Dieticians make the best psychotherapists

Dieticians make the best psychotherapists. Maybe so or maybe not. I was hoping the headline would grab attention.

You can file this post under the complaining, groaning, bitching and moaning category. I suspect that all professionals feel that their own profession gets badly treated by the media. I have thought about this in terms of psychotherapy in movies and TV shows and plan to write some things about this in the future. Do you have any suggestions about either good or bad portrayals of psychotherapy?

Today, the case to be examined is an article from March in the Pittsburgh Business Times. It is a little article, just three paragraphs, reporting, I believe, from a press release about some research being done here in Pittsburgh.

Study: Diet discussion as good as talk therapy

The opening sentence of this little three paragraph ditty goes as follows:

Discussions about healthy eating with a dietary professional were as effective as meeting with a counselor in preventing major depression among adults with mild symptoms of the mood disorder, Pitt researchers found.

This sounds rather bad for “counselors”, doesn’t it? In fact, there are some interesting findings in the psychotherapy outcome research that seem counter intuitive. For example, years of experience does not correlate with better outcomes. So maybe this fits into that somehow, no experience being as good as any experience?

There is a problem however. I only discovered this problem by tracking down the press release.

The press release headline reads:

Lifestyle interventions can prevent major depression in adults with mild symptoms

Okay, the headline is not as sensational as the one in the Pittsburgh Business Times. What does it actually say?

The team assessed whether problem-solving therapy for primary care (PST-PC), a scientifically proven seven-step approach delivered by non-mental-health professionals to help patients resolve difficulties and thus improve coping skills and confidence, could prevent elderly adults who have mild symptoms of depression from developing full-blown disease. Instead of comparing the PST-PC participants to those who received “usual care,” which would most likely mean receiving no intervention, the team took the novel approach of comparing the PST-PC group to participants who underwent a program of dietary coaching at a similar visit interval for the same number of hours.

I added the bold above, of course.

Reading the excerpt from the Pittsburgh Business Times, I assumed the “counselor” was a mental health professional, didn’t you? We don’t know what the researchers would have found if the comparison had been with a psychotherapist. As is, this little blurb just is one small way in which psychotherapy is degraded in our culture.

The other bummer about this is that this was a great study. My favorite parts of the study were not reported in the Pittsburgh Business Times. The researchers actively sought out lower income and African American subjects. They involved community leaders in doing this and the services were delivered in non-traditional settings such as homes and community settings, and medication was not prescribed.

The press release quotes co-investigators, Sandra Quinn and Stephen Thomas:

Because racial minorities are at greater risk for depression, in part due to socioeconomic disadvantages, lower educational attainment and a greater likelihood of other medical problems, we established a foundation of trust working through churches and community-based organizations in black communities,” said Dr. Quinn. Of the 244 participants, 90, or more than a third, were African-American.

“This project tells us that interventions in which people actively engage in managing their own life problems, such as financial or health issues, tend to have a positive effect on well-being and a protective effect against the onset of depression.”
“We suspect we had a higher than usual proportion of black participants because community leaders championed the project, no medication was prescribed, and treatment could be delivered at home or at other non-clinical settings,” said Dr. Thomas. “Lifestyle interventions, such as dietary coaching, may be more culturally appropriate and acceptable in racial-ethnic minority communities.”

In a new project, the researchers will examine whether PST-PC can be effectively administered by lay health counselors in low- and middle-income countries such as India.

As someone who has worked with disenfranchised people and in unconventional settings for much of my career, the findings of this study are not surprising. What would be a pleasant surprise would be to see this study used to develop properly funded programs to reach these folks. It would certainly be cost effective and well worth the efforts. I am not holding my breath.

In the meantime, why couldn’t the headline have been and the article reported:

Lifestyle interventions and problem solving prevents depression in the elderly without use of medications.

I remain a hopeful dreamer.

Marbles

 Marbles: Mania, Depression, Michelangelo & Me is a graphic memoir written and drawn by Ellen Forney. It is a brilliant depiction, from the inside, of the experience of being diagnosed, treated for and dealing with the symptoms of BiPolar Disorder. I do want to take a moment and say that while I liked “comic books” as a kid, my current love of “graphic novels” and now “graphic memoirs” can be blamed directly on Joe Roberts, who pointed me to “Watchmen”, “Sandman” and “V for Vendetta”.

 I highly recommend this graphic memoir to anyone who is struggling with this problem, who knows anyone struggling with this problem, those treating people dealing with depression and mania or folks that like a good story. This review will be reading and viewing this through my psychotherapist’s eyes.

