by Barry Duncan
Imagine a future in which the arbitrary distinction between mental and physical health has been obliterated; a future with a health care system so radically revamped that it addresses the needs of the whole person--medical, psychological and relational. In this system of integrated care, psychotherapists collaborate regularly with MDs, and clients are helped to feel that experiencing depression is no more a reflection on their character than is catching a flu. This new world will be convenient: People will be able to take care of nearly all their health needs under one roof--a medical superstore of services. It will be great for therapists, too, providing them with a seemingly inexhaustible stream of client referrals from the enormous pool of patients who, in earlier times (today), would have mistakenly identified their complaints as primarily physical.
Now, imagine a future in which every medical intervention in a patient's life is a matter of quasi-public record; in which therapy is tightly scripted and only a limited number of "approved" treatments are eligible for reimbursement. A future in which recalcitrant patients can be tracked and forced to undergo treatment, and in which therapists must serve as compliance cops for health management organizations and insurance companies. In this brave new world, integrated care actually means a more thoroughly medicalized health care system into which psychotherapy has been subsumed. Yes, therapists will work alongside medical doctors, but as junior partners, following treatment plans taken directly from authorized, standardized manuals.
These are not two different systems; rather, they are polarized descriptions of the same future, one that draws nearer every day. Make no mistake: A seismic change is coming to the American health care system. The age of integrated care is upon us, and psychotherapy may soon be incorporated in a way that will profoundly affect how and where it is practiced. But what will this new system really look like? How will therapists--and the therapeutic process--fit into it? What values will lie at its core? Although there is no question that a new system is coming, the nature and structure of this new system are still very much up for grabs. And this means that, for therapists, the future poses both tremendous opportunity and grave threat.
One version of the future--the one envisioned by such advocates of "reform" as the American Medical Association and the leading managed care companies--is of a seamless web of services that quickly identifies patients' true needs and efficiently delivers patients to the right professional for the correct treatment. The other vision--therapists' vision--has yet to be fully articulated, largely because most of us are still adjusting to the changes wrought by managed care and unaware of the implications of what's coming.
We have the opportunity now to present our vision, to argue for the holistic integration of medical and psychological services in a way that is true to the core principles of psychotherapy. We must resist the inevitable attempts to define therapy as, in essence, a treatment that gets dispensed by a professional to a patient and argue instead for therapy as a process of change that is entered into by client and therapist working together as allies. And it is critical to do so now, when psychotherapy is on the brink of another tectonic shift that could well discredit the majority of approaches therapists use today.
Carving In, Carving Out
To understand what lies ahead for the field of psychotherapy, we must first review some basic principles of health care economics. To state the matter in accountants' terms, mental health services have traditionally been "carved out"--handled and paid for separately from general health care costs and considered to be distinct from patients' medical needs. Most of us have grown accustomed to the idea that the point of entry for taking care of our medical needs is different from that of our mental health. Currently, 88 percent of the mental health cases are handled in this way. But experts such as noted psychologist Charles Kiesler--whose critical commentary on the accuracy of psychotherapy research and the expense of inpatient psychiatric care has been a springboard for policy discussions for more than 30 years, and who, in the mid-1980s, predicted that fledgling MCOs would soon dominate the American health care industry--see another sweeping change in the offing. Soon, they say, behavioral care, like most other medical specialties, will be "carved in"--that is, mental health services will be treated as an integral part of medical patient care and administered accordingly, with all the advantages and liabilities that entails. According to Kiesler, the changes to be ushered in by carve-ins will be "as dramatic as the computer revolution."
The reason for this coming change, of course, is the tremendous pressure on health care administrators to reduce spiraling costs, especially those that are racked up by patients who repeatedly seek medical treatment--often expensive specialty consultations--for complaints that are at least partly due to undiagnosed psychological issues. A typical scenario goes like this: A patient visits a physician or emergency room with a physical complaint, say neck pain. Doctors treat his physical symptoms, but don't refer him to a therapist, who might help him tackle the stress contributing to his symptoms. As a result, his neck pain flares regularly and he frequently seeks treatment from doctors. This pattern may repeat for years unless and until his behavioral problem is identified.
Over the last four decades, studies have repeatedly shown that as many as 60 to 70 percent of physician visits actually stem from psychological distress that finds somatic expression. Advocates of carving in behavioral care say it will not only save money, but will bring real advantages to therapists and patients alike. Imagine that before even meeting a client you could open a computer file and learn that her doctor put her on Prozac some years ago when her mother died of congestive heart failure. Curious about the mother's mental health history, you could click on the link to "familial predisposition" and find that the mother, too, had been treated for chronic depression. If such information were available to you in advance, argue advocates for carving in care, you'd obviously be better prepared to meet this person, and you'd have a deeper understanding of her situation.
And here's another apparent advantage of bringing together the medical and psychological disciplines: It becomes easier to provide care for people with disorders like chronic pain and insomnia that don't clearly fit into DSM categories; for people whose disorders are medical but clearly have psychological or relational components, such as irritable bowel syndrome and high blood pressure; and for people who fit into multiple categories, such as alcoholics with renal system problems.
The advantages of this new, collaborative system are evident in the case of a woman I'll call Kathy, a 23-year-old retail worker. Kathy was a client of family therapist Tom Mahan at the innovative Marillac Clinic in Grand Junction, Colorado--a model of how the integrated health care system of tomorrow can function at its best. She went to the clinic complaining of nausea, fatigue, feelings of helplessness and a constant burning in her chest. Kathy had seen six doctors in five years, and each one had told her she had no medical problem. Most recommended that she see a therapist, but she had rejected the idea that she had a "mental problem" and never followed this advice.
Then she visited the Marillac Clinic. She was seen first by a doctor, who conducted a sophisticated assessment of her biomedical, psychological, social and even spiritual life. At the end of the interview, the doctor told her that while she might have gastroesophageal reflux disease (GERD), psychosocial factors, such as high stress, relationship difficulties and perhaps depression, exacerbated her illness. He asked if Kathy would be willing to meet with "a behavioral care specialist" for some additional input and Kathy gave a tentative "maybe." So Mahan joined the interview and, in the course of an amiable chat, was able to demystify psychotherapy and explain the relevance of Kathy's emotional state to her physical complaints. By the end of the session, Kathy had agreed to meet with him to work on managing her "stress."
They met for three sessions. Kathy liked Mahan and felt she was finally making progress. While she responded positively to the treatment for GERD, which included medication and dietary changes, as well as to an antidepressant prescribed by the intake physician, she also began examining the psychosocial stressors in her life. Kathy talked about her dead-end job as a retail clerk, her frequent arguments with her boyfriend and her wish to move out of her parents' home. With Mahan's coaching and support, Kathy became more assertive in managing her own health: She learned more about GERD, formulated questions for her physicians and transformed from docile observer to active, informed consumer.
Her newfound confidence manifested itself in other areas of her life as well. She became more assertive in her relationship with her boyfriend and her family, as well as in her job. She moved away from home, started a walking regimen and finally got the wire-haired fox terrier she always wanted. In short, Kathy learned to speak up for herself and to act more decisively in her own interests. During a follow-up interview, she told Tom she was in better health and was paying more attention to her own needs. Kathy's new confidence also helped land her a more responsible position at work.
Integrated care was a godsend for Kathy. Aided by medical and behavioral professionals working in concert, she made changes in every facet of her life. Had Kathy not entered an integrated system, she might have continued to show up in the emergency room or the cardiologist's office, receiving costly, ineffective services. If she had encountered integrated health care from the beginning, she might have gotten the help she needed earlier and avoided the frustration of repeated but futile visits to doctors.
This is the beauty of an integrated system, its supporters say. Patients get a reliable diagnosis from a properly trained professional and no longer need to diagnose themselves. They get the medical and therapeutic care they need quickly and cost effectively. The system becomes more coherent--with mental health services easily available, but only through the primary care physician. The bottom line: Carve-ins--done right--increase collaboration, improve care and make psychotherapy more central to health care. And save insurance companies a lot of money.
The Nightmare of Integrated Care
So if carving in offers all this, why do many therapists fear it could undermine our relationship with clients, rob us of our creativity and challenge the fundamental values that underlie good psychotherapy? While the case of Kathy and the Marillac Clinic represents integrated care at its best, such success stories can lull us into underestimating the insidious and deeply ingrained mind-set of the traditional medical model--the idea that proper diagnosis plus prescriptive intervention equals effective treatment. What is obscured is the very real danger that in the name of "integration," psychotherapy will become ever more dominated by the assumptions of the medical model. At issue here is not the theoretical advantages of greater collaboration among health care professionals or bringing more of a therapeutic perspective to bear on medical conditions, but whether we will lose our bearings--and our autonomy--as a profession by becoming immersed in the powerful professional culture of biomedicine today.
To understand the potential danger of carving behavioral care into an integrated system, consider the case of a 15-year-old girl we'll call Carrie. Each morning, she would say goodbye to her mom and walk toward the bus stop near her home in one of the pleasantly named, planned communities that form the suburbs of a large southeastern city. But instead of getting on the bus, she'd walk to a friend's house, where she would spend the day, returning home just as the afternoon bus drove down the street. If not for the notices the school eventually mailed home, her family might never have learned what was going on.
Perplexed about her aversion to school, weary of her rebelliousness and her contentious attitude and frightened by her profound sadness, Carrie's mom took her to the family's HMO. A doctor there noted Carrie's depression, prescribed an antidepressant and recommended psychotherapy. During her visit the next week to the therapist to whom she had been referred, Carrie revealed that she'd been going into the kitchen late at night and making scratches on her arms and legs with a knife. The alarmed therapist admitted Carrie to the hospital. After three nights, she was diagnosed with depression and sent home with orders to take her meds, see the therapist regularly and come back to the hospital psychiatrist on a monthly basis.
In this case, the early referral for psychotherapy was no panacea. Carrie's therapist saw a collection of symptoms rather than a person and focused on alleviating those symptoms with the most efficient intervention at hand--medication. What happened next reflects the pitfalls of applying the medical model to complex interactional problems--when people don't respond to prescribed treatment, they are seen as "resistors" and, when in doubt, a hierarchical, medical system is likely to escalate its "treatments" in ways that compound, rather than resolve, problems.
Carrie didn't want to take the antidepressant prescribed--she said it "made her skin crawl." But in the face of the authority of the medical system, and at the insistence of her mother and the therapist, she took it anyway, and continued to feel bad and cut herself. Once, she even ran into traffic in an attempt to still the tumult inside her. Her friends ran after her, calmed her down and made sure she took her next dose of medication. But when her mother saw the scratches and the continued despair, she called the therapist and, in the next stage in the escalation of her treatment, Carrie again found herself in the hospital. At the hospital, the doctor diagnosed a Bipolar Disorder and added an anticonvulsant to her medication regimen.
But Carrie didn't want more medication--she hated the way she felt when she took the pills, and she wanted to "rule" her feelings without drugs. She just wished she didn't feel so sad. But the therapist and other health care professionals involved with her believed they knew the root of Carrie's problem--Bipolar Disorder--and were emphatic about the importance of the medication, reminding Carrie's mother that it was her legal responsibility to ensure that her daughter never missed a dose. Responding to the therapist's warning, Carrie's mom continued encouraging her daughter to take her pills and Carrie persisted in cutting herself to relieve her distress. All told, she was admitted three times to the hospital, was variously diagnosed with depression, Bipolar Disorder and Borderline Personality Disorder and was prescribed several antidepressants, lithium and an anticonvulsant.
Fortunately for her, Carrie's story doesn't end here, but let's pause to contemplate the mental health care she received in a system insidiously dominated by diagnostic thinking and a hierarchical treatment model. Even in an HMO in which therapists were closely involved early on in treatment, just as is proposed in the integrated care model of the future, Carrie was first required to be a patient; second, to see her problems as medical; and third, to listen and follow orders--her own capabilities and perspective on her problems were never enlisted in her treatment. No one ever really asked her what she wanted, or formed a personal connection with her.
Integrated care, in and of itself, does not provide safeguards that would prevent the kind of treatment Carrie received. In fact, the monolithic power of such a consolidated system, becoming, in effect, a court of last resort for health care, should alert us to its possible dangers. Of particular concern should be an element that its proponents consider a cornerstone of the health care of tomorrow--the integrated data base. With such a comprehensive, computerized record-keeping system of a patient's entire medical and psychiatric history, Carrie's treatment would permanently follow her, available to anyone with access to the system. Ten years from now, she might be unable to get insurance or join the military. And her history of suicide attempts and diagnoses of Bipolar and Borderline Personality disorders could easily affect her career prospects and even her personal relationships. Employers and colleges routinely question applicants about medical history. DSM disorders hardly qualify as preferred credentials on such applications, nor is a history of mental treatment usually included on a resume. In fact, background checks for any reason would take on ominous overtones in a system that would document "mental illness" as part of the medical record.
As it was, Carrie's treatment took an unexpected and fortuitous turn. Her truancy triggered involvement by juvenile authorities, who ordered her to receive treatment from a home-based therapist. Now outside the domain of the medical system, the focus of treatment shifted from Carrie's individual symptoms to understanding the fuller context of her life. The new therapist's first step was to include all Carrie's family members, not just her mother, in treatment. With their help, she began to develop a more complete picture of Carrie--that she was everyone's pet, and everyone's headache. The therapist learned about her karate class, about her love for the horses she cared for on the weekends and about her passion for Egyptian archaeology. The family began a home-schooling program and Carrie's mother took on responsibility for helping her daughter with her daily schoolwork. The therapist also learned, for the first time, that Carrie had been sexually abused by a friend's father.
After three months, and many intense family meetings, Carrie argued less, had stopped cutting herself and had decided to go back to school. At one point, after Carrie broke up with her boyfriend, the therapist worried that the scratching might go deeper and enlisted Carrie's family and friends in a 24-hour support network. They scheduled "check-in" points throughout the day, and Carrie and her family weathered the crisis. After six months of gradually less frequent visits with her therapist, Carrie experienced fewer periods of depression and returned to school.
In short, Carrie was finally helped by good old-fashioned therapy--the kind that entails listening to clients, meeting them in their own worlds and on their own terms and supporting them as they construct a life based on renewed confidence in their own capacities. But how would one translate this kind of treatment into medical terms? A health care system organized by traditional diagnostic thinking that addressed Carrie's symptoms had trouble grasping the larger context of her life.
Clearly, the initial involvement of a therapist in this case was no guarantee of the engagement of Carrie and her family that proved to be pivotal in the work with her. But it would be a mistake to simply write off the treatment Carrie initially received as simply bad therapy. In fact, it may closely resemble the kind of experience patients will receive within many integrated care systems. Why? Because this initial approach is far more consistent with the traditional medical-model thinking that permeates our health care system at all levels--match the right clinical method with the correct diagnosis.
And, in what is perhaps the most disturbing development that may determine the nature of "integrated" care in the future, the major professional associations have begun to position themselves as champions and adjudicators of a distinct set of "approved" interventions for targeted diagnostic groups that, in fact, ignore much of what we have learned makes therapy work in the first place. It is this fundamental misconception within the discipline itself about what constitutes effective psychotherapy that poses the gravest danger for our field.
The Myth of Evidence-Based Practice
In spite of the call to provide a bridge between therapeutic methods and scientific findings, the growing ascendancy of evidence-based practice may also be understood as the product of increasing competition among the mental health professions. Since the 1980s, the number of mental health practitioners has jumped by some 275 percent. Consumers can currently choose among psychiatrists, psychologists, social workers, counselors, marriage and family therapists, psychiatric nurses, pastoral counselors, addiction counselors and many others advertising their services under a variety of job titles and descriptions. In response, the various professional groups have felt an urgent need to document the scientific efficacy of their preferred approaches. In the early 1990s, members of the American Psychiatric Association (APA) decided that they should take the lead in determining the best treatments for the various diagnostic subgroups. So in 1993, the APA established the Steering Committee for Practice Guidelines to prepare guidelines designating specific treatments for specific disorders.
Beginning in 1993 with guidelines for Major Depression and Eating Disorders, the committee has produced guidelines for 10 disorders ranging from Bipolar Disorder to Alzheimer's Disease to Nicotine Dependence. Practice guidelines cover everything from treatment planning to psychiatric management and treatment selection for each of the disorders. More recent guidelines, issued since 1997, also include "practice parameters," ranging from "standards" (should be followed with few exceptions), to "guidelines" (exceptions are not rare, but require justification) to, finally, "options" (where there is no preference between choices). Yet, despite the committee's claim to strong empirical support for its recommendations and reliance on overwhelming clinical consensus, these guidelines have been criticized for treating open therapeutic questions about treatment effectiveness as though they have been definitively settled. For example, the guidelines for the treatment of depression are heavily skewed toward pharmacological intervention, despite the questionable evidence of the efficacy of drug therapy and the fact that studies show that psychotherapy with depressed people provides at least as much--and perhaps longer-lasting--symptom relief. However, the APA's imprimatur has given an aura of scientific legitimacy to what was primarily an agreement among psychiatrists about their preferred practices, with an emphasis on biological treatment.
The other APA, the American Psychological Association, was quick to follow psychiatry's lead, arguing that clients have a right to proven treatments. In 1993, a special APA task force, deriding psychiatry's approved treatment list as medically biased and unrepresentative of the clinical literature, set forth its conclusions about what constituted scientifically valid psychological treatments. Instead of clinical consensus and comprehensive guidelines, the task force concentrated its efforts on research demonstrations that a particular treatment has proven to be beneficial for clients in well-controlled studies. To be considered well established, a treatment must have demonstrated that its benefits exceed those of an alternative treatment or a placebo condition that controls for attention and expectancy. Additionally, this efficacy must be demonstrated by at least two independent research teams.
Since then, the task force has cited 71 empirically supported approaches for an ever-expanding list of disorders. Perhaps believing more is better, the list not only covers conditions like depression and anxiety, but also addresses marital discord, health problems and sexual dysfunction, to mention a few. While the psychiatry association's guidelines focus on a thorough delineation of psychiatric treatment for a few disorders, relying extensively on clinical consensus among experts, the psychology association's list emphasizes specific treatments with replicated empirical support.
There is a certain seductive appeal to the idea of having a specific psychological intervention for any given type of problem--the psychological equivalent of a pill for emotional distress. But, in fact, a closer look at the research literature on therapy clearly reveals that the whole idea of empirically supported treatments (ESTs) is critically flawed, especially as any kind of mandate for what should be done in therapy.
To start with, the criteria for the clinical procedures used to validate a treatment contain a fatal bias. Standard research design requires that the treatments being assessed not contain the inevitable improvisations of therapy as practiced in the real world. Instead, the approaches studied are all required to follow a script so that the "variable" presumably being examined--a precisely defined and structured form of treatment--can be strictly controlled. But while certain kinds of therapy can be scripted--cognitive-behavioral therapy (CBT) being the most prominent--most cannot. So it should come as no surprise that CBT and other behavioral approaches dominate the list of treatments that have received the imprimatur of the task force, amounting to about 80 percent of the list. Is this because these treatments are more effective? No, it is really because they are the easiest to duplicate and, therefore, have been the ones chosen to be researched. This privilege does not extend to some 250 other approaches around today.
Besides the issue of what determines whether a treatment is chosen for study in the first place, questions have also been raised about whether the specific methods associated with an EST really constitute its "active ingredient." One of the most provocative of the studies that raise doubts about this assumption was conducted by Louis Castonguay and Marvin Goldfried, two prominent cognitive-behaviorally oriented researchers who set out to compare the effects of the therapeutic alliance with the effectiveness of a highly structured cognitive approach with depression. Surprising to many who carry the banner for ESTs, their study concluded that the more emphasis a therapist placed on cognitive-behavioral techniques, the worse the treatment outcomes for clients. In their study of 30 depressed clients, Castonguay and Goldfried compared the impact of a treatment technique specific to cognitive therapy--the focus on correcting distorted cognitions--with two other, presumably, non-specific, treatment variables: the therapeutic alliance (agreement between therapist and client on treatment goals and methods) and the client's emotional involvement with the therapist. Results revealed that while the two so-called common variables were highly related to therapeutic progress, the technique unique to cognitive-behavioral therapy--eliminating negative emotions by changing distorted cognitions--was negatively related to successful outcome!
Although the American Psychological Association's intention in adopting ESTs was to demonstrate that psychiatrists had not cornered the market on empirically verifiable treatments, in effect, its task force has responded to the myth of the magic pill by propagating the myth of the magic method. In fact, the uncomfortable truth for advocates of these verified treatments is that there is no solid evidence demonstrating that specific treatment models have unique effects, or that any single therapeutic approach is superior to another. Of course, there have been studies that purport to show that a particular therapy is especially effective. CBT is an example of this. But studies have yet to show consistent differences in effectiveness among therapies developed to address a particular problem despite the Herculean efforts of legions of researchers to do just that.
The results of any attempt to rate the effectiveness of clinical methods--as opposed to the individual effectiveness of practitioners--is best summed up by the dodo bird in Alice's Adventures in Wonderland: "Everybody has won and all must have prizes." In 1936, Saul Rosenzweig invoked the dodo's words to describe the equivalent success of diverse psychotherapies. It has since been called the "dodo bird verdict" and has proven to be one of the most replicated findings in the psychotherapy literature--no approach can reliably make a greater claim to effectiveness than any other.
Perhaps the best publicized study to confirm this idea that all techniques are created equal is the landmark 1989 Treatment of Depression Collaborative Research Project, widely viewed as the most ambitious and methodologically sophisticated outcome study ever undertaken. This NIMH-funded project, which involved both psychiatrists and psychologists at multiple cites around the country, randomly assigned 250 depressed participants to four different treatments: Aaron Beck's cognitive therapy--an approach that seeks to reduce depressive symptoms by challenging irrational and distorted attitudes; Gerald Klerman and Myrna Weissman's interpersonal therapy--which focuses on developing more effective strategies for dealing with "here and now" interpersonal problems; treatment with antidepressant medication; and, finally, a placebo approach called "clinical management," which included a pill placebo plus support and encouragement. After all the effort that went into designing a study that represented the state-of-the-art in outcome research, the investigators were stunned by their own findings. Overall, the four treatments--including placebo--worked with about the same effectiveness.
Recent advancements in statistical methodology, particularly metanalytic studies, which allow researchers to comb through the vast clinical literature and draw conclusions from huge collections of data, lend even further credence to the dodo bird verdict. In psychotherapy researcher Bruce Wampold's comprehensive 1996 review of the therapy-outcome literature, some 277 studies conducted from 1970 to 1995 were analyzed--with particular attention given to the presumably more methodologically sophisticated research of recent years--to determine which therapeutic models have yielded the most robust results. This comprehensive review once again verified that no approach has reliably demonstrated superiority over any other. "Why," Wampold asks, "[do] researchers persist in attempts to find treatment differences, when they know that these effects are small?"
The Client as Partner
So, if empirically supported treatments aren't what makes psychotherapy beneficial to clients, what is? Even though Rosenzweig addressed this question 65 years ago, his conclusion still applies today. Writing in the American Journal of Orthopsychiatry, he argued that all approaches appear to be equally effective, so there must be some larger common factors in operation that overshadow any presumed differences between techniques. What are these factors? The answer isn't really a mystery. The real key to the success or failure of therapy, as Rosenzweig and many other therapists over the years have argued, is the resources a client brings into the room.
Why should it be a surprise that the very factors that were operating in a client's life before counseling also have a crucial effect on therapy? Clients who are, for example, persistent, open and optimistic, who, for that matter, have a supportive grandmother or are members of a religious community are more likely to make gains in therapy.
What else is important to therapeutic success? Researchers Alexandra Batchelor and Adam Horvath argue in their comprehensive 1999 review article that the client's perception of the therapeutic connection is the second most important ingredient of successful therapy, accounting for 30 percent of the outcome. In other words, therapy is much less about method than about the quality of the bond established between therapist and client. To many clinicians, this may seem obvious, but partisans of models and manuals too easily ignore this basic truth: The nature of a client's relationship with a therapist is more important than our cherished theoretical schools, our favorite techniques or our most worshiped gurus.
As we approach a far-reaching transformation in the way mental health services are delivered, it is more important than ever that we recognize that the very foundation of our work is the tailoring of our approaches to the unique needs and circumstances of each client. When you try to do therapy by a book, research tells us that things may not go according plan. For example, researcher Hans Strupp's classic studies, collectively known as the Vanderbilt II Psychotherapy Training Project, conducted in the early 1990s, demonstrated the dangers of overprogramming therapy. Strupp compared the work of therapists before and after they were trained with a manual on psychodynamic therapy. The results: Those who followed the manual were less approving and supportive of their clients, less optimistic and more authoritarian and defensive. Before health care systems organize themselves according to the recommendations of the APAs about what constitutes effective treatment, we need to heed such findings, as well as the previously mentioned study by Castonguay and Goldfried--practitioners of standardized therapy are in danger of developing better relationships with their treatment manuals than with their clients.
Nevertheless, within the medical world, the concept of empirically supported standardized treatments has tremendous appeal. Today, we may stand on the brink of a misguided system of "integrated care" in which manualized therapy will reduce clinicians to mere technicians. And, to make matters worse, integrated data bases will make it easier than ever for managed care organizations to keep track of whether our clients are adhering to the standardized regimens prescribed for them. Lists of approved treatments will give health care bureaucrats a potent weapon to use against those of us who don't order off the menu. This could even leave us in the ethically dubious position of enforcing compliance with treatments we don't endorse, and reporting our clients' lapses to the HMOs.
When our services are provided without a partnership with those receiving them, the client can easily become a cardboard cutout. Moreover, as the trend toward evidence-based practice picks up steam, therapists and clients uncomfortable with this market-driven standardization will find themselves under enormous pressure to conform. So before carved-in care becomes the only game in town, those of us who envision a different future for psychotherapy must step forward to make the case for therapeutic multiplicity.
No matter how invested we are in our own particular clinical methods, we first need to acknowledge that there are many ways to respect our clients' values and perceptions, many ways to be effective and many ways to maintain our clinical integrity. This isn't as easy as it sounds. We have all worked hard to establish our own distinct identity as therapists. We've invested heavily in our own methods. But if we do not unite behind methodological pluralism, we will be easy targets for medical-model ideologues, the proponents of empirically supported treatment and the bean counters of the HMOs.
Clinicians today must take stock of both the values that underlie our practices and our responsibility for professional accountability. Each of us must do his own soul searching about these issues. So what follows is not meant as a blueprint for how therapy should be practiced, just my own conclusions (along with my colleagues Scott Miller and Jacqueline Sparks) about how to extend to clients the same therapeutic freedom we must defend for ourselves and some alternative ideas about what the empirical literature can teach us regarding accountable practice.
