Results tagged “Cognitive behavioral therapy” from Ψ Dare To Dream...

Recently, I exchanged messages with Michele Rosenthal, author of the blog, Parasites of the Mind. She asked me a very good question, one that is so much a part of my everyday work, a good long contemplation was needed just to tease out a good answer.

"Speaking of inspiring, how do you inspire a client to believe in what he/she is doing? It's so difficult to believe in anything when PTSD has settled its big black cloud on your head.

Any general rules of the game for (self) empowering belief?"

Another therapist, Mary Redoutey, joined our discussion and attempted to answer this question. She took the conventional route.

"All therapy in essence is self empowered therapy.... The therapist is the partner in the process. I can sit in the chair in my office, can make suggestions, can teach, can do anything as much as I want... and nothing different will happen unless of course the client is present, listens somewhat attentively, suspends negativity long enough to experience a shift in feeling state and/or thoughts or actions.... And the work in the session does not transfer into the client's life unless the client chooses to make the necessary changes. "

Essentially, Mary says that therapists don't change people, people can only change themselves. I have commented on a release for a new book that made this point as well. While it is true that what a client brings to therapy may account for much of the effectiveness of therapy, I don't think this is the core of Michelle's question. As I understand her question, she wants to know what the therapist brings to the therapy room.

My first attempt at replying was rooted in my daily routine. I'm always helping people understand how their past experience impinges on their current symptoms.

"Consider what happens between mother and child. A child develops their self-concept initially based on how they are treated by their mother. In therapy, the therapist communicates his belief in the client. And if the connection already exists, a seed is planted. But as an adult, only the client can nurture the seed to germination and growth. The therapist can only teach them how."

Generally, when I take this tact, which is common with the childhood trauma survivors I see, I am helping them see the importance of exploring their childhood history and their relationships with their caregivers as a way to understand the origins of their symptoms. This is a much more specific answer that still only partly answers Michelle's question.

I think Michelle wants to know what is the therapists role in motivating a client in each and every step through therapy. In other words, what is the client getting from paid expert advice they can't get from a book? From Michelle's point of view, perceptions of her options are clouded by the rollercoaster existence that accompanies PTSD.

There has been extensive research on this topic. Most recently, much of this research has taken on a ideological fervor endorsing Cognitive Behavior Therapy (CBT). I've written often about my opinion CBT. Suffice it to say, CBT may be the core methodology in helping a client manage their thoughts and building treatment plans, but there is much more to behavior change than changing thoughts. One of CBT's central assumptions is patently false. Not all feelings are produced by or changable by thoughts. Much of our earliest learning occurs before thoughts begin to play a major role in our learning around the age of 8.

Patterson (1989) identified common specific factors recognized by virtually all schools of psychotherapy. He included therapist acceptance, permissiveness, warmth, respect, nonjudgmentalism, honesty, genuineness, and empathy or empathic understanding. Three of these, warmth, empathy, and genuineness have considerable research backing. In a previous article, Patterson (1984) points out:

"There are few things in the field of psychology for which the evidence is so strong. The evidence for the necessity, if not the sufficiency, of the therapist conditions of accurate empathy, respect, or warmth, and therapeutic genuineness in incontrovertible.... The fact that specific change occurs in a therapeutic relationship without the addition of so-called specific techniques, such as interpretation, suggestion, instruction, etc., is also evidence of the sufficiency of the relationship by itself. "

More recent research has found the competence of the therapist is critical. Verhofstadt et al. 2008, in their article about the value of emotional similarity and empathic accuracy in support giving with couples. They cite:

"...mounting evidence that unskilled support can be ineffective or even harmful to the support recipient.... In summary, whereas matching the partner's emotion during a support-seeking interaction may provide a sufficient basis for understanding the partner's current affective state(s) and responding with appropriate emotional support and consolation, understanding the partner's specific thoughts and feelings during a support-seeking interaction may provide a sufficient basis for understanding what kind(s) of help the partner desires and how to provide such help in an acceptable way."

Successful therapists must be able to adapt to their clients' emotional uniqueness and to accurately perceive their thoughts and feelings to provide appropriate support in an acceptable way. Perhaps even more important, therapists must be perceptive and adaptive enough to understand the clients complaint that brought them to therapy and the nature of their quandary beyond the clients' own understanding, or the underlying problems. And having discovered what must be done, therapists must be able to provide the clients insight into their dilemma, provide a rationale for a course of action, and persuade their clients to make changes they are unlikely to find easy or achieve without significant discomfort. Initially, clients are often unable to understand the significance of their problems or nature and potential benefit of the required changes. If they did they wouldn't need therapy!

There is only one experience that I find cuts through virtually any dark cloud, and that is the touch of human empathy. When people who are overwhelmed by pain suddenly find someone who seems to understand how they feel, they no longer feel alone and abandoned by the world. A skilled therapist can provide more than the usual kind of empathy. After years of exploring the human condition, the therapist reaches within the client's experience that at least begins to provide some meaning to explain and place in context her experience.

