create a story – a description that is much more conceptual and philosophical than physiological. But then again we also place it in the neocortex, a *physical* part of the brain.

I think the story we are telling about the story teller is a very useful one given the current understanding - or lack there of I should say - of how consciousness works. However, I struggle with a debate between which is more effective, talk therapy that helps us to tell a new story, or drugs that alter brain chemistry, because it seems to me like comparing apples and oranges. Or rather, thinking we are comparing apples and oranges when really we are not.

When we talk about telling a new story, we are talking about changing attitudes, behaviors and cognitions. However I feel like we need to stop shying away from the view that talking about the physical basis for mental illness somehow diminishes its importance, and instead embrace it as truly empowering. Recent research shows more and more how talk therapies have similar physiological effects on the brain to drugs. - the story teller and drugs are both effecting the same kinds of changes in the brain, this is amazing! The more I learn about the physiological effects of talk therapy, the more I find it hard to talk in terms of the story teller, because it seems to be glossing over, as Ryan mentioned, the physical mechanisms in the brain for how it works. We know the story teller does effect changes in brain chemistry that can be measured through scientific tests, and I feel like this should prove once and for all that talk therapy and drugs are working towards the same goal. To say one is better than the other makes no sense to me – they are both methods for achieving the same goal, neither of which we know nearly enough about to be making nay kind of sweeping generalizations.

Similarly, being concerned that drugs are perhaps missing the “underlying cause” of a problem I feel could just as easily be said about talk therapy. Though talk therapy can certainly help us recognize some of the thoughts that are causing our mental states, perhaps there are issues in brain chemistry that the “story teller” simply wont ever be able to address. To be saying we are missing an underlying cause almost seems to go against so much of what this class has taught us –that there is no “right” way for the brain to be, and that underlying objective causes are perhaps better understood as subjective interpretations. Sorry if not all of this makes sense, it’s all still very jumbled in my mind!
Paul Grobstein's picture

chemicals and the story teller

Yes, of course, the story teller involves neurons and chemicals, just as the rest of the brain does. But it doesn't necessarily follow from that that the same therapeutic procedures can be used in the two different cases. Nor that all effective therapies act in the same way. Cf. Brain data reveal how psychotherapy work.
ryan g's picture

My thoughts

Recently, I have noticed my thoughts going back again and again to the physiological side of things.  I keep asking myself, "how does this affect the physical structure of our brains?"  

I am reading a book right now about  a neuroscientist who suffered a stroke, recovered, and went on to write about the experience.  She reveals how she observed her cognitive functions melting away piece by piece as the blood filled her brain and destroyed more and more tissue.   

This book, along with a lot of our exploration this semester have made me realize how much of our existence is in the physical structure or our brains.  If it's not all of it, then it's pretty close.  I understand that this is not a brilliant revelation, but its developing more and more significance in my own mind.  

So, one of my issues with therapy is... how does it work?  What is the mechanism?  I am not arguing that talking, or culture, can't affect our brains.  I'm just saying that if most or all of us exists in the neural circuitry of our brain, then why don't we focus on manipulating that circuitry to achieve the changes we want?  

This is why drugs are particularly interesting to me right now.  They seem to provide a concrete way of providing change.  This also seems to be why drugs have more credibility than therapy too.  Some guy in a white coat can stand up there and say "Pill X affects structure Y which is responsible for symptom Z."

I'm not saying that therapy doesn't work.  I'm sure it does for some people... maybe it could for all people.  I think we can accept that and move on.  I think a more useful question is how does it work?  How does it change the neural connections that shape my experience?

I feel like the answer to this question, as well as a more subtle understanding of the connections in the brain and our ability to manipulate them will lead to the next generation of treatment.   

  

 

jrlewis's picture

I understand talk therapy to

I understand talk therapy to work as a series of inputs to the brain, via the usual physical structures.  These inputs are interpreted by the cognitive unconscious and the storyteller.  What is special about these inputs is that they are designed to target storytelling activity and inspire introspection and revision.  Perhaps by altering the existing neural circuitry.   Cyril Herry et al. claim their “findings indicate that switching between distinct behavioral states can be triggered by selective activation of specific neuronal circuits integrating sensory and contextual information.”  I think that there is a two-way path between neural circuits and behavior.  The storyteller is capable of traversing that road. 
ysilverman's picture

I agree fully and

I agree fully and completely with the importance and validity of talk therapy. And I disagree wholeheartedly when Martin says:

"On the other hand, forms of talk therapy (with a medical proffessional) that are used as a continuous crutch for people throughout life is an unneccessary strain upon an already strained healthcare system. I think the type of support that people get via talk therapy when they don't really have an underlying problem can and should be found among friends and family."

