Noteworthy News Articles on Mental Health Topics, March 1-21,
2000
New Study Reveals Anti-Depressants Alter Personality
Reuters New Service, 3/1/2000
Antidepressants may be able to change a person's personality, even in
people who are not depressed. Dr. Victor Reus and colleagues at the University of
California San Francisco said a small group of normal, non-depressed people who took
Paxil, one of a new class of antidepressants called SSRIs, became more easygoing and
cooperative.
"Different aspects of normal personality may be altered by psychopharmaceuticals that
act on distinct nerve pathways in the brain," Reus said in a statement.
Better Teamwork Found
His team tested 23 mentally healthy men and women. They took paroxetine for a month, and
filled out personality questionnaires before, during and after. After just a week on the
drug, they scored lower on tests measuring hostility and showed more cooperative behavior
in puzzle-solving tests. "People did seem to be…more likely to give suggestions
and less likely to be assertive and directive," Reus said in a telephone interview.
But he agreed that some people might not think that was an improvement. "As to
whether that's good or bad I would refrain from putting any moral judgment." A
matched group of volunteers who took a dummy pill showed no changes.
First of its Kind Study
"This is the first controlled study of the effects of a drug on a component of
personality in people who are not mentally ill," Reus, whose findings are published
in the American Journal of Psychiatry, said. "The result raises the issue of
cosmetic psycho-pharmacology," Reus added—the idea of using psychiatric drugs
for non-medical effects.
"The purpose of our doing the study is not to advocate usage like this," he
stressed. He said some people felt such antidepressants were inappropriately used, or that
if people were not clinically depressed the drugs would have no effect.
Question of Use
"I think what studies like this would suggest is that there really is a biologic
effect there even in normal individuals," he said. "Whether it is useful or
appropriate to use drugs in that manner is a different issue. In fact, people do this
every day with drugs like nicotine or caffeine so it's not a radical phenomenon."
Studies have shown that people with psychiatric disorders marked by hostility and
aggression have low levels of serotonin. This important neurotransmitter, or
message-carrying chemical, is linked with mood. Monkey studies have also linked serotonin
with sociability.
Side-Effects Noted
There were side-effects—notably sleepiness at work, Reus's team reported. "For
example, SSRI-treated volunteers' responses to the question 'What did you experience
during the experiment' ranged from 'I used to think about good and bad but now I don't;
I'm in a good mood,' to 'The side-effects were intense at first but then tapered
off'," they wrote. Some people also complained of lowered sex drive or trouble
achieving orgasm. SSRIs, or specific serotonin reuptake inhibitors, stop the reabsorption
of serotonin, making it available in the body for longer. Paxil, also sold as Seroxat, is
marketed by Anglo-American drugs group SmithKline Beecham Plc. The best-selling drug is
licensed from Danish drugs group Novo Nordisk, which markets it in Scandinavia. Reus said
other SSRI's such as fluoxetine, sold by Lilly under the name Prozac, would probably have
similar effects.
Women's Depression Stems from Lifestyle Choices,
Researchers Now Find
Julia McNamee Neenan, USA Today- 03/03/2000
Marsha knows she needs to exercise to keep her depression at bay. The
36-year-old West Palm Beach, Fla., psychologist works half-time and spends the rest of her
week keeping house, running errands and caring for her 2-year-old twins while her husband
works at a new job, often until 11 at night. If she doesn't jog regularly,
Marsha says, the depression from the stress of all that juggling would drag her into
"a very blue day, bad, tearful, hopeless." What Marsha describes is not unusual
in women's lives: Women are two to three times as likely as men to suffer from depression,
according to the American Psychological Association. Yet only about one-fifth will get the
treatment they need. And the National Institute of Mental Health estimates that more than
12 percent of all women suffer from depression each year, compared with 7 percent of men.
That women suffer from depression is not news. But the underlying
reasons for it are beginning to surface in a direction that may surprise many. For years,
researchers blamed sex hormones for women's depression. The common phrases were
"menopausal" or "premenstrual." Indeed, estrogen is still a factor in
some areas of depression, according to Dr. Elizabeth Young, who runs a mood disorder
clinic in Ann Arbor, Michigan. But hormone regulation doesn't account for much of the
picture. Instead, researchers are beginning to focus on the quality of women's lives and
the choices they make. In a recent article in the Journal of Personality and Social
Psychology," Susan Nolen-Hoeksema, a national expert on women and depression,
described a cycle of three factors that synergistically feed on one another to create
symptoms of depression in women.
Stress is one culprit
The cycle starts with stress. "Women face a number of situations in their lives that
make them feel out of control and helpless," says Nolen-Hoeksema, who is a professor
at the University of Michigan. "Even when there are things they can do, they feel so
out of control and helpless that they don't do what they can." It's no surprise to
most women that their lives are stressful. Many, like Marsha the psychologist, wear many
hats in their households. And few are willing to speak on the record if they are suffering
any kind of depression. Both Martha and Amanda, a 33-year-old North Carolina government
employee, didn't want their real names used so that those closest to them wouldn't
recognize their stories. Amanda was working the same number of hours each day as her
husband, but at one-fourth the pay. "I felt like I was inferior," she recalls.
