Friday, January 13, 2006

Sometimes Freud and Drugs aren't the Answer

In this previous post on fear, there is a discussion of the use of psychotropic drugs for treating phobias. PsychPundit talks about treating a patient with OCD (Obsessive Compulsive Disorder) successfully without drugs. Take a look.


Blogger Helen said...


It depends if the client has insurance. Behavioral therapy would be covered to some degree. Medications also come with a co-pay. Of course, part of the problems is weekly treatment once a week or more. It is time consuming. Taking medication takes a few seconds.

9:25 AM, January 13, 2006  
Blogger jau said...

Interesting that you brought this up. I have a friend who has been pretty deeply depressed since last August and she claims her reluctance to seek help is because her insurance will cover medication (which she refuses to take) but not psychotherapy except for a few visits. Drugs would be a quick amelioration (if she could be persuaded to take them) but my sense is that they are a quick fix, not a long-term solution. Am I being old fashioned?

10:01 AM, January 13, 2006  
Blogger Helen said...


In my opinion, depression is best treated with a combination of cognitive-behavioral therapy and anti-depressants. If your friend's coverage allows a few visits--she could find a provider on the list who does short term therapy and then refer her on to a psychiatrist for meds if needed. It really depends on the type, duration and reason for the depression as to what treatment or combination of treatments is needed. A competent therapist should be able to assist her with this. Even a few sessions may point her in the right direction.

10:48 AM, January 13, 2006  
Blogger DADvocate said...

In 1970, I worked at a summer camp for disturbed adolescents run by two clinical psychology professors from a large southern university. The same kids were there for the entire 7 weeks and the emphasis was on a behavioral approach to treatment.

One 14 year old boy in my cabin had been, in his records, described as having serious OCD. He would have to walk sideways at times because he had to be facing a certain directions. He needed to perform rituals in order to take a shower, eat or go to the bathroom. It one time he had been hospitalized because he had become impacted due to not being able perform the rituals correctly in order to go to the bathroom.

When he came to camp, he acted perfectly normally for the entire 7 weeks. No signs of OCD what-so-ever. We even had to have him sit down with the other kids in our cabin and explain why he was in camp and they could see no reason for him to be there. We believed just getting the kid out of his home environment may have done the trick.

We also wondered what, if any, role his father's occupation played in the boy's problem. His father was a child psychiatrist.

10:51 AM, January 13, 2006  
Blogger Helen said...


Great story. It's sad to say but some of the most messed up kids and adults I have met have psychologists and psychiatrists for parents.

10:58 AM, January 13, 2006  
Blogger Psych Pundit said...

This comment has been removed by a blog administrator.

11:26 AM, January 13, 2006  
Anonymous Anonymous said...

My father, now retired, has a doctorate in psychology, and all of us, his four children have some problems, nothing extreme (as in physical violence/abuse or criminality or drugs or alcohol) but still we are not well adapted to society.

I am so shy that as a kid I was hiding in the tool shed not to go to school, then as a teenager I quit school twice, then quit college after a couple of months because everytime someone spoke to me I blushed and could not think straight so embarrassed I was, I would sometimes sit in the bathroom for the whole lunch hour to avoid people...

It eventually got better and went back to complete college... in my thirties, but now I have chronic fatigue syndrome which has lowered a bit my self confidence level which I had managed to build along the years...

My older sister can not make a sentence without including something about God or the bible, her car is covered in religion slogans bumper stickers, the problem is not religion, its that she is obsessed with religion...

One of my brother, even though he never did physically hurt anyone has threatened my mother, even death threats, we havent seen him in 15 years he refuses to acknoledge we even exist...

My other brother has been on welfare all his life and can not talk about anything, from the protein value of eggs to poverty in Africa without becoming very angry and shouting and waving his finger in your face and talking non-stop, never letting you say anything, not even " Ok I give up, lets talk about something else"...
( yes he is a lefty - a far to the left lefty, anyone surprised? )

And my father has a doctorate in psychology...and my mother has a doctorate in ethnology...and we are messed up...

Raising children is the most difficult job but I believe some people are simply born "bad", nothing will ever work on them, those are the people that end up on death row or in asylums or that die from drug abuse; no one can help them, something is broken inside of them, and you can not always blame their parents.

Its sometimes nature and sometimes nurture...

11:49 AM, January 13, 2006  
Anonymous Anonymous said...

Of course Freud and drugs aren't the answer. You omitted rock n roll!

