Gary Greenberg (gberg) Thu 4 Mar 10 13:30
That's true, and I never thought of this before, and much of it came from psychiatrists. THe Menningers, Viktor Frankl, Robert Lifton--these were psychiatrists who didn't mind speculating about the human prospect, but also didn't pretend that they weren't speculating.
Jennifer Simon (fingers) Thu 4 Mar 10 13:54
> the idea of a profession that was trying to come to grips with how relatedness worked--I think that was a better idea than a profession primarily occupied with the way our brains work. Is there room in the profession to address both relatedness and the way our brains work? It seems a logical place for the two to meet. They're not really separable anyway.
Gary Greenberg (gberg) Thu 4 Mar 10 14:05
I suppose there is, but it's not modern psychiatry. Case in point: I went to Mass General Hospital to enroll in a trial for antidepressant treatment of minor depression. A Harvard psychiatrist interviewed me, using a test called the Structured Clinical Interview for the DSM-IV. He determined that I was not minorly depressed, but rather majorly depressed. The fact that I had traveled eighty miles, arrived on time, well groomed and alert, and was joking with him and talking about fairly sophisticated neuroscientific stuff in between his questions, that, in other words, the way I related to him didn't seem majorly depressed at all, didn't enter into his diagnosis. Why not? Because it's not supposed to. What he's supposed to do is add up the numbers and make the diagnosis, to keep his eyes on the notebook and not the person.
Jennifer Simon (fingers) Thu 4 Mar 10 14:15
So maybe what's needed is to bring back relatedness without casting out the effective parts of dealing with the way the brain works. There are a lot of different approaches to the latter, too. There seems to be a widening gap between the DSM and neurology.
Mark McDonough (mcdee) Thu 4 Mar 10 14:18
>Viktor Frankl Yes, the famous author of "Man's Search for Prozac." ;-) Your description of the "Structured Clinical Interview" is sad and in a somewhat pathetic way, funny. It's interesting how many sectors of our culture have become obsessed by quantifiable metrics and a desire for efficiency. In part, this reductionist tendency is driven by money, but not entirely. It seems like a way of attempting to gain a certain sort of mastery, even if illusory, over the more mysterious aspects of life, be they the gyrations of financial markets or the inner workings of the depressed mind. But I'm only speculating and philosophizing!
Lena M. Diethelm (lendie) Thu 4 Mar 10 17:10
#28 - In my most major of depressions, I could have done what you did in getting to & behaving in that appointment. Many of us serious depressos are perfectly capable of hiding how bad it is from the world. I know many people like me. So in that sense, it could be from your perspective he was wrong or he could see beneath or through (or the test did) your presence. I've been reading the book in bits and pieces. One thing that occurred to me is that you see depression having been dealt with like something such as Restless Legs Syndrome is now. A "syndrome" that some people have that now has a name, doctors to diagnose it and treat it. Some say it's a manufactured syndrome. FWIW. A side question, our cat Sweetie Pie was biting and snapping a lot, unpredictably. She appeared upset a lot. We ended up putting her on Prozac which has helped tremendously. Now she doesn't have any outside info like humans about doctors and medicine. She definitely improved. Now we want to titrate her off it which should be a challenge given how hard it can be withdrawing humans from Prozac. Maybe hard isn't the word - challenging due to the detox process. So is it manufactured for animals as well? It would be interesting to see what the various "therapy" professions ( I include psychiatrists) would be like if no insurance process was involved. We don't know what any of this could be like if it weren't mediated by 3rd party rules and procedures.
Sharon Lynne Fisher (slf) Thu 4 Mar 10 21:29
I saw a therapist for about a year after my divorce. The thing is, just the process of having to get up and shower and dress and drive the 15 miles into the city and then back again was enough to cheer me up as it was. I could never figure out whether the therapist did anything at all.
