Psychotherapy and the Brain

I must also apologize for the tardiness of my response. I must start out my response with a question, directed at no one in particular, with the aim of satisfying my own curiosity: How are CBT therapies developed? As Alex says, CBT therapies, like drug treatment strategies, work best when individualized for each patient. How is this done, especially if we have no hard evidence to show what each therapy is targeting? I understand that fMRI is the best measure of change, due to the fact that we can't section patient's brains post CBT, but there must be some historical/literature basis for each technique, or else they would not be continued in practice. Do not take this as an argument for the use of drugs solely based on the idea that one can test them, as I agree with many who think CBT can be quite effective when the conditions are right.

I also heartily support the point that a combined approach is most likely to be effective, and that treatment should be specialized based on the person; though perhaps I am ill-informed, but what are the limits of CBT? Dr. Yarin pointed out that CBT and learning are somewhat analagous, but are there things that cannot be unlearned? Or biolochemical factors that prevent the acceptance of CBT, that can be ungated?

Either way, I must state that I do support the "quick-fix" of drug application if this is what is needed to allow an individual to function effectively, and perhaps once some stability is achieved, CBT can attempted. I don't feel bound to immediately denounce psychopharmacology as a corporate conspiracy, because in the end, it is the physician who controls how much/which drugs the patient will recieve (that is based on the assumption that the physician has the patient's best interests at heart). I feel as though it is unfair to assume that every company that stands to make a profit intends to take advantage of the consumer.

Today’s discussion really made me think about the advantages of both drug and psychotherapeutic treatments.  While drugs may offer a quicker result than psychotherapy (always a factor in today’s “instant gratification” society) we also must consider that because there is still so much we don’t know about the brain we can’t be exactly sure what other effects they will have on us.  However, sometimes we do need fast results.  In the end though, I think I would side with Dr. Yadin in regards to treatment- let’s try to use what we already have first, especially if psychotherapy creates a longer, more permanent effect.   

We also didn’t really talk discuss the effectiveness of drugs, therapy and a combination thereof (are drugs often prescribed without associated psychotherapy for anxiety disorders?).  I’d really like to see statistics of both “success” rates from psychologists and patient satisfaction.  Are patients more satisfied with a quicker result or is the actual act of fixing your mental glitch with your own machinery more rewarding?

Another aspect of psychotherapy that I found myself thinking about involves the importance of mental/psychological adaptation.  I recently wrote a paper for another of professor Grobstein’s classes that I am in, regarding therapy versus drug treatment for disorders such as PTSD.  One idea I brought up there that seems to relate to this issue is the possible importance of working through things ourselves.  Is it important, or evolutionarily adaptive on some level, for our personal development, our future mental health or some other factor, that we deal with these things through our mental capacities rather than through a “quick fix” like drugs?  Is the use of simple medication in contrast to more intense and long term psychotherapy actually depriving us of a positive developmental factor?

One issue I found particularly interesting in our discussion is the idea of our behavior and conversations outside of a clinical setting as psychotherapy.  I had never really thought of this before but it makes a lot of sense.  When I have a problem I know I always feel better hashing it out with someone or taking time off for myself.  Obviously a trained professional is helpful/necessary in some situations but it is interesting to think of ourselves as self medicated, or rather self treated, in that we do what a psychologist would, only in a less obvious way.

Another topic I was wondering a bit about is that of psychotherapy as an alternative or additional treatment for other more physical diseases (i.e. cancer, chronic pain etc.).  It seems to me that thought and mental state are quite important in our physical as well as mental wellbeing, but I don’t actually know if psychotherapy in conjuncture with another treatment for those types of diseases would make that treatment more effective.  Guess I’ll have to check it out.

I have to agree with what Jenna is saying, in that I don’t see people who choose to take medicine instead of going to therapy as coping out or failing. I think the success of talk-therapy is based on who chooses to go to therapy. People who don’t want to go to therapy, for whatever reason, would probably not have as positive results as people who are motivated to go each week and do the homework they are assigned with CBT. Also, the success probably relies on the ‘disorder’ that it is treating and its nature. PTSD’s nature is one that would benefit more from talk therapy, while I don’t see that bipolar individuals would be able to do such therapy without a medical intervention first. You can see drastic differences in bipolar individuals when they are either on or off medication.

