Serious Mental Illness Blog

Official blog for LIU Post's Clinical Psychology Doctorate SMI Specialty Concentration

Posts tagged depression

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Back in the Dark House Again: The Recurrent Nature of Clinical DepressionBy Douglas Bloch, Mad in America
“There is not one of us in whom a devil does not dwell. At some time, at some point, that devil masters each of us. It is not having been in the dark house, but having left it, that counts.”- Teddy Roosevelt
Eighteen years ago, in the fall of 1996, I plunged into a major depression that almost killed me. On the evening of my admittance to a psychiatric hospital I saw the above quote from a documentary on Teddy Roosevelt. For the next ten months, it informed my experience, as I did everything I could to leave the dark house I was in. Eventually, I was healed without medication and wrote about my experience in my memoir, When Going Through Hell…Don’t Stop: A Survivor’s Guide to Overcoming Anxiety and Clinical Depression.
Over the next eighteen years I took what I had learned in my healing and put together a mental health recovery program which I taught through my books, support groups and long distance telephone coaching. In the process, I counseled many people who were in the same desperate straights that I had been in. I shared with them what I had learned through my ordeal—that if you set the intention to heal, reach out for support, and use a combination of mutually supportive therapies to treat your symptoms, you will make it through this. And in the cases where people used these strategies and hung there, they eventually were able, like myself, to emerge from the hell of depression.
During this period, I was aware that that major depression was a recurring disorder, and that while one could successfully mange the symptoms, there was no cure. As Andrew Solomon, author of The Noonday Demon said,
“Depression is recurring and cyclic. What we have is treatments, not cures. You’re never really free of it; you always have to be prepared for a recurrence and be ready to stave it off as it could creep up on you.
Thus, I knew that I was still vulnerable, but after such a long period of “emotional sobriety,” I thought that I might have finally turned a corner.
Then one day, when I least expected it, a series of personal losses led me back into Roosevelt’s dark house. In the midst of my grief reaction, the old symptoms of depression–chronic sadness, lack of pleasure, disrupted sleep, loss of appetite, heaviness in the chest, lack of energy, hopelessness and periodic agitation—were all painfully present.
Now that I am back in the underworld, I am called upon to practice those very techniques that I had been teaching others. Of course I have been using these tools all along as part of my “maintenance program,” but now there is a big difference
I am using them not to stay out of hell, but rather to get out. What makes the latter far more difficult is that you cannot will yourself out of a clinical depression any more than you can will yourself out of a tumor or an advanced case of pneumonia. There is no ten-day course of “brain antibiotics” which you can take and have the condition clear up shortly. In my case, I have learned from my previous episodes that antidepressants do not work for me.
If, then, I cannot directly make the depression leave, what can I do? As I have told my clients, “You have to muddle through and hang in there until things improve. “ Here is how I am attempting to muddle through.
I start with AA’s serenity prayer: God grant me the serenity to accept the things I cannot change, the courage the change the things I can, and the wisdom to know the difference.
Here is what I cannot control and must accept: the biochemical changes in my body and the painful sensations and feelings they bring.
Here is what can I control − how I respond to those sensations and feelings. Here is what I am doing at this time:
When I wake up and immediately feel depressed and hopeless, I recommit to my decision that I want to get well, even though I don’t know how.
Even though I feel as if a huge black bear is sitting on my chest, I still chose to sit up, step out of bed, and get on my stationary bike for 20 minutes.
Throughout the day, I make sure to reach to other people for support.
I have changed my appointment times with my therapist from once a month to once a week.
I continue to put one foot in front the other, despite feeling as if I am walking into a headwind.
When I look into the future and see no hope, I refocus my attention to the present and vow just to get through the day.
I affirm to myself, “This too shall pass.” I say to myself, “Right now you are in the acute phase of dealing with your grief. Things will get better over time.”
Finally, I am noticing those small bits of grace that come my way. For example, an old friend whom I had lost touch with found out about my plight. Now he calls me every day to check on my progress. In addition, at a recent talk I gave, a member f the audience who sensed what I am going through came up to me and said, “You have to come out of this. What other possibility is there?”
Those words reminded me what a social worker told me during one of my hospital stays–‘The best predictor of the future is the past. You have emerged from these episodes before, and you will do so again.”
Meanwhile, I am still in the dark house. I have been in this prison for two months. I don’t know how much time I have left before the cosmic warden will grant me a reprieve. But I have faith that if I keep “muddling through” and do the things that support my healing then one day, when I least expect it, that reprieve will be granted and I will emerge from the darkness into the light.
For more mental health resources, Click Here to access the Serious Mental Illness Blog.Click Here to access original SMI Blog content

Back in the Dark House Again: The Recurrent Nature of Clinical Depression
By , Mad in America

“There is not one of us in whom a devil does not dwell.
At some time, at some point, that devil masters each of us.
It is not having been in the dark house,
but having left it, that counts.”

- Teddy Roosevelt

Eighteen years ago, in the fall of 1996, I plunged into a major depression that almost killed me. On the evening of my admittance to a psychiatric hospital I saw the above quote from a documentary on Teddy Roosevelt. For the next ten months, it informed my experience, as I did everything I could to leave the dark house I was in. Eventually, I was healed without medication and wrote about my experience in my memoir, When Going Through Hell…Don’t Stop: A Survivor’s Guide to Overcoming Anxiety and Clinical Depression.

Over the next eighteen years I took what I had learned in my healing and put together a mental health recovery program which I taught through my books, support groups and long distance telephone coaching. In the process, I counseled many people who were in the same desperate straights that I had been in. I shared with them what I had learned through my ordeal—that if you set the intention to heal, reach out for support, and use a combination of mutually supportive therapies to treat your symptoms, you will make it through this. And in the cases where people used these strategies and hung there, they eventually were able, like myself, to emerge from the hell of depression.

During this period, I was aware that that major depression was a recurring disorder, and that while one could successfully mange the symptoms, there was no cure. As Andrew Solomon, author of The Noonday Demon said,

“Depression is recurring and cyclic. What we have is treatments, not cures. You’re never really free of it; you always have to be prepared for a recurrence and be ready to stave it off as it could creep up on you.

Thus, I knew that I was still vulnerable, but after such a long period of “emotional sobriety,” I thought that I might have finally turned a corner.

