BRUCE E. LEVINE

Depression Treatment: What Works and How We Know

Bruce Levine — Sun, 13 May 2012 13:04:10 +0000

Skeptic. For people satisfied with their standard depression treatments, debunking myths about them may be troubling. Many depressed people, for example, report that their antidepressants have been effective for them, and they sometimes are enraged to hear anyone question the value of these drugs. However, for critically thinking depression sufferers who have not been helped by antidepressants, psychotherapy, or other standard treatments, discovering truths about those treatments can provide ideas about what may actually work for them.

Critical thinkers aware of the research have difficulty placing faith in any depression treatment because science tells them that these treatments often work no better than placebos or nothing at all; and if one lacks faith in a depression treatment, it is not likely to be effective. Many studies have found that it is belief and faith—or what scientists call expectations and the placebo effect—that is mostly responsible for depression treatment working. People can find a way out of depression when their critical thinking about depression treatments is validated and respected, and they are challenged to think more critically about their critical thinking. There are five controversial beliefs about depression treatment that I discuss in greater depth in my book Surviving America’s Depression Epidemic.¹

1. Antidepressants Are More Effective Than Placebos
2. If the First Antidepressant Fails, Another Antidepressant Will Likely Succeed
3. Electroconvulsive Treatment (ECT) Is An Effective Last Resort
4. Cognitive Behavior Therapy (CBT) Is The Best Psychotherapy for Depression
5. No Treatment For Depression Works

1. Antidepressants Are More Effective Than Placebos

There are millions of people who swear by their antidepressants, however, the scientific question is: For depressed people as a group, do antidepressants work any better than a placebo sugar pill? Irving Kirsch, professor emeritus at the University of Connecticut and author of The Emperor’s New Drugs, has been trying to answer that question for a significant part of his career.² In 2002, Kirsch and his team examined 47 depression treatment studies that had been sponsored by drug companies on the antidepressants Prozac, Paxil, Zoloft, Effexor, Celexa, and Serzone. Many of these studies had not been published, but all had been submitted to the Food and Drug Administration (FDA), so Kirsch used the Freedom of Information Act to gain access to all the data. He discovered that in the majority of the trials, antidepressants failed to outperform sugar pill placebos. “All antidepressants,” he reported, “including the well-known SSRIs (selective serotonin reuptake inhibitors), had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and others describe it as “clinically negligible.”³

While antidepressants do about as well as placebos for moderately depressed patients, a common question is: Are antidepressants more effective for severely depressed patients? The answer is somewhat complicated. While there is no increased responsiveness to antidepressants among severely depressed patients, the placebo is slightly less powerful for this group. In a 2008 paper published in PLOS Medicine, Kirsch, now also a professor of psychology at the University of Hull in the United Kingdom, explained it this way:

Drug-placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.⁴

Why are so many doctors unaware of the general lack of superiority of antidepressants as compared to placebos? The answer became clear in 2008 when researcher and physician Erick Turner, at the Department of Psychiatry and Center for Ethics in Health Care, Oregon Health and Science University, discovered that antidepressant studies with favorable outcomes were far more likely to be published than those with unfavorable outcomes. Analyzing published and unpublished antidepressant studies registered with the FDA between 1987-2004, Turner found that 37 of 38 studies having positive results were published; however, Turner reported, “Studies viewed by the FDA as having negative or questionable results were, with three exceptions, either not published (22 studies) or published in a way that, in our opinion, falsely conveyed a positive outcome (11 studies).”⁵

2. If the First Antidepressant Fails, Another Antidepressant Will Likely Succeed.

In The Noonday Demon, the popular 2001 book about depression, writer and depression sufferer Andrew Solomon repeated the then urban legend that “more than 80% of depressed patients are responsive to medication.” Solomon accurately cites a journal article that states this statistic; however, following the “reference trail,” I discovered that the journal article that Solomon cited refers to a second article for evidence of this statistic, but this second journal article mentions nothing about 80% of depressed patients responding to some medication.⁶

The National Institute of Mental Health (NIMH) was aware that there was no research to back up the assertion that 80% of depressed patients improve if they keep trying different medications, so NIMH funded “Sequential Treatment Alternatives to Relieve Depression” (STAR*D), the largest ever study of sequential depression treatments. STAR*D results were published in 2006. In Step One of STAR*D, all depressed patients were given the antidepressant Celexa, and in Step Two, patients who failed to respond to Celexa were divided into different groups and received other treatments (mostly different drug treatments) in place of or in addition to Celexa. If their second treatment failed, there was a third and, if necessary, a fourth treatment step.

In every STAR*D treatment step, remission rates were either equal to or significantly lower than the customary placebo performance in other antidepressant studies, but to the exasperation of many scientists, there was no placebo control in this $35 million U.S. taxpayer funded STAR*D study. And to make matters worse, STAR*D researchers disclosed receiving consulting and speaker fees from the pharmaceutical companies that manufacture the antidepressants studied in STAR*D.

In March 2006, NIMH triumphantly announced that 50% of depressed people saw remission of symptoms after the first two STAR*D steps. However, NIMH failed to mention in its press release that in the same time it took to complete these first two steps—slightly over six months—previous research shows that depressed people receiving no treatment at all have a spontaneous remission rate of 50%.

In November 2006, following the completion of all four STAR*D steps, STAR*D authors claimed a 67% cumulative remission rate, which again exasperated many scientists because this number failed to incorporate STAR*D’s extremely high relapse and dropout rates. In an American Journal of Psychiatry editorial that accompanied STAR*D authors’ report, J. Craig Nelson stated, “I found a cumulative sustained recovery rate of 43% after four treatments, using a method similar to the authors but taking relapse rates into account.”⁷ However, even 43% turns out to be an inflated rate.

Separate analyses of STAR*D in 2010 by psychologist Ed Pigott and medical reporter Robert Whitaker revealed that STAR*D researchers had inflated remission numbers by switching mid-study to a more lenient measurement, and also by including patients who were not depressed enough at baseline to meet study criteria.⁸ But even taking the STAR*D data as is, Pigott’s analysis revealed that less than 3% of the entire group of depressed patients who began the STAR*D study can be ascertained as having a sustained remission (i.e., actually participated in the final assessment without relapsing and/or dropping out).⁹

3. Electroconvulsive Treatment (ECT) Is An Effective Last Resort

Andrew Solomon in The Noonday Demon also states, “ECT seems to have some significant impact between 75 and 90% of the time. About half of those who have improved on ECT still feel good a year after treatment.”¹⁰ Is ECT really that effective?

In 2004, medical researcher Joan Prudic and her team at New York State Psychiatric Institute conducted a major study of ECT involving 347 patients at seven hospitals. Reported were both the immediate outcomes and the outcomes over a 24-week followup period. With respect to immediate outcomes, Prudic reported: “In contrast to the 70 to 90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3 to 46.7%.” Even worse for ECT advocates, Prudic noted that, “10 days after ECT, patients had lost 40% of the improvement.”¹¹

There are also studies comparing ECT with a placebo (called “sham ECT”). In sham ECT, patients receive muscle-relaxing and anesthetizing drugs that routinely accompany ECT, and they are hooked up to the ECT apparatus, but they receive no electric voltage. Psychiatrist Colin Ross reports, “No study has demonstrated a significant difference between real and placebo (sham) ECT at one month post-treatment.”¹²

4. Cognitive Behavior Therapy (CBT) Is The Best Psychotherapy For Depression

First, the good news about CBT. The only non-drug treatment examined in the STAR*D study was a form of cognitive therapy that was not fully detailed by the authors and only administered in Step Two. Among those who failed Celexa in the first step, three groups in Step Two switched from Celexa to one of three antidepressants, and their remission rates ranged from 25 to 26.6%; but one group in Step Two switched from Celexa to cognitive therapy, and its remission rate was 41.9%. STAR*D researchers did not assess whether any differences in treatment effectiveness were statistically significant.