In addition, as many people have brought up, therapy and drug treatments work better together than either by themselves. With bipolar individuals who I would say ‘need’ medication, they may be able to function even better if they combine this treatment with talk-therapy. While what we talked about in class is how the two work similarly on the brain, I think this points to the fact that there is something different going on with drug and talk treatments. Maybe the end result on the brain is the same, but different pathways seem to be affected. When you’re adapting two brain pathways (in very general terms) instead of just one, you’re going to see better results. If it were the same pathways I don’t think you’d see the large increase in how many people are helped with combining the two. Someone said that they must be working on different systems because medications have different side effects—while I think different systems are affective, this doesn’t work as a reasoning since medicines we take are never specific enough to work on just one particular aspect (as we talked about in class with Dr. Yadin).

One reason that I see people as skeptical of psychotherapy is the point I brought up in class, that you can’t do the animal model testing of therapy, or even on humans, to really see changes on the chemical level of the brain. I for one find fMRI imaging as somewhat questionable as to what conclusions we can draw from this. We do see differences before or after therapy, but when you think about the size of the voxels and the slight change in ‘color’, it doesn’t seem reliable. Maybe therapy changes something else in the system so that brain areas change their activation. This doesn’t mean that I think psychotherapy isn’t valid. I think it is, but it depends on the disorder and who chooses to go into therapy. If someone is not convinced about the therapy working, they are probably more likely to have the therapy not work. If there was some way to assess the chemical signaling in humans who receive therapy (instead of just brain scans) more people would see therapy as valid. In the end, it will work for some people and not for others, as with any treatment.

Another reason people are skeptical, which I’ve touched on slightly, is that we as a society are used to the biomedical model of disease and not the biopsychosocial model which is more ‘true’ to what diseases and disorders are. Until we as a society are able to get beyond the biomedical model, people are going to be skeptical of treatments that aren’t medications that can quickly ‘fix’ us. Hopefully, as people learn more about the mechanisms by which psychotherapy is working, people will become more accepting of it.

 

Several people have mentioned during class and in this forum that taking drugs to fix problems instead of undergoing therapy is easy, which really surprised me.  Personally, I had always thought that the idea of taking drugs is psychologically much more difficult to accept than therapy, but maybe this is just a cultural difference?  Also, there is another thing that came to my mind that is related to this issue of which is more “easy” (drug vs. therapy).  I once wrote a research paper on neurotic perfectionism when I was taking the course Abnormal Psychology, and I remember reading that perfectionism is highly correlated with depression and OCD (which really didn’t surprise me).  Wouldn’t people who are perfectionists feel defeated if they have to depend on a pill to fix their problem? Wouldn’t these people want to fight and overcome their problems with their own will?  Of course I know that depression does not only happen among perfectionists and high-achievers, but I don’t think that everybody who takes drugs takes them because they feel that it is the easy way out of their problem.  For many people, including some that I know personally, the decision to take drugs comes after a lot of thought and is a way to help them reach a mind of state that would allow them to rationally process and think about their problems so that they can actually benefit from therapy.  For this mean, I think that drugs can play an important role.

I also read the BBC article that Marissa posted (and would encourage anybody who hasn’t read it yet to do so) but I personally can’t agree with the post above that “maybe when we’re not happy this is in fact adaptive, and by trying to “fix” it we’re not really helping the person”.  When you read the comments at the end of the article, it is clear that the people who talk of any kind of gain from their depression are people who overcame depression and are no longer suffering from the disorder.  I think that this is a very different situation from, say, a mother  with a child with autism who says that no matter how hard it can be sometimes, she is still glad that she has her child because she has learned so much from him.  I personally think that depression is the clearest disorder (i.e. I am perfectly comfortable calling depression a disorder though I do question calling other states that are generally labeled as a disorder like autism) and if I were a physician, I would not question trying to fix it, since I don’t think people can really benefit from it (if they do at all) unless they overcome it.

