nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Wednesday, August 4, 2010

A Life Constructed Through Psychotherapy. This Is Healing?

A life-long therapy patient asks whether treatment goals are being met, or has she just constructed a life in therapy.

The NY Times Magazine has an article written by a person who underwent various forms of psychotherapy over four decades (wow!).  At the end of it all, she questions the benefit:
"To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office. What I do know, aside from the fact that the unconscious plays strange tricks and that the past stalks the present in ways we can’t begin to imagine, is a certain language, a certain style of thinking that, in its capacity for reframing your life story, becomes — how should I put this? — addictive. Projection. Repression. Acting out. Defenses. Secondary compensation. Transference. Even in these quick-fix, medicated times, when people are more likely to look to Wellbutrin and life coaches than to the mystique-surrounded, intangible promise of psychoanalysis, these words speak to me with all the charged power of poetry, scattering light into opaque depths, interpreting that which lies beneath awareness. Whether they do so rightly or wrongly is almost beside the point."
I've written about our tendency to medicalize everything: making a disease out of being shy (social phobia disorder), conferring the diagnosis of PTSD on someone who saw an auto accident.

This person's experience seems the psychological version of that.  To my mind, psychotherapy or analysis should be undertaken with a defined goal, and a projected duration.  It should be just like attempting treatment for high blood pressure; if you prescribe a medicine and measure the impact in reducing blood pressure to normal levels over a 3 month period, and there has been no improvement...then you move on to something else.  Too often psychotherapy has no endgame, no termination criteria short of decease.

I'm reminded of how we used to treat soldiers who became unable to cope due to the stress of combat.  Up to and into the Vietnam war, these were often permanent casualties who left the war, and were often crippled by guilt and recrimination for years afterward.  Also, the more of them there were, the greater impact on combat effectiveness.

It was realized that these were not "abnormal" people, but individuals who had been placed in situations for which they were unprepared.  Military psychiatrists focused on developing strategies that would restore their confidence and allow a normal impulse to heal.  In the end, these soldiers were taken out of the line and given intensive treatment for just a few days.  Key to the success was instill in them the fact that their reaction was not unexpected, and, most important of all, emphasizing to them from the beginning that they would be returning to the fight soon and that their buddies relied of them and needed them.

There were treatment failures, but it was surprising how many could heal and return to duty...and not come back.  Most were able to experience that same stress again and adapt.

Combat is an extreme example.  But, still, maybe there's a lesson for us here:  that humans can adapt and recover if the therapy is structured in such a way that they can soon succeed on their own.

Admittedly, for some disorders--schizophrenia, and the like--a life in therapy (including drugs) may be necessary and preferable to how patients with these disorders were handled in the past:  packed away in state mental hospitals for life.  But the number of patients with serious psychoses is very small compared to the total with chronic depression and anxiety, for which a defined goal  and duration could be set, supporting healing strategies rather than just deeper insight and buzzword correlations.

We have a saying among us non-psychological docs:  wounds will heal, if you don't pick at the scab.

Doc D


evilrobotxoxo said...

I agree, the article is basically an indictment of old-school, psychoanalytic psychotherapy. One problem, however, is that it did not distinguish between those old, less evidence-based psychotherapies, and newer evidence-based therapies such as CBT. Newer therapies (as in after the 1960s) are undertaken with specific goals and projected duration.

I do take issue with your suggestion that diagnoses like social anxiety disorder or PTSD are somehow not legitimate. Untreated social phobia is not just shyness, it's a crippling anxiety disorder that can ruin people's lives. Likewise, PTSD destroys lives, and the severity of the PTSD is correlated with the severity of the trauma, but not absolutely. There is a subpopulation of patients who can have terrible PTSD from something like witnessing a car accident, but the evidence shows that most of those people have a history of more severe psychological trauma early in life, which predisposes them later on.

It always bothers me when I see other physicians engaging in subtle psychiatry bashing because the vast majority of non-psychiatrist physicians don't realize how sick psychiatric outpatients can be, given that most or all of their clinical exposure was in the inpatient setting.

Doc D said...

Again thanks for commenting. We disagree more here. I have seen patients labeled with these diagnoses who do not meet diagnostic criteria. You probably have, too. Most were not made by reputable experts and psychiatrists (so, I apologize if it sounded like I was singling out psychiatry). That's not denying that there are people disabled and suffering greatly with these symptom complexes.

I believe the old saying that whatever you subsidize you will get more of. Give something a name, provide insurance coverage, the definition broadens, and the incidence skyrockets. We saw this with ADHD, and we're seeing it with PTSD and SAD. It's a cultural and social phenomenon. It's just too easy to give a label, and there are helpers standing by to treat adjustment reactions that have a new face.

I'm not a psychiatrist. My perspective is prev med/pub hlth. I think its cultural change that explains the epidemiology, not that there are large reservoirs of unrecognized disease.

Again, good discussion.

evilrobotxoxo said...

I don't disagree that overdiagnosis happens sometimes, and you bring up an important point about how most psychiatry is not done by psychiatrists, but by primary care practitioners.

I think the real underlying issue is the idea that traits that fall on a spectrum are forced into the black and white concept of "diagnosis," which is a concept that really only applies to infectious disease or cancer. You either have syphilis or you don't, but disorders of human physiology are almost never binary, even outside psychiatry (e.g. hypertension, diabetes, etc.). I have certainly diagnosed people with things like SAD when they might not fit formal criteria, as long as sufficient functional impairment is there to warrant treatment. We treat the patient, not the diagnosis, but we have to label them for billing purposes. More often you get people who have a mix of GAD, SAD, and panic disorder, for example, and you're not sure what to call them, so you pick the most prominent one. I can't speak for other fields of medicine, but in psychiatry in particular, I do think there are large reservoirs of unrecognized disease out in the community. Just look at the homeless population. This is not to say that there aren't a bunch of Park avenue shrinks treating the worried well for $500/hr.

Another separate point is that a lot of anxiety disorders get worse under times of stress or depression, so there are lots of people who might meet criteria in 2009, but not come close to meeting criteria in 2010. Or they meet criteria when they're off their meds, but they don't when they're medicated. Or they no longer meet criteria after therapy. Anxiety disorders, in particular, can be highly treatable.

Doc D said...

While I see it a little different, I like your concept that we force gradations into a dichotomy.

Break, subject. I recently started writing for Science-Based Medicine. My stuff there is less opinion and more science than this blog.

Anyway, David Gorski posted on the tai chi NEJM article today, c.f. if you're interested. He offers a more extended critique, but you'll see similarities.

Enjoyed it.

Doc D said...

Disregard. I saw your comment.

evilrobotxoxo said...

I will also be submitting an article for SBM on a trial basis, on ketamine for depression and other novel pharmacological targets.

You might enjoy this article, on the topic of diagnosis:

I enjoyed it as well.

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