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Understanding Depression

February 10th, 2010

source: The London Times, Depressed? Don't blame your genes.

A recent article entitled, “Depressed? Don’t blame your genes” printed in the U.K.’s London Times caught my eye last month. It was published to coincide with January 18th, the day that many psychologists claim is the most depressing of the year. The article, written by Oliver James (author of “Britain on the Couch”) was an expose on the “crippling depression” that appears to be the modern scourge of our modern society.

James noted that many people are in the habit of blaming their genes and he cited the observation that many people continue to invoke the idea of a gene for depression. It turns out this assertion is complete hogwash and that one of the most interesting developments in recent years has been the growing conviction amongst scientists that genes play little or no role in depression. Indeed, James correctly notes that the Human Genome Project, which mapped all our species’ DNA, has not reliably identified a single example of a gene for mental illness whatsoever.

James and I are also in agreement that there is, in contrast, “buckers of evidence” supporting an environmental role in the development of depression. For example, the quality of care you receive in your early years, and the kind of society in which you live are big contributing factors for a person’s risk of developing depression. Hence, if the care a person receives during their first year of life was unresponsive, they are already at greater risk for depression, especially in that as a toddler they will then come to expect the worst.

James and I are also in agreement about what constitutes the ‘best cure’ or best treatment for depression. If you’re going to get better, you are going to have to talk to someone who can effectively find out what is really bothering you.  A major aspect of the work will need to involve some kind of examination of how parental care in the early years of your life affected you. I am in full agreement with James that psychodynamic therapy is usually a better bet for you than the much touted cognitive behavioural therapy (CBT).  James points out that recent studies are beginning to substantiate that the best talking cure, with some modification, is the one invented by Freud. Finally, unless a person is really desperate, they should exercise caution if intending to rely on anti-depressants for a ‘cure’. Apart from having to put up with some challenging and unpleasant side effects, in most cases, even if they do have an effect, it is no better than placebo.

Teenage Breakdown

August 21st, 2015

troubled-teen2

Newspaper articles and other media sources referencing teenagers and their ongoing struggles are common enough (e.g. Five Things Adults Get Wrong about Teens, by Rachel Vail, The Toronto Star, October 13, 2014), as are those citing more serious issues (e.g. More Canadian Girls Inflicting Self-Harm, Hospital Admissions Double, by Tristan Simpson, November 18th, 2014, The Globe and Mail). Parents are rightfully worried and concerned about how to tell when it is time to be really worried, when the troubles they are seeing in their children are representative of more serious signs of emotional disturbance. The youngsters in the latter category are the young people whose emotional lives, and in many cases actual lives, are seriously at risk. I am referring to those teens who should not be left alone with the unreal hope that they will simply “…grow out of it”.

Each developmental period has its own special characteristics and each has its own special contribution to life and development. In adolescence, there is a new and particular kind of stress, whereby the earlier ways of being male and female are put under a different type of pressure. Some adolescents are unable to feel that they have the means within themselves to manage these pressures, and as a result, are unable to maintain an adequate level of equilibrium. The way in which the troubled adolescent gives expression to his or her struggle, and the accompanying internal stress and turmoil, varies a great deal. Some become withdrawn or socially isolated, while others may for example, engage in self-harm, act out violently or aggressively, develop serious substance abuse issues, eating disorders, debilitating depression and anxiety, or become promiscuous or feel overwhelmed by other sexually-charged conflict. A suicide attempt in adolescence represents a sign that there is a massive distortion related to ones’ feelings about oneself. In these instances, the young person has lost touch with his or her mental life. These ‘signs’ or outward indicators are given impetus by the need in the teenager to keep out of consciousness the feeling that something is seriously wrong. When I refer to these signs as indicators of adolescent or ‘teenage breakdown’, I do not mean a ‘nervous breakdown’ as it is commonly understood, but rather something more specific. This is not a transitory crisis, but literally a breakdown in development. Hence, a suicide attempt (as opposed to passing and temporary ideas about suicide) in adolescence is always a sign of serious breakdown requiring immediate help and psychological treatment.

Signs of developmental breakdown are a signal that something must be done now and urgently. By taking teenagers’ concerns seriously we can provide an opportunity to intervene. Even if the despair and conflict with which the teenager has been struggling subside, my experience is that it invariably shows up again, usually during later adolescence or early adulthood, but certainly during adult life at some point. Many serious later ‘disorders’ can be prevented if we act by responding in a timely manner, seeking out good professional help when we suspect or worry that an intervention is required.