Before we start talking about whether depression should be fixed or not, it seems like it is important to think about what depression is.  I was intrigued by the question that was raised in class and restated in Danielle’s post: “do we assume depression is a disorder or is it just a particular brain state?”  When the idea that the depressive mind state may be more adaptive or skilled in some ways was brought up in class, I remember questioning Professor Grobstein about this because I had personally always thought that a crucial criterion of depression is that the individual must want to overcome the excruciating pain associated with the fear and sadness that he/she is experiencing.  In other words, it is hard for me to think that one can be diagnosed with depression if he/she is not wanting to overcome depression, no matter what the brain looks like on a neuroimaging scan.  I don’t think that looking at the brain state is necessary to diagnose depression; if an individual is reporting hopelessness, anxiety and suicidal thoughts, that should be enough for person to receive the appropriate help and treatment.  In fact, I think the idea of a “depressed brain state” could be dangerous.  If physicians start labeling people with depression just because of what their brain looks like on an image, this could lead to negative consequences…

Two topics brought up in class (and touched on briefly by Elliot in the forum) that I'd like to explore were the idea of the disorder as entity without the person and the problem of which came first; the disorder or the negative cognition.

"You do know that's the disease talking, don't you?" I've heard permutations of that concept several times from friends in therapy for whatever reason, and I've often wondered (especially when directed towards people who don't consider themselves sick) if it's the discourse that makes one sick, or if those negative cognitions are more analogous to a fever, a symptom of the disorder. It doesn't seem to make sense for a person to talk to themselves about themselves in the deprecating manner characterized by depression of their own volition: that insidious voice has to be the product of too few serotonin receptors or not enough dopamine, much as lowered inhibitions are the product of too much alcohol. You can't really talk yourself into being drunk, and why would you want to talk yourself into being depressed?

So now there's this broken piece of brain generating hateful thoughts in a patient's mind, but can we really consider this broken bit as something external or different from the person who owns it? Even that first sentence, "You know that's the disease talking..." implies that there are two parties privy to the world within the skull: the person and another, darker “disordered” entity. But wouldn't considering the disorder to be an externality, an adjunct to the person him/herself, lend some credence to earlier conceptions of psychopathology as demonic possession? Does this mean that shamanistic practices or exorcisms have the chance to re-enter a modern therapeutic arsenal? Why not, after all, when we cannot seem to decide what mechanisms are responsible for more scientifically condoned talking and/or chemical cures? What harm could a little sage incense and holy water do if the benefit was the eviction of the terrible “other” plaguing the patient?

What was it about these earlier forms of psychotherapy or even our current rudimentary tools that make a person better? From the discussion we had on Tuesday, it seems like an important part of the therapy is changing the discourse a patient engages him/herself in regarding the disorder. If all pharmacotherapy addresses is the dysfunctional biology, perhaps it is the change in self-talk that protects the brain from relapsing. But then we’ve returned agency over the disorder back to the patient’s own verbal behavior, which means, in a sense, that it’s “all in your head” and we know that’s not right either. So self-talk is enough to prevent a disorder but not cause it? And why can’t we all alter our own self-talk without assistance? And now, it seems, we’re back to the beginning, which came first the disorder or the thought?

 

I also thought this was an interesting discussion, and I was wondering about some of the same points that Liz (and Elliot) brought up here – if drug therapy and CBT seem to be affecting/changing similar areas of the brain, it seems that they are working through similar mechanisms.  But if neurotransmitters are being affected in the same way by both of these treatments, I would think that side effects associated with drug therapies should also be present during CBT.  Like Elliot said, I really have no idea if this is the case, but I have trouble imagining (maybe just because I’ve never heard anyone mention it) that patients undergoing psychotherapy experience problems like “dry mouth” or “insomnia” that are apparently common in pharmacotherapy.  Dr. Yadin brought up the point that psychotherapy doesn’t have the negative effects that may be associated with drug treatments because it doesn’t act on the periphery, and I think that this fact alone is enough to make the argument that psychotherapies like CBT should at least be considered before pharmacotherapy.

 

I completely agree with the idea that drug therapy has become so popular because it seems like a quick fix to a problem.  If one of the symptoms of depression, for example, is a loss of energy then it is easy for me to imagine that someone with depression would be overwhelmed at the idea of putting in the time and effort to talk to a therapist and work through their problems.  And, like Emily said, it hardly seems ethical to force people to try therapy before drugs.  I also think that part of the reason that drug therapy has been so widely embraced is because we understand that if taking a drug fixes a problem this means that the problem is biologically based, and I think that this in turn de-stigmatizes many mental conditions.  I think that in the past there has been a sort of idea that if someone is depressed, has OCD, etc. that this is some sort of character flaw, or that they should just get over it.  If a patient actually needs a drug to fix the problem, however, then it seems more like a medical condition that the patient has no more control over than someone who takes medication for some physical illness.  However, at this point in time I think (or at least I hope) that the  majority of people understand that severe mood disorders (and other conditions) have a biological basis, so maybe people will begin to be more willing to try psychotherapy-based approaches again.