At the end of the work day, it was her job to clean the house, prepare for company, care
for pets and run errands, like dropping off her husband's clothes at the cleaners. There
wasn't enough time in the day for her to successfully complete her obligations. And so,
she says, "I felt like a failure." The second part of the cycle, called
"loss of mastery," is the sense many women have that they have no control over
their lives. For some, like Amanda, it's a vague awareness that society has parceled out
power, and women are on the short end. For others, like Marsha, it's the day-to-day
knowledge that your life is subject to the whims of everyone from your boss to your
babies. Marsha chose to work long hours at home alone while her husband pursued a
new career. And as happy as she was to be home with her twins, she still felt isolated
from friends, from the satisfactions of a professional life unencumbered by other
responsibilities, and by the powerlessness of motherhood. "It's really hard,"
she says, and "it's really boring."
Add to all this the third part of the cycle -- the fatal habit many
women have of rumination. Unlike men, women tend not to take action, not to distract
themselves. Instead, they dwell on their problems, sometimes endlessly, which only
heightens their sense of despair and powerlessness, Nolen-Hoksema says. "I would have
this feeling of 'I'm not good enough,'" Amanda recalls. "I'd think, 'This man
obviously doesn't love me. What's the matter with me? I can't do better than this.' I'd
feel really boxed in." And that, says Nolen-Hoeksema, is typical of how many women
describe their blues. "You don't feel as though you're happy -- ever. You have no
motivation. It's not 'I feel sad,' it's, 'I just don't feel anything anymore.' "
The need to take action
Twenty years ago, most psychologists would have talked a woman through her past, to
determine the roots of her depression -- and probably add to her natural tendency to
ruminate, says University of Massachusetts psychologist Bonnie Strickland. That's less
common now, she says. Today, psychologists may recommend an anti-depressant to start with,
simply to pull the woman out of her torpor so she can function and begin to make changes.
And change is the key, says Eva Stubits, a clinical psychologist who directs Houston
Psychological Associates in Texas. Psychologists try to help women sense that they can
change their circumstances, Stubits says. Women can be shown some of the unhealthy ways
they've been perceiving their lives -- that they've been too exclusively the caretaking
members of the family. Often, Strickland says, that helps them to understand their
relationships better, "to think about what are sources of happiness and
pleasure." Concrete activities like exercise, reading, taking a class, meditation, or
talking to a friend are all recommended steps to well-being. The goal, Nolen-Hoeksema
says, is to break the cycle of despair. Women need to establish the sense that they can
change their lives in positive ways, or, as Nolen-Hoeksema puts it, opt for "action
and taking control." That's just what Marsha did, settling on the regular exercise
regime that keeps her healthy and happy -- and that "general veil of grayness"
at arm's length. Amanda hit upon an even more sweeping solution to her depression. With
the help of "a lot of expensive therapy," she worked through her insecurities
and along the way wound up ending her marriage. And, like Marsha, she now eats lots of
healthful foods and gets plenty of exercise. "It really makes a big difference,"
she says simply.
Web Research Transforms Visit to the Doctor
Gina Kolata, New York Times Magazine, 3/6/2000
Victoria Schlesinger had a puzzling rash on her face, so she visited her doctor to ask
what it was. The doctor told her she might have lupus, but declined to elaborate.
"She said, 'Let's not talk about it until we know,'" Ms. Schlesinger said, a
remark that only served to terrify her. "I walked out of there thinking, 'This can't
be good.'" Ms. Schlesinger, 31, the chief counsel for the Teligent communications
company in Vienna, Va., had never heard of lupus and was too intimidated to press her
doctor for more information. But, like more and more patients in recent years, she also
knew she had another resource. She went to her computer, typed in "lupus" and
clicked. The web sites that popped up were unsparing in their details about the disease,
which is caused when the body's immune system attacks a patient's tissues and organs.
While lupus can range from very mild to life threatening, Ms. Schlesinger found
descriptions that emphasized the grim outcomes. "I will tell you, I was pretty
shocked,' Ms. Schlesinger said. "I looked up this thing they thought I had and I saw
things like, 'survival rates.'"
She turned out not to have the disease. But partly because of her
doctor's dismissive remarks, she also ended up changing physicians. In interviews, doctors
and patients say the Internet has profoundly changed their relationships. With an
estimated 100,000 medical web sites, patients can look up any disease, drug or medical
condition in seconds. When a doctor so much as mentions a possible diagnosis, many
patients rush to their computers to learn more about it. When a doctor suggests a drug,
patients go online to find its side effects. And when they arrive at their doctor's
office, more and more patients are bearing pages of information printed from web sites.
"It's a massive revolution," said Dr. Rita Charon, a specialist in internal
medicine at Columbia University's College of Physicians and Surgeons. "It altogether
shifts what goes on when a patient comes in with pages of downloaded stuff and half the
time the doctor looking at it has never seen it before. There's a whole new set of
emotions present." The situation is complicated by time constraints on doctors who
are part of managed care groups, said Professor E. Kaavi Morreim, an ethicist at the
University of Tennessee College of Medicine. "A lot of patients come in with this
sheaf of papers," Professor Morreim said, "A lot of it may be completely
irrelevant or it may be bad information--who knows what you're getting off the Net. Now
the physician has to spend a lot of time sifting through this stuff and explaining. The
physician either resents spending the time or truly doesn't have the time. Then the
patient may feel he is being given short shrift."