Sorry. Couldn't resist. I have previously commented here on my belief (bias) that psychotherapy should be the first resort, then drugs if and only if behavior modification is ineffective. This article certainly hasn't changed my mind. A few, possibly obvious, comments.

There's a fundamental issue illustrated here for which I have no brilliant , never mind practical, suggestions. Psychiatrists are trained in medicine, receive an MD degree and then go on to specialized training in psychiatric medicine. They are, and see themselves as, medical doctors with a specialty. They tend to follow the medical model: Patient visits doctor, doctor determines diagnosis, doctor prescribes drugs, patient enters twilight zone, there is some sparse follow-up regimen.

Psychologists receive quite different training; and in order to become competent practitioners, therapists will engage in generally ongoing programs of application study, practice, training and mentoring. Drugs are not an option directly, but good therapists will recognize the need to refer patients for possible drug treatment.

The issue (finally getting to the crux of the argument), is twofold.

Part One is that the two professions are compartmentalized, and patients have free choice. If the first stop is a psychiatrist, a patient may NEVER learn that a non-drug treatment is available, and potentially more effective.

Part Two is the matter of costs and vested interests. Psychology has always had an image problem, and while insurance companies have relented somewhat, there is still the prevailing conventional attitude that drugs and medical doctors are "serious" and psychology somehow is not. The bias leads to common drug insurance programs and inadequate therapy clauses in the average policy. This in and of itself will push some needy patients in the wrong direction. Then there are related matters of governing law, state licensing practices, profession monitoring... OK. I'll stop now.

11:53 AM, January 13, 2006  
Blogger Psych Pundit said...

Thanks for the link, Helen - you're a gem! I wanted to address a couple of the comments above:

First, on the cost issue . . . it's important to consider both short-term and long-term costs. Behavior therapy for OCD lasts about 3-4 months and will typically cost about $2000 (with insurance, the patient might pay $500-1000). OCD meds tend to run about $70 a month; with psychiatrist intake and periodic med evals, that would mean a total short-term cost of about $800.

So, the meds sound cheaper, at least in the short-term. But consider that the person who chooses the medication route will be taking the meds for a lifetime (the relapse rate when meds are discontinued is over 90%). After 10 years, the medication cost is well over $10,000, while the person who chose behavior therapy still has a total cost of only $2,000 (perhaps as little as $500 out of pocket with insurance).

As for the convenience of medication vs. therapy . . . it's certainly true that swallowing a pill is a lot easier than doing the work of therapy, but in so many cases the pill doesn't represent a complete cure. The largest outcome study of meds for depression was just published last week (nearly 3,000 patients on Celexa), and only 28% of these patients were cured, even in the short-term! And do you know the average length of time a patient stays on depression meds? It's less than 45 days. Why? Side effects.

Therapy may be a bit more work, but as in so many domains of life, it's those who put in the hard work who reap the greatest rewards.


11:55 AM, January 13, 2006  
Anonymous Anonymous said...

I just wondered about bipolar disorder... my 18yr. old daughter doesn't take her meds she seems to go along okay. Her opinion is that she is different when she takes the meds (lamictal) not necessarily better, just different. Has anyone ever heard of behavior therapy for dealing with effects of bipolar?

2:02 PM, January 13, 2006  
Blogger Helen said...


While cognitive-behavioral therapy can help those with bipolar disorder--it is also important to take medications as prescribed by the psychiatrist. Adolescents with bipolar disorder tend to cycle more frequently than adults and need a great deal of monitoring. If her condition is mild, it may be that cognitive-behavioral therapy may be enough. Just make sure that the professional has a solid understanding of early-onset bipolar disorder and knows to refer when medication is needed. A therapist can teach how to recognize the escalating mood-states and teach how to de-escalate. Usually the parents are involved but in your case, with your daughter being 18, this may be an issue. I suggest taking a look at The Bipolar Child by Demitri Papolos and Janice Papolos. The book is at Amazon and has some good recommendations and explanations of bipolar illness in children and older teens.

3:06 PM, January 13, 2006  
Blogger Quadraginta said...

There are two aspects of the linked post and this therapist as a professional that bug me. First, there is the strong strain of narcissism. Certainly a moderate dose of narcissism is necessary to be of any help at all to patients, but this guy seems to display a bit much. Blogging about recent individual professional cases seems a bit iffy in itself, a tad self-centered and unprofessional, even if, as here, presumably only the patient himself and his closest friends and family can recognize enough detail to know who the patient is. But also the tone of how he presents the case smells a bit of egoism: "Look! These other fools couldn't cope, were misguided, unscientific idiots, but I solved the problem in 4 months 'and it isn't even my area of specialty.'" I exaggerate of course, but the tone isn't far from this, IMHO.