Not long ago, I worked with Erica, a woman in her mid-thirties who came into therapy searching for an identity that she believed she had lost. All her life, Erica had wanted to be a police officer. As a teenager, she rode with state troopers, and as a young woman, she became the first female to graduate from the police academy.
Erica lived her dream as an officer for several years, until a car accident plunged her into a coma that lasted for two years. In a triumph of biomedicine, an experimental drug revived her, although she was left with some brain damage and a seizure disorder that made it impossible to work as a police officer. Without this identity she had devoted her life to achieving, she was no longer certain who she was.
How might a medical system of care address Erica's concerns? Although her quest for a new identity does not neatly fit into DSM categories or empirically supported treatments, there is a good possibility that Erica would be reduced to a collection of symptoms and interventions. She might well be diagnosed as depressed and prescribed cognitive-behavioral therapy and an SSRI, along with additional skills-training for deficits left by her brain injury. In the process, the fullness of Erica as a person could easily be lost and she could be reduced to a description of "illness."
My first contact with Erica, as with all my clients, was founded not in just giving lip service to being respectful of clients and collaborative with them, but in using the set of empirically supported findings that I have found most useful in making my therapy as effective as possible. In all the research literature, perhaps the most clinically relevant finding I've discovered is that client's improvement early in treatment is one of the best predictors of successful outcome. So, instead of regarding the first few therapy sessions as a "warm-up" period or a chance to try out the latest brief-therapy technique, I believe it is crucial to be accountable in the very first contact with clients. And given all we now know about the importance of the therapeutic alliance, I approach such initial sessions as a chance to discover how to make the best possible match between myself and my prospective client. Our burgeoning alliance is monitored by clients' session-by-session evaluations of their satisfaction with and progress in treatment. In other words, the guiding principle behind my work with clients is recognizing that all my decisions as a therapist must be guided by my clients' engagement in the treatment process, their view of the quality of the therapeutic relationship, their expectation for change and--the gold standard--their assessment of whether change occurs.
When Erica first called our clinic, she was given the opportunity to structure her therapy, including a choice about whether to meet with an individual therapist or a team. She chose to see me individually, and I first met with her outside the consultation room and told her that I wanted her perceptions to be the light that guided us through the coming process. At my request, she filled out a brief form about how she felt she was progressing individually and socially. Only then did we walk to the consulting room.
She then explained that she felt at a dead end in her life. Having recovered enough to go back to work of some kind, she could not even imagine a back-up dream now that her career in police work seemed over. To complicate matters, Erica was also wrestling with the idea of being "disabled," a word she despised. She recognized that she had some limitations and could not perform the strenuous duties she had once dispatched with ease. Still, the word stuck in her craw. As we explored her experience on the path to recovery, I found myself amazed by her courage, resilience and wisdom. Here was a woman who had it all and lost it--who defied others' expectations of what she could and could not do many times--early on, when she became the first female police office, later, when she unexpectedly came out of a coma, and now, once again. Despite her problems with seizures, vision and balance, she was fighting the expectations of her "disabled" label. She knew there was much more to her than any description of her disability could begin to capture. I knew it, too, as would anyone who spent any time getting to know her. I told Erica that one of the things I liked most about her was her refusal to accept her disability.
A few minutes before the end of our meeting, I asked Erica to fill out another short form, evaluating the progress of therapy to that point. Here, the key clinical information for me was that she felt that I took her problems and ideas seriously, and that she felt hopeful about her situation. Reflecting on how impressed I had been by her, I jokingly asked her if she had ever thought about pursuing a career as a motivational speaker. It was an offhand tribute to the power of her story, but, as I learned later, it struck a deep chord. As we discussed our meeting, Erica told me that she enjoyed the process we had begun--she liked telling her life story and fielding questions about her experiences. Just as the conversation was about to end, she declared that it had occurred to her that she might pursue a career teaching police officers.
That pronouncement was a key step in Erica's journey toward reclaiming her life. She did not end up as a training officer, but was able to reestablish her relationship with the work she loved by becoming a dispatcher. This satisfied Erica's itch for reconnecting with police work, which, for her, was a key to a meaningful life. It allowed her to move on and address other issues, such as her loneliness and her current living arrangements. Erica reported improvement on the outcome measure, and therapy ended a few sessions later.
I don't mention my experience with Erica as an example of a one-session therapeutic miracle, just the reverse. In fact, it is the ordinariness of this kind of interaction that addresses the core of what we have to offer as therapists--the forming of partnerships with clients that makes therapy effective and accountable. I offered Erica no irresistibly powerful interventions, just a relationship structured around her goals and values, that showcased her talents and fortitude. And my repeated requests of Erica to tell me whether the therapy was serving her needs involved a kind of accountability that is very different from the accountability that HMOs increasingly demand from therapists, and that we may expect even more of under integrated care. It stands in sharp contrast to a decision-making process predicated on psychiatric diagnoses, "approved" therapeutic modalities or treatment plans.
As is true of most therapeutic interventions, standardized treatments can be helpful with many clients. But we need a health care system that recognizes that many clients are unlikely to be helped by a medical model of treatment. And that means that if the emerging system of integrated care adopts evidence-based practice as its standard, they may not be helped at all. It is our responsibility as therapists to lift our voices and to advocate on behalf of our clients and our profession. We must make sure that the integrated care system is truly integrated and that it draws from the best of the vast range of approaches that therapists currently tailor to their clients' needs, not the limited number of techniques that are most easily studied. As we are about to enter the next stage in the evolution of our health care system, we need to draw from the accumulated wisdom in our field that teaches us that not all of our clients' struggles fit within diagnostic categories and that therapy can never be reduced to a set of prescribed interventions, no matter how "empirically" supported they may seem to be.
Barry Duncan is professor of family therapy and psychology in the Graduate School of Humanities and Social Sciences at Nova Southeastern University (NSU) and coauthor of 10 books, including The Heroic Client (Jossey-Bass, with Scott Miller) and the forthcoming Heroic Client, Heroic Agencies:
Partnerships for Change (NSU Press, with Jacqueline Sparks). He can be reached at: www.nova.edu/~blduncan. HASH(0xb895f6c) Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
Batchelor, Alexandra, and Adam Horvath. "The Therapeutic Relationship. In The Heart and Soul of Change: What Works in Therapy . Edited by Mark A. Hubble, Barry L. Duncan and Scott D. Miller. Washington: APA Press, 1999.
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Elkin, Irene, et al. "National Institute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments." Archives of General Psychiatry 46 (1989): 971-982.
Kiesler, Charles. "The Next Wave of Change for Psychology and Mental Health Services in the Health Care Revolution." American Psychologist 55 (2000): 481-487.
Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2000. APA Clinical Resources. Washington: American Psychiatric Association, 2000.
Rosenzweig, Saul. "Some Implicit Common Factors in Diverse Methods of Psychotherapy." American Journal of Orthopsychiatry 6 (1936): 412-415.
Strupp, Hans H., et al. "Effects of Training in Time-Limited Dynamic Psychotherapy: Changes in Therapist Behavior. Journal of Consulting and Clinical Psychology 61 (1993): 434-440.
Wampold, Bruce, et al. "A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, "All Must Have Prizes." Psychological Bulletin 122 (1997): 203-215.
by Richard Simon
Suddenly, sometime in the mid-1980s, as the managed care revolution raged around them, therapists emerged as if from a dream to find that terms like "heath care delivery systems," "covered lives" and "capitated health plans" had gone from being mind-numbing policyspeak to urgent pocketbook issues. As an entire profession nervously scanned the horizon, anyone at a national conference who had something vaguely credible to say about whether the Golden Age of Private Practice was truly coming to an end was able to attract a capacity crowd. Since that time, as the sense of imminent crisis has gradually subsided, most therapists have grown much less interested in such crystal-ball gazing. Many appear to have accepted the fact that they no longer live such sheltered lives and have adapted to the economic realities of the mental health field today. In fact, lots of clinicians talk confidently about having weathered the storm, freeing themselves from managed care and, in some cases, recasting their services as coaching or consulting so as to emancipate themselves entirely from the world of corporatized mental health care.
But is this just another example of therapists' notorious head-in-the-sand attitude toward the business of therapy? What does lie ahead for the more than half-million psychiatrists, psychologists, social workers, mental health counselors, marriage and family therapists and other professionals who continue to call what they offer the public "psychotherapy"?
Lacking the sense of urgency that accompanied the dawn of managed care, therapists today seem to have little interest in the cautious generalizations and policy jargon of health care industry analysts, while few of their clinical colleagues have emerged as leaders with a compelling grasp of the Big Picture of therapy practice in the 21st century. So when one hears a quote like "health care delivery in 20 years will bear as little resemblance to the managed care organizations of today as Henry Ford's Model T had to space technology," most informed observers can quickly identify the source--Nicholas Cummings, psychotherapy's most quotable soothsayer and, arguably, one of the prime architects of modern mental health practice.
For the last 40 years, Cummings has cast himself as both a friend to the ordinary practitioner and a visionary capable of seeing just around the curve to the next stage in the evolution of the health care marketplace. His contributions to the field are almost indistinguishable from the signal turning points in the delivery of therapy services over that period. The story of his career reveals much about the changing economics of mental health and the emergence of much of what we now take for granted about how therapy is practiced and the personal career options available to today's practitioners.
The Birth of Coverage for Psychotherapy
When Cummings started out as a young psychologist in the late 1950s, not a single health plan included psychotherapy. For the actuaries of the health insurance world, psychotherapy was simply too vague and ethereal to be taken seriously. But Sidney Garfield, cofounder of Kaiser Permanente, the nation's first HMO, had become increasingly aware of complaints from overworked physicians within the Kaiser system about the time spent dealing with "hypochondriacs"--patients who required attention for problems that had little to do with physical disease. Believing that psychotherapy might be the key to reducing the workloads of his physicians and realizing enormous cost savings, Garfield hired Cummings, who had recently resigned from the graduate faculty at Cornell University after only three weeks, unable to tolerate the bureaucratic snail's pace of academic life. Cummings's assignment was to investigate the impact of including psychotherapy as a benefit in the Kaiser plan.
Instead of viewing "hypochondria" as evidence of pathology, Cummings began by normalizing what he termed "somatization"--the predictable symptoms of the stress or underlying psychological issues that are part and parcel of any major medical condition. He designed a pilot project with 30,000 Kaiser subscribers, offering them--for the first time--the option of seeing a physician-referred psychotherapist for a $5 co-payment. By the end of his three-year study, Cummings concluded that as many as 60 percent of physician visits were based on somatized complaints and demonstrated that therapy could save medical and surgical dollars far beyond the money necessary to provide psychological services. Hence the term "medical cost offset," the economic rationale that fueled the growth of mental health coverage--and, ultimately, the mass impact of therapy on American culture--was born. As a direct result of Cummings's work, in 1963 Kaiser Permanente became the first health insurer to include psychotherapy as a regular benefit, with the rest of the insurance industry soon following suit.
Over the next two decades, Cummings became a member of a core group of insurgent psychologists within the American Psychological Association (APA), dubbed by their adversaries "the dirty dozen" (even though there were 14 of them) because of their penchant for unconventional guerrilla tactics in challenging the association's status quo. Along with his co-conspirators, Cummings set out to galvanize the staid, academically oriented APA into furthering the growth of psychology as an independent clinical practice. Cummings and his allies led the way in the battles for "freedom-of-choice" legislation in the '60s and '70s that opened the way for psychologists (and later social workers and other mental health professionals) to gain licensure and the right to be reimbursed alongside psychiatrists. Determined to offer an alternative to traditional academic clinical training, in 1969 Cummings also founded the California School of Professional Psychology, the first professional school of its kind, that offered doctoral-level clinical training emphasizing experiential learning, personal therapy as a requirement for trainees and a faculty of practicing clinicans rather than academics who, as Cummings puts it, "had never seen a patient in their lives."
By the mid-1980s, Cummings became convinced that the issue for therapists was no longer recognition and reimbursement, but a sea change in the fundamental economy of contemporary health care. His assessment: "The cottage industry which constituted a fractionated and disorganized non-system of health care was about to industrialize." He urged psychologists to become leaders in the inevitable movement toward a more coherent, cost-conscious approach to health care, rather than ceding the field to corporate interests. He argued that efficient, targeted treatment was not incompatible with effective clinical services and, by way of example, he founded American Biodyne, a model for the kind of practitioner-run national company he advocated that grew to serve 14.5 million enrollees in 39 states by the time he sold his interest in it in 1993.
Today, at 77, ever ebullient and able to get by with only three hours of sleep a night, he lectures widely and runs two foundations devoted to furthering the cause of quality mental health care--the Foundation for Behavioral Health and the Nicholas and Dorothy Cummings Foundation. And, as the following conversation reveals, one of his favorite pastimes still is foretelling the future of psychotherapy and the nation's health care system.
The Industrialization of Health Care
Psychotherapy Networker: Let's start with a typically provocative quote from a paper you wrote a few years ago--"The transition from managed care to the next phase in the industrialization of health care has already begun." Most therapists I know have struggled mightily to make their peace with managed care as it exists today, so what will we need to do to adjust to this next phase that you're talking about?
Cummings: Since the '80s, along with the enormous growth of managed care, we've seen all the managed care companies swallowed up into a few huge corporations. Today two companies--Magellan and ValueOptions--control 40 percent of the managed behavioral health care market. The 5 largest managed behavioral care companies control 50 percent of the market and the top 10 companies control 98 percent. But along with the mergers and the growth of these gigantic corporations, one problem has become clearer and clearer--these companies are now run by people who don't have a clue about how to deliver mental health services and, in the privacy of their own boardrooms, they're facing that fact. And so, even though they won't admit this publicly, they're surfeited with complaints and drowning in malpractice suits. So they're getting out of the behavioral care delivery business and beginning to reorganize themselves pretty much as third-party payers.
PN: So who will be stepping in to actually provide mental health care?
Cummings: The managed care companies are beginning to "outsource it--that's the word the industry uses for doing it out of house. For example, since the beginning of this year, Magellan, the largest managed behavioral care company with 60 million covered lives, has sold all the group practices it operated, most of them back to the providers themselves. They're now just administrators, completely out of the service delivery business. So the next great trend that we're starting to see is the emergence of large group practices run by providers who are taking over the delivery of health care. And the practices that are successful are those that have learned that if you concentrate on effective, efficient therapy, there's a bonanza to be made. They're out from under managed care--they now contract with managed care.
PN: And what will determine which of these groups will actually make it?
Cummings: Most of these groups start out saying, "Well, we're going to do better than the managed care companies did. We're going to make sure that the patient gets what the patient needs." Of course, they then find out that they're swimming in red ink because they haven't learned to differentiate between what gets the job done and what just feathers the nest of an individual practitioner. They're really two very different things. For the solo practitioner--the longer the thing takes and the less turnover there has to be, the better you do; plus you don't have to have as many referrals. But from an economic standpoint--and there's just no ignoring this--the opposite is true. The faster you get the job done, the more likely you are to make a profit. The point is to make therapy both effective and efficient.
Unfortunately, most practitioner groups don't have a clue how to do this, so the ones that are doing the best have finally admitted that they're economic illiterates and are beginning to bring in the right kind of managers to help them do it. So you've got an incredible paradox here--the managed behavioral care companies are outsourcing the clinical side and then the practitioners are outsourcing the management side. So you've got three levels of outsourcing here. Anyway, that trend is in full swing, and when a huge company like Magellan decides it no longer wants to be a deliverer of mental health services, you can begin to see where the industry is headed.
The Therapist Workplace of the Future
PN: Your other big prediction about the future of health care is that the majority of mental health services will be dispensed in medical primary care facilities, with therapists located right across the hall from physicians. So are the managed care giants proponents of this new kind of "integrated care"?
Cummings: Even though the managed care companies pay tremendous lip service to the integration of care, for the most part, they've done a miserable job of trying to bring it about. They are organized to provide "carve out" services, and how in the world to "carve in" is beyond them.
PN: But wait a minute. Aren't there tremendous economic incentives to reducing physician visits by "carving in" mental health services as part of primary care?
Cummings: That's true, and that's why they have tried to do it, but they have found out that they don't know how. Look, the success of the managed care industry has been tremendous. In 1993, the Congressional Budget Office predicted that by 1998 health care expenditures would reach $1.7 trillion. In fact, in the year 2000, health care costs had reached only $1.3 trillion. Managed care has saved the United States somewhere between $350 to $400 billion last year alone! Congress, literally, balanced the budget on what they saved on Medicare and Medicaid by farming out the services to managed care. So the managed care companies don't want to change. They don't want to do something they don't know how to do. And most of all, they don't want to disturb a huge profit center unless they absolutely have to. How can I explain this? I mean, it's like asking the members of the chauffeurs' union to suddenly all become airline pilots. You're either a pilot or you're a chauffeur. It takes a lot to stop physicians from doing what they are trained to do. A patient comes in week after week with the same symptoms and the physician will repeat the same "standard" test--electrocardiograms, blood tests, X-rays--trying to chase down some physical disease. And when one physician has had it, there are always more doctors with whom to start off the whole process again. And unless the patient mentions a psychological problem, most physicians have not been trained to think of referring to a mental health specialist.
But the important thing to remember about integrated care is that it's not enough just to change a few components in an otherwise traditional medical system. That's like adding a few drops of red paint to a 50-gallon can of white paint. You have to approach every primary care problem by including attention to the behavioral care issue as well. That's true integrated care.
PN: If there is so much resistance within traditional medicine and from managed care companies satisfied with their current profits, where is the impetus for change coming from?
Cummings: The real impetus for integrated care is coming from the employer. By now, they are familiar with the medical cost-offset literature that has consistently found that 60 to 70 percent of visits to physicians are made by people who have no organic disease, but whose primary problem is that they are somatizing stress. They know that there are billions and billions of dollars to save on the medical and surgical side, if those people could be treated by mental health professionals instead. So employers are starting to pressure the companies out there to change the way they deliver health care, which will have a huge impact on therapists.
PN: What about the people who are in private practice today? As I talk to therapists around the country, it seems that most of the experienced clinicians I know are able to be quite successful in private practice. Will this trend toward integrated care affect their livelihood?
Cummings: Back in 1996, I predicted that as the managed care companies continued to fail in delivering adequate and quality mental health services, consumers would be willing to pay out of pocket for private care that wasn't covered by insurance. But I also predicted that this "boutique market" would only last for a few years. It was a transient thing, a bubble, that was going to be very much subject to economic times--boutiques don't do well in recessions--and could never grow above five to eight percent of the market. I based that percentage on the fact that in every country that has universal health care, whether you're talking about Sweden or the United Kingdom, no more than five to eight percent of the population is willing to pay out of pocket for services that are insured. So the boutique market can be seductive, but it's a transient thing.
The success of the boutique market is inversely proportional to the number of people in it. The people who got into it first are doing very well. But if 30 or 40 or 50 percent of practitioners out there decide to go after the out-of-pocket, fee-for-service clientele, they're going to find that there's a very, very small clientele out there--too small to keep a large number of practitioners in practice.
Advice for Therapists
PN: Okay. If that is the big picture, what do you say to the individual practitioner who's trying to prepare for the contingencies of the future? As a therapist, how can I best shape my own destiny, rather than having the marketplace shape it for me?
Cummings: First, don't get sucked in by the bubble that we're seeing now because some private practitioners seem to be doing so well. Second, realize that psychotherapy is finally going to go where it should have gone from the very start--to be an integral part of general health care. So the most important thing you can do to prepare for the health care system of the future is to become proficient in health psychology--the application of behavioral and psychological techniques to medical conditions. There is no such thing as a physical illness without its behavioral dimension. For example, depression is an accompaniment of almost every chronic condition, and non-compliance with medical regimens is one of the costliest issues within our current health care system. Some conditions are especially notorious for non-compliance. The worst is hypertension, probably because with hypertension, patients often don't feel any serious discomfort. They just suddenly have a heart attack; there's no incentive to change their lifestyle. Hypertension, diabetes and asthma account for almost 30 percent of all the medical expenditures in the 25 to 55 age group, and it's mostly because of non-compliance and problems in handling stress. But to tease out the psychological component of patients' problems, therapists will need to know much more about the whole range of physical diseases.
PN: On a concrete level, how will therapists actually spend their time in the kind of health care system you envision?
Cummings: Most of their time will be spent leading time-limited, protocol-based, psychoeducational groups that have been shown to reduce medical costs and improve patients' functioning more than traditional medical treatment. One type of group might be called "disease management" groups--these are designed for people with the same medical condition: rheumatoid arthritis, asthma, diabetes--all of which are chronic, have no biomedical "cure" and are extremely frustrating conditions for traditionally trained primary care physicians, who don't really know what to do with these kind of patients once the diagnosis is made. And then there are "population-based" groups that address conditions that are not primarily medical--like Borderline Personality Disorder, depression, substance abuse, Panic Disorder--but which impinge drastically on the medical system.
PN: Is it groups like that you have in mind when you say at least 50 percent of the mental health services of the future will be psychoeducational?
Cummings: Correct. The future of health care will be based on increasing the self-efficacy of people in dealing with all the chronic conditions that modern medicine can arrest but not cure and providing psychological services in a much more effective and efficient way. With many medical problems, therapists in the future will be involved with helping people learn the specific things they can do to influence the state of their health, for example, monitoring their own blood sugar, their own exercise, their own stress level and so forth, getting them out of what Martin Seligman calls "learned helplessness." A major role for therapists in the future will be getting people out of taking the position of "I'm helpless. I may as well adjust to my illness."
PN: And with psychological problems, do you also believe that group interventions are more effective?
Cummings: That's what the research seems to be telling us. The differential between a group program for substance abuse and individual psychotherapy is so astronomical that nobody even argues about it anymore. But we are beginning to see the same thing with problems like depression, agoraphobia, panic and anxiety disorders.
PN: Many therapists believe that protocol-based treatment leaves out the most important elements that make therapy work. What do you see as the essence of an effective protocol?
Cummings: That it's research based. You construct a protocol and keep trying out and measuring your results. There is no such thing as a finished protocol--you're always reevaluating it and trying it out. But I think there are a few elements that we know are necessary ingredients, whether the protocol addresses a medical or a psychological condition. All protocols have an educational component. Patients learn very frankly, with no punches being pulled, what diabetes is or what borderline personality is or what Bipolar Disorder is. Every protocol teaches patients how to monitor and evaluate their own condition--diabetics learn to monitor their blood sugar, people with Borderline Personality Disorder learn how to monitor their mood and their sense of being blown like a leaf in the wind. Every protocol has a buddy system and a peer culture that the therapist can utilize. I cannot think of any psychological protocol in which exercise would not be an important component.
PN : With all of your confidence in protocol-based approaches, you've also written that two-thirds of the people within any of these population-based, group approaches are going to need individual attention at some point. Could you explain that?
Cummings: People are very diverse, even if they share a common condition. When someone hits a snag in a program, there should always be the option of seeing him or her individually as needed. But I believe that only 25 percent of the therapy of the future will be individual. Actually, that's 25 percent of the time allotted, and much less than 25 percent of the people being treated. Because if you have a practitioner who spends 25 percent of her time in individual therapy and 75 percent in time-limited group psychotherapy and psychoeducational disease and population-based models, 75 percent of the practitioner's time will yield more like 90 percent of the patients. But clearly practitioners of the future will have to learn how to do group psychotherapy in time-limited modules. They'll have to learn how to do individual therapy that's focused and targeted, not open ended. And therapists of the future will have to take business courses in graduate school, just as physicians are starting to do in medical school.
PN: What will they learn in the business course?
Cummings: How to balance a budget and maximize their time. Most therapists couldn't balance their checkbook. So they have no way of knowing that all the things they're doing are going to plunge them into the red when they have their quarterly accounting. They need to learn the kind of business discipline that says, "Wait a minute, what is the most effective and efficient treatment I can give this patient?" Most of all, therapists have to finally get over the belief that therapy should take as long as it takes, no matter the cost. We no longer live in a world that permits us to think that way.
Richard Simon, Ph.D., is the editor of the Psychotherapy Networker and author of One on One: Interviews With the Shapers of Family Therapy . Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by Joshua Wolf Shenk
After he has awoken, from uneasy dreams, to find himself transformed in his bed into a giant insect, Gregor Samsa's first encounter with the world outside his bedroom comes in the form of his mother's voice. "Gregor," she says. "It's a quarter-to-seven. Hadn't you a train to catch?" When he opens his mouth to answer, Gregor hears a peculiar sound. The voice is "unmistakably his own" but has a "persistent horrible twittering squeak behind it like an undertone that left the words in their clear shape only for the first moment and then rose up reverberating round them to destroy their sense." And so, having at first thought that he would "explain everything," Gregor says only this: "Yes, yes, thank you Mother, I'm getting up now."
In The Metamorphosis, a story about alienation, the first rupture is one of language. Gregor Samsa cannot make himself known to the world. Just as his body has become unrecognizable, inexplicably Other, so has his voice. In this image--more clearly, even, than in Gregor's grotesque physical form--I feel the presence of the author. "I am constantly trying to communicate something incommunicable, to explain something inexplicable," Kafka wrote of himself. He was alienated from language, and even felt trapped by it. But words, metaphors, and stories were his only way out.
When I was a small child, about eight I think, I ripped apart my bedroom in a frenzy. I threw the pencil sharpener off my desk. I pulled the sheets and blankets off my bed and turned over the mattress. I pulled clothes out of their drawers, drawers out of the bureau. Eventually the bureau itself toppled. A few moments later, my mom stood in my doorway and said, with aplomb, "Looks like a tornado has been through here."
Five years later, I stood on the lawn of my father's house, just home from summer camp. My oldest brother drove up the dead-end street in his gray Fiat, and turned left into the short driveway. I ran over to see him. I recall, as I ran, feeling a false expansiveness. I wore a too-wide smile, like a clown scripted for a pratfall. As I began toward the car, my brother leaned over and rolled up the window on the Fiat's passenger side. Then he backed down the driveway and drove away.
When I was seventeen, I carried these and other fragments up the stairs of an old Victorian home in Cincinnati. As I sat in the waiting room of a psychiatry practice, I knew I was lonely, unhappy, even desperate. I did not know I was depressed. But that was the word that waited for me, a diagnosis that physicians since Hippocrates have been trying to elucidate and one that I would inherit.
The Hippocratic writers believed that gloom, abnegation, and misanthropy could be traced to excesses of black bile. Unlike the other three bodily humors (blood, phlegm, and yellow bile), black bile was never actually observed. Today, we know no such substance ever existed. Still, the Greek words--for black ( melan ) and bile ( khole )--dominated the language of inner states for more than two millennia.
In 1905, the influential American psychiatrist Adolf Meyer proposed that "melancholy" and "melancholia" be retired from the clinical vocabulary. He believed that the terms were used too broadly. They described "many dissimilar conditions" and also "implied a knowledge of something that we did not possess"--that is, the causal role of black bile. Meyer preferred the word depression. Other physicians followed him, as did medical texts and the lay culture.
