Treatment methods for Mental Illness: Which method has the best story?

Three central methods for dealing with mental health problems dominate the therapeutic scene: pharmacological, cognitive behavioral, and psychodynamic/analytic therapy. Each method attempts to restore a state of well-being or health characterized by the patient's ability to interact with the world in a productive and coherent manner. CBT and Psychodynamic therapy attempt to solve the problems without necessarily using drugs and can therefore be grouped together as Psychotherapies, as distinct from Pharmacotherapy.

There seems to be a clear distinction between two types of mental health problems but the relationship between the two types is as of yet very unclear.  On the one hand there are biological/chemical disorders that can be corrected by a drug, which restores the proper chemical balance, or a surgery that restores proper physical structure of the brain.  On the other hand there are mental disorders, which are termed "affective" or "emotional", or "personality" disorders.  These disorders often occur in conjunction with the first kind of disorders and there is substantial circumstantial evidence to support the suggestion that preexisting affective disorders can cause chemical/physical disorders.  Likewise the persistence of a chemical/physical disorder can cause an affective disorder that might remain even after the chemical/physical disorder has been corrected.  The best examples of these kinds of situations are things like phantom limb pain or psychosomatic reactions to stress. These situations illustrate how the mental state of an individual can affect their physical state. So in determining which method of treatment is appropriate for any particular patient it is common to try a little bit of psychotherapy and a little bit of pharmacotherapy and to see what works.

Psychodynamic psychotherapy is based off of the Freudian system of psychoanalysis where one uses various techniques to discover an unconscious tension within the patient that is causing the symptoms that led the patient to seek help.  The assumption is that there is some tension, that the patient himself is not aware of, that needs to be corrected. Since the patient cannot verify the validity of the analyst's theory, one cannot say for sure if psychoanalysis is bogus or not. In fact, studies have shown that both CBT and psychodynamic methods have beneficial effects on patients with certain affective disorders. [1]

The first step in the psychodynamic method is to question the patient attempting to get a detailed history without necessarily emphasizing the subject matter that the patient himself thinks is important. For example the patient may wish to speak about their current fear of public speaking but the analyst might question them about their relationship with their siblings as a child. In asking somewhat obscure questions the analyst is looking for the unconscious tension within the patient that is causing the problem.

The analyst might also use techniques such as free association to determine unconscious patterns within the individual that might point toward the inner tension.  Proverbial "Freudian Slips" are often thought to be significant evidence of some sort of unconscious tension. Dream analysis is also used to discover inner tensions. Dreams are thought to be the mind trying to fulfill subconscious desires that are actively being repressed in waking life.[2] Within the dreams, slips, and free associations careful attention is paid to things that might be symbols for other things in the subconscious.  For example a patient might be afraid of baseball bats but in the analyst's theory the bat is a symbol for something else, a nun's ruler perhaps. The explanation for that symbol would then be that a nun traumatized the patient while s/he was in grammar school.[3] Each of these techniques enables the analyst to gather information that is then used to construct a theory about the underlying unconscious tension within the patient and the original stimulus that caused the tension in the first place. Once the analyst has constructed the theory the patient and the analyst discuss ways of dealing with the symptom by way of resolving the underlying tension.  Since the patient is unable to confirm or deny the validity of the analyst's theory and they play a very minor role in generating that theory it could be argued that most of the beneficial effects of psychoanalysis arise not from the diagnosis phase of therapy but instead from the resolution phase where the analyst and the patient work together on a new method for coping/creating a new story for the patient.

Cognitive Behavioral Therapy is the newer of the two psychological treatments for mental disorders and it is used in most of the same situations. The essence of cognitive therapy is to lead the patient toward a more correct perception of the world and events so that their responses and interactions to/with the real world are more appropriate. Basically what this amounts to is assisting the patient in creating a new story to explain their experiences that better reflects reality. The clinician is not simply giving the patient a new story but instead helping the patient to fashion his own new story. 

CBT, as the name implies has two distinct parts that were in fact developed separately.  Pavlov and Skinner are famous for their work in behavioral patterns and have merited the widely known concepts of "Pavlov's dogs" and the "Skinner box". [4] Behavioral research shows that certain responses, both physical and emotional can be conditioned by repeated actions and or experiences.  This is an extremely powerful observation when it is applied to the unique situation of the human being who brings another dimension to the table, the cognitive dimension.   This allows for the possibility of forethought and a conscious effort to modify one's behaviors/responses to stimuli.