Another group in Step Two maintained Celexa and added cognitive therapy, and this “Celexa plus cognitive therapy” group’s remission rate was 29.4%, not as high as the group that received cognitive therapy without medication. This begs the question: Is it also a myth that “antidepressants plus psychotherapy” works better than either treatment alone? Research psychologist David Antonuccio at the University of Nevada School of Medicine reports, “Combined psychotherapy and drug treatment do not appear to be superior to therapy or drug treatment alone.”¹³

What psychotherapy is best for depression? While Americans hear most about CBT, it turns out that CBT or some form of cognitive therapy is no more effective for depression than any of several other types of psychotherapy. In 2008, psychologists Pim Cuijpers and Annemicke van Straten at the University of Amsterdam reported on a meta-analysis of 53 studies, each of which compared two or more different types of psychotherapy for depression. Included were varieties of cognitive behavior therapy, psychodynamic therapy, behavioral activation therapy, social skills training, problem-solving therapy, interpersonal therapy and nondirective supportive therapy. The major finding? “No large differences in efficacy between major psychotherapies for mild to moderate depression.”¹⁴

So, if psychotherapy technique is not all that important, what is? Psychologist Bruce Wampold at the University of Wisconsin reviewed the psychotherapy outcome literature, examining hundreds of studies and meta-analyses, for his book The Great Psychotherapy Debate. Wampold unequivocally states that outcome effectiveness does not depend on the specific techniques of psychotherapy, but instead depends on so-called “non-specific” factors such as the nature of the alliance between therapist and their client, and clients’ confidence in the therapy and in their therapist. “Simply stated,” Wampold concludes, “the client must believe in the treatment or be led to believe in it.”¹⁵

5. No Treatment For Depression Works

In April 2002, an NIMH-funded study on the antidepressant Zoloft, the herb St. John’s Wort, and a placebo had some curious results. The findings were that 32% of placebo-treated patients experienced remission, better than the 25% remission for the Zoloft-treated patients or the 24% remission for the St. John’s Wort-treated patients.¹⁶ Most scientists would say that this study shows that neither Zoloft nor St. John’s Wort worked, but those subjects who had positive outcomes with these two treatments would disagree. So, does this study show that antidepressants and St. John’s Wort are not helpful, or does it show that expectations, belief and faith are the likely factors that make all treatments work?

When assessing whether a specific treatment is effective, scientists are trained to rule out the effect of expectations. Researchers evaluate a depression treatment as effective if, in a controlled study, the treatment outcome is significantly better than a placebo. However, the reality of depression treatments is that expectations, faith, belief and the placebo effect are—far and away—the most important reasons why anything works.

In 2004, Heather Krell, M.D. and her group at the University of California in Los Angeles examined the influence of patient expectations on the effectiveness of an experimental antidepressant. They found that among those depressed patients expecting that the medication would be very effective, 90% had a positive response; while among those expecting the medication would be somewhat effective, only 33% had a positive response.¹⁷ No depressed people were included in this study who expected the experimental drug to be ineffective, but such nonbelievers, in my experience, rarely report a positive response with antidepressants. All treatments can work, but rarely do so if one doesn’t believe in them.

A Path For Treatment Resisters: Critical Thinking About Critical Thinking

Critical thinking and an absence of self-deception are crucial for success in many areas of life, but these same talents can be problematic with respect to depression. A more accurate notion of how truly powerless one is in a situation (such as family, an organization, or society) can result in a greater feeling of helplessness, pain and depression.

From several classic studies, we know that moderately depressed people are, in a sense, more critically thinking than are non-depressed people. These studies show that depressed people are more accurate than are non-depressed people in both their assessment of control over events and in judging people’s attitudes toward them. Researchers Lauren Alloy and Lyn Abramson at the University of Pennsylvania in 1979, studying non-depressed and depressed subjects who played a rigged game in which they had no actual control, found that depressed subjects more accurately evaluated their lack of control when either losing or winning.¹⁸ And researcher Peter Lewinsohn at the University of Oregon in 1980, found that depressed subjects judge other people’s attitudes toward them more accurately than non-depressed subjects.¹⁹

Critical thinking also creates a problem for depression treatment, as skepticism makes one stubbornly resistant to much of what helps others. Specifically, to the extent one has uncritical faith in a treatment, it is far more likely to be experienced as successful; but to the extent that one is more skeptical about the effectiveness of treatment, one is less likely to have expectations that it will be effective, and this becomes a self-fulfilling prophesy.

Before modern research borne out this problematic relationship between depression and critical thinking, the American psychologist and philosopher William James (1842-1910) recognized this reality based on his personal experience. James had a history of severe depression, which helped fuel some of his greatest wisdom as to how to overcome depression. In The Thought and Character of William James, Ralph Barton Perry’s classic biography on his teacher, we learn that at age 27 James said he went through a period of a “disgust for life” that Perry describes as an “ebbing of the will to live…a personal crisis that could only be relieved by philosophical insight.” What was James’s transformative insight?

James was a critical thinker and had no stomach for smiley-faced positive thinking, but he also concluded that his pessimism might just destroy him. With his critical thinking, he came quite pragmatically to “believe in belief.” He continued to maintain that one cannot choose to believe in whatever one wants (one cannot choose to believe that 2 + 2 = 5 for example); however, he concluded that there is a range of human experience in which one can choose beliefs. He came to understand that, “Faith in a fact can help create the fact.” So, for example, a belief that one “has a significant contribution to make to the world” can keep one from committing suicide during a period of deep despair, and remaining alive makes it possible to in fact make a significant contribution.

Critical thinkers are skeptics who have difficulty with belief based on faith, but depression treatments work to the extent that one has faith in them. Instead of viewing themselves as failures for not improving with standard treatments, depressed critical thinkers can logically acknowledge the downside of their temperament. Myth busting about standard treatments enables critically thinking treatment resisters to release their pain over “treatment failure.” The pain of failure is one of the many pains that results in depression as well as substance abuse and other compulsions that are fueled by a need to shut down one’s pain. Releasing any pain, including the pain of treatment failure, can be helpful.

When skeptics discover that there have been others like themselves who have escaped this conundrum by finding something that they could believe in without giving up their critical thinking, this can jump start them into finding their own particular antidote to depression. William James ultimately let go of his dallying with suicide, remained a tough-minded thinker with scientific loyalty to the facts, but also developed faith that, “Life shall be built in doing and suffering and creating.”

References

1. Levine, B.E. 2007. Surviving America’s Depression Epidemic. Chelsea Green Publishing.

2. Kirsch, I. 2010. The Emperor’s New Drugs: Exploding the Antidepressant Myth. New York: Basic Books.

3. Kirsch, I., et al. 2002. “The Emperor’s New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration,” Prevention & Treatment, 5 (23).

http://journals.apa.org/prevention/volume5/pre0050023a.html.

