Psychotherapy and the Brain

Paul Grobstein's picture

Welcome to the on-line forum associated with the 2008 senior seminar in Neural and Behavioral Sciences at Bryn Mawr and Haverford Colleges. Its a way to keep conversations going between course meetings, and to do so in a way that makes our conversations available to other who may in turn have interesting thoughts to contribute to them.

Thoughts this week about

and our conversation based on them ...
JaymElaine's picture

Psychotherapy and the Brain

I found this week’s topic to be quite interesting, mostly because I was not aware that psychotherapy was as effective as it is. Understanding that some neurological medications are not nearly as effective as one would think they are, now knowing more about the use of pyschotherapy, it seems to be a more reasonable approach to treating some neurological disorders as over-compulsive disorder (OCD) and depression. And although such psychotherapy treatments as cognitive-behavioral therapy (CBT) do not work for everyone and are sometimes just as effective as pharmacological treatments, if I had to choose, I would rather take the talk therapy before treating with drugs. For as our guest speaker so eloquently stated, "the brain uses its own plasticity to heal itself," and in my opinion, this is the better treatment.

Because I was so intrigued by the use of CBT and its efficacy for treating OCD and depression, I wanted to know if this type of psychotherapy can be used to treat other disorders. So, I went on a hunt for other disorders that also use CBT as a treatment on one of my favorite websites, Google Scholar (the best for finding awesome journal articles on basically anything!), and my search came back with some interesting results. CBT is often times used to treat bulimia nervosa and even severe functional bowel disorders. CBT as a treatment for bulimia nervosa is not as effective as one would think. This psychotherapy only works about half the time, and in most cases patients relapse and/or end up taking antidepressant drugs (the link for the study is below; check it out!) However, surprisingly, CBT is really effective for functional bowel disorders (FBD)! A study was done to test the clinical efficacy and safety of CBT for FBD; such bowel disorders tested were irritable bowel syndrome (IBS), functional abdominal pain, painful constipation, and unspecified FBD. Results showed that the 70% of the randomized sample who received CBT improved in their various conditions of FBD; roughly 73% of the randomized sample who received antidepressants also improved. So this shows that although CBT is not more effective than drug use, it is just as effective as drug use, and in my book, makes it less invasive and a better option. Now why they would use antidepressants to treat FBD, I have no idea. The link for the study is located below. Perhaps one of you guys can answer that! Enjoy!

 

CBT and Bowel disorders website:

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFX-490H4G8-K&_user=423519&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000020258&_version=1&_urlVersion=0&_userid=423519&md5=3d3b16a17c5fa593920e59e8eaef147c

 

Treatment of bulimia nervosa with CBT

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V5W-3VWPK6M-1&_user=423519&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000020258&_version=1&_urlVersion=0&_userid=423519&md5=6687de2a11d83c4ec98ed3cf2d29f915

 

Jayme E. Hopkins, '08

tlogan's picture

I hate to straddle, but.....

I must also apologize for the tardiness of my response. I must start out my response with a question, directed at no one in particular, with the aim of satisfying my own curiosity: How are CBT therapies developed? As Alex says, CBT therapies, like drug treatment strategies, work best when individualized for each patient. How is this done, especially if we have no hard evidence to show what each therapy is targeting? I understand that fMRI is the best measure of change, due to the fact that we can't section patient's brains post CBT, but there must be some historical/literature basis for each technique, or else they would not be continued in practice. Do not take this as an argument for the use of drugs solely based on the idea that one can test them, as I agree with many who think CBT can be quite effective when the conditions are right.

I also heartily support the point that a combined approach is most likely to be effective, and that treatment should be specialized based on the person; though perhaps I am ill-informed, but what are the limits of CBT? Dr. Yarin pointed out that CBT and learning are somewhat analagous, but are there things that cannot be unlearned? Or biolochemical factors that prevent the acceptance of CBT, that can be ungated?

Either way, I must state that I do support the "quick-fix" of drug application if this is what is needed to allow an individual to function effectively, and perhaps once some stability is achieved, CBT can attempted. I don't feel bound to immediately denounce psychopharmacology as a corporate conspiracy, because in the end, it is the physician who controls how much/which drugs the patient will recieve (that is based on the assumption that the physician has the patient's best interests at heart). I feel as though it is unfair to assume that every company that stands to make a profit intends to take advantage of the consumer.

atuttle's picture

Do any of these options work for everyone?

Sorry for the late response! I want to reflect on what I've read in the forum this past week, and offer up a question. It seems that many of us are struggling to find the "better" of the two options available to people with different types of mental illness: Either talk therapy or drug remediation. And while many point out that there is evidence that neither therapy works in every case, the majority of responses I have read appear to be making a value judgment about these remedial options. My question is, can we reach an overall conclusion about what therapy is more "natural," more "comprehensive" or "better" without looking at conditions on a case-by-case basis?

Without repeating other people's points, Dr. Yarin conceeded that CBT does not work for everyone. Additionally, as I pointed out in class last week, talk therapy is in many ways more of an art than a science; like perscribing medication, a clinician must be sensitive to a patient's individual differences. The quality and nature of the therapeutic dyad can have far-reaching and tangible differences in a patient's improvement.

And yet, we are more than the sum of our parts. Throwing a few more neurotransmitters into our "bag of chemicals" (i.e., our brain) do not appear to offer long-term benefits. Additionally, the biopsychosocial model predicts that even when we artifically control for the biological substrates of behavior, additional variables from our past experiences and current environment can throw this delicate balance out of whack. Clinical evidence seems to support this model: The longest-lasting therapeutic benefits appear to be a combination of different techniques. That being said, different people require different approaches. To summarily praise one type of therapy over another, I believe, is premature at this point in time. Due to the complexity of our mental experience, I believe a "cureall" or "silver bullet" for mental illness is impossible. Rather, therapy must be based on the individual's specific needs.