From what I know, mood disorders, phobias and other neuroses are complex and baffling things that scientifically, to use this guy's favorite word, we know at best partially, and very probably with many errors and misconceptions. Certainly the history of what has been "known" about mental illness is not encouraging about whether what we "know" now is error-free. I doubt curing them is almost as simple as curing an infection with an antibiotic, as this guy seems to imply. I think there's almost certainly significant elements of luck and mystery self-treatment by the patient in any success. Even a heart surgeon would acknowledge this in his field, and be a bit more humble about his successes, knowing them to be a bit less "my" successes than "ours" (meaning his and his patient's) and even "ours and Lady Luck's."

Second, his notion of the statistics of epidemiology seems a bit primitive for someone with a PhD. I don't think he should throw around statements like "scientifically proven" so readily. He wouldn't in a journal, would be? I suspect it is unbelievably difficult and delicate to design a study that truly controls all variables when it comes to something as complex as outcomes of treatment for human neuroses. No one with any appreciation for the subtle flaws that can infect such an effort should be nearly so off-handedly confident about what has been proven, and what not. I don't say that as a mental-health professional or patient, because I've been neither, but as a straight physical scientist. Even when you discuss the statistics of molecules in a glass of water, you have to be very, very careful about designing the statistical measures and interpreting their measured value. It's very easy to be wrong about what the numbers mean. It doesn't seem to me any harder to go wrong when you study human beings instead of molecules.

3:15 PM, January 13, 2006  
Blogger Psych Pundit said...

In reply to Quadraginta's comments:

1) The patient in question gave me permission to discuss his case publicly, provided I gave no identifying information - and none is provided in my post.

2) You've apparently misconstrued my intent in discussing the case. It's not about narcissistic self-aggrandizement . . . far from it. In fact, I'm not a particularly gifted therapist. My point was simply this: "behavior therapy for OCD is such an effective intervention that it can be used successfully even by those for whom the intervention falls outside their purview of expertise". Make sense?

3) Finally, your caveat about the inadvisability of breezy language in scientific discourse is a point well taken . . . except for the fact that I'm not writing at the moment for a scientific audience! I assure you, when addressing my colleagues in peer-refereed journals, there's a great deal more nuance - but such nuance, in my experience, does not facilitate communication with a lay audience.

Regardless, the major point of my post stands up under rigorous scientific scrutiny: the best available evidence at this time suggests that behavior therapy is the most efficacious form of interention for OCD.

3:25 PM, January 13, 2006  
Anonymous Anonymous said...

"Even a heart surgeon would acknowledge this in his field, and be a bit more humble about his successes"

You haven't met many chest-cutters, have you? Anyone who works in a hospital will tell you that "humble" and "surgeon" NEVER belong in the same sentence.

Regarding insurance company's attitudes about psychotherapy - they've become very wary of it because of decades of therapists who wouldn't dream of having a termination plan for treatment.

4:20 PM, January 13, 2006  
Blogger Quadraginta said...

psych pundit, thank you very much for the response. You are generous of your time in providing it, and I appreciate that.

(1) I think you should have said this, then. The impression conveyed to -- for example -- prospective patients would be quite different. But, fair enough. I withdraw the criticism.

(2) I was aware of your intent, and I completely agreed with the conclusion, so far as I understand the field, which is from an at best only modestly-informed viewpoint. The success of behaviour therapy for OCD and phobias seems very impressive, and represents a real breakthrough as far as I understand.

My criticism was not directed at the content of your post, but at the tone, which struck me as a bit egoistic. As I said, there's nothing wrong with a substantial bit of narcissism: you've got to believe you know what you're doing to do any good at all. But too much is equally bad; it can delay re-assessment of error and I hazard it can compromise some patient outcomes by fostering an inappropriate degree of dependency. But here I wander so far outside my area of competence that I freely admit the possibility -- even probability -- of being wrong. Let us just attribute my differing opinion on how a therapist might discuss his successes and failures to a matter of personal taste, and leave it at that.

(3) I appreciate the problem. I myself ponder this issue when I write for a popular audience instead of for a scientific journal. But perhaps I reach the opposite conclusion. I regard it is as more important to be careful about what I imply about what is known, and not known, when I am talking to people who are not in a position to independently verify what I say, for lack of experience, access to the data, education, whatever. When I teach graduate students or talk to colleagues, I feel more free to speak carelessly, because they are sufficiently sophisticated to cross-check what I say with their own understanding. When I teach freshman or speak publically, I am very, very careful, because they can't, and my responsibility for carelessly implying things that I don't mean to imply is much higher.

