Treatments have traditionally been driven by several ways of judging the best ones. The most common is trial and error, try things and see what happens. The next most is to imagine the cause of an ailment and to try methods that logically should address those causes. The outcomes of this method seems to consist of looking at results and if unsuccessful to try another method based upon the same notions about the causes. Next is the scientific method which asks simple questions that can be confirmed or dismissed by experimental results. The brain is a mystery for us even though far more is known than every before. The treatments like shock therapy and strong psychotropic drugs fall into the second category, they are not based upon what we know about the brain but how we imagine the maladies of the brain might be undone. The shock therapy operates on the theory that the brain can be restored to normal by erasing all that is going on and starting fresh, like powering off a computer to end and otherwise infinite loop due to a glitch or a bug in the software. The psychotropic drugs attempt to moderate extreme mental states like hallucinations or psychosis or persistent overreactions like ongoing anxiety or dead flat lack of feelings, symptoms that cannot be moderated by other means. Psychotherapy is sometimes called talk therapy and it's importance is still undermined by the illusion that there is a difference between the mind and the brain which is slowly being corrected.
6
I LOVE this UK organization 'Council for Evidence-Based Psychiatry' and its list of 'Unrecognized Facts' of psychiatry -- everything that many of us have been reading about for several years but is all nicely gathered in one spot:
http://cepuk.org/unrecognised-facts/
http://cepuk.org/unrecognised-facts/
12
Interesting – calling on psychiatrists to start practicing (gasp!) psychotherapy in addition to medicating people. What a concept!
Except it would be bad for business – psychiatrists charge a lot more for less time, since it takes little time to prescribe a pill and do follow-ups, and so they can see as many patients in an hour as a therapist can see in two or three. Dr. Friedman states the obvious: "It is clearly cheaper and faster to give a pill than deliver psychotherapy."
And psychotherapy is way harder than pill-pushing. Cheaper and faster and easier.
Let's see - less money, more work. Hmmm...I think Dr. Friedman's suggestion is going to fall flat with today's psychiatrists. This is something that has to start with medical schools teaching a new generation of psychiatrists, so at best his laudable concept is many years down the road.
Except it would be bad for business – psychiatrists charge a lot more for less time, since it takes little time to prescribe a pill and do follow-ups, and so they can see as many patients in an hour as a therapist can see in two or three. Dr. Friedman states the obvious: "It is clearly cheaper and faster to give a pill than deliver psychotherapy."
And psychotherapy is way harder than pill-pushing. Cheaper and faster and easier.
Let's see - less money, more work. Hmmm...I think Dr. Friedman's suggestion is going to fall flat with today's psychiatrists. This is something that has to start with medical schools teaching a new generation of psychiatrists, so at best his laudable concept is many years down the road.
10
Psychology just witnessed a scandal involving resignations and departures from its leaders at its premier professional organization.
Psychiatry has a poor history of dealing with sexual and gender non-conformity. It too is implicated in its own scandals of prescription drug overdose.
Too much emphasis on "mental health" creates incentives to expand the reach of psychology and psychiatry.
But these "disciplines" remain among the most vague of the medical "sciences." And they also produce results akin to economics in the social sciences: dismal in nature and a poor description of reality.
The disciplines should refocus on helping the truly needed, and not seek to expand their services by tweaking happiness for the middle class.
Psychiatry has a poor history of dealing with sexual and gender non-conformity. It too is implicated in its own scandals of prescription drug overdose.
Too much emphasis on "mental health" creates incentives to expand the reach of psychology and psychiatry.
But these "disciplines" remain among the most vague of the medical "sciences." And they also produce results akin to economics in the social sciences: dismal in nature and a poor description of reality.
The disciplines should refocus on helping the truly needed, and not seek to expand their services by tweaking happiness for the middle class.
3
I agree with the importance of psychotherapy, and with the idea that's underused, in theory. In practice, it is very difficult to find a competent psychotherapist who can identify problems, come up with a reasonable diagnosis and deliver competently the corresponding psychotherapy.
Studies that involve psychotherapy as an intervention are administered by well trained professionals and often the intervention is manualized and applied to a selected group of subjects. Where in the real world do you find that readily available? Much harder than finding a pharmacy for sure.
Studies that involve psychotherapy as an intervention are administered by well trained professionals and often the intervention is manualized and applied to a selected group of subjects. Where in the real world do you find that readily available? Much harder than finding a pharmacy for sure.
11
Compared to medication, psychotherapy works slowly and appears to be relatively expensive. I say that psychotherapy "appears to be" expensive because the pharmaceutical industry has done a very good job of making sure that only a very small number of Americans are aware of the industry's huge profits, partially the result of government subsidies for research and partially the result of the enormous amounts of money which the industry spends to market its products to physicians and the public.
In "America's Bitter Pill," his sobering account of the political machinations which resulted in the Affordable Care Act, Steven Brill shows how, along with the hospital and insurance industries, the pharmaceutical industry used its lobbying skills to get exactly the kind of "health care reform" which would work to its maximum benefit. By contrast, physicians and other health care clinicians - very much including psychologists and other psychotherapists - were treated as powerless losers by the politicians who crafted and passed the bill.
In "America's Bitter Pill," his sobering account of the political machinations which resulted in the Affordable Care Act, Steven Brill shows how, along with the hospital and insurance industries, the pharmaceutical industry used its lobbying skills to get exactly the kind of "health care reform" which would work to its maximum benefit. By contrast, physicians and other health care clinicians - very much including psychologists and other psychotherapists - were treated as powerless losers by the politicians who crafted and passed the bill.
12
In private industry out in the real world, if a group of people are being ineffective and failing to make forward progress, they are regarded as incompetent. Psychiatry has given us electroshock, which was used to treat everything from depression to menopause in its early years. It has given us historically cruel asylums, which have over the last century failed not only to produce cured patients, but has not significantly improved patient outcome over treatment by a witch doctor (there was a study done years ago showing that psychiatry and psychology are no more effective than treatments by a witch doctor or placebo - there have been several before and after the well-known 2008 study).
Monkeying with numbers and statistics aside psychiatry and psychology do not hold to the standards of real science or medicine. Drugs are given to patients that seem to affect symptoms, but even those who discovered these medicines cannot tell us with certainty why they work.
Pyschiatry and psychology are frauds perpetrated on the most vulnerable members of our society. Nothing more and nothing less. If taking a sugar pill or an expensive medication can produce the same result, stick with the placebo. It has far fewer side effects.
Monkeying with numbers and statistics aside psychiatry and psychology do not hold to the standards of real science or medicine. Drugs are given to patients that seem to affect symptoms, but even those who discovered these medicines cannot tell us with certainty why they work.
Pyschiatry and psychology are frauds perpetrated on the most vulnerable members of our society. Nothing more and nothing less. If taking a sugar pill or an expensive medication can produce the same result, stick with the placebo. It has far fewer side effects.
6
The mind and the brain are the effect and the cause with feedback and memory systems which allow us to do everything from learning how to adapt behavior and to imagine what might be but which is not and how to make things happen to satisfy our wants. The determinism which we understand directs the forces of nature studied by the physical sciences is transcended by the mechanisms and systems in living things reflected in our mind/brain systems. People to some extent can overcome some maladies like OCD and anxieties with conscious efforts to revise perceptions and focus of attention. This seems to show that the feedback and memory functions can help to alter the brain's function which produces OCD and anxiety. It indicates that some maladies are problems that are not due to disease processes but to habits of mind that can be changed. Other maladies are actually failures of the brain to work normally, which are physical malfunctions, and those might be better managed by understanding what does not work.
The problem isn't a lack of new drugs. The problem is that most humans seem to need a purpose in life, and most people cannot accept the Tim Minchin philosophy of life:
https://www.youtube.com/watch?v=q5RBG1PadWI
I recall an anecdote about the Buddha and one of his disciples. The disciple had been sitting at the master's feet, and he was happy with what he was learning. But he was also discontent because the Buddha was not answering some of his questions like: Where did the Universe come from? Where is it going? Why am I (the disciple) here and what is my destiny?
The disciple brought his concerns to the Buddha, who replied: *I* can teach you how to escape suffering and reach Nirvana. But those questions you ask are irrelevant.
The disciple left searching for a new prophet.
https://www.youtube.com/watch?v=q5RBG1PadWI
I recall an anecdote about the Buddha and one of his disciples. The disciple had been sitting at the master's feet, and he was happy with what he was learning. But he was also discontent because the Buddha was not answering some of his questions like: Where did the Universe come from? Where is it going? Why am I (the disciple) here and what is my destiny?
The disciple brought his concerns to the Buddha, who replied: *I* can teach you how to escape suffering and reach Nirvana. But those questions you ask are irrelevant.
The disciple left searching for a new prophet.
1
I deeply appreciate Dr. Friedman’s plea for increased funding for psychotherapy research. He calls on the NIMH and others to recognize that many mental disorders will not be reached by pharmacologic intervention any time soon, and recognizes that interactions between our biology and our experiences are at the core of mental suffering and recovery.
For over 30 years American psychiatry has been molded by the Scylla and Charybdis of decreased reimbursement for psychotherapy and the financial allure of collaboration with the pharmaceutical industry. The result is a steady decline in psychiatrists who are trained – or even believe – in psychotherapy, or understand the fundamentals of attachment, motivation, habit, and impulse.
Thus those in the best position to advocate for funding — and to cultivate two generations of psychiatrists — have turned over psychiatric clinical responsibilities and leadership to other fields. While psychiatry works hard on ever-more-beautiful neuroimaging, me-too drugs, and seeing 3-6 patients an hour in the clinic, psychology, social work and counseling professionals are left to do the heavy lifting without their medical colleagues.
Dr. Friedman reminds us that psychiatry needs to step up – in medical schools, in residencies, in practice and in our professional organizations – and stand up for attention to a sophisticated understanding and integration of biological, social and psychological perspectives on suffering and healing.
For over 30 years American psychiatry has been molded by the Scylla and Charybdis of decreased reimbursement for psychotherapy and the financial allure of collaboration with the pharmaceutical industry. The result is a steady decline in psychiatrists who are trained – or even believe – in psychotherapy, or understand the fundamentals of attachment, motivation, habit, and impulse.
Thus those in the best position to advocate for funding — and to cultivate two generations of psychiatrists — have turned over psychiatric clinical responsibilities and leadership to other fields. While psychiatry works hard on ever-more-beautiful neuroimaging, me-too drugs, and seeing 3-6 patients an hour in the clinic, psychology, social work and counseling professionals are left to do the heavy lifting without their medical colleagues.
Dr. Friedman reminds us that psychiatry needs to step up – in medical schools, in residencies, in practice and in our professional organizations – and stand up for attention to a sophisticated understanding and integration of biological, social and psychological perspectives on suffering and healing.
57
I object to this sentence, and its underlying assumptions;
' It is clearly cheaper and faster to give a pill than deliver psychotherapy'
It is cheaper in the very short term, yes. But if the research (and there IS research on this) also looks at medium and long-term use of medical resources, psychotherapy is often much, much cheaper than medication for many psychiatric illnesses.
Far better to use psychotherapy that can lead to the person having reduced chance of relapse, reduced chance of hospitalization and repeat hospitalizations, reduced frequency of medical illness requiring doctor's visits and treatments. And that's without taking into account patient preference and quality of life improvements, which are, on average, greater with psychotherapy than medication.
Here in Quebec, where our single-payer medical insurance system is trying to find ways to save money, there is a big push to provide MORE psychotherapy, so as to pay for LESS traditional medical care.
Psychiatric medications certainly have their uses and their place, but claiming that they are a cheaper solution than psychotherapy is dishonest.
' It is clearly cheaper and faster to give a pill than deliver psychotherapy'
It is cheaper in the very short term, yes. But if the research (and there IS research on this) also looks at medium and long-term use of medical resources, psychotherapy is often much, much cheaper than medication for many psychiatric illnesses.
Far better to use psychotherapy that can lead to the person having reduced chance of relapse, reduced chance of hospitalization and repeat hospitalizations, reduced frequency of medical illness requiring doctor's visits and treatments. And that's without taking into account patient preference and quality of life improvements, which are, on average, greater with psychotherapy than medication.
Here in Quebec, where our single-payer medical insurance system is trying to find ways to save money, there is a big push to provide MORE psychotherapy, so as to pay for LESS traditional medical care.
Psychiatric medications certainly have their uses and their place, but claiming that they are a cheaper solution than psychotherapy is dishonest.
11
I think we should add that psychotherapy is so time-, labor-, and emotion- intensive that the number of actual patients a skilled psychotherapist can treat is sorely limited. In the approximately 40 years that I had a clinical practice, I doubt that I actually treated (as opposed to saw in consultation) more than a few hundred patients. Long-term psychotherapy is really somewhat like raising a child. It can't really be scaled up. One really cannot often call in a replacement colleague. The relationship itself is the treatment modality, and love / empathy / understanding as much as knowledge provides the tools. It is not easily commodified, and insurers are really not that interested.
119
The most promising area which the author neglects to mention is the use of psylocibin and other entheogins for treatment of depression, addiction, end of life anxiety and other conditions. Much interesting research has been undertaken in recent years at johns hopkins, ucla, and other institutions, indicating a rebirth of interest in these substances since research was shut down in the 1960s thanks to Timothy Leary and others who gave them a bad name.
5
Friedman's article is spot-on, and long overdue. As a psychotherapist of some 30 years, I observed the virtually total abandonment of psychotherapy by psychiatrists, beginning about 20 years ago. Psychopharmacology at the time promised glitz and glamor that the painstaking process of psychotherapy did not. They made a pact with the devil (aka, the pharmaceutical industry), at the same time, that has made many of them fabulously weallthy--and morally bankrupt!
It has become apparent in those years that most of the psychotropic drugs they peddle are worthless, even harmful--and even when beneficial, the side effects are often daunting.
"We are not just a brain in a jar," the final line in Friedman's article, says it all. Unfortunately, the medical training that is the foundation of psychiatry generally works AGAINST a more sophisticated understanding of our species, as so much of allopathic medicine is mechanistic and simplistic... which means that most psychiatrists who DID practice psychiatry weren't very good at it. Only the few who overcame the biases of medical training were--and they were often brilliant.
It has become apparent in those years that most of the psychotropic drugs they peddle are worthless, even harmful--and even when beneficial, the side effects are often daunting.
"We are not just a brain in a jar," the final line in Friedman's article, says it all. Unfortunately, the medical training that is the foundation of psychiatry generally works AGAINST a more sophisticated understanding of our species, as so much of allopathic medicine is mechanistic and simplistic... which means that most psychiatrists who DID practice psychiatry weren't very good at it. Only the few who overcame the biases of medical training were--and they were often brilliant.
55
Related to this is the very disturbing trend in training in psychiatry in which the role of psychotherapy training has diminished. The new, young shiny psychiatrist often has little to no skill set in terms of talk therapy or any other form of psychotherapy. The notion of spending more than 15 minutes with a patient for anything more than a medication check is one that the modern psychiatrist cannot fathom. Clearly, not all new psychiatrists are from this mold, but many are and that is a simple truth. If you don't believe it, make an appointment with a psychiatrist and see how it goes.
4
One wonders if psychiatrists even know the effects of the drugs they prescribe from personal experience.
There are multiple feedback loops between thoughts and brain chemistry that work on a much faster time frame than psychiatric drugs that take two weeks to produce the promised effects, if at all.
There are multiple feedback loops between thoughts and brain chemistry that work on a much faster time frame than psychiatric drugs that take two weeks to produce the promised effects, if at all.
The brain is a computer specializing in adaptation. It's sole purpose is to construct a model of the world that allows us to make predictions as to how our expenditures of personal resources can maximize the outcomes in terms of fulfilling our biological imperatives and coevolved sense of meaning. Whatever process enhances our model, through the reconsolidation of experience, and leads to greater effectiveness becomes reinforced. Trauma is any experience which undermines integrative processes, through the creation of a competing nidus for organizing experience of heightened urgency. Whatever process by which this competing nidus can be brought into the fold of the individual's greater worldview will be healing...will be therapeutic. Prayer, meditation, open discussions with a loved one, psychotherapy, contemplation... if they are aimed at understanding the traumatic event in terms of the nature of the world, potential ways of avoiding unnecessary risk of recurrence, appropriately adjusting the expectation of recurrence to one's reality, connecting the traumatic event to a higher purpose or meaning... all of these will restore the top-down or executive control (through their representation within a more emotionally balanced perspective) over trauma-associated stimuli which might otherwise only trigger bottom-up networks which reflexively lead to defensiveness or avoidance with heightened anxiety.
2
I think that the field could benefit from reminding itself of the work of Dr. Murray Bowen and other pioneers in family theory and therapy. This was an effort to look at the human as more than an individual, while linking the study of the human to science in a way that goes beyond the use of pharmaceuticals.
2
It was once said that it is a constant struggle to see what is in front of one's nose. Two other things which lead to the primacy of biological research and treatments in mental health, over and above the seeming ease and affordability of medications, are American capitalism and hyperindividualism. From a very early age Americans are taught that the causes of our thoughts, feelings and behavior are rooted in our individuality whether it be character, neurotransmitters, or genes. In this contest for individualist explanations anything that can thrive in capital markets has a huge leg up. Medications can be patented and the firm capitalized. Treatments that don't offer such opportunities for profit and wealth are going to be a very distant second best. Federal funding for these non-profit friendly approaches might offer some hope, except that the profits from patents and capital can be reinvested in lobbying the public and the government for further profit friendly government subsidized research into biological factors. Finally, with regard to the relative costs of medications and psychotherapy the former is heavily subsidized and privileged from lab to couch.
5
Such a good article. Thank you.
I wonder if one problem with exposure therapy is that it's premise is a fundamental put down of the patient. That is, rather than legitimating a person's reasons for having PTSD, which are often highly rational, exposure therapy teaches a person "that their belief that they are in danger is no longer true." One of the greatest challenges to having unpleasant thoughts is knowing that people will think you're crazy or a downer or a drag for not presenting as consistently positive and resilient. A good therapist accepts you as who you are, and that's a rare thing in society. And something that could never be offered by medication.
I wonder if one problem with exposure therapy is that it's premise is a fundamental put down of the patient. That is, rather than legitimating a person's reasons for having PTSD, which are often highly rational, exposure therapy teaches a person "that their belief that they are in danger is no longer true." One of the greatest challenges to having unpleasant thoughts is knowing that people will think you're crazy or a downer or a drag for not presenting as consistently positive and resilient. A good therapist accepts you as who you are, and that's a rare thing in society. And something that could never be offered by medication.
3
Thank you Dr. Friedman. Well said! "there is no pill — and probably never will be — for any number of painful and disruptive emotional problems we are heir to."
3
"psychotherapy has been shown ... to be as effective as psychotropic medication ...."
The logic problem here is the omitted quantifiers--"all" or "some" or those in between--almost all, most, many, a few.
"Some" makes it a virtual truism. "All" makes it obviously false. This applies to both psychotherapy and psychotropic drugs.
How many methods of "talk" psychotherapy are there? (How many psychotropic drugs?)
Talk therapies themselves need to be analyzed--their logic, modes of "speech action" and semiotics. What are therapist and patient doing? Why does the patient feel better?-- if so.
One of Freud's less mysterious works is "Civilization and its Discontents"-- I about the "morality" of sexually repressive (Victorian) cultures. The nutshell summary is--on average, women choose "morality" neurosis and psychosis; men choose "immorality" and mental health.
Thus "psychotherapy" would be ideological/philosophical interpretations, analysis, advice.
Many (!) people suffer from philosophical confusion or worse--bizarre ideologies including theologies (god stories.)
But Talk Therapy techniques should be out in the open--subject to careful scrutiny--and not a secret gnostic formula--running the risk of being itself confused and bizarre.