Dr. Thomas R. Reardon, a general practitioner from Portland, Oregon,
who is the president of the American Medical Association, said that while "we do
support patients having access to good, reliable information," the problem is that
the information on the Internet varies from sound to irresponsible. "Right now,
anybody can put anything on the Internet," Dr. Reardon said. In a statement the
medical association warns, "The A.M.A. is greatly concerned that a substantial
proportion of information on the Internet might be inaccurate, erroneous, misleading or
fraudulent and thereby poses a threat to public health." Nonetheless, Dr. Reardon
said, doctors are going to have to adjust. "I think this is the wave of the
future," he said. Web sites include those sponsored by responsible groups like the
National Institutes of Health and the American Heart Association as well as ones run by
purveyors of herbs and supplements or of unproven treatments like coffee enemas for
cancer. They include sites put up by hospitals looking for business and by individual
doctors, some of whom provide links to articles in medical journals and others who say
they have secret cures. They also include countless chat rooms for patients, their
families and the worried. More sites are added each day, like one to be available soon to
be run by a company formed by the American Medical Association and six doctors'
association.
As Ms. Schlesinger discovered, those who search for medical information
soon find themselves buried in it. And some find themselves duped, doctors say. Some
fields, like plastic surgery, are almost magnets for misinformation, doctors said.
"There is so much plastic surgery on the Net," said Dr. I. Kelman Cohen, a
plastic surgeon at the Medical College of Virginia of Virginia Commonwealth University in
Richmond. "Look younger, look beautiful, have a peel at lunch and go out shopping in
the afternoon." One highly educated woman went to see a doctor who advertises widely
on the Internet that he does plastic surgery. The man is actually an oral surgeon, Dr.
Cohen noted. "He says he is board certified, but he doesn't say in what," Dr.
Cohen said. The woman wanted plastic surgery for her eyelids. Dr Cohen said she ended up
needing a skin graft from his group to repair the operation by the oral surgeon. Many
patients check out the Internet before they go to their doctors, deciding sometimes what
they think their condition is or what drugs they need or which they would refuse to take.
Doctors can be taken aback. "Some doctors deal well with it, some don't," Dr.
Reardon said. Some doctors make no pretense of being interested in the Internet data of
their patients. Dr. Albert Kligman, a dermatology professor at the University of
Pennsylvania Medical School, says he knows what is about to happen when he sees a patient
carrying in a pile of printouts from web sites. "They say, 'Doctor, I have a few
questions,'" Dr. Kligman said. "Then they take out about 200 of them. I tell
them: 'I only have 12 minutes. I can examine you or I can answer your questions. Make up
your mind.'"
Other doctors say that even though they may become frustrated when
patients look up every symptom, every diagnosis and every drug on the Internet, the
information can sometimes do more good than harm. Dr. Michael Lockshin, a rheumatologist
at the Hospital for Special Surgery in Manhattan, said: "I've had a bunch of people
say, 'I've been chasing down my symptoms and this is what I think it is and my doctor
hasn't paid attention to me.' About 50 percent of the time when I see patients like that,
they're correct." But more often doctors say they are peeved by the new demands being
placed on them, frustrated in their efforts to convince patients that a prescription drug
is not a poison or that a treatment detailed on the Internet is not proven and annoyed
when patients tend to believe the information from the Web is right and their doctor is
wrong. "If they take a drug and they have a lousy response to it, they will go to a
web page that says it's a poison," said Dr. Alan DeCherney, an infertility expert at
the University of California in Los Angeles. "You send them to the reputable pages
but they don't want that. They don't listen because it's not what they want to hear."
Patients and their families, however, tell a different story. Erin
Goldstein, legal recruiter for the McCormick Group in Arlington, Virginia said she turned
to the Internet when doctors diagnosed a brain tumor in her mother last year. "I was
feeding in keywords as fast as I could," Ms. Goldstein said. It was terrifying, at
first, she said, adding: "Everything you read says, 'prognosis very poor,'
'traditional protocols showing little effect.'" But, she said, when her mother's
biopsy results came back, Ms. Goldstein at least knew what they meant and she was able to
focus her Internet research. Her father, Ms. Goldstein said, "wanted to defer to the
doctor's expertise, but that really wasn't sufficient for me." Armed with her
Internet research, she said, she peppered her father with questions: "Why did the
doctor choose this over that? I know there are these five protocols. Why aren't they doing
a different surgery?" She stayed in touch with relatives of other brain cancer
patients through Internet chat groups, finding their experience and expertise immeasurably
helpful. Others turn to the Internet to learn what their medical test results mean. When
John Franz, a 42 year old engineer who lives in Moorestown, N.J., discovered that he had
an unusual pattern of blood cholesterol, he immediately turned to the Internet. He went to
his doctor to discuss his research, but Mr. Franz said, "He didn't think it was
important." So Mr. Franz changed doctors. "Patients now have an active
role," Mr. Franz said. "With managed care you almost have to. It's up to you
now, and if the doctor's not going to support that, you don't have to be involved with
them."