 Marbles is a memoir specific to Ellen’s diagnosis of Type 1 Bipolar Disorder. She starts as she is diagnosed and continues through her finding of relative balance and stability. She carries us through many interactions with her psychiatrist, her family and friends, her symptoms of mania and depression and fears about medications and their possibly changing her creativity.

 I want to tell you about some of the things I loved about this book.

 At numerous points during the story, Ellen portrays her sessions with her psychiatrist, Karen. I include the beginning of the first of these below. I do appreciate the psychiatrist going through the diagnosis straight from the DSM. I think this can demystify the diagnosis. I have done this numerous times. Ellen’s deflated feeling when categorized is something I need to be more sensitive about with folks I am working with in the future. Ellen has to choose what to share with Karen, omits important stuff at times, is relieved when she can escape answering certain questions (and avoid that choice of whether to be honest). She does sometimes call Karen on when she says things that don’t add up. I have often told people I am training or supervising that being a psychotherapist sanctions our behaving inappropriately, asking intrusive, impertinent questions and commenting on the behaviors of the people we are conversing with. I like to remember that when we do not get a straight answer, that may be what our client needs to do at that moment. I have never seen these therapist/patient interactions better portrayed than here.

 beginning cr

Medications are central to this story. The psychiatrist focuses on this but not exclusively. To her credit, she is never reported to have uttered the phrase “you have a chemical imbalance”. Ellen does a great job depicting her ambivalence toward medications, even when they seem to be helping. Weighing the pros and cons of side effects is shown. Figuring out the meds is shown to be trial and error. This can be agonizing and is shown as such. Her story about not being able to have an orgasm after starting Tegretol is quite funny. Ellen goes into great detail about the different meds and the hoped for pros, possible side effects and her own personal experiences while taking them. Again, this shows what I have seen many times. Ellen’s experiences with side effects are portrayed in a fair amount of detail.

side effects cr

 

Her story about her medications fits quite well into the story that Joanna Moncrieff tells about the history of psychiatric medications in her book, The Myth of the Chemical Cure. Moncrieff critiques the idea that psychiatric meds have specific actions that act on a specific brain/chemical disease (the Disease-Centered Model). Ellen’s detailed descriptions of her experiences of the medications make more sense seen through the lens of Moncrieff’s Drug-Centered Model. The basic idea is that the drug’s effects interfere with symptoms without having anything to do with the actual causes of the symptoms. I plan to write in some detail about Moncrieff’s work on this. If you are interested, stay tuned.

 

 Ellen’s artistic depictions of her experiences of depression and mania give me the feeling of, at least, getting some of what it was like. Her relationships with her symptoms are fascinating. Once she has been diagnosed, her experiences take on new meanings. Her vigilance in trying to know if some experience means she is ready for a high or a low is important. Some of her portrayals are heart wrenching.

slipping

Ellen and her psychiatrist do emphasize important things besides medications. This includes support from family and friends, self monitoring, activities (swimming and yoga for Ellen) and being actively involved in her own treatment. For me, Ellen represents the ideal client. She researches her diagnosis, actively engages in weighing the pros and cons of her experiences (symptoms?), she tries things she doesn’t really want to do at the suggestion of Karen, perseveres and is appreciative. She tries things on her own that she “shouldn’t” be doing, then evaluates their effects. I do hope those reading her book see the importance of all of these pieces rather than this being the story of a woman who found the right combination of medications.

Ellen does not directly say anything about placebo effects of the medications. The last example of her work that I will share here captures this so well that I wanted to include it:

 

tegretalPlacebo effects happen when we “Imbue with all of our hopes and dreams”. The effects are real, because our hopes and dreams are powerful.

The Michelangelo part of the book is important, examining the connections between madness and creativity. The story she tells has nuance and is likely to be helpful to others in making sense of these questions.

One caveat regarding Marbles is that I am unaware of any psychiatrist that actually does any form of psychotherapy anymore. While Ellen does not say so explicitly, her session must be more than med checks. All I know about these days that psychiatrists do 15 minute med checks and the use of the only tool they know, and they seem to use it to pound that nail relentlessly. I am sure there are exceptions and I wish I had some stories to share about them.

Marbles works on so many levels. Informative; honest; funny; heart-wrenching; artistically engaging; creative. I would use it as a primary text if I were teaching a psychotherapy class. Have you read it?

 

Valis

Phillip K. Dick’s novel Valis is a wacky and wild ride. I recommend it though it certainly isn’t for everyone. However, this is not a review but rather an appropriation of scenes in the book that illustrate what I consider a point central to doing psychotherapy. It s creatively based upon PKD’s actual experiences.

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The book begins thus:

“Horselover Fat’s nervous breakdown began the day he got the phone call from Gloria asking if he had any Nembutals. He asked her why she wanted them and she said that she intended to kill herself”.