 

~Alex Tuttle

Haverford '08

K. Smythe's picture

Psychotherapy and the brain


Today’s discussion really made me think about the advantages of both drug and psychotherapeutic treatments.  While drugs may offer a quicker result than psychotherapy (always a factor in today’s “instant gratification” society) we also must consider that because there is still so much we don’t know about the brain we can’t be exactly sure what other effects they will have on us.  However, sometimes we do need fast results.  In the end though, I think I would side with Dr. Yadin in regards to treatment- let’s try to use what we already have first, especially if psychotherapy creates a longer, more permanent effect.   

We also didn’t really talk discuss the effectiveness of drugs, therapy and a combination thereof (are drugs often prescribed without associated psychotherapy for anxiety disorders?).  I’d really like to see statistics of both “success” rates from psychologists and patient satisfaction.  Are patients more satisfied with a quicker result or is the actual act of fixing your mental glitch with your own machinery more rewarding?

Another aspect of psychotherapy that I found myself thinking about involves the importance of mental/psychological adaptation.  I recently wrote a paper for another of professor Grobstein’s classes that I am in, regarding therapy versus drug treatment for disorders such as PTSD.  One idea I brought up there that seems to relate to this issue is the possible importance of working through things ourselves.  Is it important, or evolutionarily adaptive on some level, for our personal development, our future mental health or some other factor, that we deal with these things through our mental capacities rather than through a “quick fix” like drugs?  Is the use of simple medication in contrast to more intense and long term psychotherapy actually depriving us of a positive developmental factor?

One issue I found particularly interesting in our discussion is the idea of our behavior and conversations outside of a clinical setting as psychotherapy.  I had never really thought of this before but it makes a lot of sense.  When I have a problem I know I always feel better hashing it out with someone or taking time off for myself.  Obviously a trained professional is helpful/necessary in some situations but it is interesting to think of ourselves as self medicated, or rather self treated, in that we do what a psychologist would, only in a less obvious way.

Another topic I was wondering a bit about is that of psychotherapy as an alternative or additional treatment for other more physical diseases (i.e. cancer, chronic pain etc.).  It seems to me that thought and mental state are quite important in our physical as well as mental wellbeing, but I don’t actually know if psychotherapy in conjuncture with another treatment for those types of diseases would make that treatment more effective.  Guess I’ll have to check it out.

Felicia's picture

I have to agree with Amelia

I have to agree with Amelia here. Maybe it's because I only have experience with pathways in the form of molecular biological models that I can't buy the fMRI information 100% - the resolution simply isn't good enough. I think it's the best we've got as of yet and it is great for looking at correlations, but I think that instead of drawing conclusions that are tempting to draw from this information, we should focus efforts to improve methods of looking at the brain. (Easier said than done? Maybe?)

As frustrating as it is for science, I think it's beautiful that some people respond to drugs and others to therapy. As a scientist, naturally I want to know why, but it's almost comforting to know that there is individual difference - that we don't all respond the same way.

 

Amelia's picture

Talk Therapy vs. Medicinal Therapy for different individuals

I have to agree with what Jenna is saying, in that I don’t see people who choose to take medicine instead of going to therapy as coping out or failing. I think the success of talk-therapy is based on who chooses to go to therapy. People who don’t want to go to therapy, for whatever reason, would probably not have as positive results as people who are motivated to go each week and do the homework they are assigned with CBT. Also, the success probably relies on the ‘disorder’ that it is treating and its nature. PTSD’s nature is one that would benefit more from talk therapy, while I don’t see that bipolar individuals would be able to do such therapy without a medical intervention first. You can see drastic differences in bipolar individuals when they are either on or off medication.

In addition, as many people have brought up, therapy and drug treatments work better together than either by themselves. With bipolar individuals who I would say ‘need’ medication, they may be able to function even better if they combine this treatment with talk-therapy. While what we talked about in class is how the two work similarly on the brain, I think this points to the fact that there is something different going on with drug and talk treatments. Maybe the end result on the brain is the same, but different pathways seem to be affected. When you’re adapting two brain pathways (in very general terms) instead of just one, you’re going to see better results. If it were the same pathways I don’t think you’d see the large increase in how many people are helped with combining the two. Someone said that they must be working on different systems because medications have different side effects—while I think different systems are affective, this doesn’t work as a reasoning since medicines we take are never specific enough to work on just one particular aspect (as we talked about in class with Dr. Yadin).

One reason that I see people as skeptical of psychotherapy is the point I brought up in class, that you can’t do the animal model testing of therapy, or even on humans, to really see changes on the chemical level of the brain. I for one find fMRI imaging as somewhat questionable as to what conclusions we can draw from this. We do see differences before or after therapy, but when you think about the size of the voxels and the slight change in ‘color’, it doesn’t seem reliable. Maybe therapy changes something else in the system so that brain areas change their activation. This doesn’t mean that I think psychotherapy isn’t valid. I think it is, but it depends on the disorder and who chooses to go into therapy. If someone is not convinced about the therapy working, they are probably more likely to have the therapy not work. If there was some way to assess the chemical signaling in humans who receive therapy (instead of just brain scans) more people would see therapy as valid. In the end, it will work for some people and not for others, as with any treatment.

Another reason people are skeptical, which I’ve touched on slightly, is that we as a society are used to the biomedical model of disease and not the biopsychosocial model which is more ‘true’ to what diseases and disorders are. Until we as a society are able to get beyond the biomedical model, people are going to be skeptical of treatments that aren’t medications that can quickly ‘fix’ us. Hopefully, as people learn more about the mechanisms by which psychotherapy is working, people will become more accepting of it.