Gary Greenberg (gberg) Fri 5 Mar 10 04:12
>In my most major of depressions, I could have done what you did in getting to & behaving in that appointment. Many of us serious depressos are perfectly capable of hiding how bad it is from the world. I know many people like me. So in that sense, it could be from your perspective he was wrong or he could see beneath or through (or the test did) your presence. One of the things I write about in the book is the way that depression (as a disease, not merely a description of a feeling) has changed from a condition that is life-threatening and debilitating to the point of requiring hospitalization to something that you can have even if you are still capable of hiding it from the world. How this happened is what my book is about, and I think the history that's in there helps us understand why this expansion is a problem. Restless legs syndrome is a purer example of disease mongering than depression. I wrote about that in my last book, The Noble Lie. You can see the corporate strategy very clearly in RLS--from the time that Requip began to be promoted as the cure for a disease that no one ahd heard of to the time that the disease itself was described. All this happened before the consumer advertising started. >A side question, our cat Sweetie Pie was biting and snapping a lot, unpredictably. She appeared upset a lot. We ended up putting her on Prozac which has helped tremendously. Now she doesn't have any outside info like humans about doctors and medicine. She definitely improved. Now we want to titrate her off it which should be a challenge given how hard it can be withdrawing humans from Prozac. Maybe hard isn't the word - challenging due to the detox process. So is it manufactured for animals as well? Does the fact that Sweetie responded well to a drug mean that she was sick in the first place? That's probably not a very important question, cat-wise. But humans engage in self-understanding, and once we start to think of ourselves as sick, that self-understanding changes. I mean, if you take LSD and you have one of those moments of cosmic revelation and your life is changed forever, does that mean you were sick to begin with? And if it does mean that, does that change the nature and meaning of your transformation?
Gary Greenberg (gberg) Fri 5 Mar 10 04:54
> saw a therapist for about a year after my divorce. The thing is, just the process of having to get up and shower and dress and drive the 15 miles into the city and then back again was enough to cheer me up as it was. I could never figure out whether the therapist did anything at all. I love this story! And you'll be glad to know, Sharon, that scientifically speaking no one else can figure that out either. Or to be more specific, since 1937, researchers have been trying to figure out how (and if) therapy works. And the thing they keep coming back to is that there is no specific ingredient or orientation or intervention that works better than any other. The only thing that matters, statistically speaking, is therapeutic alliance (how much the patient believes in the therapist) and therapist allegiance (how much the therapist believes in what he is doing). This is known as the dodo bird effect, because the first paper about it was called "Everyone Wins and All Must Have Prizes," the Dodo Bird's verdict from Alice in Wonderland. One way to say this is that it's all placebo effect. Another way to say it is that intimate, caring relationships are healing, even when they're bought and paid for and parceled out by the hour.
Gary Greenberg (gberg) Fri 5 Mar 10 05:07
>It would be interesting to see what the various "therapy" professions ( I include psychiatrists) would be like if no insurance process was involved. We don't know what any of this could be like if it weren't mediated by 3rd party rules and procedures. I can say a little about this. I write in the book about what I do when patients ask to use their insurance to pay for therapy. I explain that I don't participate in any panels, but I will give them a statement that will allow them to seek reimbursement for out of network services, which many policies in Connecticut have. But then I explain th I will have to diagnose them with a mental illness and how this diagnosis will become part of their permanent medical record. Most people find this surprising. In some cases, I tell them what mental illness I think they have, but more often I give them some choices, including not diagnosing them, and making our relationship strictly between us, which means cash on the barrelhead. I haven't kept statistics on this, but at any given moment, probably half of my practice is done without third-party payers, which means no diagnosis. This costs me a little money, of course. But it gains me self-respect. I don't have to try to reduce the patient to the little boxes on the treatment reports that companies often require, nor do I have to figure out what to say in order to get services extended, or, in other words, I don't have to lie. It also changes the nature of the therapy relationship, especially since this decision gets made early on, and alerts the patient to the fact that I am not screwing around when it comes to honesty, that I am not going to enter into a collusion with them, at least not without making it clear that this is waht we are doing. And it obviates the need for a person to feel any worse about having to see a therapist, i.e., to feel like a mentally ill person. The interesting thing about this, however, is how little difference it ultimately makes in what we do in therapy, which tells you something about the significance of diagnosis. It's not like "adjustment disorder, mixed emotional features" or "major depression" tells me much about how to proceed, and to the extent that it does make a difference, it's not the label that matters. It's the impression that I get that would lead me to that label in the first place. DIagnosis give you an idea of what to look for--i.e., if someone is depressed, you shouldlook for suicidal thoughts; if someone has PTSD, you should find out about reactions to sudden stressors--and how to put together a clinical picutre--i.e., if a person is anxious and sleepless and has an exaggerated startle response, you should think PTSD and look for a traumatic event. It also gives you a shorthand to use with your colleagues. But psychiatric diagnosis is really different from, say, infectious disease diagnosis, where specifying the problem is directly tied to the solution.