After all--the therapist is supposed to be a healer/fixer--not a neutral observer. The goal is for the patient to "catch" the therapist's perspective and values. If it's merely to make him/her feel better, many cheap pills will do.
The logic problem here is the omitted quantifiers--"all" or "some" or those in between--almost all, most, many, a few.
"Some" makes it a virtual truism. "All" makes it obviously false. This applies to both psychotherapy and psychotropic drugs.
How many methods of "talk" psychotherapy are there? (How many psychotropic drugs?)
Talk therapies themselves need to be analyzed--their logic, modes of "speech action" and semiotics. What are therapist and patient doing? Why does the patient feel better?-- if so.
One of Freud's less mysterious works is "Civilization and its Discontents"-- I about the "morality" of sexually repressive (Victorian) cultures. The nutshell summary is--on average, women choose "morality" neurosis and psychosis; men choose "immorality" and mental health.
Thus "psychotherapy" would be ideological/philosophical interpretations, analysis, advice.
Many (!) people suffer from philosophical confusion or worse--bizarre ideologies including theologies (god stories.)
But Talk Therapy techniques should be out in the open--subject to careful scrutiny--and not a secret gnostic formula--running the risk of being itself confused and bizarre.
After all--the therapist is supposed to be a healer/fixer--not a neutral observer. The goal is for the patient to "catch" the therapist's perspective and values. If it's merely to make him/her feel better, many cheap pills will do.
1
"I began to tire of certain types of irrational thinking. I was doing things at the time, studying or doing some calculations. So it may be that the delusional thinking began to come unsatisfying. I think people become mentally ill when they're somehow not too happy - not just after you've won the lottery you go crazy. It's when you don't win the lottery."
- John Nash (http://www.schizophrenia.com/sznews/archives/001617.html#)
As a person diagnosed with bipolar disorder I, I find the stories of people who have "healed" from the manifestation of severe mental illness to be the best guide for how to truly approach how to think about how to heal. The psychiatric establishment is in the business of trying to offer such healing. However, as I have found, true healing often comes from a complex interplay of inner development and seeking. Personally, I like this article because it acknowledges what many patients already know. Medications are very crude tools and the real healing comes from dealing with the inner state of the mind. Yes, medications such as lithium carbonate are helpful to some. They have helped me. However, they are only a stop gap solution. True healing often comes from outside psychiatry for the simple fact that the cost of a "complete treatment" is to expensive. American psychiatry often does not want to encourage the idea that healing on ones own is possible because it obviously would lead to less money being spent by the patient on treatments.
- John Nash (http://www.schizophrenia.com/sznews/archives/001617.html#)
As a person diagnosed with bipolar disorder I, I find the stories of people who have "healed" from the manifestation of severe mental illness to be the best guide for how to truly approach how to think about how to heal. The psychiatric establishment is in the business of trying to offer such healing. However, as I have found, true healing often comes from a complex interplay of inner development and seeking. Personally, I like this article because it acknowledges what many patients already know. Medications are very crude tools and the real healing comes from dealing with the inner state of the mind. Yes, medications such as lithium carbonate are helpful to some. They have helped me. However, they are only a stop gap solution. True healing often comes from outside psychiatry for the simple fact that the cost of a "complete treatment" is to expensive. American psychiatry often does not want to encourage the idea that healing on ones own is possible because it obviously would lead to less money being spent by the patient on treatments.
2
Comment nyt
What good is psychiatry, anyway? My son has suffered from schizophrenia for almost 20 years. That is 20 years of his life lost, like a person in jail. He will never marry, have a family or a job. When I die he will end up on the streets or in jail. Psychiatry is next to useless when it comes to dealing with a serious mental illness.The doctors at the well-respected Gifford Clinic at the University of California San Diego never spent more than a few minutes with him but instead wrote prescriptions for pills he refused to take. The doctors at the worse-than-useless student health clinic at UC-Berkeley (where he had his first psychotic break) did not even refer him to a real hospital. California laws ensure he is free to be as crazy as he wants to be as long as he is "not a threat to himself or others." If I were my son I would put a bullet in my head but -- is this a small mercy or a curse? -- he does not even think he is mentally ill.
What good is psychiatry, anyway? My son has suffered from schizophrenia for almost 20 years. That is 20 years of his life lost, like a person in jail. He will never marry, have a family or a job. When I die he will end up on the streets or in jail. Psychiatry is next to useless when it comes to dealing with a serious mental illness.The doctors at the well-respected Gifford Clinic at the University of California San Diego never spent more than a few minutes with him but instead wrote prescriptions for pills he refused to take. The doctors at the worse-than-useless student health clinic at UC-Berkeley (where he had his first psychotic break) did not even refer him to a real hospital. California laws ensure he is free to be as crazy as he wants to be as long as he is "not a threat to himself or others." If I were my son I would put a bullet in my head but -- is this a small mercy or a curse? -- he does not even think he is mentally ill.
13
Thank evolution, environment and genetics I seem to be mostly unattracted to, and feel no need for, most drugs, legal as well as illegal. Two or three cups of good coffee per day, carbonated mineral water, and a glass of cheap rosé (preferably Tuscan or Portuguese), and I'm good to go. But I do try to empathize with those we do feel they have no choice but to attempt to alter reality with drugs. Unfortunately, I disagree strongly with the psychologists who recently published an article in the NY Times that claims that anyone can be empathetic if they want to.
5
Thank you Dr. Friedman. I have not only benefited from psychotherapy it saved my life. More specifically Transference Focused Psychotherapy (TFP) which is a specialized form of psychotherapy used to treat borderline personality disorder. I also have been diagnosed with anorexia and major depressive disorder. I have been in TFP for the past ten years with a psychiatrist who is also a psychoanalyst. I have been fortunate to have had the resources to pay her privately as she does not take insurance, but I might add that she has also lowered her fee to a ridiculous amount so that when I was struggling financially we could continue our work together. I am most grateful to her for she not only saved my life, but after four suicide attempts, helped me build a life worth living. Now we are beginning the termination phase of the therapy which should take about 12 to 18 months (my timeframe, not hers). I am on medication and have accepted that I will always be for a severe depression with psychotic features, but the TFP gave me a life that I never had.
71
If the profession trained better therapists, most of those yuppie psychotropic drugs would not be necessary. The drugs are a cop-out, except for treating the most extreme mental conditions.
2
All well and good but it's near impossible to find a therapist. My son, living in NYC and struggling with a job, needs one, but he has to find one who will meet at night, in order to keep said job. I finally found one for him...for $400 an hour. After insurance coverage--adjusting the $400 to what is deemed local customary cost, and further for his deductible--his cost would exceed $200 per 45 minute visit.
7
Combine Dr. Friedman's column with your astute observations and one has a pretty complete description of mental health care in this country. The sad stories and, here and there, ill-advised opinions among these comments complete the picture.
2
Mental illness invoves too many systems to be corrected by a few types of medication. Look at duodenal ulcers , the accepted cause was wrong and the treatment was complicated and disasterous. Better science better results.
2
Big companies develop drugs. Individuals perform psychotherapy. This is probably the primary reason for the discrepancy in funding and usage of these two approaches. Both obviously have their place, but there must be more of a balance.
4
Psychiatry -- the "science" based on the work of a guy who believed a child's fear of horses -- a child whom the guy only ever met once -- was caused by the child's fear that his father would castrate him. No wonder other physicians don't take psychiatrists seriously.
2
I am a well-trained research psychiatrist and drug developer who took learning psychotherapy very seriously. The current floundering state of psychiatry is a function of a certain number of realities. Not everyone can learn to become a psychotherapist no matter how hard they try. By contrast, learning pharmacotherapy is much easier. Because there is no over arching concept of how the brain works, psychopharmacology is largely the application of algorithms that can be learned by any one who can get through medical school. Another reality is that psychiatry is largely guided by the insurance industry. A psychopharmacologist will see between 2 and 5 patients per hour and gets paid the same amount for each that would be paid psychotherapy with one patient. A pre-eminent senior research psychiatrist and psychoanalyst said to me that he didn't understand why we waste the resident’s time on “this stuff” [psychotherapy] because they will never get paid for it.
The interaction between patient and psychopharmacologist around medication administration becomes its own form of psychotherapy. We are beginning to understand that both psychological interventions and psychopharmacology impact the regulation of the genome via epigenetic changes and are beginning to document an association of epigenetic changes with certain psychiatric conditions. One can only hope that psychiatry is headed toward a way to have a scientific approach to pharmacotherapy and to find its mind again.
The interaction between patient and psychopharmacologist around medication administration becomes its own form of psychotherapy. We are beginning to understand that both psychological interventions and psychopharmacology impact the regulation of the genome via epigenetic changes and are beginning to document an association of epigenetic changes with certain psychiatric conditions. One can only hope that psychiatry is headed toward a way to have a scientific approach to pharmacotherapy and to find its mind again.
5
We need more research on body based therapies. The study on interpersonal is a good example. Exposure can be retraumatizing. Therapies like Somatic Experiencing are far more effective, but not well enough known or studied. Psychotherapy that doesn't include the body is part of its bad rep, and over-medicating the public at large isn't helping either. I hope the next wave of health care reform moves us off the pills.
7
It is refreshing to hear Dr. Friedman's understanding of the limitations of psychiatry. The quandary has been present for a long time with psychiatry "medicalizing" treatment as do other medical specialties. This has been facilitated by the drug industry who have corrupted many psychiatrists with "thought leaders" paid huge honorariums to convince their colleagues at lavish restaurants of the superiority of the new and most expensive drugs being marketed. TV advertising of drugs also leads to misinforming the public who hope for a quick fix for what ever ails them. The sad truth is that many psychotropic drugs, especially the antidepressants, when compared to placebo are often not more effective and less effective than psychotherapy.
5
Dr. Friedman makes reference to an important area of investigation and work for psychiatrist and for medicine in general - the impact of trauma and stress on health in its broadest definition.
A tremendous share of our medical and mental health resources are devoted to finding solutions to the consequences of family dysfunction, poverty, and societal marginalization. Understanding this clearly and moving our efforts upstream to the support of families and individuals who are disadvantaged as a result of race, ethnicity, identity, or income will go a tremendous way toward making our science relevant and beneficial.
Jon Porter, MD
A tremendous share of our medical and mental health resources are devoted to finding solutions to the consequences of family dysfunction, poverty, and societal marginalization. Understanding this clearly and moving our efforts upstream to the support of families and individuals who are disadvantaged as a result of race, ethnicity, identity, or income will go a tremendous way toward making our science relevant and beneficial.
Jon Porter, MD
5
With the debate about biological versus emotional mental health people often overlook a central philosophical point. We are already generally accepting of the view that all our mental states correspond with physical states of the brain - and that means the explanatory power of those physical states is extremely limited.
Imagine that we understood the biology involved in the development of depression. That information would in no way indicate that the personal, emotional development of depression was no longer genuine or relevant. Because the complex interplay of the mental and the physical cannot possibly be wholly explained by biology, biological accounts of mental health problems can never dissolve the need for emotional understanding.
Suppose we developed a complete biochemical account of love. What value could that possibly have in the quest to love better or less painfully?
Imagine that we understood the biology involved in the development of depression. That information would in no way indicate that the personal, emotional development of depression was no longer genuine or relevant. Because the complex interplay of the mental and the physical cannot possibly be wholly explained by biology, biological accounts of mental health problems can never dissolve the need for emotional understanding.
Suppose we developed a complete biochemical account of love. What value could that possibly have in the quest to love better or less painfully?
1
Dr. Friedman makes a valid point that often times patients suffering from MDD, for example, are prescribed medications without a course of psychotherapy or cognitive-behavioral therapy. There is evidence that pharmacological with "talk" therapy has greater efficacy. However, I find the premise that psychotherapy or CBT has no effect on brain circuitry and function to be inherently flawed. I'd refer the author to work by Eric Kandel's group regarding the neurobiological mechanisms of "learned safety" published in Neuron. Also, work by several groups on the neurobiology of the "placebo effect". I am a big believer in "talk" therapies as I believe it allows restoration of executive-limbic function (what you may think of as the superego vs id) in brains of patients where these functions have become dysfunctional. (There are also several basic and fMRI studies addressing this imbalance). This may be aided by pharmaceutical treatments. Finally, I believe that this article underestimates the advances that have been made regarding the neurobiology of mental health disorders and the advancements that our now possible due to our investment in technical innovations #BRAINInitiative. This, perhaps, reflects a gap in communication between basic neuroscientists and our colleagues in adjoining fields. I would welcome more opportunities for clinicians including psychotherapists like Dr. Friedman and basic neuroscientists such as myself to interact.
6
I felt increasingly uncomfortable with idea of a psychiatrist who only sees me for 20 minutes once every six weeks (which is the standard by most insurance policies) prescribe powerful psychotropic meds for me. He has no knowledge of the situational pitfalls I struggle with on a day to day basis, nor is it his role anymore to help me deal with those issues. Fortunately I have found an alternative in the selection of a psychiatric nurse practitioner (PNP) as my primary mental health provider.She provides supportive psychotherapy as well write prescriptions , like psychiatrists were able to do in the good old days. I hope insurance companies don't shackle the practice of these professionals with limitations that restrict psychiatrists today. My prescriber actually knows me as an individual. What a concept!
7
I am a psychologist. Sometimes listening to our patients is far more therapeutic than medicating them. I'm glad the author acknowledged that.
6
A breath of fresh air in a room stagnated by short-sighted, reductionistic research that is inaccurate and misleading beyond a superficial and impersonal level within a system that is under the powerful toxic effect of corporate control by insurance "Utilization Review", arbitrary limitations and pharmacological over-sell - NONE of which is truly "Evidence Based."
Well put, accurate and sorely needed!
Well put, accurate and sorely needed!
8
Dr. Friedman seems to suggest that the treatment of mental disorders is somehow atypical.
In fact, as a physician specializing in pain management, I can say that the exact same things could be say about the management of chronic pain. The new analgesic drugs work the same as the drugs that have been available for 50 years or, in the case of opioids, thousands of years. Also repeated research has shown that treatment based on psychosocial and physical rehabilitation are more effective than medications and surgery. Furthermore, we don't even have studies to show that the latter two are at all effective for chronic pain yet they are more likely to be the treatments provided. And, in contrast to psychiatry, this isn't to save money. Rather it is that insurance companies have chosen to ignore research.
In fact, as a physician specializing in pain management, I can say that the exact same things could be say about the management of chronic pain. The new analgesic drugs work the same as the drugs that have been available for 50 years or, in the case of opioids, thousands of years. Also repeated research has shown that treatment based on psychosocial and physical rehabilitation are more effective than medications and surgery. Furthermore, we don't even have studies to show that the latter two are at all effective for chronic pain yet they are more likely to be the treatments provided. And, in contrast to psychiatry, this isn't to save money. Rather it is that insurance companies have chosen to ignore research.
10
In this well conceived article I don't believe Dr. Friedman mentioned the chaotic state of psychiatric diagnosis. Dr. Shorter in this May 's American Psychiatric Association meeting gave a erudite explanation of the arbitrary criteria and definitions of diagnosis. In the day to day world of psychiatry practice, fad diagnosis such as ADHD , bipolar disorder etc are rampant: often diagnosis are used that require a pill rather than talking . And despite the glowing conclusions that DBT CBT and similar therapy helps, the failure to listen to the patient's story is common , since pills and therapy manuals, though helpful for many protect the psychiatrist or therapist from listening to emotional lives.
11
A few years ago I suffered from chronic depression that was resistant to both medicine and psychotherapy. I decided if I was ever to overcome my depression I would have to think for myself and "think outside the box". After reviewing thousands of anecdotal inferences on the internet - I to began adding adderall
to my mix. THE FIRST DAY, I felt like I had felt pre-depression. I have stayed the course ever since - against the psychiatrist's advice. 2 years post adderall I can say I still feel good. An open mind is a wonderful thing.
to my mix. THE FIRST DAY, I felt like I had felt pre-depression. I have stayed the course ever since - against the psychiatrist's advice. 2 years post adderall I can say I still feel good. An open mind is a wonderful thing.
3
I love the opening graphic. Well done!
Hats off to Dr. Friedman for his honest appraisal of the state of knowledge in psychiatry. I began my psychiatric training in 1987. At the time, it seemed that work on the human genome and other biological research, as well as the much simpler diagnostic schema introduced by DSM-3, would finally solve the problems of mental illness. Almost 30 years on, it is obvious nothing of the kind has happened: as the author notes, the only advance in psychopharmacology has been in the reduction of side effects. (He does not mention that, in the only naturalistic study of the treatment of schizophrenia comparing the newer and older drugs, fewer side effects did not improve treatment compliance at all – contrary to the expectations of academic psychiatry). This lack of evidence of efficacy in pursuing biological psychiatric research seemed to me so obvious, I was alarmed last year when the head of NIMH said that its research focus would now be exclusively on neuroscience. But, again, thanks to Dr. Friedman for being so open about the problem.
10
>
"Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front." (RAF)
Did it ever occur to you, or the neuroscience community, that Pascal may have hit the nail on the head when he wrote?
"The natural misfortune of our mortal and feeble condition is so wretched
that when we consider it closely, nothing can console us.”
Pascal
As for the great catholic apologist, his solution was to “stupefy yourself, take holy water, receive sacraments, and in the end all shall be well”, which by your our account seems to have a better track record for many. In short, Pascal saw the benefit in believing in the illiusion of the Trinity, as ridiculous as that may be. Hence, the operable word "stupefy". If Pascal is right we are just a baby step away from admitting neuroscience is a failed religion if its goal is to make people happy. If it is to make money it is a roaring success; invest now!
Note: I'm an atheist. I'm just making an observation.
"Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front." (RAF)
Did it ever occur to you, or the neuroscience community, that Pascal may have hit the nail on the head when he wrote?
"The natural misfortune of our mortal and feeble condition is so wretched
that when we consider it closely, nothing can console us.”
Pascal
As for the great catholic apologist, his solution was to “stupefy yourself, take holy water, receive sacraments, and in the end all shall be well”, which by your our account seems to have a better track record for many. In short, Pascal saw the benefit in believing in the illiusion of the Trinity, as ridiculous as that may be. Hence, the operable word "stupefy". If Pascal is right we are just a baby step away from admitting neuroscience is a failed religion if its goal is to make people happy. If it is to make money it is a roaring success; invest now!
Note: I'm an atheist. I'm just making an observation.
2
I think that part of the problem are psychotherapists, counselors, etc., As Friedman says, the brain changes with therapy (meaning as one changes thought patterns and controls emotions better the brain connections change (some get stronger and some weaker). Other discoveries through neuroscience have helped to understand how we store and retrieve memories, how habits are formed. The problem is that research for new treatments by psychotherapists must now take advantage of such neuroscience discoveries and verify and modify their treatment. But just like psychiatrists, therapists are also myopic and are hesitant to integrate the neuroscience research into their profession. I think it starts with our higher educational system which raises professionals in these islands.
3
I am a Canadian Psychiatrist I was explaining to my American Psychiatrist friend that I am able to chose what therapy is best for my patient, be it psychotherapy or medications, or both.
2
The 60s model of psychotherapy is outdated, ineffective, and expensive. As a society, we are evolving towards a single payer system and the understanding that humans are neuro-diverse, not good or bad. We can afford a yearly doctor's visit and remove the stigma for mandated treatment.
A family or general practice doctor's evaluation with a standardized checklist once a year could be made a requirement for all citizens. Confidential referrals would be made to psychiatrists who perform diagnoses and design treatment plans (re-evaluated bi-annually for outpatients). Psychiatric nurses with the authority to adjust medications and therapies supervise trained counselors to carry out the treatments and visit with their patients weekly, alternating home visits with office visits and electronic chats. An independent corps of investigators could guard against abuses both medical and legal, and data mines using random scanning of records with identifiers removed to protect privacy. Psychiatrists would notify mental health law enforcement specialists when a patient required legal intervention and an advocate.