 

Jenna's picture

I think this discussion has

I think this discussion has been very interesting, specifically the general negative attitude towards prescription medication.  I can understand why some people believe it is a “quick fix” to a problem, but I don’t think that is necessarily a bad thing.  If somebody has an infection it’s generally looked down upon if they try natural or alternative remedies before seeking medical help or an antibiotic.  Therefore why do we tend to consider it somewhat of a copout to take medication for disorders such as depression and anxiety?  If we agree that there is a biological basis to these disorders, such as a “glitch” in the brain as Dr. Yadin said, then why do we fight against taking a medication to fix it?  I agree that it is better in some cases to try to use therapy first, but I also believe in other cases it is necessary to try therapy first.  Ultimately, the treatment should depend on what the patient is comfortable with and not society’s definition of how we believe they should be treated.   

 

 

I recognize that there are many problems with the medications; however, since those have already been discussed in this forum I would like to point out some problems I have with therapy.  First, there are some people who would feel uncomfortable discussing their intimate thoughts with a stranger and this process would ultimately fail because of a lack of commitment.  Also, they may believe that talking won’t help their problems because at the moment the problem seems too big to fix.  I think this may be one of the reasons therapy and medication together work best.  If the medication can give someone enough of a lift to make it seem like talking through problems could improve their life then maybe they are more likely to work hard in therapy.

 

Although I have supported medication in this post, I would like to end with support for talk therapy.  If talking to friends and family is a form of therapy than maybe most people on medication are actually seeing the benefits of that therapy and not the medication.  If someone is on medication they are actively seeking help and had to talk to a doctor about their problem to receive it.  I think it is hard to argue that these people are not receiving any type of talk therapy benefit and perhaps just admitting to someone that you have a problem and wanting to fix it is enough to start to improve.  Therefore the medication improvement rates reported may actually be due to non-traditional talk therapy, whereas it is impossible to argue that people just undergoing talk therapy are also benefiting from medication.  

Paul Grobstein's picture

Depression and exuberance

Lots and lots of interesting issues brought up in our last discussion, and more so here. The upshot is that I had more to say than can fit reasonably here (see Kay Redfield Jamieson on Exuberance), so I put it elsewhere. See Exploring depression: drugs, psychotherapy, stories, conflicts, conscious/unconscious dissociation. The suggestion is that we take variability of therapeutic response seriously. Which is to say we stop arguing about drugs versus talk therapy (of various kinds) and start asking instead what are the observations actually telling us about how the brain works and what depression actually is. Along which lines, some expansion of the parallel between depression and motion sickness I briefly suggested during our conversation, and some more explicit development of what the nature of "conflict" is in the case of depression. For which, thanks Elna, thanks all.
Emily Alspector's picture

Trends in science

I think Liz brought up a great point about what's "trendy". Today it's organic foods and "going green". Maybe in the future, talk therapy will be replaced completely by the idea of a quick fix, at least that's where it seems society is heading. It's almost as if taking prescribed medicines coulds become the next trend. But one thing we didn't discuss was the dangers of having a physical pill compared to talk therapy and CBT with respect to street drugs and even patients sharing with others. I'll admit I'm guilty of this; my mom allowed me to take some of her Xanex, prescribed to her to ease her on a plane ride, when I was taking a long plane ride of my own. Was the doctor wrong in the first place for prescribing xanex to a woman with no mental illness (except maybe neuroticism towards planes?)? That could be up for discussion another time, and this doesn't seem like a dangerous situation, but one can imagine a similar situation in which the drug of choice was meant for the patient, and it got into the wrong hands. The effects of CBT, because they are not physical entities, cannot be misused (or even abused), and, like Dr. Yadin stressed using "what we have", perhaps CBT is actually more valuable a tool than introducing new chemicals via external means. Another question of food for thought, what about the idea of accomplishment? Many people feel they have actually changed themselves and accomplished something after sitting through 20-30 sessions of therapy; they put in effort and see results based on the work they put in. With something like OCD, this can be more effective and maybe even lead to lower relapse rates than someone who just popped some pills. Some might consider this to be cheating, almost, and with no sense of accomplishment, not feel like they are really changed within, only superficially. Of course this is all just conjecture, but I think the main idea here, which I'm echoing from many other previous posts, is that CBT & drugs need to be administered simultaneously. I am just curious to see how either (or both) may affect the view of the self.

I also was wondering if there were many findings of patients becoming addicted to therapy; if the same chemical changes are occurring in CBT as in drug administration, and many people seem to become dependent on prescribed drugs, have there been findings of therapy addictions? If the reward pathways are enacted in both processes, I don't see why this wouldn't occur, although I've never heard of it.

We talked briefly about OCD and post partem depression, and how OCD mothers are the least likely to inflict harm upon their babies, which I found to be incredibly interesting. This made me think about possible attachment styles and how the baby develops. While the mother is keeping her baby from harm, she might become overbearing and cause unecessary anxiety in the baby. In addition, I'm wondering, then, if the effects that OCD has on a person (heightened anxiety & fears) could be induced on mothers with post-partem as a treatment? It seems strange, but the effects could be huge, if only to be used as a temporary remedy to keep the baby safe from harm. I also wonder what other positive affects having a disorder like OCD might have on someone. Maybe someone can help me brainstorm, but to think of induction of a disorder in order to cure another is not so far fetched, I don't think.

 

natsu's picture

A depressed brain state?

Several people have mentioned during class and in this forum that taking drugs to fix problems instead of undergoing therapy is easy, which really surprised me.  Personally, I had always thought that the idea of taking drugs is psychologically much more difficult to accept than therapy, but maybe this is just a cultural difference?  Also, there is another thing that came to my mind that is related to this issue of which is more “easy” (drug vs. therapy).  I once wrote a research paper on neurotic perfectionism when I was taking the course Abnormal Psychology, and I remember reading that perfectionism is highly correlated with depression and OCD (which really didn’t surprise me).  Wouldn’t people who are perfectionists feel defeated if they have to depend on a pill to fix their problem? Wouldn’t these people want to fight and overcome their problems with their own will?  Of course I know that depression does not only happen among perfectionists and high-achievers, but I don’t think that everybody who takes drugs takes them because they feel that it is the easy way out of their problem.  For many people, including some that I know personally, the decision to take drugs comes after a lot of thought and is a way to help them reach a mind of state that would allow them to rationally process and think about their problems so that they can actually benefit from therapy.  For this mean, I think that drugs can play an important role.