Preston and de Waal (2002) describes the nature of human interaction as involving an exchange of complementary emotional and thought messages. These shared representations allow people to adjust their responses based on the communicated states of others suited to relieve each others' distress. (Cited in Gruhn et al., 2008)

Grillion et al. (2008) describe the emotional exchange between client and therapist and the unique skills required of the therapist.

"When the context becomes safe enough for the client to lower his or her defenses, the alteration of regulatory structures becomes possible. The therapist's own self-regulatory movements reveal his or her inner states to the client. Much like the "good enough mother", the therapist's efforts to regulate his or her own inner states show the client that he or she is in contact with the client. Personal therapy for therapists helps to extend the range of experience that they can draw upon in their work with clients (Schore, 2006, cited in Grillion et al. (2008). According to Amini et al. (1996) the most effective interventions are based on the therapist's awareness of his or her own physical, emotional, and ideational responses to the client's veiled messages.

Accordingly, when the therapist has increasingly expanded self-integration and awareness in regard to his or her state of mind with respect to attachment, then he or she has a larger capacity for assisting clients to achieve integration and awareness. This understanding derives from the primary attachment relationship within the developmental psychobiological perspective in which parents who have secure or "earned" secure states of mind with respect to attachment function in certain ways (including attunement and sensitivity) with their infants that result in attachment security in their children. Therefore, from an attachment point of view, the more secure the therapist is, the greater the likelihood is that he or she can assist clients with achieving greater security (Beebe, 1998, cited in Grillion et al. (2008). Therapist self-awareness broadens "clinical intuition", which is referred to as the art of psychotherapy (Bugental, 1987; Schore, 2006; cited in Grillion et al. (2008). "

Thus the relationship of between therapist and client is perhaps the second most important aspect therapy, right behind client characteristics and motivation. So it is critically important that the client has a good relationship with the therapist. Clients must be willing to shop around to make sure there is a good match. Cooper (2008, quoted in Croft, 2008) makes research based recommendations for finding the right therapist.

"Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

References

Croft, Alison. (2008, October 17). Clients, Not Practitioners, Make Therapy Work. Press release by the British Association For Counselling & Psychotherapy on a new book Cooper, Mick (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. In Medical News Today. Retrieved May 1, 2009, from http://www.medicalnewstoday.com/articles/125815.php.

Grillon, C., Pine, D., Lissek, S., Rabin, S., & Vythilingam, M. (2009). Increased Anxiety During Anticipation of Unpredictable Aversive Stimuli in Posttraumatic Stress Disorder but not in Generalized Anxiety Disorder Biological Psychiatry DOI: 10.1016/j.biopsych.2008.12.028

Grühn, D., Rebucal, K., Diehl, M., Lumley, M., & Labouvie-Vief, G. (2008). Empathy across the adult lifespan: Longitudinal and experience-sampling findings. Emotion, 8 (6), 753-765 DOI: 10.1037/a0014123

Patterson, C. H. (1984). Empathy Warmth And Genuiness In Psychotherapy: A Review Of Reviews. Psychotherapy, 21, 431-438

Patterson, C. H. (1986). Foundations For A Systematic Eclectic Psychotherapy. Psychotherapy, 29, 427-435

Verhofstadt, L., Buysse, A., Ickes, W., Davis, M., & Devoldre, I. (2008). Support provision in marriage: The role of emotional similarity and empathic accuracy. Emotion, 8 (6), 792-802 DOI: 10.1037/a0013976

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I have been really enjoying my access to a large number of professional journals over the past couple years. Working at a teaching hospital definitely has it's academic perks. I've been particularly gratified to see a growing sophistication in research methods, creative approaches and a maturing view of results.

Until recently, practice based research articles have often taken the form of providing some support for a therapist preferred approach to therapy. I can understand that, for I am too, highly invested in how I do and why I do it. But many if not most therapy based research describes a new fangled therapy with a new name. This sort of research seems to me to be more self-serving and contributing to a ever fracturing of psychological science. There are so many theories and therapy methods with rather limited clear definitions or research support, there is little opportunity for advancing knowledge of what works.

A new book was announced at the Annual Conference of the British Association For Counselling & Psychotherapy. Titled Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly, it is written by Professor Mick Cooper of the University of Strathclyde. The book is a research review focused on common factors successful therapy. "The book, which is the first reader-friendly summary of research findings in the field, also offers advice to people who are considering seeing a therapist, on their choice of practitioner and the best type of therapy available to them." The author concludes that the most important factor is a client who is motivated and actively involved in using therapy to build on his or her strengths. In addition, one of the best indicators of a positive therapeutic outcome is a strong relationship between therapist and client. These two factors are far more important than a therapist's ideology or particular techniques.

This is not news to those inside the field who have been paying attention. When I was in training in the late 70's, warmth, empathy, genuineness and humor were thought of as important therapist attibutes because they contributed to a good working relationship with the client. Then it was widely understood that psychologically minded persons, capable of abstraction, insight, self-reflection, and most importantly, with motivation to follow through on treatment outside of the session were found to be ideal candidates for therapy. Unfortunately, they were those least likely to need therapy!