Think of the savings. Employment and productivity would go up, crime would go down, and our criminal justice system could turn to addressing criminal justice instead of warehousing the mentally ill.
The mentally ill deserve civil rights. We have the technology now to get them treatment with respect and dignity. Pills combined with talk therapy is effective and a good value.
A family or general practice doctor's evaluation with a standardized checklist once a year could be made a requirement for all citizens. Confidential referrals would be made to psychiatrists who perform diagnoses and design treatment plans (re-evaluated bi-annually for outpatients). Psychiatric nurses with the authority to adjust medications and therapies supervise trained counselors to carry out the treatments and visit with their patients weekly, alternating home visits with office visits and electronic chats. An independent corps of investigators could guard against abuses both medical and legal, and data mines using random scanning of records with identifiers removed to protect privacy. Psychiatrists would notify mental health law enforcement specialists when a patient required legal intervention and an advocate.
Think of the savings. Employment and productivity would go up, crime would go down, and our criminal justice system could turn to addressing criminal justice instead of warehousing the mentally ill.
The mentally ill deserve civil rights. We have the technology now to get them treatment with respect and dignity. Pills combined with talk therapy is effective and a good value.
What an irony that a brain-dead industry is charged with and given expert status on discerning and treating brain disorders. Why such a rude observation? Because a little knowledge is a dangerous thing. If it weren't tragic, it would be funny. There's hope however. After all, generalized bloodletting only lasted about a thousand years. That had arrogant experts in charge of that too.
There are Asian-inspired therapies that resolve many mental health disorders through so-called mind-body techniques. As the article points out, embedded trauma leads to numerous disorders. Although scoffed at by Western medicine, many of those approaches have been in use for thousands of years. On our side of the cultural barrier, a few years back Aristotle had it figured out. Know thyself; heal thyself.
There are Asian-inspired therapies that resolve many mental health disorders through so-called mind-body techniques. As the article points out, embedded trauma leads to numerous disorders. Although scoffed at by Western medicine, many of those approaches have been in use for thousands of years. On our side of the cultural barrier, a few years back Aristotle had it figured out. Know thyself; heal thyself.
1
I am wondering why no one has mentioned the recent new time restraints on appointments with a therapist, if one is lucky enough to find one suitable, set by insurance companies. Meetings times are no longer 50 minutes or an hour but 45 minutes, except for the first one--that one, considered an intake, can be a 60 minute meeting. When I asked one of the claims workers at Harvard Health when these times frames changed and why, I was told that it had been decided that what ever needed to be accomplished could occur within a 45 minute session. When I asked who decided this, she said the therapists and the insurance companies. Why was I asking? Because I'd submitted paperwork 2 times and had not been reimbursed and each time I "fixed" what I was supposed to fix, I got another notice that something else was wrong. The last time, I waited 2 months and found out that they hadn't sent the forms along due to a typo. I asked them if that meant the forms would sit there until I called and the woman said, "I hate to say this, but yes."
The arbitrary time limits and the failure to reimburse in a timely fashion--or, as in my case, failure to reimburse at all, does prove profitable when we think of counseling and psychiatry as commerce. Otherwise, your therapist better be great--mine was. But even so, I stopped seeing her, in order to nip in the bud the mental stress I was enduring while dealing my insurance company.
The arbitrary time limits and the failure to reimburse in a timely fashion--or, as in my case, failure to reimburse at all, does prove profitable when we think of counseling and psychiatry as commerce. Otherwise, your therapist better be great--mine was. But even so, I stopped seeing her, in order to nip in the bud the mental stress I was enduring while dealing my insurance company.
4
As doctors discover new pills to do the job psychiatry will go the way of the dodo.
John Forrester in his book “Dispatches From The Freud Wars: Psychoanalysis and Its Passions” (Harvard University), wrote that ''none of Freud's reports concerning what happened to his patients, or indeed of what they said, can be trusted . . . because the analyst made it all up."
In 1970, Henri Ellenberger reported that Anna O. was far from cured when her treatment with Breuer ended in 1882. In fact, she checked into a Swiss sanitarium. And Freud knew this, the critics complained, when he pushed Breuer to publish the case.
In ''The Interpretation of Dreams,'' Freud mocks himself as an ambitious, self-justifying man.
We always wondered where Freud developed his fictitious ideas about the human personality as sexual—Cocaine Imagination!
So Freud was a fraud!
A cocaine-head, addled-mind, fiction writer who created a whole new approach to psychiatry based on his imagination with a little truth to spice the fakery.
It worked and everyone in the industry took it in.
His corrupt ideas of humans beings are recognized as fiction today at long last. But, Oh! How many millions of humanity has his ideas corrupted?
R.I.P. psychiatry.
John Forrester in his book “Dispatches From The Freud Wars: Psychoanalysis and Its Passions” (Harvard University), wrote that ''none of Freud's reports concerning what happened to his patients, or indeed of what they said, can be trusted . . . because the analyst made it all up."
In 1970, Henri Ellenberger reported that Anna O. was far from cured when her treatment with Breuer ended in 1882. In fact, she checked into a Swiss sanitarium. And Freud knew this, the critics complained, when he pushed Breuer to publish the case.
In ''The Interpretation of Dreams,'' Freud mocks himself as an ambitious, self-justifying man.
We always wondered where Freud developed his fictitious ideas about the human personality as sexual—Cocaine Imagination!
So Freud was a fraud!
A cocaine-head, addled-mind, fiction writer who created a whole new approach to psychiatry based on his imagination with a little truth to spice the fakery.
It worked and everyone in the industry took it in.
His corrupt ideas of humans beings are recognized as fiction today at long last. But, Oh! How many millions of humanity has his ideas corrupted?
R.I.P. psychiatry.
It's amazing that even now Freud-phobia can still overwhelm otherwise rational people.
2
Dr. Friedman's seems to say that psychiatrists could be performing more psychotherapy than they do, especially for conditions where it is equally effective as medications. A variation of this theme is that the art of psychotherapy, once a cornerstone of psychiatry, is much less robust than it once was as a consequence of the wide use of psychiatric medications. I see much less of an identity crisis, psychiatrists seem comfortable with who they are, than a dilemma, especially for those psychiatrists who wish to spend more time doing the psychotherapy that Dr. Friedman espouses. It's a very practical dilemma. Economics contribute to it. If relying on insurance reimbursement, which is low for psychotherapy and treating only one patient each hour, a psychiatrist's income suffers. Seeing several patients each hour for brief visits to manage their medication is economically more realistic. Patients may receive psychotherapy from a clinician other than the psychiatrist. In one response to the dilemma, psychiatrists stop working with insurance carriers and accept only direct payment of their fee, making it practical for them to perform psychotherapy. This response may affect the distribution and availability of psychiatrists, especially child psychiatrists, already in short supply, possibly impacting patients with lower income who rely on insurance for payment. Study is needed to assess the impact and its magnitude.
4
The concern is understandable, a dubious convergence of realms is inevitable: economy, research, public health/policy, as well as psychic and philosophical speculations. We have the best of so much these days in terms of technology and science, but something is holding us up, perhaps tech-overload, or Patriarch overload. Whatever it is it seems to be pushing humanity to reach for other 'answers'. As someone who has struggled long with PTSD, while ferociously avoiding pharma, what has helped most by far has been human communion: festivals, sweat lodge/ meditative retreats, village/tribal council, not sporting events, not for me. Settings where I am a human, rather than a client, or an adversary (sports). I believe I speak for many. We are sorely malnourished in this communion one.
1
“In the end, it is the reality of personal relationships that saves everything.” – Thomas Merton
3
The low funding level for psychotherapy research is fully deserved. Psychotherapy is a racket where the typical patients are well insured, upper middle class, white women who think their middle class problems are deserving of endless discussion. Therapists don't solve problems, they just listen to problems. And given the mandatory requirements for insurance companies to pay for psychotherapy, these sessions go on month after month, year after year at the expense of policy holders with more legitimate health problems.
You're correct about one thing: therapists don't solve problems. That's not their job. Therapists help people learn how to solve their own problems.
They NEED to study the effects of outdoor exercise on PTSD. And different KINDS of outdoor exercise. Because the brain responds to different environments, and to exercising in different environments, in different ways. The right kind of outdoor exercise, when used as a supplement to other kinds of therapy, can have enormous impacts.
In addition, stimulating the brain is at issue here. Exercise induces the brain to stimulate itself in a natural way -- while the sights, sounds, and in particular SMELLS (sense of smell is implicated in depression) of different outdoor environments bombard the brain with stimuli which, in conjunction with the raising of various hormone levels, will have a permanent stimulant effect on parts of the brain, I do believe.
Meanwhile, drugs which inhibit certain parts of the brain will cause those parts of the brain to shrink over time, causing permanent damage and dependency. But, think of the brain as sort of like a set of coupled oscillators which need to be kept in balance, perhaps the inhibition of one part of the brain isn't the solution to a problem as opposed to counterbalancing stimulation of another part of the brain.
The fact that anxiety and depression go together can be seen as an imbalance where one part of the brain is inhibited, which causes another part to become over-stimulated. But, as in the case of PTSD, these aren't chemical imbalances but, rather, imbalances that have been introduced into the brain by outside experiences.
In addition, stimulating the brain is at issue here. Exercise induces the brain to stimulate itself in a natural way -- while the sights, sounds, and in particular SMELLS (sense of smell is implicated in depression) of different outdoor environments bombard the brain with stimuli which, in conjunction with the raising of various hormone levels, will have a permanent stimulant effect on parts of the brain, I do believe.
Meanwhile, drugs which inhibit certain parts of the brain will cause those parts of the brain to shrink over time, causing permanent damage and dependency. But, think of the brain as sort of like a set of coupled oscillators which need to be kept in balance, perhaps the inhibition of one part of the brain isn't the solution to a problem as opposed to counterbalancing stimulation of another part of the brain.
The fact that anxiety and depression go together can be seen as an imbalance where one part of the brain is inhibited, which causes another part to become over-stimulated. But, as in the case of PTSD, these aren't chemical imbalances but, rather, imbalances that have been introduced into the brain by outside experiences.
At last, Dr. Friedman writes something that makes sense, instead of his usual cheerleading for psychiatric drugs.
3
Every psychologist I know (yes, I spelled that correctly) HATES psychiatrists because there's so little to crow about on the treatment front. "... AMERICAN psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front. ..."
1
Research with psychdelics is showing promise treating addiction and PTSD.
http://www.newyorker.com/magazine/2015/02/09/trip-treatment
Need to take them off schedule 1 so more research studies can happen.
http://www.newyorker.com/magazine/2015/02/09/trip-treatment
Need to take them off schedule 1 so more research studies can happen.
1
Psychiatry certainly has many problems. But at least psychiatrists to their credit, and other mental health professionals in this country, with the GLARING exception of the one I belong to, psychology, refused to participate in legitimizing and enabling the CIA torture programs of the 2000s. Though I opposed it as a member of both the state and national psychological associations, I will forever be ashamed of the role the American Psychological Association (as detailed in this newspaper and elsewhere) played in those programs.
1
I agree talk therapy can be good. So can talking with good friends. My one question is this. If this author "is a psychiatrist and psychopharmacolgist(even)
who loves neuroscience", why hasn't he heard of amisulpride? Some of it is made in England and I believe it originated in France when it was Sanofi-Synthelabo. I believe it was bought by Sanofi-Aventis which has many drugs in the US but not Amisulpride(brand name Solian). I have been getting this from England since 2001 and Richard, it is different. How come my psychopharmacologist was the only one industrious enough to life a finger to research this different drug which has even less side-effects than the un-new new ones you're talking about and which has more positive effects than the perfect American atypical antipsychotic would? Stabilizes bipolar mood swings, is an anti-depressant without the danger of a negative high and also,a good sleeping pill and very smal, doses are needed.
This company(whatever it is now; the history of its parentage is confusing) felt no need to go through the expensive FDA process of approval because they knee the parent was running out and that it would soon be sold in generic form.
Which it is today. The "best healthcare system in the world"(with all honor to the ACA: That is a huge piece of the Obama legacy) and even nice guys like this author? Oblivious. Maybe one needs a psychopharmological database and it's not just Googling but there are message boards about Solian. Lift a finger.
who loves neuroscience", why hasn't he heard of amisulpride? Some of it is made in England and I believe it originated in France when it was Sanofi-Synthelabo. I believe it was bought by Sanofi-Aventis which has many drugs in the US but not Amisulpride(brand name Solian). I have been getting this from England since 2001 and Richard, it is different. How come my psychopharmacologist was the only one industrious enough to life a finger to research this different drug which has even less side-effects than the un-new new ones you're talking about and which has more positive effects than the perfect American atypical antipsychotic would? Stabilizes bipolar mood swings, is an anti-depressant without the danger of a negative high and also,a good sleeping pill and very smal, doses are needed.
This company(whatever it is now; the history of its parentage is confusing) felt no need to go through the expensive FDA process of approval because they knee the parent was running out and that it would soon be sold in generic form.
Which it is today. The "best healthcare system in the world"(with all honor to the ACA: That is a huge piece of the Obama legacy) and even nice guys like this author? Oblivious. Maybe one needs a psychopharmological database and it's not just Googling but there are message boards about Solian. Lift a finger.
I must say the article by Dr. Friedman has amusing aspects for one like myself educated in the late 60's at an Ivy League school renown for its community clinical psychology program. Dr. F. is talking here about the age-old dilemma of mind over mater and the etiology of mental illness.
After three years of study I learned three important things:
1. Behavior modification through rewards and controls was VERY unpopular when it offered and still offers considerable efficacy in treatment of any kind of acting out. Moreover, one doesn't need eight years of advanced study to provide it.
2. My professors school simply did not believe that people could be changed by psychotherapy. This was most impressive to me. Their hypocrisy and duplicity was saddening and started me thinking about how I would be able to shoulder this incongruity.
3. The ONLY examples of effective personal encounter treatment that I witnessed involved providers who were unafraid of the spiritual world and ready to enter realms mysterious and unknown to retrieve people lost in separate realities. The MOST effective were clergy and avant-garde shrinks who wrestled with patient's demons on the floor with them. Jewish holy men and Buddhist monks could transcend craziness and bring some peaceful understanding.
The human psyche and its attendant neuro-system will never be understood through investigations into chemical receptors and medical notions of disease. The brain is as complicated as the universe. Go figure.
After three years of study I learned three important things:
1. Behavior modification through rewards and controls was VERY unpopular when it offered and still offers considerable efficacy in treatment of any kind of acting out. Moreover, one doesn't need eight years of advanced study to provide it.
2. My professors school simply did not believe that people could be changed by psychotherapy. This was most impressive to me. Their hypocrisy and duplicity was saddening and started me thinking about how I would be able to shoulder this incongruity.
3. The ONLY examples of effective personal encounter treatment that I witnessed involved providers who were unafraid of the spiritual world and ready to enter realms mysterious and unknown to retrieve people lost in separate realities. The MOST effective were clergy and avant-garde shrinks who wrestled with patient's demons on the floor with them. Jewish holy men and Buddhist monks could transcend craziness and bring some peaceful understanding.
The human psyche and its attendant neuro-system will never be understood through investigations into chemical receptors and medical notions of disease. The brain is as complicated as the universe. Go figure.
6
This is the most inciteful comment I have read yet. I agree 110%.
Dr. Friedman, Your "identity crisis" description of psychiatry sounds more like the field of cancer care 25 years ago. This was right at the beginning of the cancer care revolution. At that time, behavioral modifications and interventions reshaped the risk paradigm by urging people to stop smoking and get pap smears. At the same time, 25 years ago chemotherapy and radiation had remained unchanged for decades. A purring of focus and resources at both was what led to the new era of cancer care we are now in.
I think you should rename your piece" Psychiatry's Opportunity
I think you should rename your piece" Psychiatry's Opportunity
1
This conversation is so important. Ever since watching Dr. Lynn Fenton testify in the case of James Holmes I have wondered what difference it might have made had his sessions been more than 15-20 minutes to talk about how his meds were working. She cannot be blamed personally because she was following the professions' standards of care. That is what we need to examine- the idea that medication alone and a few short sessions checking is an appropriate standard of care. We know from research that the most effective mechanism of change in therapy is related to the working relationship that the client and therapist develop. This relationship takes time and effort. The profession of psychiatry should reflect on this truth and change how they practice.
7
Many insurance plans cover psychotherapy (though usually with a small co-pay) but try to find a therapist who will take the time to do the necessary paperwork. Then from that small group of therapists who don't demand cash payments up-front, try to find a therapist that you like and can talk to. For people who are already depressed and anxious, this can present a burden that they might not be able to get past.
4
This is mostly the fault of insurance companies. Only in the US do we have restrictive "networks." Everywhere with "single payer" you can see any therapist you want. The inscos do this to control access and make more profit.
All the paperwork? Its the insurance companies. Therapists are not paid for time to do paperwork and the fees the insurance company pays their "providers" is usually less than half the going rate. Plus usually therapists have to hire someone (and pay) just to get the payments billed and collected. No wonder therapist don't want to be "in network."
All the paperwork? Its the insurance companies. Therapists are not paid for time to do paperwork and the fees the insurance company pays their "providers" is usually less than half the going rate. Plus usually therapists have to hire someone (and pay) just to get the payments billed and collected. No wonder therapist don't want to be "in network."
2
To anyone seeking out effective psychotherapy :Seek out a clinical psychologist,rather than a psychiatrist. Psychologist have far more extensive training in conduction psychotherapy than do psychiatrists ,who training is focused on psychopharmacology.
7
Psychiatry is suffering the same as 'modern medicine'. It is driven by the insurance industry motivation of cutting costs. Trying to treat chronic illnesses in an acute model is the epitome of fitting a square peg in a round hole. Medications at their optimum alleviate tremendous suffering but do not address the underlying causes. Statins lower cholesterol but don't mistake this one step of a solution as a treatment. Shifting treatment paradigms, recognizing the complexity of chronic diseases, and treating the whole person and their environment is what is desperately needed. As a 20 year + practicing psychiatrist I see the tremendous value of pharmaceuticals and psychotherapy (all varieties) but they have their limitations. In my opinion, functional medicine is the beginning of the must needed shift in the way we look at disease and begin to address health and wellness as more than the absence of symptoms.
81
This is a very interesting comment. What do you mean by "functional medicine?"