Aaron Beck, the founder of cognitive therapy, discusses how one can change the way one feels about things (the emotional response) and the behaviors which result from the emotional response by changing the way one thinks about things. This means that if you can change your story that you use to interpret an experience you can change your emotional response to it. Beck notes that the first step of learning to distinguish between one's perception of the real world (your story) and the real world itself are essential to successful therapy. Once one understands how one is thinking about the world and one's self, one can then examine whether or not one's thinking actually corresponds to the real world. Identifying specific thought/imaging events which precede emotional responses to events/objects in the real world and evaluating these thoughts and images on how well they correspond to the real situation allows one to determine if the emotional response is appropriate. If the story that was the basis for an emotional response is tested and shown to be inadequate then the patient will understand the emotional response to be inappropriate as well.  For example, if someone hears a dog bark and instantly thinks they are going to be attacked by a dog were to test this thought pattern by going to a kennel and seeing and hearing many barking dogs; they would see that not every barking dog is going to attack them and they can judge that the fear they had of he dog's bark as irrational. Then, by changing the thought patterns and images which one has a result of particular stimuli one is capable of changing the emotional response.[5]

As was mentioned before CBT and Psychodynamic therapy both have shown that they can be effective in certain situations. However, it is also widely understood that CBT lends itself better to the necessary standardized testing that would validate anecdotal findings with statistical/scientific evidence.  The reason for this is that CBT is more methodical and more easily standardized and practiced uniformly. Neither CBT nor Dynamic psychotherapy is as easily studied empirically as pharmacotherapy because pharmacotherapy is far more easily standardized because all you need to do is fill out a checklist of symptoms and then dispense a pill. Another benefit of CBT, that Beck points out, is that it grounds the experience of the patient in something they actually recognize and can focus on instead of pointing to something that the patient himself cannot really "see". 

This idea of grounding the experience in something the patient can "see" himself is key.  Human experience is often recognized to be a continuous stream of stimuli that the individual undergoes and interacts with. There are an almost infinite number of things that a person can watch and hear, but only a few that they can see and listen to. As a result of this, much of what we experience is either lost or stored in some unconscious form. The fact that we can look at a photograph and only see the faces at first, and then a week later try to "remember"/ call up from the unconscious what the people were wearing gives evidence to this fact. Psychoanalysis is essentially attempting to call to consciousness these things that were looked at and heard but not neither see nor listened to.

Psychopharmacology is the practice of using drugs to modify mental states. There are a number of different types of drugs, most of which fall into six major categories: antidepressants, stimulants, antipsychotics, mood stabilizers, anxiolytics, and depressants.  Each drug interacts with the brain to change the stoichiometric ratio of some chemical relationship that might be out of balance. The relevance of different chemicals in the brain to particular mental states is debated but there is certainly some relationship. For example, a drug for depression will increase the levels of chemicals like serotonin and norepinephrine and the result is that in a few days the patient feels less depressed. This means that the serotonin and norepinephrine and their corresponding metabolites have an effect on the mood of the patient. [6]

There are without a doubt certain disorders which cannot be treated with psychotherapy alone, simply because these disorders are more somatic in nature and less psychological. Things like schizophrenia, bi-polar disorder, Alzheimer's, Parkinson's, or a psychotic state brought about by a tumor, or anything similar to these diseases must first be treated with medications. In conjunction with these medications psychotherapy is an appropriate way to help patients deal with their somatic brain problems. 

The current status of psychiatric medication is rather primitive. Direct relationships and explanations of why a certain drug or brain chemical has a certain effect on mental states are hard to come by. Treatment for patients with mental illness by medication mostly consists of trial and error and tweaking dosages.  We simply do not know what all the effects of a drug are or what those effects produce in terms of mental states.[7] There are two reasons why we should not hope to solve all of mental illness with a purely chemical cure: relatively very little is currently known about the relationships between brain chemicals and mental states and therefore some other means of treatment is necessary to help most people right now, and secondly, as was mentioned before, the affective/mental state of a person can effect their chemistry.[8] This second reason points to the fact that at least some mental illnesses have as their cause something that is not in the brain but that those illnesses (the result of some other problem) have an effect on the brain.  Since it is unlikely we will have a complete explanation of the brain in terms of chemistry we should focus on non-pharmacological therapies to treat mental illness.

