Psychotherapy, Medication, and Severe Mental Illness

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I wanted to respond to Simon’s comment:

{Psychoanalysis is one of the only places in society that is OK with allowing people to not be happy”

I can’t agree with you more. Therapy has become secondary to ‘life’ where therapists are seen as people who’ll ‘fix’ your problems so that you can go on with your business. No need for a relationship, they’re just there as a means to getting you back on the road, maybe to do just the very things which may have caused the symptom in the first place! Therapy’s become commodified. You’re sick? Go to therapist, get ‘cured’ and outcha come. Just like a drive-thru. The logic is “You have X? Take a pill”—it’s all about getting things done, overcoming these obstacles so that you can ‘maximise and realise your true potentials’ and all that nonsense. Now everything’s considered a mental disease—every little abnormality’s a disease and people WANT to make their ‘faults’ into diseases because diseases are considered to have explanations, to be beyond your control and ‘curable’. We need answers; we need something to blame so we don’t have to properly deal with it (just postpone it, repress it); we need to get rid of this problem (that’s what I’ve paid you for, therapist!). No wonder CBT’s endorsed by so many companies—it assumes that everyone’s normal; that you can go back to that normality. But that comes at the cost of ignoring the symptom. Like people who misread Interpretation of Dreams, they search for the meaning of their symptoms so that they can make sense of them then ignore them; they don’t try to engage with the question of WHY the symptoms took the FORM they did. People are too caught up with content and explanations and not with the process of ‘symptomisation’…

Sorry for my little rant}

I understand the spirit of your comment and share similar concerns, but I think it needs more nuance. A couple of thoughts:

1) As a practicing (training) psychoanalytic psychotherapist, I do share some of your reservations about CBT. However, we should be careful here. When CBT is considered to be the only empirically-supported treatment (EST) out there, then we are being fed lies mostly because of the narrowly defined criteria that qualifies a treatment to be considered EST (e.g. required manualized treatment). Yet if CBT is considered to be an intervention or tool in the psychotherapist’s toolkit, then I have no problem with using it for some types of disorders (e.g. OCD, panic attacks, PTSD) where it has proven to especially effective.

2) Psychiatrists prescribe meds not psychologists and most psychiatrists no longer offer psychotherapy as a service.

3) Regarding medicine, some people DO have neuorchemical imbalances. This should be acknowledged as a real problem. Sure there is some problem with over-medication, the question is this: whom do you think is being over-medicated? I’m all for doing talk-therapy because it certainly has its benefits. The research demonstrates that meds + talk therapy are usually most successful when used in tandem. Also, I don’t doubt that some people suffering from depression and anxiety disorders are over-medicated. However, there are many people out there who are under-medicated, especially those suffering from more severe mental illness (e.g. schizophrenia, schizoaffective, bipolar I disorder). These individuals are suffering greatly and need medication. They also need some psychotherapeutic support.

4) Also, some people are suffering from an illusion that everything can be explained. They think there’s some red thread that if unraveled by a talented psychotherapist will alleviate the individual’s symptomatology. However, people suffering from delusions all share remarkably similar delusions. Why is that? I don’t think there’s always a reason why symptoms take the FORM they do, or perhaps, the idiosyncratic reason will not magically cure someone. Schizophrenia impacts the brain, drastically. This is a fact. Read more about this here

5) You’re oversimplifying this idea of responsibility and labeling. You’re right that some people use their ‘mental illness’ label as an excuse to evade responsibility, although I believe these people are in the minority. The majority of people are actually ostracized by ignorant individuals and blamed for having some moral weakness. Diagnosing these individuals can bring great relief and comfort since they no longer feel completely alone and crazy.

6) I suppose your comments are more accurate when applied to those suffering from less debilitating forms of mental illness. My professional interests include the treatment of individuals suffering from severe illness (e.g. psychosis). I just don’t think your rant really does justice to their suffering as it tends towards making unilateral assumptions about persons suffering from mental illness. Unfortunately, effective treatment is still being developed for these types of disorders, and no treatment has yet proven to be consistently effective.

7) Finally you’ve touched upon CBT’s dominance in modern health care. Here’s the problem: CBT is very selective with the clientele it treats in empirical research studies. Many CBT studies enforce wide exclusion criteria which help make studies more precise and internally valid (and ultimately more effective). For example, imagine there’s a CBT treatment for OCD. To keep the study precise, individuals who also suffer from personality disorders, substance abuse problems, homelessness, and other co-occurring disorders (e.g. schizophrenia) will be excluded from the study. Although this allows the to make sure they are just treating OCD, it sacrifices the ecological validity, i.e. this severely diminishes the generalizability of such findings because people suffering from mental illness rarely have one condition. In the end, those individuals who struggle most mightily from severe mental illness along with poverty and substance abuse are never considered in these studies, suggesting CBT is often a treatment only effective for high-functioning and middle-upper class individuals. Unsurprisingly, it has been most successful for very isolated problems such as OCD, panic disorder, and specific phobias.

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6 Responses to “Psychotherapy, Medication, and Severe Mental Illness”

  1. Simon Says:

    Jeremy,

    Thank you for the detailed and generous response — I’m quite new to the ideas of psychotherapy/psychoanalysis so getting feedback from an actual trainee in that field is invaluable! You have clarified a lot of things for me, and that Nietzsche article was very insightful — I had never looked at psychoanalysis in that light. [But I have a question with regard to that article — shouldn’t the analyst provide the psychotic analysand with a suppléance/sinthome so that his/her knot is sufficiently secure and he/she can integrate into society?]