“57% of the trials funded by the pharmaceutical industry failed to show a
significant difference between drug and placebo,” in Kirsch, I., et al., “Response to the Commentaries: Antidepressants and Placebos: Secrets, Revelations, and Unanswered Questions,” Prevention & Treatment, 5:33 (July 15, 2002), http://journals.apa.org/prevention/volume5/pre0050033r.html

4. Kirsch, I., et al. 2008. “Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration,” February, PLos Medicine http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045

5. Turner, E. H., et al. 2008. “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy,” New England Journal of Medicine, 358(3):252-260.

6. Solomon, A. 2001. The Noonday Demon: An Atlas of Depression, New York: Touchstone. Solomon refers to Mary Whooley and Gregory Simon, “Managing Depression in Medical Outpatients,” New England Journal of Medicine 343:26 (2000), who indeed report “more than 80% of depressed patients have a response to at least one medication” pp. 1942-1949. Whooley and Simon refer these statistics to H.C. Schulberg, W. Katon, G.E. Simon, and A.J. Rush, “Treating Major Depression in Primary Care Practice: An Update of the Agency for Health Care Policy Research Practice Guidelines,” Archives of General Psychiatry 55 (1998) pp. 1121-1127, where there is, however, no mention of 80% responding to at least one medication.

7. Nelson, C. 2006. “The STAR*D Study: A Four-Course Meal That Leaves Us Wanting More,” American Journal of Psychiatry, 163 (11):1864-66. See also: Rush. A. J. et al. 2006. “Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report,” American Journal of Psychiatry, 163(11):1905-17; Trivedi, M. H., et al. 2006. “Evaluation of Outcomes with Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice,” American Journal of Psychiatry, 163:28-40.

8. Whitaker, R. 2010. “The STAR*D Scandal: A New Paper Sums It All Up,” Psychology Today Blog, August 27. http://www.psychologytoday.com/blog/mad-in-america/201008/the-stard-scandal-new-paper-sums-it-all

9. Pigott, H. E. 2010. “Efficacy and Effectiveness of Antidepressants: Current Status of Research,” Psychotherapy and Psychosomatics, 79 (5): 267-279.

10. Solomon, 2001.

11. Prudic, J., et at. 2004. “Effectiveness of Electroconvulsive Therapy in Community Settings,” Biological Psychiatry, 55(3):301-12.

12. Ross, C. A. 2006. “The Sham ECT Literature: Implications For Consent to ECT,”Ethical Human Psychology and Psychiatry, 8(1):17-28.

13. Antonuccio, D. O., et al. 1999. “Raising Questions about Antidepressants,”Psychotherapy and Psychosomatics, 68:3-14.

14. Cuijpers, P. et al. 2008. “Psychotherapy for Depression in Adults: A Meta-Analysis of Comparative Outcome Studies,” Journal of Consulting and Clinical Psychology, 76 (6):909-922.

15. Wampold, B. 2001. The Great Psychotherapy Debate: Models, Methods, and Findings. Mahweh, NJ: Lawrence Erlbaum.

16. Davidson, J. R. T., et al. 2002. “Effect of Hypericum Perforatum (St John’s Wort) in Major Depressive Disorder,” Journal of the American Medical Association, 287 (14):1807-14.

17. Krell, H.V. et al. 2004. “Subject Expectations of Treatment Effectiveness and Outcome of Treatment with an Experimental Antidepressant,” Journal of Clinical Psychiatry, 65 (9):1174-79.

18. Alloy, L.B. and Abramson, L.Y. “Judgment of Contingency in Depressed and Nondepressed Students: Sadder but Wiser?” Journal of Experimental Psychology: General 108:4 (1979): 441-85.

19. Lewinsohn, P. M. et al. 1980. “Social Competence and Depression: The Role of Illusory Self-Perceptions,” Journal of Abnormal Psychology 89:203-12. McKenzie, K. et al. 2004. “Learning from Low Income Countries: Mental Health,” BMJ 329:1138-40.

Anti-Authoritarians and Schizophrenia: Do Rebels Who Defy Treatment Do Better?

Bruce Levine — Fri, 04 May 2012 12:26:11 +0000

Preface: Failing in my efforts to get this article published for the general public, apparently only here can I talk about a “cool subculture of anti-authoritarians” and how the Harrow study shows medication resisters have greater recovery.

While many Americans are troubled by psychiatry’s over medicating of children, and they doubt the legitimacy of some psychiatric illnesses such as “oppositional defiant disorder,” few question psychiatry with respect to schizophrenia, an often frightening phenomenon characterized by hallucinations, delusions, incoherent speech, and bizarre behaviors. But a major long-term study on schizophrenia challenges psychiatry’s authority here as well, and it just may get Americans to pay attention to a group of anti-authoritarians diagnosed with schizophrenia who have recovered without medication or doctors—and have become activists.

In February 2012, University of Illinois College of Medicine researcher Martin Harrow published, “Do All Schizophrenia Patients Need Antipsychotic Treatment Continuously Throughout their Lifetime? A 20-Year Longitudinal Study,” funded by the National Institute of Mental Health and the United States Public Health Service.

Harrow and his research team found that schizophrenia patients who were “not on antipsychotics [which include “typicals” such as Thorazine and Haldol, and “atypicals” such as Zyprexa, Risperdal, Seroquel, Geodon, and Abilify] for prolonged periods were significantly less likely to be psychotic and experienced more periods of recovery.”

Unseen by most psychiatrists and other mental health professionals, there is a group of people diagnosed with schizophrenia who, at some point, reject doctors and medication and are in recovery. How big is this group? Harrow reports, “Our 20-year data indicate that the subsample of SZ not on antipsychotics represent a moderate-sized group (30–40%) of SZ”; and many of them, according to Harrow’s results, achieve recovery without doctors. Some within this group are self-identified “psychiatric survivors,” activists who fight against coercive treatments and for informed choice and more treatment options.

Welcome to a Cool Subculture of Anti-Authoritarians

If my sole experience of people who had been diagnosed with schizophrenia was purely a clinical one, I too would be wary of them going off their medication, and I too would have a far less hopeful view of the possibility of recovery. One of my earliest professional positions was as a psychiatric emergency room therapist where I saw many patients who were agitated and acting bizarrely and who were dragged into the hospital by police and family. These patients were diagnosed with schizophrenia, schizoffective disorder, or some other psychotic disorder. Most of them would in fact calm down after being given medication, and so it is common for police, family, and mental health professionals to view being “off one’s meds” as problematic.

Many mental health professionals, myself included, have seen psychotic relapse among diagnosed schizophrenics who have been “medication noncompliant.” But professionals ordinarily don’t compare this group to those “medication compliant” patients who also relapse or remain chronically psychotic. And most importantly, in their clinical practice, mental health professionals do not routinely see diagnosed schizophrenics who have recovered without medication and without doctors.

Outside of my practice, I have come to know this group of diagnosed schizophrenics who have long-term recovery without medication. In his research, Harrow discovered them as well and states, “For most SZ [schizophrenia patients] not on medications or not in treatment this was their choice, at times against professional advice.” It is my experience that those who have rejected medication and recovered are virtually all anti-authoritarians who question the legitimacy of authorities and resist those authorities they assess to be illegitimate ones.