Medical experts say the most trustworthy web sites are those run by the
federal government like www.nih.gov and by national organizations like the American Heart
Association. Beyond those sites, however, experts say there are guidelines and even web
sites that can help individuals decide whether to trust an electronic site. The American
Medical Association suggests checking the source of the information and the financing for
the site in judging its reliability. Warning signs include sites that seem to be promoting
products or that offer miraculous treatments or cures. The association also says to check
how often the information is updated and who reviews it. Other advice comes from Dr.
Ragnar Levi of the Swedish Council on Technology Assessment in Health Care, who recently
analyzed the problem of determining the quality of information on web sites. Writing in
the current issue of the magazine Skeptical Inquirer, Dr. Levi notes that a web site by
the Health on the Net Foundation based in Geneva www.hon.ch/honcode/honcode_check.html
provides a checklist of questions that can help people assess a site's credibility.
Heroin Addicts Cleaner on Methadone
Nicolle Charbonneau, USA Today- 03/07/2000
Methadone beats detox when it come to getting addicts off of heroin, say
two studies in the latest Journal of the American Medical Association. And one
concludes that it's time to move the treatment out of specialized facilities and into the
doctor's office. Although these findings add to 25 years of research supporting methadone,
treatment programs still face serious opposition from politicians such as New York City
Mayor Rudolph Giuliani, who thinks the treatment is soft on drug addicts. Methadone
maintenance treatment (MMT) involves daily, usually oral, doses of methadone, a man-made
opiate that is in itself addictive. While not a cure for heroin addiction, it suppresses
drug cravings and wards off withdrawal symptoms without producing a high. It
can be taken for decades without serious side effects. MMT programs usually include
counseling. The goal: to reduce drug use and dangerous related behaviors, such as crime,
needle-sharing and unsafe sex.
In the first study, researchers at the University of California, San
Francisco followed 179 heroin addicts randomly assigned to either MMT or a 180-day
detoxification program. Ninety-one patients got MMT along with two hours a week of
counseling for six months. Eighty-eight patients in the detox program received methadone
for 120 days, then were weaned off it over 60 days. They also received three hours of
counseling a week and other support. The differences were dramatic. Patients
in the MMT group stayed in treatment for an average of 438.5 days, compared to 174 days in
the detox group. MMT isn't perfect, however: One year later, MMT patients were just as
likely to practice unsafe sex, abuse alcohol, or to have legal, employment or family
problems. "Maintenance is more successful at preventing heroin use and
needle-sharing," says senior author Sharon Hall, a professor and vice-chair of
psychiatry at UCSF. "[Methadone] is the most effective treatment that we have right
now." "Detox alone has generally been a dismal failure," says Dr. Bruce
Rounsaville, a professor of psychiatry at Yale University in New Haven, Conn., and the
author of an accompanying editorial.
MMT is controversial
Substance abuse experts generally agree that MMT works better than detox, according to
Rounsaville. But MMT is also controversial, since drug addiction is viewed as a disease by
some and as a moral failing by others. In the latter case, says Rounsaville, people think
that it's wrong to offer addicts more opiates. Hall disagrees. "We're dealing with a
chronic disease," she says, comparing addiction to diabetes or hypertension. There
are over 800,000 opiate addicts in the United States, yet only 115,000 are involved in MMT
programs. One major reason seems to be access: Most MMT programs are in specialized
facilities in major cities. In the second study, lead author Dr. Michael Weinrich looked
at how the Scottish cities of Glasgow and Edinburgh have dealt with MMT programs, and he
now thinks that a major part of the solution lies with general practitioners. In Glasgow,
heroin addicts in the first year of MMT must take their methadone under supervision at a
community pharmacy. Afterwards, they must seek their treatment at the office of a
physician, who can enroll between five and 20 drug-abusing patients and prescribe
methadone. The patients also receive drug counseling from a counselor or trained nurse. By
1998-'99, 41 percent to 73 percent of injection drug users (IDU) in Glasgow were enrolled
in the program. In Edinburgh, a similar program had drawn 60 percent to 80 percent of the
city's IDUs. Between 1988 and 1993 in Edinburgh, the rates of sharing injecting equipment
dropped from 85 percent to 51 percent. The HIV-positive rate among referrals to the
program fell from 21 percent to 8 percent. "The integration of primary care and
substance abuse treatment is very desirable," says Weinrich, a neurologist at the
National Institute of Child Health and Human Development in Bethesda, Md.
Rounsaville's editorial supports the findings of both studies. "It is possible to
safely and effectively provide methadone treatment in a primary care setting," says
Rounsaville. "If methadone treatment could be offered in primary care clinics, it
could become available to anyone who needs it across the country."
Throwing Pills at Kids Is Bad, But It's Only a Symptom of
the Real Problem.
Amy Bloom, New York Times Magazine, 3/12/2000
Junior Drugs: One Parent's Testimonial. "We too have tried Adderall and
Dexedrine and have the same effects. I am interested in learning more about when the
F.D.A. is approving the Ritalin patch!! Our main thing with our daughter is she is a
living nightmare in the mornings….because no meds are in her system, with the patch
that would solve this up and down reactions they have!…My son age five was just put
on Clonidine for his ADHD…It is working wonderfully for calming him down and making
him think before acting for once in his life!!…My daughter used to take that only
before bedtime to get her to sleep!! So I guess that just proves how each med is different
for each child!" From the alt.support.atttn-devidit newsgroup, an online forum for
discussing attention deficit disorders.
