Bernards Voices

From Dr. Leslie Becker-Phelps Psychology Today blog, Making Change.

In contrast, kindness brings emotions in more closely. Acceptance calms them and dispenses with their need to defend against a critical adversary. Then, when a person experiences – in an accepting way – their painful emotion, they become more comfortable with it and less upset by it. It still hurts, but they are no longer also feeling distress about having the emotion.

Kindness, compassion … being generous to yourself. These are repeating themes: in Leslie’s posts, and in my visits to my therapist and yoga studio. And from my friend’s recommendation 5 years ago of Naomi Shihab Nye’s poem, Kindness, which Libby and I read at Jack’s memorial service.

I’ve attached two articles from last week’s New York Times that I believe many of you will find interesting (and may have already seen)….

…the first, Learning Empathy by Looking Beyond Disabilities is an account of a program initiated at Ridgewood High School that seeks to create empathy and understanding between teens with and without special needs. I think this is something that could be easily transferable to our community, so I’d love to hear your thoughts.

The second, Expert on Mental Illness Reveals Her Own Fight, was a front page article about a prominent psychologist and researcher who has developed an approach to therapy for those who are at risk for suicide — it is based on her own struggles, and it’s a very inspiring testimony. Moreover, it underscores that slowly, but surely, mental illness is coming out of the closet, and it’s stories like these that are pushing it along. There’s an excellent companion piece by Tara Parker Pope that I’ve also included.

Researchers began tracking the “feminization” of mental health care more than a generation ago, when women started to outnumber men in fields like psychology and counseling. Today the takeover is almost complete.

Men earn only one in five of all master’s degrees awarded in psychology, down from half in the 1970s. They account for less than 10 percent of social workers under the age of 34, according to a recent survey. And their numbers have dwindled among professional counselors — to 10 percent of the American Counseling Association’s membership today from 30 percent in 1982 — and appear to be declining among marriage and family therapists.

May 22, 2011 Benedict Carey reports Need Therapy? A Good Man Is Hard to Find – NYTimes.com.

The reasons for the shift are economic as well as cultural, most people in these professions agree. Managed care took a bite out of therapists’ incomes in the 1990s. Psychiatry, the most male-dominated corner of therapy, increasingly turned to drug treatments. And as women entered the work force in greater numbers, they proved to be more drawn to the talking cure than men — in giving the treatment as well as in receiving it.

The impact of this gender switch on the value of therapy is negligible, studies suggest. A good therapist is a good therapist, male or female, and a mediocre one is a mediocre one.

Studies that I’ve posted on here emphasize that there has to be a good fit, or chemistry, between the therapist and patient. I, personally, have found good that fit with both one woman and two men, but their three styles were different, and that difference helpful.

“Many men like this believe that only another man can help them, and it doesn’t matter whether that’s true or not,” Dr. Levant said. “What’s important is what the client believes.”

Anecdotally, Carey reports, male therapists and male patients both say that topics like sex, affairs, aggression, fatherhood are best discussed within gender.

Ryan McKelley, a psychologist at the University of Wisconsin, La Crosse. “Now I tell my male students, if you’re interested in clinical care, you can write your own ticket. You’ll be hired immediately.”

From May 10th, The New York Times, Alastair Gee reports that “Hazy Recall as a Signal Foretelling Depression”

–in studies under way at Oxford and elsewhere, scientists are looking … to gain new insights into the diagnosis and treatment of depression. They are focusing not on what people remember, but how.

The phenomenon is called overgeneral memory, a tendency to recall past events in a broad, vague manner. “It’s an unsung vulnerability factor for unhelpful reactions when things go wrong in life,” said Mark Williams, the clinical psychologist who has been leading the Oxford studies.

Some forgetting is essential for healthy functioning — “If you’re trying to remember where you parked the car at the supermarket, it would be disastrous if all other times you parked the car at the supermarket came to mind,” said Martin Conway, a cognitive psychologist at the University of Leeds in England. But, a chronic tendency to obliterate details has been linked to longer and more intense episodes of depression.

This is one of my posts, which is just a string of excerpts from the article, but the article is clear, really speaks for itself.

And an unusual paper suggests that overgeneral memory is a risk factor for post-traumatic stress disorder. Scientists at the University of New South Wales in Sydney, Australia, assessed 46 firefighters during their initial training and again four years later, when all had experienced traumatic events like seeing comrades injured or killed. Those who could not recall the past in specific detail during the first assessment were much likelier to have developed the disorder by the later one.