In the hands of modern writers, "melancholy" has recently experienced a renaissance. In Darkness Visible, William Styron charges that Meyer "had a tin ear for the finer rhythms of English and therefore was unaware of the semantic damage he had inflicted by offering 'depression' as a descriptive noun for such a dreadful and raging disease." The word depression, Styron continues, has "slithered innocuously through the language like a slug, preventing, by its very insipidity, a general awareness of the horrible intensity of the disease when out of control."
It strikes me as telling that writers--for whom words are tools and imprecision deathly--knowingly use a term that is literally untrue; and that they use "depression," "melancholy," and other imperfect words interchangeably. These are two of many indications that the experience they describe has no true name. Styron, for instance, readily concedes the paradox that his memoir of melancholia is but a hazy shadow of something "indescribable." Most accounts of depression will have this sort of disclaimer. Others disclaim implicitly through dependence on metaphor and allusion.
Perhaps depression is simply hard to convey--even, as Styron says, "indescribable." But I'd like to suggest another possibility: That what we call "depression," like the mythical black bile, is a chimera. That it is cobbled together of so many different parts, causes, experiences, and affects as to render the word ineffectual and perhaps even noxious to a full, true narrative.
It is ironic, given the criticism directed at him, that Adolf Meyer seemed to have in mind the limits of single-word diagnoses when he proposed that depression replace melancholy. Meyer believed the former word, obviously inadequate, would force doctors to tailor their descriptions to individual cases. "Nobody would doubt that for medical purposes the term would have to be amplified so as to denote the kind of depression," Meyer wrote. (Italics added.) Perhaps Meyer even liked the insipid quality of "depression," believing it would announce (like a blank canvas or the blue screen on a film set) the absence of material to come.
If so, what transpired over the century can be counted among the great tragicomedies in the history of language: Somehow, we have come to believe that "depression" is the art, is the phantasm of special effects, is the evocative detail or phrase or story rather than a mere placeholder. The DSM-IV lists only a few qualifiers for "major depressive disorder." Psychiatrists and medical texts treat depression as a discrete entity, and assume it adheres to a particular course and treatment. Ads for drugs, herbal remedies, and nutritional supplements refer to depression as though it is a foreign invader, unrelated to the authentic self.
In lay culture, meanwhile, the word is often used with no context at all. A New York Times report on the rising suicide rate in Japan notes that the cause might be "depression," but does not offer even a single phrase to elaborate. In conversation, otherwise imaginative, articulate speakers toss around the words "depressive" and "depressed" as if they capture a person's essence. In his story "The Depressed Person," David Foster Wallace gives the eponymous character no other name, which I take as sardonic reflection on the way we drape over diverse sufferers a label that hides more than it reveals.
Perhaps, for many, staying hidden is part of the point. I think of Tipper Gore, who first spoke publicly of her depression in a front-page interview with USA Today. After her son recovered from a nearly fatal accident, Gore explained, she saw a social worker and was told she "had a clinical depression and one that I was going to have to have help to overcome."
She continued, "What I learned about it is your brain needs a certain amount of serotonin and when you run out of that, it's like running out of gas, it's like you're on empty. When you get to this point of being seriously depressed or what we call 'clinically depressed,' you just can't will your way out of that or pray your way out of that or pull yourself up by the boot straps out of that. You really have to go and get help, and I did. And I was treated for it successfully, I'm happy to report."
Gore did not describe in what way she felt depressed, nor how it affected her life only that she had a "clinical depression . . . and I was treated for it successfully." Her reticence might have been motivated by discretion, or a wish for privacy, and I do not begrudge her these. I appreciate her candor, insofar as many would choose to say nothing. Still, like so many public figures who have made similar confessions, she hinted at intimacy then quickly withdrew behind a wall. The word depression was that wall.
It is inevitable that we abbreviate and simplify. (It is apparent even in this essay that I see no way around the words "depression" and "melancholy.") But it is one thing to use shorthand while straining against the limits of language. It is quite another to mistake such brevities for the face of suffering. Each year, seventeen million Americans and one hundred million people worldwide experience clinical depression. What does this mean, exactly? Perhaps they all have deficits of serotonin, feel hopeless, ruminate on suicide. But why? What wrinkles crease their minds? How are they impaired? For how long--two weeks? a month each year? an entire life? And from where does this depression come?
Rather than acknowledge these variations and uncertainties, many react against them, taking comfort in language that raises the fewest questions, provokes the least fear of the unknown. Such is the case with the equation of emotional problems and mechanical failure. Phrases like "running out of gas," "neurotransmitter deficits," "biochemical malfunctions," and "biological brain disease" are terribly common, and are favored by well-intentioned activists who seek parity between emotional and somatic illnesses. Pharmaceutical companies also like machine imagery, since they manufacture the oils, coolants, and fuels that are supposed to make us run without knocks or stalls.
This language not only reflects, but constructs, our reality. When we funnel a sea of human experience into the linguistic equivalent of a laboratory beaker, when we discuss suffering in simple terms of broken and fixed, mad and sane, depressed and "treated successfully," we choke the long streams of breath needed to tell of a life in whole.
Just as we hear music through intervals, experience is often easiest to understand in terms of contrast. And so despair is often best expressed in terms of what has changed. "I used to relish crowds on the street, but now people repulse me." Or, "I used to wake up with a feeling of expectancy. Now I can only wrap the pillow around my head and pray for more sleep."
When I began psychotherapy late in high school, I had a clear and persistent sense that something was wrong with me, but no vocabulary with which to describe it. I could not draw on contrast because I didn't remember a time when I felt differently or better. I did not have seasons of happiness followed by epochs of misery, or fall off cliffs and climb back up among the daisies. I felt as I felt for as long as I could remember. I did not go to therapy to understand, or to get through, an episode. I needed to understand and get through my life.
Since my "condition" is so deeply rooted, much of my personality grew out of it and developed to cloak it. This made expressing myself even harder. I did well in school, stayed out of trouble, behaved like a son my parents could be proud of. I wrapped myself in a skin of normalcy and success but grew more hidden, from others and from myself. In high school, I wrote in a poem that I wished "to be a slug," to have an exterior that expressed what I felt. Like Gregor Samsa, I greatly desired to speak the whole truth. Instead, much of the time, I merely said, Thank you, thank you, I'm getting up now--going to school, going eventually to college and the bright future that everyone expected. But the present, which I tried so hard to dodge, could not be dodged.
In Seeing Voices, his book on the language of the deaf, Oliver Sacks notes that philosophers have long dreamed of "a primordial or original human language, in which everything has its true and natural name; a language so concrete, so particular, that it can catch the essence, the 'itness,' of everything; so spontaneous that it expresses all emotion directly; and so transparent that it is incapable of any evasion or deception. Such a language would be without (and indeed would have no need for) logic, grammar, metaphor, or abstractions--it would be a language not mediated, a symbolic expression of thought and feeling, but, almost magically, an im mediate one."
I hoped for such fluid, full, direct communication in therapy. I tried to express the relentless stream of criticism that I directed at myself and others, the way I felt split in two, the dull and sharp aches that moved around my body as though taunting me. I wished to plug a probe from my brain to the doctor's, so that he could see--without mediation--how I stood outside myself, watching and criticizing, and could never fully participate in a moment. How I felt bewildered, anguished, horrified.
Instead, I often found myself silent. When I spoke, it was with stumbles and stammers. Words-- unhappy, anxious, lonely --seemed plainly inadequate, as did modifiers: all the time, without relief. Ordinary phrases such as I feel bad or I am unhappy seemed pallid. Evocative metaphors-- My soul is like burnt skin, aching at any touch; I have the emotional equivalent of a dislocated limb --were garish. Though this language hinted at how bad I felt, it could not express what it felt like to be me.
I suppose the combination of words, body language, and silence did in some measure convey the message, because my first therapist was able to offer me a helpful phrase. "Is it," he asked, "as though you have a soundtrack of negative thoughts in your head--the volume rising or falling, but never going silent?" I pictured an old reel-to-reel tape machine, sitting alone on a table in an empty room. I lingered over the image, comforted especially by the acknowledgment that it never stopped. And I felt a spark of recognition, a kind of introduction to the meaning of my own experience.
The soundtrack image was an imperfect one, as I do not "hear voices" in the sense of hallucination; nor are the bad feelings that echo inside me always in words; nor can I always discern the difference between "self-criticism" and observation, between a gratuitous self-slap and a guide to truth.
But of several hundred afternoons in that Cincinnati office, this moment stands out--the offer and acceptance of a liberating, idiosyncratic metaphor, one that would need many revisions, but at least got me on the page. By contrast, I have no memory of hearing the word "depressed," which was how I was described at that time to my parents and to insurance companies.
In his exhaustive survey, Melancholia & Depression: From Hippocratic Times to Modern Times, the historian Stanley W. Jackson concludes that "no literal statement" can convey the experience. But he found that, over 2,500 years, two images recur most often: "being in a state of darkness and being weighed down." If we consider "melancholy" and "depression" as condensations of these images--as more than diagnoses--they retain enormous power. One of my earliest attempts at essay writing dwelled at length on an image of a dark room lit only by the space beneath the closed door. I did not make a habit of spending time in such rooms. The image of darkness imposed itself upon me, as it has for so many, as a symbol of distress.
And my dislike for the word "depression" does not mean that it has no application to my life. I am often "bowed down greatly" (from Psalm 38), feel weighed upon, feel myself on lower than level ground. Compared with others, it seems, I get less pleasure from what's pleasurable and have a harder time with what's hard. My sex drive is often muted (even without antidepressant medication, which exacerbates this problem). Work and activity that require some suspension of self-consciousness--like playing team sports--are difficult, bordering on impossible. I've tended toward activities in which self-criticism can be an asset, like writing. A tightness, an anxiety, a desperation usually grips me when I wake, relaxes its hold only occasionally through the day, and accompanies me when I lie down.
But, even as metaphors, these words are too thin to contain a life. For example, the times when I do pass from withdrawn to talkative are often quite unpleasant. Darkness aches, but light blinds.
At this point I encounter in the margins a note from my editor asking for further explanation of what is written above. And I shudder from the memory of moments like this: I am trying to explain myself and I encounter "Why?s" and "What do you mean?s" questions I fear can't be answered. I imagine the seams of this essay splitting, and the meaning and emotion I am struggling to convey here falling out like beans from a sack.
And so I remind myself: An imperfect word is sometimes better than silence, a pale metaphor better than suicide. Researchers and therapists want to understand problems in their broad dimensions; families and friends want to make sense of their afflicted loved ones; and, of course, those who suffer in isolation, starved for connection, mad with the sense that they will never be understood and never find relief, need to say something, even if it's wrong, or not wholly right.
Still, while we cannot be silent, or forsake the available word or metaphor for the perfect one that eludes us, we also cannot stop at those less-than-perfect words and metaphors. Insufficient or overused phrases--which resolve eventually into clicheÂ´s--lose their power to evoke a fresh, startling image. They stop tapping into the field of primal meaning that precedes language and to which, through language, we are forever trying to return. Worse, poor language can cripple the capacity to imagine. "A man may take to drink because he feels himself to be a failure," George Orwell writes, "and then fail all the more completely because he drinks."
The failure begins when words intended to codify or categorize, what Maurice Merleau-Ponty calls "empirical speech," actually disrupts or preempts "creative speech," or "that which frees the meaning captive in a thing." Every breath and word is an effort at translation and, at times, that effort can seem impossible. But poems, lyrics, stories can do an end run around the stubborn distance that separates us, helping us feel what it is to be alive. Words can create meaning, teach us our own thoughts, and perhaps even describe a life. But we have to plumb, with curiosity sustained over time, with toleration of uncertainty, the unsettling, elusive stories that make us who we are.
Letters form meaning from lines and curves. Words form meaning from letters. Metaphors form meaning from words. None of these units are large enough to encompass, to identify, to "diagnose" a person. If pressed, one could call Ahab "mad," or Bartleby "depressed." But to know these characters, you must read the story. To tell a life, you must tell a story.
Which is not by any means a straightforward task. Freud's idea of "repression" suggests that unconscious experience is like water pressed against a dam, that we need only remove the blockage and allow our memories to pour out. This is a dominant image of emotional healing in our culture. I think of it as the Hawkeye Pierce model of psychotherapy, after the last episode in M*A*S*H, in which Alan Alda's character has been confined in an asylum and is coaxed into retelling a traumatic episode. One by one, the authentic details emerge until he remembers the repressed memory of a small child's death. He cries. He is healed.
The psychoanalyst Donnel Stern, in his book Unformulated Experience, suggests another way of thinking about "repression." He uses the metaphor of the rock at the bottom of a lake, which requires great and sustained effort to recover. Perhaps our lives are many such rocks. Perhaps we have to raise the ones we can, imagine the rest and then, with these images and memories and emotions laid before us, find the patterns and shapes.
We are all natural storytellers. Even as we think we are just seeing a concrete image or hearing a distinct sound, we are in fact filling in gaps, putting material in context, constructing a narrative. That muted howl from the apartment next door--is it a woman crying, or a child laughing, or the laugh track from a television set? We make such choices at every moment, usually without conscious thought. We tell stories about other people, and we tell one big story about ourselves.
But sometimes, for some people, the story is torn. The essential sense of who we are, of what the world means, becomes lost. All the bits of life's evidence that must be sifted, digested, or passed over, instead fly like shrapnel. This happened to me a long time ago. In high school, when I first saw my name over small stories and articles, those words "Josh Shenk"--in ink against newsprint--struck me with dumb shock. I was thrilled and horrified at a small glimpse of what it meant to be real. It may seem strange that someone haunted by the inadequacy of words would become a writer, but I've often felt no other choice but to struggle and claw for what should be a simple birthright: to tell myself and others who I am.
Like everyone, I start with a handicap, which is that I don't know my own beginnings. Births and early infancy precede memory. Many later memories, which we should in theory have access to, are still as elusive as mist. So we become historians of our own lives, dependent on unreliable, reluctant sources. I can describe with precision the home I grew up in, its brown paint and simple brick, the gnarled limbs on the trees outside. But what did it feel like to live there? How did it form me?
I need to find these feelings, because the facts communicate so little. For instance, I was the youngest of three children and my parents divorced when I was seven. This is a story too common to be distinctive, but too important to be ignored--the slow leakage of affection and kindness from my parents' marriage, the grim entrance of resentment, confusion, and anger. The unspoken rules of the house forbade expressing these emotions, and this remained true after the divorce.
My brothers fled the home as best they could. I, the adoring younger brother, tried to follow them. But they had no interest in me, except as an occasional object of humiliation. I suppose I reminded them of what they hated in themselves: the vulnerable, longing, suffering son of their parents.
When I tried to let out my own feelings--tearing apart that room, for instance--my family pretended they were invisible. I learned to not speak how I felt, soon stopped knowing, and slowly but certainly developed a way of being--a sense of being split, an aching numbness, a cascade of critical voices--that would keep things that way. Some psychiatrists have described this as "depersonalization." It is a diagnosis listed in the DSM-IV in the category of dissociative disorders, along with post-traumatic stress and what used to be called multiple-personality disorder. Depersonalization, the manual says, is characterized by persistent or recurring feelings of "detachment or estrangement from one's self, a sensation of being an outside observer of one's mental process, one's body, or parts of one's body."
"Often," the manual continues, "individuals with Depersonalization Disorder may have difficulty describing their symptoms."
No diagnosis can tell my story. Still, depersonalization has the advantage of nicely announcing what is missing. To treat this "disorder" requires nothing less than removing the "de" to find the person--whatever is real beneath.
There is no drug for depersonalization, which leaves me adrift in an era where pharmaceuticals offer identity: If Ritalin or lithium or Xanax ease your symptoms, you can fit into the narrative of the corresponding disorder (attention deficit, bipolar, anxiety). If an anti-depressant helps, you can toss off the four letters preceding the hyphen and proudly affix to yourself the word that remains. I haven't been helped by medication. Many have. But I wonder if all of us are depleted by the way brand names, dosages, and combinations have eclipsed talk of agonies, fears, and dreams. Good stories must be reined in from chaos (the whole truth), which our imaginations are too feeble to comprehend. But good stories are never simple or precise. To shape and order our lives, without molding them into caricatures, is to hew a course between the poles of chaos and cliche--the course of authenticity.
This is a truncated memoir, an introduction to my own introduction to my story. I still need to imagine my life, to find my story by living it, following moments of emotional clarity through life's maze. I look for help in therapy, in relationships, and faith in its broadest sense--the faith of the gardener, the faith of the lover, the faith of the writer. The faith that I can experience what is real about the world, that I can hurt plainly, love ravenously, feel purely, and be strong enough to go on.
At the end of As You Like It, Shakespeare's famous "melancholy" character Jaques hears that a duke has "put on a religious life/ And thrown into neglect the pompous court." Jaques instantly declares, "To him will I/ Out of these convertites/ There is much matter to be heard and learn'd." It is a striking contrast to his earlier cynicism that "All the world's a stage/ And all the men and women merely players." It is the declaration of a character intent on finding some meaning.
But, in contrast to the smug assurance that passes for faith on the "700 Club," the truest faith reckons with uncertainty. It must account for the inevitable mystery, must survive the tension between the familiar and the shocking unknown (and the shocking unknowable). If one were forced to choose a single word to describe Jaques--who anguishes at the death of animals, wishes for love, longs for a fool's easy laughter--perhaps "melancholy" or "depressed" would be a good choice among poor options. Shakespeare chose "melancholy," but then had Jaques proclaim that he has neither the scholar's melancholy, nor the musician's, nor the courtier's, nor the soldier's, nor the lawyer's, nor the lady's, nor the lover's. Jaques has, he insists, "a melancholy of mine own, compounded of many simples, extracted from many objects." And off the stage he walks. Having hinted at his story, he goes to live it.
Joshua Wolf Shenk has contributed articles, essays and reviews to Harper's Magazine , The Nation , The Economist andÂ The New York Times . He is a past fellow in mental health journalism at the Carter Center. He lives in New York City and teaches writing at the New School University. His first book, The Melancholy of Abraham Lincoln , will be published in 2002 by Viking Press. Address c/o Psychotherapy Networker, 7705 13th Street, N.W. Washington, D.C. 20012; e-mail address: email@example.com. This essay first appeared in the recently published Unholy Ghost: Writers on Depression (William Morrow, an imprint of Harper Collins), edited by Nell Casey, and is reprinted by permission. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
by Michael Ventura
Till change hath broken down
All things save Beauty alone.
-- Ezra Pound
In Brooklyn, circa 1957--when doctors still smoked cigarettes while examining their patients in small stuffy rooms--I was in a hospital, 12 years old, dying. If I hadn't been fever crazed I might have known I was dying, for we were poor, we lived in what was then called "slums" and what was I doing in a private room? In those days, before health insurance as we know it now, and before federal programs, my family had no possibility of paying the bill. I was a "charity case," and, with true charity, the hospital had given me a private room to die in. My diagnosis had something to do with "acute malnutrition"--in other words, hunger--complicated by a seemingly untreatable fever. Though nobody told me what was going on, I should have known I was dying when my aunts (my father's sisters) visited. For my aunts to be in the same room as my mother was an event; they did not often speak. In a Sicilian family, grudges go deep, so when my aunts and my mother treated each other tenderly . . . well, I must have been dying. But my family and the doctors, and even my skinny fever-wracked body, all seemed then, and in memory seem now, like figures in a dream. What was most real to me, and what remains vivid even now, was the window.
For several days and nights, too weak to lift my head, all my attention was fixed on that window. It was . . . just a window. Nothing remarkable about it. But pigeons would alight on the sill, suddenly, as though out of nowhere. They would make their clucking and cooing sounds. Occasionally, one would simply sit very still for a long time. Then, just as inexplicably, fly off. Through that window I would watch the changing light of the sky, and the clouds--I had never noticed how many shades of light inhabited the sky. And sometimes a flock of pigeons would sail across my field of vision, high up and far away; I would wait for that, wish for that. Sometimes, too, their wings would catch the sun as they banked all together at some unseen mutual signal, and that flash of many- winged light thrilled my heart.
I think I remember that window so well because it was my first consciousness of beauty--that is, my first independent, deeply inner meeting between the beauty of the world and my own soul. All my former contexts had been shattered, I could hardly even move, I was in a sense utterly on my own, yet even in this state (or because of this state?) I was being touched directly by a sweet and transforming force, or feeling, for which I know no other word but beauty. I was many years away from the concepts of contemplation and meditation, but I believe now that those were the fundamental elements, or activities, of my enthrallment, my rapt attention, as I focused upon that window. It's impossible to prove, but I believe that my intake, my inspiration (literally, my breathing in) of the elegance, the beauty, of the birds and the sky, gave me strength and saved my life. This, at least, is sure: from that time on I have been extraordinarily, gratefully susceptible to, and conscious of, the beauty of the physical world, even in the bleakest of places--like Brooklyn.
I do remember one fragment of conversation from that hospital bed. My Aunt Anna, in a way that was hardly typical of her, commented to my mother that I had "pretty hands." My mother said in response, "He has an artist's hands." This was the first time it occurred to me that anything about me might be beautiful. After they said this, when alone in that room, I often looked at my hands, and, yes, thought them beautiful--as though, like the pigeons and sky, and unlike anything else about me or my life, they were a part of the beautiful world. I can still hear the soft proud way my mother spoke those words. I believe now that she somehow sensed or grasped what was going on; for it's clear to me, 40-odd years later, that in that hospital bed, my soul took its first, wondering and gloriously unselfconscious steps (steps more unselfconscious than they would ever be again) toward being an artist--for not very long after I left the hospital I began to write. By the age of 14, writing became, consciously, all that I wanted to do with my life--became, that is, my devotion, the calling to which I intended to devote my life.
The illness had stripped me down to the core of my being, which, like the core of anyone's being, feels itself most intensely when at the meeting-point of life and death.
And the window--the window!--had poured beauty into me at just that terribly vulnerable moment. And everything changed; or, to put it more accurately and less dramatically, many disparate and not-yet-coherent elements in me coalesced and found their focus.
Many walk into the therapist's consulting room exactly at the moment, and because of the moment, that they have been stripped to the core of their being. While not at the physical meeting-point of life and death, they are often at its emotional and spiritual equivalent. One element they seek and are desperate for, one element they usually feel they've lost, is beauty; they present a situation that's cut them off from experiencing beauty. They may not articulate it that way, but that's what's going on. Yet, beauty has not still been sufficiently recognized as both a healing balm and a necessity--something without which we may die, and through which we may live.
In Carl Jung's Memories, Dreams, and Reflections, he relates a dream in which he went into the center of a darkened city--Liverpool. It does not take an analyst of Jung's caliber to know that a dream that takes you to the center of your liver (an organ that cleanses the blood of toxins) is a journey to where your innermost self deals with the poisons you've ingested from the world. Jung's "Liverpool" was very dark except for its centermost point, where a tree glowed all on its own. "A single tree, a magnolia, in a shower of reddish blossoms. It was as though the tree stood in the sunlight and was at the same time the source of light." That tree was one of the most beautiful things Jung had ever seen. He wrote, "I had had a vision of unearthly beauty, and that was why I was able to live at all."
He had found in a dream what I had found in a window. His movement toward the sustenance of beauty was from the inner (his dream, his soul) to the outer (his life); mine was from the outer to the inner; but the result was the same: "that was why I was able to live at all." Every day these movements of beauty happen in many small ways to many people; and almost everyone, except the most severely damaged, remembers at least a few events that, whether dramatic or everyday, are startling in that they suddenly open the soul, the self, the psyche, to beauty. While it is difficult to define what beauty is, because different people find so many different beauties, the experience of beauty is not as hard to define: one's soul and one's world are connected in an engagement of wonder. Sometimes we experience this with others--while listening to music, perhaps, or in an intimate moment with someone we love. Sometimes the experience is solitary, and can even come in a dream. But the singular quality, however fleeting, is an awakening of, and a connection to, wonder. The experience of beauty is always one of expansion, of opening, of inclusion--a moment of connection, often mysterious, that extends the possibilities of all connection.
So beauty isn't merely decorative; its primary function is to connect--beauty connects our innermost being to the world. It is precisely this lack of connection that afflicts so many. And while suffering usually has its source in the personal life, it's reinforced by the ugliness we live amidst. Much depression is a symptom (James Hillman might call it a healthy symptom) of resistance to ugliness--a holding-back of the spirit from an aggressively ugly environment. In most urban neighborhoods, there is only an immense and slowly deteriorating sameness of brick, building after building, street after street--a relentless and unforgiving sameness, a dull labyrinth in which to struggle for the basics. The suburbs are only slightly more benign; they have become a culture of malls, the same franchises and signs and structures everywhere, and houses built without distinction, without excitement, without inspiration. Millions go from dull ugly rooms on dull ugly streets, on clogged roads, to dull ugly workplaces where they do work that has little or nothing of the saving grace of beauty. It's impossible to overestimate how Americans have come to take this extent and degree of dull ugliness for granted; but it is not surprising that, taking it for granted, we have become too dulled as a culture to ask what this ugliness does to us.
As beauty opens us, ugliness closes us. We shut down. We blunt our perceptions, our sensitivities. We stop seeing, because seeing gives us no sustenance. We enclose ourselves in our own bodies, the personal circle of our own bodies, because it is unpleasant, unrewarding, to see, feel, scent, and touch what's around us. We become resigned. That is what ugliness, or a continual lack of beauty, conditions us to do. I have seen, more than once, a magnificent rainbow over a city, with thick bands of brilliant color, and no one on the crowded street was looking at it, no one else seemed to notice it. Not because they were insensitive dolts, but because they were so accustomed to the absence of beauty that they'd conditioned themselves not to see anything but what was directly in front of them, not to see anything they didn't have to deal with directly. So much shutting down, done so automatically and done by so many that it's taken for "normal," can't help but have consequences. It makes a certain dullness-of-spirit, a certain boredom-of-perception, seem commonplace and therefore "right" and "normal." So it is no surprise that when we try to address problems in our intimate lives, whether in our homes or in the consulting room, the insensitivity we've conditioned ourselves to accept and practice is an invisible but potent factor. How can people so conditioned to dullness-of-perception by the absence of beauty in their world--how can they ever really see each other? It is crucial to realize that this insensitivity, this reluctance to see, cannot be attributed only to a childhood or familial situation, and still less to a genetic or otherwise "natural" lack of intelligence; whatever our personal situation, for many of us, the reluctance to see, to feel, has literally been "built in" to our environment, and is reinforced every day by that dull ugliness, the attack on beauty, that is the environment for so many.