I have been treating a young girl since her father's sudden death six months
ago. One Saturday night, while her mother is out with her new gentleman friend, she makes
what we in the business call a "suicidal gesture," which is much less than a
full-fledged attempt, but obviously a sign that all is not well, and not likely to be, any
time soon. She is in the hospital from Sunday to Friday. On Friday, the "discharge
planner" calls to notify me that my young patient will be returning home that
afternoon. Her five days of covered hospitalization are now up, and since she is no longer
a threat to herself (no suicidal gestures during the four full days of her hospital stay),
and was never a threat to others, the HMO says it is time to go and, by the way, it won't
pay for family therapy. I suggest that a weekend of hanging around with her mother and the
new beau is not a great treatment plan for an impulsive, nonverbal kid. A few more days
might give her a chance to connect to the other kids on the unit, to have several sessions
of family therapy with her mother, to come to terms with having found herself in a
hospital in the first place. I tell the planner what a great girl this is (she is not a
great girl yet; right now she is a sad, confused, self-pitying and irritable girl, but she
might become a great girl, with some help) and the planner sighs. "Well," she
says, "how about medication?" It is the consensus of her treatment team,
including me, that what is needed is more talking, more strolling around the grounds with
the sympathetic nurse's aid, whose own father died in a car accident, some intensive help
for her and Mom at the hospital and more room to grieve. "Medication for what?"
I ask. "For whatever. We could keep her another eleven days with a medication
trial."
Prescribing psychotropic medications for school-age children is a
booming business these days. Ritalin's production alone is up 700 percent since 1990, and
stories like mine are commonplace. As a result, a battle has arisen between the
pro-medication and anti-medication camps: heated, public and utterly spurious. Some
children need medication; others don't. The real trouble lies in how we make that
assessment. This process begins before the doctor ever sees the patient. The person with
the cash, the power and even the transportation usually gets to identify the patient,
setting the stage for all subsequent decisions. Which is why women without children were
called "barren" and men without were just unlucky; why Freud treated the
obstreperous Doras but not their parents; why aged, uncertain parents find themselves in
nursing homes against their will. It is especially so when the murky questions of behavior
and psychology are raised; is it adolescent moodiness or pre-Columbine sociopathy? Was she
born that way or did we make her that way?
The theoretical basis of family therapy--and common sense--holds that
the most vulnerable point in the family structure will reveal its stress first. And the
way children show stress is often called "symptoms." Parents, of course, do not
always wish to interpret the symptoms, nor are family doctors always trained to read them.
Even well intentioned parents who wish to make things better, quickly, may override their
child's experience and capacity to express it. For American children right now--especially
the fidgety, the distractible and the extra lively-- their vulnerability is made worse by
a ghastly convergence of social anxiety, overwhelmed and uninspired schools and widespread
fixation on the bottom line.
Find a symptom, find a treatment, treat it and, in a modern twist, make
it no one's fault. Fix them, we say, and these new drugs do "fix" them--quickly,
inexpensively and inappropriately. We fix them at a younger and younger age--these days
even when they're toddlers. And we do so even when we use medications intended for adults.
As a result, four million children are on Ritalin and 2.5 million are on antidepressants.
Attention deficit disorder and hyperactive disorder) both formerly known as minimal brain
damage, but nicely renamed by the drug companies) do exist, and it would be cruel to
withhold Ritalin from children who suffer from them. Just as it would be unfair to
stigmatize them as spoiled brats and ridiculous to blame their concerned parents. But
these drugs are being wildly prescribed because they are cheaper and less time consuming
than psychotherapy and much easier to sell, both to the consumer and to the average family
doctor. Prescriptions are less work than conversation and careful evaluation. And handing
out medication at lunchtime is easier than creating classes that keep intelligent and
curious kids from squirming, daydreaming and talking back. Most of all, we prescribe
medications for children who don't need them because the medications are available, and a
cure for parental vanity and irresponsibility--along with the single minded greed of
HMOs--is not.
A couple come into my office. They tell me they are happily married and
need only a consult on their child, who is "out of control." The husband says
that he is a fair disciplinarian (although it seems to me that it must be difficult to get
much disciplining done between his arrival home at 8:00pm and the child's bedtime at
8:30pm) and that the mother, full time at home, is a pushover who can neither keep to a
schedule nor follow through with suitable consequences. She says that he has no idea what
he is talking about, since he is never home, and that he makes unreasonable demands on her
and their six year old. I suggest that their family is both under stress and producing it.
They cancel the next appointment. They call a year later-- their daughter is on Ritalin
because of ADD which is now official, and the kids make fun of her for the daily trip to
the nurse. "Can I suggest someone who will help boost her self-esteem?"
Demystifying Sessions on the Couch: A Book Review of
Talk Is Not Enough: How Psychotherapy Really Works by Willard Gaylin
Christopher Lehmann-Haupt, New York Times- 3/13/2000
"Although we live in a society that has become psychologically saturated,
psychotherapy still seems to have a somewhat clouded image, " writes Willard Gaylin
at the opening of his expert and instructive new book, "Talk Is Not Enough: How
Psychotherapy Really Works." The reasons for this cloudiness are several, he
continues: first, the growing confusion over what exactly constitutes mental illness (we
have engineered "the medicalization of woe," he writes); second, the decline of
psychoanalysis's standing over the last 40 years and the emergence of "quirkier,
trendier, slicker treatments" ("EST and other forms of cathartic weekend
cures"); and finally the sinking of Freud's reputation to "its lowest point
since he achieved early fame at the beginning of the 20th century."
