Tag Archives: Psychotherapy

Who Is Normal, Anyway? Part V

29 Nov

There is always some reason in madness

– Friedrich Nietzsche

V – What Does Work?

There are no simple fix-all cures, but there are techniques and tricks that can help.

Everything you do rewires your brain, alters your brain chemistry. Even making a cup of tea. What really beds in change is regular practice. For example musicians and taxi drivers significantly change their brains due to their practice. Neuroplasticity shows how we can rewire our brains to great advantage – recent research shows that we create thousands of new neurons each day, even into old age.

And so talk therapies can leverage this to get the root of the problem and literally rewire the brain. For example, many therapies can give you tricks to push your mind out of the negative rumination that is at the core of the destructive cycle of depression.

Study after study backs this up. And the evidence is clear that although drugs may reduce some symptoms in the short term as much as these therapies, the relapse rate with drugs is more than double that of these approaches.

Jonah Lehrer said: “patients who escaped depression with the help of anti-depressants, and then stopped taking the drugs, relapsed about 70 percent of the time. The chemical boost was temporary. However, during the 18 month follow-up period, only 28 percent of patients in mindfulness therapy slipped back into the mental illness. What we often forget is that therapy alters the chemical brain, just like a pill. It’s easy to dismiss words as airy nothings and talk therapy as mere talk. Sitting on a couch can seem like such an antiquated form of treatment. But the right kind of talk can fix our broken mind, helping us escape from the recursive loop of stress and negative emotion that’s making us depressed. Changing our thoughts is never easy and, in severe cases, might seem virtually impossible. We live busy lives and therapy requires hours of work and constant practice; our cortex can be so damn stubborn. But the data is clear: If we are seeking a long-lasting cure for depression, then it’s typically our most effective treatment.

In fact, psychotherapy and mindfulness mediation can even alleviate physical conditions, for example gastritis and tinnitus.

There’s a better way to understand people with psychological problems: psychologists and psychiatrists use formulation: “we don’t ask what is wrong with someone, rather we ask what has happened to them.

There are so many different theraputic approaches:

Psychoanalysis looks at childhood, emotional drives, and the unconscious, usually drawing from Freud, Jung and the like.

Cognitive Behavioural Therapy – rather than delving into the past looks at your perceptions, emotions and behaviour in the present.

Systemic Therapy – looks at a person as defined by their relationships with other people.

Body Psychotherapy is pretty cool – using the body to gain a greater awareness of mind. After all the mind would not exist as it is, without the inputs from the body. I’ve tried Focusing and found it effective.

Mindfulness is an approach I’ve been using for a few years and, while I don’t have issues with depression or the like, it has helped me to sleep better, to relax more, to appreciate the moment, and maintain more healthy relationships. Self awareness is what this practice gives you, which is the first and hardest step towards change, as most therapists will agree.

Point is, there are plenty of approaches, so you can choose the style that best suits you and your problems.

Part IV – Psychiatry in the previous post.

The Drugs Don’t Work

15 Jul

Instead of asking what is wrong with you, we need to ask what has happened to you.

– Dr Lucy Johnstone

Recently the British Psychological Society called bullshit on those claiming the efficacy of the arbitrary psychiatric diagnoses in the DSM†, and the drug based treatments in which they usually result.

They have released a report whose abstract reads:

The DCP believes there is need to move away from psychiatric diagnoses such as schizophrenia, Attention Deficit Hyperactivity Disorder, personality disorder and conduct disorder, which have significant conceptual and empirical limitations, and develop alternative approaches which recognise the centrality of the complex range of life experiences in the emergence of mental distress, and the personal impact of social and relational circumstances including trauma.

The best overview of the report comes from this short interview with Johnstone on Radio 4, which is well worth the listen. I’ve added an abridged version of the interview text below.

Of course the BPS are not the only ones to hold this view. The National Institute of Mental Health issued an inflammatory press release criticizing current psychiatry for being “brainless and invalid“. Plenty of others have been publicly pushing this, and much stronger views, for many decades. For example, in the sixties, notable luminaries such as RD Laing and Michael Foucault, not to mention many “survivors” groups.

The Interview
John Humphries: “Schizophrenia is a terrible disease. It destroys many lives, the people who suffer and those who have to live with them, and yet there is no scientific evidence that a diagnosis of it is vital or useful. That is the view of the British Psychological Society itself. The same goes for bipolar disease.

I’m joined by Dr Lucy Johnstone who’s a Consultant clinical psychologist, and she’s on the working party that drew up that statement.

Dr Lucy Johnstone: “This isn’t an argument between psychologists and psychiatrists. Many psychologists, many psychiatrists and many health professionals are united in saying that the evidence for the current way of understanding mental distress, just doesn’t exist“.

