Inkwell: Authors and Artists

    
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. 
  

    
>  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.
  

    
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. 
  

    
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.
  

    
>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!
  

    

#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.
  

    
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.
  

    
>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?
  

    
> 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.
  

    
>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. 
  

    
#34: Hawthorne
  

    
Say more.
  

    
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.  
  

    
Gary, what kind of reaction to your book have you gotten from your
colleagues?
  

    
>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, 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.
  

    
http://en.wikipedia.org/wiki/Hawthorne_effect
  

    
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.  
  

    <scribbled by fingers Sat 6 Mar 10 11:52>
  

    
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.
  

    
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.
  

    
>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.
  

    
>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.
  

    
>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.
  

    
>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.