I had not heard about psychiatric survivors until 1994, when I was contacted by David Oaks, director of MindFreedom, a coalition of psychiatric survivor organizations from around the world. David, now a good friend, comes from a working class family in the South Side of Chicago and won scholarships to attend Harvard in the early 1970s, but he says, “I didn’t fit in at Harvard, and I was under a lot of stress. Now and again I ingested too much cannabis, to which I’m highly sensitive. I stopped sleeping.” His behavior became erratic with psychotic symptoms (e.g., “thought the CIA was making my teeth grow” and that “a UFO was appearing in my living room”). He was checked into various psychiatric facilities five different times. David recalls, “A dozen psychiatrists diagnosed me as a psychotic. I was told I would have to stay on psychiatric drugs the rest of my life, like a diabetic on insulin. I was told that I was genetically flawed and had a permanently broken brain.”

David ultimately joined the then existing Mental Patients Liberation Front where fellow psychiatric survivors shared stories, went on camping trips, and supported and encouraged each other to exercise and eat better. David graduated with honors from Harvard, and he has been free of psychiatric medication since 1977. Today, he is living in Eugene, Oregon, married, directs MindFreedom, and maintains a busy schedule of organizing and speaking around the world.

I’ve become friends with many other people who were once diagnosed as schizophrenic or with other psychotic disorder but who have moved into long-term recovery without psychiatric drugs (see their personal stories). They include Alaskan attorney Jim Gottstein, now President/CEO of the Law Project for Psychiatric Rights, and currently a leading organizer of Occupy the American Psychiatric Association in Philadelphia on May 5. Will Hall, now a psychotherapist and a radio host, co-founded the peer-support organization Freedom Center in Western Massachusetts along with Oryx Cohen, who is now the Technical Assistance Director at the National Empowerment Center (NEC).

Oryx and psychiatrist Dan Fisher, NEC director, like the term lived experience for those who have experienced hallucinations, delusions, and other “extreme states.” And the mission of NEC is “to carry a message of recovery, empowerment, hope and healing to people with lived experience with mental health issues, trauma, and and/or extreme states.”

Dan Fisher was psychiatrically hospitalized several times prior to becoming a psychiatrist, and he is one of the few psychiatrists in the world who publicly discusses his own recovery from schizophrenia. For anybody who doubts the possibility of full recovery from schizophrenia without psychiatry’s “standard of care” and who could also use a strong dose of morale, I recommend the video Psychiatrist Daniel Fisher Talks about Hope and Recovery.

I have spent time with hundreds of treatment reform activists who were once diagnosed with schizophrenia but who have recovered without medication, and my experience is that they consider themselves lucky to have had family and/or friend support for their choice to resist psychiatric authorities. They tell me that overwhelming anxiety is often a trigger for relapse, and having family or friends with confidence in the possibility of recovery and in their treatment choices is a great anxiety reducer.

Harrow’s Study

Martin Harrow and his research team enrolled patients from two Chicago hospitals diagnosed with schizophrenia (as well as patients diagnosed with mood disorders with psychosis), so as to examine long-term outcomes. All of the patients had received conventional medication treatments when hospitalized, and then Harrow followed them as their lives unfolded, periodically assessing how well they were doing. The majority of patients continued their antipsychotic medications, while about a third of them did not comply with medication treatment and stopped taking them.

The 20-year results showed that schizophrenia patients (and those patients with mood disorders with psychosis) who took antipsychotic medication regularly during the 20 years actually experienced more psychosis, more anxiety, and were more cognitively impaired and had fewer periods of sustained recovery than those who quit taking antipsychotic medications.

“Recovery,” according to the study criteria, required no psychotic symptoms, no rehospitalizations during the follow-up year, and partially adequate (or better) work and social functioning. Among the schizophrenia patients who remained continuously on antipsychotics throughout the 20 years of the study, only 17% ever entered into any period of recovery during any of the six follow-ups. By contrast, among the schizophrenia patients who remained off antipsychotics after the two-year follow-up and for the remainder of the 20 years, 87% experienced two or more periods of recovery.

Harrow’s results are inconvenient for the psychiatric establishment because, as Harrow points out, “Prolonged use of antipsychotic medications is the current standard of care in the field and is viewed as the cornerstone of treatment for SZ [schizophrenia patients].” And the pharmaceutical industry has good reason to want Harrow’s study buried, as antipsychotics are now the largest grossing class of drugs in the United States, grossing $16 billion in 2010. So, the psychiatric establishment and the corporate press have, for the most part, ignored Harrow’s findings.

The psychiatric establishment would like the public to believe that diagnosed schizophrenics who stopped taking their medication and gained recovery must have either been misdiagnosed or were less severely psychotic. However, Harrow makes clear, “At the 2-year assessment there were no significant differences in severity of psychosis between SZ on antipsychotic medications and SZ not on any medications. However, starting at the 4.5-year follow-ups and continuing over the next 15 years, the SZ who were not on antipsychotic medications were significantly less psychotic than those on antipsychotics.”

Explanations for Harrow’s Findings

Harrow concludes that those who stopped taking medication, while not initially different in severity of psychosis than the medication compliant group, are a “self-selected group with better internal resources associated with greater resiliency. They have better prognostic factors, better pre-morbid developmental achievements, less vulnerability to anxiety, better neurocognitive skills, less vulnerability to psychosis and experience more periods of recovery.”

For journalist Robert Whitaker, winner of the George Polk Award for Medical Writing and author Anatomy of an Epidemic, the most plausible explanation for why patients not on antipsychotics were significantly less likely to be psychotic and experienced more periods of recovery is that the medication non-compliant group was not damaged by long-term use of medication.

Whitaker, in “Interpreting Harrow’s 20-Year Results: Are the Drugs to Blame?” notes, “Those with milder psychotic disorders could be expected to have a better long-term course than those diagnosed with schizophrenia. Yet, the schizophrenia patients off meds fared better over the long-term than those with milder disorders on the medications. If the drugs have long-term iatrogenic effects, wouldn’t that explain this surprising outcome?” Whitaker points out, “Nancy Andreasen [one of psychiatry’s most respected researchers] has reported that antipsychotic usage is associated with a decrease in brain volumes over time, and that this decrease in brain volumes is associated with an increase in negative symptoms and cognitive impairment.”

The Harrow study results offer other support for Whitaker’s explanation of the long-term damage of medication. At the two-year follow up, an equal percentage, about 50% of medication compliant schizophrenia patients and 50% of the medication noncompliant schizophrenia patients, experienced “high anxiety.” But at the 4.5 year mark, 75% of the medication compliant group had “high anxiety,” while only about 20% of the medication noncompliant group experienced “high anxiety,” and this same difference persisted at the 20-year follow up. Harrow notes, “Some have proposed that, over a prolonged period of antipsychotic treatment, supersensitivity of dopamine receptors may occur as a compensation of the brain for many years of reduced dopamine resulting from dopamine blockade,” as many medicated patients develop tolerance for their antipsychotics, which means they need an increasingly higher dosage to reduce their anxiety.

So, was the greater recovery among the medication non-compliant directly caused by what Harrow calls their greater “protective factors” and “internal resources”? Or did those protective factors and internal resources provide some patients diagnosed with schizophrenia the strength and resolve to resist psychiatric treatment and thus not be damaged by the medication?

Harrow’s Recommendations

Harrow’s study does not challenge the idea that for those in the acute phase of a psychotic reaction, the short-term use of some tranquilizing medication can be helpful. Harrow’s results do challenge the idea that all patients diagnosed with schizophrenia or other psychotic disorders need to remain on psychiatric medication throughout their lives.