Research took an ideological turn when Cognitive Behavior Therapy became the most thoroughly researched treatment method. And early claims were that results were consistently better than what they called "placebo". Now it seems, advocates, academia, even insurance companies are on the CBT bandwagon, tauting this one method as the only way to go. Even the British government has invested committed £170 million over three years to expanding the availability of CBT.

The trouble is that 20 years of research had complied an impressively large pile of research papers that document a very little differences in improvement when comparing CBT, every kind of manual defined treatment modality known to man. The author of the book argues:

"Many clients will benefit from CBT but there is a danger in putting too much emphasis on the type of therapy that a therapist provides, rather than the therapist's ability to relate to his or her client in caring and understanding ways, and the needs and preferences of individual clients. Rather than moving towards a therapeutic 'monoculture', we need to be able to provide people with a range of therapies and therapists, so that they can choose the one that best suits them and build on their particular strengths.

[..]Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. Ask yourself whether you like your therapist and feel respected by them - the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

What a breath of fresh air!

Reading this book review reminded me of a number of articles I read a couple years ago linked to The Institute for the Study of Therapeutic Change (ISTC) founded by Scott Miller, Barry Duncan, and Mark Hubble. Their collaboration "resulted in several books and dozens of articles, and culminated in the APA best selling, The Heart and Soul of Change. As detailed in that book, the things that make therapy work are largely about the client--the true hero of therapeutic change--and the quality of the relationship formed with the therapist, far more important than model or technique."

Michael J. Lambert of Brigham Young University in 2005 published an article in the Journal of Clinical Psychology on common factors in effective psychotherapy. Lambert takes his argument down a creative path. He suggests that the attention placebo includes therapeutic effective common factors.

Placebo is a research concept that is most commonly used in pharmacological research. Basically, if you find a drug that most people find better than a sugar pill, you have a new product! There is a problem when you apply this concept to researching outcomes in psychotherapy. Just what is the therapy version of a sugar pill? A placebo for therapy outcome has been said to include life events, social support, hopeful expectations, and biochemical changes that accompany treatment and enhance immune function and biochemical balances that facilitate recovery. The problem is therapy is all about providing social support and hopeful expectations from the effectiveness of the therapeutic relationship, the so called "attention placebo."

The "social support, hopeful expectations" part of therapy are essentially the "attention" part of the placebo effect. Certainly this part of a placebo effect is an essential part of psychotherapy, not something to be merely separated or controlled from measurement of therapeutic effectiveness. Lambert effectively makes that point:

"Placebo controls make less sense when extended to psychotherapy research because the benefits of treatments and placebos depend on psychological mechanisms. Many authors in the 1980s rejected the placebo concept in psychotherapy research because it is not conceptually consistent with testing the efficacy of psychological procedures (e.g., Dush, 1986; Horvath, 1988; Wilkins, 1984). Nevertheless, the search for causes of improved patient functioning within the traditional scientific method has persisted, albeit under a variety of different terms. Rosenthal and Frank (1956) defined a placebo as being theoretically inert. It is inert, however, only from the standpoint of the theory behind the therapy studied. As Critelli and Neumann (1984) have observed, "virtually every currently established psychotherapy would be considered inert, and therefore a placebo, from the viewpoint of other established theories of cure" (p. 33). Consequently, placebos have sometimes been labeled as nonspecific factors (e.g., Oei & Shuttlewood, 1996). This conceptualization raises serious questions about the definition of nonspecific. Once a nonspecific factor is labeled, does it then become a specific factor and fall outside the domain of a placebo effect? For example, if a variable like therapist warmth is operationally defined and measured does it then become a specific factor, but if not measured a nonspecific (i.e., placebo)? (Bowers & Clum, 1988). Others have suggested the term common factors as a replacement for terms like placebo and nonspecific, in recognition that many therapies have ingredients that are not unique but are nonetheless efficacious. Thus, research on placebo effects might be better conceptualized as research on common factors versus the specific effects of a particular and unique technique.

Common factors are those dimensions of the treatment setting (therapist, therapy, client) that are not specific to any particular technique. Research on the broader concept of common factors investigates causal mechanisms such as expectation for improvement, therapist confidence, and a therapeutic relationship that is characterized by trust, warmth, understanding, acceptance, kindness, and human wisdom. But also can be expanded to include some mechanisms that are often regarded as unique to a particular form of treatment such as exposure to anxiety-provoking stimuli, encouragement to participate in other risk-taking behavior (facing rather than avoiding situations that make the patient uncomfortable), and encouraging client efforts at mastery such as practicing and rehearsing behaviors. Such a view of common factors recognizes that while specific theories of psychotherapy may emphasize systematic in vivo or in vitro exposure to frightening situations, or social skills training, nearly all therapies encourage people to review and discuss the things they fear and face rather than avoid such situations. Common factors, no matter how unimportant they may be from the point of view of a particular theory (theoretically inert or trivial) are central to nearly all psychological interventions in practice, if not, theory."