I concur; a skilled, licensed Naturopathic physician is an invaluable healthcare team member for effectively managing the wellness of the whole person. Fifteen years ago my PCP had only four prescriptions to offer me, one of which was an anti-depressant, as I struggled with a collage of conditions which I discovered were contributing to my psycho-emotional downfall. I quickly decided to find a Naturopath who over time has helped me peel away the layers to an even stronger state of wellness than I ever thought possible! Who knew these physiological issues had anything to do with the imbalances in my brain chemistry?! And, that I could naturally, over time restore balance - just me, my ND, and Mother Nature!!! I'm so glad I tried a "conservative" path first; the big guns were there if I needed them. But, thankfully I'm pharmaceutical-medication-free, which sadly is unlike most people I know in my "baby-boomer" age bracket.
as i recall the metastudy from decades ago, persons put on a waiting list for psychotherapy had the same cure rate or level of recovery as persons who actually received treatment.
then there was the study that showed it wasn't the type, school or kind of psychotherapy that produced a positive outcome, but the perceived positive human relationship of trust and empathy from the therapist.
finally, there's the inherent inequality in cost comparisons: surely it costs much more money to manufacture and test small quantities of a new drug in a clinical trial then to test the outcomes of a new talk therapy through routine office visits.
finally i don't think psychiatry has recovered from the reputational harm done by the fraud of psychoanalysis, or psychotherapy generally from the many self help and motivational movements of the '60s. why have science, if all you really need is a guru?
psychotherapy occupies a precarious and orphan position, a paid intimacy that is not really prostitution, a contrived trust that is not really parental, a therapeutic service that profoundly depends on the personal attributes of the practitioner.
i agree: too much drug dependence, and too many drugs that only produce compliance with a menacing and reckless infrastructure of waste and empty routine. but the pharmacological industry is not the problem with psychotherapy -- and it's still the brain, not the benefits of talking, that is the great mystery.
then there was the study that showed it wasn't the type, school or kind of psychotherapy that produced a positive outcome, but the perceived positive human relationship of trust and empathy from the therapist.
finally, there's the inherent inequality in cost comparisons: surely it costs much more money to manufacture and test small quantities of a new drug in a clinical trial then to test the outcomes of a new talk therapy through routine office visits.
finally i don't think psychiatry has recovered from the reputational harm done by the fraud of psychoanalysis, or psychotherapy generally from the many self help and motivational movements of the '60s. why have science, if all you really need is a guru?
psychotherapy occupies a precarious and orphan position, a paid intimacy that is not really prostitution, a contrived trust that is not really parental, a therapeutic service that profoundly depends on the personal attributes of the practitioner.
i agree: too much drug dependence, and too many drugs that only produce compliance with a menacing and reckless infrastructure of waste and empty routine. but the pharmacological industry is not the problem with psychotherapy -- and it's still the brain, not the benefits of talking, that is the great mystery.
1
How imperfect is human recall.
In general, psychotherapy comes down to rearranging deck chairs; shuffling, reordering thoughts in the mind.
In order to be free of pain and disorder, the nature of thought and the human mind itself needs to be perceived for what it is and what it is doing to us all.
And then thought can be be put in its place: https://www.youtube.com/watch?v=1y6l7maIdI4
In order to be free of pain and disorder, the nature of thought and the human mind itself needs to be perceived for what it is and what it is doing to us all.
And then thought can be be put in its place: https://www.youtube.com/watch?v=1y6l7maIdI4
2
Glad to hear this opinion. When you treat the illnesses with meds, the cure consists of person + meds, there is no permanent change. Permanent change requires psychotherapy.
6
I was cured of clinical depression over 30 years ago with medication
prescribed after several blood and urine tests. I still take the med
(nortryptaline) daily.
Eli Meisler
prescribed after several blood and urine tests. I still take the med
(nortryptaline) daily.
Eli Meisler
Unless disorders are frankly biologically based--and even when they are--the most painful aspects of psychological problems are relational ones. The loss of hope, the isolation, the anxiety, e.g. What did humans do before there were therapists? They sought, or were sought out by others whose care and regard reduced these symptoms, provided respite, hope, companionship and guidance. What happened to these natural forms of help? Professionalization. We have created a mystique about helping...without at least a master's degree, no one is believed to be capable of helping. And we kicked it up a notch with psychotropic drugs which eventually came to be used far beyond their scope of usefulness, often creating problems themselves. It's time to put a human face back on therapy. It's arrogant for any profession to claim they can fully understand any individual. That takes time, acceptance, absolute regard and dialogue with whoever sits before you--whether you have 3 professional degrees, or none.
76
...... one British psychiatrist commented that, "You don't need a psychiatrist, you need a friend."
1
I help run a county mental health service that stabilizes people with very serious mental illnesses. I also have a panel of patients I follow all of whom are very ill often having been hospitalized dozens of times. The most striking feature of the entire enterprise is the way very seriously ill people refuse medication, because they are fine, and people who are not seriously ill insist on getting medication, because they are not fine. I recently had a family member of a young man with new onset psychosis become enraged because I was focusing on medication rather than therapy for his "trauma." The American public, and much of the mental health community in America, have lost their ability to tell who is, and is not, mentally ill. In this kind of environment trying to discuss appropriate therapy is almost pointless.
92
.........and many pt.s on Lithium don't "comply" 'cause they, "miss the high".
Thanks for this comment. I think it's really true. The conversation around medication versus psychotherapy in our culture never seems to be accompanied by a checklist that defines severe versus mild to moderate illness. Which I think turns Americans upside down on this issue! It's all too easy for friends and relatives of someone who is seriously ill to hide their heads in the sand about what constitutes "mild" versus "severe" impairment which often results in discouraging a really sick person from getting help early on and can worsen their illness. I'd like to see all news articles on the benefits of treatment x over treatment y be accompanied by a list of symptoms that constitute mild versus severe impairment so that Americans can truly learn to distinguish between the two and advocate for themselves and their loved ones appropriately. Don't tell your cousin with severe OCD that all she needs is more yoga or that psychoanalysis will relieve all her symptoms if the research shows medication is truly the best option for someone with this diagnosis.
If there's not enough psychotherapy, it's because of the medical insurance business. Financial considerations also dictate that people who want psychotherapy see a psychologist or social worker, rather than a psychiatrist - too expensive. So psychiatrists are mostly called upon when medication is required, because it takes an MD to prescribe medication.
2
In arguing for the importance of investment and research into psychotherapy Mr. Friedman cites a study that found that patients were three times more likely to want psychotherapy than psychotropic drugs.
However that study itself also found that "more than half of those with a psychiatric disorder perceive barriers (either logistical or attitudinal) to seeking mental health care and accordingly did not utilize any mental health
services in the previous year".
And it is very clear what those perceived barriers are in a large part. And those are the fact that psychotherapy requires an open ended commitment to therapy that may take either weeks or years. This literally means undertaking a new activity in ones life. In addition many people do not look forward to the idea of sitting with a stranger and having their whole life picked apart and examined.
And all of this to solve a problem that can just as easily be solved by taking a pill. The argument made here for psychotherapy is "that psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses". That is "as effective" and no evidence that it is any more effective.
And the fact is, as that study found, that in the real world more than half of those with a psychiatric disorder didn't pursue psychotherapy just for the reason of "perceived barriers". As such it would seem that the research funding priorities are in fact appropriate.
However that study itself also found that "more than half of those with a psychiatric disorder perceive barriers (either logistical or attitudinal) to seeking mental health care and accordingly did not utilize any mental health
services in the previous year".
And it is very clear what those perceived barriers are in a large part. And those are the fact that psychotherapy requires an open ended commitment to therapy that may take either weeks or years. This literally means undertaking a new activity in ones life. In addition many people do not look forward to the idea of sitting with a stranger and having their whole life picked apart and examined.
And all of this to solve a problem that can just as easily be solved by taking a pill. The argument made here for psychotherapy is "that psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses". That is "as effective" and no evidence that it is any more effective.
And the fact is, as that study found, that in the real world more than half of those with a psychiatric disorder didn't pursue psychotherapy just for the reason of "perceived barriers". As such it would seem that the research funding priorities are in fact appropriate.
The advent of anti-depressants has helped destigmatize depression: while it was previously regarded as a character flaw, now it's largely seen as a medical problem.
However, the tendency to see depression as a largely medical disorder concerns me. Among the people I know, their depression doesn't emerge from a vacuum. These people have had devastating life experiences: childhood and adult abuse, violence, unemployment, poverty, serious illness, etc.
Medicalizing such problems enables society to look away from the root causes of these problems. As in most aspects of American life, it's up to the individual to solve her/his problem, not for society to change.
I would submit that, for people who have had some of the devastating experiences I listed above, they would be crazy to NOT be depressed.
While medication and talk therapy are certainly valuable, much depression could be alleviated if we made our society more humane. Bernie Sanders is on the right track as far as that goes.
However, the tendency to see depression as a largely medical disorder concerns me. Among the people I know, their depression doesn't emerge from a vacuum. These people have had devastating life experiences: childhood and adult abuse, violence, unemployment, poverty, serious illness, etc.
Medicalizing such problems enables society to look away from the root causes of these problems. As in most aspects of American life, it's up to the individual to solve her/his problem, not for society to change.
I would submit that, for people who have had some of the devastating experiences I listed above, they would be crazy to NOT be depressed.
While medication and talk therapy are certainly valuable, much depression could be alleviated if we made our society more humane. Bernie Sanders is on the right track as far as that goes.
6
With respect. serious mental illnesses are chronic biological diseases of human brains. You need to open up your reading preferences to include scientific research and the history of neurological diseases like mad cow disease.
A reading of science writer Jay Ingram's book "Fata Flaws: How a Misfolded Protein Baffled Scientists and Changed the Way we Look at the Brain" is a great introduction to the biological reality of brain diseases. We can no longer blindly accept sociology as a cause.
Social engineering has no place in treatment or the cure for them.
A reading of science writer Jay Ingram's book "Fata Flaws: How a Misfolded Protein Baffled Scientists and Changed the Way we Look at the Brain" is a great introduction to the biological reality of brain diseases. We can no longer blindly accept sociology as a cause.
Social engineering has no place in treatment or the cure for them.
My professor of psychiatry emphasized that the patient had to pay for the psychotherapy. This was a critical part of the treatment. The poor results in today's environment are understandable when one considers that very few are self pay.
I wholeheartedly disagree with this. In fact, the clinical trials that have show the efficacy for certain therapy modalities are almost always free. More importantly, if you only treat patients who can pay you are excluding an entire class of people who can't afford therapy and are likely in even more need of help. I am a clinical social worker and provide therapy to the most vulnerable and impoverished citizens of New Mexico, young children in CPS custody. I have data to show our treatment works, despite these children's lack of a co-pay!
1
Here's a novel thought: why don't you ask your patients what they think might help them (no holds barred). Maybe they have the knowledge and the imagination to invent a treatment (not a medication), that is unavailable for one reason or another, that just might help others like them.
I'd love to be asked because I have some ideas, but the medical/psychological world might not be prepared to hear them. As long as a treatment does no harm and is ethical and legal, why not try it?
I'd love to be asked because I have some ideas, but the medical/psychological world might not be prepared to hear them. As long as a treatment does no harm and is ethical and legal, why not try it?
1
Good idea!
Years ago when I was studying mental health, we had staff meetings to plan for patients. We had one patient who we thought to put in group therapy, but she had an "outside" indidivual therapist. The staff decision was to call this therapist and ask if the patient should be in a group. I did so, and the therapist said (and I'll never forget it): "Why don't you ask the patient?"
That was a very novel idea at the time.
Years ago when I was studying mental health, we had staff meetings to plan for patients. We had one patient who we thought to put in group therapy, but she had an "outside" indidivual therapist. The staff decision was to call this therapist and ask if the patient should be in a group. I did so, and the therapist said (and I'll never forget it): "Why don't you ask the patient?"
That was a very novel idea at the time.
As an independent community representative who inspected mental health facilities and assisted involuntary patients I was amazed at the ever increasing number of men & women who requested ECT. Most were at the end of their tether. One, a 90 year old man, had a positive outcome and his medications were reduced by a third. He is now back 'at home' living a 'normal' life. But ECT isn't for everyone & it is difficult to select patients who might benefit.
Shrinks psychiatrists) of whom I have met many and done much research about are inheritors of Sigmund Freuds ideaologies and theories.
They are only interested in personal financial gains and they full know that no one wants to try and question them because they dwell in a never never land that most intelligent folk want to avoid
They are only interested in personal financial gains and they full know that no one wants to try and question them because they dwell in a never never land that most intelligent folk want to avoid
The answer is still two human beings communicating with each other, isn't it? Whatever else you throw into the mixture, it's still two human beings in a relationship that promises to improve the life of the one seeking that relationship. I was a psychiatry researcher and saw how the influence of psychotropic drugs relieved pain but then what? Then you were left with the job of enhancing the patient's sense of his or her own personhood.
76
Yes! I worked with a traumatized mother and her 5 year old daughter for 2 years and during the termination phase, I asked her what was the most helpful to her in our work together. She stated that I once mailed her and her daughter a card over my 2 week vacation stating that I was thinking of them, missed them both, and looked forward to seeing them soon. She told me that she had never been told by anyone in her life that they missed her and were thinking of her. I believe that the fact that I was "holding them both in mind" and communicating that they were both truly important to me both inside and outside of the treatment room solidified the authenticity of our relationship to her. (Caveat, I was using an evidence-based treatment modality, Child-Parent Psychotherapy.)
How I managed to achieve a measure of mental health and the difference between psychiatry and psychology?
I grew up traveling a lot, but even if not having travelled I would have had "mental problems" because of living in a dysfunctional family and existing in generally confused society. My first course of action, as a teenager, was the primitive psychiatry, self-medication of substance abuse. Fortunately one of the drugs I took was LSD which resulted in a profound mystical experience and turned me to literature, science, art, etc.
I realized, as thousands of writers have, as Freud himself did, that the primary goal is self-integration through talk, reading,--all we mean by culture (both writer's task and psychotherapy) and that all forms of psychiatry, whether alcohol or LSD or most advanced medicine are something of emergency measure in absence of healthy social and personal relations or measures for only the most acute and intractable cases.
I was really lucky. After having taken LSD I embarked on rigorous literature, writing, spirituality and indeed found as vocation the attempt to heal as best as possible society. I see that I should have been born in honest, rigorous, cultured environment in first place so as not to have suffered so much and fallen into course of substance abuse. Primary task: Create culture, healthy and noble living. Medicine of any type should only come after all attempts at healthy culture and not be something in place of healthy culture.
I grew up traveling a lot, but even if not having travelled I would have had "mental problems" because of living in a dysfunctional family and existing in generally confused society. My first course of action, as a teenager, was the primitive psychiatry, self-medication of substance abuse. Fortunately one of the drugs I took was LSD which resulted in a profound mystical experience and turned me to literature, science, art, etc.
I realized, as thousands of writers have, as Freud himself did, that the primary goal is self-integration through talk, reading,--all we mean by culture (both writer's task and psychotherapy) and that all forms of psychiatry, whether alcohol or LSD or most advanced medicine are something of emergency measure in absence of healthy social and personal relations or measures for only the most acute and intractable cases.
I was really lucky. After having taken LSD I embarked on rigorous literature, writing, spirituality and indeed found as vocation the attempt to heal as best as possible society. I see that I should have been born in honest, rigorous, cultured environment in first place so as not to have suffered so much and fallen into course of substance abuse. Primary task: Create culture, healthy and noble living. Medicine of any type should only come after all attempts at healthy culture and not be something in place of healthy culture.
1
Just ask anyone who has benefited from psychotherapy?
How many are out there? It doesn't seem like many.
Whether lack of reimbursement, lack of interest, lack of motivation, lack of not good fits with therapists, lack of time....you get it....just doesn't seem that helpful.
Hooray for those that it does benefit. It would be great to see what makes a difference and why.
Numbers, data, and research studies might be nice, but let's talk about reality stuff.
How many are out there? It doesn't seem like many.
Whether lack of reimbursement, lack of interest, lack of motivation, lack of not good fits with therapists, lack of time....you get it....just doesn't seem that helpful.
Hooray for those that it does benefit. It would be great to see what makes a difference and why.
Numbers, data, and research studies might be nice, but let's talk about reality stuff.
1
The brain is a chemical computer that has developed uniquely in each of us through a combination of life experiences and genetics. In the end, some minor issues can be resolved by talk therapy. Those people should be referred to a psychologist. But in many cases, it is a mechanical or electrical malfunction of the brain, and medicine is the answer. Medication works, and TMS works for many, without the memory loss and hospitalization of EST. Let's not go overboard and demonize life saving treatments again.
I had roughly 30 years in the mental-health (or illness) system. I cannot even remember all the different therapists I saw. I do remember, however, that therapy was always in a room with the door closed and, often, a "white noise machine" on. There were always and only two people, the person seated opposite me and me. I would like to know what kind of expensive research could possibly be needed for sessions like those I had. You talk. The therapist comments, or asks something, or stays silent. There is a clock facing the therapist, who says "our time is almost up" when you are to leave. What in the world by way of research is needed for this? Yes, I am angry. No, I am not in therapy, haven't been for years, and never will be again. Yes, I take drugs. Yes, they help me.
2
I've used prescription medications for sleep and anxiety and have found they are great during take-off, but, landings are rough. Even when you strictly follow the doctors, orders long term use often leads to habituation and dependency. Psychotherapy, understanding family of origin issues and CBT take longer, cost more but it is worth it if you can afford the time and money. Clearly, there are some mental illnesses where drugs must be part of the equation.
2
Ironic to talk about psychiatrists and neuroscientists as favoring pharmacotherapy because they are reductionists. I think they aren't reductionist enough. If they really believed it was all the brain, they'd have to confess that therapy (and good relationships more broadly) also work by changing the brain, and they'd be promoters of it. Instead, they take a very peculiar stance that only electrochemicals can be considered treatments. This is unsupported by current research. There is vast evidence that good therapy changes brains. There is vast evidence that medications used for many disorders are not very effective, compared to placebo. Why insist that the brain theory that fails on both sides must be correct? This isn't science, it's ideology.
4
Psychotherapy is a BUSINESS.... not a science.
5
Psychopharmacology is a business too. Pharamceuticals are a very big business indeed.
10
And reformulating medications with molecular tweaks or "extended release" formulations every 17 years so that drug companies can charge thousands of dollars a month for the same medications....that is "science?"
Is there a nw antidepressant that works better than Elavil? A mood stabilizer that works better than LiCO3? What has "science" accomplished in the last 50 years?
Is there a nw antidepressant that works better than Elavil? A mood stabilizer that works better than LiCO3? What has "science" accomplished in the last 50 years?
This is something better that works. Not clear why this is not on Professor Friedman's radar.
https://www.youtube.com/watch?v=bjeJC86RBgE
https://www.youtube.com/watch?v=nmJDkzDMllc
https://www.youtube.com/watch?v=xPhasHMSyas
https://www.youtube.com/watch?v=bjeJC86RBgE
https://www.youtube.com/watch?v=nmJDkzDMllc
https://www.youtube.com/watch?v=xPhasHMSyas
6
The first one is a wonderful story. Thanks.
REALLY? . . .
Dr. Friedman, you seem to be far too pessimistic than me. As Freud and others who used psychodynamic therapies, in the main, through the 1950s little of consequence was accomplished: long, expensive and never scientifically validated.
Then, the introduction of lithium, the many groups of antidepressants, antianxiety agents and the major tranquilizers which for the first time ameliorated the dangerous and frightful psychotic manifestations. Were there often serious side effects? Of course. Almost all drug treatments have this potential. So one has the use the cost benefit analysis.
Psychotherapy was morphed by the new approached of Carl Rogers and Aaron Beck. Beck's cognitive behavioral therapy was weeks instead of year ... and more importantly was validated in peer reviewed journals.
As more treatment worked this led to prominent people coming out of the closet (William Styron, Art Buchwald, Mike Wallace and a host of actors and other performers. This reduced stigma and allowed people to acknowledge their psychopathologies and get treatment.
Via the genome project and brain research, we have learned more during the past decades than in the past century.
You seem to view the glass as one third full as I am far more optimistic. And as I peer ahead, I suspect that such serious pathologies as schizophrenia, bipolar disorder ... and even the dementias will be as polio is seen in the developed countries now. So rare that few physicians have ever seen it ever.
Dr. Friedman, you seem to be far too pessimistic than me. As Freud and others who used psychodynamic therapies, in the main, through the 1950s little of consequence was accomplished: long, expensive and never scientifically validated.
Then, the introduction of lithium, the many groups of antidepressants, antianxiety agents and the major tranquilizers which for the first time ameliorated the dangerous and frightful psychotic manifestations. Were there often serious side effects? Of course. Almost all drug treatments have this potential. So one has the use the cost benefit analysis.