I also read the BBC article that Marissa posted (and would encourage anybody who hasn’t read it yet to do so) but I personally can’t agree with the post above that “maybe when we’re not happy this is in fact adaptive, and by trying to “fix” it we’re not really helping the person”.  When you read the comments at the end of the article, it is clear that the people who talk of any kind of gain from their depression are people who overcame depression and are no longer suffering from the disorder.  I think that this is a very different situation from, say, a mother  with a child with autism who says that no matter how hard it can be sometimes, she is still glad that she has her child because she has learned so much from him.  I personally think that depression is the clearest disorder (i.e. I am perfectly comfortable calling depression a disorder though I do question calling other states that are generally labeled as a disorder like autism) and if I were a physician, I would not question trying to fix it, since I don’t think people can really benefit from it (if they do at all) unless they overcome it.

Before we start talking about whether depression should be fixed or not, it seems like it is important to think about what depression is.  I was intrigued by the question that was raised in class and restated in Danielle’s post: “do we assume depression is a disorder or is it just a particular brain state?”  When the idea that the depressive mind state may be more adaptive or skilled in some ways was brought up in class, I remember questioning Professor Grobstein about this because I had personally always thought that a crucial criterion of depression is that the individual must want to overcome the excruciating pain associated with the fear and sadness that he/she is experiencing.  In other words, it is hard for me to think that one can be diagnosed with depression if he/she is not wanting to overcome depression, no matter what the brain looks like on a neuroimaging scan.  I don’t think that looking at the brain state is necessary to diagnose depression; if an individual is reporting hopelessness, anxiety and suicidal thoughts, that should be enough for person to receive the appropriate help and treatment.  In fact, I think the idea of a “depressed brain state” could be dangerous.  If physicians start labeling people with depression just because of what their brain looks like on an image, this could lead to negative consequences…

Paul Grobstein's picture

depression and suffering: individuals and cultures again?

I think its actually an open question whether "hopelessness, anxiety, and suicidal thoughts" are an intrinsic characteristic of the "brain state" or something that results from how people with that brain state are treated by those around them. That isn't to say I wouldn't encourage people with those feelings to seek medical help, but I do think its another case where care-givers should at least think about whether what is needed is changes in individuals or changes in culture.
natsu's picture

Depression due to culture or something internal?

Yes, I agree that there are some cases of depression when one has to wonder whether the cause of their depression is really something due to the individual or the culture.  Maybe if the society changed to be more accepting and supportive, then there may be some cases of "depression" that could be avoided.  However, I also know that depression (or what I think of as depression) is also very common among people who are considered as leading "ideal lives" by the rest of the society.  (At least they are where I am from)  I have read many writings by people who suffered from depression even though others around them could not see any reason why they should be depressed. I find it extremely interesting that depression can even haunt such people. 
llamprou's picture

Bags of Chemicals

This is going to sound almost as crazy as I did in class when I described my distaste in comparing the human body to a bag of chemicals. I wrote my first web paper on deja vu. What is interesting about this phenomenon is that nothing has yet been set in stone regarding why it happens or even how it happens. There are several neurobiological theories, and several theories that have absolutely nothing to do with science and more to do with spirituality. Why is it then that in class and in most instances human beings tend to lean toward the scientific explanation even though it has by no means been proven accurate. What amazes me even more is that the first part of this course was spent making us all aware of how little we really knew about the world around us, how everything we believed to be 'true' about our bodies may in fact be fabrications of our own minds, yet now we are all ready to throw in the towel and 'believe' that we are just a bunch of battery activated action potentials, well excuse my language when I say "I think its crap!"

 

I do not believe that all my feelings, and emotions are just a bunch of battery activated impulses. If this is true then what can be said about moral, values, the belief in a higher power. Are our neurotransmitters that clever?

Jessica Krueger's picture

Two topics brought up in

Two topics brought up in class (and touched on briefly by Elliot in the forum) that I'd like to explore were the idea of the disorder as entity without the person and the problem of which came first; the disorder or the negative cognition.

"You do know that's the disease talking, don't you?" I've heard permutations of that concept several times from friends in therapy for whatever reason, and I've often wondered (especially when directed towards people who don't consider themselves sick) if it's the discourse that makes one sick, or if those negative cognitions are more analogous to a fever, a symptom of the disorder. It doesn't seem to make sense for a person to talk to themselves about themselves in the deprecating manner characterized by depression of their own volition: that insidious voice has to be the product of too few serotonin receptors or not enough dopamine, much as lowered inhibitions are the product of too much alcohol. You can't really talk yourself into being drunk, and why would you want to talk yourself into being depressed?

So now there's this broken piece of brain generating hateful thoughts in a patient's mind, but can we really consider this broken bit as something external or different from the person who owns it? Even that first sentence, "You know that's the disease talking..." implies that there are two parties privy to the world within the skull: the person and another, darker “disordered” entity. But wouldn't considering the disorder to be an externality, an adjunct to the person him/herself, lend some credence to earlier conceptions of psychopathology as demonic possession? Does this mean that shamanistic practices or exorcisms have the chance to re-enter a modern therapeutic arsenal? Why not, after all, when we cannot seem to decide what mechanisms are responsible for more scientifically condoned talking and/or chemical cures? What harm could a little sage incense and holy water do if the benefit was the eviction of the terrible “other” plaguing the patient?