I think that *almost everyone* has an underlying problem that can be helped through therapy. (I know we're trying to move away from the comparison between mental and physical health ... But to bring them together again, at the same time, I feel that there is no reason that people need physical health care -- a yearly physical, sick visits,  medication when sick -- and yet don't need comparable focus on mental states.) Terms like "crutch" and "underlying problem" are never used in reference to physical care. (In fact, we blanche when a physically healthy person says "I haven't been to the doctor in twenty years," yet consider it a "strain on resources" when a seemingly mentally sound person deems it necessary to talk to a professional about perceived psychological issues?)

And yet I found Antonia's comment about medication troubling too. If the view we are looking for a is a more nuanced one, our process shouldn't necessarily be about dismissing options that are viable ones for many people. Lots of people who go on medication don't go one it because it is the easiest answer, but because it is one answer that works (and for some people may work better than others). I would concede that medication is most effective in concert with talk therapy (though there are people who, I believe, may need to be on medication continuously, even if they may not always need to be engaged in talk therapy). Additionally, as Merry said, there are people who need medication in order to regain the motivation to get to therapy.

I don't disagree with Professor Grobstein that medication may end up masking a symptom, but I also think that curing a symptom can, sometimes, help a person work through their own narratives to reach cures for a problem. If a person is in an untenable situation, and gets depressed perhaps because of it (on an anti-medication site I looked at a someone brought up a story of a women who was given medication because of her anxiety about her husband's reckless investment of their money -- and then their husband lost of all of their money) medication may fix a symptom, putting the person into a mental state in which they feel able to work towards solving problems. 

I agree with Sophie that pathologizing can be a dangerous thing, and I think ADHD is one of those diagnoses that seems truly odd when looked at from other angles. (If 2,000,000 kids are taking ADHD medication, maybe the problem is school, not them.) Still, I worry simultaneously about balancing the process of de-pathologizing with a push to increase accessibility to mental health treatments. In the classroom I agree wholeheartedly. But, I feel like it has been such a battle to get people to recognize the severity of so many of these issues -- I know a few people whose necessary mental health care bankrupted them, and certainly there is still a stigma against mental health problems -- and I don't know how do-able this feels. Though maybe this practical worry is besides the point. (Isn't the motto of the week "Yes we can!"?)

Sarah's activity was fun ... Though I don't know if it seems particularly therapeutic to me (except in the sense that I think most examined actions can lead to growth and change -- which, I guess, is a pretty real sense, so, I take that back). 

Sophie F's picture

Some thoughts...

I think the problem is not with the medications themselves that are used to treat mental illness, but the framework in which they are utilized. The medical model, indeed, often sees intervention as being the only and best way in which to alleviate stresses to the body. This myopic understanding of health, mental and otherwise, is of great detriment to the patient and physician alike. Physicians are trained in specialization of the body, not its connectedness, as evidenced by the growing number of clinical sub-specialities. It is this view of health and the body that makes medication an obvious choice in cases of mental distress. Cause and effect in disease and mental health are not always so linear as to make a “magic-bullet” the ideal “solution” to complicated, multi-faceted problems. This can be a problem with talk-therapy, too, when the symptoms as they manifest to an outside observer or are reported by the patient reign supreme over the “whys” of the scenario, over the individual experience of the patient of that “illness.” Treating symptoms is the hallmark of modern medicine, but overlooks the context in which illness takes place, the individual who is experiencing the illness. And what is that individual’s experience of the illness itself? This may well not be as formulaic as medicine would like to think. When medication can be utilized to enable a person to be more available, emotionally, physically, etc. to engage in re-shaping their story, I think it is important, perhaps necessary. As was raised in class, a valid and important issue of which to be mindful is the potential for the medicine to mask the underlying problems and to become, yes, a “fix” to the problem, but sometimes one that is not sustainable without medication. I’m not sure this is a desirable end. If mental health can be viewed as the possibility of continually refining and reshaping out ability to tell stories that maximize choices (free will?), medication alone may not enable us to do that in the long-term, though it may allow us to be open to the possibility of revision of our stories. Psychiatrist Peter Breggin, writes :

“Children become diagnosed with ADHD when they are in conflict with the expectations or demands of parents and/or teachers. The ADHD diagnosis is simply a list of the behaviors that most commonly cause conflict or disturbance in classrooms, especially those that require a high degree of conformity.