Harrow’s recommendations, given the study results and the adverse effects of antipsychotics, might sound conservative to the general public but are heretical to the psychiatric establishment. Specifically, Harrow recommends: “If protective factors are present and the SZ [schizophrenia patients] has already shown some periods of recovery, and wants to try a period without antipsychotics, then he/she is a good candidate to try going off antipsychotics, although, as with many other medical procedures, there is no certainty of the results.”

There are some mental health treatment activists in MindFreedom, the Freedom Center, and the National Empowerment Center who utilize medications to reduce their anxiety or to help them sleep so they can function. But Martin Harrow’s study and the lives of David Oaks, Jim Gottstein, Will Hall, Orxy Cohen, Dan Fisher, and many others dispel the myth that people do not fully recover from multiple psychotic states. The fact is that people can experience long-term recovery from schizophrenia and other psychotic states without medication, and for many of these people, rejecting mainstream psychiatric treatment has been their salvation.

Anti-Authoritarians and Schizophrenia: Do Rebels Who Defy Treatment Do Better?

Bruce Levine — Fri, 04 May 2012 12:24:36 +0000

Welcome to a Cool Subculture of Anti-Authoritarians

Harrow’s Study

Explanations for Harrow’s Findings

Harrow’s Recommendations

How Psychiatry Stigmatizes Depression Sufferers

Bruce Levine — Sat, 14 Apr 2012 16:00:19 +0000

Viewing depression as a “brain defect” rather than a “character defect” is supposed to reduce the stigma of depression, according to the American Psychiatric Association, the National Alliance for the Mentally Ill, and the rest of the mental health establishment. But any defect can be stigmatizing. What if depression is the result of neither a brain defect nor a character defect?

At one time in U.S. history, Americans actually elected a known depression sufferer as president. In Lincoln’s Melancholy, Joshua Wolf Shenk reports that Abraham Lincoln’s long-time law partner William Herndon observed about Lincoln that “gloom and sadness were his predominant state.” And Shenk reports that Lincoln experienced two major depressive breakdowns which included suicidal statements that frightened friends enough to form a suicide watch. However, in Lincoln’s era, when depression was seen as neither a character defect nor a brain defect, Lincoln’s depression actually helped him politically more than it hurt him. Lincoln’s depression gained him sympathy and compassion, and drew people toward him, as it “seemed not a matter of shame but an intriguing aspect of his character, and indeed an aspect of his grand nature,” according to Shenk.

Today, when we treat depression as a brain defect, it appears unlikely that anyone with Lincoln’s temperament would receive a U.S. presidential or vice presidential nomination. In 1972, George McGovern’s vice presidential running mate Thomas Eagleton was shoved off the ticket because of his history of depression and medical treatment for it. And today, it would seem near impossible for a candidate who had received electroshock for depression to be elected president.

Lincoln’s words, humor, and face revealed a man who suffered from deep pains. This is also true for Winston Churchill, William Tecumseh Sherman, and other critically thinking leaders who have suffered from depression. Lincoln, Churchill, and Sherman visibly experienced pain but inspired people because of, in part, their capacity to overcome their pain. Today, we reject leaders who visibly suffer from pain.

While Lincoln, Churchill, and Sherman were certainly not without flaws, so too are the “compulsively upbeat”— the “bright-sided,” to use Barbara Ehrenreich’s term. The U.S. political preference for the compulsively upbeat became clear with the ascent of Ronald Reagan. Reagan’s reputation as a “great” and a “transformative” president has been cemented not only by the corporate media and Republicans but by Democrats such as Bill Clinton and Barack Obama. All this despite Reagan’s committing one of the most heinous offenses in U.S. presidential history—selling arms to Iran in violation of an embargo so as to illegally fund the Nicaraguan Contras. Reagan’s offenses have been largely ignored by present America; but not ignored, especially by modern American politicians, is the fact that Reagan’s sunny disposition defeated his more downbeat political rivals and helped create the Reagan legacy.

Americans have been increasingly socialized to be terrified of the overwhelming pain that can fuel depression, and they have been taught to distrust their own and other’s ability to overcome it. This terror, like any terror, inhibits critical thinking. Without critical thinking, it is difficult to accurately assess the legitimacy of authorities. And Americans have become easy prey for mental health authorities’ proclamation that depression is a result of a brain defect. But what does science actually say about the brain defect theory of depression?

Science and the Brain Defect Theory of Depression

The reality is there is as no scientific proof that depression is caused by either a character defect or a brain defect.

Medical conditions such as hypothyroidism and anemia can cause depression, but the American Psychiatric Association’s diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), states that a patient should not be diagnosed with the psychiatric disorder of depression when the symptoms of depression are due to a general medical condition. The mental health establishment is committed to the idea that depression is a separate brain disorder, and it has declared several biological-chemical-electrical theories for it.

For nearly a generation, doctors and the general public have been told that depression is caused by an imbalance of neurotransmitters, most notably serotonin. However, in the 1990s, this theory was disproved, but the National Institute of Mental Health made no serious effort to communicate this to the general public until 2007, and even today today, the National Alliance for the Mentally Ill, an influential U.S. institution that disseminates mental health information, keeps this truth buried. Here’s the details of this history.

For quite some time, unknown to most of the general public and even many doctors, researchers have used a variety of methods to test the serotonin (and other neurotransmitter) imbalance theory of depression. Research methods included comparing serotonin metabolites in depressed and nondepressed people, and depleting serotonin levels through a variety of means and then observing whether this caused depression. The results? Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan, in Blaming the Brain, reported in 1998 that it is just as likely for people with normal serotonin levels to feel depressed as it is for people with abnormal serotonin levels, and that it is just as likely for people with abnormally high serotonin levels to feel depressed as it is for people with abnormally low serotonin levels. Valenstein concluded, “Furthermore, there is no convincing evidence that depressed people have a serotonin or norepinephrine deficiency.”

In 1999 the journal International Clinical Psychopharmacology ( in “Antidepressants and the Brain”) reported on serotonin, norepinephrine, and dopamine depletion studies, and stated that “depletion in unmedicated patients with depression did not worsen the depressive symptoms, neither did [depletion] cause depression in healthy subjects with no history of mental illness.”

In 1996 Pharmacopsychiatry (in “The Revised Monoamine Theory of Depression: A Modulatory Role fo Monamines, Based on New Findings from Monamine Depletion Experiments in Humans”) reported that nonmedicated subjects—whether depressed or nondepressed —do not suffer depression deterioration in response to depletion of serotonin, dopamine, or norepineprhine. Ironically, subjects previously medicated with antidepressants do suffer depression deterioration in response to depletion of these neurotransmitters. In other words, a person’s naturally occurring level of serotonin (and other neurotransmitters) is unrelated to depression but, as psychiatrist Grace Jackson writes in 2005 in Rethinking Psychiatric Drugs, “The available evidence suggests that antidepressants may induce persistent sensitivities in the brain which increase a patient’s vulnerability to recurrent depression beyond that which would occur naturally.”

Thus, by the 1990s, it was known in the scientific community that the serotonin (and other neurotransmitters) imbalance theory of depression had been disproved. Yet, as detailed in Society in 2008 (“The Media and the Chemical Imbalance Theory of Depression”), the general public continued to hear—through antidepressant commercials, the mainstream media, and some mental health authorities—about the neurotransmitter imbalance theory of depression. Even today, the National Alliance for the Mentally Ill states on its Web site, “Scientists believe that if there is a chemical imbalance in these neurotransmitters [norepinephrine, serotonin and dopamine], then clinical states of depression result.”