Psychotherapy was morphed by the new approached of Carl Rogers and Aaron Beck. Beck's cognitive behavioral therapy was weeks instead of year ... and more importantly was validated in peer reviewed journals.
As more treatment worked this led to prominent people coming out of the closet (William Styron, Art Buchwald, Mike Wallace and a host of actors and other performers. This reduced stigma and allowed people to acknowledge their psychopathologies and get treatment.
Via the genome project and brain research, we have learned more during the past decades than in the past century.
You seem to view the glass as one third full as I am far more optimistic. And as I peer ahead, I suspect that such serious pathologies as schizophrenia, bipolar disorder ... and even the dementias will be as polio is seen in the developed countries now. So rare that few physicians have ever seen it ever.
1
If CBT worked it would be the best thing since sliced bread. It does, for a while, for some simple problems, if the patient doesn't drop out as many do. But other forms of psychotherapy are more effective, particularly for complex trauma, because CBT addresses the wrong part of the brain and, not infrequently, the wrong time of life.
The newer and more effective therapies have more in common with psychodynamics than CBT for that reason. They do not ignore traumatic history and they address the paleomammalian brain rather than the neocortex, since it is in the paleomammalian brain that the emotional difficulties for which people seek therapy are localized.
The newer and more effective therapies have more in common with psychodynamics than CBT for that reason. They do not ignore traumatic history and they address the paleomammalian brain rather than the neocortex, since it is in the paleomammalian brain that the emotional difficulties for which people seek therapy are localized.
6
CBT,as practiced by a skillful practitioner,has in fact,been proven to be the MOST effective form of psychotherapy.,along with D.B.T. C.B.T. as practice by a clinician who has received extensive training in CBT,does NOT ignore trauma.I can’t imagine where you’ve gotten these ideas.I am a trauma patients.and I’ve been helped more by by cognitive behavioral trained psychologist that by anyone else.I don’t know where you got your ideas about the paleo-mammalian brain. It’s new to me.Dr.Chow is clinical psychologist and professor of psychology,and I respect his point of view,while having not yet read the comment to which you responded.
"...it seems that leaders in my field are turning their backs on psychotherapy and psychotherapy research."
Gee, ya think?!
I do appreciate Dr. Friedman's perspective here -- I think he's right on target. But to suggest that this is a relatively new phenomenon is disingenuous at best.
For the past two decades at least, the field has systematically and doggedly divorced psychiatry from psychology. The former is all about pills, and has arrogantly appropriated all the "medical" prestige. Insurers are all too often willing to cover psych meds -- even though psychiatrists themselves admit that they only help about 50% of patients, and that they don't really understand why they do (or don't).
Meanwhile, psychotherapy of all kinds has been relegated to a kind of "quasi-medical" ghetto, deemed unscientific and impressionistic, and severely underfunded in terms of both practice and research.
Gee, ya think?!
I do appreciate Dr. Friedman's perspective here -- I think he's right on target. But to suggest that this is a relatively new phenomenon is disingenuous at best.
For the past two decades at least, the field has systematically and doggedly divorced psychiatry from psychology. The former is all about pills, and has arrogantly appropriated all the "medical" prestige. Insurers are all too often willing to cover psych meds -- even though psychiatrists themselves admit that they only help about 50% of patients, and that they don't really understand why they do (or don't).
Meanwhile, psychotherapy of all kinds has been relegated to a kind of "quasi-medical" ghetto, deemed unscientific and impressionistic, and severely underfunded in terms of both practice and research.
100
I think medical schools are responsible for the belief that big pharma has a pill or two or three for ever ill that afflicts us. Money talks- as always. We need to get rid of the sellouts.
4
Once the patient is made to accept his or her worm on a fish hook experience learning not to wiggle , the pill is his or her ticket to take away the pain of the worm on a fish hook experience and adding another pill or two will take away the pain of being a worm on a fish hook experience . Then if the worm is having an off day ,the therapist will ask :are you taking your medication with therapist and patient free of being curious if the pill is what is giving the patient the worm on the fish hook experience . It could be worse for the patient with such a question fearing a shutter island experience
but the day could come with another medication adjustment where only a shutter island experience could save the patient
but the day could come with another medication adjustment where only a shutter island experience could save the patient
I think it's good to remember that pushing pills and the physical brain they influence (rather than that messy metaphysical concept of "mind") serves to enrich the 1%-ers in our economy much better than talk therapy. Who cares if talk therapy creates more healing when there's lots of profit to be made by selling cheaply manufactured pills at exorbitant prices?
43
A big change happened in the 1980s along with the introduction of the then new SSRI meds / all of a sudden the psychiatrist was told to stop talking to the patient. Previous to that, and still in the case of older practitioners (as described by Lynn Ochberg below) and in countries where patient health is more important than money, the psychiatrist routinely talked and still talks, performes and works within his/her type of psychotherapy coordinated with new medications (((and no Freud has been out of date for many years, our psychiatrists in training benefit from a wealth of therapeutic approaches including versions of CBT, body/mind, common sense talk)) - The psychiatrist can prescribe and monitor the efficacy of medication through talk which explores the interaction between the medication effects and the feelings, behaviors, reactions to life reported by the patient.
This approach is common in good psychiatry in Mexico and it works, is much better than the dual psychologist/psychiatrist model because one dedicated professional is likely to see the whole picture.
The professionals as this writer clearly is really want to help, they already have the tools, yes research would be great but your patients need help NOW!. The uber-Capitalist insurance dominated system once again destroys the possibility of a decent life for many Americans.
This approach is common in good psychiatry in Mexico and it works, is much better than the dual psychologist/psychiatrist model because one dedicated professional is likely to see the whole picture.
The professionals as this writer clearly is really want to help, they already have the tools, yes research would be great but your patients need help NOW!. The uber-Capitalist insurance dominated system once again destroys the possibility of a decent life for many Americans.
15
The many psychiatrists who I've seen do not know what to do when I enlist their help. They keep writing & writing on their yellow pads until I leave. I am in my sixth decade of life and never had an experience with a psychiatrist that in any form resembled hope.
5
You don't say what you're struggling with but you're seeing the wrong people. See the link to the short documentary in Phyllis Stein's post above to get an idea of just how effective some new forms of therapy can be. The link is to somatic therapy, but there are others as well, such as EMDR, and you need to find the approaches that work for you.
2
Access to good psychotherapy is challenging because the cost is prohibitive for many without using their insurance. Finding a 'good fit' psychotheraist is difficult because mental health coverage is often limited to a panel of therapists who agree to accept insurance rates. Clients are in pain, or crisis, and see a long list of names with no idea who these therapists are and if they are accepting new clients. Many therapists are on insurance panels, but are reluctant to take new patients because of low reimbursement rates. I know of people who have called dozens of therapists on their panel, and if they get a return call, are told that their practice is full. The relationship with the therapist is crucial. Studies have shown that the non-specific effects of therapy are often as important as type of therapy-- the empathy, warmth, and interest a therapist shows play a major role in outcomes.
88
“Most therapists are on insurance panels”?! Not in New York!
Freud was an explorer. While he may not discovered a definitive cure for mental illness many of his cutting edge ideas were valid and have so deeply penetrated the culture we accept them as facts of nature and no longer associate them with a source.
6
The focus on biological therapies is really a focus on the most severely ill patients, including patients with schizophrenia, bipolar disorder and severe depression.
The focus on psychotherapy is really a focus on many patients who have experienced trauma, where we know medications do not seem to work very well. This is especially true for patients with borderline personality disorder.
Of course, not all patients neatly fit into one particular category.
Nevertheless, we are really talking about two very different groups of patients.
The focus on psychotherapy is really a focus on many patients who have experienced trauma, where we know medications do not seem to work very well. This is especially true for patients with borderline personality disorder.
Of course, not all patients neatly fit into one particular category.
Nevertheless, we are really talking about two very different groups of patients.
18
Yes, and I think our failure to make a distinction between those two groups of patients has been harmful. For one thing, it creates stigma that discourages people from getting the help they need; just look at one of those TV shows where they confuse neurotic conditions with psychotic ones to see how confused the public is about these matters. For another, it discourages us from devoting sufficient medical funds to the more serious conditions because the "disorders" have been expanded to include everything up to and including nail biting.
3
If your fingers are bleeding much of the time, you could probably use some psychotherapy.
Actually, Michael, this is a bit of an over-simplification. Take Obsessive-Compulsive Disorder, for example: it can be as debilitating as any of the mental illnesses you mention, and yet a form of psychotherapy called Exposure and Response Prevention (Ex/RP) is at least as effective as the medications that can also be used to treat it. In addition, there are empirically supported psychotherapy interventions that improve pharmacotherapy treatment outcomes in schizophrenia and bipolar disorder. Both psychotherapy and pharmacotherapy are important tools for mental health treatment providers and the turn away from psychotherapy research funding by NIMH is very unfortunate.
Research needs to be done on biological causes of mental illness like in PANS or PANDAS (Pediatric, Autoimmune, Neuropsychiatric Disorder Associated with Strep.) Also, the possibility that depression in adults is a symptom of an infectious disease. In my experience a lot of mental health providers are resistant to looking for physical causes of mental illness.
5
I am sure I am not original when I point out that the brain is a concrete physical object and the mind is not.
A useful definition of what is meant by mind (free of talk about neurons and brain activity) is I believe important, if not fundamental, to our understanding of both normal and abnormal mental function.
Kudos to Dr. Friedman for his Op-Ed piece.
Stephen Rinsler, MD
A useful definition of what is meant by mind (free of talk about neurons and brain activity) is I believe important, if not fundamental, to our understanding of both normal and abnormal mental function.
Kudos to Dr. Friedman for his Op-Ed piece.
Stephen Rinsler, MD
11
Ss a practicing psychiatrist and foer neurochemist, I thank you Dr. Friedman for pointing out that the biopsychistry emperor has no clothes. Indeed, there cannot be promarily a primarily biological basis for conditions of the whole person. Also the economic gain pf the pharmaceutical industry in creating the myth of biological causation must be pointed out,
In addition to the value of psychotherapies in even the most severe psychiatric conditions, there is a movement of recovery from mental health disorders through peer support amd empowerment. As part of that movement, many of us who have experienced our own recovery from conditions such as schizophrenia have developed training programs helpful for laypersons assisting others through emotional crises. An example is Emotional CPR (www.emotional-cpr.org) which is being used in many countries in addition to US. By teaching Emotional CPR to the general public people can help each other recover in the 143 hours between weekly psychotherapy sessions.
In addition to the value of psychotherapies in even the most severe psychiatric conditions, there is a movement of recovery from mental health disorders through peer support amd empowerment. As part of that movement, many of us who have experienced our own recovery from conditions such as schizophrenia have developed training programs helpful for laypersons assisting others through emotional crises. An example is Emotional CPR (www.emotional-cpr.org) which is being used in many countries in addition to US. By teaching Emotional CPR to the general public people can help each other recover in the 143 hours between weekly psychotherapy sessions.
I think Ray Charles had it right when he said in one of his songs ".... when you're dead you're done...." The brain controls everything. And when it's finished working it's finished working.
Bill Sprague, not an MD
Bill Sprague, not an MD
I was treated with psychotherapy and I was going once a week. Not only is it time consuming, it was gut wrenching. I'd be depressed for days after and stressed the day before the session.
I did start to treat it a bit differently after a few sessions. I found enormous comfort in being able to have one person that I could tell my feelings honestly. Of course, I had to pay for it but that aspect was a huge boost at the time. Let's face it, very few people can honestly say that they have a 100% secure relationship.family and friends don't keep your secrets. Not to mention the gossipy ness of social media. No one keeps their mouths shut about anything.
I did like the freedom to just say anything to my therapist. But I also know a lot of nurses who talk about everyone. And I have heard AA menbers mention other people they saw at meetings so it seems like the last place you can truly feel secure is with a psychoanalyst.
I did start to treat it a bit differently after a few sessions. I found enormous comfort in being able to have one person that I could tell my feelings honestly. Of course, I had to pay for it but that aspect was a huge boost at the time. Let's face it, very few people can honestly say that they have a 100% secure relationship.family and friends don't keep your secrets. Not to mention the gossipy ness of social media. No one keeps their mouths shut about anything.
I did like the freedom to just say anything to my therapist. But I also know a lot of nurses who talk about everyone. And I have heard AA menbers mention other people they saw at meetings so it seems like the last place you can truly feel secure is with a psychoanalyst.
10
The therapists I know are *very* careful with confidentiality.
Also, the experience should not leave you feeling depressed! Such disturbances as occur should for the most part be brief and the therapist should be able to calm them.
It sounds to me like you were seeing the wrong person.
Also, the experience should not leave you feeling depressed! Such disturbances as occur should for the most part be brief and the therapist should be able to calm them.
It sounds to me like you were seeing the wrong person.
2
I hate to break it to you,but you shouldn’t feel “truly secure with a psychoanalyst. “
My doctor’s wife came over to me in a public place and put her arm on mine.I asked my doctor how his wife knew I was his patient.He told me that he discusses his cases with his wife and children at dinner,using first and last names,obviously,for how else would his wife know I was his patient?He readily admitted that he had told his wife I was his patient.I ran into my next door neighbor leaving his office.My doctor told me her DIAGNOSIS.We were all members of a tightly knit community,where everyone knew everyone else,which made matters that much worse.Had I been not been young and naive,I would have reported him to the New York State Disciplinary Committee..A psychiatrist told me that a “Friend”who was also a psychiatrist,was discussing a patient at a DINER,when the patient,who happened to be sitting at the next booth,and overheard this, came over to the table and confronted her psychiatrist for breaching her confidentiality.
There are psychiatrists and psychologist who do keep confidentiality and those who do not.In regard to “Friends and family don’t keep your secrets.”&”No one keeps their mouth shut: :I told NO ONE including my sister,when I found out she had cancer.I did not tell my brother.My brother did not tell me.I haven’t shared this with others in over 10 years.I can keep a secret.
Therapy should not leave one depressed for days afterwards,or stressed the day before.
My doctor’s wife came over to me in a public place and put her arm on mine.I asked my doctor how his wife knew I was his patient.He told me that he discusses his cases with his wife and children at dinner,using first and last names,obviously,for how else would his wife know I was his patient?He readily admitted that he had told his wife I was his patient.I ran into my next door neighbor leaving his office.My doctor told me her DIAGNOSIS.We were all members of a tightly knit community,where everyone knew everyone else,which made matters that much worse.Had I been not been young and naive,I would have reported him to the New York State Disciplinary Committee..A psychiatrist told me that a “Friend”who was also a psychiatrist,was discussing a patient at a DINER,when the patient,who happened to be sitting at the next booth,and overheard this, came over to the table and confronted her psychiatrist for breaching her confidentiality.
There are psychiatrists and psychologist who do keep confidentiality and those who do not.In regard to “Friends and family don’t keep your secrets.”&”No one keeps their mouth shut: :I told NO ONE including my sister,when I found out she had cancer.I did not tell my brother.My brother did not tell me.I haven’t shared this with others in over 10 years.I can keep a secret.
Therapy should not leave one depressed for days afterwards,or stressed the day before.
... I'm glad for you. But I think psychotherapy is for white people who can pay the bills. Yes, the web-based things and even therapists (trust me on this one) disclose to others what happens and what their "clients" said. Everything I ever said to one therapist came out of the mouth of another therapist a week later....
1
My thoughts are: PTSD is implicated in many psychiatric disorders.
It can be caused by trauma during war and adulthood but a huge amount is caused by childhood trauma and neglect.
Question: which children are at most risk of childhood trauma and neglect?
The answer is children whose conception was unplanned and who are unwanted.
How do we prevent childhood trauma and neglect? Clear discussion of the realities of parenthood, especially economic realities, coupled with universally available affordable birth control.
Victims of childhood abuse and neglect suffer horribly as children and continue to suffer throughout adulthood.
READ: "The Body Keeps the Score" by Bessel Van der Kolk. It's the best psychiatric book available and is very readable. Not too technical.
As for the victims of PTSD through war: I recommend peace. Universal birth control is more likely than peace.
It can be caused by trauma during war and adulthood but a huge amount is caused by childhood trauma and neglect.
Question: which children are at most risk of childhood trauma and neglect?
The answer is children whose conception was unplanned and who are unwanted.
How do we prevent childhood trauma and neglect? Clear discussion of the realities of parenthood, especially economic realities, coupled with universally available affordable birth control.
Victims of childhood abuse and neglect suffer horribly as children and continue to suffer throughout adulthood.
READ: "The Body Keeps the Score" by Bessel Van der Kolk. It's the best psychiatric book available and is very readable. Not too technical.
As for the victims of PTSD through war: I recommend peace. Universal birth control is more likely than peace.
35
Second both your recommendation of van der Kolk's book, and your argument that the best way to treat childhood trauma and neglect is birth control. The recent stunning success of free long-term contraception is perhaps the most effective form of psychotherapy we have!
3
I was diagnosed with PTSD two years ago. And this occurred *years* after I had gone to psychotherapy earlier in my life...on more than one occasion. Over the last two years I went to therapy again. But this time two critical factors were different: 1) I was older and thus determined to seek out the root of my problems and 2) I underwent EMDR therapy.
To my knowledge EMDR therapy is still not commonly practiced among psychiatrists. Whereas my earlier experience of therapy was with psychiatrists my current treatment was offered by a clinical social worker. EMDR radically transformed the quality of my life.
I think more creativity, diligence and intelligence needs to be brought to bear on the issue of mental illness. It's my opinion that PTSD is more common in the population than we may realize. My PTSD developed due to poor parenting (schizophrenic mother and a father who was later nearly murdered...by his second wife), an extended family unwilling to intervene in the horror and a culture (Texas) that prefers to meet violence with more violence (more guns anyone?). Successful treatment of PTSD can be very complex. The motivation of the person undergoing treatment is also vital.
To my knowledge EMDR therapy is still not commonly practiced among psychiatrists. Whereas my earlier experience of therapy was with psychiatrists my current treatment was offered by a clinical social worker. EMDR radically transformed the quality of my life.
I think more creativity, diligence and intelligence needs to be brought to bear on the issue of mental illness. It's my opinion that PTSD is more common in the population than we may realize. My PTSD developed due to poor parenting (schizophrenic mother and a father who was later nearly murdered...by his second wife), an extended family unwilling to intervene in the horror and a culture (Texas) that prefers to meet violence with more violence (more guns anyone?). Successful treatment of PTSD can be very complex. The motivation of the person undergoing treatment is also vital.
Good point. And unwanted children threaten the sanity of the mother, the partner, the family, those stressed economically and emotionally by this birth as well as the poor child who is not adequately cared for and who of course recognizes his/her unwanted status throughout life.
One of the things that I think would help is to remove the stigma attached to mental illness. In many cases due to that stigma, people wait until they have a severe problem before seeking help, no wonder the issue is hard to treat! It would be the equivalent of waiting until your tooth is abscessed before seeing the dentist, at that point, there are not a whole lot of options left.
Most people think nothing of going to the doctor or dentist for a yearly check up; however they will resist going to a mental health professional for a check up. Yet professional athletes, some of whom earn $10 million a year or more and are the best in the world at what they do, have a personal coach. You need someone with an outside perspective to give you an objective opinion on how you're doing.
I would call for the mental health field to develop a standardized check up and for the insurance industry to provide coverage for it just as they do for a yearly physical. Let's try to catch these issues when they are small and treatable.
Most people think nothing of going to the doctor or dentist for a yearly check up; however they will resist going to a mental health professional for a check up. Yet professional athletes, some of whom earn $10 million a year or more and are the best in the world at what they do, have a personal coach. You need someone with an outside perspective to give you an objective opinion on how you're doing.