The problem that now faces us is to decide which mode of psychotherapy is better and why. Presumably we want to answer this question so that we can eradicate false theories in favor of true ones. However, our only means for determining if a theory is false is if it fails to produce the predicted results. But, both forms of psychotherapy do have the predicted effect; the question is why. What is true about both of them that makes them to be useful in treating mental illness.

I suggest that the common factor that each form of successful psychotherapy has is that it trains the patient to distance themselves from their current story of the world and understanding of their own feelings and then to generate a new story that works better.  Logotherapy, developed as an offshoot of Freudian psychoanalysis by Viktor Frankel, does this by getting the patient to distance themselves from their current story through "humorous exaggeration" or "exaggerated self observation" and which allows them to "perceive their unrealistic and counterproductive attitudes and to develop a new outlook (story) that may be a basis for a fulfilled life."[9] Cognitive therapy does something very similar as was mentioned before. Psychoanalysis achieves this by giving the patient the tools to create a new story even if the story they think they are replacing (the conjectures of the analyst) is not true. The point is that a new story is created that works better when applied to the real world outside of the patient's head.

This phenomena of story making and the story's compatibility with the real world points us toward a good definition of mental health. In every form of mental illness treatment what is being restored is the patient's ability to create a story for himself that allows him to interact with his environment in a coherent and often constructive way. This does not mean that a mentally healthy person will be able to or should be able to construct a story that makes them "happy" in any given situation. But, instead, they can and should be able to construct a story that corresponds to the real situation and not be paralyzed to inaction or despair. There are many different ways to go about this process of teaching patients how to make a good story but some are objectively better than others because the method itself is a better story than another method/story about how to help people make better stories.

The most significant factor/ reality check in any method of psychotherapy will be how well the method appreciates the fact that the patient is a human being that has rational faculties. Simply because those faculties are not expressed by their current story and behavior patterns does not mean they don't have those powers. Enabling the person to use those faculties for their own benefit is how the patient gets better. But, if the method of therapy is deceitful and tricks the patient into generating a new story by proposing some extravagant, improbable, and improvable theory, as psychoanalysis often does, the method is not compatible with the reality of the patient's potential for rational thought. Making people act and think "normally" by scaring them with something they can't test is a great example flouting human dignity.

So, to conclude this analysis of the main forms of therapies for mental illnesses I point to a classic analysis of human action. When determining what action should be taken (what story or therapy works best) one needs to consider, the actor involved (the therapist or patient), the intention behind the action (be it in the patient or in the therapist), the action itself, and the consequences of that action. If the proposed story or action adequately reflects the nature of the actor, has the good intention of benefiting the patient, and actually brings about the good of the patient, but does not adequately represent the nature of the act; then the proposed story/therapy is not really a step toward getting anything less wrong. I think psychoanalysis is guilty of this sort of incompatibility with reality. Trying to pass of a theory as a true explanation for a patient's problems that is just a fabrication, even if a successful and well-intentioned fabrication is still the wrong way to approach the problem. I think the best story that any therapist can offer is a story of their own ignorance and suggestions about how to craft a better story always acknowledging that there is no way to explain everything or to even pinpoint a single source for any sort of mental health problem. Every epistemological problem must be approached with the acknowledgement of Socratic ignorance and then proceed forward from their. 

[1] Falk Leichsenring, Wolfgang Hiller, Michael Weissberg, Eric Leibing. Cognitive-Behavioral Therapy and Psychodynamic Psychotherapy: Techniques, Efficacy, and Indications 2006. American Journal of Psychotherapy 60(3): 233-259.

[2] http://www.freudfile.org/psychoanalysis/techniques.html

[3]http://www.freudfile.org/psychoanalysis/dream_interpretation_and.html

[4] http://www.essortment.com/all/pavlovdogs_oif.htm and http://webspace.ship.edu/cgboer/skinner.html

[5] Beck, Aaron T. M.D. Cognitive Therapy and the Emotional Disorders. NY: International Universities Press, INC. 1976.

[6] http://www.psychiatrist.com/pcc/pccpdf/v06n04/v06n0403.pdf

[7] http://www.rci.rutgers.edu/~lwh/drugs/chap03.htm#Drugs%20Have%20Multiple%20Effects

[8] http://www.rci.rutgers.edu/~lwh/drugs/chap01.htm#INTERACTIONS%20OF%20BEHAVIOR,%20ENVIRONMENT

[9] http://www.viktorfrankl.org/e/logotherapy.html