So, many Americans are surprised to discover that by 2007 the National Institute of Mental Health had moved on to another theory. Newsweek, in its February 26, 2007 cover story, reported that:

For decades, scientists believed the main cause of depression was low levels of the neurotransmitters serotonin and norepinephrine. Newer research, however, focuses [on something else]. . . . A depressed brain is not necessarily underproducing something, says Dr. Thomas Insel, head of the National Institute of Mental Health—it’s doing too much. . . . Instead of focusing on boosting neurotransmitters. . . scientists are developing medications that block the production of excess stress chemicals.

Stress can stimulate the release of cortisol, which can negatively affect both body and mind. And many other medical conditions can also result in symptoms of depression. However, as noted, the DSM states that a patient should not be diagnosed with the psychiatric disorder depression when the symptoms of depression are due to the “direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).” If hypothyroidism is considered a medical condition, it’s unclear why the overproduction of cortisol would not also be considered a medical condition.

Thus, rather than a specific psychiatric brain disorder causing depression, we are simply talking about the uncontroversial reality that certain physical, familial, and societal pains can trigger depression.

While individuals vary in their belief about the benefits and costs of continuing to view depression as a psychiatric disorder caused by a brain defect, as long as depression is considered a psychiatric disorder caused by a brain defect, Americans are unlikely to ever elect another pained depressive such as Abraham Lincoln as president. I can’t help but wonder what American political leadership would be like if Americans had been led to believe that it’s actually the insipidly upbeat who have a brain defect.

How the “Brain Defect” Theory of Depression Stigmatizes Depression Sufferers

Bruce Levine — Sat, 14 Apr 2012 13:08:53 +0000

Science and the Brain Defect Theory of Depression

The reality is there is as no scientific proof that depression is caused by either a character defect or a brain defect.

So, many Americans are surprised to discover that by 2007 the National Institute of Mental Health had moved on to another theory. Newsweek, in its February 26, 2007 cover story, reported that:

For decades, scientists believed the main cause of depression was low levels of the neurotransmitters serotonin and norepinephrine. Newer research, however, focuses [on something else]. . . . A depressed brain is not necessarily underproducing something, says Dr. Thomas Insel, head of the National Institute of Mental Health—it’s doing too much. . . . Instead of focusing on boosting neurotransmitters. . . scientists are developing medications that block the production of excess stress chemicals.

How Technology Worship Keeps Americans Ignorant about Depression Treatment

Bruce Levine — Mon, 26 Mar 2012 18:32:01 +0000

How Technology Worship Keeps Americans Ignorant about Depression Treatment

Technology is worshipped in U.S. culture, but when it comes to transforming depression and emotional suffering, is this predilection for technology justified?

Technology worship means a reverence for machines, manipulations, and manuals designed to control. It also means valuing the objective and the quantifiable over the subjective and the non-quantifiable, and prizing the synthetic versus the natural.

An American penchant for mental health technology, techniques, and technician practitioners is evidenced in several ways. Synthetic antidepressants are now taken by 11% of Americans. Electroconvulsive/shock treatment continues to utilized despite its severe adverse effects. And psychotherapies that can be reduced to standardized manuals of techniques (such as cognitive-behavioral therapy) are taken more seriously than other approaches that are equally effective and often more interesting and fun.

What is problematic about technology worship? What does science tell us about the effectiveness of technological mental health treatments compared with other approaches? And what non-technological variables are crucial for transforming immobilizing depression and emotional suffering?

Respect versus Worship of Technology

A rejection of technology worship does not mean the rejection of technology. Instead, it means a recognition that machines, manipulations, and manuals can be—depending on the arena—helpful, useless, or dangerous.

Perhaps the twentieth century’s most well-respected critic of technology worship was Lewis Mumford (1895-1990). As a young man, Mumford was fascinated by electrical engineering, and his first published articles were in Modern Electrics in 1911. Later, he came to be well-known as a critic and historian of architecture, urban planning, literature—and technology. Mumford’s two-volumed The Myth of the Machine (Technics and Human Development and The Pentagon of Power) has compelled many of us to rethink Western civilization.

Mumford was not anti-technology, only opposed to the irrational, dehumanizing use of such. He understood that technology worship results in the reduction of all of life to objects of manipulation, and such a reductionism results in eliminating a great deal of what makes life worth living.

With respect to depression, the worship of technology creates a cultural edge for synthetic drugs such as antidepressants, for electroconvulsive/shock machines, and for technique-type psychotherapies that can be reduced to training manuals. In this arena of emotional suffering, does the preference for techniques, machines, and the synthetic make sense?

Synthetic Drugs versus Natural Substances

St John’s Wort is used as a natural herbal treatment for depression, and in April 2002, the Journal of the American Medical Association (JAMA) published “Effect of Hypericum perforatum (St John’s Wort) in Major Depressive Disorder,” a study funded by the National Institute of Mental Health (NIMH). Of note, JAMA’s accompanying financial disclosure about the lead author of the study stated that “Dr. Davidson holds stock in Pfizer [manufacturer of Zoloft].”

Omitted from the article title, the antidepressant Zoloft was also examined in this study. And Zoloft’s performance also went unmentioned in the study press release, which reported only that St John’s Wort was ineffective compared with the placebo. The study result that the general public never heard about was that Zoloft did almost as poorly as St John’s Wort, and both were less effective than the placebo. Specifically, on the study’s primary depression measure, 32% of placebo-treated patients experienced remission, better than the 24% remission for the St John’s Wort-treated patients or the 25% remission for the Zoloft-treated patients. The corporate media, which routinely relies on press releases rather than actually reading scientific articles, reported only on St John’s Wort’s ineffectiveness but did not mention that Zoloft did almost as poorly as did St John’s Wort.

Thanks to a lazy media, Zoloft manufacturer Pfizer avoided a publicity hit when this study was published in 2002. However, GlaxoSmithKline, the manufacturer of the antidepressant Paxil, wasn’t so lucky in 2004.

Glaxo thought itself brilliant when, in a campaign to sell Paxil for both depression and social anxiety, the drug company recruited celebrity spokesmen athletes, former Pittsburg Steeler quarterback Terry Bradshaw and running back Ricky Williams, then playing with the Miami Dolphins. Bradshaw worked out great for Glaxo, but Williams was another matter. In July 2004, Williams announced that he found marijuana to be “ten times more helpful than Paxil.” That made sports pages headlines.

The geniuses at Glaxo apparently missed the fact that the free-spirited Williams, who had dreadlocks before they were fashionable, had Bob Marley tattoos all over his body, named his first child Marley, was friends with Marley’s children, and had stated he didn’t see anything wrong with marijuana because it is “just a plant.” After Williams’s announcement that he found marijuana to be ten times more helpful for his anxiety than Paxil, Glaxo purged him from the Paxil website.

NIMH and drug companies are not exactly in the practice of funding studies to check out Ricky Williams’s claim that marijuana is superior to antidepressants, but there are a boatload of studies comparing antidepressants with another natural substance, a sugar pill. Just as there are millions of people around the world who swear by marijuana, there are millions of Americans who swear by their antidepressant drugs. For depressed people as a group, do antidepressants work any better than a placebo sugar pill?

Author of The Emperor’s New Drugs, Irving Kirsch (professor emeritus at the University of Connecticut and professor of psychology at the University of Hull in the United Kingdom and Harvard) in 2002 examined 47 depression treatment studies that had been sponsored by drug companies on the antidepressants Prozac, Paxil, Zoloft, Effexor, Celexa, and Serzone. Many of these studies had not been published, but all had been submitted to the Food and Drug Administration (FDA), so Kirsch used the Freedom of Information Act to gain access to all the data. Kirsch discovered that in the majority of the trials, antidepressants failed to outperform sugar pill placebos.