Eating Disorders: A “Deadly Passion”, Neglected and Misunderstood

March 8th, 2015

scaleAndre Picard’s article (Globe and Mail, December 2, 2014), A Scourge in Need of a Strategy, highlighted, in his words, “…shocking findings about how Canada treats anorexia and bulimia”.

Picard is right when he points out that eating disorders can be the, “…most deadly” affliction and he goes on to state that, “…between 10% and 15% of young women hospitalized for treatment of anorexia and bulimia will be dead within 10 years”. While the numbers quoted vary, there are estimates that between half a million and a million Canadians are struggling with an eating disorder of some kind.

Picard notes that this is the most neglected and misunderstood condition and he also emphasizes that the problem is made worse by protracted wait times for treatment due to the fact that few hospitals have the resources to offer care. As well, he points out that psychological treatment offered in the private domain typically represents the only option but can be too costly for a lot of people.

Adriana Barton’s article published earlier in the year, What if Anorexia wasn’t a Disorder but a Passion? (Globe and Mail, Life Section, September 15th, 2014) features Dr Louis Charland, who argues intriguingly that eating disordered patients are actually caught up in what she describes as the grip of  a, “…dark passion”. Charland explains that patients somehow become fixated on an ‘idea’, such as ‘I am too fat’, and that idea becomes the organizational focus of the passion, which in turn prompts broader patterns of thoughts and behaviour to support the now ‘fixed idea’. Soon the passion becomes integrated within rational thought and a belief system whereby the person becomes a, “…slave to passion”. Dr Russell Marx, cited in the same article, supports Picard’s contention with the sombre assertion that if Charland is right, it is indeed the most deadly of passions. Although more common in young girls and women, we know now that eating disorders affect all ages and, as Picard asserts, an estimated 10% of patients are male. I would suspect these numbers are higher because we traditionally see less boys and men presenting for treatment.

In another article in the same newspaper (What its like to live with an Eating Disorder), Kyla Fox (Globe and Mail, Life and Arts Section, September 15th, 2014) makes a very important point, asserting that manipulating food and the body serves as a necessary distraction from deep rooted, seemingly out of control emotions and life circumstances. It is the ‘distraction’ that offers the sadly perverse ‘reprieve’ from the real turmoil with which sufferers are struggling. Similarly, in my experience working with these particular patients, many of them, and young people in particular, express conflict through the manipulation of the body. Expanding on Kyla Fox’s observations, I have found that there has usually been a loss of faith somehow for the patient in the reliability of human relationships. Although I find in the course of therapy, that the need for a relationship is still evident, it remains sequestered or hidden. The world of the eating disordered patient is a closely guarded, sealed-off area and very difficult to access without necessary longer-term therapeutic work. In this regard, I agree with Dr Charland in that this sealed-off world can become an exclusive and much idealized passion.

Finally, Picard is rightfully critical of the government in their failure to address the issue of eating disorders as a serious mental health concern. Disconcertingly, he cites the typical case or scenario when it comes to addressing the need for action, commenting that, “…committee recommendations” often represent little more than, “…indifference and platitudes”.

Anxiety: Deciphering Meaning

January 1st, 2015

snwstorm

J. M. W.  Turner, Snowstorm, 1842

About a year ago, I clipped an article from The Toronto Star (Marcia Kaye, Sunday January 5th, 2014) on a review of Scott Stossel’s book, “My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind”. Stossel points out that an estimated 4o million North Americans have an anxiety disorder in any given year and one in four will suffer an anxiety disorder at some point in their lives. He also suggests that the true numbers are a lot higher since a lot of people press on without mentioning the symptoms to his or her family physician. According to Leyla Sanai’s article in the UK Independent, (January 10, 2014), Stossel first saw a psychiatrist at age 10, since when he has tried 27 different medications not to mention a number of therapies in an effort to assuage his anxiety-related problem.

Feeling now, at the start of a new year and due to the fact that we are unquestionably living in anxious times, the moment seems right to revisit the concept that reflects a treatment orientation from a psychoanalytic perspective or, in particular (despite Stossel’s stated reservations about his own experience with a variety of different therapeutic approaches), how I would approach a patient and their concerns about anxiety.