I would call for the mental health field to develop a standardized check up and for the insurance industry to provide coverage for it just as they do for a yearly physical. Let's try to catch these issues when they are small and treatable.
112
A big part of this problem is that we call neurotic conditions mental illness when they aren't. The person with a personality disorder is generally a victim -- of trauma such as war and rape and molestation, of childhood beatings and neglect.
Anyone who has lived with an alcoholic knows how terrifying and damaging his rages can be. Now imagine what it's like for a child in that situation.
People who have been through these things tend to have low self esteem, to blame themselves. It isn't uncommon for a girl who was molested by her father to blame herself for having been seductive! The worst thing you can do is stigmatize the victim by calling them mentally ill.
It's high time we stopped referring to every undesirable personality trait as mental illness and reserved that term for the poor souls who suffer from physiological diseases like schizophrenia and bipolar disorder.
Anyone who has lived with an alcoholic knows how terrifying and damaging his rages can be. Now imagine what it's like for a child in that situation.
People who have been through these things tend to have low self esteem, to blame themselves. It isn't uncommon for a girl who was molested by her father to blame herself for having been seductive! The worst thing you can do is stigmatize the victim by calling them mentally ill.
It's high time we stopped referring to every undesirable personality trait as mental illness and reserved that term for the poor souls who suffer from physiological diseases like schizophrenia and bipolar disorder.
10
It’s not typically the girl who is molested by her father who “blames herself for being seductive.” It is the family members who prefer to ram in in denial and blame the victim,including the mothers who refuse to believe the daughters who come to them,reporting that they have been molested by their fathers,because the mothers don’t want to give up their social standing or leave their husband for other reasons.
You would “call for the mental health field to develop a mental health field to develop a standardized check up,and for the insurance industry to provide coverage for it,”so that these issues could be caught when they are small and treatable ?”
How will the mental health field develop a standardized check up? Psychiatrists can barely put together a DSM they can agree upon,which they revise on a regular basis.
Who will be on the committee that determines what this standardized check up should include? What tests would the mental health professional order which would yield quantifiable results which would definitively reveal if someone has an undiagnosed mental health condition which is yet to manifest?
“Let’s try to catch these issues when they are small and treatable.”?!!
Psychiatric illnesses such as Schizophrenia or Bipolar Disorder, do not start out as “small ,treatable”conditions.They aren’t small,and they are often refractory to treatment. Mental illness can’t be detected when it’s “small and treatable”and nipped in the bud,as you seem to believe,any more than pancreatic cancer or Huntington’s Disease can be caught when they are "small and treatable”for they are not small or treatable.
How will the mental health field develop a standardized check up? Psychiatrists can barely put together a DSM they can agree upon,which they revise on a regular basis.
Who will be on the committee that determines what this standardized check up should include? What tests would the mental health professional order which would yield quantifiable results which would definitively reveal if someone has an undiagnosed mental health condition which is yet to manifest?
“Let’s try to catch these issues when they are small and treatable.”?!!
Psychiatric illnesses such as Schizophrenia or Bipolar Disorder, do not start out as “small ,treatable”conditions.They aren’t small,and they are often refractory to treatment. Mental illness can’t be detected when it’s “small and treatable”and nipped in the bud,as you seem to believe,any more than pancreatic cancer or Huntington’s Disease can be caught when they are "small and treatable”for they are not small or treatable.
1
I wish more health insurance companies valued psychotherapy as much as Dr. Freidman does. I've twice had United Healthcare try to stop my psychotherapy visits because they question its effectivess. According to my therapist, United (and only United) has been trying this with lots of patients, in the belief that people who are in psychotherapy don't have enough agency to challenge the company's decision. Yet the company has no problem continuing to pay for antidepressant medications.
214
My guess is that your therapist is not a cognitive behaviorist for you’ve stated :”According to my therapist.United (and only United) has been trying this with lots of patients,in the belief that people who are in psychotherapy don’t have enough agency to challenge the company’s decision.” My C.B.T.psychologist would never say anything of the sort and would challenge your therapist as lacking basis in evidence .It is highly unlikely that one insurance company,and ONLY one insurance company has tried to stop psychotherapy visits because they question its effectiveness.I have been told by mental health professionals that they have had this problem with multiple insurance carriers,which is was a contributing factor towards many of them opting out of insurance panels.Did United inform your therapist that the reason they are challenging the efficacy of therapy and trying to stop payment because they don’t believe patients have the agency to challenge such decisions?I find that hardly unlikely,in which case your therapist is presenting your with conjecture as if it is a fact.
1
We more willing to call out as you did here. Thank you! Am I cynical to think United will hire it's own commenters to outnumber any negative comments? Bury the true comments in an avalanche of fictitious PR passed of as the comments of an individual if more did speak out?
To the NYTimes: perhaps coverage, not what it says in the policy statement but what customers of the new policies actually get is something you MUST research. The woman in the cubicle next to me has a brother with a benchmark plan but so few in the network he did not receive the care he needed for blood pressure at stroke causing highs that ruined his kidneys last week. There were no beds at a participating rehab clinic to stabilize him although there were many empty in the area because he had coverage they didn't accept. Where I live this is common place. Mental health treatment and dental care is largely unheard of, frills really for the haves and the middle class hanging on by their fingernails too afraid to seek mental help in particular.
To the NYTimes: perhaps coverage, not what it says in the policy statement but what customers of the new policies actually get is something you MUST research. The woman in the cubicle next to me has a brother with a benchmark plan but so few in the network he did not receive the care he needed for blood pressure at stroke causing highs that ruined his kidneys last week. There were no beds at a participating rehab clinic to stabilize him although there were many empty in the area because he had coverage they didn't accept. Where I live this is common place. Mental health treatment and dental care is largely unheard of, frills really for the haves and the middle class hanging on by their fingernails too afraid to seek mental help in particular.
2
Only UHC? Mais non! UHC is perhaps the most ham-fisted and arrogant in their denials, but Aetna, Anthem, Humana( what a misnomer!) and all the rest do this too. Take the time to challenge them with peer--reviewed evidence or litigation and you may get somewhere, but most people do mot have the resources for that. Attrition is their objective in the service of the fiduciary interests of their owners - and it works.
1
Psychotherapy costs more than a bottle of pills. Managed care/insurance companies and big pharma control the health care that anyone receives. Their goals are in conflict with a goal of achieving relief for an individual. Dr. Friedman does a very good job of explaining the picture. I only regret that he throws in what appears to be approval of "shock treatment". Among readers of this article there will be many who may remember this when a loved one may receive a recommendation of such treatment. What a shame that a treatment from the dark ages of mental health care should still be encouraged and used. I expect someone will reply with wonderful studies and evidence that it is useful and different now but I suspect that it receives more funding for study than psychotherapy. After all shock treatment is about a quick fix rather than giving a patient the time and attention the patient needs.
48
In what way is shock treatment a “quick fix”?In the way orthopedic surgery is a “quick fix”?!
The treatment is not what it used to be nor as depicted in movies intended to scare the begezus out of its viewers. It simply is NOT barbarically performed as depicted in the movies any more. It should be mentioned that the equivalent of ice pick lobotomies to cure depression also are no longer done! ECT or deep stimulation as it is termed in the article is, still, the only treatment we have for people suffering from the most severe and intractable forms of major depression. It is the equivalent of the triple by-pass for depression. Like most patients respond to much less invasive treatments, still there are some for whom these are not effective and are grateful that the triple by-pass--or ECT is available. When candidates are properly vetted and the procedure is properly administered with appropriate after care, it is nothing short of life saving.
Painting the present with the past will only slow progress in the future.
Painting the present with the past will only slow progress in the future.
2
I totally agree with Blue's response to the previous ill-informed comment bashing the current use of ECT. Patients who choose this option have chosen it as their last resort, therapeutically speaking. It has come down to ECT or suicide for them. Life vs death. And they are indeed grateful. Just ask Carrie Fisher
2
Psychotherapy has clearly been sacrificed to the limits of expensive medical care. If I have several hundred dollars and the time, I'm sure I'll have no problem finding a therapist. But my nephew, without a job and a bare bones insurance policy, surely not.
And even if were not so expensive, psychotherapy has failed to solve any of the most severe psychiatric problems: schizophrenia, bi-polar affective disorder, character disorders.
And the areas where it seems most suited, in the treatment of milder forms of depression, are usually complicated by intractable social problems (financial, crime, substance abuse) that it seems little more than a band-aid, unworthy of either the practitioner's time or societies' investment.
I left medical school 32 years ago for a residency, training in psychiatry, I lasted 4 months before switching into a medicine training program. No question, psychiatry is interesting. But it just isn't now or likely ever, to be very useful.
And even if were not so expensive, psychotherapy has failed to solve any of the most severe psychiatric problems: schizophrenia, bi-polar affective disorder, character disorders.
And the areas where it seems most suited, in the treatment of milder forms of depression, are usually complicated by intractable social problems (financial, crime, substance abuse) that it seems little more than a band-aid, unworthy of either the practitioner's time or societies' investment.
I left medical school 32 years ago for a residency, training in psychiatry, I lasted 4 months before switching into a medicine training program. No question, psychiatry is interesting. But it just isn't now or likely ever, to be very useful.
59
Of course psychotherapy doesn't cure psychosis. Some though it might be 75 or 100 years ago but we now know that true mental illness requires medication.
That leaves a lot of sufferers -- the vast majority -- who are suffering from PTSD, childhood trauma, neglect -- and the consequent "personality disorders." For them, psychotherapy is far and away the most effective solution.
If psychotherapy is merely a Band-Aid, how do you explain the resutls of Dr. Markowitz's study, referred to in the essay, which found interpersonal therapy highly effective for PTSD?
Of course, there's some truth in what you say -- we all know people who have had years of Woody Allen-style therapy without resolving their issues. For them, the psychologist or psychiatrist is a very expensive holder of hands. But psychotherapy has become more effective and studies have found modern therapy effective for a number of crippling conditions, e.g., in controlled studies it is as effective in the treatment of depression as medication. New developments in the treatment of PTSD and the complex childhood trauma and neglect that underlie most neurotic suffering promise to make it even more effective, and to treat previously intractable issues, issues against which medication, with its broad-brush effects, is at best marginally efficacious.
That leaves a lot of sufferers -- the vast majority -- who are suffering from PTSD, childhood trauma, neglect -- and the consequent "personality disorders." For them, psychotherapy is far and away the most effective solution.
If psychotherapy is merely a Band-Aid, how do you explain the resutls of Dr. Markowitz's study, referred to in the essay, which found interpersonal therapy highly effective for PTSD?
Of course, there's some truth in what you say -- we all know people who have had years of Woody Allen-style therapy without resolving their issues. For them, the psychologist or psychiatrist is a very expensive holder of hands. But psychotherapy has become more effective and studies have found modern therapy effective for a number of crippling conditions, e.g., in controlled studies it is as effective in the treatment of depression as medication. New developments in the treatment of PTSD and the complex childhood trauma and neglect that underlie most neurotic suffering promise to make it even more effective, and to treat previously intractable issues, issues against which medication, with its broad-brush effects, is at best marginally efficacious.
4
I'm sorry to see this comment as a New York Times "pick," since it's full of misstatements of fact. There are proven effective psychotherapies for numerous psychiatric disorders, including OCD, PTSD, other anxiety disorders, and major depression (not just its "milder" forms); there are also proven effective adjunctive psychosocial interventions that improve outcomes in schizophrenia and bipolar disorder as compared with pharmacotherapy alone. (Of note, many of these therapies have more empirical evidence of effectiveness and lower "number needed to treat" than many common treatments for other kinds of medical problems.) As for the expense: if insurances covered psychotherapies at the same level as they do pharmacotherapies then many more people would have access to these effective treatments.
2
Whether or not psychotherapy is useful is dependent on the skills, values and personality of the therapist and how these match with the patient. There are many poor therapists practicing, and they not only do no good, they can harm patients.
This very article contains one of the greatest obstacles to better and more research (at no fault of the author!)
The link to Dr. John C. Markowitz's article takes you to the abstract of the article. To access the text of article costs $35.00. If one can and does pay, most believe it is to defray the cost of the research of the article. No! It goes to the publisher and portal provider.
The miracle of the internet held the promise of making information more accessible but, in fact, has become a tool to gate, monetize and limit access to information. The study was funded by the federal government. That means we the tax payers paid for the research. Yet, we must pay $35.00 for what we already paid for?
This means most people are significantly barred from information like Richard Friedman wants to make us aware of. As it is he is stuck having to do as he did here, the equivalent of having to put your face up to the store window, nose smashed against the glass to see what is for sale in the store. This instance is particularly galling because we already paid for it.
Perhaps it's time to also change the manner research is juried and packaged. The current system gives outsized power to determine who and what is published where new research is most active while also limiting who has access to the results--for their profit and counter to the profit the research can create monetary and otherwise.
The link to Dr. John C. Markowitz's article takes you to the abstract of the article. To access the text of article costs $35.00. If one can and does pay, most believe it is to defray the cost of the research of the article. No! It goes to the publisher and portal provider.
The miracle of the internet held the promise of making information more accessible but, in fact, has become a tool to gate, monetize and limit access to information. The study was funded by the federal government. That means we the tax payers paid for the research. Yet, we must pay $35.00 for what we already paid for?
This means most people are significantly barred from information like Richard Friedman wants to make us aware of. As it is he is stuck having to do as he did here, the equivalent of having to put your face up to the store window, nose smashed against the glass to see what is for sale in the store. This instance is particularly galling because we already paid for it.
Perhaps it's time to also change the manner research is juried and packaged. The current system gives outsized power to determine who and what is published where new research is most active while also limiting who has access to the results--for their profit and counter to the profit the research can create monetary and otherwise.
307
Follow the money, indeed. When I was in graduate school to become a therapist and needed to cite research for papers, etc. I began to notice that most of the useful psychotherapy (and sociology) research had been done in other countries. I could find numerous articles on research studies funded by the government in Finland, for example, but few in the United States. However, I guarantee that during the same time period, there was no shortage of studies on the effects of medication - most likely funded almost entirely by pharmaceutical companies themselves. We get what we pay for, and if the government must out-source research to for-profit companies (as they do with everything else) there will be few if any studies done of treatments other than medications, no matter how effective they may be.
4
Those engaged in the research actually have little incentive to making the details of the studies widely available, leaving us to the news media headlines: "A new study shows ... ." So psychotherapists studying psychotherapy find that psychotherapy works. Shock! Look deeper into the new study and you discover that it is either an observational study (i.e., totally worthless) or the study compares the treatment to untreated patients "in the wild" and excludes from the results of the treatment arm those patients who drop out of the study. Why shouldn't all those patients who don't succeed be included in the failure count? The truth is that neither therapy nor drugs is very helpful, but drugs are cheaper. I'm all for much more money going to research, but the idea that turning loose a ton of money to fund a legion of poorly trained therapist using a menagerie of treatment methods (many completely unvalidated, even with poor studies) is a bit odd.
As someone who has served on the board of editors of several major scientific journals, I feel it is important to point out that Blue is mixing apples and oranges.
Although those who do the studies that are published may have received federal grant money, the journals that publish them do not. Even with voluntary efforts (I have never received a dime for my work as an editor or as a reviewer), it is still very expensive to produce a journal. Whom does Blue expect to pay for this? The only way journals can do so is by charging for access or through advertisements. I wonder if Blue is reading The New York Times for free.
Although those who do the studies that are published may have received federal grant money, the journals that publish them do not. Even with voluntary efforts (I have never received a dime for my work as an editor or as a reviewer), it is still very expensive to produce a journal. Whom does Blue expect to pay for this? The only way journals can do so is by charging for access or through advertisements. I wonder if Blue is reading The New York Times for free.
1
More funding for psychotherapy research sounds great relative to psychiatric pharmaceutical research funding yet I wonder about research into the relationship of body and brain and the psychological manifestations thereof. It seems to me that so much of what the brain does goes on outside of the direct experience of the mind that the more reductive research approaches are only useful to a certain point. I know some psychotherapy involves much more than cognitive work but so much of that seems driven by individual therapists experience that the benefits seem to rarely spread. The effects of the gut, the heart, the senses and perception, the skin, and bodily motion all have such profound effects on mental health and healing and are generally well filtered by the brain before they reach the mind. This means that to affect them therapy has to bypass the mind/brain interface in very subtle ways to make changes. Very tricky to research but so important to our human condition as beings in relationship with our environment. It reminds me of how some psychologists have explored indigenous healing and spiritual practices in search of more holistic ways of helping their patients. Even if classic double blind research is not practical for these kinds of therapies maybe an accepted and monitored database/forum for exchange of practices and results for these therapies would be useful to fund.
Jim
Jim
You're right, there are such therapies and despite resistance from some in the field they're effective and I think increasingly important.
Too often, therapy fails because it focuses on the neocortex, the wrong part of the mind. Because most of the damage people seek treatment for occurs at the primitive, emotional level.
Right now, it's up to the patient to find someone who recognizes that and knows how to heal that more primitive part.
Too often, therapy fails because it focuses on the neocortex, the wrong part of the mind. Because most of the damage people seek treatment for occurs at the primitive, emotional level.
Right now, it's up to the patient to find someone who recognizes that and knows how to heal that more primitive part.
2
Bravo, for making an argument that puts wide spread phenomena like histories of trauma, sexual abuse, the stress of poverty or deprivation together with a failed treatment delivery system disproportionately focused on pills as the solution.
Discussion of negative effect of economic inequality largely focuses on wages and the like. Abuse and poverty exact far reaching and long term damage on the fabric of our society the cause fingered accurately point to the inequality of resources of our society. Not only do the sufferers fail to receive effective treatment, research determining what the best treatment would be is also withheld.
Meanwhile those with their thumb on the scale with a disproportionate share of resources plainly exhibit severe pathology, personality disorders, like borderline and narcissistic personality disorders, but also sociopathy and psychopathy. It is no hyperbole to call the degree of the impact of their pathology combined with the power they wield over everyone else an acute crisis. The root cause of this crisis is the combination of and relationship between pathology and inequality of means.
I will put it bluntly, the failure so well outlined here is as significant to the root causes of inequality as campaign finance and wage erosion. The degree to which those in power prevent expansion of research and treatment, wittingly or not, are intended to protect their current upper hand in the workings of our society.
Discussion of negative effect of economic inequality largely focuses on wages and the like. Abuse and poverty exact far reaching and long term damage on the fabric of our society the cause fingered accurately point to the inequality of resources of our society. Not only do the sufferers fail to receive effective treatment, research determining what the best treatment would be is also withheld.
Meanwhile those with their thumb on the scale with a disproportionate share of resources plainly exhibit severe pathology, personality disorders, like borderline and narcissistic personality disorders, but also sociopathy and psychopathy. It is no hyperbole to call the degree of the impact of their pathology combined with the power they wield over everyone else an acute crisis. The root cause of this crisis is the combination of and relationship between pathology and inequality of means.
I will put it bluntly, the failure so well outlined here is as significant to the root causes of inequality as campaign finance and wage erosion. The degree to which those in power prevent expansion of research and treatment, wittingly or not, are intended to protect their current upper hand in the workings of our society.
4
How interesting that a significant number of commenters felt the need to mention Freud - in at least one case, with the clear intention of discrediting psychotherapy.
The field of psychoneuroimmunology (popularly known as an important scientific underpinning of "mind body medicine") is now over a quarter century old. Even the most intransigent skeptics have (grudgingly) admitted the placebos work - and they work due to beliefs, expectations, attitudes, (i.e. psychological or mental/emotional phenomena) which have a direct and often powerful effect on the body - including effects on brain chemistry (see Dr. Jeffrey Schwartz' ground breaking research on mindfulness and obsessive-compulsive disorder for more of this).