The result is that an assumption of dullness and ugliness has become an unconscious psychic foundation for many of our feelings, thoughts, perceptions. Only this can explain America's need for continually more sensational entertainments--ever louder music, ever cruder sexual depictions and the loutish popularity of wrestling, shouting-matches on political "discussion" programs, effusive and argumentative talk shows where people willingly give up dignity to get attention and nothing gaining wide public notice unless it is extreme. The root of these phenomena is in large part aesthetic: an ugly dull environment in which brutish behavior becomes a positive value because it at least has the force to cut through, momentarily, our shielded, blocked ability to perceive.
All of which leaves us, each of us, facing one piercing question: What is beautiful in your life?
The therapist-client relationship is just about the last functioning shared space in this country where this question can be asked and, more important, heard. Which is why it's so crucial that therapists find a way to ask it. Directly or by implication, that question leads to others, questions that would make any of us squirm--and so they need to be asked all the more. Questions such as: Your children, your friends--do you find them beautiful? But what, exactly, is beautiful about them, and do you contemplate it much, does it shine in your behavior? In theirs? Your wife, husband, lover, what is their beauty in your eyes? But how does it play in your life, how does it nourish or inspire or challenge you? How do you acknowledge, salute, and cherish their beauty? And if you don't, why don't you? Your home, your city, your town, are they beautiful? How do you enter and celebrate and preserve their beauty, or do you? And if your surroundings are not beautiful or, more to the point, if you can find no beauty in them--what is there to do about this? What is the beauty in your work? And if this question stops you in your tracks, what does that say about your work--and about what your work gives to you and to others? And: What is your beauty? And does that question embarrass, frighten, annoy, or depress you? Why?
In an ugly world, beauty is a revolutionary idea. Which is why these questions strip us of comfortable and/or evasive language, cut through our technical professional language, and demand responses that are specific, concrete, immediate. Psychotherapy is in a unique position to ask these questions, to introduce these questions into our cultural life once more, for people seek therapy in that state of vulnerability in which the discovery of beauty is desperately needed--especially the beauty of relationship. Psychotherapy has forged a precise and immensely useful language for dealing with the negative and problematic aspects of relationship, but it has no corresponding language for the beauty of relationship. This is because problems between people are reducible; we can break them into pieces, concepts, and deal with them. But beauty between people is irreducibly itself. A rose is a rose is a rose. Jose Ortega y Gasset said, "Why do I love this woman? Because she is this woman." We can't be abstract about the beauty of one another, or that beauty flees. My wife Hannah has a marvelous laugh. When I feel and hear and see the beauty of her laughter, I experience as natural a beauty as the flash of sunlight on the wings of those birds I first noticed in that hospital, or the changing light upon the clouds that I learned to watch for in the sky. When I look into her eyes, I see a depth, a glow, a presence, to which I cannot give a name, not even hers. "I had had a vision of unearthly beauty, and that was why I was able to live at all." A psychology of beauty must somehow grope its way toward experiencing the Other as part of the beauty of the natural world--a beauty to which, in relationship, we have privileged access.
So the question, "What is beautiful in your life?" goes beyond analysis and into what was always intended as the end result of analysis: experience. Beauty doesn't matter much as an idea, it only matters, it only gains force, as an experience. A psychology of beauty is a psychology of experience, a psychology that appreciates and teaches an aesthetics of experience. For our very lives depend upon the beauty that we are capable of experiencing in each other and ourselves.
Another hospital, some 40 years after my view from that window: In my father's 81st year he was on a gurney about to be wheeled into the OR for a serious operation, a procedure that might well kill him. I held his hands, and their grip was still strong--his small, thick, deft peasant hands, that had earned his living all his life, hands that had an intelligence of their own, so precise were they in work. He looked up at me, and I was astounded by his eyes. I had never seen such eyes. So deep and calm, so full of an all-encompassing love--so unlike him! Had he been waiting all his life to muster the incredible focus of love with which he now looked at me? But not just at me. It was as though I were a representative for all of life, in that moment, in his eyes. In that moment we were all we had both been, and far more than we had ever been--the love in his eyes, for me and for life itself, was that overwhelming. It was, and remains, the most beautiful face I have ever seen. That it was my father's face is almost incidental. It was a face of humanity, looking upon the world with unalloyed adoration. You'll have to trust that I am not exaggerating--for, believe me, no one could have been more surprised than I that this man had that look in him. His beauty, and the beauty he could see, had been his best-kept secret, revealed only now at the end of his life. If this bitter, failed, enraged human being could achieve that look--then perhaps it was a gaze inherent and waiting in all of us. As they wheeled him away to what might be death, I stood in that bleak hospital hall stunned with joy. I had seen nothing less than pure human beauty--a beauty within, reaching out to bless and beautify all it saw. How can we leave beauty unaddressed, when so many long for beauty and are withering for the lack of it; and when so many keep the beauty they feel secret, and never reveal it, or reveal it only in extreme situations, perhaps at the very end?
Beauty is specific, personal, intimate--for it is experienced, in tiny but crucial ways. In dreams, in a child looking out a window, in hearing a lover laugh, in an old man taking what could be his last look at life. Which is precisely why beauty is in the terrain of psychotherapy--an as-yet-undiscovered country at the center of psychotherapy. "What is beautiful in your life?" is a question psychotropic drugs can't answer.
Our eyes go dead for want of a connection with beauty. And deadness, dullness, of the eyes is the very death that psychotherapy is dedicated to resurrecting.
I remember my very first therapist. I was about 13, and New York City had instituted some sort of program--through the schools? I don't remember--enabling emotionally disturbed street kids like me to receive help from "uptown" shrinks on an individual basis. His name was Dr. B.T. Lassar or Lasser. He was a portly, very dignified gent with deeply serious yet sweet eyes. His office on Central Park West was the most well-appointed, monied room I had, at that point in my life, entered--a plush room, not very well lit, full of portent and shadow, but I found the dimness appealing. The strange thing was . . . I was comfortable in that room. Lasser couldn't have been more different from the adults I'd known--for one thing, he was quiet and patient, and I hadn't seen much of that in the adults of my family. Perhaps because I was a child, he was careful to speak in words I understood, though now I remember almost nothing of what he said. What I remember most was the long subway ride from my tenement to his office--for the ride had the quality, going and coming, of a passage into and out of another world, a world that valued what my world didn't or couldn't. And that, I know now, was the healing power of his therapy for me: he put a value on qualities in me that my world mostly didn't notice, didn't want to notice. On the subway, I journeyed to and from a space where different things were valued, cherished, nurtured--which meant that there was such a space to be journeyed to, even if it was only one dim room in which sat one attentive person, attending to what the world devalued and ignored.
The consulting room has the power to be such a space--in it, value can be placed on what one's world will not or cannot consider. And in that space, that value can grow and become strong. In that space, in addition to dealing concretely with dilemmas, it is possible to value beauty--it is possible to make that space a place where the maligned and attacked beauty of the world and of humanity is emphasized, explored and made more real to whoever seeks that space. If the question "What is beautiful in your life?" can root itself in that space, then from that space, beauty will radiate, exert itself, find itself in the only way that beauty finally matters: in the experience of a soul that is, by degrees, less and less afraid to ask that question of itself.
Michael Ventura's biweekly column appears in the Austin Chronicle .
by Karen Smith
I'm sitting on a metal folding chair in the corner of a large, open room watching my son misbehave. I'm trying not to interfere. He is being tested by Rebecca, an occupational therapist, but he is not cooperating. She asks him to imitate a simple sequence of hand movements: she taps the child-size table where they are sitting with her right hand once, then with her left hand, then with her right hand once again. Evan flashes her a beautiful 5-year-old's grin, but then beats out his own rhythm on the table. She calmly repeats the instructions and tries again, with no success.
Next, she demonstrates a sequence of foot stomps. He ignores her and asks if he can play on the mats in the center of the room. I wonder, "Does he understand what he is supposed to do?" I suggest that I show him how to do it. Rebecca indulges me and I carefully copy her alternating foot movements. Evan just laughs at us both and runs off.
I cringe. This is exactly why we're here: He won't follow directions. For weeks now, Susan, his Montessori preschool teacher, has been greeting me with a furrowed brow when I arrive to pick him up each afternoon. She catches me on the playground and, with increasing agitation, catalogues the ways in which Evan refuses to follow the routine, respond to direction or make any apparent attempt to stay out of trouble.
He bumps into other children, steps on their work, makes loud noises, jumps and wanders aimlessly around the room, refuses to stand in line or join the group at circle time. He talks about poop and penises, obsesses about Scooby-Doo, generally acts the fool. When told to choose among the array of activities lining the shelves of the classroom, he rejects all of the options. When asked to sit on the back porch of the school building where his noise making won't disturb other children, he explodes. When forced to talk about his misbehavior, he shows little remorse and avoids looking Susan in the eye.
I am struck silent by these descriptions of Evan. As a child psychologist, I've heard parents of so-called oppositional children describe similar behavior, and I've made scores of recommendations about how to handle these kids at home and at school--how to set limits, define boundaries, support change. My practice is full of parents and children burdened by their individual and shared failures; and I have based my efforts to help them on the unspoken belief that good parents raise good children, despite the inevitable problems that come their way. But, now my child is failing. Now, I'm questioning whether I know how to be a good parent. What can I tell Susan? I'm not the expert here. I have no suggestions to offer about how to entice or coerce my own son to cooperate.
For months, I have been feeling helpless as a mother and utterly without grounding as a psychologist and family therapist. I watch myself get tangled up in power struggles with Evan. I hear myself bully him in ways that I could never admit, let alone recommend, to my patients. I ask myself how I can expect a preschooler to control himself when I'm so out of control. I joke, half-heartedly, that the day is coming when I will have nothing more to offer families than a sympathetic ear and a sad story of my own.
At home, my husband and I constantly argue with Evan about the simplest everyday things: getting dressed, washing his hands, picking up his toys, turning off the TV, taking a bath, brushing his teeth, going to sleep. He ignores us, then complains, whines, resists, falls on the floor, cries, screams. Really screams. We try being firm, we try being playful, we repeat ourselves over and over again. Then we give warnings, threaten, yell.
Nothing is easy at our house. Everything is hard.
Now as I watch Evan with Rebecca, I recognize the battle lines that are being drawn. She reminds him of the rules. He insists that he needs a snack. She bargains with him and promises a break after he does more work. He falls out of his chair onto the floor. I roll my eyes. She asks, "Does it feel good to fall?" He doesn't answer, but the question intrigues me.
I'm reminded that six months ago Evan rolled around on the floor at the Parents' Breakfast while his classmates stood in two neat rows singing Woody Guthrie favorites. At the time, Mr. Warren, the director of his school, characterized Evan as a "contrarian." He meant this in a vaguely complimentary way, and I actually took some comfort in his description. I could imagine a contrarian growing up to be a social activist, an artist, even a Pulitzer Prize winner.
But in the fall of Evan's second year of preschool, Mr. Warren's view of my son's future took a turn. He began describing him as "disruptive," "aggressive" and, on one occasion, "violent." He hinted that his school might not be the right place for Evan and suggested that we get a "behavioral analysis" at the university psychology clinic. I was furious--and grateful--that he didn't seem to remember that I analyze behavior for a living.
In our culture, we don't take kindly to children who refuse to do what they are told. We label them with euphemisms, such as difficult, willful or spirited. When these kids show up in my office as early as age 3 or 4, their parents--often tearful, angry, guilt ridden--want quick advice about how to win the battles they are losing. In single-minded pursuit of control, they contort themselves and try to twist their offspring into whatever shape fits their idealized notion of how parents and children should behave.
Sometimes these families don't seek help until the children run into trouble at school. There, where the rules don't bend, kids who push against the system are punished for their resistance. And parents are held culpable if they can't, or won't, make their kids knuckle under.
If their defiance persists, we call these kids maladjusted, antisocial or delinquent. We send them to the principal, to the school counselor, to a therapist--perhaps to their physician and a pharmacist. When these efforts fail, we send them to the judge, to the parole officer, to the warden.
I remember clearly the day my father asked me if Evan might need to see a psychiatrist. His well-intended suggestion landed on me like a slap in the face. From his point of view, Evan's misbehavior seemed pathological. But, as I saw it, the standard psychiatric tools were unlikely to be helpful. I knew the DSM-IV forward and backward, and our situation didn't fit into any of those boxes. This was not Depression, nor was it Anxiety. It was not Post-Traumatic Stress Disorder, Pervasive Developmental Disorder or Attention-Deficit/Hyperactivity Disorder. Maybe it was Oppositional Defiant Disorder, but what was a psychiatrist going to do about that?
One day as I was driving Evan to school, he said, "I wish Maria Montessori was in my class." I looked at him quizzically and asked why. "Because then maybe I could have a good day," he explained. As he saw it, only the benevolent spirit of the founder of his preschool could help him. The rest of us were clueless.
A week later he was sent home from school for slapping Susan in the face. I held him in my lap and tried to comfort him as he cried hysterically.
"We have to take down the school," he sobbed. "We have to, Mom. All the boards and all the nails. We have to take it down."
"Why?" I asked.
"Because I'm always bad there," he insisted.
These conversations--and many more just like them--devastated me. Every night, I fell into bed, exhausted by the day's failures, by my confusion, by the unrelenting struggle. And Evan was unhappy. "I wish God didn't make me to do bad things," he lamented one night just before he drifted off to sleep. As I groped in the dark for a reply, he added, "I think God feels sorry for me."
I imagined that my life would be spent clearing a path for my son in this world. A path where he would not be penalized for his obstinance. But I didn't feel up to the job. I was tired of pushing him through each day, trying to keep him on track, telling him every step to take and then arguing with him about why he had to take it. How could I expect his teacher or anyone else to tolerate his constant resistance?
Near desperation, I followed a friend's suggestion and called her son, a newly licensed neuropsychologist with a small practice and time to talk. That conversation led me to a murky netherworld outside the DSM-IV, where I discovered alternative diagnoses such as nonverbal learning disabilities, regulatory disorders and sensory integrative dysfunction. I wasn't sure where we were headed, but I knew that the map I had been using for years as an expert on children and families couldn't get us to where we needed to go.
This is how we came to Rebecca. Cautiously. Skeptically, even. I knew that occupational therapists sometimes worked collaboratively with psychologists; yet, in five years as a staff psychologist at one of the leading pediatric hospitals in the country and eight years in private practice, I had never met an OT. I had a vague notion that they helped babies with feeding problems, children with fine-motor delays and survivors of traumatic injury. What was an OT going to do for my precocious, uncooperative son?
In my first conversation with her, I sensed that Rebecca knew something about Evan that I didn't know. She was the first person who suggested that he wanted to please me, but couldn't. That in most situations he was doing his best. That many things that seemed simple and reasonable to me were, in fact, impossible for him. That there might be reasons for everything he did--and didn't do. That there was help.
She tested him on 17 different tasks that measured visual skills, coordination between the right and left sides of his body, balance, sensitivity to touch, accurate positioning of his body in space, imitation of movement and the ability to follow a sequence of instructions. Initially, the tasks were nonverbal but highly visual, like recognizing a picture embedded within another picture or copying geometric designs. Then she asked him to do things like move his finger from one spot on a map to another--without looking at the map--or to stand on one foot with his eyes closed. At first, he seemed to do pretty well, despite his reluctance to participate. But when he was forced to rely on touch, balance and sensory information coming from his muscles and joints rather than from his eyes and his ears, he flat out failed. For example, when Rebecca lightly touched one of his fingers without allowing him to look at his hand and then asked him to identify which finger she had touched, he couldn't do it. In most instances, he chose the wrong finger.
I was shocked. Evan was a creative, vivacious character who could talk circles around anyone on almost any subject. I had never thought of him as anything other than gifted. "He escapes into language," Rebecca explained. "He uses it as a distraction from tasks that are too difficult." Tasks too difficult? For Evan? With that comment, my understanding of my son began to change dramatically.
Several days later, my husband and I sat with Rebecca in her clinic. She reminded us that she had not evaluated Evan's intelligence, only his ability to process sensory information. And she confirmed that she had, in fact, found evidence of sensory processing problems. He was extremely sensitive to touch, but he often couldn't tell where he was being touched. As a result, he responded to tactile sensation defensively. His balance was shaky and his upper body was weak, so he often held his left arm bent and close to his body to stabilize himself. Because of this, he didn't use the right and left sides of his body in a coordinated manner. He also had a great deal of difficulty with what Rebecca called motor planning--the ability to plan, organize and carry out new or unfamiliar movements. She explained that these weaknesses interfered with his ability to pay attention, follow basic directions, participate in group activities and engage in purposeful, independent activity. They were also likely explanations for his emotional reactivity, his resistance and his sense of helplessness.
According to Rebecca, Evan was not oppositional by nature. (And he had not been poorly parented.) He was at the end of his rope, trying to meet the behavioral expectations of a typical preschooler's world without the neurological equipment required. Trying--but failing--to please his parents, who were dragging him through his life oblivious to the challenges he faced every day.
For most of us, the delicate interaction between the brain and body known as sensory integration (SI) is nothing short of marvelous. It allows us to move purposefully through the world without being driven to distraction by the cacophony of sensory experience that bombards us each minute we are awake. It is how we can sit at a computer, concentrating on abstract ideas without thinking about how to position our body in the chair so that we don't fall on the floor, or where to move our fingers on the keyboard without looking at them or when to ignore the sounds of the wind at the window and the barking dog and when to tune in to the ringing telephone or the crying child.
Rebecca talked to us about "sensory integrative dysfunction," a malfunction in the brain's translation of sensation into meaning and action. For example, the brain might not automatically recognize that pressure on the skin and muscles of the abdomen is coming from a too-tight waistband. It may not judge accurately whether the sensation is important or trivial, dangerous or benign and, therefore, may not respond logically or efficiently. It's like there is a traffic jam in the lower brain. Important information that needs four-lane access to the thinking centers of the brain--like the awareness that you're about to lose your balance--can't get through. Other information that should be diverted into a parking lot--like the feeling of a shirt tag rubbing against your neck--gets full attention, creating havoc and confusion.
When brain-body connections are intact, the lower brain constantly interprets input from sensory receptors all over the body and responds with motor reactions. Those actions create more sensory feedback, which provides self-correcting information to the brain in a never-ending cycle. Thankfully, this occurs outside of our awareness in most instances. We are free to focus on conscious thoughts, while our subcortical brain and its agents, literally, keep us from bumping into walls.
Children like Evan are not so fortunate. They vacillate between states of over- and under-stimulation and, as a result, often act in ways that are erratic and inconsistent. Everyday tasks--washing their hair or brushing their teeth--quickly overwhelm them. Complex tasks--learning to ride a bike or cleaning up a messy room--totally confound them. They become discouraged, irritable, whiny, explosive.
Because we assume that these children are neurologically and physiologically capable of doing what we ask them to do, we may describe them as inattentive, hyperactive or clumsy and complain that they are stubborn, angry or oppositional. In fact, they are all of those things--but for a reason. That reason is faulty sensory processing. Sensory integrative dysfunction is not a diagnosis like AD/HD, which is merely a list of symptoms that can be identified reliably. Rather, it is a conceptual framework for understanding what is causing some of the symptoms on that list (and others).
I was flooded with sadness and relief as I listened to Rebecca's descriptions of Evan. Through her eyes, I saw a boy who couldn't-- absolutely couldn't --stop thinking about the seam of his sock, or the waistband of his underwear or the tag on the back of his shirt. A boy who didn't yet button his pants, zip his jacket or fasten his seatbelt because he wasn't able to determine which of his fingers were touching the things he was handling. A boy who constantly made noise in order to screen out noise. A boy who had to bump into things or keep moving in order to maintain his balance. A boy who felt under attack by his skin, by smells, by noises. By his friends. By his father. By me. No wonder he was pushing back. His body was in a constant state of alert--and he was putting out tremendous effort just to get through each day.
It was the first explanation of Evan's behavior that made sense.
We quickly learned to recognize the obvious examples of sensory interference in his life. His consistent, adamant refusal to hug his grandparents because of his fear of losing his balance and the confusion and discomfort that light pressure on his skin created. His extreme reaction to the least little bump, scrape or cut. With Rebecca's guidance, we learned to detect the more subtle clues: the times he was driven under the dining room table by the smell of a fish stew, collard greens or even fresh bay leaves. The severe meltdown following a friend's crowded, noisy birthday party. The way he avoided schoolwork that involved tracing or writing because he couldn't discriminate between his fingers and couldn't control a pencil.
We started taking him to Rebecca for twice-a-week therapy sessions, but I would have taken him once a day if she would have agreed to it. She predicted that he would respond well to treatment, but that it would take time--at least a year. This was not magic: it was hands-on, developmentally oriented therapy based on the notion that the brain is shaped by experience. Through play, Rebecca provided Evan with sensorimotor challenges difficult enough to be appealing, but easy enough to be attainable. She said that these experiences would build upon one another, gradually laying the neural pathways between body and brain that were necessary for more efficient sensory processing.
Watching Evan and Rebecca together, I had to remind myself that they were shaping his brain. To my untrained eye, it looked like they were just having fun--crawling through tunnels, spinning in tire swings, diving into bean bags, tooting on horns, jumping through hoops. But surreptitiously, she was working him. Decreasing tactile sensitivity. Increasing upper body strength and postural stability. Encouraging bilateral coordination. Practicing motor planning. Building self-confidence. Developing a sense of mastery.
Meanwhile, life at our house was still hard. Power struggles persisted and temper tantrums were a regular occurrence, usually just before dinner, when the accumulation of the day's irritations crashed in on us all. Even though we couldn't always figure out what was causing him to crumble, we no longer blamed Evan for his frustration. We eased up and tried to listen.
With encouragement, he began to describe the peculiarities of how his body worked. Over a peanut butter snack one morning, he said, "Andrew is allergic to peanut butter, but I'm allergic to things on my skin." After we gave in to his request to wear the same pair of soft cotton shorts day after day, he happily said, "I love smooth. It's my favorite thing." When I asked him what happened when kids at school accidentally bumped into him, he replied, "Oh, I have to fall down to get away from them."
One of the children I wished he could get away from was a boy in his class named Jack. I didn't like Jack. He was loud and disruptive and annoying--and Evan was drawn to him like a pig to mud. Each morning, just as Evan was settling into some methodical Montessori-style activity, Jack would cavort by, chanting some nonsensical rap, tapping him on the head, knocking over his carefully arranged work. And Evan would be off in a flash. The two of them would bound around the classroom together, working each other into a frenzy that would usually get them both sent to time-out.
I was fighting my unfriendly feelings one afternoon as Jack stood in front of me in a new hooded sweatshirt. I dug deep to find something nice to say. "That's a great red jacket," I offered lamely. His mom, Terre, overheard me.
"Jack has just started treatment for sensory integration problems and we've discovered that he's very sensitive to noise," she explained. "He likes to wear jackets that he can pull up over his ears, even when he's inside."
I was stunned. I had dismissed Jack as a troublemaker, but now I could see that I had been wrong. He and Evan had the same fundamental problem. No wonder they couldn't resist each other.
Terre told me that Jack had been a difficult child from early on. As an infant, he didn't sleep, he couldn't breast-feed, he was restless, hyperactive, difficult to settle. From the first moment that he could crawl, he sought out small, enclosed spaces where he could hide. Even though she had raised two older children, Terre didn't know what to make of Jack's unusual behavior. Before she knew about sensory integrative dysfunction, she had gone to see a family therapist, who had recommended a behavior modification program to decrease Jack's "aggressive behavior." It hadn't worked (just like a sticker chart I'd designed for Evan hadn't worked). "I felt desperate," she said. "I didn't know what to do. I had this underlying fear that if we didn't do something, we were headed for medication."
Jack was 5 years old when a family friend who was the director of an OT training program told Terre about sensory integrative dysfunction. She had Jack evaluated and immediately started him in therapy with Rebecca. For the first time since her son was born, Terre felt hopeful.
Fortunately for both Jack and Evan, their teacher, Susan, was interested in learning about sensory integration. She read everything that I downloaded off the Internet about school-based interventions for SI kids. She created work spaces away from the noise and activity of the busy, open classroom. She allowed us to set up an old refrigerator box as a sensory shelter, which we decorated and called the "chill zone." She consulted with Rebecca whenever their opposition to a task puzzled her. Most important, she maintained her composure in the face of their sensitivities.
Within a few months, Evan stopped hating school. He started to recognize his own weaknesses, which made it easier for him to calm himself when he got upset, rather than exploding or disintegrating into a crying heap. When the din of the classroom became too intense and he started to get jumpy and loud, he asked for permission to go into the refrigerator box for a break. As his sensory processing became more efficient, he was able to focus on learning and enjoy its natural rewards.
"I'm so busy doing work at school that I don't have to try to be a good boy," I heard him tell his grandmother one afternoon.
His body was now working for him rather than against him, and he gradually developed the ability to ignore little discomforts. Because he was less sensitive to touch, getting dressed was no longer a painful chore. One morning, with wonder in his voice, he told me, "Mom, when I put on my underpants, they were too tight. But by the time I got downstairs, they were just the right size." Habituation--the brain's automatic modulation of sensory awareness--is no small miracle, when you think about it.
Emotionally, a vulnerable side of him emerged. "I don't want anyone to be mad at me," he said when he heard even the slightest irritation in my voice. This was the boy I had so recently thought of as impervious to my wishes. It was now painfully obvious that he had always wanted to do the right thing.
One night at dinner I found myself repeatedly correcting him: Lower your voice. Don't lean back in your chair. Stop teasing your sister. You know you can't have dessert until you eat your food. No singing at the table. Don't interrupt me. Suddenly, my patience ran out and I yelled at him before I could stop myself. He cried inconsolably, a wellspring of discouragement and self-doubt.
"Oh, I just hate it when this happens," he wailed. "What if it starts happening all the time? What if all my nights are bad nights? What if I never have a good night again?"
In my therapy office, I began to recognize children who were similarly misunderstood. Children described as angry now sounded hopeless; kids whose parents complained that they were stubborn seemed stuck. Defiance became a red flag for me--as did explosiveness and even hyperactivity. My map was changing: perhaps being out of control was a survival strategy for some kids.
Now I frequently hear myself defending kids' best intentions to their exasperated parents: Nothing would make your son happier than to please you. He wants to, but he can't-- and it's up to us to figure out why. I find myself comforting parents who blame themselves for not being in charge of their children: It's not your fault. You have not caused this. I tell them honestly that I know how it feels to say things to your child that you deeply regret. I give them permission to ease up: It's okay to give in. Love is more powerful than control.
Parents willing to accept alternative explanations for what appears to be misbehavior respond eagerly to my suggestion that these problems are not evidence of personal failure. "I'm hoping you'll tell me I'm not the worst mother in the world," the mother of an uncontrollable 4-year-old boy with significant sensory integration problems recently said to me. Once she and her husband recognized the source of their son's difficult behavior, they were able to appreciate his predicament, alter their expectations and rethink their ideas about how to discipline him. I encouraged them to accept and support him as he was , and to adopt a lifestyle that would accommodate his many needs. In consultation with their son's OT, they learned to control his environment in order to prevent sensory overload as much as possible.