The DCP [Division of Clinical Psychology, part of the BPS] has issued this consensus statement: there is actually no evidence for the current view – and we agree with many senior psychiatrists in saying that – we do have an overwhelming amount of evidence that even severe psychiatric breakdown is actually the end result of a complex mix of social and psychological circumstances. People who have suffered things like bereavement, loss, discrimination, poverty, trauma, abuse, domestic violence, in other words things that have happened to you.

John: “So where does that leave us in terms of treating it? Because there is no question that it is a disease. Schizophrenia is a horrible thing?

Lucy: “Well actually that’s exactly what we are questioning. We are questioning the disease model, along with many psychiatrists. Of course the distress is very real.

John: “Doesn’t that make it a disease? If you are desperately distressed, to the point sometimes of killing yourself, or harming somebody else perhaps, doesn’t that make it a disease?

Lucy: “Well there’s no evidence that it does. We are told a great deal of stuff about genes or biochemical imbalances, and as one of America’s most senior psychiatrists said only a couple of weeks ago, we have been telling patients for several decades that we are waiting for biomarkers, in other words evidence for a disease process. We are still waiting. So these are very serious problems, but there is an increasing amount of evidence that there is a way of understanding them, for example very often as the end result, not always, of extremely severe trauma.

John: “But you can’t turn back the clock, you can’t remove that trauma or make it never happen, so how do you deal with this, whatever you call it, disorder?

Lucy: “We would probably not want to use the term disorder. It does bring into question all the traditional vocabulary. We are actually calling for a change of language among other things.

John: “How does this understanding change the way you treat it?

Lucy: “It changes it in a very helpful and ultimately very productive way: in essence, instead of asking what is wrong with you, we need to ask what has happened to you? People break down for reasons, those reasons aren’t always immediately obvious, it can take quite a while to put the pieces together, but once we know those reasons we can offer them the right help to recover.

John: “Which would probably be counseling rather than drugs would it?

Lucy: “Well drugs might well play a part but i think we have to be clear about the role of medication. If we’re talking about the end result of complex social and relationship problems, by definition medication can’t solve those. It can certainly help keep people going, it can certainly help with some of the more overwhelming themes of distress. But essentially, what psychologists would say, we use a jargon word, which is formulation, which is a way of putting together the psychological evidence about the impact of very difficult life experiences, understanding how those affected the person in front of you, the personal meaning of those events, and on that basis you draw up an individual plan which will actually have a very good chance of helping that person recover.

John: “Well that’s encouraging. Dr Lucy Johnstone, thank you very much indeed.

As a close friend of mine with first hand experience of such issues said: “I sincerely hope that this discussion will eventually go on to reduce a lot of unnecessary suffering“.

† The DSM is the  Diagnostic and Statistical Manual of Mental Disorders, containing definitions of certain states of mind from depression to “Disruptive Mood Dysregulation disorder”, with has implications on how people are diagnosed and hence treated. I’ve referred to this previously.

How Well Does Freud’s Work Stand the Test of Time?

18 Jun

I recently went to a lecture by psychiatrist Allen Frances MD in which he argued that Sigmund Freud was half right and half wrong. And just because half of his ideas aren’t right it doesn’t mean that we should throw out the rest, as is popular these days.

Interestingly, Frances asserts that Freud didn’t come up with many original ideas, rather he was excellent at bringing together the latest ideas into an overarching and coherent model linking the brain and the mind. In particular he took Darwin’s work and popularised it. The excessive sexualisation within Freud’s work comes from the idea that natural and sexual selection “leads to the evolution of instincts, emotions and intellect“. What this means is that psychological behaviour is informed by sexual selection, i.e. we try to be more attractive. And therefore in Freud’s mind, the key link between the brain and the mind is the libido. He used the analogy of the brain as a hydraulic power plant, and the libido as the power source. As such, issues with the mind are due to build up, discharge or transfer of this energy.

From Darwin he took the ideas of “instinct interacting with the environment” and “everything has or once had a purpose“, ideas still alive and well today. He also took “introspection and dream analysis“: dreams “explain not only symptoms, but myth, art, literature and psychopathology of everyday life“. He saw the unconscious as having a major role in influencing behaviour. Dreams therefore are a great research tool as a window into the unconscious. However the jury is still out on what dreams & sleep are really about, though there is a clear link between them and memory and psychological stability.

Freud also took from Darwin the idea of comparing animal and human behaviours. He challenged human exceptionalism, that being the idea that we humans are somehow above all the other animals. I’ve written about this before, and it’s clear that we can learn much about ourselves by studying other animals, such as the bonobo ape. This was quite revolutionary thinking at the time – Frances called this “the most amazing discovery in the history of psychology“.