The purpose of Dr. Gaylin's book is to demystify psychotherapy and
explain it; as he puts it, "to examine the complex and often perplexing interactions
between therapist and patient that produce significant changes in the patient's behavior
and perceptions." It is a "book about psychotherapy by a man who still
passionately believes in it." Dr. Gaylin translates his passion by defining the
fundamentals of therapy and the theories of the school he happens to belong to. A graduate
of the Columbia Psychoanalytic Center and now a clinical professor of psychiatry at
Columbia College of Physicians and Surgeons, he illustrates his more elusive points with
lively case histories from his experience as a therapist. The fundamentals seem obvious:
how to pick a therapist; how the initial interview usually goes; what purpose dreams
serve; the roles of catharsis, insight, free association, transference and the
"much-maligned couch," which he argues can free patients to fantasize but can
also sink them into passivity. "One intriguing area of nonverbal communication with
which we are all familiar is lateness, a common-place personality trait," he writes.
"Chronic lateness is a planned event," and "is the quintessential
passive-aggressive mechanism." Just as the patient often feels hostile toward the
therapist, "the therapist will have some negative emotional responses to his most
cherished patients," Dr. Gaylin writes. "Often it will be impatience ('For God's
sake, why doesn't he finally take the woman to bed. She has been waiting for this for
weeks.' ). For the most part these must not be explicated."
But from such practical observations Dr. Gaylin can plunge rather
suddenly into his own fundamental theories. For instance, writing about the seemingly
simple phenomenon of insight, he recalls the offhand observation of a mentor of his,
wondering "if insight isn't really the product of change rather than the cause of
it," by which he meant "that the recovered unconscious memories which were
presumed to initiate the process of change were actually the products of unconscious
changes that had already occurred." With similar plunges Dr. Gaylin takes us back to
his training as an analyst at the Columbia Psychoanalytic Center. And he introduces us to
the ideas of the center's founder, Dr. Sandor Rado (1890-1972), who rejected Freud's
theory of the libido, in which human development was viewed in a psychosexual perspective,
and replaced it with a theory that focused on childhood dependency as its central concern.
From the vantage point of his training, Dr. Gaylin sees the cure of neuroses as involving
the recognition in the present of distorted perspectives that trace back to childhood.
Then once patients see, therapist must encourage them to act on their insights in the real
world. Because therapists are far from neutral agents, Dr. Gaylin insists, they are
required morally to do so.
So by summing up his techniques Dr. Gaylin attempts to dispel the
clouds obscuring psychotherapy. As for Freud, Dr. Gaylin writes that he may have been
"an imperfect psychiatrist with a somewhat narrow view of mental illness," but
he remains "the father of all modern knowledge of human perceptions and
behavior," and his current low standing guarantees "an early rediscovery and
resurrection." What is puzzling about Dr. Gaylin's defense of psychotherapy is that
he does not directly address its severest critics: the sleep theorists, for instance, who
argue that dreams have nothing to do with the unconscious, or the pharmacologists who say
that drugs are the only solution to psychological problems, or the empiricists who insist
that the efficacy of psychotherapy can never be measured. Strangely, he does not draw on
helpful evidence to the contrary, like the latest dream research, which at least allows
for the possibility that Freud was right; or experiments with snails suggesting that by
inducing certain behavior one can produce physiological changes; or pharmacological
research indicating that so far most psychotropic drugs tend to attack symptoms rather
than causes. Instead Dr. Gaylin simply asserts: "Psychotherapy is not a fraud. It
does work." And then sets about to prove it by identifying what he calls "the
most common therapeutic maneuvers that are operative under the general rubric of
psychotherapy."
Well, as things turn out, he does considerably better than mere
identification. He makes clear how more than talk goes on in the therapeutic session and
why the oddly asymmetrical exchanges of the therapist and the patient can theoretically
effect change. But mind and matter are converging faster than is dreamed of in Dr.
Gaylin's philosophy. One of these days, we'll understand scientifically why psychotherapy
can be so healing.
Frequent Binge Drinking on Rise
Tom Kirchofer, Associated Press- 3/14/2000
Binge drinkers on college campuses are likely to be white, live in a fraternity and
have a history of binge drinking in high school. And the percentage of frequent bingers is
on the rise, according to a study released Tuesday by the Harvard School of Public Health.
The survey, conducted last year, was based on responses to written questionnaires from
14,000 students at 119 colleges around the country. The survey, sponsored by the Robert
Wood Johnson Foundation, was published in the March issue of the Journal of American
College Health. The margin of error was plus or minus 1 percentage point. The study found
the population of frequent binge drinkers rose last year to 22.7 percent of the student
population, up from 19.8 percent in 1993 and 20.9 percent in 1997. The percentage of
students going on binges stayed roughly the same through the 1990s, but American campuses
grew more polarized between students whose binges are severe and students who don't touch
alcohol. Binge drinker was defined as a man who drank at least five drinks in a row, or a
woman who drank four, at least once in the two weeks prior to the survey. A frequent binge
drinker had binged three or more times in the two weeks.