 

On a totally different note, I read the article that Marissa posted from BBC (“Is Depression Good for You?”) and it reminded me of a topic we covered in one of my classes last semester.  I don’t remember the specific articles or studies that we looked at, but it basically had to do with the idea that negative or depressed moods evolutionarily probably arose in response to conditions where something is wrong or needs to be fixed, and that in order to fix a problem we need to be able to think clearly and rationally.  To support this hypothesis researchers were showing that when people are upset or sad (however you measure that) they are better at memory tasks and solving problems than when they are happy.  Basically, it just seems to me like our culture is so focused on the idea that we should be happy all the time – but maybe when we’re not happy this is in fact adaptive, and by trying to “fix” it we’re not really helping the person.  Of course in cases of severe depression I think that something should be done, but it seems like it’s fairly easy to fall in the DSM category of “clinically depressed”, and maybe not everyone in that category actually needs clinical or (especially) medical help.

To bounce off of Liz’s last point, I did not really think about the side effects of psychotherapy as compared to drug therapy. Side effects from exogenous substances put into one’s body seem to be expected for just about any drug taken for any “disorder”. I would imagine that psychotherapy also probably generates some side effects in a number of individuals. Whether these side effects are exactly the same as those seen in individuals on medication, I am not sure (but would certainly like to know). However, I also guess that there may be fewer side effects, simply for the reason that although psychotherapy may lead to similar outcomes as drug therapy, it works in a different way. Psychotherapy, at least CBT, seems focused on individual drive and perseverance. As stated in a number of the people’s posts above, taking drugs is a lot easier. However, drugs are then an external force on the body’s system. Working through CBT seems more natural. From what Dr. Yadin said, it truly sounds like a progression of working with the patient through multiple steps. This step-wise process, though intense, seems more conducive to minimizing secondary effects as compared to a drug shocking one’s body. However, I am just thinking about this theoretically without any real data on which to base my hypothesis, so anyone else’s ideas would be more than welcomed.

 

Something else that Dr. Yadin brought up that I found particularly intriguing was the idea of separating oneself from one’s disorder, whatever it may be. She described it as a relationship between a person and their disorder. This relationship can change over time and one’s feelings towards it can vary. I cannot say that I have personally felt this relationship, but I can imagine that this description would be true. We somewhat touched on the idea of depression as advantageous in different settings and at different times, but also often more negative in other situations. Maybe this leads people to accept and reject their depression depending on the situation (even if it is often viewed as something unwanted). As to what this all means for psychotherapy, I could also imagine that different therapeutic techniques may not only work better for different people, but also for specific people at different times in their life depending on their relationship with their disorder. We also touched on this idea when discussing how people sometimes need a refresher course in CBT to avoid relapse. I wonder if taking drugs to treat relapses works more effectively in individuals who have undergone CBT at an earlier point in their life. Or maybe they don’t do any better, and CBT is usually more effective in such cases.

 

All of this seems to relate back to what Emily posted – the importance of individual differences. People need to be thought of in relation to the environment in which they live, the relationship they have with their “disorder,” the hopes they have for therapeutic results, the seriousness of their physical and mental states, their cultural beliefs, etc. Even though our fundamental biological systems are so genetically and physically similar, it is still important to remember all of the things that make us different.

We've talked about this a few times in class, but it came up again this week. Here is a link to a BBC article entitled "Is Depression Good For You?"

http://news.bbc.co.uk/2/hi/uk_news/magazine/7268496.stm

I completely agree with Stephanie, Emily, and Danielle that Dr. Yadin posed some really great arguments for the promotion of CBT over the drug alternatives.  The brain is highly plastic, and if we can encourage plasticity that will help people overcome debilitating issues such as OCD a little more naturally and holistically then that seems to be a great alternative (especially since it may have more lasting effects and can be easily refreshed if needed later in life).  As previously pointed out, the biggest pro-psychotropic drugs argument is that taking a pill is a lot easier.  In our culture everyone wants things as quickly and easily as possible.  For the people who don’t want to or can’t spend the time necessary, or don’t want to face their fears, the pill seems like a nice alternative.