Also controversial at the time was his materialist view of human nature. No Cartesian dualism for him.

While he is most famous as the father of psychoanalysis he “began his professional career as a neurologist and made several notable contributions to the fields of neurology, neuropathology, and anesthesia“. He had the “ability to observe and describe a variety of disease processes“. He predicted epigenetics and pushed forward our understanding of neurons with his experiments. He did a lot to help further understanding how brain nerve cells worked and communicated.

Prior to Freud people were really writing about how the mind works from a first person perspective, and what Freud introduced was a slightly more empirical approach. He did this by looking at other people, even his own children. However, “he didn’t have much respect for experimental psychology, and certainly not for statistics“. So his approach was more rationalist than empirical: he would build up a convincing sounding theory but then not bother to do experiments to verify them.

This was one of his big blind spots: he was unable to keep followers that disagreed with him so couldn’t benefit from criticism. In fact he maintained that his detractors were neurotic! Frances claimed that what he saw in his patients were in fact his own modes of thinking he was protecting onto others. He wasn’t aware that someone could see things differently if they had a different set of experiences.

Sadly, Frances says, this still goes on today, with various groups and institutes having their own grand theories, and so closing their ears to new theories and research.

Francis added other defenses of Freud’s contributions, the big one being psychoanalytical practice – he can be considered the father of all modern talk therapies. He came up with the idea that psychosis is just carrying dreams in to waking state so the subconscious is not repressed. This clearly fits with the data today and means the condition is much easier to understand. He made the amusing observation that economists are just coming up with the idea that humans are not rational actors – if they’d have read Freud they might have come up with this earlier. I disagree with this – just because we don’t always understand our motivations, it doesn’t necessarily imply a lack of rationality.

One thing Frances didn’t mention was Freud’s negative view of the unconscious. He considered it to contain thoughts and urges  that are unacceptable to society: dark and immoral desires. Hence Freudian slips, and so on. It was, in his mind (pun intended), something to be controlled and kept at bay. Some have said that this held back research into the mind for decades.

However we now see the unconscious as something valuable, full of black box functions that allow us to do things without thinking. For example, I’m not thinking about the keys I’m pressing, the letters, morphemes or structure of this sentence. I’m simply considering the meaning I’m trying to convey and the rest is taken care of for me by my unconscious mind.

He summed up saying that we still understand so little about the brain and how it links to the mind, and consciousness. Brain imaging (fMRI) doesn’t say as much as we think – it’s way oversold. Plenty of people have commented on this saying that neuroscience is in its infancy. However we now have a much better model of the mind, that being the computational one: it’s about information processing rather than energies, and symptoms are a result of either hardware of software malfunction.

Addendum – Psychiatry In Crisis

Allen Frances is a sound chap. He is a psychiatrist who “was the Chair of the Task Force that prepared the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), often called the bible of the American psychiatric profession. However, he has been a vocal critic of the new DSM V, condemning what he calls its diagnostic hyperinflation. His new book, Saving Normal, explores why psychiatry has always been subject to so many fads, while deploring the medicalisation of everyday human experience and the excessive use of psychiatric medicine“. Given that overview I was sold.

During questions he opened up on the idiocy of much of modern psychiatry. He is a psychiatrist and he says that big pharmaceuticals have taken over the profession, and pedaled the nonsense that biological changes can be made with drugs and so fix people’s problems due to their “chemical imbalances“. He says this has harmed people. The brain is a very sophisticated computer so yes we need to understand it’s biology, but we also need to understand its workings.

He says that DSM III was useful to give more standard accepted criteria by which to admit people to hospital, but the unintended consequence is that people now just get 10 minutes with a psychiatrist ticking off items on a DSM checklist and prescribing drugs. 80% of these mind-altering drugs are prescribed by GPs or psychiatrists in such short consultations. Now “the DSM is rushed to publication to make money, by a small American association with 35000 members“. He reiterates his point, saying it’s so dangerous because these new silly diagnoses mean more harmful drugs are given to people. He quoted one psychiatrist who says that she recognises herself in almost every condition in the DSM. Some people like labels: it helps them feel understood and part of a group. But people can feel permanently stigmatised, and too often is used to explain away behaviours or abdicate responsibility.

Everything we do in life has a psychological impact. The great thing is this means that psychotherapy changes brain functions. The theme he kept coming back to was that in psychological therapy, it’s the relationship that makes the difference.

He quoted Hippocrates who said “it’s more important to know the patient that has the disease than the disease that the patient has“.

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