“All antidepressants,” Kirsch reported, “including the well-known SSRIs (selective serotonin reuptake inhibitors), had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and other researchers describe it as “clinically negligible.”

Electroshock Technology

Some Americans believe that electroconvulsive therapy (ECT), commonly known as electroshock, has gone the way of bloodletting, but it is still utilized by U.S. psychiatry, and in 2006 received a celebrity boost from Kitty Dukakis’s book about her ECT. ECT has a high potential for serious adverse affects, but is it still worth the risk?

In 2004, Joan Prudic, professor of psychiatry at Columbia University, and her team at New York State Psychiatric Institute conducted a major study of ECT involving 347 patients at seven hospitals. Reported in the journal Biological Psychiatry were both the immediate outcomes and the outcomes over a 24-week follow up period. With respect to immediate outcomes, Prudic reported: “In contrast to the 70 to 90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3 to 46.7%.” Even worse for ECT advocates, Prudic noted that, “10 days after ECT, patients had lost 40% of the improvement.”

Psychiatry is well aware of the bad press of ECT, including Sylvia Plath’s ordeal, so today ECT is more pleasant to observe, but the adverse effects have not changed. While anesthetic and muscle relaxant drugs keep patients from writhing in agony as seizures are induced, brain damage still occurs. In January 2007, the journal Neuropsychopharmacology published an article about a large-scale study on the cognitive effects (immediately and six months later) of currently used ECT techniques. The researchers found that modern ECT techniques produce “pronounced slowing of reaction time” and “persisting retrograde amnesia” (the inability to recall events before the onset of amnesia) that continue six months after treatment.

Does Psychotherapy Technique Matter?

While psychotherapy, like any treatment, often has a positive outcome, scientific effectiveness requires that a treatment be superior to a placebo. However, creating a “psychotherapy placebo”—an event that appears to the patient, therapist, and researcher to be psychotherapy but is not psychotherapy—is scientifically problematic. More easily accomplished, psychotherapy can be compared with other treatments, and different psychotherapies can be compared with one another.

Of all psychotherapies, the one most researched, well known, and highly touted by the mental health establishment is called cognitive-behavioral therapy (CBT). CBT is integration of cognitive and behavioral therapy and consists of an array of techniques for transforming self-defeating thoughts, beliefs, and behaviors. For example, patients learn to identify their “dysfunctional thoughts” (e.g., exaggerations and black-and-white thinking). CBT is commonsense stuff, and many psychotherapists utilize it along with several other approaches. CBT prides itself on techniques that can be defined in manuals such as the Beck manual, and there are CBT workbooks that are assigned to patients for homework.

Does CBT work? Are CBT’s specific techniques the reasons why it works? And do CBT techniques work better than other non-technique psychotherapies?

A form of CBT was the only non-drug treatment studied in the $35 million NIMH funded “Sequential Treatment Alternatives to Relieve Depression” (STAR*D) . STAR*D is the largest study ever done of sequential depression treatments in which nine different psychiatric drugs were also examined. In Step One of STAR*D, all depressed patients were given the antidepressant Celexa, and in Step Two, those patients who failed to respond to Celexa received other treatments, and if their second treatment failed, there was a third and, if necessary, a fourth treatment step.

First, the good news about CBT. In STAR*D, among those patients who initially failed Celexa, three groups in Step Two switched from Celexa to one of three other antidepressants, and their remission rates ranged from 25% to 26.6%. But one group in Step Two switched from Celexa to a form of CBT, and its remission rate was better at 41.9%—this unmentioned in the study press release. STAR*D researchers did not assess whether differences in treatment effectiveness were statistically significant (STAR*D researchers had several financial relationships with drug companies).

While CBT works as well or better than antidepressants, does it work any better than non-technique psychotherapies? In 2008, psychologists Pim Cuijpers and Annemicke van Straten at the University of Amsterdam reported on a meta-analysis of 53 studies, each of which compared two or more different types of psychotherapy for depression. Included were varieties of CBT, psychodynamic therapy, behavioral activation therapy, social skills training, problem-solving therapy, interpersonal therapy, and nondirective supportive therapy. Study results were reported in the Journal of Consulting and Clinical Psychology.

The major findings? The authors concluded, “We found no indication that cognitive-behavioral therapy is indeed more efficacious than other psychological treatments.” Actually, interpersonal therapy was slightly most effective, however, the authors make clear, “No large differences in efficacy between major psychotherapies.” The equivalent effectiveness of all psychotherapeutic approaches has long been called by psychologists “the Dodo Bird Effect,” the term coming from the Dodo bird in Alice in Wonderland who famously said, “Everybody has won, and all must have prizes.”

If Not Technology and Technique, What is Most Important?

For his book The Great Psychotherapy Debate, psychologist Bruce Wampold at the University of Wisconsin reviewed the psychotherapy outcome literature, examining hundreds of studies and meta-analyses. Wampold found that outcome effectiveness does not depend on the specific techniques of psychotherapy, but instead depends on so-called “non-specific” factors such as the nature of the alliance between therapist and their client as well as the client’s confidence in the therapy and in their therapist.

Psychologist Michael Lambert at Brigham Young University, like Wampold, has spent a good part of his career studying psychotherapy outcome. Lambert, in the Handbook of

Psychotherapy Integration, estimates that the “factors responsible for client improvement in psychotherapy” can be broken down in this manner: (1) 40% of client improvement can be explained by “events external to therapy”; for example, changes in social support or fortunate events that have nothing to do with treatments; (2) 30% can be explained by “therapist characteristics” such as empathy, acceptance, warmth, encouragement; (3) 15% can be explained by “expectancy” or the placebo effect, which can be enhanced with greater therapist credibility; (4) 15% can be explained by “techniques” which can increase expectancy, and so therapist and client belief in a technique may be more important than the technique itself.

The reality is that what gets most of us out of our immobilizing depression and other unpleasant emotional places is decidedly non-technological. What helps most is support and love, faith and confidence, exercise and humor, courage and determination, and serendipity and luck—all very subjective, non-quantifiable, and ill-suited for a manual of techniques.

In a society in which many of their patients worship technology, psychiatrists and psychologists have gained prestige by embracing technology, techniques, the objective, and the quantifiable. However, there has been a price for ignoring subjective and non-quantifiable dimensions. The price paid by mental health professionals is that many of them have become, by their own definition, “psychotic”—losing contact with reality, at least those human realities that are non-technical and highly subjective but are of vital importance in transforming our emotional difficulties. And their patients pay the price of losing out on potential antidotes for their suffering.

How Technology Worship Keeps Americans Ignorant about Depression Treatment

Bruce Levine — Mon, 26 Mar 2012 18:29:54 +0000

Technology is worshipped in U.S. culture, but when it comes to transforming depression and emotional suffering, is this predilection for technology justified?

Respect versus Worship of Technology

Synthetic Drugs versus Natural Substances

Electroshock Technology

Does Psychotherapy Technique Matter?

Does CBT work? Are CBT’s specific techniques the reasons why it works? And do CBT techniques work better than other non-technique psychotherapies?

If Not Technology and Technique, What is Most Important?