Then one day, when I least expected it, a series of personal losses led me back into Roosevelt’s dark house. In the midst of my grief reaction, the old symptoms of depression–chronic sadness, lack of pleasure, disrupted sleep, loss of appetite, heaviness in the chest, lack of energy, hopelessness and periodic agitation—were all painfully present.

Now that I am back in the underworld, I am called upon to practice those very techniques that I had been teaching others. Of course I have been using these tools all along as part of my “maintenance program,” but now there is a big difference

I am using them not to stay out of hell, but rather to get out. What makes the latter far more difficult is that you cannot will yourself out of a clinical depression any more than you can will yourself out of a tumor or an advanced case of pneumonia. There is no ten-day course of “brain antibiotics” which you can take and have the condition clear up shortly. In my case, I have learned from my previous episodes that antidepressants do not work for me.

If, then, I cannot directly make the depression leave, what can I do? As I have told my clients, “You have to muddle through and hang in there until things improve. “ Here is how I am attempting to muddle through.

I start with AA’s serenity prayer: God grant me the serenity to accept the things I cannot change, the courage the change the things I can, and the wisdom to know the difference.

Here is what I cannot control and must accept: the biochemical changes in my body and the painful sensations and feelings they bring.

Here is what can I control − how I respond to those sensations and feelings. Here is what I am doing at this time:

  • When I wake up and immediately feel depressed and hopeless, I recommit to my decision that I want to get well, even though I don’t know how.
  • Even though I feel as if a huge black bear is sitting on my chest, I still chose to sit up, step out of bed, and get on my stationary bike for 20 minutes.
  • Throughout the day, I make sure to reach to other people for support.
  • I have changed my appointment times with my therapist from once a month to once a week.
  • I continue to put one foot in front the other, despite feeling as if I am walking into a headwind.
  • When I look into the future and see no hope, I refocus my attention to the present and vow just to get through the day.
  • I affirm to myself, “This too shall pass.” I say to myself, “Right now you are in the acute phase of dealing with your grief. Things will get better over time.”
  • Finally, I am noticing those small bits of grace that come my way. For example, an old friend whom I had lost touch with found out about my plight. Now he calls me every day to check on my progress. In addition, at a recent talk I gave, a member f the audience who sensed what I am going through came up to me and said, “You have to come out of this. What other possibility is there?”

Those words reminded me what a social worker told me during one of my hospital stays–‘The best predictor of the future is the past. You have emerged from these episodes before, and you will do so again.”

Meanwhile, I am still in the dark house. I have been in this prison for two months. I don’t know how much time I have left before the cosmic warden will grant me a reprieve. But I have faith that if I keep “muddling through” and do the things that support my healing then one day, when I least expect it, that reprieve will be granted and I will emerge from the darkness into the light.

For more mental health resources, Click Here to access the Serious Mental Illness Blog.
Click Here
 to access original SMI Blog content

Filed under depression depressed depressing sad sadness anger angry health healthy recover recovery hope mind body brain wellness mental health mental mental illness diagnosis disorder thought thoughts emotion emotions feeling feelings story personal psychology

21 notes

Early Psychotherapy May Head Off Major DepressionBy Deborah Brauser, Medscape Medical News
Psychotherapy may be effective in treating subclinical depression and may prevent progression to major depressive disorder, (MDD), new research suggests.
A meta-analysis of 18 studies of adult participants with subclinical depression showed that among those who received some form of psychotherapy, there was a significant reduction in the incidence of major depressive episode 6 months later compared with those who received a controlled condition.
In addition, psychotherapy had a moderate effect on lowering depressive symptoms.
"We found that psychological treatments had a small to moderate but statistically significant effect on subclinical depression," write the investigators, led by Pim Cuijpers, PhD, from the Department of Clinical Psychology at VU University Amsterdam, the Netherlands.
"We also found that these treatments had a significant preventive effect on the onset of major depressive disorder."
However, because of the differing quality of the included studies, the researchers add that “more high-quality research is needed” ― and that the results should be interpreted with caution.
The study was published in the October issue of the British Journal of Psychiatry.
Recent Controversy
The investigators note that there has been recent controversy regarding the efficacy of psychotherapy in treating subclinical depression. In addition, a recent meta-analysis suggested that antidepressants and benzodiazepines are no better than placebo for treating this condition.
"Subclinical depression is important from a clinical perspective not only because it can be a disabling condition that needs treatment, but also because of the associated risk of developing major depression, which may be averted by treatment."
For the current analysis, the researchers reviewed data for 18 studies, with a total of 1913 participants older than 18 years. Of these, 947 received some form of psychotherapy, and 966 were in designated “control groups.”
The most common form of psychotherapy used was cognitive-behavioral therapy. Unfortunately, the overall data were not ideal.
"The target groups, therapies and characteristics of the included studies differed considerably from each other, and the quality of many studies was not optimal," the investigators write.
Nonetheless, results showed that undergoing psychotherapy significantly reduced the incidence of MDD at the 6-month follow-up, with a relative risk (RR) of 0.61 vs the control groups (95% confidence interval [CI], 0.37 - 0.99; P < .05). “That is, a reduction in incidence of 39%.”
Change in the numbers needed to treat (NNT) was also significant at 6 months (10.3; 95% CI, 6.3 - 28.6; P < .01).
Needs Confirmation
The RR for the group at 12 months was 0.74 (a reduction in incidence of 26%), which was not deemed significant. However, the NNT at 12-month follow-up of 16.4 was significant (P < .05).
A small to moderate effect on depressive symptoms was also shown for those receiving psychotherapy in comparison with those receiving a controlled condition (pooled effect size, 0.35; NNT, 5.10).
Additional analysis examined 56 studies to compare psychotherapy used to treat subclinical depression with the use of the intervention to treat MDD.
Its results showed that the effect size was significantly larger when psychotherapy was used to treat MDD (P< .01), and that it remained significant even after multiple adjustments.
"This is not surprising, as possibilities for improvement are more limited in subclinical depression," write the investigators.
Overall, they note that the findings show that psychological therapies “may be effective” for treating this condition.
"These results should, however, be confirmed in further randomized trials because of the clinical heterogeneity, the low quality of the included studies, and because the clinicians-rated outcomes did not achieve significance," the authors conclude.
For more mental health resources, Click Here to access the Serious Mental Illness Blog. Click Here to access original SMI Blog content

Early Psychotherapy May Head Off Major Depression
By Deborah Brauser, Medscape Medical News

Psychotherapy may be effective in treating subclinical depression and may prevent progression to major depressive disorder, (MDD), new research suggests.