But I'm still learning myself, and I'm not always certain when sensory integration is a reasonable framework for understanding behavior problems. When kids persist in everyday battles, I routinely inquire about their over- and under-sensitivity to sensory experience. I recommend an OT evaluation before a medication consultation for most hyperactive children. I don't want to overidentify sensory integration problems; on the other hand, I don't want to ignore the possibility that some kids cannot follow the rules, earn the points or honor the family contract despite considerable effort on their part.
I've discussed the possible connection between oppositional behavior and sensory integrative dysfunction with physicians, teachers and therapists--many of whom are considered authorities on the topic of disruptive behavior. Not one of them has been well informed about sensory integration theory. Most of them dismiss it out of hand because it has not been empirically validated. I find their closed-mindedness puzzling.
Therapists forced to appease managed care administrators are understandably hesitant to embrace alternative diagnoses. "Unproved" treatments are unlikely to be authorized. However, our track record for treating angry, defiant kids is not impressive. What I am discovering is that many difficult, oppositional kids can be helped. Not all of them have sensory integration problems, certainly, but a large number of them may. If they could be identified and treated early--before they get labeled as "behavior disordered," before peer problems develop, before they alienate their teachers, before their relationships with their parents get tangled up in guilt and rage and shame, before they lose faith in themselves--they might be spared the social, emotional and psychological repercussions of repeatedly failing to meet the expectations of adults.
Evan is a different child today than he was 18 months ago, when I first sat on that chair in Rebecca's clinic watching him fail. Collaboration between a talented occupational therapist, a sensitive teacher and parents who were willing to be flexible opened up new possibilities for him. He is a happy, successful first grader in a public school. He makes it through most days without a serious problem. He is kind and funny and affectionate. He is still clumsy, and he will probably never be athletic; but he has developed an astonishing talent for art. Best of all, he believes in himself.
The other morning as I drove him to school, we were talking about all the things he can do now. "I just might be the best person there ever was," he said dreamily. I smiled at him through a sudden mist of tears and kept driving, convinced that we're heading in the right direction.
Karen Smith, Ph.D., is a clinical psychologist in private practice in Athens, Georgia. She is currently writing a book about the possible connections between disruptive behavior and sensory integrative dysfunction. Address: 892 Prince Avenue, Athens, GA 30606; e-mail address: firstname.lastname@example.org
Sensory Integration: A Primer
The theory of sensory integration (SI) attempts to explain a process so integral to our experience that few of us are aware of it--the organization, interpretation and utilization of the continuous stream of input from our eyes, ears, skin, tendons, muscles and joints. As Evan recently commented: "Your brain is all over your body." Once we understand that, we are on our way to appreciating the many ways children's lives can be disrupted by sensory integrative dysfunction.
SI theory is the life work of the late Jean Ayres, an occupational therapist and educational psychologist whose observations of neurologically impaired children caused her to wonder about the contribution of the senses to behavior. She was particularly interested in the "hidden senses"--those that provide information about balance, the position of our bodies in space, touch, pain and temperature. Her work at UCLA's Brain Research Institute in the 1960s convinced her that irregularities in sensory processing, which she called sensory integrative dysfunction, could lead to a vast array of problems, such as inattention and poor self-regulation, over- or under-sensitivity to sensory input, disturbances in activity level, floppy muscle tone and lack of motor coordination, emotional reactivity, speech and language problems and oppositional behavior.
Ayres developed a battery of tests (the Sensory Integration and Praxis Tests or SIPT) to assess the fundamental components of sensory integration: touch reception, balance, processing of input from the muscles and joints, form and space perception, visuomotor coordination, bilateral integration, sequencing and motor planning. Results from the SIPT, which was recently standardized on a large sample of American children, provide a profile of a child's strengths and weaknesses and can be used to set specific treatment goals.
The SI framework suggests an explanation for many of the symptoms associated with an assortment of behavioral, emotional and academic conditions, including specific learning disabilities, Developmental Coordination Disorder, Reactive Attachment Disorder, Fetal Alcohol Syndrome, Schizophrenia, Pervasive Developmental Disorders and Attention-Deficit/Hyperactivity Disorder. It offers promise for understanding difficult children without a specific diagnosis, like Evan and Jack.
SI treatment is based on the concept of neuroplasticity, the nervous system's capacity to modify its structure and function in response to environmental demands. There is increasing scientific evidence of the brain's capacity for reorganization throughout the life span. SI therapists believe that purposeful activities that stimulate sensory receptors in the inner ear, skin, muscles and joints enhance the nervous system's ability to process and integrate sensory information, which in turn make higher levels of functional behavior possible.
Does SI treatment actually lay new neural pathways and reorganize sensory processing circuitry? Because we can't map or measure the complexity of neuronal connections, we can only infer neurological changes by observing a child's behavior. There is a great deal of anecdotal, clinical evidence of dramatic improvements in kids' emotional, social and academic functioning following SI treatment. What has caused those changes is unclear. Was it a natural process of maturation that would have occurred with or without occupational therapy? Was it the unconditional positive regard of the therapist? Was it the change in family dynamics once the parents understood the child's problem? Was it the SI treatment?
These are empirical questions and, admittedly, the empirical literature on sensory integration is limited. Occupational therapy is still a "young" discipline without a solid scientific foundation. Findings from studies of SI treatment outcome range from negative, to contradictory to positive; but many of those studies fail to meet the rigorous standards of scientific methodology. Nevertheless, a growing number of OT researchers are focusing on basic questions, such as how to reliably identify and classify children with SI problems, how to define SI treatment and how to select reasonable outcome measures. Until these questions are addressed with well-designed research, we will not have clear guidelines about when to recommend SI treatment and what to expect from it.
The fact that more progress has not been made in the 30 years since Jean Ayres first proposed her ideas about sensory integration is no reason to reject them outright. It wasn't so long ago that the empirical and theoretical underpinnings of psychotherapy were similarly shaky. SI theory could be a diamond in the rough, an unpolished gem with great potential value, a dream come true for many unhappy, unsuccessful children who are not receiving the help they need.
To consult with an occupational therapist who has a solid background in sensory integration, start by contacting local hospitals, pediatric rehabilitation clinics or early childhood intervention programs and asking for a pediatric OT with expertise in SI treatment. To refer a child for an SI evaluation, contact Sensory Integration International at www.sensoryint.com or call (310)320-2335 for a list of SIPT-certified occupational therapists in your geographical area. This organization also offers courses for parents, OTs and other professionals about SI theory and treatment. Another good source of information about SI research, clinical work and treatment resources is the website www.sinetwork.org, which is sponsored by the KID Foundation in Littleton, Colorado.
For more information about occupational therapy in general, refer to the American Occupational Therapy Association's website at www.aota.org .
by David Treadway
The sky had gone dark and ominous. The halyards kept banging on the mast as the wind picked up. I was in an exposed anchorage and had to get out of there before the blow hit. Unfortunately, this was my last writing day on my boat, and I had barely started winnowing down my list of most challenging cases. I wondered what criteria I should use to select the best one to write about. Was it the most complex cases, like those in which I have been the marriage, family and individual therapist to many different members of three generations? Or, maybe, the most dangerous, like the time when I was inadvertently locked in with a violently psychotic kid and the staff forgot about me for six hours? Perhaps, I'd talk about the most unusual, like the group I ran for three teenage transvestite male prostitutes.
I had finally narrowed the list to six clients who were culled from 30 years of clinical practice. I wondered what those last six cases had in common? As I shut down the computer, it was suddenly obvious why I had chosen them. The cases I had listed were really different, except for one thing: they all had been emotionally devastating for me. It was then that I knew I had to write about Amy.
I went up on deck and put a double reef in the main before raising the anchor. Better safe than sorry, I thought to myself. I wish I had been so wise when I started working with Amy a long time ago.
1978 --After 22 years, I can still see Amy sitting there, cross-legged, with her arms folded across her chest and her dirty blond hair falling down over her face. She was perched on the hood of my car. It was 9:00 p.m., and I was just leaving my office. Amy glared at me as I approached. Our therapy session had ended five hours earlier.
"Don't you think your Moms will be worried? You better head on home."
She took a long, studied drag on her cigarette and then flicked the butt away. "I'm not going home. I'm headed for the mountains of Montana. I just wanted to say goodbye. Do you have a problem with that? Or do you shrinks only care what happens when your victim's in your office and you're getting paid to be nice."
"Oh shit," I thought to myself, "here we go again." And I was dumb enough to think that we had had a good session earlier. Amy was one of my first private practice patients, and I was too embarrassed by the case to admit to myself what a mess it had become. It hadn't started out that way.
Amy's mother and her same-sex partner had asked me to see 16-year-old Amy in individual therapy because they thought she was depressed and possibly had an eating disorder. They also described her as increasingly combative and hostile. They had heard that I was good with adolescents, and even thought that my being a male might help a little, since she had no relationship with her father.
Since I was primarily a family therapist, I met the whole family at the first interview. Amy wore baggy clothes and looked a little like a war refugee, but she wasn't overtly hostile. She just stared at the ground and spoke in a barely audible whisper. Amy's mom seemed engaged and concerned. The stepmom seemed to understand the importance of not being too parental. Amy hardly spoke, but she did mumble agreement when asked if she wanted to have a few sessions alone.
Our work started off well. Amy was basically a good kid who was terribly lonely and very self-conscious. After a month or so of pretty benign how-to-deal-with-high-school sessions, Amy began to hint at the need to tell things she had never said to anyone. I was as gentle and reassuring as I knew how to be. After several false starts, she whispered haltingly about being little and her dad in the middle of the night; the smell of his breath, the weight of his body. Despite my never having done trauma work with an incest survivor, I felt I could help. I hoped that my bearing witness to her darkness and shame would allow her to risk opening herself back up to the world around her. She soon asked to come for more frequent sessions because she felt they were so helpful. I was pleased. Then she confided in me that she sometimes cut her wrists and often thought of killing herself. "I never thought I would ever be able to tell anyone," she said. I felt like her knight in shining armor. I should have known then that I was headed for trouble.
Amy began calling me at home. When I tried to help her understand that it wasn't okay to call me there, she was devastated. That's when she accused me of just being a rent-a-friend. Then she began making hang-up phone calls, started cutting her wrists again and threatened suicide. I utterly believed her when she promised to kill herself if I told anyone how suicidal she was. She told me that I was the only one who could possibly save her life. I remember her saying to me, "If you quit on me, Treadway, I'll be dead before you get home." And I was arrogant, foolish and scared enough to believe her.
My mother had killed herself seven years earlier, and both my father and older sister had had nervous breakdowns. I had been the de facto head of my family for years and was fairly entrenched in my role as codependent rescuer. Because I had been in my own therapy and believed that I had dealt with my issues, I didn't see how much my work with Amy had become a reprise of my desperate desire to save my mom and protect my sister.
Finally, I got so distraught over the hang-up phone calls, her suicidal threats and her desperate pleas for help that my wife insisted that I get some kind of help. I recognized that my heroic efforts might be doing more harm than good and that it was time to invite her mother to a session. Amy tried to make good on her threat and slashed her wrists, took an overdose of Valium and drank a bottle of wine. She was rushed to the hospital. The staff there concluded that Amy was a Borderline, that she was overly dependent on me and that it would be better for her to stop seeing me. I felt both relieved and terribly guilty. I knew Amy would be deeply hurt by my withdrawing from the case, but I didn't stand up to the clinicians. I was too afraid that they already felt I had bungled the case and was way too enmeshed with Amy.
The last session was harsh. Amy sat curled up in a fetal position, while the psychiatrist, social worker, her mother and I all tried to engage her. She wouldn't look at me or talk to me. I tried to tell her how sorry I was that our work had to stop and that I hadn't been able to help her enough. "Amy, it's not your fault. I just didn't know enough about how to work with you. I am so sorry." "So, Dr. Rat gets to leave the sinking ship," she spat out. "Good for the rat, bad for the fucking ship."
The psychiatrist motioned for me to leave. I closed the door of the office. I felt like ripping my face off.
1996--The phone rang during dinner one summer evening. "Just don't hang up. I'm okay now. Please let me talk to you. Just for a minute. Please."
After 17 years, I still recognized that voice. Through the years, I had assumed that Amy had either continued to struggle in and out of hospitals or had finally killed herself. Instead, she sounded great. She had actually moved to Montana and become a dental hygienist. She also reported that she was happily married and had a 2-year-old baby girl. She said she just wanted to bring me up-to-date on her success and thank me for being there for her during her tough times. I was delighted for her.
A couple of months later, Amy called again. This time, she confided that she had been to many therapists since seeing me and that no one had ever been able to help her as well as I had. She asked if I would please be willing to consider doing a few phone sessions with her about parenting, because she was having a little difficulty with her daughter.
Incredibly, I agreed. I thought I knew what I was doing. I had written a therapy book and many articles, had directed a family therapy training institute for a decade and had traveled the country giving workshops. More important, I had some decent training in treating trauma survivors. Surely I could help Amy appropriately within safe boundaries in a carefully managed short-term contract. I thought that, if I set it up carefully, I might be a bridge for her into a healthy therapeutic alliance in her own community. Part of me worried that once again I was falling into my knight in shining armor role, but I felt like I was being careful and avoiding the obvious pitfalls.
First, I talked with her and her husband together. He had heard all about me and, apparently, I had been placed back on the pedestal in the intervening years. So he thought it was a great idea. I warned her that the work had to be short term, and encouraged her to join a parenting group and find a local family therapist. I also contracted with her for safety, even though she laughingly said that I didn't have anything to worry about on that score, after all, she had her daughter, Heather, to worry about. She and I even talked about transference issues and how difficult it might be for her to work with me again even on a short-term basis. We both seemed to understand the risks.
Unfortunately, within the first month of seemingly benign phone sessions, Amy's secrets began tumbling out again. She had been stealing pain killers from the dentist's office and drinking wine. She confessed that she sometimes raged at Heather, which would made her feel terrible, which led to cutting and suicidal fantasies.
She was caught in the vortex once more and, like a complete fool, so was I. I even wondered if I had caused all this. But at least I knew that I couldn't be her therapist over the phone. Like many trauma survivors, Amy was desperately seeking gentle, loving compassion. But our therapeutic relationship seems to have provided a dollop of caring that invariably stimulated an insatiable hunger in Amy that she couldn't manage. It was almost as if she had a kind of lactose intolerance to nurturing. And I hadn't been able to manage my anxiety and grandiose codependency well enough to maintain the stringent boundaries that might allow Amy to tolerate our relationship and grow through our work together.
When I insisted that Amy find a therapist locally, she went into crisis again, and there were hang-up phone calls, another suicide attempt and an emergency hospitalization. Fortunately, a gifted therapist at the hospital was willing to take her case. On a conference call with her new therapist, I terminated with Amy. Once again, she was furious. Once again, I felt that, somehow, I had let her down. I realized I had gotten caught in my own grandiosity. I tried to reassure myself that as messy as it was, at least Amy had found a good person and maybe it would still turn out alright. I felt sad for her, and for me. And I also felt relieved.
1999--Once again, the sound of Amy's voice on the line was a jolt. "Joe was killed in a car accident. I didn't know who else to call. This time, I'm not going to make it," she said in a flat monotone.
Three years had passed, but it seemed like a day. I can imagine your thoughts, gentle readers, "No, Treadway, you didn't do it again! How arrogant and dumb can you be?"
At least, this time, I knew that I couldn't be her therapist, even temporarily. That was progress. But I couldn't turn my back on Amy when she was in such desperate straits. I'd known her since she was 16, and I couldn't just refer her to her local emergency room. So I told Amy that I would talk with her if she went back to her therapist and the three of us worked out a plan. Although I was essentially using myself as a bribe, at least it got her back to therapy. Amy acknowledged that it wouldn't work for me to be her therapist, but pleaded with me not to just dump her again. Given what she was going through, both her therapist and I thought it was a reasonable request. Even though it was highly unconventional, we agreed that Amy could have a once-a-month, half-hour, check-in call with me, if she was willing to recommit to her therapy out there. I volunteered to be a support person for her as long as she and her therapist thought her contact with me was helpful and that she was making progress. Although I had never done it before with a client, I decided to offer this contact without charging a fee, because I wanted to make my limited role with her absolutely clear.
Many of you may feel this latest arrangement was also highly suspect and that Treadway and his lifetime client were just remixing the same old brew in a different bowl. I hoped, for both Amy's and my sake, that this wasn't true. Despite my best efforts through the years, I may have done Amy more harm than good. Certainly, if I had to do it all over again, I would have insisted on family therapy and groups as the two main treatment modalities as soon as she acknowledged her suicidality. I also should have sought intensive consultation early on. I might have gotten some therapy around my intense countertransference vulnerability to suicidality. I never should have tried to do long-distance phone therapy. Would'ves, could'ves and should'ves. However, although there was nothing I could do to change the past, I wanted to support her through the loss of her husband and help her slowly find a way to rebuild her life.
Was I still playing the knight in shining armor after all these years? Probably. But I had turned my back on Amy twice, and I simply decided that I was going to hang in there and hope for the best. The role we three defined for me felt like a balance between my being overly involved and simply disconnecting from her. I hope it was the right choice.
2000--"Heather looked so cute in her life preserver, holding her paddle. I just wish Joe could see her." Amy said wistfully.
I just listened.
It's been more than a year since Joe died. She has absolutely kept to the rules of our contract and, to the best of my knowledge, is no longer cutting herself and drinking. Although she still thinks about suicide, she also has a part-time job and a good relationship with her daughter. Her therapist has been as steady as a heartbeat and feels that Amy's making slow, but substantive, progress. Our monthly talks are just support calls. She gives me honest and painful updates on her struggles, and I don't offer much advice. I commiserate and bear witness. I don't know that it's making any difference. I hope it is. We both know that, someday, she still might kill herself, but we don't talk about it much anymore. One day, I hope to say goodbye to Amy and see her on her way. But I don't know if we will have a good ending. I am still scared for her. Her life is truly in her hands. I pray for her.
It's been embarrassing to write about Amy's and my story, because it seems clear that I made a lot of mistakes throughout, and maybe I am continuing to make a mistake. This is what makes it my most challenging case. I don't know to this day if it's a success or a failure. If Amy ultimately kills herself, does that mean my involvement in her life was wrong. If she makes it, do I deserve the credit for a job well done? Am I still acting out some ancient rescue fantasies? Probably. But it's unclear whether the impact of my efforts is ultimately positive for her or not. I don't know, nor do I think I ever will. I do know that, in the end, I have to live with my choices, and I'd rather have risked caring too much than too little. I pray for me, too.
David Treadway, Ph.D., is a family therapist in private practice. He is the author of Before It's Too Late: Working With Substance Abuse in the Family and Dead Reckoning: A Therapist Confronts His Own Grief. Address: 228 Boston Post Road, Weston, MA 02193.
by Barry Duncan and Scott Miller
There was a time when therapists, and much of our larger culture, saw depression and other human troubles as complex conditions of mind and heart, influenced by many subtle inner and outer forces. But in the last decade, a vast intellectual and emotional sea change has taken place. We now inhabit a culture where many people hold the view that their emotional pain is "biochemical" and can be cured by simply taking a pill.
Emotional suffering, according to this new view, is a genetic glitch, successfully treatable by drugs. Depression is no longer thought to be shaped by such diverse forces as a sedentary, lonely or impoverished life;
the loss of love, health or community; "learned helplessness" or feelings of powerlessness arising from unsatisfying work or an abusive relationship. Its resolution no longer requires anyone to get meaningful support from others, to establish a collaborative relationship with a good psychotherapist, to draw on community resources, or for communities to address conditions that breed depression. No, depression is now publicly defined as a purely biological illness, treatable--thank heaven--by the miracle antidepressants.
Consider, for example, this interview, which ran on the CBS news program 60 Minutes in 1991, three years after Prozac began its meteoric rise to therapeutic dominance:
Lesley Stahl: [voice-over]... For 10 years, Maria Romero has been suffering from depression, a serious illness. Sometimes she spends weeks on an unmade bed, in a filthy apartment. She told us that she didn't care about anything, and she often thought of suicide. . . . Most doctors believe chronic depression like Romero's is caused by a chemical imbalance in the brain. To correct it, the doctor prescribed Prozac . . . and two and a half weeks later, we paid her another visit.
Stahl: I can't get over it. You're smiling.
Romero: Thank you. Yeah.
Stahl: How do you feel?
Romero: Great. I feel great. I feel like--like I'm a different person, somebody else. Somebody--something left my body and another person came in.
Stahl: She no longer spends her days in a filthy apartment. So two weeks after you started on this drug, whammo? . . . You stopped being depressed?
Romero: I stopped being depressed.
Stahl: Got out of bed . . . fixed your apartment, fixed yourself, and are losing--
Romero: --Fixed my life --
Romero: Yeah. Mmm-hmm. Yep. I'm happy about it. I think it's great.
In the eight years since this segment was broadcast, hundreds of stories like Romero's have been whispered between close friends, described by journalists and repeated in books like Peter Kramer's bestseller, Listening to Prozac. They have become our culture's conventional wisdom. The grinding despair and helplessness of depression is, these stories imply, just a "chemical imbalance" somewhat like diabetes or high blood pressure. The treatment of choice, we are told, is always a drug: Prozac, another Selective Serotonin Reuptake Inhibitor (SSRI) like Zoloft or Paxil, or perhaps another, newer antidepressant like Wellbutrin or Serzone. These miraculous drugs, the story goes, are effective with 75 to 85 percent of the people who take them. In this prevailing cultural script, therapy, like an old character actor, is sometimes ignored altogether, and never given more than a minor supporting role. Only one solution, apparently, is needed, and only one is offered: the passive consumption of a pill.
These views have taken on the luster of scientific truths. But they are not truths. They are myths. They have not been confirmed by the latest discoveries of neuroscience, nor are they supported by outcome research. They seem true because they have been repeated and reinforced by mass-market advertising intended to make taking antidepressants seem as normal and pervasive as swallowing aspirin: Zoloft's logo smiles from long-distance calling cards, coffee mugs, luggage tags and complimentary pens and pencils. A commercial during the World Series trumpets Paxil's power to cure social anxiety disorder. And the sides of colorful tissue boxes in physicians' offices proclaim: "Sue's playing with her kids again," "Walter's fishing again" and "Just like normal--thanks to Prozac!" SSRIs, these advertising campaigns imply, are simply the best first choice for treating depression.
The message is seductive and it works: if these drugs were books, they would be runaway bestsellers. More than 130 million prescriptions were written for them last year alone, and more than $8.58 billion was spent on them. And while most mental health professionals would acknowledge that the explanation given to clients is a gross oversimplification of actual brain functioning, few reject the biochemical model altogether. Fewer still question the effectiveness of the drugs, and virtually no one challenges the idea that combining medication with therapy is the best of all treatment options. At least it includes what talk therapists have to offer. The problem with these common beliefs and practices emerges, however, when they are examined in the light of scientific research.
On a level playing field, antidepressants would be regarded as one valid therapeutic choice among many--one with risks far more grave than those usually attendant on therapy. The awareness of many side effects is just beginning to make it into mainstream consciousness, and the future may reveal further unanticipated consequences: witness the silent epidemics of drug addiction among American women in the 1950s, produced by the widespread prescribing of "mother's little helpers"--amphetamine diet pills and Librium.
Not only are side effects underrated and underreported, outcome research does not confirm the miracle status these drugs have been accorded in the popular imagination. Our culture's exaggerated faith in these psychiatric medications rests not on science, but on brilliant marketing by a profit-driven industry. Outcome research--even outcome research funded by the companies that manufacture pharmaceuticals--has not found these drugs to be any better than therapy, and only marginally better than placebos. Knowing what the research really says will empower therapists to challenge the myths our culture holds about psychoactive medications, reinvigorate their belief in therapy and offer their clients choices based on fact, not superstition masquerading as science.
The first and perhaps most pervasive myth about SSRIs and other newer antidepressants is that their effectiveness is a matter of scientific record, conclusively demonstrated in strict, controlled, double-blind, placebo studies--the gold standard in medical research. According to this myth, the development of SSRIs was a pharmaceutical watershed and the drugs are "magic bullets" far more effective than the older tricyclic antidepressants like Elavil. This message is not only retailed by drug companies, but by the mass media and professional journals: in October 1995, for instance, the American Association for Marriage and Family Therapy's (AAMFT) Family Therapy News cited "overwhelming evidence" in support of antidepressants and their undisputed effectiveness with all but 25 percent of people suffering from unipolar depression.
This is a gross overstatement. Last year, a federal research review of hundreds of clinical trials found that the newer antidepressants were effective with only half of the depressed people who took them and outperformed placebos by only 18 percent. The finding came from the federal Agency for Health Care Policy and Research (AHCPR), a branch of the Public Health Service that promotes "evidence based" health care practices. The AHCPR reviewed all 338 relevant clinical trials of antidepressants conducted between 1980 and 1998, including 206 that directly compared SSRIs and other new antidepressants with older tricyclic antidepressants like Elavil. It found "no difference in overall efficacy" between SSRIs (costing about $66.41 a month) and tricyclic antidepressants (costing less than a tenth as much, or about $5.50). About 50 percent of trial subjects responded well to either drug, while 32 percent responded equally well to placebos; thus, all drugs helped only 18 percent more people than did sugar pills (plus hope and regular contact with a researcher or clinician).
Even at the anecdotal level, miracle stories like Maria Romero's are more rare than we have been led to believe: an online survey of 1,400 depressed people by the National Depressive and Manic-Depressive Association (NDMDA) in November 1999 found that 25 percent reported that antidepressants had no effect on their symptoms, 40 percent reported no improvement in fatigue and loss of energy and 35 percent reported no increase in their ability to experience pleasure.
Leaving aside the question of effectiveness, we turn to another major myth about Prozac and other newer antidepressants: that clients are more likely to tolerate them because their side effects are relatively mild compared with older tricyclic antidepressants like Elavil. In reality, the SSRIs' advantages are marginal; it's more a question of picking your poison. According to the AHCPR review, takers of tricyclics complained more of dry mouth, constipation, dizziness, blurred vision and tremors. SSRIs and other new antidepressants, on the other hand, produced more diarrhea, nausea, insomnia and headaches. Another side effect well known to clinicians went unmentioned by the AHCPR: SSRIs cause sexual problems, including pain during intercourse and difficulty reaching orgasm, in somewhere between 30 and 70 percent of the men and women who take them. SSRIs are also associated with rarer, but much graver, side effects, including bleeding, liver damage, seizures and akasthisia, an almost unbearable jitteriness that can escalate into suicidal thoughts and violent impulses: more than 200 lawsuits have been filed against pharmaceutical companies contending that SSRIs helped precipitate murders and suicides (see the Networker, September/ October 1999).