Sharon Lynne Fisher (slf) Fri 5 Mar 10 05:15
Gary Greenberg (gberg) Fri 5 Mar 10 05:30
Steven McGarity (sundog) Fri 5 Mar 10 20:01
Thank you for the continuing discussion. I find it very thought-provoking. Diagnosis is a very large issue of course. Last year I was doing a major amount of therapy work with the VA in Austin, as much as I wanted really. I know my lead psychologist wandered around my diagnosis quite a bit. I did a lot of testing and talk and other people were involved as well. There was a large group of PhD therapy people and rarely was a psychiatrist ever to be seen there. I think it was a lot to do with the intimate caring relationship, you mention. Not so much as a placebo but just that someone cared enough to ask specific questions and listen. Somewhat the problem with that is circling the same ground again and again. Groups can be bad for that. After a while I can often do everyone's part if I wanted. There never seemed to be any breakthrough, or even any movement at all. That gets boring! If we could only learn tools for coping. What's wrong is only opening the door. Does it really even matter? I got involved because I questioned my decision-making processes. Stopped trusting my decisions. And I hoped I could fix that. I looked around and didn't like what I saw. And obviously it was me, my problem. I can't say I have made any progress at all with that but I do still try at least. I stay pretty withdrawn from people and relationships. I try and force myself to get out and mingle in a few things. I usually like it when I do. I can feel myself shifting into spring as the days get longer. Not sure what will happen next.
Lisa Harris (lrph) Fri 5 Mar 10 21:38
Gary, what kind of reaction to your book have you gotten from your colleagues?
Gary Greenberg (gberg) Sat 6 Mar 10 04:20
>I think it was a lot to do with the intimate caring relationship, you mention. Not so much as a placebo but just that someone cared enough to ask specific questions and listen. I think that this is probably what the placebo effect is. It's just that with the ascendance of scientific medicine it has acquired this bad reputation. Even the name--placebo, which comes from teh Latin for "I will please"--connotes a kind of condescesion, as if the physician is merely humoring someone who is too stupid to get better from medicine. But medicine worked for thousands of years largely on the placebo effect. And it still does, even if doctors don't want to admit it. I should add that I do think that scientific medicine is largely a good thing. Treating pneumonia or syphilis with mercury, as they did up to the nineteenth century (20th in the case of syphilis), is definitely not as good as treating them with antibiotics. But the discovery of these magic bullets has turned too many doctors into gunslingers. (which, by the way, I think is a very good thing, at least when it comes to things like curing infection; it's just that it has this tendency to overstep its bounds)
Gary Greenberg (gberg) Sat 6 Mar 10 05:02
>Gary, what kind of reaction to your book have you gotten from your >colleagues? I think there's a sector of the mental health industry that has been waiting for someone to say some of what I'm saying. It confirms somethign they've suspected--that the diagnosis has gotten out of hand, and that there is more than science involved--and provides historical and scientific evidence that this isn't just an impression. So these folks have been grateful. On the other hand, people like Peter Kramer, the author of Listning to Prozac, are fairly dismissive. (In the case of Kramer in particular, I can't fault him--I take him on fairly directly, if respectfully, in this book.) In general, I think that the people I call "depression doctors" in the book are convinced of the scientific accuracy of what they are doing, which in turn means that they think they are on the side of light and knowledge in their identification of depression as a disease (i.e., an unncecessary form of suffering) and people like me are married to a romantic view of melancholy and thus wishing pain upon all of us. It's hard for me to understand this, given that my book is in part a memoir of my own depression and I clearly don't relish it, but this is usually how doctors react to being criticized about this stuff--by accusing the critic of being on the side of sickness and pain. But I think that in general the reaction has been confusion. This doesn't surprise me--the book is stirs up a lot more questions than it answers, and I am sort of your classic unreliable narrator. IN the book, I admit to being a drug abuser, an adulterer, and a depressive who pranks doctors and does some unconventional things with my patients. The book starts with my confusion about whether