A meta-analysis of 18 studies of adult participants with subclinical depression showed that among those who received some form of psychotherapy, there was a significant reduction in the incidence of major depressive episode 6 months later compared with those who received a controlled condition.

In addition, psychotherapy had a moderate effect on lowering depressive symptoms.

"We found that psychological treatments had a small to moderate but statistically significant effect on subclinical depression," write the investigators, led by Pim Cuijpers, PhD, from the Department of Clinical Psychology at VU University Amsterdam, the Netherlands.

"We also found that these treatments had a significant preventive effect on the onset of major depressive disorder."

However, because of the differing quality of the included studies, the researchers add that “more high-quality research is needed” ― and that the results should be interpreted with caution.

The study was published in the October issue of the British Journal of Psychiatry.

Recent Controversy

The investigators note that there has been recent controversy regarding the efficacy of psychotherapy in treating subclinical depression. In addition, a recent meta-analysis suggested that antidepressants and benzodiazepines are no better than placebo for treating this condition.

"Subclinical depression is important from a clinical perspective not only because it can be a disabling condition that needs treatment, but also because of the associated risk of developing major depression, which may be averted by treatment."

For the current analysis, the researchers reviewed data for 18 studies, with a total of 1913 participants older than 18 years. Of these, 947 received some form of psychotherapy, and 966 were in designated “control groups.”

The most common form of psychotherapy used was cognitive-behavioral therapy. Unfortunately, the overall data were not ideal.

"The target groups, therapies and characteristics of the included studies differed considerably from each other, and the quality of many studies was not optimal," the investigators write.

Nonetheless, results showed that undergoing psychotherapy significantly reduced the incidence of MDD at the 6-month follow-up, with a relative risk (RR) of 0.61 vs the control groups (95% confidence interval [CI], 0.37 - 0.99; P < .05). “That is, a reduction in incidence of 39%.”

Change in the numbers needed to treat (NNT) was also significant at 6 months (10.3; 95% CI, 6.3 - 28.6; P < .01).

Needs Confirmation

The RR for the group at 12 months was 0.74 (a reduction in incidence of 26%), which was not deemed significant. However, the NNT at 12-month follow-up of 16.4 was significant (P < .05).

A small to moderate effect on depressive symptoms was also shown for those receiving psychotherapy in comparison with those receiving a controlled condition (pooled effect size, 0.35; NNT, 5.10).

Additional analysis examined 56 studies to compare psychotherapy used to treat subclinical depression with the use of the intervention to treat MDD.

Its results showed that the effect size was significantly larger when psychotherapy was used to treat MDD (P< .01), and that it remained significant even after multiple adjustments.

"This is not surprising, as possibilities for improvement are more limited in subclinical depression," write the investigators.

Overall, they note that the findings show that psychological therapies “may be effective” for treating this condition.

"These results should, however, be confirmed in further randomized trials because of the clinical heterogeneity, the low quality of the included studies, and because the clinicians-rated outcomes did not achieve significance," the authors conclude.

For more mental health resources, Click Here to access the Serious Mental Illness Blog.
Click Here
 to access original SMI Blog content

Filed under mind body brain wellness health healthy recover recovery treatment therapy depression depressed depressive sad sadness emotion emotions feeling feelings thought thoughts major depression major depressive disorder disorder diagnosis psychology med meds drug drugs

69 notes

Psychosis and Dissociation, Part 2: On Diagnosis, and Beyond
By Noel Hunter, M.A., M.S., Mad in America 

“You treat a disease, you win, you lose.
You treat a person, I guarantee you, you’ll win,
No matter what the outcome.”

- Robin Williams in Patch Adams

Recently I wrote an article on MIA entitled Trauma, Psychosis, and Dissociation. Several people responded privately with some very thought-provoking questions that I would like to explore and possibly answer to some extent here. Most of these questions regarded the relationship of diagnoses and treatment, which was a subject that I superficially critiqued but did not explicitly analyze. Dedicated readers of the MIA website are all too familiar with the myriad problems that exist with diagnoses in general, the stereotypical (and often untrue) assumptions associated with these various categories, and their lack of scientific validity or reliability. For those who are not as familiar with this research, there are many on this site who have tackled this issue (see: Harm ReductionDo Diagnoses InjureDoes DSM-5 MatterHow Reliable is DSM-5Psychiatry-Based Valid Science).  I do not wish to echo what has already been exquisitely written elsewhere, but I do want to address some specifics with regard to dissociation and psychosis.

First, though, I want to state that my area of experience and research is with trauma, psychosis, and dissociation. Surely, the following assertions and arguments could be said about any comparative diagnostic categories or phenomena; however, I do not have the knowledge, experience, or research to back up discussions on phenomena related to categories such as bipolar, depression, borderline personality disorder, etc. That is the only reason that I focus on the categories of Dissociative Identity Disorder (DID) and schizophrenia (and their related labels) – NOT because I believe that some other standard holds true for other categories. As a broad statement to begin with, I want to assert that above and beyond anything else, when an individual is suffering some type of distress (whether understood to an outsider or not) it should be assumed that there is a logical reason that such distress developed.

If this is the first assumption made, then there is no need to search for “what is wrong” with the person; I will repeat until the end of time that the Hearing Voices Network put it perfectly by stating we must seek to understand “what happened” to the person. Until such a time that the person is able or willing to acknowledge/remember/process/understand the complicated interpersonal, familial, and societal dynamics that may have led to the distressing experiences in the present, it should always be assumed (once real medical and nutritional factors are ruled out) that there is meaning in said experience. Placing a priority on diagnosing and categorizing prevents meaning from being made.

“But why?” many will ask; if a diagnosis is “correct” and thereby will inform targeted “treatment” then is it not best practice to proceed in such a manner? Although I recognize that we live in a society that demands immediate results, immediate answers, and immediate eradication of pain and suffering, that does not mean that science must follow suit. The following is my reasoning behind why I unequivocally answer the previous question with an emphatic “No.”