Lambert's review reports one factor that is consistently found to be important to therapeutic effectiveness, the relationship between the therapist and the client. Most notably, outcome may be largely related to early response to treatment, before the core techniques have been implemented by the therapist.

"At present, the active mechanism linking early response to long-term outcomes is unknown. Whatever the active ingredients are, they appear to work quickly in many cases. The timing of improvements during psychotherapy has theoretical implications beyond placebo explanations for change. If response to therapy precedes introduction of theoretically important techniques, then it is difficult to attribute central importance to these techniques in the healing process. Early responders to psychotherapy may be more resilient, better prepared, more motivated, and thus more receptive to therapeutic influences of any kind. Early response may also indicate a better fit between client and therapist and reflect the positive effects of the working alliance which often can be detected by the third session of treatment. For example, Krupnick et al. (2000) found that the relationship between the client and his or her therapist was most predictive of outcome. This finding is notable because the authors encountered this result across treatment modalities, including two distinct psychotherapies, as well as antidepressant medication, and placebo conditions."

This and a number of other research reviews make a persuasive argument that therapeutic technique is relatively unimportant in maximizing a positive outcome. CBT has been found to be minimally more effective than other therapy approaches. I could imagine how manualized treatment that is most common in these research studies may well minimize the early response factors Lambert mentions above. CBT, designed for a manualized approach, may be less susceptible to suppressing early responses and thus has a more consistent record of comparatively more positive outcomes. Since the magnitude of response when comparing outcomes across therapeutic techniques are minimal in most cases, it seems particularly unwise to attribute CBT with the best outcomes, especially since some of the most important factors related to therapeutic outcomes have been systematically controlled out or inadvertently suppressed by the manualized approach.

References:

Michael J. Lambert (2005). Early response in psychotherapy: Further evidence for the importance of common factors rather than "placebo effects" Journal of Clinical Psychology, 61 (7), 855-869 DOI: 10.1002/jclp.20130
Miller, S., & Duncan, B. (n.d.). "What Works" in Therapy? TalkingCure.com. Retrieved December 28, 2008, from http://www.talkingcure.com/reference.asp?id=100.

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Aaron Beck, considered the Father of Cognitive Therapy, is an American psychiatrist and a professor emeritus at the Department of Psychiatry at the University of Pennsylvania. He is President of the Beck Institute for Cognitive Therapy and Research that is directed by his daughter, Judith S. Beck, Ph.D.. He is noted for his research in psychotherapy, psychopathology, suicide, and psychometrics, and the Beck Depression Inventory (BDI), one of the most widely used instruments for measuring depression severity. At age 87, the man is still publishing, building on his pioneering work on the cognitive model of depression. In his latest article published in the American Journal of Psychiatry, he recalls his early work:

"Caught up with the contagion of the times, I was prompted to start something on my own. I was particularly intrigued by the paradox of depression. This disorder appeared to violate the time-honored canons of human nature: the self-preservation instinct, the maternal instinct, the sexual instinct, and the pleasure principle. All of these normal human yearnings were dulled or reversed. Even vital biological functions like eating or sleeping were attenuated. The leading causal theory of depression at the time was the notion of inverted hostility. This seemed a reasonable, logical explanation if translated into a need to suffer. The need to punish one's self could account for the loss of pleasure, loss of libido, self-criticism, and suicidal wishes and would be triggered by guilt. I was drawn to conducting clinical research in depression because the field was wide open--and besides, I had a testable hypothesis.

I decided at first to make a foray into the "deepest" level: the dreams of depressed patients. I expected to find signs of more hostility in the dream content of depressed patients than nondepressed patients, but they actually showed less hostility. I did observe, however, that the dreams of depressed patients contained the themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased. At first I assumed the idea that the negative themes in the dream content expressed the need to punish one's self (or "masochism"), but I was soon disabused of this notion. When encouraged to express hostility, my patients became more, not less, depressed. Further, in experiments, they reacted positively to success experiences and positive reinforcement when the "masochism" hypothesis predicted the opposite (summarized in Beck).

Some revealing observations helped to provide the basis for the subsequent cognitive model of depression. I noted that the dream content contained the same themes as the patients' conscious cognitions--their negative self-evaluations, expectancies, and memories--but in an exaggerated, more dramatic form. The depressive cognitions contained errors or distortions in the interpretations (or misinterpretations) of experience. What finally clinched the new model (for me) was our research finding that when the patients reappraised and corrected their misinterpretations, their depression started to lift and--in 10 or 12 sessions--would remit."

We owe a lot to Dr. Beck. His cognitive model of depression still dominates how I and most of my colleagues write treatment plans for persons suffering with depression. Our goal is to inspire and teach our clients to change their negative self-evaluations, correct distorted memories, and create an expectation of success. The only problem is depression is not that simple.

Try as they might, many clients are able to recognize what they need to do, understand how their thoughts about themselves and their world need to change, are able to state those changes, and diligently practice them. But when they really need to be able to master their fate, when ruminative thoughts spiral downward into the depths of depression, their efforts quickly collapse and they succumb.