What was it about these earlier forms of psychotherapy or even our current rudimentary tools that make a person better? From the discussion we had on Tuesday, it seems like an important part of the therapy is changing the discourse a patient engages him/herself in regarding the disorder. If all pharmacotherapy addresses is the dysfunctional biology, perhaps it is the change in self-talk that protects the brain from relapsing. But then we’ve returned agency over the disorder back to the patient’s own verbal behavior, which means, in a sense, that it’s “all in your head” and we know that’s not right either. So self-talk is enough to prevent a disorder but not cause it? And why can’t we all alter our own self-talk without assistance? And now, it seems, we’re back to the beginning, which came first the disorder or the thought?

 

Paul Grobstein's picture

mental health: "changing the discourse"

It is indeed an interesting notion that we could "return agency ... to the patient's verbal behavior". No, I don't think that means returning to "it's all in your head", except in the Bio 202 sense that it is indeed all in your brain. What it instead means is adjusting (with the help of others, as needed) one's self-perception to the signals one is getting from one's unconscious. See Exploring Depression ...
aamen's picture

I also thought this was an

I also thought this was an interesting discussion, and I was wondering about some of the same points that Liz (and Elliot) brought up here – if drug therapy and CBT seem to be affecting/changing similar areas of the brain, it seems that they are working through similar mechanisms.  But if neurotransmitters are being affected in the same way by both of these treatments, I would think that side effects associated with drug therapies should also be present during CBT.  Like Elliot said, I really have no idea if this is the case, but I have trouble imagining (maybe just because I’ve never heard anyone mention it) that patients undergoing psychotherapy experience problems like “dry mouth” or “insomnia” that are apparently common in pharmacotherapy.  Dr. Yadin brought up the point that psychotherapy doesn’t have the negative effects that may be associated with drug treatments because it doesn’t act on the periphery, and I think that this fact alone is enough to make the argument that psychotherapies like CBT should at least be considered before pharmacotherapy.

 

I completely agree with the idea that drug therapy has become so popular because it seems like a quick fix to a problem.  If one of the symptoms of depression, for example, is a loss of energy then it is easy for me to imagine that someone with depression would be overwhelmed at the idea of putting in the time and effort to talk to a therapist and work through their problems.  And, like Emily said, it hardly seems ethical to force people to try therapy before drugs.  I also think that part of the reason that drug therapy has been so widely embraced is because we understand that if taking a drug fixes a problem this means that the problem is biologically based, and I think that this in turn de-stigmatizes many mental conditions.  I think that in the past there has been a sort of idea that if someone is depressed, has OCD, etc. that this is some sort of character flaw, or that they should just get over it.  If a patient actually needs a drug to fix the problem, however, then it seems more like a medical condition that the patient has no more control over than someone who takes medication for some physical illness.  However, at this point in time I think (or at least I hope) that the  majority of people understand that severe mood disorders (and other conditions) have a biological basis, so maybe people will begin to be more willing to try psychotherapy-based approaches again.

 

On a totally different note, I read the article that Marissa posted from BBC (“Is Depression Good for You?”) and it reminded me of a topic we covered in one of my classes last semester.  I don’t remember the specific articles or studies that we looked at, but it basically had to do with the idea that negative or depressed moods evolutionarily probably arose in response to conditions where something is wrong or needs to be fixed, and that in order to fix a problem we need to be able to think clearly and rationally.  To support this hypothesis researchers were showing that when people are upset or sad (however you measure that) they are better at memory tasks and solving problems than when they are happy.  Basically, it just seems to me like our culture is so focused on the idea that we should be happy all the time – but maybe when we’re not happy this is in fact adaptive, and by trying to “fix” it we’re not really helping the person.  Of course in cases of severe depression I think that something should be done, but it seems like it’s fairly easy to fall in the DSM category of “clinically depressed”, and maybe not everyone in that category actually needs clinical or (especially) medical help.

Felicia's picture

Psychotherapy

I think Emily brings up a great point, and one that we seem to be coming back to - controlling for individual difference in any study seems to be one main limiting factor. CBT and/or drugs don't work for everyone, where is this individual difference coming from? genes? With such a range of depressive disorders and each arising from different triggers or for different reasons, I'm sure depressive disorders are tricky to study biologically, but I wouldn't be surprised if there were genetic markers for depression (I could be wrong, but I think I've heard of a family link?).

I'm very interested in this idea of societally contructed illness, and I found myself wondering after class what epidemiological studies of depression might look like - across states, cities, cultures. I'm not sure how much can be extrapolated from simply percentages of people that are depressed, but I couldn't help but think that I knew what it would look like: I would expect cities (going with the "stressed out" trigger) to be more depressed, which wasn't the case (according to http://www.msnbc.msn.com/id/22087867/ ) I know that's not the greatest source, but just looking at the top few depressed states...Utah, West Virginia, Kentucky...isn't what I expected. Thoughts?

Something else that's really interesting to me is CBT versus social networks, which we talked about briefly in class. I don't know specifics of CBT, but I would imagine some of the exercises are similar, and in a way CBT seems like a more intense form of social communication that we see within social groups.