I realize of course this is a personal blog we are talking about, and you are making semi-personal reflections, not issuing professional advice. But, the common practice notwithstanding, a blog published on the Internet is not the same as a private diary. It's more like an op-ed column in a newspaper. If a professional would be careful writing a column in a newspaper, or an article in Newsweek, it's not unreasonable to suggest some similar caution in his blog. Perhaps a bit less, granted, given the more ephemeral and clearly personal nature of a blog.

I recognize, too, that these areas of professional ethics are so new as to be fully protean. What is one's responsibility to the public reading your blog when you identify yourself as a professional (doctor, scientist, lawyer), and you reflect on aspects of the field on which you can be expected to have a professional opinion? Is a token disclaimer sufficient? I'm not at all sure. It's an interesting question. I agree reasonable men may differ.

dweeb, please allow me to modify my comment post posto to interject the adjective superior before the noun phrase heart surgeon. Perhaps that removes your complaint? I've never met a truly first-class professional in any field who isn't humble about his successes, and well aware of the role of Dame Fortune. It's the second tier that tends towards arrogance.

5:31 PM, January 13, 2006  
Anonymous Anonymous said...

I think if SSRIs as being like a cast for a broken arm. They don't cause the healing, but they can create conditions that allow the healing to occur.

6:40 PM, January 13, 2006  
Blogger Assistant Village Idiot said...

I didn't know that Anafranil was still used that much. I thought the SSRI's were the medication gold standard. Of course, my experience with outpatient care is pretty much limited to myself, at this point.

I can well believe that the exposure and CBT type approaches would be superior long-term. Part of the question is how debilitating the symptoms are, and how much relief you want. In my case, 2.5 years of psychodynamic therapy was enjoyable, but did nothing, while Prozac knocked my symptoms back in three weeks.

But the symptoms are only reduced, not eliminated. I count things, adjust things, make lists, and think spoonerisms. Cutting those back by 70% is about all I need. If my current symptoms were more distressing, I might be motivated to go back to a therapy that I had to work at. But as it is now, after investing a lot of effort and coming up empty, my view is No pain = NO PAIN.

12:15 AM, January 14, 2006  
Blogger Assistant Village Idiot said...

Medical Savings Accounts.

Nothing fixes everything, but that would be a big step forward.

10:05 AM, January 14, 2006  
Anonymous Anonymous said...

Quadraginta, superior, first class, put whatever superlative you want on it, that dog won't hunt. Numerous relatives and friends in who are experienced professionals in healthcare will talk about a cardiac surgeon at their hospital who is too arrogant to know humility if it bit him/her on the nose, and they all follow it with "but if I ever need open hear surgery, he/she is the one I want cutting." I don't see this as a negative. Some tasks require sych a degree of confidence that they require a personality like that - reaching into a living person's chest and repairing their heart is one of them.

A relative of mine flies attack helicopters - most of the family thinks he's a swaggering jerk. Maybe that's what it takes to strap into a big box of kerosene and explosives that looks like it shouldn't be able to fly and go out looking for similarly armed people who want to kill you. It takes all kinds to make a world and there's a role for almost all of them.

This is one reason I object to a mental health industry that, ultimately wants to homogenize humanity so everyone falls within a specified range for happiness, extroversion, self-esteem, satisfaction, etc. It's been speculated that most of history's brilliant artists, composers, authors, were clinically depressed, bipolar, or something else that today would make them a candidate for pharmaceutical intervention. Maybe the dissatisfaction with how one perceives the world that correlates so well with decreased serotonin is what drives people to invent, compose, etc. Any personality variation that occurs in more than 1-2% of the population over multiple generations wouldn't exist if it hadn't conferred some evolutionary advantage to humans.

9:46 PM, January 14, 2006  
Anonymous Anonymous said...

Of course, it's often inappropriate to use "facts" and "Wikipedia" in the same sentence. Anyone can add anything, and they often do.

11:53 AM, January 16, 2006  
Blogger Unknown said...

Forinpatient and outpatient care, quality improvement efforts may be most productively focused on providers and processes of care rather than on specific patient subgroups. Drug rehabilitation center will drive those results to complete health and wellness of being.

4:02 AM, November 07, 2008  
Anonymous Anonymous said...


9:53 PM, June 07, 2009  

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