So is the Cognitive Model of Depression wrong? No, I think it's incomplete. There is the biomedical model of depression involving errant neurotransmitter levels treated by various anti-depressants. That discussion is beyond this article's purpose. I'm more interested in what we as therapists can do differently in the counseling office. Of course we need to be sure a severely depressed client is referred for a medication review. But I want to know how we might better facilitate our clients attempts to master their mood. To this end, I will review my recent reading on the subject of emotion and argue to include emotion in a new Cognitive Theory.

Horwitz and Wakefield (2007) have released what may prove to be a highly influencial book titled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder. The title implies that psychiatry transformed sadness into depression. It's an unfortunate catchy title that misleads the uninformed reader. Instead, the book explores in a scholarly way a fundamental principle upon which The Diagnostic and Statistical Manual (DSM) was developed.

A review of Horwitz and Wakefield (2007) by Andreea L. Seritan appeared in Am J Psychiatry 164 (11): 1764.

"The central thesis of this book is a persuasive argument that contemporary psychiatry confuses normal sadness with depressive mental disorder because it ignores the relationship between symptoms and the context from which they emerge. Although he remains cautious about the possibility of incorporating situational context into diagnostic criteria, Dr. Spitzer encourages psychiatrists to place this issue on the agenda for the upcoming formulation of DSM-V.

The book's title is a reminder of the central role of loss as a potentially severe life stressor leading to depression, as well as of how modern psychiatry is being blindsided into extrapolating most states of sadness into depression. In the first chapter, "The Concept of Depression," Drs. Horwitz and Wakefield address the move toward using descriptive criteria in diagnosing mental illness. In response to criticisms during the 1960s and 1970s about the lack of reliability of psychiatric diagnoses, DSM-III started using lists of symptoms to establish clear definitions for each disorder. The authors argue that this approach, while greatly increasing diagnostic reliability, has created new validity problems (p. 8). In the definition of major depressive disorder, DSM-III "fails to take into account the context of the symptoms and thus fails to exclude from the disorder category intense sadness, other than in reaction to death of a loved one, that arises from the way human beings naturally respond to major losses" (p. 14).

Chapter 2, "The Anatomy of Normal Sadness," discusses biologically based nonverbal expressions of grief, with emphasis on their universality across cultures and their presence in nonhuman primates and human infants prior to socialization into cultural emotional scripts (p. 39). Besides grief at the loss of a loved one, loss of meaningful relationships, loss of job or status, chronic stress, and disasters are listed as additional factors to be taken into account. Chapters 3 and 4, "Sadness With and Without Cause" and "Depression in the Twentieth Century" are a historical review of descriptions of depressive states from ancient times to the present. Disordered sadness is considered "without cause" (or "endogenous" in later terminology), as opposed to sadness "with cause" (or "reactive" sadness), which arises in people who suffer losses. Robert Burton's classic work The Anatomy of Melancholy, published in 1621, was the first to describe the three major components of depression--mood, cognition, and physical symptoms--that are still viewed as its distinguishing features. In his seminal paper Mourning and Melancholia (1917), Freud made the same distinction between mourning due to conscious losses and melancholia due to the experience of unconscious losses. DSM-III eliminated psychodynamic etiologies, instead focusing on symptoms. In large epidemiological studies, such as the Epidemiologic Catchment Area study in the early 1980s, diagnosis was based on structured tools administered by trained nonpsychiatric interviewers. The authors argue that prevalence data was skewed and advocate for a more specific screening process, as well as careful use of subthreshold diagnoses, such as minor depression.

Thoroughly documented, the first chapters caution readers about the limitations of psychiatric diagnosis. However, momentum is lost in the second half of the book. Chapter 7, "The Surveillance of Sadness," makes assumptions about psychiatric treatment that are not supported by the literature. For example, it is suggested that in primary care, "diagnosis of a depressive disorder tends to quickly foreclose...discussions in the direction of medication" (p. 156). The recent avalanche of data from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) study suggests not only that depressed primary care patients prefer psychotherapy to medication when offered (1) but that therapy is successfully delivered in this setting, along with pharmacologic management (2). In Chapter 8, "The DSM and Biological Research About Depression," the authors again overreach, selectively analyzing individual cardinal papers and doubting their "range of applicability" without turning to the multiple evidence- based studies available in the literature (p. 176).

Although a poignant reflection on how the misapplication of psychiatric knowledge can decontextualize the lives of its patients, this book seems to miss the point that psychiatric care is a great deal more than diagnostic labeling. In practice, mental health professionals who do not rely exclusively on DSM-IV-TR use biopsychosocial formulations, viewing the individual in his or her context. Thus for many psychiatrists, treatment planning is informed by this comprehensive understanding of the person, and not solely by the description and duration of their symptoms."