As far as drugs vs. CBT, I still can't get over my initial negative reaction with drug therapy. Maybe it has something to do with, like Liz mentioned, just feeling like "talking it out" is more "natural" and therefore "better". I can't help but think that drugs are a band aid for the real problem. Along those lines while I think CBT is a better first option (I had never thought of the brain as plastic as Dr. Yadin spoke about), I want to go to the source of the problem and prevent it. CBT and drug therapy are great options for those with depressive illness, but why do we (in the U.S.) have the highest rates of depression in the world? I'm not talking about altering any biological factors that would prevent depression, but rather the environmental factors that lend to higher rates. If a major factor is stress, let's go to the source. How can we change these environmental factors to prevent illness?

krosania's picture

Individual differences

I've been thinking a lot about this idea of individual differences, and I'm wondering if the difference is not in the effects of treatment, but in the initial "disorders" themselves. A case of depression can look vastly different from one individual to the next, as can OCD and bipolar disorder. I doubt if any two people ever have the exact same disfunction going on in their brains. Therefore it makes sense that the same dose of the same drug is not going to have the same effect in two different people with supposedly the same disorder. The advantage of CBT is that it treats the detailed effects of whatever is going on neurologically, and addresses the person's experience rather then their neurochemistry. That being said, I am still not that surprised that CBT doesn't work for everyone because people have vastly different views and attitudes about what is means to have a mental disorder and to undergo psychotherapeutic treatment. Many people do not have the time, or desire, to really commit themselves to getting better. I think that both CBT and pharmacotherapy have individual differences in treatment effectiveness for very different reasons.
Paul Grobstein's picture

"societally constructed illness"

See Culture and Behavior on Serendip for links to some relevant materials.
Elliot Rabinowitz's picture

more on psychotherapy...

To bounce off of Liz’s last point, I did not really think about the side effects of psychotherapy as compared to drug therapy. Side effects from exogenous substances put into one’s body seem to be expected for just about any drug taken for any “disorder”. I would imagine that psychotherapy also probably generates some side effects in a number of individuals. Whether these side effects are exactly the same as those seen in individuals on medication, I am not sure (but would certainly like to know). However, I also guess that there may be fewer side effects, simply for the reason that although psychotherapy may lead to similar outcomes as drug therapy, it works in a different way. Psychotherapy, at least CBT, seems focused on individual drive and perseverance. As stated in a number of the people’s posts above, taking drugs is a lot easier. However, drugs are then an external force on the body’s system. Working through CBT seems more natural. From what Dr. Yadin said, it truly sounds like a progression of working with the patient through multiple steps. This step-wise process, though intense, seems more conducive to minimizing secondary effects as compared to a drug shocking one’s body. However, I am just thinking about this theoretically without any real data on which to base my hypothesis, so anyone else’s ideas would be more than welcomed.

 

Something else that Dr. Yadin brought up that I found particularly intriguing was the idea of separating oneself from one’s disorder, whatever it may be. She described it as a relationship between a person and their disorder. This relationship can change over time and one’s feelings towards it can vary. I cannot say that I have personally felt this relationship, but I can imagine that this description would be true. We somewhat touched on the idea of depression as advantageous in different settings and at different times, but also often more negative in other situations. Maybe this leads people to accept and reject their depression depending on the situation (even if it is often viewed as something unwanted). As to what this all means for psychotherapy, I could also imagine that different therapeutic techniques may not only work better for different people, but also for specific people at different times in their life depending on their relationship with their disorder. We also touched on this idea when discussing how people sometimes need a refresher course in CBT to avoid relapse. I wonder if taking drugs to treat relapses works more effectively in individuals who have undergone CBT at an earlier point in their life. Or maybe they don’t do any better, and CBT is usually more effective in such cases.

 

All of this seems to relate back to what Emily posted – the importance of individual differences. People need to be thought of in relation to the environment in which they live, the relationship they have with their “disorder,” the hopes they have for therapeutic results, the seriousness of their physical and mental states, their cultural beliefs, etc. Even though our fundamental biological systems are so genetically and physically similar, it is still important to remember all of the things that make us different.

Paul Grobstein's picture

"separating oneself from one’s disorder"

Is an interesting/important idea indeed, common to a variety of forms of talk therapy and with good neurobiological foundations. See Exploring depression ...
Marissa Patterson's picture

We've talked about this a

We've talked about this a few times in class, but it came up again this week. Here is a link to a BBC article entitled "Is Depression Good For You?"

http://news.bbc.co.uk/2/hi/uk_news/magazine/7268496.stm

Paul Grobstein's picture

Many thanks for this. See

Many thanks for this. See end of Exploring depression ...
ebitler's picture

psychotherapy thoughts...

I completely agree with Stephanie, Emily, and Danielle that Dr. Yadin posed some really great arguments for the promotion of CBT over the drug alternatives.  The brain is highly plastic, and if we can encourage plasticity that will help people overcome debilitating issues such as OCD a little more naturally and holistically then that seems to be a great alternative (especially since it may have more lasting effects and can be easily refreshed if needed later in life).  As previously pointed out, the biggest pro-psychotropic drugs argument is that taking a pill is a lot easier.  In our culture everyone wants things as quickly and easily as possible.  For the people who don’t want to or can’t spend the time necessary, or don’t want to face their fears, the pill seems like a nice alternative.

 

Because I think what has driven Americans to prefer the easy alternative stems from our culture, I think that how our culture is now changing may help in a transition away from psychopharmacology treatments (at least a little).  The trendy thing now is the more “natural” alternative.  Organic foods, alternative medicine, and even hybrid SUVs exemplify America’s return to nature, and I think we’re at a point now where people are more willing to spend a little extra time and money for the more natural alternative.  This observation paired with the research of physiological changes associated with psychotherapy make now a good time for psychotherapy’s comeback.  That’s not to say that everyone will choose psychotherapy over drug therapy (which they probably shouldn’t as drug therapy seems to be more effective in severe cases and talk therapy doesn’t work for everyone), but I do think more people will be willing to give psychotherapy a shot.

 

The other thing that I was thinking about is that no one really brought up the issue of undesirable downstream changes in the psychotherapy model. We talked about how changing the neurotransmitter availability at one synapse has the potential to effect a great deal of other systems through upregulation/downregulation of receptors, synapse plasticity, and cell plasticity for the drug therapy model, but I’m a little curious about why it didn’t come up for the talk therapy model.  If evidence is showing that talk therapy is producing similar effects on NT levels or plasticity (although in some different areas), then it seems to me that these changes will likely affect other systems downstream as well.  I’d just be curious to hear if it wasn’t brought up in class because people think that these downstream side effects aren’t as likely with psychotherapy or if we’re just used to thinking of physiological side effects as being inevitable for drugs and not thinking about them at all for psychotherapy?