So why is there still so much resistance to psychotherapy?
yes, the insurance companies love of simplistic research is no doubt one reason.
Lack of time, easy availability of medications is another.
But perhaps the fundamental reason is implicit in the JAMA editorial statement regarding mental illness as a "disease.. of the brain." It is, I think, the implicit physicalist prejudice which continues to make psychotherapy less than acceptable to the medical professionals desperately seeking to assuage their "physics envy." As one neuroscientist said to a colleague who mentioned the word "mind": "Do you want to bring our profession back to the 19th century?"
Solve this, and a truly integrative approach to treating mental illness will be at hand.
The field of psychoneuroimmunology (popularly known as an important scientific underpinning of "mind body medicine") is now over a quarter century old. Even the most intransigent skeptics have (grudgingly) admitted the placebos work - and they work due to beliefs, expectations, attitudes, (i.e. psychological or mental/emotional phenomena) which have a direct and often powerful effect on the body - including effects on brain chemistry (see Dr. Jeffrey Schwartz' ground breaking research on mindfulness and obsessive-compulsive disorder for more of this).
So why is there still so much resistance to psychotherapy?
yes, the insurance companies love of simplistic research is no doubt one reason.
Lack of time, easy availability of medications is another.
But perhaps the fundamental reason is implicit in the JAMA editorial statement regarding mental illness as a "disease.. of the brain." It is, I think, the implicit physicalist prejudice which continues to make psychotherapy less than acceptable to the medical professionals desperately seeking to assuage their "physics envy." As one neuroscientist said to a colleague who mentioned the word "mind": "Do you want to bring our profession back to the 19th century?"
Solve this, and a truly integrative approach to treating mental illness will be at hand.
5
This seems more a problem of professional expectation than anything fundamental. There is room for treatment both of physiological illnesses of the brain -- psychosis, autism, and the like -- and treatment of adverse circumstances that affect people with physiologically healthy brain functioning, e.g., the PTSD of a rape victim or a veteran who spent two years watching his friends die. Medication is the primary and appropriate treatment for psychotic conditions, which seem to be caused by neurotransmitter imbalances of uncertain cause; psychotherapy is a sometimes-useful adjunct. Psychotherapy *should* be the primary treatment for neurotic conditions, with medication in this case playing the adjunctive role by stabilizing the patient or perhaps facilitating emotional relearning.
1
Josh, are you in practice? My experience, overwhelmingly, is that therapeutic (non-medication related) interventions for autism are much more successful overall than medication for autism. Tx of psychosis has been shown by research dating back at least a half century to be much more effective when combining medication and therapy. There's actually a world wide network of psychotic mindfulness practitioners who use mindfulness to help them recognize voices and paranoid delusions (really, delusions!).
As far as the dualist distinction of physiological and psychological, since there is no possible empirical evidence for the existence of a purely physical anything outside of some kind of awareness (not necessarily human) it not only does not need to be posited for the sake of any field of science, it is, I think, the single greatest impediment to the advancement of psychology.
See my Amazon review of "Beyond Physicalism" for details.
As far as the dualist distinction of physiological and psychological, since there is no possible empirical evidence for the existence of a purely physical anything outside of some kind of awareness (not necessarily human) it not only does not need to be posited for the sake of any field of science, it is, I think, the single greatest impediment to the advancement of psychology.
See my Amazon review of "Beyond Physicalism" for details.
The difference between psychiatry and psychology?
The clue and origin is to be found in what we mean by the "writer" historically--the person of often greater greater psychological acuity (psychologist) than average yet often plagued with substance abuse disorder (primitive psychiatry). The great bridge from writer to therapist (psychology) was Freud; he in a sense tried to bring the relationship of author/reader to greater immediacy and concentration by actually having a person (patient) meet with someone (like a writer) of great psychological acuity (the therapist).
The goal of therapy at foundation is to in a sense transform as many people as possible--not necessarily sick people although the concentration of task has been put there--into the psychological and artistic sense and integrative sense of writer with ultimate result of total and higher integration of society (better, more wise, healthy way of living). Psychiatry has always been secondary, having always been an attempt to replace substance abuse disorder--which is itself a symptom of social and personal disorder, failure of integration of self and society.
That psychiatry should become primary and psychology secondary is actually a sign of social and personal failure of cohesion and it is significant the rise of psychiatry has gone hand in hand with the decline of a powerful literary, psychological sense in society. The emphasis in society must be on trust, psychological acuity, honesty, integration, insight.
The clue and origin is to be found in what we mean by the "writer" historically--the person of often greater greater psychological acuity (psychologist) than average yet often plagued with substance abuse disorder (primitive psychiatry). The great bridge from writer to therapist (psychology) was Freud; he in a sense tried to bring the relationship of author/reader to greater immediacy and concentration by actually having a person (patient) meet with someone (like a writer) of great psychological acuity (the therapist).
The goal of therapy at foundation is to in a sense transform as many people as possible--not necessarily sick people although the concentration of task has been put there--into the psychological and artistic sense and integrative sense of writer with ultimate result of total and higher integration of society (better, more wise, healthy way of living). Psychiatry has always been secondary, having always been an attempt to replace substance abuse disorder--which is itself a symptom of social and personal disorder, failure of integration of self and society.
That psychiatry should become primary and psychology secondary is actually a sign of social and personal failure of cohesion and it is significant the rise of psychiatry has gone hand in hand with the decline of a powerful literary, psychological sense in society. The emphasis in society must be on trust, psychological acuity, honesty, integration, insight.
15 years ago I gave up the traditional practice of psychiatry because I saw little in the way of improvement and too much in the way of adverse effects from psychiatric treatments. Psychotherapy and medications do have limited utility, but their efficacy is often too slow or too limited to be deemed anything close to successful. Like the proverbial drunk under the lamppost looking for the keys he lost elsewhere, we continue to look in the familiar well trodden territories of pharmacology and psychotherapy for the answers. It has been my experience that a great many people are not substantially helped by these treatments or find them intolerable, but benefit from one or more of a variety of alternative therapies. I regularly observe that, while not always successful, acupuncture, herbal medicine, homeopathy, Bowenwork, nutrition, functional medicine and other treatments help many people with chronic psychiatric illness. Part of their successes stems from viewing psychiatric illness holistically, i.e., as a more generalized dysregulation of the mind-body system. Alternative therapies have been impugned by narrow-minded individuals who are ignorant of the extensive scientific evidence supporting their efficacy, but this can only be expected because people are sometimes fearful of giving up old paradigms that make apparent sense of the world, even if they are inaccurate. Although no panaceas, these approaches have much to offer to the spectrum of health care.
3
Nutrition and dietary changes can help a variety of problems, but acupuncture is totally unproven.
It was a mistake to think that physiological illnesses like schizophrenia could be resolved with talk therapy, and similarly, it was a mistake to believe that neurotic conditions or personality disorders, which are essentially psychological adaptations to adverse experience, are nothing more than neurotransmitter imbalances and so best treated with medication.
Now it's time to drop the bandwagon approach and recognized that neither medication nor psychotherapy are one-size-fits-all solutions.
On the clinical front, there have been some exciting developments in therapy, such as EMDR, which can have an almost miraculous effect on PTSD. These point towards new therapeutic modalities that are faster and surer in effect than traditional psychoanalysis, while retaining the ability to heal complex childhood trauma and the consequent personality disorders that are resistant to blunt instruments like drugs and exposure therapy.
Meanwhile, brain scans are both confirming and refining Freud's classic observations about the psyche, and in so doing, giving us a powerful new tool with which to judge the efficacy of various therapeutic approaches.
It's an exciting time in psychology and it would be a shame indeed if we didn't fund the research necessary to refine our understanding of non-pharmaceutical therapy, which, when appropriate, is better both for the patient and for our nation's health bill, since it can produce a cure while medication has to be taken for life.
Now it's time to drop the bandwagon approach and recognized that neither medication nor psychotherapy are one-size-fits-all solutions.
On the clinical front, there have been some exciting developments in therapy, such as EMDR, which can have an almost miraculous effect on PTSD. These point towards new therapeutic modalities that are faster and surer in effect than traditional psychoanalysis, while retaining the ability to heal complex childhood trauma and the consequent personality disorders that are resistant to blunt instruments like drugs and exposure therapy.
Meanwhile, brain scans are both confirming and refining Freud's classic observations about the psyche, and in so doing, giving us a powerful new tool with which to judge the efficacy of various therapeutic approaches.
It's an exciting time in psychology and it would be a shame indeed if we didn't fund the research necessary to refine our understanding of non-pharmaceutical therapy, which, when appropriate, is better both for the patient and for our nation's health bill, since it can produce a cure while medication has to be taken for life.
32
I concur on the amazing benefits of EMDR therapy. I have benefited extensively from undergoing it. It changed my life.
http://bcwellkamp.blogspot.com
http://bcwellkamp.blogspot.com
“Brain scans are both confirming and refining Freud’s classic observations about
the psyche..” They are? This is the first I hear of it.I would appreciate a citation or two if you have one available.I was told to forget all the psychoanalytic theory I’d been taught as an undergraduate,by the time I entered graduate school in psychology in the mid 1980s.
EMDR has no proven basis in fact.
the psyche..” They are? This is the first I hear of it.I would appreciate a citation or two if you have one available.I was told to forget all the psychoanalytic theory I’d been taught as an undergraduate,by the time I entered graduate school in psychology in the mid 1980s.
EMDR has no proven basis in fact.
Right. There are many experiences of psychological distress from mild, but painful disruption to more severe life-stopping anguish, which do not respond to any medication. Many psychological illnesses are rooted in interpersonal experiences which have included abuse, abandonment, betrayal, neglect, or indifference. Such relational dysfunction is particularly destructive to the developing child. Such scars can be healed, but it takes time and a supportive therapeutic relationship. Medications may help with symptoms, but will not fix things.
48
Exactly. What can a medication do for a woman who was raped by her father? Drug her, is all, and she'll be on the medication for life, never really resolving the trauma, suffering whatever side effects the medication has, and costing the insurance company more than a year or two of therapy would have!
23
“Costing the insurance company more than a year or two of therapy would have !” You believe that a women who has been raped by her father is going to be “cured”of her trauma in a “year or two of therapy”?A woman who has been raped by her father is probably going to need psychotherapy for many,many years.The price of lifetime supply of medication will ,in fact,be cheaper for the insurance company,if ineffective.
1
Good article.
Once we asume all mental health issues are "diseases of the brain" (ignoring the bio-psycho-social model) we will coninue to favor "brain research." And if that premise is incorrect or insufficient, we will waste much money and research time.
However, from a cognitive point of view, wenmust consider more. For example, there are some people that respond well to therapy, some to medication, some to both. While I favor psychotherapy, some people do not want to open themslves up to a stranger, or won't keep regular visits, or have limited expressive/language/intellectual skills, or can't afford therapy/have no good therapists nearby (that's a health care policy question), etc.
Also good therapy needs to be tailored to each individualized, not just from a manual/cookbook. We need research aboutt which therapy is best for client preference, too, not just based on DSM diagnosis. For example, someone with a higher "IQ" might do better with some than therapises; someone with a lower "IQ". Someone with a simple, single "diagnosis" needs something different from someone with multple diagnoses. If there is a personality disorder, this also complicates the simple research therapy. (in research it is excluded but in real life it is common).
So let's be "real" about research and not reductionistic as well. But yes, lets have more research and support for therapy (the "human" solution).
Once we asume all mental health issues are "diseases of the brain" (ignoring the bio-psycho-social model) we will coninue to favor "brain research." And if that premise is incorrect or insufficient, we will waste much money and research time.
However, from a cognitive point of view, wenmust consider more. For example, there are some people that respond well to therapy, some to medication, some to both. While I favor psychotherapy, some people do not want to open themslves up to a stranger, or won't keep regular visits, or have limited expressive/language/intellectual skills, or can't afford therapy/have no good therapists nearby (that's a health care policy question), etc.
Also good therapy needs to be tailored to each individualized, not just from a manual/cookbook. We need research aboutt which therapy is best for client preference, too, not just based on DSM diagnosis. For example, someone with a higher "IQ" might do better with some than therapises; someone with a lower "IQ". Someone with a simple, single "diagnosis" needs something different from someone with multple diagnoses. If there is a personality disorder, this also complicates the simple research therapy. (in research it is excluded but in real life it is common).
So let's be "real" about research and not reductionistic as well. But yes, lets have more research and support for therapy (the "human" solution).
19
I think it's wroth adding that while psychotherapy may seem more cost-effective than medication, there are many cases in which it isn't. The medication has to be taken for life, while psychotherapy can produce a permanent cure. It has side effects that can be costly to manage. And if a therapeutic modality is sub-optimal, there may well be other costs, e.g., suicide attempts.
That being said, one of the problems with psychotherapy is that there is a lot of endless talk therapy that resolves no serious issues. I don't know how many people I know who are, after years of psychotherapy, almost as neurotic as they were before it.
So I think we have to do a better job both of diagnosis -- the DSM lacks a unifying theoretical basis and so is basically a scratching chicken approach -- and of identifying appropriately effective therapeutic modalities. So much still depends on the judgment of the therapist, and his choice of untested or inadequately tested (e.g., CBT) techniques -- and, according to research, fo the fit between patient and therapist.
That being said, one of the problems with psychotherapy is that there is a lot of endless talk therapy that resolves no serious issues. I don't know how many people I know who are, after years of psychotherapy, almost as neurotic as they were before it.
So I think we have to do a better job both of diagnosis -- the DSM lacks a unifying theoretical basis and so is basically a scratching chicken approach -- and of identifying appropriately effective therapeutic modalities. So much still depends on the judgment of the therapist, and his choice of untested or inadequately tested (e.g., CBT) techniques -- and, according to research, fo the fit between patient and therapist.
4
C.B.T. has been tested far more extensively than nearly every other form of psychotherapy. I am baffled by your support of Freudian psychology,along with your claim that C.B.T. is “Untested or inadequately tested”when it has ,in fact,been extensively tested,and been proven to be just as effective as anti-depressant in the treatment of depression.My psychologist is a clinician, researcher,and teacher in the field of Cognitive Behavior.The director of his practice has published at least 14 books on C.B.T. and lectured nationally and internationally on C.B.T.
DJS: Psychotherapy research is a very complex field, as is all research. I agree that CBT get the "best" results and is an effective form of therapy. But there is also some "propaganda" here, as most of the research is designed to get good results. Complex cases are not included in research although are common in "real life." Follow-up rates (1-2 years later) are not consistenly high; there is often relapse. There is also s growing body of psychodynamic research that is successful. There is also NIMH research on "Interpersonal Therapy" (which in some ways resembles psychodynamics) which is highly effective for depression (and other issues).
BTW, to prove that CBT is "as effective" as anti-depressants may not be saying much.
BTW, to prove that CBT is "as effective" as anti-depressants may not be saying much.
1
Quote:
“The diseases that we treat are diseases of the brain.”
Perhaps, but I contend the diseases of depression, anxiety and PTSD are
more the "diseases that cause these issues are more the disease of pain'.
Pain that many patients are not even aware that they carry until a well guided therapist can bring out. The almost new treatment is to treat what is happening today and how to deal with it but so many have carried pain for so long that is is buried and talking about 'now' will not help. Problems of 'now' are smaller problems than the problems of the past.
I have visited more therapists that have their own problems and the closest I have come to healing is when a Social Worker, a black woman, told me I was not going to get what I needed from my parents and to move away from them and to find what I needed from a caring mate. That worked! However, the past pain still causes me periods of great depression. If I could have my brain rewired, I would be relieved but this is not going to happen, no matter how many studies are completed.
As far as antidepressants go, they do not work well and carry many unpleasant side affects. Finding a competent therapist is a burden to carry and can take a long time. Realizing I am complaining, I do not have the wherewithal to think of anything to suggest for this very painful problem.
“The diseases that we treat are diseases of the brain.”
Perhaps, but I contend the diseases of depression, anxiety and PTSD are
more the "diseases that cause these issues are more the disease of pain'.
Pain that many patients are not even aware that they carry until a well guided therapist can bring out. The almost new treatment is to treat what is happening today and how to deal with it but so many have carried pain for so long that is is buried and talking about 'now' will not help. Problems of 'now' are smaller problems than the problems of the past.
I have visited more therapists that have their own problems and the closest I have come to healing is when a Social Worker, a black woman, told me I was not going to get what I needed from my parents and to move away from them and to find what I needed from a caring mate. That worked! However, the past pain still causes me periods of great depression. If I could have my brain rewired, I would be relieved but this is not going to happen, no matter how many studies are completed.
As far as antidepressants go, they do not work well and carry many unpleasant side affects. Finding a competent therapist is a burden to carry and can take a long time. Realizing I am complaining, I do not have the wherewithal to think of anything to suggest for this very painful problem.
10
Gfaigen,
Run, don't walk, to someone who does EMDR and other techniques that can address complex childhood trauma. If the trauma occurred very early, before explicit memories formed, find someone who is trained in or specializes in the treatment of early trauma.
In the mean time, you mgiht want to read Bessel van der Kolk's The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma and Francine Schapiro's Getting Past your Past.
These new techniques really can rewire your brain, sometimes with startling speed and efficacy.
If I sound enthusiastic, it's because I am -- after 60 years of living with that pain, I've finally found something that discharges it.
Run, don't walk, to someone who does EMDR and other techniques that can address complex childhood trauma. If the trauma occurred very early, before explicit memories formed, find someone who is trained in or specializes in the treatment of early trauma.
In the mean time, you mgiht want to read Bessel van der Kolk's The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma and Francine Schapiro's Getting Past your Past.
These new techniques really can rewire your brain, sometimes with startling speed and efficacy.
If I sound enthusiastic, it's because I am -- after 60 years of living with that pain, I've finally found something that discharges it.
20
As a clinical psychologist I applaud Dr Friedman's honesty about the relative value of psychotherapy and psychotropic drugs. Part of the problem with psychotherapy research is that the gold standard of the randomized double blind study is difficult or impossible to meet for psychotherapy. How could a psychotherapist be blind to which method he is using to treat the patient? The most common standards for psychotherapy research have produced questionable results. The studies mostly look only at patients with one clear diagnosis, while people who actually seek therapy come with complex, inter related problems. The studies artificially limit the number of treatments, a reason the insurance companies love these simplistic studies. More subtle meta analyses have shown that psychodynamic or psychoanalytic treatment is more effective over the long term than cognitive behavioral therapy or medication. Those are results the insurance companies don't want to hear. Research funders need to grasp that the important psychotherapy research that needs to be done can't look at all like the research that is done in neuroscience or particle physics. This will take a profound change in attitudes about the nature of scientific research.
58
Agreed except that I don't think it has to depart (or should depart) from the principles of sound scientific research, which are grounded in the logically rigorous testing of falsifiable hypotheses, and as such are essentially immutable.
Perhaps the problem is that some see scientific research in unrealistically limited terms. Darwin didn't demonstrate evolution in a test tube. He made numerous field observations and used them to demonstrate, with great efficacy, the soundness of a hypothesis, evolution through natural selection. The sheer wealth of his observations and the observations that came after statistically overwhelmed the confounding variables that are inherent in the observation of complex phenomena. The stochastic validity of this process is perhaps a bit harder to intuit than that of a controlled experiment on a simple phenomenon, but at the same time, it is essential if scientific rigor is to be maintained.
Perhaps the problem is that some see scientific research in unrealistically limited terms. Darwin didn't demonstrate evolution in a test tube. He made numerous field observations and used them to demonstrate, with great efficacy, the soundness of a hypothesis, evolution through natural selection. The sheer wealth of his observations and the observations that came after statistically overwhelmed the confounding variables that are inherent in the observation of complex phenomena. The stochastic validity of this process is perhaps a bit harder to intuit than that of a controlled experiment on a simple phenomenon, but at the same time, it is essential if scientific rigor is to be maintained.