``To make the situation harder for college administrators, most of
these students do not feel they have a problem, and the large majority consider themselves
moderate drinkers,'' said Henry Wechsler, a social psychologist and Harvard researcher who
led the study. Meredith Petrin, a 20-year-old Harvard junior, said while many of her peers
would probably be classified as binge drinkers by Wechsler, she thinks they generally have
a healthy attitude towards alcohol. ``I don't see a problem with it,'' she said. ``It's a
good release and it's fun.'' The study found the overall portion of binge drinkers has
stayed at about two out of five students since a study was done in 1993, while the
proportion of frequent bingers — and nondrinkers — rose. The percentage of
students who don't drink at all has been rising steadily, from 15.4 percent in 1993 to
18.9 percent in 1997 and finally, 19.2 percent in 1999, the study found.
Wechsler said it was unclear why campuses were being increasingly
polarized between frequent binge drinkers and nondrinkers. ``It may be that the drawing
off of nondrinkers and light drinkers from the drinking scene are making it a much heavier
drinking scene,'' he said. ``But that's just speculation.'' The people most likely to
binge drink tend to be white and male. The study found that 78.9 percent of students who
lived in fraternity or sorority houses were binge drinkers. The students least likely to
be binge drinkers were black or Asian, over the age of 24, married, and had not been binge
drinkers in high school. While the study found binge drinkers have increased risks of
missing class, falling behind in schoolwork, getting in trouble or getting hurt, it also
found that such drinkers create ``secondhand effects'' on campus. Students who did not
binge drink and lived on campuses where bingeing was common were twice as likely to report
being assaulted, awakened or kept from studying by drinking students than were nonbinge
drinkers and nondrinkers at campuses where bingeing was less common. Joel Wiegert, a
University of Nebraska-Lincoln senior who described himself as a former binge drinker,
said he quit drinking to excess when he realized he often said stupid things while drunk,
disrespected people and once broke a table. ``It was a cost-benefit analysis for me,'' the
economics major said. ``I have yet to come up with one benefit to high-risk drinking.
Finding Hope Amid Despair in Treating Compulsive Disorders
Annette Fuentes, New York Times- 3/21/2000
In hindsight, Debbie McDowell now realizes that the quirks and idiosyncrasies her son
Jake displayed when he was very young were the first warnings of an illness that would
eventually debilitate her child and test her own mettle as a parent. Jake would wear only
shoes with Velcro closures that he could pull tight and his pants had to have skin-tight
legs. Little kids do bizarre things, she told herself. What's the harm in indulging him?
But when Jake was in second grade, a classmate was hospitalized with a heart infection and
required a heart transplant, all of which was patiently explained to pupils by a
well-intentioned teacher. "My kid heard 'germ', 'infection,' and 'heart' and O.C.D.
was born," said Ms. McDowell of Waltham, Mass.
Obsessive-compulsive disorder is a biologically based psychiatric
disorder characterized by persistent, distressing thoughts or images and accompanying
ritual behaviors or mental acts that a person is driven to perform. For Jake McDowell,
germs were the initial obsession and hand-washing the compulsion, but his symptoms soon
expanded and grew progressively worse. He feared contamination from pesticides on the lawn
and household cleaners. And then he could not put on his socks. "I would sit on the
floor with him with 25 pairs of the same socks trying to find a pair that would go
on." Ms. McDowell recalled. "He said it felt like they had rocks in them. And
finally, he couldn't go to school. At 8 & 1/2 Jake thought he was nuts."
It took a year and a half before Jake's illness was ultimately
diagnosed as obsessive-compulsive disorder, a period during which the McDowells endured
dead-end encounters with a psychologist who suggested the problem was that Jake's father
traveled too much. School officials, noting that Jake had seemed depressed and suspected
child abuse, reported the McDowells to state officials. Although no investigation
occurred, the episode was wrenching and moved Jake no closer to help. Eventually, Ms.
McDowell found a psychologist who gave Jake's problem a name and gave the family hope.
"It was like the weight of the world was lifted from his shoulders." Ms.
McDowell said. Behavior therapy in combination with medication very quickly improved
Jake's symptoms. Today, Jake is 13 and although his condition will not be cured, "he
is living a very normal life," his mother said.
Not all O.C.D. stories have such a happy resolution, but the McDowells'
tale proves both how far medical science has come in understanding and treating the
disorder and how much remains to be done. Just 20 years ago, the condition was considered
a rare anxiety disorder, affecting no more than 0.5 percent of the population. Now it is
widely believed that 2 to 3 percent of the population and one percent of children meet the
criteria for the disorder. More recent research indicates that among adults with the
disorder, onset was before age 15. Yet it can go undiagnosed for many years, in part
because its sufferers are motivated by fear and shame to hide their symptoms. For adults,
the average time between the first appearance of symptoms and diagnosis is 17 years.
"It used to be thought that if you saw two or three of these kids
in a practice in a lifetime, that would be a lot," said Dr. John March, director of
the program in Child and Adolescent Anxiety Disorders a t Duke University Medical Center.
"Now it appears the prevalence rate is probably on the order of 1 in 200 children.