Danielle's picture

 Neurological Changes Associated with Psychotherapy      

            Thank you to everyone who participated in the conversation this past Tuesday! Also, thank you to Dr. Yadin for joining our discussion and sharing with us her knowledge of CBT. I think everyone brought up some very interesting and important points when thinking about psychotherapy, pharmacotherapy and the brain.

            From our discussions, the idea that the brain can heal itself without medication is extremely valuable. Perhaps pharmacotherapy seems like the easy route to take, but what ends up making a person move past their states of depression, for example, is either a cruise (as proposed by Professor Grobstein) or CBT. CBT is extremely effective because it can be modified to treat or change a person’s behavior accordingly. With pharmacotherapy there are many extremes that do not cater to the wide spectrum of symptoms as seen in depression. Also, CBT provides patients with the tools so that they can change, what psychologists call, maladaptive behaviors. Dr. Yadin brought up a very important point that the brain is extremely plastic and that we should work with our own mechanisms to create change. As said by Dr. Yadin, CBT activates what we already have. I think that by activating what we already have allows us to truly change our brains and behavior in a way that is more permanent than the effects of psychotropic drugs. How can we be sure that psychotropic drugs are not affecting many systems within the body?

            The main question is, do we assume depression is a disorder or is it just a particular brain state? The world is extremely heterogeneous so are these mental “disorders” another form of diversity? 

            I think that it is very easy to over simplify the brain, when in fact it is an extremely complex organ which is still not completely understood.

ehinchcl's picture

Individuality...

So one thing that I was struck by throughout our conversation was how much in psychotherapy individual difference plays a role. There are a few main things that I wanted to relate this to, and see what everyone else thought. (I would also love to hear Dr. Yadin's views on if this variation is good or bad for CBT as a treatment)

First, even using pure statistical results, we find that individuals vary quite a lot in terms of responsiveness to treatment. Some respond to CBT, some to drugs, some to neither (ex. CBT or drugs work 48% of the time, together they work 73%). I think its interesting that it seems like we approach these therapies on a rather general level, and then tailor them to specific individuals. Can we really say we understand the mechanism for our treatment when we can't get it to work for every patient? Are there other ways we should be approaching it to try and get it to work generally-- or is it good that the tailoring occurs?

Second, and somewhat more interesting to me, was the idea of the patient population being somewhat self-selecting. It seems that to do treatment like CBT you must be highly motivated, and you must consider yourself to HAVE a "disorder." The idea that anything that impedes normal functioning is a disorder is interesting to me-- like we've talked about all along, isn't this 'normal functioning' somewhat of a societal construct? However, being realistic, whether or not it is societal or biological the manifestations still deserve to be treated if the person wants them to be. However, this want is a big thing-- I don't know about you all, but i certainly don't approach my fears/worries head on all the time and allow myself to think about them and then let them go. (Seems to me like perhaps CBT would be useful for 'normal' people as well). I think it therefore requires a lot of dedication for something like CBT to be useful, which may decrease its success. Drugs are so much easier-- you pop a pill and feel better-- and in our current culture of instant gratification i think CBT may seem to be more and more of a hassle. This is worrisome, as I feel that what Dr. Yadin said was correct-- that we should use the brain itself for fixes first (if we have the plasticity, why not use it!?!) and drugs second because drugs can be removed and leave the initial problem. But is it ethical to deny people the 'quick fix' if it works for them? Denying treatment doesn't sound like the way to go either... Should we force people to try CBT first? Again, not so ethical.

I'd be interested to know what you guys think,

Emily

Andrea G.'s picture

Individualizing treatment

Hi Emily,

I think one of the great things about CBT is that it can account for individual differences so well.  There are only so many different doses or variations on drugs that a psychiatrist can prescribe for treatment, but CBT is tailored to the individual.  This still doesn't mean that it works for everyone; the studies show this very clearly, and just thinking about it abstractly, it's easy to see that a treatment that requires so much self-motivation and individual effort would be more effective for certain types of people.

 Also, I'm wondering about your characterization of CBT as something you must recognize you have a disorder to undergo.  I definitely agree with your statement, but I'm wondering why that's any different from getting a prescription and taking it.  In going to a doctor for treatment, aren't you also acknowledging that you need some kind of help?  You may not have a clinical diagnosis, but you've certainly admitted to yourself and to your doctor that something isn't right.  In that respect, I think both treatment approaches are more similar than we might have thought.

krosania's picture

Along this line of thought...

It seems to me that one of the best things about having the brain "fix" itself rather than using pharmacotherapy is the sustainability of the treatment effects. If the brain is producing more of a necessary chemical in a specific region of the brain where it was stimulated to do so, that is an effect that will last as long as that part of the brain continues to be stimulated. This is opposed to pharmacotherapy, which stops working as soon as (or a little while after) you stop taking the drug. I think probably why the best thing is for the two to be used together is that typically, use of the drug is intended to get the person to the point where they can respond to the CBT effectively. Many people are prohibited for neurological reasons beyond their control from changing their behavior in a meaningful way. Drug treatments can often break down the barrier that prevents the patient from enacting change, and allows them to then do what is necessary to keep the wall down for good. For this reason, I agree that it is necessary for the person to be highly motivated in order for CBT to work, but I also think that pharmacological approaches can be useful in helping to motivate the person.
Paul Grobstein's picture

Therapy and variability

Yep, agree with you that its time to take variability seriously. See Exploring depression ...
Mawrtyr2008's picture

Combining Therapeutic Strategies

Emily,

 