Seritan has a point that many clinicians do not rely exclusively on the DSM for diagnosis. However, the classification model considered the gold standard for diagnosis DOES decontextualize diagnosis. That is a concern for training and continuing education. Given all the incentives in practice to base treatment on measurable criteria from malpractice claims, insurance payors and accreditation agencies, its very easy to slip into a comfortable criteria based practice that requires little emotional investment.

Mulder wrote an article on an even more important point about diagnosis, titled An epidemic of depression or the medicalization of distress in Perspect Biol Med. 2008 Spring;51(2):238-50.

"The syndrome of major depression is widely regarded as a specific mental illness that has increased to the point where it will be second in the International Burden of Disease ranking by 2020. This article examines the assumption that major depression is a specific illness, that it is rapidly increasing, and that a medical response is justified. I argue that major depression is not a natural entity and does not identify a homogenous group of patients. The apparent increase in major depression results from: confusing those who are ill with those who share their symptoms; the surveying of symptoms out of context; the benefits that accrue from such a diagnosis to drug companies, researchers, and clinicians; and changing social constructions around sadness and distress. Standardized medical treatment of all these individuals is neither possible nor desirable. The major depression category should be replaced by a clinical staging strategy that acknowledges the continuous distribution of depressive symptoms. Trials that test social and lifestyle treatments as well as drugs and cognitive behavioral therapy across different levels of severity, chronicity, and symptom patterns might lead to the development of a coherent evidence-based stepped treatment model."

Mulder's point is that diagnosis is a academic exercise designed to communicate a cluster of symptoms among professional colleagues. It's a model of communication. The syndromes described have acquired meaning well beyond communication. Diagnostic labels have been elevated from theoretical constructs into real phenomena. Major depression includes a cluster of symptoms that is shared by many people who are not depressed.

Wade Schuette expresses the apparent paradox of diagnosis as a prerequisite for treatment.

"If depression is largely an internal phenomenon, caused by genetics and bad wiring in the brain, that leads to one type of intervention - drugs and CBT. If depression is largely a social phenomenon, related to the well-documented collapse in social interaction documented by Putnam and the group at Duke, then personal intervention will simply deal with symptoms, and result in an ever growing prevalence of drug-dependent victims of social dysfunction - precisely the observation we find about the USA today."

The truth is all of these viewpoints have merit. Major Depression can be conceptualized and described in many ways, none of which are sufficient to explain the phenomena without considering all other viewpoints. Diagnostic categories are scientific models for communication. They are not readily amenable to measurable criteria because the concepts are complex and largely abstract constructs that fit a theory.

Sadness is an abstract concept designed to communicate a common human experience associated with grief and loss. I believe sadness is an emotion that is a critical component of a productive grief process that helps us survive and adapt to major loss. Sadness is normal and healthy. Major Depression may include sadness, maybe associated with loss, but it is a clinical syndrome that includes significant functional impairment, a loss of survival skills. Sadness is an emotional motivation that ENHANCES survival.

Mental illness is less understood than most people think. Common sense would have it that good parenting makes all the difference. It's just not that simple. The NY Times has a great series on "Troubled Children" that is well worth the read. The articles include some good background on the nature of mental illness and it's development.

Today six million American children have been diagnosed with a serious mental disorders, a number that has tripled since the early 1990's.

But that doesn't mean that the rates of illness have increased in the past few decades. Rather, it is the decease in stigma of seeking help and that more professionals and parents are willing to attribute problems with children to mental illness. ADHD and Bipolar illness is diagnosed with alarming frequency these days, clearly an indication of misdiagnosis in both the past and the present.

From the NY Times series:

Still, many psychiatrists believe that, although childhood bipolar disorder may be real in families like the Finns, it is being wildly over-diagnosed. One of the largest continuing surveys of mental illness in children, tracking 4,500 children ages 9 to 13, found no cases of full-blown bipolar disorder and only a few children with the mild flights of excessive energy that could be considered nascent bipolar disorder -- a small fraction of the 1 percent or so some psychiatrists say may suffer from the disease.

Moreover, the symptoms diagnosed as bipolar disorder in children often bear little resemblance to those in adults. Instead, the children's moods seem to flip on and off like a stoplight throughout the day, and their upswings often look to some psychiatrists more like extreme agitation than euphoria.

[...]The children in one group, a minority, have mood cycles similar to those of adults with bipolar disorder, complete with grandiose moods, and a high likelihood of having a family history of the illness. Those in the other group have severe problems regulating their moods and little family history, and may have some other psychiatric disorder instead.

[...]Last year in the United States, about 1.6 million children and teenagers -- 280,000 of them under age 10 -- were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.

Many psychiatrists and parents believe that such drug combinations, often referred to as drug cocktails, help. But there is virtually no scientific evidence to justify this multiplication of pills, researchers say. A few studies have shown that a combination of two drugs can be helpful in adult patients, but the evidence in children is scant. And there is no evidence at all -- "zero," "zip," "nil," experts said -- that combining three or more drugs is appropriate or even effective in children or adults.

Diagnosis is very complicated, largely because the whole concept is a rather crude way to explain all the varieties of behavioral disorders into a linear and causal model of mental illness that will facilitate treatment planning. Unfortunately, diagnosis and treatment is more like shaping Jello without a mold.