That's two or three kids in every elementary school. It is about the same prevalence rate
as juvenile diabetes." Dr. March credits pioneering research by Dr. Judith L.
Rapoport at the National Institute of Mental Health and her 1989 book, "The Boy Who
Couldn't Stop Washing", for increasing the recognition of the disorder in children.
Researchers have yet to identify the cause for the disorder, but brain
imaging work by Dr. Lewis R. Baxter, Jr., a neuropsychiatric researcher at the University
of California at Los Angeles, has located the likely site of the problem in the basal
ganglia, an area of the brain that is connected to impulse-carrying circuits. One of these
circuits, involving the orbital frontal cortical thalamic regions of the brain, is
supposed to screen incoming sensations and thoughts and determine which are important.
Chemical imbalance in this circuitry may cause a "mental hiccup," in which
thoughts or actions are repeated incessantly. But what causes the imbalance affecting that
circuit is still not clear, said Dr. Susan Swedo, head of behavioral pediatrics at the
National Institute of Mental Health. "The circuit is a loop, like a string of
Christmas tree lights," she said. "When one goes out, they all go out, so you
can't tell exactly where the problem originates."
But researchers do know that stress can trigger the disorder, as can
strokes. Dr. Swedo is also involved in long-term research into common strep infections in
children as a trigger for the disorder, a syndrome called Pandas for pediatric auto immune
neuropsychiatric disorders associated with strep infections. Pandas cases represent a
small subset of all children who have O.C.D. More significant is the role of genetics. One
in four children with the disorder has a first-degree relative with a similar condition or
with a tic disorder. For one girl from upstate New York, genetics is the likely cause for
her disorder. But it was not until her symptoms surfaced at age five that her mother,
Arlene, made the connection to her husband's own idiosyncratic behaviors. "He's a
hoarder," said Arlene, who did not want her last name used. "No one meeting him
would know, although you might think he is slightly compulsive." Arlene's daughter's
condition worsened as she got older, manifesting as tantrums and then a compulsion to
lick-- the garage floor, electrical outlets, a gym mat at school. Homework was a
frustrating exercise and the girl's grades reflected her difficulties.
When the girl was eight, Arlene took her to a psychotherapist and then
a psychiatrist, and neither helped. The psychiatrist even made things worse when he
prescribed Paxil, and anti-depressant, which gave the girl symptoms of attention deficit
disorder. At her wits end, Arlene went to Marni Jaffer, a psychiatric nurse at the O.C.D.
and Anxiety Disorder Service for Children and Adolescents at New York Presbyterian Medical
Center in White Plains. "The minute Marni met her she said, 'She's in distress, but
don't worry, this is the beginning of the end,'" Arlene recalled. Ms. Jaffer began a
widely used approach for anxiety disorders, called cognitive behavior therapy, that lasted
for six months, beginning with three sessions weekly. The girl also began taking Luvox,
one of several antidepressants approved for treating children with the disorder. In less
than a year, the girl was much improved. She was getting A's and B's is school and taking
dance classes. Now 11, she goes back to Ms. Jaffer for occasional booster therapy sessions
and she still takes Luvox. But, Arlene said, "She is the child I always thought she
could be." Her husband is a different story. He had a hard time acknowledging his
condition and seeking help. "He's doing much better but he's not willing to talk
about it. He sees it as a stigma," Arlene said.
Early diagnosis and treatment is especially critical for children for
several reasons, Dr. March said. Left untreated, the disorder can interfere with
children's growth as the rituals come to dominate their lives, crowding out other
activities. The disorder also derails a child's normal developmental growth, Dr. March
said. Research also suggests that early treatment could prevent depression and other
conditions that often exist with the disorder in adults. In just the last decade,
treatments for children with the disorder have evolved along with understanding of the
disease. The class of anti-depressants known as selective serotonin reuptake inhibitors
(S.S.R.I.'s), of which fluoxetine (Prozac) is the best known, is one tool doctors use to
bring the symptoms under control. Three of them--Anafranil, Zoloft and Luvox--are approved
by the Federal Food and Drug Administration for treating children with the disorder. But
research done by Dr. March and others suggests that for many children, the behavior
therapy that helped Jake McDowell and the young girl with their disorders, can have
equally effective and longer lasting results than medication alone.
At the O.C.D. and Anxiety Disorder Service for Children and
Adolescents, Ms. Jaffer and the clinic's founder, Dr. Flemming Graae, use exposure and
response-prevention therapy, a form of cognitive behavior therapy that forces patients to
confront the objects of their obsession while preventing them from acting out their
rituals. So children obsessed with germs would have to touch or drink from dirty glasses,
for example, and then not be permitted to wash their hands. "What you're doing,"
Ms. Jaffer said, "is putting them in the situation that triggers the symptoms and
then showing them that nothing bad will happen, and that they can get relief."
Another proponent of exposure response-prevention therapy, Dr. March has published a
manual for practitioners and parents, "O.C.D. in Children and Adolescents",
which maps out a treatment through cognitive behavior therapy, or C.B.T. Among his
patients, Dr. March said he had an 80 percent success rate in diminishing symptoms.
"Fifteen years ago, if you were a kid with O.C.D., you were up a creek without a
paddle," he said. "Now, if you can get access to C.B.T., once you get well, you
stay well. You may need boosters, but the long-term prognosis is good." |