A third widely held myth is that tolerating even severe sexual side effects is worthwhile, because SSRIs are so much more effective than therapy for depressed people. This myth, too, is junk science, and is not supported by any large-scale methodologically sound study. According to the AHCPR review, the only known, well-controlled research study directly comparing antidepressants and therapy gave a slight edge to therapy. The 1996 study, involving 31 subjects and published in the journal Â Depression, found that Prozac and cognitive therapy were both effective, with no statistically significant differences between them. But a full third of the Prozac group dropped out of treatment or were unavailable for a final assessment, while only 3 of the 13 who received cognitive therapy dropped out.
The myth that SSRIs have proven their superiority to therapy echoes the belief held earlier about tricyclic antidepressants, which were also, in their heyday, thought to be a therapeutic watershed. But in 1989, another large federal study found that therapy was just as effective in the short run, and more effective in the long run, than tricyclics. This finding came from the landmark Treatment of Depression Collaborative Research Project (TDCRP), a National Institute of Mental Health (NIMH) study led by psychologist Irene Elkin. The four-month project involved psychiatrists and psychologists in Washington, D.C., Pittsburgh and Oklahoma City who treated 239 patients diagnosed with major depression. Patients were randomly assigned to one of four groups: Aaron Beck's cognitive therapy; Gerald Klerman and Myrna Weissman's interpersonal therapy; treatment with the tricyclic antidepressant imipramine; and, finally, treatment by placebo. After four months of treatment, the talk therapies had narrowly outperformed the drug: 39 percent of those receiving cognitive therapy, 34 percent of those receiving interpersonal therapy and 32 percent of those receiving drug therapy were rated as recovered. (In the placebo group, 16 percent had recovered.)
In the 18 months following the conclusion of the study, however, the people who had taken part in talk therapy did much better than those who had been given drug treatment. Psychologist Tracie Shea, of Brown University, and her colleagues found that about 24 percent of the therapy clients had recovered without a subsequent major depressive relapse, compared with only 16 percent of the pharmacotherapy clients and an equal percentage of the placebo group. Those receiving the antidepressants did worse on practically every outcome measure: they sought treatment more often during the follow-up period, were more likely to relapse and experienced fewer weeks of minimal or no symptoms than members of either of the two therapy groups. Shea did not speculate on why this was so. But her provocative findings dovetail with the findings reported by outcome researchers Michael Lambert and Allan Bergin in 1994, that clients who attribute change to their own efforts are more likely to maintain positive changes. One plausible hypothesis is that the therapy clients gained the tools and confidence to draw on when other life problems arose, while those who had been given drugs had nothing new to draw on.
But wouldn't the best of all possible worlds be one in which medications were combined with therapy, giving clients enough stability to make use of therapy and creating a sort of double-whammy treatment effect? The idea that both together must be better than either one alone for treating depression has become the newest orthodoxy among many professional groups. In fact, this sensible-sounding "compromise" solution actually promotes the use of medications, by implicitly suggesting that virtually anybody who enters therapy for any reason could usefully take them. Many managed care funded practices now routinely require all therapy clients to undergo medical evaluations as a prerequisite to reimbursement for treatment. But neither outcome studies nor clients themselves offer much support for applying this two-is-better-than-one approach.
In one of the broadest surveys ever conducted of therapy under real-life conditions, Consumer Reports in 1995 tabulated the responses of 4,000 members who filled out a questionnaire on their experiences with therapy. On the whole, their self-reports of both therapy and drug treatment were positive: 54 percent of those who said their state of mind had been "very poor" said treatment made things "a lot better." But people who received only psychotherapy reported as much improvement, on the whole, as people who tried drugs-plus-therapy. Given the additional expense of medication and the risks of side effects, we think therapy alone should be the treatment of first resort rather than drugs-plus-therapy.
The Consumer Reports survey has obvious limitations: those who filled it out had sought therapy for many problems besides depression; the results were based on self-reports by a self-selected group of members willing to discuss therapy on a questionnaire; and the sample was not randomized or demographically balanced. But its conclusions echo those of a research metareview by Yale University psychiatrist Bruce Wexler published in the Journal of Nervous and Mental Diseases in 1992. Wexler examined seven well-controlled outcome studies of 513 patients treated for depression. Therapy alone, he found, helped as many people as therapy-plus-drugs, with fewer dropping out of treatment. The review concluded with this simple summary: out of 100 patients with major depression, 29 would be expected to recover if given drugs alone, compared to 47 given therapy alone and 47 given combined treatment. On the other hand, 52 drug-only patients would be expected to drop out or have a poor response to treatment, compared to 30 therapy-only patients and 34 patients getting therapy-plus-drugs.
Â In all of the healing arts, there is no single explanation or simple, infallible remedy for any of the problems that beset humankind. Yet the growing power of the biological perspective in mental health discourse and practice suggests not only that there are solely biological explanations, but perfect, fail-safe biological solutions as well--simple pills that mark finis to everything from mild depression and nervous tension to panic attacks, bipolar disorder and full-blown psychosis and schizophrenia. How did this scientifically anomalous, weirdly simplistic point of view come about? If the science behind the advertised superiority of psychotropic drugs is so lacking, how did medications come to hold almost unchallenged sway over both public and professional opinion?
In the days of the Watergate investigation, the government informant known as "Deep Throat" met with Washington Post reporters Carl Bernstein and Bob Woodward in an underground garage and advised them to "follow the money" if they wanted to find who was really behind the break-in at Democratic National Committee Headquarters. The same advice can help explain why psychiatric medications have permeated every aspect of our culture. Follow the money, and you will begin to understand the growth of the pharmaceutical behemoth.
In March 1992, Consumer Reports estimated that the $63 billion drug industry spent $5 billion a year on promotion and publicity, and it spends at least as much today: advertising in medical journals, on television and in women's magazines; helping fund "public awareness" efforts like the National Depression Awareness Day; giving grants to organizations like the Anxiety Disorder Association of America (ADAA), the National Depressive and Manic Depressive Association (NDMDA) and even the American Association for Marriage and Family Therapy (AAMFT.) The American Psychiatric Association confirms that at least 30 percent of its budget is now underwritten by drug companies through grants, glossy paid advertisements in its journals and paid exhibits at professional conferences. Psychotherapy organizations cannot begin to compete with this billion-dollar promotional machine, even though the data upholding the value of therapy are clear.
Drug companies also fund much of the drug research that supports, however weakly, the myths that have taken hold of almost everyone from psychiatrists and journalists to therapists and the average client in the street. Because of the shrinking of federal grants and the privatization of research funding that began in the Reagan years, pharmaceutical companies now pay for the majority of clinical trials of drugs. The AHCPR metareview, for example, noted that out of 315 published clinical trials of 29 antidepressant drugs, every study that identified a sponsor had been funded by a drug company. The ubiquity of drug company funding may also help account for the dearth of research comparing the effectiveness of therapy and medication: why would drug companies fund research that might prove a competing product (such as therapy) was equally or more effective?
In the broader field of nonpsychiatric medical research, those who pay the piper tend to enjoy the tune: researchers with financial ties to drug companies usually publish results friendly to their funders, and friendly researchers, likewise, tend to get funded. An October 1999 study of 44 journal articles on anticancer drugs, for instance, published in The Journal of the American Medical Association ( JAMA ), reported that only 5 percent of drug-company funded research found that the drugs were not cost-effective, while 38 percent of the research sponsored by universities, foundations and other nonprofit organizations found the drugs not cost-effective. A study in the January 1998 New England Journal of Medicine produced similar results: of researchers whose published studies supported the use of calcium channel blockers to treat high blood pressure and angina, 96 percent had financial relationships with the manufacturers; only 37 percent of researchers whose work did not support the use of calcium channel blockers, on the other hand, had received drug company funding. Thus, like a flower opening itself to the sun, published research results tend to be skewed in the direction of the money source.
Our exaggerated sense of the efficacy of psychiatric drugs may also be colored by the fact that drug companies are under no obligation to publish the results of failed clinical trials. Thomas J. Moore, a health policy analyst at George Washington University, for example, recently found, in a search of FDA files, the results of two identical trials of the antidepressant Serzone. The one showing a marginally positive result was published, but Moore found no indication that the other trial, showing no measurable drug effect, was ever published.
While drug-neutral and drug-negative research is underplayed, drug-friendly research is sometimes overplayed and made to serve the purposes of marketing. In February 1999, for example, JAMA published a study showing that as many as 40 percent of American women and 30 percent of men suffered from some form of sexual dysfunction. "I think it gives us a base for explaining why we had this enormous response to Viagra," one of the coauthors, sociologist Edward Laumann, told The New York Times at the time. The article, widely reported in the popular media, was actually a recalculation of data first published in 1994. The JAMA article did not disclose that two of the coauthors, Laumann and Raymond Rosen, had served as paid consultants to Pfizer, the makers of Viagra.
Closer to home, the American Association for Marriage and Family Therapy (AAMFT) recently took part in a major public relations campaign focusing on depression, intimacy and antidepressants. The campaign was primarily funded by Glaxo-Wellcome,Â makers of Wellbutrin, an antidepressant notable for its lack of sexual side effects. With the help of a $50,000 grant from Glaxo-Wellcome,Â the AAMFT 1998 national conference in Dallas featured a panel on intimacy and depression at its opening plenary--a session historically reserved for one of the real movers of the family therapy field. The slick, Oprah-style session featured clips from the television series Party of Five Â and a five-member panel that included three speakers with financial relationships with Glaxo-Wellcome: psychologist Martha Manning; her husband, social worker Brian Depenbrock; and psychiatrist Anita Clayton, associate professor in the University of Virginia's Department of Psychiatric Medicine.
Over the next hour and a half, the audience of 2,000 therapists was reminded 11 times of the tragic sexual side effects of some antidepressants. Although Wellbutrin was never mentioned by name, Clayton mentioned several times that someÂ antidepressants don't deprive clients of a sex life. She did not disclose that she is a member of Glaxo-Wellcome's advisory board and speakers bureau, nor that Glaxo-Wellcome has funded her research. Nor didÂ Manning, who has written widely about her own depression, disclose that she has sometimes acted as a paid consultant to Glaxo-Wellcome and has cowritten a brochure for them on intimacy and depression.
The plenary was part of a larger public relations effort funded by Glaxo-Wellcome and cosponsored by AAMFT and the National Depressive and Manic Depressive Association (NDMDA)Â a private non-profit "public education" organization that gets the bulk of its funding from pharmaceutical companies. The campaign included a brochure for the public on intimacy and depression, bearing the AAMFT and NDMDA logos, but copyrighted by Glaxo-Wellcome and written from the point of view that drugs are the treatment of choice for depression. Nearly four full pages are devoted to the nuances of antidepressants, while individual and couples therapy rate a few sentences. ("Antidepressants are usually effective . . . psychotherapies developed specifically for the treatment of depression can be useful. . . .") Wellbutrin is not mentioned by name, but the point is prominently made that consumers should consult their physicians about medications free of sexual side effects. The campaign also took a panel that included two AAMFT officials, plus Manning and her husband (and on occasion, actors from Party of Five and John Gray of Men Are from Mars, Women Are from Venus fame) to three well-publicized and advertised "town hall meetings" on intimacy and depression held in New York, San Francisco and Seattle.
Psychiatrist Anita Clayton told the Networker that her airfare and lodging expenses for her participation inÂ the AAMFT 1998 plenary had been paid, but she had not receivedÂ an honorarium. She also noted that she has received research funding from, and is on the speakers' bureaus of, other pharmaceutical companies beside Glaxo-Wellcome.
We the authors were so concerned about AAMFT's involvement in the depression and intimacy campaign that we organized an e-mail protest to AAMFT before the plenary, leafleted the event and spoke in opposition to it at an AAMFTÂ "town meeting." Although AAMFT did not violate the ethical standards of any group with which it is affiliated, the failure to prominently disclose the speakers' relationships to Glaxo-Wellcome at an event presented for continuing education credit would violate the standards of other professional groups, including the American Psychiatric Association and the Accreditation Council for Continuing Medical Education.
Manning says that she routinely discloses that she is sometimes a paid consultant to Glaxo-Wellcome, but was never asked by the AAMFT to do so for the 1998 plenary; her involvement with the drug company's campaign, she says, resulted in far more focus on therapeutic and relational issues. "We cannot afford to isolate ourselves from the medical approach to depression, which has been enormously useful in my own experience, as has psychotherapy," she said. "Depression is such a horrible thing that we have got to be involved in all kinds of cross-fertilization." We do not argue that her views, and those of other consultants, aren't sincerely held. But what therapeutic school can afford to fund its advocates to put on an equivalent national public-relations road show?
This magazine, likewise, has never routinely asked its authors to disclose financial ties to pharmaceutical companies. In March 1999, the Networker published "Rx for Passion: Antidepressants Needn't Depress the Libido," about the sexual side effects of antidepressants, by Valerie Davis-Raskin, M.D, in which she recommended Wellbutrin. The editors were not aware that Davis-Raskin was also a member of Glaxo-Wellcome's speaker's bureau. The ubiquity of nondisclosure of financial ties, like these, makes it impossible for the general public, including therapists, to critically evaluate the objectivity of so called medical experts.
Marketing masquerades not only as research, but as public education. Take National Depression Screening Day, for example, a public relations and marketing extravaganza riding on the back of a public service campaign. On October 7 every year, volunteer mental health workers offer simple screening tests for depression (as well as counseling and referrals), at more than 3,000 hospitals, mental health clinics, doctors' offices, libraries, grocery stores and shopping malls across the country. Public service radio spots publicize the day. The American Psychiatric Association and the National Institute of Mental Health (NIMH) lend their names to the event, which is administered by a private, not-for-profit organization called the National Mental Illness Screening Project (NMISP) of Wellesley Hills, Massachusetts.Â NMISP also sponsors screening days for other mental illnesses.
According to information provided by NMISP to the IRS, Eli Lilly, the makers of Prozac, gave the group $1.75 million between 1993 and 1997--nearly half of the organization's $3.6 million income for those years. Almost all of Depression Day's largest funders (giving $50,000 or more) are pharmaceutical companies, as are six of the seven major funders named on the web site for the event. The director of NMISP told the Networker that revenue from other sources has since increased, and that only 25 to 30 percent of Depression Day's funding now comes from pharmaceutical companies.
Some marketing connected with Depression Day has been directed specifically at children. In 1995, for example, The Washington Post reported that several students at Walter Johnson High School in Bethesda, Maryland, complained after sales representatives of Eli Lilly spoke at a school assembly on Depression Day and then passed out free pens, pads and brochures touting Prozac. One student said she had been forced to listen to "a 45 minute plug for Prozac," and her mother told the Post that no other alternative treatment for depression, such as counseling, had been presented. These campaigns have a predictable effect: more than 453,000 prescriptions for Prozac alone were written last year for kids under the age of 18. Another recent Depression Day initiative focused on primary care physicians, teaching them how easily their patients could take screening tests in the waiting room, to be later scored by staff without imposing on the doctor's time.
Adrift in this cultural sea of overprescription and overpromotion, what is the responsible therapist to do? The solution is not to dismiss SSRIs and other antidepressants out of hand, but to put them in their place. Therapists should stop kowtowing to their supposedly superior powers and think of them as one choice among many--and certainly not as the treatment of first resort.
In our own practices, we never suggest medication as the treatment of first resort. Instead, we begin therapy on the assumption that if we follow the client's lead, ask about the client's own theory of how change takes place and strengthen the therapeutic bond, we will enhance therapeutic outcomes of all kinds--with and without medication. When clients believe that medication will help and are "in the driver's seat" in making an informed choice, we have found that SSRIs can be helpful at times. Whatever approach evolves from the dynamic, moment to moment synthesis of ideas, it is the client who judges its helpfulness. Finding something that fits is facilitated by routinely inviting each client's feedback about the treatment he or she is receiving. Whether the approach is medication or one of the 400 available therapy methods and techniques, we think therapy should be a partnership that involves the client's voice at every juncture and in every decision. And if talk therapy has not produced results in three to six weeks, we brainstorm options with our clients; one of them may be antidepressants, while others include switching to another therapist or another approach. But SSRIs are never our first choice unless the client suggests them.
Guidelines like these don't make the treatment of depression simple. Nor can guidelines--or any drug--fully prepare any of us for those horrible moments when we sit face to face with the smothering despair of our clients. Not long ago, one therapist at our clinic at Nova Southeastern University worked with a weeping, financially desperate woman named Alina. The therapist listened with growing concern as Alina talked about her inability to leave her emotionally abusive husband, her worry about her four children and her humiliation at her new job, where her boss mocked her Spanish accent in front of customers. "I can hardly get up in the morning. If I had the guts, I'd just crash my car into a tree and be done with it," she said. Her tears, anguish, and despair were so palpable during the session that the therapist found herself having to fight her own feelings of hopelessness and fear for Alina.
It was this painful resonance that permitted the therapist to connect with her client, and that helped create the possibility that Alina and she could be part of some kind of change together.
But this very resonance also made the therapist vulnerable to finding herself, like Alina, in momentary despair. For many therapists, this is the moment when the voice of bad research and great marketing emerges, whispering of the superiority of "modern science" over primitive "talk therapy." It leads many therapists to reach for what looks like a sure thing to give their clients (and themselves) hope and relief. The medication solution is like fast food: it takes the work, time and anxiety out of answering "What's for supper?" But the introduction of the topic of medication in therapy carries numerous messages, among them, "Your problem is so severe, and you are so biologically damaged, that we have to look at something other than what we are doing together, or what you can do on your own." These messages serve to abort most clients' naturally occurring search for solutions and to block access to their own innate resourcefulness that lies at the heart of good therapy.
Reaching for that sure thing, the therapist thought as she faced Alina, would have predictable results. She would refer Alina to a physician who could prescribe drugs, and he or she would inevitably focus on Alina's mental state, her fragility and her potential for suicide. The therapist also considered the implications of the fact that 70 percent of all antidepressants are prescribed to women. Other paths were far more uncertain. As the therapist struggled internally, Alina volunteered that she didn't like pills, and wanted to solve her problems herself. Knowing that other options could be introduced at any time, the therapist trusted in Alina's direction and in the power of the therapeutic relationship.
At the end of the first visit, the therapist pointed out Alina's strengths and all she had done to extricate herself and her children from unbearable situations. Alina concluded the session by emphatically stating that she had no plans to hurt herself. Over two months of therapy, the therapist met with Alina every week, encouraging her concrete efforts to deal with the circumstances that were distressing her, and Alina's life and mood slowly improved. When federal funding for the therapy program ended, Alina was no longer desperate, validating the therapist's faith in her client's innate resourcefulness. Alina was going out with girlfriends more, she had conquered her job and was getting praise there and she had much more confidence in herself. She had even begun saving money for an independent future without her abusive husband. She and the therapist had weathered the storm together, with Alina, not medication or the therapist, at the helm.
Some people, like Alina, struggle with despair and oppressive life circumstances over time; others, including the severely depressed, sometimes make stunning turnarounds within the course of a single therapy hour. If the option to try something different is not at least as attractive as the medical option, the magic pill will win every time. What is required is a reconnection to what good therapists already know: that most people can and will develop solutions to even the most daunting dilemmas, given support and encouragement.
At the core of this approach is our faith that change occurs naturally and almost universally: the human organism, shaped by millennia of evolution and survival, tends to heal and to find a way, even out of the heart of darkness. When we hang on to this belief in our hearts, we level the playing field and can compete with the noisy medical ideologies promoted by profit-making drug companies and championed by factions within our own professions.
Every good therapist knows that each case is as different as the faces we greet each hour. Each experience of depression will take its own course. Rather than being hostage to the notion that "it's all biochemical," we can remind ourselves that every emotional human experience--including hope, reassurance, trust, love, faith and rapport--affects the body's chemistry and has neurochemical correlates in the brain. Rather than turning to the magic pill, therapists can access the real magic: the connection created by listening to and exploring their clients' stories, experiences and interpretations of their problems. That rapport, as the sustained power of the much misunderstood and underrated "placebo effect" suggests, can positively affect not only clients' bodies and brain chemistries, but their willingness to act and their sense of who they are and who they can become. A mountain of outcome studies conducted over the last 40 years has shown that forming a therapeutic alliance is not a prerequisite to successful treatment--it is Â the real treatment. In study after study, therapies in which the client perceives a helpful therapeutic bond and a mutual agreement on goals are the most successful. Finally realizing that psychiatric drug therapy is a profit-driven industry, built on flimsy science, may be the bad tasting medicine we've needed. Although it may be hard to swallow, empowered with the knowledge, therapists can regain their voices, trusting what they have known all along about depression and other human travails: there is no better medicine than a good therapeutic relationship.
Barry Duncan Psy.D., is an associate professor at the School of Social and Systemic Studies at Nova Southeastern University in Fort Lauderdale, Florida, and Scott Miller, Ph.D., is a therapist and an international workshop presenter based in Chicago, Illinois. They are cofounders of the Institute for the Study of Therapeutic Change (ISTC). Jacqueline Sparks is a member of ISTC and a doctoral candidate at Nova Southeastern University. This article is adapted from Duncan and Miller's latest book, The Heroic Client: Doing Client Directed Outcome Informed Therapy . The authors can be reached at: www.talkingcure.com
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Elkin, Irene, et al. "National Institute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments." Archives of General Psychiatry 46 (1989): 971-82.
Murlow, Cynthia D., et al. Treatment of Depression: New Pharmacotherapies. Evidence Report/Technology Assessment Number 7. AHCPR Publication No. 99-E014. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, February 1999.
Shea, M. Tracie, et al. "Course of Depressive Symptoms Over Follow-up: Findings From the National Institute of Mental Health Treatment of Depression Collaborative Research Program." Archives of General Psychiatry 49, no. 10 (October 1992): 782-87.
Wexler, Bruce E., and Domenic V. Cicchetti. "The Outpatient Treatment of Depression: Implications of Outcome Research for Clinical Practice." Journal of Nervous and Mental Disease 180, no. 5 (May 1992): 277-86.
by Pat Love
Late on a chilly spring night several years ago, my husband inquired when I would be coming to bed. "Mmm, a little later," I replied. Translation: "Do you want to make love?" Answer: "Not a chance." The dialogue was familiar, but this time it was edged with a quality of brooding tension that distinguished it from the hundreds of similar invitation-and-refusal scenes we'd enacted before. When I finally came to bed that night, my husband was still awake, bristling with outrage and hurt. "Every night, it's the same routine," he stormed. "Aren't we ever going to have sex?"
I began to marshal my usual arguments about being exhausted after a day of chasing two small kids when, suddenly, I felt myself go limp with dejection. I felt bone-weary of the years of conflict, guilt and crushing sense of inadequacy that pervaded my lack of interest in lovemaking. Turning my face to the wall, I said softly but entirely audibly: "I don't care if I ever do it again."
From the other side of the bed, there was silence.
How had it come to this? When I first began dating my husband, a rangy, dark-haired college athlete with a chiseled physique and a talent for making me feel like the only woman on the planet, I was plenty attracted. Saving sex for our wedding night only heightened my desire. But even after our marriage, we made love frequently, passionately and often for hours at a time. If, during those early years, he wanted sex slightly more than I did, the difference in our sexual setpoints seemed negligible. On the erotic front, we seemed about as perfectly matched as any couple could hope to be.
Until it all ended. Two years into our marriage, my libido began to wilt; after giving birth to our first child, it went permanently AWOL. Truth to tell, I didn't much care about the demise of our sexual synchrony. Furiously busy with the demands of an infant son, homemaking and church work, I rarely even thought about sex, much less craved it. My husband's desire for me, however, had dimmed not one iota. One evening he arrived home, full of hope, bearing a book on sensual massage for couples. When I glanced through the photos of smiling, nude women pleasuring their partners, I felt my inadequacy like a physical attack and threw the book into the trash.
Silently, I blamed my husband for being inconsiderate enough to desire me when the feeling wasn't mutual, and while he never explicitly said so, he must have felt profoundly unwanted. For years, we coped by simply repressing all of our anger and sorrow--each of us fearful to say out loud how desperately unhappy we had become in our marriage.Â Then, on the night I finally spoke the unspeakable--"I don't care if I ever do it again"--our mutual disenchantment bottomed out into despair. Like many people, my husband and I equated sexual passion with love, so we concluded that if I had lost all interest in sex, I must no longer love him. At the very least, it seemed that each of us was trapped in an unbearably incompatible marriage, a union that doomed one partner to everlasting sexual frustration and rejection, and the other to feeling perpetually invaded and, at the same time, somehow defective. These convictions led to an action that remains the deepest regret of my life--an unnecessary divorce from a thoroughly decent, loving man and the father of my two children.
I say "unnecessary" not because we didn't try to work things out. We sought therapy and got the best that was available. But the intensity of shame and hopelessness that permeated our mutual sense of sexual failure was beyond the usual therapeutic jump-starts. Rather, I believe our divorce was unnecessary because we did not understand then that our desire gap was rooted, to a large degree, in powerful, automatic, biochemical processes that had little to do with how attractive I found my husband or how much I actually cared for him. In fact, I did love him; the problem was that my body didn't know it.
If the idea that desire is orchestrated by our body chemistry hasn't yet found its way into the clinical conversation, it may be because the evidence is still largely buried in scientific journals, primarily from the emerging fields of behavioral endocrinology and psychophysiology. The provocative core of the new research is this: Each of us approaches our erotic encounters already primed by a premixed neurochemical and hormonal "cocktail" that influences both the strength and staying power of sexual passion. Having delved into this new biological evidence and observed its impact in my own couples therapy practice, I am convinced that as long as our clients remain unaware of these bodily processes, they are at high risk for making disastrous decisions about their intimate commitments. Some clients will misread their clashing desire levels as the death of love and lose faith in basically sound marriages, as my husband and I did. Others will choose badly to begin with, making lifelong commitments while under the influence of short-lived, highly irrational brain states.
But I believe that both catastrophes are largely preventable. The emergent data on the biology of desire offers therapists a potent new tool for helping troubled couples--a genuinely new kind of sex psychoeducation. This form of "desire ed," which I now use routinely in my work with couples, doesn't dwell on the usual sex therapy instruction about performance anxiety or the search for the elusive G spot. Instead, its objective is to help clients understand how their hidden neurobiological agendas may operate in the bedroom, so that they can make conscious, thoughtful decisions about their intimate relationships rather than ones that misinterpret the critical messages of the body.
But let me be clear: I am not proposing that the complexities of sexual desire can be reduced to Chemistry l0l. There is no question that problems of passion also can be influenced by relationship conflicts and a long list of other factors, from depression, stress and past sexual trauma to certain medications and a host of medical disorders. Likewise, it goes without saying that chronic sexual problems can contribute hugely to relationship difficulties. Nonetheless, the biochemical action of the human brain--the organ that nature writer Diane Ackerman calls our "three pounds of blood, dream and electricity"--may influence how often and how badly each of us wants sex more than we ever imagined.