Psychologist Michael Lambert at Brigham Young University, like Wampold, has spent a good part of his career studying psychotherapy outcome. Lambert, in the Handbook of

Nelson Algren, Phil Ochs, Marginalization, the Mental Health Industry Racket, and the Occupy Movement

Bruce Levine — Sat, 24 Mar 2012 17:47:39 +0000

How America’s Obsession With Money Deadens Us

Bruce Levine — Mon, 19 Mar 2012 13:09:11 +0000

A preoccupation with money is nothing new in our culture, but have Americans become even more “money-centric,” and does this deaden us, making us incapable of resisting injustices?

A money-centric society is one in which money is at the center of virtually all thoughts, decisions, and activities. While capitalism certainly gives rise to money-centrism, any society in which individuals have little know-how and lack supportive community—and are thus totally dependent on money for their survival—will create a money-obsessed society. Such a society coerces even the non-greedy to focus on money at the expense of damn near everything else in order to survive.

Have We Become More Money-Centric?

Sociologist Robert Putnam reported in Bowling Alone (2000) that when American adults were asked in 1975 to identify the elements of the “good life,” 38 percent chose “a lot of money,” compared to 63 percent who chose “a lot of money” in 1996. Since then, from my experience, this focus on money has only increased. Both greed and fear make one more money-centric, and in recent years, it has become more socially acceptable to be greedy and increasingly commonplace to be financially insecure.

When I began private practice nearly three decades ago, my clients who worked for major Cincinnati corporations such as Procter and Gamble felt secure in their employment, but that security began disappearing two decades ago. And nowadays, nearly everybody—even teachers and postal workers—lack job security. Today, I see money worries, more than anything else, triggering panic attacks, depression, and alcohol abuse. Money discussions have even come to dominate family counseling sessions, where high school students increasingly talk about their fear of becoming financial losers, and parents fear their children will ruin their lives by accumulating student-loan debt while pursuing fields where there are few decent-paying jobs. Between my clients’ and my own money preoccupations, the dead shit of money routinely deadens me, especially when I lose my sense of humor about it.

It is difficult to maintain a sense of humor about all of this, so for most of us, having a stash of money feels increasingly important—and money accumulation has become increasingly the center of our lives.

In 1900, only 1 percent of Americans were in the stock market; by 1950, this had increased to only 4 percent; but by 2000, more than 50 percent of Americans were in the stock market. While some of these people merely have pensions that own shares on their behalf, many Americans have in fact chosen to invest in the stock market. How many of those people are investing their money in companies whose products they believe in? Almost none.

For those Americans not in the stock market and who are living from paycheck to paycheck or on public assistance, they also are assured by the state that it is quite okay to gamble where the odds are more stacked against them than in the stock market. Many state governments not only offer lotteries but advertise them heavily on television, radio, billboards, and with mass mailing coupons—and this today is socially acceptable.

Younger generations are increasingly told that they won’t have job security in their working years or social security later on. So, while many young people would rather be gaining life experiences, they feel pressure early on to accumulate a large pile of cash.

When Did Greed Become “Respectable”?

Money has always been a big deal in America, but through much of history, the money-centrism of the greedy has not had the social acceptability that it has recently gained. For the non-elite, greed was seen as the practice of villains such as Charles Dickens’s money-obsessed Scrooge, a psychologically and spiritually sick man in need of conversion. As late as 1936, a sitting president of the United States running for reelection knew that that it was quite popular to blast the greedy, selfish elite:

We know now that Government by organized money is just as dangerous as Government by organized mob. Never before in all our history have these forces been so united against one candidate as they stand today. They are unanimous in their hate for me—and I welcome their hatred. I should like to have it said of my first Administration that in it the forces of selfishness and of lust for power met their match. I should like to have it said of my second Administration that in it these forces met their master.

That was Franklin D. Roosevelt on October 31, 1936. Contrast FDR’s speech with President Barack Obama’s response in an interview excerpted by Bloomberg Businessweek and the Wall Street Journal in February 2010. When asked about Goldman Sachs CEO Lloyd Blankfein’s $9 million bonus and JPMorgan Chase CEO Jamie Dimon’s $17 million bonus, Obama responded:

First of all, I know both those guys. They’re very savvy businessmen. And I, like most of the American people, don’t begrudge people success or wealth. That’s part of the free market system. I do think that the compensation packages that we’ve seen over the last decade at least have not matched up always to performance . . . Listen, $17 million is an extraordinary amount of money. Of course, there are some baseball players who are making more than that who don’t get to the World Series either.

How did greed come to be so respectable? What Paul of Tarsus, in the first century after the death of Jesus, was to the dissemination and legitimization of Christianity, Ayn Rand, in the last half of the twentieth century, was to the dissemination and legitimization of money-centrism and greed. Rand ends her novel Atlas Shrugged with this image of its hero John Galt: “He raised his hand and over the desolate earth he traced in space the sign of the dollar.” Rand exhorted her followers to believe in what she called “radical capitalism,” and she lived—and even died—in radical money-centrism. At Rand’s funeral, in accordance with her specified requests, a six-foot floral arrangement in the shape of a dollar sign was placed near her casket.

Money-centrism, of course, has been caused by many other forces and perpetuated by many other people.

How Money-Centrism Deadens Us and Makes Us Incapable of Resistance

When one cares only about money, one neglects everything else necessary to build and maintain self-respect. Neglecting other aspects of our humanity results in destroying out integrity, and integrity is necessary for strength. And when one is willing to do whatever it takes to make money, one assumes others are acting similarly, which destroys trust and makes it impossible to create the solidarity necessary to successfully challenge illegitimate authorities.

Money-centrism is especially malevolent when it attacks societal forces that are potentially liberating. Much has been written about how spiritual revolts (such as those begun by Jesus and other rebels) eventually morph into organized religions, which are then driven by money and used by the elite as an “opiate of the masses.” The elite in religious hierarchies have routinely commercialized spirituality, and by so doing have reduced the power of spirituality as a potent force to take down the ruling elite.

But spirituality is not the only potentially rebellious force that has been destroyed by money-centrism, and commercializing any powerful idea, belief, or emotion deadens its power.

Even the rebellion of folk/protest music and rock-and-roll has been increasingly commercialized, resulting in a dissipation of actual rebellious energy. Bob Dylan’s “Times They Are A-Changin’” has been used by accounting firm Coopers & Lybrand and by the Bank of Montreal; and the Rolling Stones’ “Start Me Up” has been used by Microsoft. When songs of “perceived” rebellious artists are utilized as background music in commercials to manipulate listeners into associating their rebellious urges with consumer products, it can pacify even those of us who do not fall for the manipulation; it makes us more cynical, as it appears that it’s completely about the money for everyone.

To defeat the elite, the rest of us need energy. Rebellion is a powerful idea, but when rebellion is used merely to attract an audience for financial profit, the idea itself becomes less powerful. So, whether it is spirituality, folk/protest music, or rock-and-roll, when rebellious energy is commercialized, that energy dissipates.

Spirituality, music, theater, cinema, and other arts can be revolutionary forces, but the gross commercialization of these has deadened their capacity to energize rebellion. So now damn near everything—not just organized religion—has become an “opiate of the masses.”

In a radically capitalist society where “one market under God” (as Thomas Frank called it) is worshipped, we are all forced to be somewhat money-centric in order to survive. No shame here. But since money is not alive, to the extent that we become radically money-centric and money is at the center of all of our thoughts, decisions, and activities, we are dead and incapable of any resistance to injustices.