The human body doesn't work in a linear way. There is no simple way to describe a step-by-step process of disease development and no simply way to ensure an accurate way to prescribe treatment. Instead, the body, while a whole in itself, it is too complex to be thought of as one interacting system. The best we can do is break it up into parts and posit hypotheses about how parts might function. Our model of brain function, mental illness and treatment has fallen behind our knowledge. Worse yet, economics has pushed medicine to embrace a simple solution for a very complex problem. Giving a patient a pill sometimes works. It's so simple and cheap to do, if one pill doesn't work, another pill is offered, sometimes replacing the first, sometimes adding to it.

Frankly the state of our science doesn't really support the first pill, much less the second. There is growing evidence that therapy is as effective as the primary treatment or at least in combination with medications.

Psychotherapy has had it's own problem with linear thinking. There is more research on Cognitive Behavior Therapy, showing it as effective or more so than all other treatments, so the assumption is made that since the practice of CBT is "evidence-based", that it must be the treatment of choice. CBT is a simple straight forward process that can often be encapsulated into a manual. But there is no consistent evidence that CBT is any better than any other treatment. There is a dearth of meaningful comparison studies.

The problem is that mental health treatment is not amenable to meaningful research. Mental illness often has life long process of ebbs and flow where only part of the time is it "clinically" treatable, but it's roots and symptoms are pervasive throughout the lifespan. Studies are necessarily time limited. Treatments are offered most often for no more than six months and then outcomes are measured. Not surprisingly, treatment is demonstrated as disappointingly little more effective than "placebo". A placebo is a an intervention, such as giving the patient some helpful attention, which might reasonably be seen as helpful by a patient but there no reason to believe it should be as effective as the studied treatment. But the placebo is pretty effective itself, much more so than sitting on a waiting list for treatment.

Lets take a fresh look at the model of mental health, illness and behavioral science. Lets simplify the model from the biological realities but not so much as a singular linear model of one sequence of events producing an outcome. Actually, I've found it useful to conceive of the mind as having two main parts. One part is largely made up by the cortex, or the evolutionary most recently developed brain function. It's this part of the brain that is largely responsible for manipulating symbols, interpreting and remembering patterns of perceptions, and self-awareness and self-monitoring.

The cortex overlies a phylogenetically older part of the brain that largely makes up the autonomic nervous system. In this part of the brain, the body functions largely "automatically" with little interaction with the cortex. Here the heart is stimulated to beat, breath is maintained, pain sensors are monitored and automatic behaviors like walking and steering a car is monitored, largely without conscious awareness. Here is also the roots of our emotions, the biochemical and hormonal precursors to the thoughts whose symbolic representations we create to understand our emotions.

The cortex is the thinking part of the brain. The autonomic nervous system is the emotional and functionally analogic part of the brain. That part of us we imagine as "rational" or "logical" largely resides in the cortex. Those parts of us that are instantly compelled to act out of sheer emotion reside in the autonomic brain. Virtually all of our behavior is in fact the result of BOTH parts of the brain. So it is equally inaccurate to call our behaviors as rational manifestations or solely emotionally based. Our behavior is largely the result of both parts of us.

So, given this, its not surprising that there are times we wonder why we behave certain ways, or why we know we need to make a change, but mysteriously find ourselves unable to do so. While our awareness directs most functions of the rational cortex, we have relatively little "rational" control over the autonomic brain.

Traditionally, culture has attempted to explain this as a mind/soul duality. Judeo/Christian tradition posits that the primitive nature of humanity must be overcome by suppression of our autonomic impulses. Freud developed that concept into his scientific systemic model of the id (autonomic), ego (awareness), and superego (conscience). His concepts led to the idea that suppressed impulses caused problems, internal conflicts, that were manifested in dysfunctional behavior.

I think it's much more useful to think of the body as a functional whole that emerged from millions of years of natural section into a amazingly effective organism. I'd rather assume that ALL parts of us are as necessary to survival as any one. On an experiential basis, this requires a leap of faith. Ambivalence is an uncomfortable condition. Our mind is known to do all sorts of convenient fictional explanations of motives and their behavioral manifestations in attempt to maintain an illusion of rationality. One such example is cognitive dissonance.

In order to make use of our incredibly effective brain, we must be aware of as many of it's manifestations as is possible. We must recognize and be able to put into words emotions as complex and varied as our thoughts. We must also accept the fact that our thoughts and emotions OFTEN contradict each other, but in a real and very personal sense, both are right. Both parts of the brain learn their reactions. They also are born with reactions characteristic of the genes they inherit. Environmental insults, such as neuro-toxins and brain trauma can alter both parts of the brain structurally and functionally.

My assumption is that we function best when we make the most of everything we have. Marsha Linehan in developing Dialectical Behavior Therapy, took a similar view. The "Wise Mind" was conceived of as a combination of "Emotion Mind" and "Rational Mind". This all may seem simplistic and convenient thinking, but from a clinical stand point, the concepts work quite well.