To begin to understand the biology of desire, think back to the last time you fell fiercely, feverishly in love. He, or she, merely walked into the room and your body was zapped by a thousand-watt current, transforming you from a reasonably rational, functional adult into a trembling, mushy puddle of pure yearning. When the two of you were together, the most mundane activity--say, going to Wal-Mart for poultry scissors--became an exhilarating, deeply rewarding event. Not to mention the sex. Remember? The sex was amazing .
Most of us who have spent any time in infatuation's clutches also remember the sense of pure, utter helplessness that permeates this state. In the throes of new romance, there is something strangely involuntary about one's behavior--the workaholic misses deadlines; the penny-pincher blows his paycheck on plane tickets for two to Paris; the solidly married woman finds herself whispering on the phone, making furtive, high-risk plans with her paramour. Our culture speaks of "falling" in love. Other societies have compared infatuation to divine revelation, and to psychosis. We often say, in jest, that this experience of hurricane-force passion is "like a drug."
But that oft-quipped analogy may turn out to be no joke. Some scientists now believe that the frenzied euphoria of romantic love may well be a bona fide, altered state of consciousness, primarily brought on by the action of phenylethylamine (PEA), a naturally occurring, amphetamine-like neurotransmitter. Michael Liebowitz, a research psychiatrist at the New York State Psychiatric Institute, believes that when we come into contact with a person who highly attracts us, our brains become saturated with a "love cocktail" comprised of PEA and several other excitatory neurotransmitters, including dopamine. This chemical brain-bath theory explains why new lovers can talk till dawn, make love for hours on end, lose weight without trying and feel so outrageously, unquenchably optimistic. Their neurons are soaking in natural speed.
Thus far, much of what we know about PEA's action comes from animal studies. When mice are injected with PEA, they cavort and squeal in displays of rodent rapture, while rhesus monkeys dosed with PEA-like chemicals make pleasure calls and smack their lips, a courting gesture. While the brains of romance-besotted humans have yet to be directly studied, Theresa Crenshaw, a sexual medicine researcher and author of Sexual Pharmacology , reports that elevated levels of PEA have been found in the bloodstreams of lovers. Crenshaw also has found that women's PEA levels tend to rise at ovulation, which suggests a role for this potent molecule in the survival of the species.
Still, speed-spiked blood and the antics of small animals hardly prove a pivotal role for PEA in firing human passion. To date, the most compelling evidence comes from studies on a group of people suffering from a disorder known as hysteroid dysphoria, characterized by a desperate, boundless craving for attention and admiration, coupled with an acute hypersensitivity to rejection. Unlike most adults, who succumb to infatuation upon occasion, the hysteroid dysphoric is a kind of "romance junkie," falling in love constantly, violently and often with unsuitable partners. This person's usual pattern is to enjoy a brief, thrilling infatuation, followed by a traumatic breakup, often precipitated by his or her anxious, seemingly bottomless need for displays of love and affection. Upon rejection, the romance-hooked person predictably plunges into deep depression, which he or she tries to cure by falling in love all over again.
Research psychiatrist Liebowitz and his colleague Donald Klein suspected that such "infatuation junkies" might suffer from some kind of biochemical imbalance--perhaps abnormally low PEA levels. They wondered: Was it possible that these individuals jumped compulsively from lover to lover in order to keep their PEA sufficiently revved up to feel normal? To find out, Liebowitz and Klein treated a group of hysteroid dysphorics with the class of antidepressants known as monoamine oxidase (MAO) inhibitors, which block the action of brain enzymes that break down PEA. MAO inhibitors, therefore, act to boost PEA levels. Within weeks of starting their medication regimen, some of the lovesick subjects began to choose partners more judiciously, while others reported feeling reasonably comfortable without any love interest in their lives at all. Apparently, these individuals no longer craved the PEA jolt they once got from their euphoric, disastrous romances.
But one doesn't have to have a diagnosable love disorder to be influenced by PEA. Researchers propose that in the presence of a sufficiently intense sexual and emotional attraction, virtually everyone's neural lattices become marinated in natural speed. Given some of the dangerously delusionary thinking that accompanies new romance, the concept of an overstimulated brain makes compelling sense. If the frenzied action of lovers' neurons tends to render them maniacally optimistic, it is no wonder that they tend to discount patently alarming qualities in their sweethearts. You may gently remind a love-struck client: "Have you really considered the fact that she is a practicing alcoholic, has lost three jobs in a row and has been divorced only two months?" Your client sweetly responds: "We can work it out." Indeed, in a study of 400 men and women involved in a new romance, psychologist Dorothy Tennov found that while infatuated individuals had no trouble identifying shortcomings in their lovers, they tended to recast even the most serious liabilities as trivial, tractable and even charming.
What about sex? We don't need a slew of studies to convince us that with a new lover, sex is the Mount Everest of romantic peak experiences. Some neuropsychologists now think that the sexual euphoria that accompanies infatuation issues from brain secretions of both PEA and dopamine, a neurotransmitter that both stimulates libido and mobilizes people to actively pursue the pleasure of lovemaking. With two potent brain molecules working overtime, it's as though our erotic thermostat gets overwhelmed--we want scads of sex with our beloved, we get our fill, then in short order we're ready for more. It must be love.
Until it's not. For the universal and much-denied truth is this: Romance has no legs. Numerous studies that have measured the duration of infatuation--from the first moment of stuttering euphoria to the first feeling of neutrality for one's love object--have found that the state of romantic rapture predictably burns out after 18 to 36 months. And while the demise of infatuation certainly encompasses emotional components, such as the resentment that attends the inevitable discovery that our lover has other priorities besides keeping us happy, our wilting desire is also likely to be grounded in brain physiology. Liebowitz and others theorize that the brain cannot eternally maintain its revved-up, lust-crazed state of romantic bliss, either because the nerve endings become habituated to the brain's natural stimulants or because levels of PEA and related substances begin to drop. It certainly makes sense that if infatuation is a "high" that is chemically analogous to an amphetamine jolt, lovers would develop a tolerance for each other over a period of time. Whatever the precise mechanism involved, all of us have experienced this downshift in desire--slowly but predictably, euphoria sneaks out the back door while reality, that perpetually unwelcome houseguest, makes its sullen entrance.
If the sexual reality facing postinfatuation couples were limited to plummeting desire, it would be tough enough to cope with. But the dilemma of many disillusioned lovers is made far more difficult by a substantial desire gap between partners. To fully understand this element of a couple's sexual struggle, we need to introduce a second biological factor--testosterone. When most of us think of this steroid hormone, we reflexively think "male," and a pumped-up, perpetually horny one at that. We almost never think about the ways in which testosterone influences women--and consequently, we may be missing one of the biggest clues to the desire difficulties of many couples.
Scientists have known for decades that both sexes produce testosterone: men manufacture gobs of the stuff in their testes and adrenals, while women pump out smaller quantities from their ovaries and adrenals. But while testosterone has been conclusively shown to highly correlate with male libido, it was long dismissed as a nonfactor in the sex drive of women. Then, in 1987, Barbara Sherwin, a psychologist and psychoendocrinology researcher at McGill University in Montreal, published her now-classic study on the impact of hormone replacement therapy on women's sex lives. Sherwin divided her 43 subjects, all of whom had undergone surgical removal of their ovaries, into three groups, giving one group estrogen medication, a second group a regimen of estrogen and testosterone and a third group a placebo.
The results were swift and dramatic. The women who received the testosterone-estrogen cocktail reported a greater upsurge in sexual arousal, more lustful fantasies, a stronger desire for sex, more frequent intercourse and higher rates of orgasm than the women in either of the two other groups. Sherwin replicated these findings in several other carefully conducted, double-blind studies.
Subsequent research on women's naturally produced testosterone has yielded similar results. In the absence of infatuation, women with high baseline levels of testosterone--so-called "high-T" women-- tend to be significantly more sexually interested and responsive than "low-T" women. This now-substantial body of psychoendocrinological research has exploded decades of mythology about female sexuality by establishing that libido requires a goodly supply of testosterone in women as well as in men. But herein lies a key source of the postinfatuation desire gap. Both genders rely on testosterone for a robust sex drive, yet on average, men have 10 times more of the stuff circulating in their systems as women do. This doesn't mean that women are typically only one-tenth as lusty as men; many endocrinologists suspect that because women are exposed to lower levels of testosterone, they are more sensitive than men to a given amount. Nor does it mean that all men are the sexual equivalents of the Energizer Bunny. Testosterone levels drop gradually with age, and at any stage of life, the genetically determined sensitivity of androgen receptors in the genitals and brain influences how strongly testosterone pumps up male libido.
Nonetheless, the biological reality remains that, on average, men tend to be hornier than women--by quite a bit. Surveys show that, among both heterosexuals and homosexuals, men think about sex more frequently, masturbate more often and rank sex as more important in their lives than women do. Of course, there are millions of exceptions to this gender-typed scenario. I worked with one young couple in which the woman wanted daily lovemaking, while her husband felt the urge maybe once a week. Sharing a bed with him aroused her to such a pitch that she had taken to sleeping alone in a back bedroom. I also have worked with many lesbian and gay couples on problems of mismatched desire, indicating that passion quotients vary within as well as across gender lines.
Whatever the gender positions of this lust gap, it is a commonplace phenomenon: A survey of 289 sex therapists found "desire discrepancy" to be the single most common presenting problem of clients. Yet couples might be able to cope more sanely with their divergent desire levels were it not for the biochemical blinders they wear in the early stages of their relationship. It is during the infatuation stage that the two major components of the biology of desire--the time-limited PEA factor and T-level mismatches--collide to create sexual catastrophe for many couples. If the brains and bloodstreams of new lovers are awash in the aphrodisiac properties of PEA and other brain molecules, any disparity in libido is, at first, likely to go blissfully unnoticed.
Let us say, for argument's sake, that you are a "low-T" woman who has fallen fervently in love with a "high-T" man. You, a person whose needle on the sex meter usually points close to zero, suddenly find yourself fantasizing about sex in graphic, Omnivision detail, and approaching lovemaking with a level of gusto bordering on zeal. You think to yourself: "I am a sexual person--I just needed the right partner." Your naturally highly sexed new lover, meanwhile, finds himself in a state of erotic nirvana: "Finally, I've found someone as hot as me!" Over and over again, I have heard clients recall their mingled sense of exhilaration and relief at having finally found their "perfect" lover. Even if they had experienced a similar sense of sexual harmony in the early months of a past romance, infatuated people tend to discount history: It is this lover, at this moment, who satisfies me more deeply than any other. That is, until the tide of PEA begins to recede and preexisting T-levels emerge, unveiling for each person his or her "real" sexual partner.
At this juncture, the "high-T" person is apt to feel bitterly disappointed, even betrayed. For even though his or her brain may no longer be drenched in a PEA-dopamine cocktail, he or she typically has sufficiently high T-levels to still want plenty of action in the bedroom. The "low-T" partner, meanwhile, is likely to feel bewildered by the loss of his or her temporarily turbocharged libido, as well as sexually pressured by what now seems like an insensitive, even predatory, partner. A downward spiral of mutual anger, bad sex, more anger and still worse sex--or none at all--finally leads many couples into therapists' consulting rooms, raging with sorrow, shame and profound doubts about the future of their disappointing marriages.
At first glance, the proposal that something as fluffy-sounding as "desire education" could make any difference to dispirited couples sounds inflated, if not preposterous. As University of Washington psychologist John Gottman's research indicates, on average, couples straggle into therapy a full six years after their troubles first erupt. If anything is going to help at this late date, it seems as though it would have to be an intervention that does something fairly dramatic--something that packs a real emotional wallop or teaches potent relationship skills or both. Faced with the typical couple's end-of-their-rope discouragement, how is dispensing a bunch of facts on body chemistry going to make any difference?
In my experience, the difference is as profound as hope. For beneath the "dry" facts on neuronal and hormonal processes lies a radically normalizing, shame-reducing message: Sexual passion is rooted in our natural body rhythms. That means that if the thrill is gone or if the thrill is different for you than it is for me, I have not failed and you have not failed. Nor has our relationship failed. There may be plenty of emotional junk that is also mucking up our sexual connection, but that's not all that's going on. If our desire problems are at least partly innate--mirroring neither messed-up psyches nor a bankrupt relationship, but rather the pulse and flow of ordinary bodily processes--then maybe we don't need to feel quite so ashamed and despairing about the muddle we're in. Maybe each of us, and the embattled, fragile relationship we're trying to sustain, are even fundamentally okay. Maybe we've got a chance.
Of course, every therapeutic approach tries to engender hope. The particular potency of desire education is its capacity to plant seeds of optimism so early in therapy--sometimes as soon as the first session. Every clinician who works with discouraged couples understands that there is no time to waste: You need a way to show them, quickly and compellingly, that what they view as a sorry excuse for a relationship is even worth expending further energy on. The problem here is that the palpable rewards of most couples work--the profound emotional breakthroughs, the fruits of well-learned relationship skills, the mastery of new sexual techniques--take time to emerge. By contrast, the matter-of-fact, calming information of "desire ed" can be dispensed almost immediately to interrupt the furious, toxic, blame-shame cycle that sabotages so many sexually polarized couples at the very outset of therapy. As a potent, front-end couples intervention, desire education can make the difference between a willingness to plunge into relationship work with a measure of motivation and the decision to prematurely quit in despair.
When Eddie and Joyce, a couple in their mid-thirties, arrived for their first session with me, it quickly became clear that their sexual standoff was already calcifying into a kind of listless bitterness. Slumped in his chair, Eddie complained that Joyce was his "wife in name only"--that is, she had avoided sex with him as much as possible duringÂ the past five years. "Your basic ice queen," he quipped grimly. Joyce countered that Eddie made her feel ugly and invisible by openly flirting with other women, to which she often responded by collapsing into tears, panic stricken that she was losing her husband. Eddie made clear that this was a real possibility. "Do you know what it feels like to get down on your knees and beg for sex?" he asked me. Joyce snapped, "It's more like being cornered by a dog in heat." Twice before, they had tried therapy, which had focused on improving communication and injecting more novelty into their erotic repertoire, to little effect. In a last-ditch attempt to stave off separation, Joyce had dragged Eddie to see me.
In the past, I would have begun therapy with a couple like Joyce and Eddie by focusing immediately on communication about relationship issues, such as Joyce's anger and "withholding" of sex and Eddie's motives for his blatant attentions to other women. But my experience has been that sexually struggling couples can rarely focus on such efforts at relationship repair at the outset, because they feel too deeply flawed and full of shame to believe that genuine change is even possible.
Instead, I began by empathizing with each of them about how painful it must be to live in a relationship in which one partner wants sex more than the other. Then, gently probing about their desire history, I learned that both partners had experienced their particular passion level over time, with several different partners. This suggested to me that Eddie and Joyce's sexual problem wasn't purely relationship-driven, but probably also had a hormonal component. So I introduced some information about T-levels and the consequent normality, even near inevitability, of their desire gap.Â As I spoke, Eddie and Joyce became quiet and attentive. Neither of them had had the slightest idea that testosterone--or the relative lack of it--was such a major player in female desire. I concluded with my core message: "What all of this means is that it's entirely possible to love someone a lot, but still not be very sexually turned on by him or her." Joyce and Eddie remained silent for a moment. Finally, Joyce spoke up. "So what you're saying," she said slowly, "is that I'm not just trying to punish my husband."
She glanced quickly at Eddie, who seemed lost in thought. "Well," he finally said, "I guess the good news is that maybe I don't have to feel like such a jerk when I get turned down." I sat quietly with them for a few minutes, letting the deeper message of my mini-primer soak in. I wasn't expecting any big epiphanies or tearful embraces, nor did they materialize. All I wanted was to give this couple sufficient relief from their mutual sense of sexual failure to commit to the work ahead. I wanted time. Eddie gave me my opening. "I like the idea that the trouble we're having maybe isn't all personal," he began. "But, not to be rude, so what? If I'm some kind of hormone factory and she's not, what the hell are we supposed to do now?" I responded that even if their hormonal makeup contributed to a natural difference in libido, it was entirely possible, with sufficient time and effort on their part, to develop a satisfying sexual connection. When, in the last few minutes of the session, they agreed to try, I felt a small jolt of elation.
Having now worked with scores of couples who suffer a substantial desire gap, I understand more about the private hell that couples like Joyce and Eddie inhabit. In our sex-saturated culture, the woman or man who is "low-T" is already, by definition, defective. But if you are that person, imagine then the experience of living with a "high-T" partner, who comes to you for sex again and again and again, when you truly feel you have little to give. The screws of inadequacy get turned still tighter as you experience your many varieties of unworthiness--unworthiness for not matching the "normal" sex drive of your partner, unworthiness for failing to live up to a fundamental expectation of a committed relationship, unworthiness for repeatedly turning your back on your partner's helpless, fervent desire for you.
And the inescapable truth is that your partner is hurting. How could it be otherwise, when he or she inhabits a reality of constantly slamming doors? Because of the raw exposure of self that attends sexual intimacy, this more ardent partner may experience chronic sexual rejection as an existential wound. Again and again, I have heard the more sexually desirous partner say to the other: "I've shown you myself--the real me. And you don't want it."
As I worked with Joyce and Eddie in the succeeding months, my goal was never to transform them into the hot couple of the month; nor was it theirs. Using other strands of "desire ed" that I wove into our therapy sessions, they understood that they had long since spent their allowance of PEA-spiked passion; from now on, whatever sexual intimacy they might experience would have to be consciously created.
To begin this process, I asked each partner to share with each other what kind of sexual-emotional activity would feel most loving and satisfying to them. For Eddie, it was what this couple jokingly came to call a "marital"--a periodic, 15-minute session of sex that gave him both a measure of physical release and, more important, the feeling that Joyce cared for him. For Joyce, it was receivingÂ regular, leisurely massages from her husband, which might or might not culminate in intercourse, depending on her wishes. Haltingly at first, each tried to respond to the other's requests for behavior that seemed, initially, alien to his or her own impulses. But as they gradually deepened their understanding that their partner's experience of passion was both different from their own and entirely valid, they became more generous in their capacity to stretch to respond to it. The result wasn't blood-boiling sexual fireworks, but rather a budding sense of mutual intimacy and trust that began to energize both their erotic and emotional connection. Slowly but perseveringly, they began to feel their way toward a state of marital grace that I call mature love.
I am not arguing here for any particular therapeutic approach to sexual desire problems. My observation is that a number of useful ones already exist, from the skill-building orientation of traditional sex therapy to the more emotion-centered approaches of numerous schools of couples therapy. Many therapists, no doubt, pick and choose from several models. My point is that whatever overall approach you favor will almost certainly be rendered more potent and effective by integrating some basic education on the biology of passion. By the same token, if you omit desire education, you risk giving your clients a hazardously incomplete understanding of their situation.
For example, if Eddie and Joyce had taken their dilemma to a mainstream sex therapy clinic, their problem would likely have been diagnosed as "hypoactive sexual desire" on Joyce's part, with a program of sensate focus exercises prescribed. There is much to be said for sensate focus, in which partners are taught to hold and stroke each other while attending to the sensations that emerge, to help each discover what kind of touch is pleasurable. The limitation of traditional sex therapy antidotes is that they are typically taught in the absence of context: They rarely give unhappy couples a way to feel less flawed and freakish about the sexual afflictions they have laid bare. In fact, a couple's shame may even be deepened by sex therapy's habitual use of such pathology-laden labels as "hypoactive sexual desire" or "retarded ejaculation." Desire education, by contrast, avoidsÂ the medicalization of sex in favor of a gentle, humanizing context. It conveys the idea that nobody here is inherently damaged or inherently unlovable. Desire differences are natural and normal. Relax.
Desire education also has a key role to play in couples therapies that focus explicitly on the emotional aspects of sexual desire dilemmas. The hazard of purely relationship-centered sex therapies is that by focusing solely on the interpersonal factors that fuel passion problems, a therapist may convey the message that once partners resolve these emotional conflicts, they will become, once again, the effortlessly synchronized sexual match of their courting days. But by judicious melding of information on the psychology and the biology of desire--especially about the experience of red-hot sex as a short-lived, PEA phenomenon--a therapist can convey reasonable optimism about a couple's sexual future without raising erotic expectations to untenable levels. For the reality is that when a substantial, hormonally mediated desire gap exists between partners, their ultimate erotic satisfaction will depend on a steady, vigilant effort to sustain their sexual connection. Even when two people love each other deeply, postinfatuation passion is rarely a free ride.
Even as I write this, I am confronting this challenge in my own life. I am still a classic "low-T" woman who, just three months ago, married an unmistakably "high-T" man. Fortunately, this time I knew--and so did he--that the exquisite tango of brand-new love would downshift, inevitably, into the reality of differing sexual setpoints. We know, now, that our work together for the long term will encompass much stretching beyond our respective sexual comfort zones--stretching to understand, to empathize with and to accommodate the other's unique experience of passion. Neither of us expects this process to be easy; at times, it may well be excruciating. Our hope is that during the toughest moments, when even our best efforts cannot bridge our differences, we can hold fast to the conviction that our desire dissonances are rooted in nature, not in an insufficiency of love.
For clinicians, perhaps the most invigorating potential of the emerging science of passion is the challenge it poses to radically reenvision our concept of human sexual relationships. Up to now, therapists have been offered two divergent, even diametrically opposed, ways of looking at clients' sexual problems: Either they are a direct reflection of the troubled state of the relationship, requiring deep emotional work, or they are a set of physiological problems, requiring primarily technical intervention--usually through referral to a sex therapist. The biology of desire offers a more encompassing vision: Our sexual selves are mind-body creations in the deepest, most inclusive sense. To consider the influence of our neural and hormonal processes is neither to diminish the power of emotional factors nor to deny the usefulness of sexual skill-building; instead, therapists can use the lens of human biochemistry to enlarge clients' understanding of the entire spectrum of influences on human erotic connection.
All of us need to become active, knowledgeable sex educators in this new, more inclusive sense. While we may think of this realm as belonging to clinicians who somehow "specialize" in sexual difficulties, the reality is that virtually all therapists work with people who are struggling with problems of passion--the woman who wonders whether she should leave her boring husband for the new, more enthralling man she has met at the office; the love-struck, single man who is rushing to the altar far too precipitously; the couple on the verge of splitting up because she wants it and he doesn't. These are deeply emotional concerns, but they are also matters of raw, palpitating bodily desire, and our clients can ill afford to have us uninformed about them. The emerging science of passion, which has relevance for nearly every sexual-emotional event that transpires between two individuals, can help us explicate these dilemmas for clients with a new level of depth and authority.
Still, it can be tricky, demanding work. As we teach clients more about the biology of desire, the age-old, inexorably human tug-of-war between biological imperative and moral responsibility is likely to emerge with renewed force in the consulting room. If desire is tied to biological processes, how responsible are clients for their sexually motivated behavior? Under the influence of PEA, can a long-married man "help" having an affair with his sexy new law partner? Or, if a woman now comfortably accepts herself as a "low-T" person, is that a legitimate reason to abandon all efforts to revitalize a sexually stagnant, otherwise committed relationship?
These are the moments when therapy becomes a high-wire act, as we try to maintain a fragile balance between a generous acceptance of biological reality and a fierce, nonnegotiable allegiance to consciousness, the quality that makes us human and saves us from being utterly at the mercy of our molecules. If we are serious about trying to stem the tide of marital and family misery in this culture, our clients' most torturous questions about their intimate relationships--Do I stay? Do I bail? DoÂ I officially stay but just go through the motions?--will require arduous discussions about choice and responsibility, as well as about the proclivities of neurons and hormones. Our body chemistry counts--much more than we ever imagined. But in the end, biology is only backdrop.
Pat Love, Ed.D., a family life educator, trainer and lecturer, is the coauthor of Â Hot Monogamy. Â Address: 6705 Highway 290 West, Suite 502-291, Austin, TX 78735; e-mail address: Pat@patlove.com
Rx for Passion
Antidepressants needn't depress the libido
by Valerie Davis-Raskin
As a psychiatrist and couples therapist, some days it seems as if I never talk about anything but sex. And increasingly, I find myself educating my patients about the impact of the new selective serotonin reuptake inhibitors (SSRIs) on sexual interest and pleasure. Sure, I've had patients blush or change the topic, but most welcome the invitation to discuss problems in their sex lives, some related to medication, others not.
I didn't used to talk so much about sex and the sexual side effects of antidepressant medications. When I started practicing psychiatry a dozen years ago, we weren't yet in the better-sex-through-modern-chemistry era. Then the landscape changed. We began to live and practice in a culture that has come to consider pharmacology an acceptable (if not ideal) means of reducing depression. But until we had some ideas about how to counteract the sexual side effects of antidepressants, it still didn't much matter whether we talked about them or not.
Things are different now. We know that sexual side effects are among the most common and most troublesome difficulties experienced by antidepressant consumers. And more important, I know that I usually can help my patients recover from debilitating depression or anxiety without paying a sexual price.
When Prozac first came on the market, the medical profession didn't have a clue about how vital serotonin was to sexual pleasure and responsiveness. We didn't realize that Prozac and its two bestselling counterparts, Paxil and Zoloft, can and often do greatly reduce human suffering, but they also frequently kill sex drive, cause delayed ejaculation or completely eradicate orgasms. To this day, the Physician's Desk Reference (PDR) grossly underestimates the rate of sexual dysfunction caused by SSRIs. The PDR lists an incidence rate of medication-induced sexual dysfunction in the range of two percent or less. Would that this were true! In reality, between one third and one half of all individuals taking the most commonly prescribed antidepressants experience sexual side effects. And these three drugs--Prozac, Paxil and Zoloft--are among the top 10 most common prescriptions written in the United States for any condition--affecting, literally, millions of Americans.
The target of antidepressants are the neurotransmitters, our brains' chemical messengers. But neurotransmitters like serotonin are also found outside the brain wherever there are small blood vessels, a fact that accounts for many of the common side effects of SSRIs, such as nausea or jitteriness. Because serotonin is a sexually inhibitory neurotransmitter, increased serotonin in the brain may curtail the urge to have sex. Outside of the brain, serotonin may reduce genital sensation, somewhat like a mild anesthetic: what used to feel great feels good, what used to feel good feels okay, and what used to feel okay doesn't even register now. This means that arousal, both the psychological interest and physiological blood vessel reaction (blood flow to the clitoris, while less obvious, is as important for pleasure for females as blood flow to the penis is for males), may be suppressed by antidepressants that increase serotonin. Clinically, this translates into any combination of possibilities: lack of interest in sex, difficulty reaching an orgasm or outright absence of orgasm, inability to maintain an erection or prolonged erection. Some individuals experience a variety of side effects, while others experience only one, in an unpredictable fashion. And of course, it's just common sense that if you can't have an orgasm, eventually the libido falters as a consequence.