By diagnosing the child with ADHD, blame for the conflict is placed on the child. Instead of examining the context of the child's life why the child is restless or disobedient in the classroom or home - the problem is attributed to the child's faulty brain.”


I think this raises an interesting issue, one of which to be wary. By pathologizing to a greater and greater extent, behaviors that are in some way non-conformist, the context of those behaviors is overlooked and the underpinnings of mental distress may fade into obscurity. Medication tends to give us license to ignore the “real” problems by treating the symptoms. The issue of whether medication or therapy or both are useful ways to treat mental illness cannot themselves be removed from the contexts in which they are used. In my mind, over-utilizing therapy is not at issue here, in terms of straining the system. Many people do not have mental health coverage that adequately ensure they receive the best care, so end up cycling in and out of hospitals or taking numerous expensive medications, rather than being able to engage in meaningful long-term therapy that may enable them to break the cycle. I’m not sure how mental health parity  will in real terms affect the quality of care, but hopefully it will make access to care less of an issue. I'm not sure that more money will, in and of itself, enhance understanding or awareness about mental health, but perhaps it can be seen as a step in the right direction... 

I think a general sense of interpersonal disconnection is very much a theme of modernity. As such, therapy enable an interpersonal connection that people may not be encouraged to foster in daily life. It is not the only or best connection, but a unique and important one for many people. 

On group therapy… I really enjoyed the exercise we did in class with Sarah. For me, it was a novel way to enact the working of tacit knowledge. Prior to the exercise, I did not have a working knowledge that I may have certain intution about people. The exercise brought to light some of those unconscious understandings and crafting a story after being drawn to a particular person pushed me to examine and understand my intuition in a way that I likely would not have done otherwise.

In certain contexts, I think group therapy has the potential to be incredibly constructive in serving as a source of new understandings, alternate stories that may prove more useful for the individual. My friend attends Alcholics Anonymous and, for him, this form of therapy is useful. He is open to and actively seeking a new story and interacting with people who have had similar experiences is helping him to create a new story. I think victims of trauma and abuse, may well, also, be served by group work, where shared experience may help to diminish grief, shame, etc. and translate those feelings into a story that is less paralyzing and more conducive to health. This is all very individual, as with anything else, and, of course, not everyone is open to this kind of forum or desirous of sharing their personal experiences with a group.

On the other hand, there are contexts in which I think group therapy may not be constructive and may, in fact, be deleterious. If there is no awareness of an alternative story, the possibility of an alternative story, the story teller may well take any incoming information and translate it in such a way so as to confirm and re-confirm the existing story. In group contexts in which a number of people are dealing with the same issues, the group dynamic may serve to reinforce the existing story. Until there is awareness of and openness to another possibility, I think group work may not be constructive.

I found the notion that blogging can be considered a modern form of group therapy an interesting one  For many, blogging can be a way to share a story and receive feedback in order to create new meaning by weaving together the others’ stories and sorting out what may or may not be useful/constructive for one’s own story.

Paul Grobstein's picture

The requirments for constructive exchange, at all levels?

I wonder whether what is need to make group work "constructive" is the same thing that is needed to make more traditional therapy constructive, and perhaps the same thing that is needed to make the dialogue between the unconscious and the story teller constructive? See above.
vpizzini's picture

In many cases, the

In many cases, the treatments for mental illnesses depend on standard tools of the physician's trade: the administration of drugs, surgery or particular medical intervention. These procedures focus on repairing specific biological problems. However, this view is too easy because mental illnesses involve many different causes, some are biological but other are lodged in a person's circumstances. When a particular form of therapy must be chosen, then it's important to focus on what works instead of focusing only on how the disorder arose. In fact, there may be not a direct correspondence between the trigger of a disorder and the nature of the treatment. Drug therapies appear to be effective but it's absolutely important to seek different forms of therapy that tries to change the thinking and the behavior of the patient.

It's clear that different forms of therapy exist but do they work and why? Are they able to help people? 