or not depression is a disease and ends not with a firm yes or no, but with a different and more unsettling doubt: about whether it is possible, or even a good idea, to resist the impetus behind the disease model--the rendering of all human experience as neurochemistry. Not that I don't have an opinion about this, but I admit in the end that my opinion is largely faith-based, that I can't submit evidence, scientific or otherwise, for my conviction that there is something human that transcends our molecules, that this is just a story that could well be wrong. So a certain amount of bewilderment is inevitable, and it may be asking too much of a reader to persist through all the history and science, no matter how entertaining the anecdotes are, only to end up with so much uncertainty. Some people react to this by complaining--a review that otherwise seemed fair and reasonable, and even positive, was titled "An Unstaisfying Mess." Others seem to exult in it--another review that called it "dazzling and dizzying." But for the most part, people can't seem to figure out what to do with it, or, more commonly, they try to make me sound much more certain of myself than I am. So Luke Menand, in the New Yorker, said that I thought that depression was a capitalist conspiracy to slap a smiley-face sticker over our social problems, and that I think antidepressants are evil==the first a vast oversimplification and the second just plain inaccurate. And the reporters and tv/radio hosts I've dealt with are mostly impatient to get to the part that will get people screaming at me or each other. I think that the antidepressant/depression debate, like most of our cultural/political debates, long ago polarized, and I think it's very hard to escape the gravity of that kind of narrative.
Sharon Lynne Fisher (slf) Sat 6 Mar 10 07:19
Steven McGarity (sundog) Sat 6 Mar 10 08:52
Thanks for the Western Electric link. Lot of neat stuff in Industrial Psychology, especially in that early Progressive era. >romantic view of melancholy Interesting viewpoint. If it were true that it was all neuro, then we are just waiting for the map. Plug me in and get a print-out. Adjust me to the norm. And there lies the problem of course. And still we haven't considered how drugs address trauma or abuse unless we are just talking sedatives. The driver should be to keep the "patient" functioning in society. It still becomes more a skill set than a med kit. But, if they would make me feel better? It's a hard question. I was pondering whether in their zeal to be the only script writers it turned out in the end writing script was all the psychiatrist could really do.
Jennifer Simon (fingers) Sat 6 Mar 10 10:53
<scribbled by fingers Sat 6 Mar 10 11:52>
Jennifer Simon (fingers) Sat 6 Mar 10 11:51
Mmm, no, the map only describes the territory. Finding a way through the wilderness takes more than that, and we're a long way from even having a map yet. It's more like a few sets of squiggly lines and spirals on the side of a boulder at this point. I can't quite see how all human experience wouldn't come down to neurochemistry, from one point of view, but then I don't see what would be so awful about that. From another point of view, all human experience comes down to stories. What things come down to is not all they are and varies depending upon how you look, besides. What is unnecessarily limiting is only looking one way.
Gail Williams (gail) Sat 6 Mar 10 16:19
Oddly, I read "looking" in the other sense, referring to the object being seen, rather than as a verb actively undertaken by a subject. What's appropriate (or healthy) depends on how you look, in both senses. That brings up the social context for all of this. Part of depression is social - a reaction to bringing other people down. If you take the example of bereavement, something human society has sympathy for, you will generally see that if we know you were recently widowed, we will collectively put less pressure on you to get over it and just make yourself upbeat, more willingness to allow you the time to heal slowly. Traditions like having a widow wear black explain the situation to strangers. She (or he) looks so sad, why not just say "cheer up!" The current crop of TV ads about depression have a subtext of how depression hurts everybody around the protagonist/patient. Part of the marketing seems to be directed at those people who are not affected. They probably work to increase general acceptance of psychotropic drugs in this context, which is presumably a better state of affairs than the old taboos. To some degree, the social aspect is wildly different than the brain chemistry and illness model, and it's odd seeing it mashed together, but that's the human brain for ya. What a complicated area this is.