The chart below summarizes the degree of sexual side effects likely to be caused by the most frequently prescribed antidepressants.
Prevalence of Sexual Side Effects Caused by Antidepressants
Monoamine oxidase inhibitors (Nardil, Parnate)
One common intervention for any SSRI-induced sexual side effect is simply to lower the dose, as long as effective treatment for the psychiatric condition can be maintained. Since arousal, erection and orgasm changes are all dose-related phenomena, a substantial number of people will continue to benefit emotionally from smaller amounts of the offending SSRI. However, lowering the dose always carries the risk of a symptomatic relapse, and should symptoms exacerbate following dose reduction, other strategies are necessary.
Some people will benefit from a so-called "drug holiday" (an intervention that does not work for Prozac, due to the much longer time that Prozac remains in the bloodstream, compared with the shorter-acting SSRIs). A physician might recommend a regular drug holiday, in which the medication is taken on Thursday morning, skipped on Friday and Saturday, and resumed on Sunday morning. Ideally, a couple would opt to make love first thing Sunday morning, but many couples would find that a Saturday-night schedule is preferred.
Should these more conservative measures fail (or be clinically inappropriate in the prescribing physician's or patient's view) there are other options. Three of the new antidepressants--Wellbutrin, Serzone and Remeron--have no sexual side effects at all. Wellbutrin is generally well tolerated, but may cause insomnia, headache, tremor or increased anxiety. Its major drawback is that it is only effective for depression and may exacerbate conditions such as panic disorder. Wellbutrin is pharmacologically distinct from the SSRIs in that it enhances the neurotransmitter dopamine rather than serotonin. As a result, while it has comparable efficacy for depressive disorders in general, any particular individual may respond preferentially to an SSRI (or vice versa).
Both Serzone and Remeron are very sedating, although this effect often wears off over time, especially for Remeron, which is taken at bedtime. However, Serzone must be taken in the morning as well, and sedation is a troublesome side effect for many. Remeron's major drawback is the high incidence of weight gain, a side effect far less tolerable in many cases than low libido.
The tricyclic antidepressants, such as Elavil, Norpramin, Pamelor and Tofranil, may cause sexual side effects, including erectile or arousal problems and anorgasmia. Nevertheless, the incidence is far lower than with the SSRIs. The major drawback to tricyclic antidepressants is their potentially negative cardiac effect, elevating the risk of suicide and overdose. Higher doses may cause sedation, constipation, dry mouth and weight gain. Tricyclics have a particular utility for panic disorder, since lower doses than those needed for depression may be effective, allowing a mid-range dose that causes neither sexual dysfunction nor other significant side effects. Antianxiety medications, such as Klonopin and Xanax, do not affect serotonin and do not have sexual side effects as a rule.
Finally, some physicians may recommend St. John's wort, which is not believed to cause sexual side effects, although this has not been systemically studied. Unfortunately, because St. John's wort is not regulated as a pharmaceutical substance, efficacy may vary widely among preparations, and even from one bottle of the same brand to the next. This, along with the fact that it has not been rigorously tested in head-to-head comparisons with traditional antidepressants (for efficacy and also for side effects), limits its use to mild cases of depression or anxiety. St. John's wort should be taken three times per day and many people have a problem remembering the midday dose.
If switching to an alternative medication is not clinically appropriate or effective, a physician might recommend adding another medication on a daily or as-needed basis. Taking a second medication may be problematic on several counts. Women often feel awkward about actively seeking sexual pleasure. Many people also are extremely hesitant to take anything for depression, let alone two drugs. For others, a second medication offers a wonderful antidote to the side effects of an otherwise helpful medication.
Most commonly, psychiatrists prefer a single low dose of Wellbutrin for patients complaining of sexual side effects from other antidepressants. It is prescribed initially only as needed, but daily if required. This comedication strategy employs lower doses of Wellbutrin than would be necessary to treat depression. Pharmacologically, Wellbutrin enhances dopamine, which has the opposite effect on libido and orgasm of serotonin. Small doses may restore the serotonin-dopamine balance, alleviating sexual side effects.
The list of agents used to comedicate for sexual side effects include stimulants such as Ritalin (methylphenidate), Urecholine (bethanechol), Yocan (yohimbine), Symmetrel (amantadine) and Periactin (cyproheptadine). Anecdotal evidence suggests that the botanical preparation ginkgo biloba may reverse libido, arousal and/or orgasm problems. Anecdotal reports also suggest that Viagra (sildenafil) is effective for SSRI-induced absence of orgasm--even in women--but its use may be limited by cost ($9 per pill).
At times, it's easy to distinguish whether sexual problems are a relationship issue or are caused by side effects. SSRI-induced sexual dysfunction follows a typical pattern: it begins within days or weeks of starting the new medication. For example, soon after she began takingÂ Prozac for obsessive-compulsive disorder, Maria found she could no longer reach climax with her husband, Steve. She did not volunteer this information, which is one reason I routinely ask women about inability to orgasm. My male patients can tell me that "things aren't working right sexually," without having to look me in the eye and complain that sex is no longer pleasurable. Many women, however, experience an ambivalence about whether nice girls are allowed to like sex or should just go along with it. And some women are terribly embarrassed to talk about orgasms. "He could stand on his head and nothing happens" is Maria's euphemistic description of her sexual difficulty. "It's like a switch turned off down there." Maria hasn't talked about this with Steve, and I suggest that she let him know that medication is the problem, since he may be wondering if it's his "fault." Maria looks horrified at the thought, so I give her some written information to hand him.
I invite Maria to bring her husband to a session so that we can talk this over together. In our joint session, I explain that she is on a high dose of an SSRI for Obsessive-Compulsive Disorder, an illness that only responds to serotonin enhancing antidepressants. Because an SSRI is the only reasonable medication, switching to something like Wellbutrin isn't an option. Further, I explain to her that since effective doses of SSRIs are typically higher for OCD than for depression or panic disorder, lowering the dose isn't a good idea. Likewise, the drug-holiday approach isn't appropriate for Maria. This leaves co-medication, an idea that Steve likes a lot more than does Maria.
Steve reveals that he feels so selfish since Maria stopped having orgasms, and he would like things to be the way they were before. He feels that he is imposing on Maria, because these days, he's the only one reaching a climax when they make love. Somewhat reluctantly, Maria agrees to try comedication and I review the alternatives. Does trying something just when needed prior to intercourse seem best, or would a regular daily comedication be better? I explain that the only-when-needed medication is like a diaphragm--you lose spontaneity, but you don't have to ingest it all the time. When I mention that the only "natural" remedy I know of that may alleviate inability to orgasm requires daily use, however, Maria jumps at this, stating that she'd rather take something natural even if it means taking it every day. I tell her about ginkgo bilboa, which she purchases at her health food store. Six weeks later, she reports that "it's not like fireworks or anything, but it's lots better. Steve says thank you."
Maria remains reluctant to "own" sexual pleasure, continuing to describe her medication-induced sexual side effects-- and return of orgasms--as Steve's issue. Until Prozac came into her bedroom, Maria's unexamined belief was that Steve mostly cared about his own pleasure, and that she was just there fulfilling her wifely duties. Now she's heard from Steve loud and clear that her sexual pleasure is an integral part of his pleasure. A seed has been planted. For the first time, she and her husband have discussed their sexual relationship openly, and she has an opportunity to reframe her sexual self-image.
Valerie Davis-Raskin, M.D., is the director of academic psychiatry at MacNeal Hospital in Berwyn, Illinois, and a clinical associate professor of psychiatry at the University of Chicago. She is the author of When Words Are Not Enough: The Women's Prescription for Depression and Anxiety Â and coauthor with Karen Kleiman, M.S.W., of Â This Isn't What I Expected: Overcoming Postpartum Depression.
by Lynne Stevens
A fee policy can clarify the therapeutic relationship
Money is an underdiscussed topic in graduate programs, supervision and peer groups, yet every therapist I know has felt the awkwardness of seeming mercenary when insisting to a client who has fallen behind that he or she needs to pay. Unfortunately, most therapists were never coached about how to reconcile the closeness of the therapeutic encounter with the fact that therapy is also a business. When I first started out, I made the mistake of letting my caretaker impulse overcome me and charging a certain client who was in crisis a lower fee for several sessions. When she didn't pay even that fee and later let it drop that she had gone on an extravagant vacation, I felt like a fool. It has taken me years to understand that therapy is not separate from the exchange of money. I am in this profession because I care and have skills and knowledge that can help, and I also need to make a living.
These days, I run into the problem of clients who don't pay far less frequently than I used to. I attribute this to two changes I've made. The first was convening a peer group to discuss money issues. We examined our family values and messages about both the importance of money and the secrecy that often surrounds money matters, while also looking at the impact of social messages about gender and earning potential. When I heard everyone's war stories about clients who owed hundreds of dollars or terminated therapy without paying, I realized that my discomfort with money wasn't a character flaw, but a deficit in my training. More than anything, doing this personal exploration is what prepared me to explore the topic with my clients. The second change I made was developing a few practical steps to make it more likely that my clients will pay on time: prevention, intervention and having a bottom line. Prevention involves setting clear boundaries up front about my expectations regarding payment. I give written guidelines to clients during the first session that explain how I run my business: I prefer to be paid weekly, but will accept payment monthly; I charge for missed sessions unless clients give me 24 hours' notice. My guidelines also extend to questions about sliding fee scales and how much notice I give before I raise my fee. I ask my clients to read and sign die guidelines while they are in my office. The next week, I follow up and ask them if they have any questions or thoughts about them. Even though it's not legally binding, the document signals a commitment to take the business side of therapy seriously. Later, if money issues come up, I show them the signed copy I keep on file.
Of course, having a signed piece of paper doesn't eliminate conflicts over money. When the client's checks keep bouncing or are never sent, I have to intervene. One client, Sherry, was four weeks behind in her payments, for which she offered a series of reasonable excuses. The next week, Sherry's session focused on a very intense description of an episode of childhood abuse. But when she got up to leave at the end of the session without paying me, I cleared my throat and said, "So, today is the day you need to settle up for the last few sessions, as we agreed." She was upset that I could care about money after she had just revealed her deepest pain. At that moment, thinking about money as a boundary made it easier to stick to my guns. Sherry's not paying was not only a violation of our contract, but a replication of old family patterns in which uncomfortable issues were not discussed and boundaries were regularly violated. My kind but insistent tone let Sherry know that I was not her mother or her best friend, and that money was a fact in our relationship as surely as the clock that told us when it was time to end the session. Although she was angry, she wrote me a check before she left.
At the beginning of the next session, Sherry talked about feeling humiliated that she had to pay someone to care about her. It gave us an excellent opportunity to talk about the therapeutic relationship, what she could expect from me and how I was different from a friend or parent. I saw this conversation as a deepening of the bond of trust between us. She admitted that my treating her like an adult by expecting her to pay had given her a positive sense of herself as being capable and mature even while she was exploring her childhood wounds.
Having a bottom line about our fees is hard for all of us in the helping professions. It doesn't mean cutting off anyone who doesn't pay like clockwork, but it does mean not being a doormat. I try to catch potentially disruptive money issues by dealing with clients' accrued balances in a timely way. I also address clients' resentment at being charged for a missed session that they forgot to cancel and explore their expectations of how "understanding" I will be when they tell me about financial hard times. With some clients, there has come a point at which I have had to recommend that they take a break for a few months until they can catch up on payments, or I've discussed options such as coming in less often to make therapy more affordable. There are very few cases in which I have had to say to clients, "No more therapy until you pay me for the sessions you owe." Sometimes, hearing that I am going to be that firm about payment jolts clients into action and a check appears in my mailbox. Other times, the client hears it as a rejection and leaves in anger. I try to leave the door open as much as I can, while at the same time holding to my bottom line. I am always on the lookout for creative options. One colleague who had past experience of clients who ; ended therapy without paying their balances now asks clients ending therapy to write postdated checks that she can ! cash throughout the year. It has cut I down on the amount of collections she ; has to do, and makes it easy for clients, who don't have to remember to send money every month.
The only way I can make sure that money issues don't harm the therapeutic relationship is to be self-aware enough about my own issues around money, and then be willing to raise the | subject with my clients when it comes | up between us. There is an old truism : that therapists are more comfortable discussing clients' most intimate sexual details than talking about money. This is no longer true in my practice. I now welcome the opportunity to examine the meaning of money with my clients. Our clients are not going to lead the way. When money issues come up in therapy, it's up to the therapist to blaze a trail of openness, honesty and healthy limit setting.
Lynne Stevens, C.S.W., B.C.D., has been a psychotherapist in private practice in New York for 20 years. Address: 159 West 95th Street, Apt. B, New York, NY 10025.
by Michael Yapko
IT WAS MID-MORNING ON THE FIRST DAY OF THE LARGE Psychotherapy conference when I first began noticing the small white buttons with their pithy little saying sprouting on the lapels of conference attendees: "DEPRESSION: IT'S AN ILLNESS, NOT A WEAKNESS." By late afternoon, the buttons, dispensed at an exhibit booth for a large pharmaceutical company, were everywhere. I glimpsed them affixed to collars, pockets, belt loops, purses, backpacks, folders, any spare inch of apparel or appurtenance. It was startling to see how quickly a slogan could capture the allegiance of so many of my colleagues, especially when so many of them shared a common preference for brief, solution-oriented psychotherapies. Why were they so willing to make a public endorsement of the saying? For one thing, the slogan is catchy. It seems to suggest that we've moved beyond an era of superstitious belief and finally uncovered depression's "true" nature. The idea that depression is a clear-cut illness, caused by a "chemical imbalance" that can be cleared up with a daily dose of Prozac or Zoloft, now threatens to become a widely accepted clinical mantra and a popular shibboleth, repeated in best-selling books, mass-circulation periodicals and morning TV talk shows.
Currently, the most common mental health disorder in America and one of the most costly depression racks up a staggering $54 billion a year in costs from work absenteeism, reduced productivity, lost earnings and treatment expenses, according to a 1995 study by the National Institute of Mental Health. Depression is also among the most medicalized of psychiatric diagnoses; indeed, family doctors, not psychiatrists, write up to 70 percent of antidepressant prescriptions, with a wide array of meds to choose from. With the lion's share of mental health research dollars going into psychopharmacology during the past 15 years, there are now five major classes of antidepressants on the market. Seven new medications have been introduced within the last 10 years alone, and about 15 more are now being tested by the pharmaceutical companies.
But does the wide prevalence of depression, the staggering popularity of drugs to treat it and the obvious zeal for medicalizing the whole problem constitute prima facie proof that it is a disease? Can we now reduce the complex phenomena of depression, with all its emotional, cognitive, relational, social and biological elements, to a simple neuro-chemical mistake? Or is it possible that most depressed people are not "sick," and that biology only represents one component in the reasons for their depression and the way they experience it?
While thesymptoms of depression, at least as officially described in the Diagnostic and Statistical Manual, may seem to many to be fairly clear-cut and predictable, its origins and antecedents are not. Genetics, childhood trauma, unconscious guilt, neurochemical imbalance, poor interpersonal skills, learned helplessness are all potential "ground zeroes" by one school of therapy or another. In fact, the way therapists regard and treat depression might be considered as a kind of professional Rorschach test, revealing far more about their theoretical allegiance than about the true condition of their depressed clients. Analysts are trained to think of depression as the consequence of unresolved childhood developmental losses; cognitive therapists look for errors in thinking and belief that reinforce negative emotions; behaviorists help clients extinguish habits that contribute to depression; and family therapists study systemic or interpersonal triggers for depressive symptoms. However different the methods and the philosophies of their proponents, all these models provide valuable insights into the hydra-headed entity of depression, and none can stand as the final, defining word. But of all of the methods for treating depressed clients, biological psychiatry is today in the ascendancy, due largely to the proliferation during the last 15 years of effective medications for treating depressive symptoms with fewer side effects than ever before.
The rising fascination with evolutionary psychology and biological determination has led some experts to proclaim, without much evidence, that all emotional states (including depression) are ultimately based on biology.
One study published in Psychological Science in 1990 by Robert Plomin, Robin Corley, John DeFries and David Fulker, for example, suggests that one's amount of television viewing may be genetically determined. A 1992 study in the same journal by Matt McGue and David Lykken indicates that the tendency to divorce is also biologically determined. Do we really have genes for TV and divorce? Where and how in human history would we have acquired such genes (that only seem to have been activated in the last 30 or so years)? Indeed, as psychologist Stanton Peele writes in Diseasing of America, it is currently fashionable to view all kinds of self-defeating personal behaviors, including eating disorders, excessive shopping and too much sex, as evidence of disease.
The push to redefine depression as a disease is aided and abetted by the managed care industry, which encourages the use of antidepressant medication as a treatment approach. According to psychiatrist Matthew Dumont, "It seems that if we so much as inquire whether a depression might be related to the stresses or losses of life before blasting it with a chemical, we are virtually guilty of malpractice."
But this devaluation of therapy that inevitably accompanies the new emphasis on biological approaches is wrong-headed on two fronts. In the first place, epidemiological, social and cultural data indicate that, for most people, depression is not a disease of biological origin. Increasing in prevalence among all age groups, it is growing most rapidly among late adolescents and young adults. The average age of onset for a first major depressive episode has been steadily decreasing and is now the mid-twenties. Since gene pools and biochemistry do not tend to change so markedly in so short a time, the evidence supports an argument for social and cultural causes for depression in most cases. Since 1945, when the first of the baby boomers, who suffer dis-proportionately from depression, were born, our cultural mores have changed profoundly. The breakup of the family, explosive technological growth, dwindling resources, violence, terrorism and the threat of nuclear disaster have undermined our sense of social stability and cast deep shadows over future expectations. Writing in the Archives of General Psychiatry in July 1985, psychiatrist Gerald Klerman and his colleagues identified some of the social stresses they believe account for the higher rates of depression. These include urbanization, changes in family structure, new gender roles and occupational shifts. All of these trends unsettle people, uproot them from traditional mores and meanings, confuse them about who they are and what is expected of them and create many new opportunities for experiencing inadequacy and failure. Psychology researcher Martin Seligman suggests that, as a people, we tend to be more self-absorbed than our forebears, and thus more hypersensitive to each transient mood. Seligman thinks that we may also have unrealistically high expectations of ourselves and others, even as we increasingly feel both more helpless and hopeless about controlling our lives.
This dichotomy is even more confounding for our own emotional well-being, Rates of depression and symptomatology vary widely from culture to culture and between genders, also lending support to the theory that the interplay of social, cultural and psychological factors is generally more important than biology. The Amish, for example, have considerably lower rates of depression than do other Americans. Their lower incidence of depression presumably relates to cultural factors, including vital religious beliefs, close-knit community ties and a reliance on their own labor rather than technology. Women in this country are two or three times more likely to be diagnosed as depressed than men, in part for biological reasons (reproductive events like postpartum depression and possibly premenstrual syndrome), but more likely because of systemic social inequities and cultural conditions.
There is no question that genetics and biochemistry play a part in depression, but the best data from identical-and fraternal-twin studies indicate that genetics can be identified as a cause of unipolar depression less than 20 percent of the time. But, if, as the evidence now shows, cultural and social forces contribute more to the onset of depression than does biology, medication is only a partial solution.
More important, there is now abundant evidence that therapy is as effective or more effective than drugs are for treating depression, with lower rates of relapse. In the January 1994 issue of American Psychologist, Ricardo Munoz, Steven Hollon et al. reviewed guidelines for treatment of depression developed by the Agency for Health Care Policy and Research (AHCPR) that compared thousands of treatment outcome studies using drugs alone, psychotherapy alone or a combination. Evaluating the guidelines, the authors concluded that psychotherapy was at least as efficient as drugs for relieving depression. And, on many measures, including treatment-dropout rate, social adjustment, symptomimprovement and relapse rate, psychotherapy performed better than meds. Several metanalyses of many controlled studies involving thousands of patients have reached the same conclusion. One is a recent review by David Antonuccio et al. of numerous studies comparing drugs to therapy and the value of both approaches combined, published in the December 1995 issue of Professional Psychology: Research and Practice, which reports substantial evidence for the superior effectiveness of therapy. There is "no stronger medicine" for depression than psychotherapy, writes Antonuccio in a recent issue of the American Psychologist. So, while medications can help relieve symptoms, and possibly help clients take better advantage of therapy, the reputation of Prozac or Zoloft as miracle cures for depression, rendering therapy obsolete, is simply not supported by research.
Late last year, the position of therapy was buttressed even more by the largest survey ever conducted of people who had undergone outpatient psychotherapy treatment, published in the November 1995 issue of Consumer Reports (See Around the Network, January/February 1996 Networker) and based on extensive reader-response questionnaires submitted by 4,000 subscribers. Unlike standard efficacy studies, with their random assignments of clients meeting rigid eligibility requirements to standardized treatments, the Consumer Reports survey caught the experience of therapy as it really is for most people with therapists who typically offer an eclectic mix of approaches and adjust their work to individual clients.
Of respondents to the survey, 87 percent said they felt better after treatment. There was no significant difference between psychotherapy alone and in combination with medication for any disorder, including depression. And social workers, psychologists and psychiatrists all had roughly the same rates of success. Most surprising, perhaps, to a field giving increased emphasis to brief therapy, respondents reported better results for longer treatment. Among those with similar levels of emotional difficulty, those who stayed in therapy more than six months said they made greater progress than those who left earlier. Not surprisingly, people whose choice of therapist or whose length of treatment was dictated by insurance coverage improved less than those who freely chose the clinician and modality.
Although the Consumer Reports study is not without problems low response rate to the questionnaire, lack of specificity to the depression diagnosis and other possibly distorting factors it broke new ground. By going directly to the mental health consumer, it produced the most naturalistic view of the actual experience of therapy of any study of the field ever conducted. According to psychology researcher Martin Seligman, principal consultant on the survey, writing in the December 1995 American Psychologist, "[The survey] is large-scale; it samples treatment as it is actually delivered in the field; it samples without obvious bias those who seek out treatment; it measures multiple outcomes . . .; it is statistically stringent and finds clinically meaningful results ... Its major advantage over the efficacy method for studying the effectiveness of psychotherapy and medications is that it captures how mid to whom treatment is actually delivered and toward what end. ... It provides a powerful addition to what we know about the effectiveness of psychotherapy and a pioneering way of finding out more."
While medications are often invaluable for symptom relief of depression, their effectiveness is not evidence for an underlying physical pathology. Medications work because they have a relevant chemical effect, indicating a correlation between their impact on specific neurotransmitters and mood. But while there are some cases in which medications may help depression sufferers without additional treatment, the consensus among most depression experts is that only prescribing medications is generally a disservice to the client. Most people require much more substantial psychotherapeutic help to learn the skills necessary for solving problems and avoiding future difficulties, if their medication-improved mood is to endure.
What is it about psychotherapy that makes it so vital to treatment, that gives depressed clients something they cannot obtain from medications? People become and stay depressed partly because they tend to explain life's ordinary defeats and disappointments in terms of their personal inadequacies and failures, and then believe their own negative opinion of themselves. Others have deeply pessimistic worldviews that influence their mood states and tend to engender self-fulfilling prophecies. A healing relationship with a therapist can provide the kind of personal support and teaching that can clear up the misperceptions that contribute to the negativistic view of life typical of depressed people. Therapy can help clients see life events from different perspectives and reattribute experience by assigning alternative explanations for life events that are less damaging to themselves than the typical depressive worldview. The ability to see and interpret events from new perspectives is critical to mental health.
As we become increasingly a nation of wanderers, our lack of steady and sustained social connections and consequent lack of competence in relationship skills provokes even higher rates of depression. Our ethos of extreme individuality and personal rights over collective responsibility and social accommodation increases the likelihood that we will be lonely and depressed, without the deep ties to family and friends that can immunize us against alienation and despair. But there is no disease here, just a way of responding to life that is proving ever more toxic to our individual and collective psyches.
As therapists, what can we do in the face of this rising tide of depression, which deeply implicates not the faulty biology of millions of people but the depressing nature of our civilization? And how can we counter the myth of pharmaceutical omnipotence that undermines our own confidence in therapy and our appreciation for its irreplaceable role? We must be aware that therapy works with depressed people because it draws on the clinical skills and adaptability required to understand a complex disorder skills no pill can mimic. Therapists also need to emphasize active, solution-oriented treatments over pathology-based passive ones. Rather than search the dim past for causes of presumed deficits, we need to actively teach clients the specific skills they need to manage their feelings and develop what author Daniel Goleman calls their "emotional intelligence."
Martin Seligman, in his book, The Optimistic Child, writes that antidepressant skills for interpreting and responding intelligently to life events can be taught at a young age. We can prevent later misery by teaching children to be more flexible in their interactions and empower them to solve problems before they lead to entrenched, self-destructive patterns of behavior. Similarly, Robert Ornstein and Paul Ehrlich, in their book New World, New Mind, argue cogently that learning to think preventively acquiring a refined sense of the relationship between "this" course of action and "that" predictable consequence helps people avoid being sucked under by their own moods and emotional reactions. In short, therapists are badly needed to help people learn the tried-and-true skills that used to be considered the hallmark of adulthood. They include the ability to think ahead, critically consider alternatives, anticipate consequences, recognize when to give precedence to the heart or the head and, perhaps most of all, create and maintain solid and satisfying personal connections to other people.
Just as there is no single cause for depression, which is the personal and idiosyncratic response of individuals to a multitude of biological, psychological and social factors, so there can be no all-purpose panacea, like the simple act of taking a pill, that resolves life's difficulties. The idea that depression is a disease reflects, in part, the benign intention to destigmatize the suffering it causes and, less benevolently, the economic pressures to find a cheaper cure. Americans have a history of valuing quick-fix solutions to difficult problems. But this simplistic approach to depressive disorders underestimates the remarkable human capacity for self-transformation. We have the ability to use imagination and intelligence to change our life circumstances, our attitudes and emotions, even, to some extent, our personalities. It is the privilege of our profession to be able to help troubled people along this path, and though medications may make this journey less arduous, in the long run, therapists are indispensable for getting their clients to this destination.
So, for the sake of your profession and your integrity, watch out for facile explanations of depression and pluck off those buttons that reduce complex issues to catchy slogans. Your clients will thank you, and you'll feel better about your vital role in treatment.
Michael Yapko, Ph.D., is a clinical psychologist and marriage and family therapist in private practice in Solana Beach, California. He conducts workshops nationally and internationally in hypnosis and brief therapy methods, and is the author of the new book Breaking the Patterns of Depression (Doubleday). Address: 462 Stevens Avenue, Suite 309, Solana Beach, CA 92075.