Paul Grobstein's picture

pharmacotherapy, experiential therapy, and story sharing

Lots of thoughts bubbling around in my head from Monday's session. Looking forward to continuing discussion of pharmacotherapy, but glad we had the juxtaposition we had on Monday.

It would, it seems to me, be a huge step forward to get wide-spread agreement that "nobody should be allowed to just dispense drugs in order to solve mental problems." The point here is partly a simple clinical one, easily made within the "medical model" framework, and relates to observations summarized in several of the background quotes Sophie and Ryan offered us. The response to psychoactive agents is so variable from individual to individual and so context dependent that it seems to me irresponsible on the face of it for doctors to be prescribing such drugs without frequent and active monitoring of their effects in individual cases.

But there is a deeper issue here, one to which the highly variable responses to psychoactive agents is also relevant. My guess is that yes, the "story teller" is involved in "depression, bipolar, etc.", indeed in all "mental illness," that the variablity of drug response reflects this, and hence that some form of "talk therapy," some engagement with the story telling process itself, is an essential component of all good mental health work.

I'm less comfortable with the idea of a "faulty story teller that is far from reality and leads to bad thoughts." Stories are ways to summarize observations, not to describe "reality." And are "real" to people who have them, not "correctable" by appeals to "reality." What makes more sense to me is to presume that what is at issue is not a "faulty" story teller nor "bad" thoughts but rather an interaction between the unconscious and the story teller that is getting in the way of the ongoing critique and revision of stories ("unresolveable ("destructive," "unconstructive?") conflict"). The goal of mental health treatment, pharmacological and otherwise, should be to enhance story telling and revising ability (using whatever thoughts are present and result).

Maybe this perspective can be useful in thinking about various forms of therapy, drugs and others? Severe pain/discomfort, among other things, can get in the way of story tellling, and so should be alleviated as quickly as possible. This, though, should always be regarded as an interim symptomatic treatment, not as a goal in its own right. And such treatment should never be used to try and eliminate the underlying conflict without knowing exactly what that conflict is and being sure its elimination has greater benefits than costs. Pharmacotherapy is not only unpredictable but "at best a very coarse tool" for the critical issues beyond symptomatic alleviation, and will always be.

And that, of course, brings us to "talk therapy", of various kinds. Yes, there are issues here of "legitimate use of community resources," but those arise in connection with other health matters too (chronic treatment for diabetes, vision problems, etc) and so don't seem to me to get to the heart of a reluctance to embrace one or another forum of talk therapy, either institutionally or individually.

Perhaps closer is the notion that talk therapy "can and should be found among friends and family." And perhaps in a more ideal world it would be. But we live in a world in which the integrity and stability of an individual's story is often of great importance to that person's "friends and family," and so they are perhaps the last people who are willing to encourage an individual to explore alternate stories of themselves, whether they possess the skill to do so or not. To put it differently, interpersonal interactions may sometimes facilitate story telling and story revision, but they may also in some cases inhibit it. A good mental health worker should have not only the skills but the inclination to faciliate story revision. That may sometimes require a certain "professional" distance, a willingness to lay aside one's own stories and allow another person's to story evolve in whatever ways it does. And/or a certain transactional empathy that encourages story revision?

My guess is that a delicate balancing act between inhibiting and enhancing story revision is inherent in all forms of talk therapy. And Sarah's experiential therapy exercise helped me to see that more clearly. I have a lot of experience with individualized talk therapy and a lot of confidence in its potential to facilitate story revision. I'm more skeptical about group therapy, but also have less experience with it. What struck me after the session is that there is some inconsistency between my skepticism about group therapy and my sense from experience that group conversation is valuable in an educational context (like our course), that the spontaneous sharing of diverse stories can be quite productive in encouraging revision of individual ones.

That conflict, as well as several conversations after our session, has made me think more why I have been skeptical about group therapy and about the several paths of interpersonal exchange, with the upshot that my story about group therapy may undergo some changes. I suspect my skepticism about group theory in general, and experiential therapy in particular, has to do with an unconscious understanding that interpersonal interactions in groups, and associated non-verbal exchange, tend to stabilize stories rather than to encourage their revision. And that unconscious understanding must have to do with a different set of observations/experiences than those I've had in the classroom.