paralyzed by a question like that (debunix) Sat 6 Mar 10 17:49
>I don't have to try to reduce the patient to the little boxes on the treatment reports that companies often require, nor do I have to figure out what to say in order to get services extended, or, in other words, I don't have to lie. It's not only a problem in psychiatry and psychology. I'm a rheumatologist, and I have plenty of patients where we have to do a silly dance to get them the care they need. They don't fit diagnostic criteria which are designed to group very similar patients under a single umbrella to facilitate clinical research, where you generally want a uniform group of patients you can divide into different treatment groups, or track over time. Lots of patients don't meet criteria but still have clear and convincing disease, and trying to get insurers to pay for stratospherically expensive treatments is a nightmare when criteria aren't met. And many of the diagnostic criteria change when we get new diagnostic or therapeutic tools that help distinguish between diseases....like peptic ulcers mostly morphed into Helicobacter pylori infections, treated with antibiotics.
Gary Greenberg (gberg) Sun 7 Mar 10 11:44
>I can't quite see how all human experience wouldn't come down to >neurochemistry, from one point of view, but then I don't see what >would be so awful about that. I think the first part is right, not so sure about the second. Much depends on who has the knowledge and what they will do with it. One of the differences between earlier theories of mind and neuroscience is that most of the earlier ones were somewhere in the neighborhood of understandable to regular people. I mean, take out the ego/id/cathexis/complex mumbo-jumbo (and, as Bruno Bettelheim pointed out, much of that language was due to a translation made intentionally obscure by people other than Freud) and you basically have a narrative device, a myth that guides the assembly of biography. And everyone can tell a story about themselves, especially a story about their parents, their upbringing, and their love lives. Even if it's wrong in many of its particulars, still it's a democratic narrative device. On the other hand, the neurochemical account of the self is impenetrable to most of us. So the people who wield it have the power to understand and, potentially, to control us. I'm not talking conspiracies here, just the way power tends to work in a free society. If you have a bunch of highly educated, authoritative doctors telling you that you have an imbalance in your brain chemistry, and that this means your depression is more like diabetes than despair, that's going to change the way you see yourself and your suffering. It's also going to move you in the direction of taking the cure, and, not that I have anything against drugs, but I don't know if we understand Prozac consciousness well enough to be able to say that those drugs, especially when taken to treat a chronic illness, are benign. So to me the neurochemical account of selfhood is an inevitable one, but it is also frightening, because it carries the risks of losing control of our own stories.
Gary Greenberg (gberg) Sun 7 Mar 10 11:49
>The current crop of TV ads about depression have a subtext of how depression hurts everybody around the protagonist/patient. Part of the marketing seems to be directed at those people who are not affected. They probably work to increase general acceptance of psychotropic drugs in this context, which is presumably a better state of affairs than the old taboos. To some degree, the social aspect is wildly different than the brain chemistry and illness model, and it's odd seeing it mashed together, but that's the human brain for ya. Wider acceptance of and tolerance for drug use is a good thing overall, but only if it accompanied by justice. 800,000 people a year get arrested for using one drug--pot--presumably to make themselves feel better. Those ads are just peer group pressure turned on its head. My book is nowhere near as critical of positive thinking as Barbara Ehrenreich's Bright-Sided, but it has the same basic critique: that the myth we live by--that adversity is alwasy something we should overcome--can be oppressive and woefully insensitive to the particulars of people's lives.
Gary Greenberg (gberg) Sun 7 Mar 10 11:57
>I'm a rheumatologist, and I have plenty of patients where we have to do a silly dance to get them the care they need. Yeah, it's totally nuts. The difference I see is that when you do that as a rheumatologist, it is not in the context of getting money to pay for a treatment which is, at its core, supposed to be about honesty. I don't mind colluding with my patients against the insurance companies, but we must both know that is what we are doing, and generally talking about it puts limits on our dishonesty. I won't, for instance, trump up a garden variety malaise into major depression. This isn't just an ethical point, or even mostly an ethical point. It's a clinical one. Bad faith is often the disease, so it shouldn't be part of the treatment. In my book, I talk about a case of a woman whose mother died on the same day that she discovered that the man whom she thought was her father was not, at least not biologically speaking. One of those coincidences that if you put it in a novel, your editor would say, "Nah." She hadn't had the best life up to that point, and this reallly put her into a tailspin. It seemed ridiculous to call her sick, since who would not be pretty darn upset about this, and yet she qualified for the major depression diagnosis.
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