Is overgeneral memory the chicken or the egg? “perhaps overgeneral memory exists in the first place … to block particular traumatic or painful memories.”

Without detailed memories to draw upon, dispelling a black mood can seem impossible. Patients may remember once having felt happy, but cannot recall specific things that contributed to their happiness, like visiting friends or a favorite restaurant.

Some experts think such insights could also be helpful in treating depression. For example, Spanish researchers have reported that aging patients showed fewer symptoms of depression and hopelessness after they practiced techniques for retrieving detailed memories.

Dr. Williams has found that specificity can be increased with training in mindfulness, a form of meditation increasingly popular in combating some types of depression. Subjects are taught to focus on moment-to-moment experiences and to accept their negative thoughts rather than trying to avoid them.

Prof. Murray B Stein MD and Prof. Dan J Stein MD, in The Lancet, Volume 371, Issue 9618, Pages 1115 – 1125, 29 March 2008.

Abstract:

Our understanding of social anxiety disorder (also known as social phobia) has moved from rudimentary awareness that it is not merely shyness to a much more sophisticated appreciation of its prevalence, its chronic and pernicious nature, and its neurobiological underpinnings. Social anxiety disorder is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (eg, personality trait neuroticism) core phenotypes to identify risk loci. A range of effective cognitive behavioural and pharmacological treatments [SSRIs] for children and adults now exists; the challenges lie in optimum integration and dissemination of these treatments, and learning how to help the 30—40% of patients for whom treatment does not work.

Listen to the podcast (interview starts at minute 6:00).

My notes from the podcast–bolded items in abstract plus:

• like sadness vs depression, shyness vs social anxiety exist on a spectrum, and it is the “most shy person you know” where this disorder may interfere with their life, and is worth treatment.
• diagnosable in 5% of the population
• easy to diagnosis.  physician/therapists asks: “Does you shyness interfere with your life?”  A yes answer is a strong predictor.
• stigma:  eg. General Physicians often themselves consider it trivial

Also in the issue Simon Wessely provides a dissenting view, reviewing How shyness became social phobia by Christopher Lane.

Pathologising shyness, eccentricity, or sadness does few any favours—neither those who receive unhelpful labels, nor those with major mental disorders who need all the resources and research we can muster.

In the March 5th, New York Times, Gardiner Harris, reports that insurance does not pay enough to justify a psychiatrist providing talk therapy.

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

When Dr. Levin began his practice in 1972:

he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart.

The article seems to deal, first, with the impact on the doctor–the loss of intimacy and connection he feels with his patients. But that it is insignificant, I feel, compared to the loss to the patients. Many studies conclude that medications, when necessary, combined with talk therapy provide the best results.

I’m not implying that Dr. Levin isn’t recommending talk therapy, he is, but finding a second doctor, either in-network, or paying for it out of pocket, or the patient filling out his own paperwork to get partially reimbursed for the therapy, just adds more and more obstacles to getting care. And many people don’t follow through. If you are suffering, maybe you’re depressed, anxious … just how many hoops are you going to jump through?

“Medication is important,” [Dr. Louisa Lance] said, “but it’s the relationship that gets people better.”

Harris makes a tricky little point below by conflating social workers and psychologists. Psychologists with PhDs or PsyDs have invested quite a lot of money as well, and do more training than social workers. I doubt they are very happy, actually I know from experience, that they aren’t happy with the reimbursement rates from insurers either.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Here is a related post, from March last year. And another post, from January last year.

Psychotherapy Eases Chronic Fatigue, Researchers Say – NYTimes.com.

Good news: cognitive behavioral therapy works!

In the long-awaited study, patients who were randomly assigned to receive cognitive behavioral therapy or exercise therapy, in combination with specialized medical care, reported reduced fatigue levels and greater improvement in physical functioning than those receiving the medical care alone — or getting the medical care along with training in how to recognize the onset of fatigue and to adjust their activities accordingly.

But some patients would prefer believing it is a viral infection, David Tuller reports, and treated (for a lifetime) with anti-viral medications.  And the researchers have some financial ties to medical insurers.  So dismiss the study immediately?

A major difficulty with conducting studies on the syndrome is that there are several different ways of defining and identifying the illness. These variations have led to a wide range of estimates of its prevalence.