I need to, and will, mull this more, but the upshot of this (and some other recent experiences) is to lead me to suspect that group and non-verbal interactions have the potential to play a more positive role in story revision than I have been inclined in the past to think. And to wonder exactly what the circumstances are that would achieve that. My guess is that it depends on a context in which people in the group share a common interest in and commitment to an ongoing process of both individual and group story revision, as well as some significant level of confidence in the ability of both themselves and others to contribute to that process.

Is that achievable in a group context? I suspect so, but it depends (as it does in a more traditional talk therapy context) on an atmosphere of interpersonal trust that all involved have a meaningful role to play in the process. And that all involved will value differences among people as contributions to the process rather than use them as ways to validate one's own existing story by attacking others.

Maybe that's a key to thinking not only about group therapy but also about talk therapy in general? "when put in groups ... I go blank," perhaps because of an unconscious feeling that one will be judged rather than valued? And perhaps that one will hear things from others that will cause one to be critical not only of others but oneself as well?

Maybe talk therapy is less accepted than in might/ought to be not because it isn't effective but rather because it is? Because it brings out into the open things that our story tellers would prefer not to have to try and make sense of? Because as individuals and a culture we're suspicious of interpersonal interaction, rather than seeing it as a useful route to continuing story revision? Maybe we all need more experience with the potentials and benefits of experiential reciprocity?

kgins's picture

thoughts..

I thought the idea that a mood disorder could be a symptom was really interesting, and that by giving drugs, it would be dulling the symptom, and perhaps ignoring the real problem. If everything we feel might be a symptom, is the self, in the larger sense, the problem? Maybe we're sad because of something else going on, and maybe we can make that sadness go away with drugs, but if, under it all, the reason why we were sad stays the same, will the sadness manifest in another way? I'm a big believer in experiencing and feeling what we're meant to experience and feel. The thought of drugs scares me- it scares me that part of a person, that's maybe meant to be there, for some reason or another, can be removed, or covered. I want to believe that we are the way we are for actual reasons rather than randomness. I want to believe that maybe sometimes we're meant to be sad for awhile, if for nothing else, than to be able to empathize with and feel for someone else who may need help from someone who can relate.

I thought the talk therapy activity was interesting and difficult. I like being given ample time to consider different situations, especially when people are involved. I find that I either think things through in a million different ways, when given the time or in a one on one situation, but when put in groups, and especially under timed pressure, I go blank. I don't like saying things that don't have some sort of conscious foundation in my head in front of a group of people, since I like to be able to expand on and defend my views, and with the pressure of being in a group of people, unless I know why I'm doing what I'm doing, I know it'll be difficult to think out something the way I'd like to on the spot. I think it's also hard to genuinely tell someone you barely know why you think you can relate them to others in your life.

Paul Grobstein's picture

the interpersonal realm

I'm intrigued by the notion that interpersonal relations can both inhibit and advance story telling/revision by individuals. See below.
Paul B's picture

Storyteller as the cause of mental disorders...

Throughout last class, I was thinking that perhaps the storyteller is responsible for depression, bipolar, etc.

I think a faulty storyteller can tell a story that is far from reality and lead to bad thoughts. Such thoughts then lead to unhealthy feelings, and unhealthy feelings are the root of 'mental illnesses'.

This ties well into the whole therapy model...I think the drugs are effective in that they predispose one to more pleasant thoughts and make people receptive to therapy. However, I believe that it is only through therapy that one can adjust their storyteller to tell stories that are more in touch with reality.

Paul Grobstein's picture

story telling and ... "reality'?

Do think that indeed the story teller is involved in "depression, bipolar, etc" but "responsible for," "faulty," needing to be "more in touch with reality"? See below.
PS2007's picture

I think some other reasons

I think some other reasons that talk therapy is not as popular as medication is simply because of supply and demand.  There are not enough good therapists who have the time and can afford to help all the people that need it.  As we talked about in class, therapy has become the norm around the Upper East Side because those are the people who can afford it.  Maybe if there was some way to provide good, easily accessible, cheaper therapy more people would try it instead of medication.  

I read an article awhile ago about computerized psychotherapy, which was really interesting.  I wonder if this is the future of talk therapy:

http://www.slate.com/id/2190204/
Paul Grobstein's picture

Psychotherapy: good, accessible, cheap?

How about something that "costs relatively little and does not require legions of doctor"? As currently being tried out in India? See Psychotherapy for all: an experiment.
akerle's picture

Cultre is as culture does.