 

Because I think what has driven Americans to prefer the easy alternative stems from our culture, I think that how our culture is now changing may help in a transition away from psychopharmacology treatments (at least a little).  The trendy thing now is the more “natural” alternative.  Organic foods, alternative medicine, and even hybrid SUVs exemplify America’s return to nature, and I think we’re at a point now where people are more willing to spend a little extra time and money for the more natural alternative.  This observation paired with the research of physiological changes associated with psychotherapy make now a good time for psychotherapy’s comeback.  That’s not to say that everyone will choose psychotherapy over drug therapy (which they probably shouldn’t as drug therapy seems to be more effective in severe cases and talk therapy doesn’t work for everyone), but I do think more people will be willing to give psychotherapy a shot.

 

The other thing that I was thinking about is that no one really brought up the issue of undesirable downstream changes in the psychotherapy model. We talked about how changing the neurotransmitter availability at one synapse has the potential to effect a great deal of other systems through upregulation/downregulation of receptors, synapse plasticity, and cell plasticity for the drug therapy model, but I’m a little curious about why it didn’t come up for the talk therapy model.  If evidence is showing that talk therapy is producing similar effects on NT levels or plasticity (although in some different areas), then it seems to me that these changes will likely affect other systems downstream as well.  I’d just be curious to hear if it wasn’t brought up in class because people think that these downstream side effects aren’t as likely with psychotherapy or if we’re just used to thinking of physiological side effects as being inevitable for drugs and not thinking about them at all for psychotherapy?

So one thing that I was struck by throughout our conversation was how much in psychotherapy individual difference plays a role. There are a few main things that I wanted to relate this to, and see what everyone else thought. (I would also love to hear Dr. Yadin's views on if this variation is good or bad for CBT as a treatment)

First, even using pure statistical results, we find that individuals vary quite a lot in terms of responsiveness to treatment. Some respond to CBT, some to drugs, some to neither (ex. CBT or drugs work 48% of the time, together they work 73%). I think its interesting that it seems like we approach these therapies on a rather general level, and then tailor them to specific individuals. Can we really say we understand the mechanism for our treatment when we can't get it to work for every patient? Are there other ways we should be approaching it to try and get it to work generally-- or is it good that the tailoring occurs?

Second, and somewhat more interesting to me, was the idea of the patient population being somewhat self-selecting. It seems that to do treatment like CBT you must be highly motivated, and you must consider yourself to HAVE a "disorder." The idea that anything that impedes normal functioning is a disorder is interesting to me-- like we've talked about all along, isn't this 'normal functioning' somewhat of a societal construct? However, being realistic, whether or not it is societal or biological the manifestations still deserve to be treated if the person wants them to be. However, this want is a big thing-- I don't know about you all, but i certainly don't approach my fears/worries head on all the time and allow myself to think about them and then let them go. (Seems to me like perhaps CBT would be useful for 'normal' people as well). I think it therefore requires a lot of dedication for something like CBT to be useful, which may decrease its success. Drugs are so much easier-- you pop a pill and feel better-- and in our current culture of instant gratification i think CBT may seem to be more and more of a hassle. This is worrisome, as I feel that what Dr. Yadin said was correct-- that we should use the brain itself for fixes first (if we have the plasticity, why not use it!?!) and drugs second because drugs can be removed and leave the initial problem. But is it ethical to deny people the 'quick fix' if it works for them? Denying treatment doesn't sound like the way to go either... Should we force people to try CBT first? Again, not so ethical.

I'd be interested to know what you guys think,

Emily

Thanks to everyone for such a great conversation last night! It was so fabulous to see everyone's opinions about therapy and I can't wait to see what else you have to say.

A few questions to think about:

What do these studies mean for future methods of treatment?

What happens to our models of "disease?"

Are psychotropic treatments valid? Are more talk-based treatments more appropriate?

Why are people still so skeptical of psychotherapy?

What is treatment doing? Is it bringing people back to "baseline?" What is baseline?

Dr. Yadin will be looking at the forum too, so feel free to pose any questions you have for her. We look forward to seeing your thoughts.

 

Here is the link to BBC article about anti-depressants having little effect we were talking about. http://news.bbc.co.uk/2/hi/health/7263494.stm