When a patient uses the word ‘anxiety’, it is usually an attempt by the person to give a name to a feeling. In this sense, I believe that there is a need to find a language that connects in some way to that particular person’s frame of reference. Indeed often, in the very first session, there is the germ of everything that will appear as the central or critical problem of the treatment;  it’s just the case that up until now the person struggling with anxiety has not been able to find a way to resolve an internally based conflict. Anxious feeling states once expressed in words, invariably become far less overwhelming, representable in the mind and hence far more understood and acceptable to the self. It is not uncommon to find that some people live their lives in disregard of their internal world and the part played by the unconscious life. Sometimes an individual will be afraid of entering this space, to find a way out of his or her difficulties, but within the therapeutic process something is awakened and discovered and one can no longer pretend to oneself that it does not exist. I find that people need help in unlocking the door to this unexpected world so that they can discover its’ presence within themselves. While anxious states in some people clearly reflect multiple causal factors, I think that the key in many cases is in helping the patient find a way to de-codify the meaning and give language to something previously experienced as elusive and unrecognizable.

Is Psychoanalytic Therapy For You?

August 31st, 2014

choicesPsychoanalytically informed treatment can be beneficial to most people. For example, it can provide relief from the troubling symptoms of anxiety, depression and other life-disrupting concerns. You might, for instance, be plagued by private rituals, compulsions and repetitive thoughts of which no one else is aware. Alternatively, you might be living a constricted life of isolation and loneliness, or feel incapable of getting close to others. In some cases, as a result of destructive patterns of behaviour, you may have experienced repeated failures, particularly in key areas such as work and love.

As an alternative to more simplistic, short term interventions, psychoanalytically-oriented therapy can be a particularly beneficial treatment option for individuals managing high stress-related worries or concerns, typical of those confronting busy professionals in their work or lives generally. Despite relative satisfaction and success in their lives, individuals fitting this category may nonetheless be suffering disruptive symptoms that restrict choices and other opportunities for pleasure. Hence, certain people may choose to seek out this treatment approach because other interventions have not resolved their problems or, at best, only temporarily so.

In working with a psychologist who is also an internationally accredited psychoanalyst, patients can be confident that they are being treated by a uniquely trained mental health practitioner. Psychologists with this extra level of expertise have not only completed the rigours of their own professional training (i.e. an extensive graduate program in clinical psychology), but also at least 4 years of additional training in psychoanalytic theory and clinical practice. In particular, psychologist-psychoanalysts, trained under the auspices of the Toronto Psychoanalytic Society and Institute have received the most rigorous training available. This particular training leads to membership in both the Canadian Psychoanalytic Association and International Psychoanalytic Association (the world wide umbrella organization for the training of psychoanalysts). In summary, people undergoing psychoanalysis or psychoanalytically-oriented therapy can feel confident that practitioners with affiliation to the International Association meet the highest training standards available for this particular treatment.

Suicide: No Easy Answers

August 31st, 2014

IMG_1393Robin Williams’ recent suicide prompted an enormous reaction from the general public, evoking a variety of opinions and perspectives. Locally, Carly Weeks, (Globe and Mail, August 15th, 2014) rightfully asserts that there are no easy answers to understanding suicide and that we are often left at a loss as to try and understand why someone would take their own life. She cites Dr Martin Heisel, a researcher at the University of Western Ontario who emphasizes the fact that, “…there are variety of factors” that go into a individual’s death by suicide, and rarely just one consideration.

Weeks states that the vast majority of those who die by suicide have some form of mental health difficulty, with depression being the most frequently occurring syndrome. As David Gratzer (also The Globe and Mail,  August 15) points out, many people carry with them on a daily basis, the burden of depression, anxiety, addiction or other some the debilitating affliction. Michael Redhill’s poignant commentary on depression particularly caught my eye (The Globe and Mail, August 16) and is a particularly personal account from the perspective of an “artistic mind”.

Instead of avoiding talking about depression and suicide, Heisel, (from Week’s article), rightly stresses the importance of speaking about depression openly, that  helping a person express how she or he feels is critical. As a psychoanalyst listening to people talk about suicide I feel that it is vital to listen with an attitude of equanimity, non-judgement, seriousness and patience. I think that the capacity to listen to a patient verbalize suicidal feelings or ideas can actually strengthen the boundary between thought and action. In my mind it is important to give the individual (implicit) permission to express the powerful emotions that are threatening from within. In particular, I have found that this can help improve a person’s capacity to understand his or her inner and outer realities.