In your post, you brought up a really important observation that I think merits more discussion.  In all the conversations I've had with psychologists or psychiatrists, I've consistently heard that neither pharmacotherapy nor talk therapy work as well as they do in tandem.  You brought this point up, and I'd like to continue discussion about it because it reflects a lot about the current therapeutic paradigm.  The obvious question this raises is why the two strategies work the best together?  What kind of interaction between talk therapy related changes and pharmacotherapy is taking place in the brain?  People in the forum and in general seem to be wary of pharmacotherapy nowadays, which doesn't all together surprise me because that strategy seems to be to flood the entire brain with a chemical that's intended to affect a very small portion of the brain.  I, for one, think talk therapy is a very interesting therapeutic option because it has the capacity to do the opposite of the pharmacotherapy.  Brain imaging technologies demonstrate that asking a person to do tasks like recalling a memory, describing a situation, imagining an alternative to a crisis, (tasks that are often done in a psychology session!) increase blood flow to very specific parts of the brain.  This, with Dr. Yadin's account of neuroplasticity suggests that talk therapy could start with very local change (that perhaps extrapolates to much larger change) while pharmacotherapy targets the whole brain at once.  Isn't it weird, then, that both of these strategies work best together???

 

To step away from the neurobiological questions these findings raise, I think the social message is pretty clear: that treating those who seek treatment with drugs alone is not sufficient, and though it may be more costly and time consuming and less efficient, talk therapy is a must.  This all leads me to another question that was raised in class on Tuesday.  I can't help wondering if you have to have the title and the credentials of a psychologist to create this kind of change in another person.  Is it possible that a religious advisor, a good friend, a mentor, a parent, or any trustworthy confidante can fill the role of a psychologist just as effectively?  I think the answer must be yes, based not only on the anecdotal evidence I can provide based on feelings of a "new perspective" after confiding in a trusted friend about a crisis, and also when considering how many people simply do not have access to credentialed psychological care.  Does this then mean that advisors, friends, parents are all psychologists without the formal training and the degree?  Are we all capable of profound psychological and neurobiological impact on those we have meaningful discussions with?  Is it just me, or does this seems to hearken back to our conversation on diversity and education and the ability to change the brain....?  

 

Lastly, I'd like to draw attention to a recent study called "Cognitive enhancers as adjuncts to psychotherapy: use of D-cycloserine in phobic individuals to facilitate extinction of fear." that looked at the effects of the "cognitive enhancer", D-cycloserine on NMDA receptors.  Basically, this study found that people who were given this drug learned and extinguished their fear of heights more quickly than the control.  This drug seem to have very interesting implications for the future of pharmacotherapy.... Could this be used to enhance talk therapy?  What kinds of people would benefit from this drug?

 

 The study can be found at:

http://archpsyc.ama-assn.org/cgi/content/full/61/11/1136

Stephanie's picture

Psychotherapy

I enjoyed our discussion on Tuesday night about psychotherapy. This discussion is of particular interest to me because I may be attending graduate school in a Doctor of Psychology program this fall- and in these programs, I am trained in different types of psychotherapy- cognitive-behavioral, psychodynamic, & family systems therapy. I am very excited about learning these techniques, and I really enjoyed hearing Dr. Yadin discuss her experiences with psychotherapy, specifically cognitive behavioral therapy. One thing I think it is important to keep in mind is that there is no one therapy that has been proven to be the best type of therapy for everything (all disorders)-but instead it is important to value each type of therapy for its strengths. For example, cognitive-behavioral therapy has proven to be extremely successful for OCD- however, CBT may not be the best choice for all types of psychological disorders. As a future clinical child psychologist, I want to learn about and be trained in different types of therapies so that I can use the most appropriate therapy for each patient depending on the patient and the patient's disorder. I value all different types of psychotherapy. I would be interested to see what brain changes occur for different types of therapy (other than CBT) like for psychodynamic therapy. And, I think comparing brain changes between different types of therapies that are being used to treat the same disorder would also be interesting.

I really liked Dr. Yadin's idea of using the brain to fix/ heal itself- as a first line of treatment- then if that does not work, maybe then considering employing drugs. The brain is the most "plastic" organ in the body and that is a such an important feature, and ultimately allows us to use our own brains to help our selves & our own brain.

And, during our discussion of psychopharmocology, I think Prof. Morris brought up a very important point- when we effect one molecule (or target one molecule) with a drug, it is bound to effect many other molecules and pathways downstream- I think this is important to consider when using drugs to treat psychological disorders- although we think we know exactly what molecules or chemicals are in an "imbalance" we probably are not seeing the whole picture because molecules and chemicals in the brain and body work together and effect each other- and they are not working alone in a vacuum. I think more studies should be done to figure out exactly what other molecules, chemicals, and pathways these drugs that attempt to "target one molecule" are effecting. These down stream effects may shed light on the delay of the therapeutic effect of these drugs and drug side effects.

Marissa Patterson's picture

Thanks

Thanks to everyone for such a great conversation last night! It was so fabulous to see everyone's opinions about therapy and I can't wait to see what else you have to say.

A few questions to think about:

What do these studies mean for future methods of treatment?

What happens to our models of "disease?"

Are psychotropic treatments valid? Are more talk-based treatments more appropriate?

Why are people still so skeptical of psychotherapy?

What is treatment doing? Is it bringing people back to "baseline?" What is baseline?

Dr. Yadin will be looking at the forum too, so feel free to pose any questions you have for her. We look forward to seeing your thoughts.

 

Here is the link to BBC article about anti-depressants having little effect we were talking about. http://news.bbc.co.uk/2/hi/health/7263494.stm

Paul Grobstein's picture

Forms of psychotherapy in psychiatry

A couple of recent articles relatd to our upcoming discussion:

The second one, in particular, is worth reading in connection with Of Two Minds: An Anthropologist Looks at American Psychiatry , a book by T.M. Luhrmann that appeared in 2000 and describes changes in psychiatric training practices in the previous ten or twenty years. Not an entirely happy story, and one that is clearly still playing out.

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