Breaking down the experience

Within the domain of the dissociative and psychotic disorder categories, the following are the most common phenomena that people subjectively and internally experience:

  • Anxiety
  • Sadness
  • Emptiness
  • Confusion
  • Hopelessness
  • Rage
  • Extreme fear
  • Overwhelming emotions
  • Lack of emotions/numbness
  • Lack of motivation or interest in anything
  • Feeling unreal
  • Feeling the world is unreal
  • Hearing voices or other auditory stimuli others cannot hear
  • Seeing/feeling/smelling stimuli that others cannot see/feel/smell
  • Identity confusion
  • Identity alteration with amnesia
  • (Note: “Dissociation” is not included here for reasons outlined in my previous post; the definition is so confused and biased at this point that there is no need to use this word to describe anything)

Now, of course, there are many other experiences that could be added to this list when looking at any individual; and that is also kind of to the point: Individual experiences are very individual. Additionally, any individual may experience any combination of the above, to different severities, at different times, and interpret these experiences in different ways. If one interprets such experiences in a manner that goes against consensus belief, then others may claim it is a “delusion,” but a “delusion” is not the internal process or experience … it is just an explanation like anything else. In this sense, even the term “psychosis” ceases to have meaning.

Seeing as how a “delusion” can be seen as a logical explanation for an incomprehensible experience, or an attempt to bring structure to a chaotic internal or external world,  then it makes no sense to me that “delusion” becomes a separate “symptom” that defines a specific “disease” that is distinct from all others. How is a person helped by being told that their internal experience is irrelevant, as is their past, because they are “delusional,” and therefore have an illness that must immediately be “treated”? I genuinely look forward to anybody responding with a constructive answer to this question.

Putting the idea of “delusion” aside (because an entire separate article could be written about that), how does diagnosis then fit in to the picture? DID is an interesting diagnosis because it is actually one of the few that has a high degree of validity and reliability when structured interviewing is utilized. Additionally, many individuals who receive this diagnosis may experience some level of relief that: 1) they are officially not “crazy” (i.e., “schizophrenic”); and 2) their trauma has been recognized. Further, trauma-informed treatments designed for DID experiences can be highly effective, validating, and rewarding … though, like any other treatment can also be incredibly harmful as well.

I might surmise, though no direct studies have been done to evaluate this, that the large portion of the harm done in this type of treatment occurs when an overzealous practitioner insists on his or her framework, pushes too hard for recognition and processing of trauma, focuses on the anomalous experiences at the expense of doing the difficult work, and the more general problems that come with relying on hospitalizations and psychotropic drugs for long periods of time. My point in stating this is to say that I come from a position wherein I believe that the dissociative disorder field has a lot to offer, but errs tremendously in its steadfast reliance on the biomedical categorical system.

On the other hand, the diagnosis piece is another story. The diagnosis of DID is based on one experience: identity alteration with amnesia. It is not surprising, then, that this category would have validity and some degree of reliability. If we took, instead, the experience of hearing voices and turned it into “Hearing Voices Disorder” it would also likely have a high degree of validity. This is because it is referring to one experience that the person has presented with: It is entirely tautological. I do not dispute that people experience identity alteration with amnesia, but this does not equate with having a disease or anything else above the experience itself.

Schizophrenia, however, is quite the opposite; this category is an amalgamation of broad and varied phenomena that may or may not have anything in common at all. As I stated in my previous blog, and certainly what has been articulated numerous times elsewhere, the problems inherent in the assumptions and associations made with this diagnosis are, quite frankly, a travesty.

Even so, there are plenty of individuals who also find reassurance and comfort in formulating their experiences from a disease model and find value in this label. We learn how to explain our experiences through group-mind or society’s authoritarian dictate of accepted knowledge; even those who are deemed “schizophrenic” learn to explain their experiences through the mind of the doctor. Just as the idea that doctors’ insistence that a “delusional” patient must accept consensus reality can be incredibly harmful and completely ineffective, so too is the insistence that all people with lived experience accept the same explanation for their experiences. I do not wish to invalidate their way of making sense of things. But, that does not negate that the travesty exists, nor does it make the diagnosis a valid one.

Diagnostic Confusion

Any two individuals who experience distress that gets labeled as schizophrenia may have nothing at all in common. One may present with hearing voices, fear, rage, and overwhelming emotions, while the other has a lack of motivation, feels unreal, has a lack of emotions, and physically feels profound anxiety. The first person might have experienced significant sexual abuse, and the voices are the person’s way of making sense of this abuse while the resulting fear and extreme emotions are perfectly understandable responses to such a violation. The second individual may have experienced severe invalidation, a lack of mastery in life, and bullying. Both meet criteria for schizophrenia, and, for argument’s sake, let’s say there is no debate that this is an “accurate” diagnosis. How, then, does this diagnosis help in any way with “treatment”?

It just doesn’t.

Similarly, a person who experiences identity alteration with amnesia, thereby leading to a diagnosis of DID, may also experience hearing voices, fear, rage, and overwhelming emotions due to significant sexual abuse. Her experience is not entirely different from person #1’s experience in the preceding paragraph except for the added experience of identity alteration and amnesia. Do these two people then logically have entirely different diseases? Does “treatment” really logically flow from the diagnosis of either individual? Do these two people really need some drastically different kind of “treatment” at all?

More common within the DID realm is the person who experiences identity alteration with amnesia, fear, lack of emotion, lack of motivation, overwhelming emotion, profound anxiety, hearing voices, seeing/feeling/smelling things that others do not, feeling unreal, feeling the world is unreal, extreme fear, anxiety, hopelessness, sadness, and suicidality. This person now meets criteria for about 10 different diagnoses, DID being only one of them. When the individual does not agree with the clinician about how to explain these ever-changing symptoms, then more diagnoses may be added. Usually this will include several personality disorder diagnoses and, if the explanations sound bizarre to the clinician, then the person is said to also have schizophrenia. Again I ask; how does this help in any way with “treatment”?

It just doesn’t.

At the end of the day, any “diagnosis” or technical, medical term serves to distance everybody involved from the experience itself. It most often leads to internalization of stigma, otherness, inferiority, hopelessness, dependency, and shame. For many, it reinforces the very beliefs that contributed to the development of the distress in the first place: the person is broken and defective and deserved the mistreatment that he or she might have been victim to. It leads clinicians to fall into the trap of believing that any annoying or disturbing behaviors are indicative of disease or personality rather than an understandable response to internal or external events.