Themes of mental illness, suicide and depression are right there at the start.

When Horselover Fat makes his own “spectacular suicide attempt”, he ends up in an inpatient psych unit. His experiences are described in the fourth and beginning of the fifth chapters of Valis. If I had my way, these chapters would be required reading for all mental health practitioners. His descriptions of his experiences on the ward are brilliant, hilarious and ring true (from my perspective as an outsider practitioner who has tried to still listen to the people that end up on the units).

Eventually, Fat has an interview with his psychiatrist, Doctor Stone. Early in the meeting,

“He could see that Dr. Stone was totally crazy, but in a good way. Dr. Stone was the first person at the North Ward, outside the patients, who had talked to him as if he were human”.

Dr. Stone reads him a passage out of the Tao Te Ching. They then begin a mad conversation in which Fat goes into some detail about his esoteric, labyrinthine Gnostic and other theories.

““I am very interested in what you are saying”, Dr. Stone said.
Fat realized that one of two possibilities existed and only two; either Dr. Stone was totally insane – not just insane but totally so – or else in an artful, professional fashion he had gotten Fat to talk; he had drawn Fat out and now knew that Fat was totally insane. Which meant that Fat could look forward to a court appearance and ninety days.

This is a mournful discovery.

1.Those who agree with you are insane.
2.Those who do not agree with you are in power.” (p. 61)

Fat decides to throw caution to the wind and goes all in with Dr. Stone. Their mad conversation continues as a conversation between two human beings. Fat feels validated by this.

Fat does not end up at a court hearing that keeps him on the ward for ninety days. He does not see Dr. Stone again until after thirteen days Dr. Stone tells him he is ready to leave. They have another brief conversation, at the end of which PKD writes:

““So I am right about Nag Hammadi,” he said to Dr. Stone.
“You would know,” Dr. Stone said, and then he said something that no one had ever said to Fat before. “You’re the authority”, Dr. Stone said.” (p. 66)

Fat has an epiphany regarding Dr. Stone at this moment. Last quote:

“Dr. Stone wasn’t insane; Stone was a healer. He held down the right job. Probably he healed many people and in many ways. He adapted his therapy to the individual, not the individual to the therapy.

I’ll be goddamned, Fat thought.

In that simple sentence, “You’re the authority,” Stone had given Fat back his soul.”(p. 67)

 

The idea that you can decide what someone needs based solely on a diagnosis, apply specific treatment based on manuals, or other ways treatments are recommended/encouraged based upon minimal information happens too often and are ways the individual is fit to the therapy.

I do not know if you will want to go out and read this book. It is strange though quite enjoyable for me. It has a decidedly unreliable and fragmented narrator. I find that appealing. It is definitely a journey through madness and hopelessness to some sort of peace, if decidedly not an end to the journey.

For my work as a psychotherapist, providing treatment that embraces common factors, feedback and trying to work outside of the medical model of psychotherapy, I would like my epitaph to be:

Adapted therapy to the individual, not the individual to the therapy.

Have you read Valis?

Inaugural Blog Post

This is the inaugural post on my psychotherapy blog. I do intend my posts to have a focus on psychotherapy and mental health issues without being too rigid about this. That said, I hope to be entertaining, wide ranging, informative, thought provoking and not too technical. I also would like to encourage comments, though these will be moderated.

My wanderings here will include:

  • Comments on popular news and health science articles dealing with mental health treatments, diagnosis and psychotherapy. One of the first of these will be about using low level electrical currents to treat depression. There is probably a way to make your bicycle into a generator and put electrodes into your bike helmet, exercise AND cutting edge mental health treatment, yeah.
  • Reviews/discussions of movies and TV shows that deal with mental health and, especially, depict psychotherapy. If you have suggestions, I would love to have them. My first wanderings in this area will likely be Ikiru, Kurasawa’s 1952 masterpiece, and Sarah Polley’s Stories We Tell, from 2013. These really do not say anything directly about mental health or psychotherapy. They both are about story telling and how we make sense of ourselves and the people around us.
  • Posts dealing with books and short stories that are relevant. My first of these will deal with Vallis by Philip K. Dick, which has a great (fictionalized?) description of his Inpatient Psychiatric hospitalization in California in the 1970’s.
  • Discussion of books and articles that are of a professional nature, such as journal articles and books written for psychotherapists. I will certainly be writing about the work of authors such as Irving Kirsch on Placebos, David Healy about the Pharmaceutical Industry and Joanna Moncrieff on an alternative understanding of how psychiatric drugs work.
  • Notices about relevant happenings here and elsewhere that I hope you may find interesting.
  • Who knows?

(more…)