    Your comment on the utility of CBT as a ‘tool’ was helpful too, but I still have a problem with its assumption of normality, because even if CBT is effective for conditions such as OCD — and I’m all for helping the patient in whatever way possible since, after all, that’s the purpose of psychotherapy — I think that assumption is dangerous, insofar as it may affect one’s conception of oneself in a negative way. It’ll make one more prone to believing in and equating himself/herself to the fictional, ideal self [ego ideal?] and more attentive and susceptible to claims, whether trivial or not, which one sees as potentially undermining that ‘self’. Couldn’t that result in one’s life becoming too engaged in trying to assert or even achieve this ideal self, which is, to some extent, a social construct? What I mean is, if a transcendental One is posited — the ‘Normal’ One — then wouldn’t one always feel as falling short of that, being a kind of disappointment to the One?

    Also, I didn’t mean to equate therapy with medication — I should’ve made my self clearer on that. What I wanted to convey was that the modern-day logic is analogous to that of “You have X? Take a pill” approach — we expect every problem to have a quick solution. But I thought that therapy was not like this — it’s not like a pill you just ingest and forget about, but the treatment is long-term and the relationship between analyst and analysand is a crucial aspect of treatment. It’s not a ‘simple’ business transaction, with the analyst giving the analysand his required product. [But then there’s the objection that the whole point of the analyst as sujet-supposé-savoir is that the analysand believes the analyst to possess and be able to give him this very product…?] Isn’t there a relationship, which is deep and personal, between the two parties and without which transference won’t be established? Analysis shouldn’t be done with the end in view — some treatments, I’ve heard, take many, many years — but the relational aspect should be emphasised.

    But again, I have to admit, a lot of these are assumptions/guesses and generalisations, due to my still very limited knowledge of the field. I plan to embark on the training course at CFAR from September, so I hope it’ll all be made clearer soon! But at the moment, I am really in need of someone to tell me if I’m reading the texts and interpreting the concepts wrongly, so again, Jeremy, your comments are priceless!

  2. Jeremy Says:

    The treatment of psychotic individuals with psychoanalysis is something I plan to post on next week, so I’ll delay my commentary for now.

    I don’t think CBT operates on normative assumptions. Most CB therapists probably assume some distress model, i.e., client X is in distress because of symptom Y so lets implement strategy Z to alleviate symptom Y. There’s no real assumption that suffering from symptom Y makes client X abnormal or strange. I think that this normality assumption you mention would have been more applicable for strict behavior therapy back in the 60s and 70s. CB therapists tend to be a bit more nuanced and complex when it comes to understanding mental illness.

    You’re right that the ego-ideal is an oppressive concept. I personally think most individuals might find it less distressing than debilitating symptoms of panic or OCD. However, I don’t think there’s really any calculus there. The fact of the matter is that CBT treats anxiety disorders very quickly and efficiently.

    I understand you regarding the logic You’re right and this is, as I said earlier, the Lacanian superego’s injunction to Enjoy! You must have sex so take the pill to have the erection! You must exercise because it is good for you!

    I want to write another post on the subject-supposed-to-know later on this week (you’re anticipating my moves).

    Some treatments can take many years, usually psychoanalysis. Although the difference between psychotherapy and psychoanalysis is a bit fluid, they’re usually differentiated based on the number of sessions a week (psychoanalysis usually 3+ session/wk).

    Transference is always already established from the beginning. The client always brings a world of internal objects to analysis.. (Lacan assumed transference begins once the analyst is put in the position of knowledge by the client). One of the goals is to give the client the freedom to rearrange her internal object world. The relationship does deepen, but I wouldn’t equate intimacy with transference. Transference will inevitably change, but Freud posited that there is no such thing as non-transferential love.

  3. Simon Says:

    Ah, brilliant! — I look forward to those posts!

    I wasn’t aware of the ‘distress’ model of CBT; but now that I do, it makes much more sense.

    A quick question — I was reading your ‘Subject supposed to be awkward’ post and the phenomenon described in Klein’s definition of projective identification sounded quite similar to counter-transference. Would it be correct to say that counter-transference is a ‘result’ of projective identification? Or can counter-transference be accounted for in other terms?

  4. Jeremy Says:

    I’m not sure if it’s officially called the “distress model”. I just think they’d be less likely to make strong assumptions about normality.

    I’m actually studying for an exam on Kleinian theory this weekend. Countertransference is simply the transferential feelings the therapist experiences regarding the client.

    Projective identification is more complicated and a bit difficult to explain. The idea is that the client splits off something, that is to say the client denies and projects it into the therapist. For example, let’s say the client is unable to experience feelings of aggression so they completely deny aggression and project it onto the therapist. Then the client acts in such a way so as to invoke aggression in the therapist. The client can then from a distance identify with the aggression that is too difficult to experience directly. The therapist often acts in such a way that they cannot help but respond to the very thing the client has projected.

    Honestly this is a very complex idea. It is different that countertransference. It involves both the splitting off and projection of feeling X into the therapist. Then client identifies with X which the therapist now contains. The therapist introjects feeling X because of the way the client acts so as to provoke the therapist to experience feeling X and responds in such a way so as to confirm the that feeling X resides NOT in the client but in the therapist.

    Hope that helps out.

  5. pimlico Says:

    This is a good and interesting conversation. I find myself sympathetic to Simon’s points, so thank you both for raising and discussing them.

  6. Psychotherapy, Medication, and Severe Mental Illness « JRidenour : Schizophrenia Page Says:

    […] Original post: Psychotherapy, Medication, and Severe Mental Illness « JRidenour […]

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