If one were to break down the seemingly incomprehensible presentation of distress into the individual experiences that may or may not include any or all of the above, then suddenly things begin to make sense. The clinician or family member might be able to relate, and the experiencer might also be able to relate to others and to his or her self in a more compassionate and humane way. There is no “othering” of the individual; rather, the experience is couched in a way that can be viewed as a very human, very understandable reaction to a very un-understandable world. Additionally, there is no disease or symptom to “cure” or “treat”; instead there is a journey to go on that includes relationship, meaning-making, healing deep wounds, coming to know one’s self, forgiveness, compassion, growth, and spirituality.

Beyond Diagnoses

The British Psychological Society published guidelines in 2011 for the use of “psychological formulation” that, in theory, could replace diagnoses in mental health treatment (Division of Clinical Psychology, 2011). Basically, and I am really simplifying this here, they  recommend that psychologists take an approach that focuses on personal meaning within familial, societal, and systemic contexts that honors collaboration and the role of trauma and chronic stress. Lucy Johnstone, MIA author and the lead author of these guidelines, has discussed this in more detailhere. Using the previously listed phenomena, it might work something like this:

A 20-something-year-old woman presented to the emergency room after family members believed that she might hurt herself or someone else. She reported having large gaps in memory, was accused of being a liar, does not trust anybody, believes the staff of the hospital is going to attack her, hears voices, sees visions, and has a history of suicide attempts.

This is not an uncommon situation, but instead of saying she is “manipulative, attention-seeking, hallucinating, paranoid, delusional, and threatens suicide” the report is just a factual recount of her actual subjective experience. The formulation might go on to say that this individual denies any trauma or abuse, she has a lot of friends, is intelligent, aims to pursue X career, and does not believe that she has anything wrong with her. The psychologist could validate this and say “you’re right, you are clearly experiencing a great deal of confusion and distress and let’s work together to try and understand what might be going on.” The psychologist assumes that some external dynamic or event slowly over time led to the extreme experience in the present and does not insist that this dynamic or event be known right away. Each behavior, statement, or outburst can be seen as an attempt to express the very confusing internal world instead of being viewed as a disease or personality problem. Everything is a clue to finding meaning and reaching the goals of pursuing X career through a focus on strengths and understanding. The person in distress and the clinician can work together to understand  what areas may need to be addressed first, how to more effectively cope with overwhelming emotions and pain, and building trust. Eventually, the meaning will come and any trauma or other painful experiences can slowly be processed. Specific techniques or activities can be planned around specific complaints of the experiencer: if she has identity alteration or hears voices … you can, together, get to know them and what they have to say. If she experiences feelings of being unreal or her surroundings being unreal, you can use grounding exercises. If she complains of heart palpitations and difficulty breathing, use relaxation exercises, if she has beliefs that the clinician does not understand or agree with, try to figure out how these beliefs are serving the individual, etc.

Nowhere in this formulation is there a need for diagnosis, “cure,” or an explanatory model beyond the context in which such phenomena developed. Some find comfort in diagnoses because they find comradery or normalization in knowing other people have experienced something similar. The Hearing Voices Network has shown how this same comfort can be found without diagnoses. A person who experiences mania, anxiety, depression (not in the DSM sense), identity alteration with amnesia, extreme fear and distrust of others, etc., can find that same comradery by seeking out others with that same experience; a diagnosis does NOT mean any commonality at all. Two people with the same diagnosis can have COMPLETELY different experiences and have NOTHING in common!

Alternatively, some find comfort in the diagnostic and medical explanations because they validate the lack of will or intention that the suffering individual may experience. This is a serious concern and must be addressed more sufficiently than has been thus far. Just because something is not medical, this does not insinuate the intention of one’s behavior. These experiences are very, very real. They have very real biological correlations. For instance, when one goes into a trance state (or dissociative state in some circles), every part of the brain shuts down relative to the verbal and animalistic/limbic portions of the brain. This is real, but; this is not a disease.

Lastly, using the formulation approach requires a bit more work for the professional engaging in such a practice. There is no automatic categorization, prediction, prescription, and rigid, manualized “treatment” plan, although there could be a place for all of these things based on the collaborative assessment of specific complaints. Instead, there is a need to practice an art of relating, collaborating, engaging, and dealing with really frightening, overwhelming, and uncomfortable emotions on BOTH parts. Diagnoses and medical/symptom-based approaches help the practitioner, and sometimes even the experiencer, maintain a comfortable distance from the traumatic, death-anxiety-provoking reality of life. But, we must move past this. We must do better. Again, back to the Hearing Voices movement: “Nothing about us without us.”

Indeed.

* * * * *

References:

Division of Clinical Psychology. (December, 2011). Good practice guidelines on the use of psychological formulationLeicester, United Kingdom: British Psychological Society.

For more mental health resources, Click Here to access the Serious Mental Illness Blog.
Click Here
 to access original SMI Blog content

Filed under mind body brain wellness health healthy recovery anxiety anxious sadness sad depressed depression confused empty hopeless hope scared emotion emotions feeling feelings trauma abuse dissociation psychosis psychotic dissociated dissociative identity disorder schizophrenia