Cognitive learning is the most available for change. We think, therefore we do. If we change how we think, we change what we do. However, everyone knows from their last New Year's resolution that it's not that simple for the many behaviors we want to change.

Our culture has developed the concept of "character" to explain how some people can change and others cannot. Character is largely thought to be genetically determined. That makes the non-thinking part of us to be very difficult and unlikely to change. Indeed, that has been the bias of psychiatry for many years. Diagnostically, Personality Disorders are roughly equivalent to the common concept of character. Though, psychological developmental models have demonstrated that nurture has quite a bit of influence over nature, it is still largely assumed personality is unchangeable. Medicare and many other insurance companies won't pay for treatment based on a diagnosis of a Personality Disorder.

But we do know from Behavior Theory that even reflexive behavior like salivating, heart rate and emotions can be learned and unlearned. Personality Disorders are assumed to be so pervasive and embedded in lifestyle and biochemistry to be largely untreatable. However, those of us who have worked a lot with persons with personality disorders know that they can change with knowledge and sustained effort and lifestyle change.

Personality Disorders seem to emerge from unfortunate childhood events, child abuse, neglect, or trauma, especially repeated trauma and chaotic lifestyles in the parents or caregivers. Parents with personality disorders beget children who grow up similarly impaired. While the actual behavioral style and sensitivity to the environment may well be genetically determined, the behavior is largely learned by emotional conditioning.

In Behavior Theory, a strong emotion creates a unique learning sequence. Elicit a strong emotion, with say a loud noise, the person will be strongly motivated to do something. They may jump in a startle response. But the person will also learn approach or avoidance behavior, based on the valence of the emotion, rewarding or punishing. Then, when you pair a neutral environmental stimulus with the intense emotion, eventually, just the neutral stimulus acquires the emotion eliciting effects of the original.

When a child grows up in a chaotic environment, she experiences strong emotions all the time. She is likely to also learn approach and avoidance behaviors in a way that is often random associated with unrelated environmental events. She is said to have learned "superstitious" behavior. Unlearning this behavior is a major challenge. That is because emotional learning is in a way "hardwired" in the autonomic brain. Representations of the environment are paired with an emotional responses outside of her cognitive awareness. She develops persistent bad habits that over time pile up into patterns of dysfunctional behaviors and can become a Personality Disorder.

Treatment of a Personality Disorder must address the behavior, often manifested in a characteristic lifestyle, the thoughts and attitudes of the individual, and the emotional responses that together drive the behavior. The basic paradigm of therapy becomes conditioned emotional responses described above and must be repeated over and over again, with the cooperation of the individual during periods of withering emotions. Not surprisingly, few volunteer for this sort of treatment until things become intolerable. The other problem, is that few clinicians offer this sort of treatment. Despite it's grounding in Behavior Therapy, this is not mainstream CBT. DBT covers some of the same ground, but the experiential notion of making changes in the context of strong emotions seems to be absent.

Traditional psychoanalytic therapy has used "abreaction" for many years. Crisis intervention theory also had a similar concept. But neither of these models claim that the method is effective with long standing chronic psychopathology. Marsha Linehan's DBT is the one of the few treatments that claim to be effective with personality disorders, especially borderline personality disorder. Although Linehan's model continues the tradition of encouraging suppression of excessive emotion by teaching incompatible behaviors, it does encourage patients to be "mindful" of their emotions and to combine them with rational thought for wisdom.

Why aren't more people doing this? There is several reasons. There is little recent theoretical formulations beyond Linehan's that support this approach. Current concepts of crisis intervention emphasize stabilization as the goal. In fact, virtually all the insurance company criteria for termination of mental health treatment call for stabilization of symptoms, rather than permanent behavior change! This is the same reasoning that got psychiatry stuck on handing out pills first.

Medication is often a helpful option. But given the recent highlight on suicidality with anti-depressants, side-effects of all medications, especially anti-psychotics, psychotherapy seems a prudent course to start and use medication adjunctively, rather than the other way around.

A number of people maybe wondering just how we can best help children and their parents who have faced the disaster in New Orleans. Here is an approach that has produced convincing research results treating children and their families. Contact the authors for more information. The link is below.

SAMHSA

Trauma-Focused Cognitive Behavioral (TF-CBT) is a psychotherapeutic intervention designed to help children, youth, and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse; traumatic loss of a loved one; domestic, school, or community violence; or exposure to disasters, terrorist attacks, or war trauma. It was developed by integrating cognitive and behavioral interventions with traditional child abuse therapies that focus on enhancement of interpersonal trust and empowerment. The program can be provided to children 3 to 18 years of age and their parents by trained mental health professionals in individual, family, and group sessions in outpatient settings. It targets symptoms of posttraumatic stress disorder (PTSD), which often co-occurs with depression and behavior problems. The intervention also addresses issues commonly experienced by traumatized children, such as poor self-esteem, difficulty trusting others, mood instability, and self-injurious behavior, including substance use.