Paul's flippant comment at my dislike of the activity on Monday night really exposed something for me. I'm not british. I'll receive my citizenship in about a years time- provided I pass the test. Yet, I have been raised in a very anglophilic household and spent the better part of my education in schools with a large population of Brits. So yes, perhaps because of that I am not a big fan of public displays of emotion. But what does this mean about culture in terms of mental health?

 

When we talk about pharmacotherapy in the US something really strikes me. A great deal of American culture is based on instant gratification, fast food, fast weight loss, fast money. We like quick fixes. So maybe that is your simple answer to why pharmacology appears to be more prevelent within our society. Drugs are easily administered and require little extra effort on the part of both doctors and patients. And best of all, if you take a pill- poof! You're cured. The problem with psychotherapy is it takes a really, really long time. Years. And maybe the individual will never see the effects because for some reason or another their therapist wasn't entirely effective. 

I don't want to be anti-consumer, because I consume about as much as the next person, but I do believe that this aspect of American society in particular makes pharmacotherapy such an attractive option. 

Paul Grobstein's picture

Flippancy and apology

Paul apologizes extensively/abjectly for "flippant" comment. Is an example of risks, and benefits?, of group therapy? Maybe pharmacotherapy not only avoids "public displays of emotion" but also reduces risks, and benefits?, of interpersonal misunderstanding?
Martin's picture

Drugs and Talking

I think we all agree that nobody should be allowed to just dispense drugs in order to solve a mental problem. Some blend of the two therapies is necessary to ensure that drugs are not abused as a quick fix masking real problems that underly the mental symptoms. 

On the other hand, forms of talk therapy (with a medical proffessional) that are used as a continuous crutch for people throughout life is an unneccessary strain upon an already strained healthcare system. I think the type of support that people get via talk therapy when they don't really have an underlying problem can and should be found among friends and family. Billing your insurance company for that doesn't seem like a legitimate use of community resources. 

For that reason I instinctively dislike activities like the one we all participated in last monday. I think they can be breading gounds for peoples desire to seek self affirmation when what they might need is a stern but caring friend/realitve to tell them to cut the crap and do x y or z.  But, that is just my first thoughts on the subject. I am sure there are situations where that kind of therapy is not only legitimate but it might even be useful.  

adiflesher's picture

Illness as a profound opportunity for spiritual transformation

 

 Following up on many of the comments made in classand in the forum, I think we should remember that illness can by a profoundopportunity for spiritual transformation. By spiritual transformation, I mean, creating a new story that allows usto interpret our suffering and mortality in a new way. This may come in theform of religion. It may also come in the form a profound change in underlyingstories. 

 

I know that in my family, my father’s illness wasa reminder of how short and precious life is. It made us all re-think where we live, how often we talk on the phone,what we decide to do with our lives, our relationship with money and so muchmore.

 

 

 

In fact many spiritual traditions have use theencounter with physical or emotional pain as the root for spiritual transformation.See the example below of monks in Thailand:


“When you are a monk in Thailand, it’s almostinevitable that you will get malaria,” he said. “So when you finally get it,you don’t see it as something abnormal, but rather as a normal human experienceand an opportunity for spiritual practice.” 

When skillfully and fearlessly embraced, Chandakosaid, illness offers a rare chance to directly experience the most essentialtruths of nature. While unwelcome and painful, such an experience naturallyimparts an intrinsic wisdom that can replace deep-seated arrogance withhumility, anxiety with equanimity, and narrow self-regard with broad compassion.

 

http://groups.google.com/group/bpf-tampabay/msg/4e16ce357c572339

Paul B's picture

I don't really know much

I don't really know much about isurance policies towards therapy, but if casual therapy is covered, I completely agree with Martin that this is a strain on an already strained system.

However, I think that for people with severe mental illnesses, therapy is neccesary part of treatment that a good friend can't emulate. (and insurance companies should cover at least some of the expenses)

... however I also think that therapy should be designed to help people help themselves so that they don't rely on therapy for the rest of their lives (and strain the already strained system until they die).

Sophie F's picture

Who decides what constitutes

Who decides what constitutes an “underlying problem?” If a life-long smoker develops health problems or someone morbidly obese does, should these people not be offered care, if an “underlying problem” cannot be determined? I say they should be offered care. Why is mental health any less "valid?"

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