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Selling Prozac as the Life-Enhancing Cure for Mental WoesBy Clyde Haberman, The New York Times
When it came to pharmacological solutions to life’s despairs, Aldous Huxley was ahead of the curve. In Huxley’s 1932 novel about a dystopian future, the Alphas, Betas and others populating his “Brave New World” have at their disposal a drug called soma. A little bit of it chases the blues away: “A gramme” — Huxley was English, remember, spelling included — “is better than a damn.” With a swallow, negative feelings are dispelled.
Prozac, the subject of this week’s video documentary from Retro Report, is hardly soma. But its guiding spirit is not dissimilar: A few milligrams of this drug are preferable to the many damns that lie at the core of some people’s lives. Looking back at Prozac’s introduction by Eli Lilly and Company in 1988, and hopscotching to today, the documentary explores the enormous influence, both chemical and cultural, that Prozac and its brethren have had in treating depression, a concern that gained new resonance with the recent suicide of the comedian Robin Williams.
In the late 1980s and the 90s, Prozac was widely viewed as a miracle pill, a life preserver thrown to those who felt themselves drowning in the high waters of mental anguish. It was the star in a class of new pharmaceuticals known as S.S.R.I.s — selective serotonin reuptake inhibitors. Underlying their use is a belief that depression is caused by a shortage of the neurotransmitter serotonin. Pump up the levels of this brain chemical and, voilà, the mood lifts. Indeed, millions have embraced Prozac, and swear by it. Depression left them emotionally paralyzed, they say. Now, for the first time in years, they think clearly and can embrace life.
Pharmacological merits aside, the green-and-cream pill was also a marvel of commercial branding, down to its market-tested name. Its chemical name is fluoxetine hydrochloride, not the most felicitous of terms. A company called Interbrand went to work for Eli Lilly and came up with Prozac. “Pro” sounds positive. Professional, too. “Ac”? That could signify action. As for the Z, it suggests a certain strength, perhaps with a faint high-techy quality.
(X is a pharmacological cousin to Z. Both letters are somewhat unusual, worth many points in Scrabble. It is surely not a coincidence that a striking number of modern medications contain either Z or X, or both, in their names, like Luvox, Paxil, Celexa, Effexor, Zantac, Xanax, Zoloft, Lexapro and Zocor, to name but a few. Not surprisingly, confusion can set in. Zantac or Xanax — remind me which one is for heartburn and which for panic disorder?)
Pendulums, by definition, swing, and the one on which Prozac rides is no exception. After the early talk about it as a wonder pill — a rather chic one at that — a backlash developed, perhaps unsurprisingly. Grave questions arose among some psychiatrists about whether the S.S.R.I.s increased chances that some people, notably teenagers, would commit suicide or at least contemplate it. No definite link was confirmed, but that did not end the concern of some prominent skeptics, like a British psychiatrist, Dr. David Healy. He has dismissed the notion of S.S.R.I.s as saviors as “bio-babble.”
If some users deem Prozac lifesaving, others consider it sensory-depriving. A loss of libido is a common side effect. Some writers and artists, while often relieved to be liberated from depression’s tightest grip, also say that Prozac leaves them mentally hazy. In his 2012 book, “Antifragile: Things That Gain From Disorder,” Nassim Nicholas Taleb offered this: “Had Prozac been available last century, Baudelaire’s ‘spleen,’ Edgar Allan Poe’s moods, the poetry of Sylvia Plath, the lamentations of so many other poets, everything with a soul would have been silenced.”
Then, too, S.S.R.I. critics express doubts that these drugs have proved themselves significantly more effective than placebos. Some among them question the very concept that serotonin levels, on their own, cause depression or prevent it. One psychotherapist in that camp is Gary Greenberg, an author of several books on mood disorders. Writing in The New Yorker last year, Dr. Greenberg said that scientists had “concluded that serotonin was only a finger pointing at one’s mood — that the causes of depression and the effects of the drugs were far more complex than the chemical-imbalance theory implied.”
“The ensuing research,” he continued, “has mostly yielded more evidence that the brain, which has more neurons than the Milky Way has stars and is perhaps one of the most complex objects in the universe, is an elusive target for drugs.”
More broadly, this retrospective on Prozac introduces a discussion of whether the medical establishment, and perhaps society in general, has gone too far in turning normal conditions, like sadness, into pathologies. And have we paved a path — shades of soma — toward wanton reliance on drugs to enhance life, not to conquer true illness?
This is what a prominent psychiatrist, Dr. Peter Kramer, has called “cosmetic psychopharmacology,” a Botox approach, if you will, to matters of the mind: Why not take Prozac and its S.S.R.I. mates even if you are not clinically depressed but believe that they can boost your confidence, or maybe help you make a stronger pitch at the sales meeting?
A response from others in Dr. Kramer’s field is that we are taking traits that are normal parts of human nature and casting them as diseases simply because remedies now exist. For instance, shyness is now regarded by some as a condition in need of treatment. In its more severe form, it is placed under the heading of social anxiety disorder. Then there are those much-heralded life enhancers, Viagra and its erection-aiding cousins. They are marketed not only to men with sexual dysfunction but also to those whose aging bodies are enduring normal wear and tear.
One area of shyness that the S.S.R.I. class has helped overcome is discussion of depression. Decades ago, Hollywood stars and other celebrities dared not touch the subject. Now they routinely go public with their anguish. Robin Williams was an example.
Of course, there are those in other realms of society for whom the topic remains taboo. Take one man who confesses to his wife that he is on Prozac but cautions her to tell no one. “I’m serious,” he says. “The wrong person finds out about this and I get a steel-jacketed antidepressant right in the back of the head.” This is Tony Soprano talking to his wife, Carmela. An extreme example from a work of fiction? Sure. But in all likelihood many Americans have similar fears about what others might think, and keep depression to themselves.
The video with this article is part of a documentary series presented by The New York Times. The video project was started with a grant from Christopher Buck. Retro Report has a staff of 13 journalists and 10 contributors led by Kyra Darnton. It is a nonprofit video news organization that aims to provide a thoughtful counterweight to today’s 24/7 news cycle.
For more mental health resources, Click Here to access the Serious Mental Illness Blog.Click Here to access original SMI Blog content

Selling Prozac as the Life-Enhancing Cure for Mental Woes
By Clyde Haberman, The New York Times

When it came to pharmacological solutions to life’s despairs, Aldous Huxley was ahead of the curve. In Huxley’s 1932 novel about a dystopian future, the Alphas, Betas and others populating his “Brave New World” have at their disposal a drug called soma. A little bit of it chases the blues away: “A gramme” — Huxley was English, remember, spelling included — “is better than a damn.” With a swallow, negative feelings are dispelled.

Prozac, the subject of this week’s video documentary from Retro Report, is hardly soma. But its guiding spirit is not dissimilar: A few milligrams of this drug are preferable to the many damns that lie at the core of some people’s lives. Looking back at Prozac’s introduction by Eli Lilly and Company in 1988, and hopscotching to today, the documentary explores the enormous influence, both chemical and cultural, that Prozac and its brethren have had in treating depression, a concern that gained new resonance with the recent suicide of the comedian Robin Williams.

In the late 1980s and the 90s, Prozac was widely viewed as a miracle pill, a life preserver thrown to those who felt themselves drowning in the high waters of mental anguish. It was the star in a class of new pharmaceuticals known as S.S.R.I.s — selective serotonin reuptake inhibitors. Underlying their use is a belief that depression is caused by a shortage of the neurotransmitter serotonin. Pump up the levels of this brain chemical and, voilà, the mood lifts. Indeed, millions have embraced Prozac, and swear by it. Depression left them emotionally paralyzed, they say. Now, for the first time in years, they think clearly and can embrace life.