Dr. Richard Friedman on Monday offers more commentary in The New York Times–this time his point is that therapy (particularly therapy focused on self-awareness and insight) does not bring happiness.

His article bothered for me for two reasons. The first 2/3 of the article reads anti-therapy.  I don’t like articles that reinforce all the reasons the general public would resist giving it a try.  Some quotes:

• “recent experience [with patients] makes me wonder whether insight is all it’s cracked up to be”
• “demystified his feelings, but had done little to change them”
• “psychoanalysts and other therapists have argued for years”
• “how therapy works (when it does)“
• “the Dodo effect”

The second reason I’m bothered is that he in fact doesn’t believe what he is writing. He wraps up his article by saying: “I realized then that I am pretty good at treating clinical misery with drugs and therapy …, ” but that isn’t the same as creating happiness.

Despite the negativism in the first 2/3 of his article he does endorse therapy, qualifying its relevance using the word clinical: “clinical misery” or “clinically depressed.”  If you are a member of the general public, when do you know if your feelings of sadness, misery, or when you berate yourself or lack focus or energy, whether your symptoms approach the clinical threshold?

See a doctor.

He or she will diagnose.   You don’t know enough to diagnose yourself, and unfortunately articles like this, lessen the chance you’ll pick up the phone and make an appointment.

I’ve posted before on Dr. Friedman.   Here. And here.

In today’s New York Times, Pam Belluck reports on a new study from the Archives of General Psychiatry, and efficacy of treatments for adolescent depression.

About half of adolescents who recovered from major depression became depressed again within five years, regardless of what treatment or therapy they received to get over their initial depression

In the study, nearly 200 adolescents, 12 to 17, received 12 weeks of fluoxetine (Prozac), cognitive behavioral therapy, both, or a placebo pill. (Those not receiving cognitive therapy met with a psychiatrist for basic support.) Placebo-takers who did not improve after 12 weeks could choose any of the other treatments.

Researchers had previously found that those receiving the Prozac-and-cognitive-therapy combination recovered faster from the first depression. So they expected those youths to be less prone to another depression.

But that did not happen. After 36 weeks, improvement for everyone was similar, researchers said, and by two years most completely recovered. But by five years, 47 percent suffered another major depression, no matter what treatment had helped them recover.

The researchers also expected that youths who improved almost fully during the 12 weeks would have less chance of recurrence. They did not, although those showing no improvement at all at 12 weeks were more prone to another depression after recovery than those who showed at least some progress during the 12 weeks. Teenagers who also suffered from anxiety were more likely to become depressed again.

I’ve posted (eg. in March) here many times before on depression: it is progressive, it is chronic, it needs to be attacked aggressively. In my family’s own personal experience it is devastating if not treated.

Dr. Curry said one limitation to the study was that researchers did not look at specific events in the youths’ lives to see if some encountered more stress than others.

I’ve also posted recently (and in August) that having the parents involved in therapy helps. That doesn’t appear to have been considered in this study. My personal theory is that the parents could use the therapy just as much as the kids. We learn so little about how to parent. We do it seat of the pants. And of course we parents may have issues all of our own.

In The New York Times, October 18th, Roni Caryn Rabin reports on the success of “Bringing in the Family to Fight Anorexia.”

Now a new study by Dr. Le Grange, of the University of Chicago, reports that the family approach, called the Maudsley method after the London hospital where it was developed, not only is more effective than individual therapy but also keeps working even after the treatment ends. The study, published this month in Archives of General Psychiatry, is one of just a handful of clinical trials that have evaluated treatments for anorexia nervosa in adolescents. Researchers randomly assigned 121 patients ages 12 to 18, mostly girls, to a year of either family or individual therapy at the University of Chicago and at Stanford — 24 hours in all.

Impressive results:

Twelve months after the treatment had ended, 49 percent of those who had been in family therapy were in full remission, more than double the 23 percent of those who had been in individual therapy. And among patients who were in remission at the end of the treatment itself, only 10 percent of the family-therapy group had relapsed a year later, compared with 40 percent of those who had individual therapy.

[One] therapist told her that parents should not be the “food police,” and that therapy had to get to the root causes of the problem before her daughter would resume eating.

“It doesn’t work that way,” Ms. Brown said in an interview. “You need the physical recovery first, and then the cognitive recovery. The patient is racked with guilt, anxiety, feeling she’s fat and loathsome if she eats — it was our job to be louder and drown out those voices in her head.”