2
Once upon a time the randomized double blind study was not yet the gold standard. When the idea became accepted in medicine it became widely used.
There are many other ways to compare the effects of treatment. For many established interests, sticking to the old way even after it is against all reason, is the mode of operation.
A profound change in attitudes is needed. Hopefully the advances in computing and probabilistic statistics will come to help within the next twenty years. It is sad that it seems to take about 50 years to make improvements.
Forty-one years ago when I studied advance math in high school in Silicon Valley I could not guess that things progress this slow. At the heart of science is not the knowledge but the sociology of knowledge.
There are many other ways to compare the effects of treatment. For many established interests, sticking to the old way even after it is against all reason, is the mode of operation.
A profound change in attitudes is needed. Hopefully the advances in computing and probabilistic statistics will come to help within the next twenty years. It is sad that it seems to take about 50 years to make improvements.
Forty-one years ago when I studied advance math in high school in Silicon Valley I could not guess that things progress this slow. At the heart of science is not the knowledge but the sociology of knowledge.
2
Randomized double blind trials may be difficult (as they are for any treatment) but they are certainly not impossible and are used all the time in psychotherapy research. Just as in drug research, these studies have "placebo" treatments that are used as the comparison to the treatment being tested. The person rating the subject's treatment response is blinded to the condition and does not know which group the individual is in.
My husband, Dr. Frank Ochberg, has been treating PTSD patients with combinations of 'talk therapy' and psychotropic medications (where appropriate) for decades with nearly universally positive results. Unfortunately, he is now 75 and still receiving calls daily with requests for treatment, especially from veterans, but also from many victims of a horrible variety of abuses. His eclectic approach is customized for each individual but without a substantial investment in basic psychotherapy research, his and other dedicated psychiatrists' marvelous helping techniques will be lost with their deaths. My husband simply has no time to do research, publish, or teach when so many sufferers demand and receive his attentions daily.
86
I don't mean my suggestion to be a facile solution at all. Perhaps finding someone added to your team to secure funding then to assemble the case data of your husband's lifetime body of work might create a way for his work to speak not just for those he has treated but also make that body of work a legacy he offers the future. Perhaps a phd candidate who can make the project their doctoral thesis? Surely there are a good number of future professionals who would be honored to have the chance of such a project. It is also just the kind of spontaneous experiment that collectively meets the kind of research this column contemplates. Maybe contact Friedman or the researcher he mentions, Dr. John C. Markowitz if not your local university. It sounds like you are a bit beleagured by the enormity of the need. Doing so might also be the balm you husband needs approaching the end of his career and the way for him to hand some of his experience to a few lucky enough to have the chance to work with him.
3
Yes I agree: interpersonal therapy is important but it's wholesale abandonment is entirely understandable, and in my opinion symptomatic of the weakens of its own philosophical origins.
I do not think that Freud's ideas have much more to contribute to contemporary mental health treatment, but it is not exactly as if psychotherapists are doing much to modernise their own approach either.
How about writing a slightly more daring article, about the need to create a scientifically valid and truly modern psychotherapeutic approach? I am taking about one that draws from a much deeper body of philosophy than psychoanalysis. I think you will find that such an approach, while entirely reasonable, would be not especially politically pragmatic from the perspective of the fields professional stakeholders. And thus: psychotherapy sows the seeds of its own destruction.
I do not think that Freud's ideas have much more to contribute to contemporary mental health treatment, but it is not exactly as if psychotherapists are doing much to modernise their own approach either.
How about writing a slightly more daring article, about the need to create a scientifically valid and truly modern psychotherapeutic approach? I am taking about one that draws from a much deeper body of philosophy than psychoanalysis. I think you will find that such an approach, while entirely reasonable, would be not especially politically pragmatic from the perspective of the fields professional stakeholders. And thus: psychotherapy sows the seeds of its own destruction.
4
I'd have to disagree about Freud. While he wrote 100 years ago and made his share of mistakes, his basic psychodynamic model of the mind is still sound and functional, and his therapeutic approaches are still a big part of what we do today. Brain imaging has actually reinforced the validity of his best work -- we can now literally see, in broad outline but with more detail than he could, much of the interplay between instinct and drive and ego.
Also, often, lesser lights in psychology have touted theories that are a sadly superficial compared to what Freud intuited in the 19th century!
That being said, we *are* moving to the more modern therapeutic approaches of which you speak. While some of what has been done is risible, e.g., CBT, most therapists today use an eclectic approach that uses a mix of techniques as appropriate, and there have been exciting new therapeutic developments in the discharge of trauma, from some of which I've benefited personally.
I do hope we'll start to put things on a sounder scientific basis. Dr. Markowitz's study is precisely the kind of work that we need, not just to identify the overall effectiveness of therapeutic modalities but also to better identify which approaches are most effective for which people, and to obtain a more rigorous understanding of the interplay between early experience and genetic and epigenetic traits and symptoms later in life.
Also, often, lesser lights in psychology have touted theories that are a sadly superficial compared to what Freud intuited in the 19th century!
That being said, we *are* moving to the more modern therapeutic approaches of which you speak. While some of what has been done is risible, e.g., CBT, most therapists today use an eclectic approach that uses a mix of techniques as appropriate, and there have been exciting new therapeutic developments in the discharge of trauma, from some of which I've benefited personally.
I do hope we'll start to put things on a sounder scientific basis. Dr. Markowitz's study is precisely the kind of work that we need, not just to identify the overall effectiveness of therapeutic modalities but also to better identify which approaches are most effective for which people, and to obtain a more rigorous understanding of the interplay between early experience and genetic and epigenetic traits and symptoms later in life.
1
It exists, it's called cognitive behavioral therapy.
1
Josh: I see you're very active on this comment page, so I'm hoping to understand something. I agree with you about the way much if not most of CBT is done - but I wonder if you're familiar with the way CBT is done in connection with mindfulness and experientially oriented therapy. I know compassionate therapists who combine cognitive approaches with EMDR and mindfulness, in the context of improving interpersonal functioning (using psychodynamic approaches in some cases) and who get wonderful results. I wonder if you would reject CBT altogether or consider it possibly useful in this larger context?
1
How about giving psychedelics another try? We threw the baby out with the bathwater in the 1960s. Psychedelics were promising medicines for a variety of psychiatric conditions. Now, save for a few trials, research is essentially banned.
9
Yes. But I think you are too pessimistic, Kyle. The trials that are happening are getting very good results, and increasing intention. As I noted above, no less than Thomas Insell, who I expect is a pretty conservative fellow (having gotten the the head of the NIMH) seems to have become enthusiastic about MDMA--not a true psychedelic, but certainly in the ballpark.
This was meant as a reply but I mistakenly posted it elsewhere earlier:
Yes. But I think you are too pessimistic, Kyle. The trials that are happening are getting very good results, and increasing intention. As I noted above, no less than Thomas Insell, who I expect is a pretty conservative fellow (having gotten to the head of the NIMH) seems to have become enthusiastic about MDMA--not a true psychedelic, but certainly in the ballpark.
Yes. But I think you are too pessimistic, Kyle. The trials that are happening are getting very good results, and increasing intention. As I noted above, no less than Thomas Insell, who I expect is a pretty conservative fellow (having gotten to the head of the NIMH) seems to have become enthusiastic about MDMA--not a true psychedelic, but certainly in the ballpark.
I do think that the turn against Freudianism in the U.S. goes a long way to explain the lack of support for psychoanalysis. My understanding is that in Europe and the UK, this is not the case--a British publisher is issuing new translations of Freud's works, for example.
Kind of odd, considering how much Americans like to expose their neuroses in public.
Kind of odd, considering how much Americans like to expose their neuroses in public.
8
LOL
Well, Freud is an example of something we all use, even as we dismiss him. I mean, how many people don't use concepts like the unconscious mind? Freud has become so much a part of our basic understanding that we use his insights even as we dismiss them.
Often, we just invent new names for the same old thing -- the DSM, in particular, was a renaming orgy, neurosis becoming personality disorder, etc. And effective new protocols can actually be refinements of phenomena that have been known since antiquity. they just have different names attached to them.
That being said, i think the main force behind the abandonment of psychotherapy has been the insurance industry, which doesn't want to pay for it. Pills are cheaper. So they took to heart the theories of overenthusiastic biologists who thought that because neurotransmitter imbalances occur in *psychosis,* they must be primarily to blame in neurotic conditions as well. And they fell in love with CBT, an overly simplistic model and therapeutic modality that was bolstered by shoddy research, again, because it was cheap.
That's America in a nutshell -- in love with quick fixes and intellectual fads, and obsessed with the bottom line.
At the same time, psychoanalysis deserves part of the blame for too often treating Freud as a religion, or else setting up competing schools without a scientific basis. Good work gets done, but without rigorous studies like Dr. Markowitz's it's hard to know which techniques are best.
Well, Freud is an example of something we all use, even as we dismiss him. I mean, how many people don't use concepts like the unconscious mind? Freud has become so much a part of our basic understanding that we use his insights even as we dismiss them.
Often, we just invent new names for the same old thing -- the DSM, in particular, was a renaming orgy, neurosis becoming personality disorder, etc. And effective new protocols can actually be refinements of phenomena that have been known since antiquity. they just have different names attached to them.
That being said, i think the main force behind the abandonment of psychotherapy has been the insurance industry, which doesn't want to pay for it. Pills are cheaper. So they took to heart the theories of overenthusiastic biologists who thought that because neurotransmitter imbalances occur in *psychosis,* they must be primarily to blame in neurotic conditions as well. And they fell in love with CBT, an overly simplistic model and therapeutic modality that was bolstered by shoddy research, again, because it was cheap.
That's America in a nutshell -- in love with quick fixes and intellectual fads, and obsessed with the bottom line.
At the same time, psychoanalysis deserves part of the blame for too often treating Freud as a religion, or else setting up competing schools without a scientific basis. Good work gets done, but without rigorous studies like Dr. Markowitz's it's hard to know which techniques are best.
7
Psychoanalysis and psychotherapy are not one and the same.There are plenty of clinicians in the United State who believe in psychotherapy, The term neurosis is no longer commonly used,as it is Freudian term to which most no longer subscribe.
Wow.You are entranced by with Freud and Freudian theory.
"How may people don’t use concepts like the unconscious mind?”
Everyone I know.including all the mental health professionals I know.
Shoddy research bolstering C.B.T. ? I suppose there is no reasoning with you.
You’re convinced that Freud had all the answers,and of any number of things
which have no basis in evidence.
"How may people don’t use concepts like the unconscious mind?”
Everyone I know.including all the mental health professionals I know.
Shoddy research bolstering C.B.T. ? I suppose there is no reasoning with you.
You’re convinced that Freud had all the answers,and of any number of things
which have no basis in evidence.
Thank you Dr. Friedman. It is a pleasure to hear a psychiatrist advocate for increased funding for psychotherapy. You made excellent points. I fear, however, there is still a bias toward biological treatment. That, despite research showing the effectiveness of psychotherapy, the bias remains toward "medical model" solutions. I have benefited from receiving psychotherapy and after extensive training and education, I now provide psychotherapy. I have seen and felt its efficacy. I am encouraged to read that research has shown interpersonal therapy to be as good as, or better than exposure for PTSD. I have always been against the idea of making people re-live their trauma in order to reduce their problematic symptoms. This is just one example of the good that can come from increased psychotherapy research. Thank you very much for your informative and helpful article.
26
It is heartening to see a psychiatrist (and psychopharmachologist, no less) writing in favor of psychotherapy, and admitting that drugs have little or no advantage over talking cures, at a time when drugs are so clearly the frontline treatment, and wrongly so. Many psychiatrists seem still to be stuck in the brain chemistry paradigm, and of course the public remains wrongly "educated" by the pharmaceutical companies that depression is a "chemical imbalance"--a theory that never had much empirical support and now is pretty much dead.
One thing I would add is that psych drugs also produce fairly serious side effects, such as weight gain, loss of libido, flattened emotion, dependency--withdrawal can be an excrutiating process that takes months and even years--and in rare but important cases, aggression and suicide. There is also very promising work being done with drugs, most notably MDMA, which are taken only occasionally in conjunction with psychotherapeutic sessions. MDMA is showing remarkable promise in patients with treatment resistant PTSD becuase it dampens down fear responses while allowing continued mental processing and remarkable healing of traumatic events. Thomas Insel, director of NIMH, has recently said that “It’s a really interesting and a very powerful new approach. It’s not just taking MDMA. It’s taking it in the context of a treatment that involves improved insight and increased skills and using this in the broader context of psychotherapy.”
One thing I would add is that psych drugs also produce fairly serious side effects, such as weight gain, loss of libido, flattened emotion, dependency--withdrawal can be an excrutiating process that takes months and even years--and in rare but important cases, aggression and suicide. There is also very promising work being done with drugs, most notably MDMA, which are taken only occasionally in conjunction with psychotherapeutic sessions. MDMA is showing remarkable promise in patients with treatment resistant PTSD becuase it dampens down fear responses while allowing continued mental processing and remarkable healing of traumatic events. Thomas Insel, director of NIMH, has recently said that “It’s a really interesting and a very powerful new approach. It’s not just taking MDMA. It’s taking it in the context of a treatment that involves improved insight and increased skills and using this in the broader context of psychotherapy.”
14
I think many psychiatrists would agree with Dr. Friedman. However, in real world practice psychiatrists are under enormous pressures to produce. Medicine is part of capitalism. As a practitioner, if you do not get with the program, prescribing drugs, you are eventually out the door. One issue is that patients do not present with one disorder. Anxiety is the most common psychiatric disorder. If one is born with a genetic vulnerability to anxiety. A small seed of a problem could get go down a number of paths as the individual matures. If they have certain small adverse environmental experiences, or grow up in a less protective environment, something as small as going to an average primary school, could be an adverse emotional experience. People who are anxious tend to be quiet. Their anxiety and it's limitations are easily over-looked and they fall between the cracks. As one gets older the anxious young person now has to deal with increasing demands with limited coping strategies. If one is anxious long enough their is a good chance they will become depressed, or abuse drugs or both. Now you have a very malleable young nervous brain which gets hard wired in some respects to ways of dealing with everyday problems. The issue is larger than psychotherapy versus medication The answer involves both treating the individuals ecosystem multifactorial way and our also the pressures our society which emphasizes increasing consumption to fuel the economy places on parents, etc.
3
And what about the Wolfsmann? A patient Freud treated for almost five years on a daily basis, claimed was completely cured, but when tracked down in the 1970s by medical researchers said he had not benefited at all from Freud or any of the myriad other psychotherapists who had treated him (although he liked and admired Freud, and following Freud's advice inadvertently lost him his fortune).
By many indications he might have been bipolar and thus largely impervious to talk therapy, but who beside Emil Kraepelin knew that then? And how much more do we really know now?
By many indications he might have been bipolar and thus largely impervious to talk therapy, but who beside Emil Kraepelin knew that then? And how much more do we really know now?
2
Well, one of the things we *do* know now is that the psychoses are medical conditions and so cannot be cured by talk therapy (although talk therapy can be beneficial for those who are afflicted).
I've long believed that it was time to recognize that distinction and stop speaking of neurosis, however severe, as illness. Because while neurotic conditions are influenced by genetics and epigenetics -- that's something else we know now too -- they are basically normal responses to adverse circumstance, such as childhood abuse and neglect, or trauma such as being sent to war.
But look at what we can do now! We don't yet understand the cause of most psychoses (we do understand that it can be caused by for example syphilis and vitamin deficiency), but we do know that neuotransmitters are involved and we can treat them with some success using antipsychotics, antidepressants, lithium. So we are way ahead of Freud there.
Similarly, we have some psychotherapeutic techniques now that Freud didn't, and a deeper understanding of the psyche, informed by brain scans and other forms of research.
It has to be remembered that Freud, for all his genius and the insights that are now as basic to our thought as Newton's gravity, worked a century ago and was learning as he went, based on his own clinical observations. We have learned something since, despite the tendency of some lesser lights in the field to discard what Freud already knew in favor of overly simplistic models.
I've long believed that it was time to recognize that distinction and stop speaking of neurosis, however severe, as illness. Because while neurotic conditions are influenced by genetics and epigenetics -- that's something else we know now too -- they are basically normal responses to adverse circumstance, such as childhood abuse and neglect, or trauma such as being sent to war.
But look at what we can do now! We don't yet understand the cause of most psychoses (we do understand that it can be caused by for example syphilis and vitamin deficiency), but we do know that neuotransmitters are involved and we can treat them with some success using antipsychotics, antidepressants, lithium. So we are way ahead of Freud there.
Similarly, we have some psychotherapeutic techniques now that Freud didn't, and a deeper understanding of the psyche, informed by brain scans and other forms of research.
It has to be remembered that Freud, for all his genius and the insights that are now as basic to our thought as Newton's gravity, worked a century ago and was learning as he went, based on his own clinical observations. We have learned something since, despite the tendency of some lesser lights in the field to discard what Freud already knew in favor of overly simplistic models.
6
Not one mention of Sigmund Freud?
Is he the Man now to avoid?
Out of sight, out of mind,
And left far far behind,
Who once veneration enjoyed?
Is he the Man now to avoid?
Out of sight, out of mind,
And left far far behind,
Who once veneration enjoyed?
11
While I respect Freud's immense contributions, I see no reason why he needed to be included in this article. Were you merely looking for a reason to post your poem?
14
Larry, wonderful poem as usual. Freud really has a minimal place in psychiatry. He may be the father of psychoanalysis and his theories on an array of topics could fill a social science course. He himself was a neurologist. While psychiatrists and some neurologists study Freud, relying on his findings is like a physicist relying on the findings of Aristotle. Certainly Newton and Einstein have a greater place in physics. Certainly Bleuler, Kandel, Pinel, Charcot, Spitzer, Kraepelin and Itard have a closer relationship to psychiatry than Freud. Maybe you should look up these great physicians of yore.
I mentioned Freud.
He is from the past.
He is not someone to avoid.
But in psychiatry he is somewhat miscast.
He was one of the greats, but I know not of what.
I mentioned Freud.
He is from the past.
He is not someone to avoid.
But in psychiatry he is somewhat miscast.
He was one of the greats, but I know not of what.
5
Ariff, I think your comment is way off base. No clinical psychologist I know doesn't give Freud primacy of place. Yes, his work was done 100 years ago, but the concepts he introduced, and the very concept of talk therapy, still underlie much of what we know and do.
Furthermore, modern brain research has shown that the mind is organized along lines that are very like what Freud miraculously intuited from a few neurotic patients 100 years ago.
Freud spoke of the id, we speak of the paleomammalian brain. He spoke of the pleasure principle, we speak of dopamine receptors.
Do you not see Freud's genius in intuiting such things from talking to a few Viennese women with hysteria? Or how fundamental his insights are to the way we think about the human mind, both in practice and in therapy?
Freud's insights still retain enormous utility and are still the basis of what we do, even when, as is often the case, they are called by new and different names.
Furthermore, modern brain research has shown that the mind is organized along lines that are very like what Freud miraculously intuited from a few neurotic patients 100 years ago.
Freud spoke of the id, we speak of the paleomammalian brain. He spoke of the pleasure principle, we speak of dopamine receptors.
Do you not see Freud's genius in intuiting such things from talking to a few Viennese women with hysteria? Or how fundamental his insights are to the way we think about the human mind, both in practice and in therapy?
Freud's insights still retain enormous utility and are still the basis of what we do, even when, as is often the case, they are called by new and different names.
13