Pharmacological merits aside, the green-and-cream pill was also a marvel of commercial branding, down to its market-tested name. Its chemical name is fluoxetine hydrochloride, not the most felicitous of terms. A company called Interbrand went to work for Eli Lilly and came up with Prozac. “Pro” sounds positive. Professional, too. “Ac”? That could signify action. As for the Z, it suggests a certain strength, perhaps with a faint high-techy quality.

(X is a pharmacological cousin to Z. Both letters are somewhat unusual, worth many points in Scrabble. It is surely not a coincidence that a striking number of modern medications contain either Z or X, or both, in their names, like Luvox, Paxil, Celexa, Effexor, Zantac, Xanax, Zoloft, Lexapro and Zocor, to name but a few. Not surprisingly, confusion can set in. Zantac or Xanax — remind me which one is for heartburn and which for panic disorder?)

Pendulums, by definition, swing, and the one on which Prozac rides is no exception. After the early talk about it as a wonder pill — a rather chic one at that — a backlash developed, perhaps unsurprisingly. Grave questions arose among some psychiatrists about whether the S.S.R.I.s increased chances that some people, notably teenagers, would commit suicide or at least contemplate it. No definite link was confirmed, but that did not end the concern of some prominent skeptics, like a British psychiatrist, Dr. David Healy. He has dismissed the notion of S.S.R.I.s as saviors as “bio-babble.”

If some users deem Prozac lifesaving, others consider it sensory-depriving. A loss of libido is a common side effect. Some writers and artists, while often relieved to be liberated from depression’s tightest grip, also say that Prozac leaves them mentally hazy. In his 2012 book, “Antifragile: Things That Gain From Disorder,” Nassim Nicholas Taleb offered this: “Had Prozac been available last century, Baudelaire’s ‘spleen,’ Edgar Allan Poe’s moods, the poetry of Sylvia Plath, the lamentations of so many other poets, everything with a soul would have been silenced.”

Then, too, S.S.R.I. critics express doubts that these drugs have proved themselves significantly more effective than placebos. Some among them question the very concept that serotonin levels, on their own, cause depression or prevent it. One psychotherapist in that camp is Gary Greenberg, an author of several books on mood disorders. Writing in The New Yorker last year, Dr. Greenberg said that scientists had “concluded that serotonin was only a finger pointing at one’s mood — that the causes of depression and the effects of the drugs were far more complex than the chemical-imbalance theory implied.”

“The ensuing research,” he continued, “has mostly yielded more evidence that the brain, which has more neurons than the Milky Way has stars and is perhaps one of the most complex objects in the universe, is an elusive target for drugs.”

More broadly, this retrospective on Prozac introduces a discussion of whether the medical establishment, and perhaps society in general, has gone too far in turning normal conditions, like sadness, into pathologies. And have we paved a path — shades of soma — toward wanton reliance on drugs to enhance life, not to conquer true illness?

This is what a prominent psychiatrist, Dr. Peter Kramer, has called “cosmetic psychopharmacology,” a Botox approach, if you will, to matters of the mind: Why not take Prozac and its S.S.R.I. mates even if you are not clinically depressed but believe that they can boost your confidence, or maybe help you make a stronger pitch at the sales meeting?

A response from others in Dr. Kramer’s field is that we are taking traits that are normal parts of human nature and casting them as diseases simply because remedies now exist. For instance, shyness is now regarded by some as a condition in need of treatment. In its more severe form, it is placed under the heading of social anxiety disorder. Then there are those much-heralded life enhancers, Viagra and its erection-aiding cousins. They are marketed not only to men with sexual dysfunction but also to those whose aging bodies are enduring normal wear and tear.

One area of shyness that the S.S.R.I. class has helped overcome is discussion of depression. Decades ago, Hollywood stars and other celebrities dared not touch the subject. Now they routinely go public with their anguish. Robin Williams was an example.

Of course, there are those in other realms of society for whom the topic remains taboo. Take one man who confesses to his wife that he is on Prozac but cautions her to tell no one. “I’m serious,” he says. “The wrong person finds out about this and I get a steel-jacketed antidepressant right in the back of the head.” This is Tony Soprano talking to his wife, Carmela. An extreme example from a work of fiction? Sure. But in all likelihood many Americans have similar fears about what others might think, and keep depression to themselves.

The video with this article is part of a documentary series presented by The New York Times. The video project was started with a grant from Christopher Buck. Retro Report has a staff of 13 journalists and 10 contributors led by Kyra Darnton. It is a nonprofit video news organization that aims to provide a thoughtful counterweight to today’s 24/7 news cycle.

For more mental health resources, Click Here to access the Serious Mental Illness Blog.
Click Here
 to access original SMI Blog content

Filed under prozac ssri drug drugs med meds medication medications suicide suicidal robin williams depression depressed psychology psychiatry counseling chemical xanax celexa mind body brain wellness health healthy effexor zantac zoloft lexapro zocor

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Web therapy could be an option for bipolar disorderBy Liat Clark, Wired
An online platform that helps people with bipolar disorder self-administer therapy has proven to be successful in a small trial, with 92 percent of participants saying they found the content positive.
Nicholas Todd, a psychologist in clinical training at the NHS Trust, has developed the site as part of a project he&#8217;s running called Living with Bipolar.
In it, he asked 122 people to use a sort of e-learning environment that uses audiovisual models and worksheets, incorporating parts of cognitive behavioral therapy and psycho-education known to be effective in bipolar patients. There&#8217;s also a peer support forum, which is moderated by a member of Todd&#8217;s research team, and motivational emails were periodically sent to those on the trial.
"Service users were encouraged to access the intervention flexibly and use it as and when they felt appropriate," Todd told Wired.co.uk. That&#8217;s because, as he presents in a paper on the platform, for patients &#8220;recovery is defined as people living a fulfilling life alongside their condition&#8221;. As such, it needs to fit in around them, their lifestyle and their changing needs.
One participant comments: &#8220;&#8230;.for me recovery is certainly not about being symptom free… it is about coping and having a reasonable quality of life, being able to work productively and enjoy things outside of work.&#8221;
Thus, Todd explains, &#8220;service users did not focus on a &#8216;cure&#8217; as their desired outcome but instead personally defined recovery goals and improved quality of life.&#8221;
By the trial end, Todd found that on average, users who stayed till the end completed 60 percent of the program. Of the people that completed the whole thing &#8212; 15 modules &#8212; 74 percent took under three months to do so.
The platform took a year to develop, spent looking at the most effective components of psychological therapy for bipolar disorder. As this was narrowed down, the group carried out five focus groups and tested it online via a consultancy group.
The system gets users to identify their own mood using an established scale, the idea being they &#8212; and the system &#8212; can track their own ups and downs. &#8220;Service users would then receive information about the most appropriate modules, given their mood symptoms,&#8221; says Todd.
The forum, he says, played a key role in the project&#8217;s success. One participant commented, &#8220;&#8230;part of it [bipolar disorder] is feeling very alone&#8230; you don&#8217;t get that and I do think that the forum works extremely well with the intervention&#8230;&#8221; Todd explains how participants used it to support each other not only through the new intervention process, but through life events.
"A balance was struck between allowing participants to offload, and posts which encourage or talk about acts of suicide, self-harm, harm to others and are unhelpful to participants&#8217; recovery." A total of 70 percent of the users signed up to the forum, and 1,927 posts on 130 topics were accumulated. "The participants who used the forum tended to complete more modules, and all participants who completed the entire program used the forum, albeit in different ways."
The idea behind the platform is to help bridge those periods between appointments, or those appointments that a patient misses. As with depression, health services can be known to administer solely medication to help alleviate symptoms. More and more, the NHS is striving to ensure psychological therapy is integrated alongside a prescription for mood stabilizers, such as lithium. &#8220;However, severe inequalities in access to psychological interventions for bipolar disorder currently exist in the NHS,&#8221; Todd says. &#8220;This intervention aims to increase access to psychological intervention.&#8221;
Todd tells us the NHS is actively training more staff to deliver psychological therapy, to plug the gap. For now, that initiative is being piloted for severe mental health conditions. &#8220;This intervention may fit as part of this initiative in giving service users with bipolar disorder greater access to psychological therapy.
"Computerized interventions are not about replacing face-to-face interventions, but giving someone another option to receive psychological support. In fact, some people prefer accessing psychological support in this way as it fits better with their lives."
For one woman in particular the experience has been, in her words, &#8220;life changing&#8221;.
She said: &#8220;I have encountered insights in the modules that have significantly helped me to survive the blackest moments. I cannot measure the value of this, as it has contributed to their difference between life and death. My husband and I are sincerely grateful for the immeasurable impact this has had on our family.&#8221;
For more mental health resources, Click Here to access the Serious Mental Illness Blog.Click Here to access original SMI Blog content

Web therapy could be an option for bipolar disorder
By Liat Clark, Wired

An online platform that helps people with bipolar disorder self-administer therapy has proven to be successful in a small trial, with 92 percent of participants saying they found the content positive.

Nicholas Todd, a psychologist in clinical training at the NHS Trust, has developed the site as part of a project he’s running called Living with Bipolar.

In it, he asked 122 people to use a sort of e-learning environment that uses audiovisual models and worksheets, incorporating parts of cognitive behavioral therapy and psycho-education known to be effective in bipolar patients. There’s also a peer support forum, which is moderated by a member of Todd’s research team, and motivational emails were periodically sent to those on the trial.

"Service users were encouraged to access the intervention flexibly and use it as and when they felt appropriate," Todd told Wired.co.uk. That’s because, as he presents in a paper on the platform, for patients “recovery is defined as people living a fulfilling life alongside their condition”. As such, it needs to fit in around them, their lifestyle and their changing needs.

One participant comments: “….for me recovery is certainly not about being symptom free… it is about coping and having a reasonable quality of life, being able to work productively and enjoy things outside of work.”

Thus, Todd explains, “service users did not focus on a ‘cure’ as their desired outcome but instead personally defined recovery goals and improved quality of life.”

By the trial end, Todd found that on average, users who stayed till the end completed 60 percent of the program. Of the people that completed the whole thing — 15 modules — 74 percent took under three months to do so.

The platform took a year to develop, spent looking at the most effective components of psychological therapy for bipolar disorder. As this was narrowed down, the group carried out five focus groups and tested it online via a consultancy group.

The system gets users to identify their own mood using an established scale, the idea being they — and the system — can track their own ups and downs. “Service users would then receive information about the most appropriate modules, given their mood symptoms,” says Todd.

The forum, he says, played a key role in the project’s success. One participant commented, “…part of it [bipolar disorder] is feeling very alone… you don’t get that and I do think that the forum works extremely well with the intervention…” Todd explains how participants used it to support each other not only through the new intervention process, but through life events.

"A balance was struck between allowing participants to offload, and posts which encourage or talk about acts of suicide, self-harm, harm to others and are unhelpful to participants’ recovery." A total of 70 percent of the users signed up to the forum, and 1,927 posts on 130 topics were accumulated. "The participants who used the forum tended to complete more modules, and all participants who completed the entire program used the forum, albeit in different ways."

The idea behind the platform is to help bridge those periods between appointments, or those appointments that a patient misses. As with depression, health services can be known to administer solely medication to help alleviate symptoms. More and more, the NHS is striving to ensure psychological therapy is integrated alongside a prescription for mood stabilizers, such as lithium. “However, severe inequalities in access to psychological interventions for bipolar disorder currently exist in the NHS,” Todd says. “This intervention aims to increase access to psychological intervention.”

Todd tells us the NHS is actively training more staff to deliver psychological therapy, to plug the gap. For now, that initiative is being piloted for severe mental health conditions. “This intervention may fit as part of this initiative in giving service users with bipolar disorder greater access to psychological therapy.

"Computerized interventions are not about replacing face-to-face interventions, but giving someone another option to receive psychological support. In fact, some people prefer accessing psychological support in this way as it fits better with their lives."

For one woman in particular the experience has been, in her words, “life changing”.

She said: “I have encountered insights in the modules that have significantly helped me to survive the blackest moments. I cannot measure the value of this, as it has contributed to their difference between life and death. My husband and I are sincerely grateful for the immeasurable impact this has had on our family.”

For more mental health resources, Click Here to access the Serious Mental Illness Blog.
Click Here
 to access original SMI Blog content

Filed under internet web therapy treatment recover recovery therapist psychology psychiatry counseling online disorder diagnosis bipolar manic depressed depression emotion emotions feeling feelings thought thoughts sad sadness mind body brain wellness health