In circumstances where matters are thought to be getting more out of hand, often as a result of the patient becoming too depressed to communicate or indeed making practical plans for committing suicide, it is important that the individual be actively protected. However,  I always feel that such behavioural limit setting should be combined, as much as possible, with a continual emphasis on understanding and on attempting to uncover the potential meanings of impulses and actions. Otherwise, I feel that a patient can get  the impression that I’m only interested in his/her behaviour and not the subjective distress that underlies it. At times we, as psychoanalysts dealing with suicidal patients,  should realize that there are situations when one to one psychotherapy is simply not enough to contain the psychosocial distress involved. Hence, I might deploy adjunct measures including, amongst other things, the enlistment of family members’ help.

ADHD: Over-Diagnosed?

August 20th, 2013

Ritalin tablets

Photo: The Guardian, August 13, 2013, Murdo Macleod

A recent article published in the UK newspaper, The Guardian (Tuesday August 13th, 2013) entitled, ADHD Prescriptions Rise Sparks ‘Smart Drugs’ Fears is noteworthy for reasons that go beyond the main thrust of the commentary. While the piece highlights the dangers ensuing from “diversion or misuse”, what alarmed me most of all was the underlying acceptance of the trend toward “increased diagnosis of, and prescribing for, the treatment of attention deficit hyperactivity disorder (ADHD)”.

Apart from the fact that all pharmaceuticals are potentially powerful and dangerous (for example, stimulants routinely cause ‘rebound’ involving a worsening of behavioural symptoms) we are now well aware of this industry’s typically dubious research claims as being a particularly noxious example of the mishandling of science. There is certainly a lack of valid scientific evidence to support the claim that these drugs contribute to improved learning and academic performance. While ritalin has a good chance of making a child more compliant in class, I’m not sure that this is the kind of ‘improvement’ we should be advocating for our children. Indeed, children are often put on stimulants as a result of pressure from schools who encourage parents to seek medical consultations directed at ‘controlling’ classroom behaviour.

Peter Breggin, author of Talking Back to Ritalin: What Doctors Aren’t Telling You About Stimulants and ADHD, has astutely pointed out that children are often actually suffering from “parent attention deficit disorder”; that parents rarely find enough time to give children all the attention they need. Often, the kids get the “left over time”. Perhaps its no wonder that parents give in so easily to the idea of medication as children make fewer demands while on drugs. If you would like to read more, I would recommend Breggin’s book. He discusses many of the subjects related to what I have touched on in this review, including how to deal with schools and it also includes tips about parenting skills.

 

 

 

The Examined Life: How We Lose and Find Ourselves

August 19th, 2013

The-examined-life

Stephen Grosz’s book, The Examined Life – How We Lose and Find Ourselves, is a wonderful read for anyone who has ever contemplated psychoanalysis or deeper insight-oriented therapy, but I would also recommend this book to anyone who is generally curious about the perplexities of everyday life and human behaviour. There are several excellent reviews of this book worth reading including one from “The Independent Review” The Independent and another from The New York Times.

Grosz’s chapter titles are immediately attention grabbing: “How praise can cause a loss of confidence“, “Why parents envy their children“, and “On not being in a couple“, to name a few.  The stories he tells connect the past, the present and the future and demonstrate that inner change is possible. Mr. Grosz quotes Isak Dinesen, observing that “all sorrows can be borne if you put them into a story or tell a story about them”. He adds that  stories can help us to make sense of our lives, but that if “we cannot find a way of telling our story, our story tells us — we dream these stories, we develop symptoms, or we find ourselves acting in ways we don’t understand.”

Grosz’s book also highlights is the fact that psychoanalysis goes against the grain: How on earth in our virtual world of speed, tweeting and texting and other sophisticated means of communication can a person take the time to drop everything 3, 4 or 5 times a week to lie down on a couch for almost an hour and attend to what is going on in his or her inner world? If efficiency is defined as doing the most in the least time, the slow pace of analysis seems almost mad or at least a little absurd.

How can people with no experience of analysis imagine what happens in it. There are some kinds of knowledge that can be taught and others that are discovered by personal experience, and I think psychoanalysis falls into the latter category. However, in making use of beautifully written and deceptively simple human stories, Grosz’s book manages to at least convey some of the nuanced complexities of psychoanalysis.

Grosz, is a practicing psychoanalyst, a teacher at the Institute of Psychoanalysis and in the Psychoanalytic Unit at University College London.

Why Men Hesitate to Seek Therapy

July 18th, 2012

male-symbol-sign_1_

Erin Anderssen’s article in last Friday’s (July 13th, 2012, Focus Section) edition of The Globe and Mailfocusing on men’s general aversion to psychotherapy immediately captured my attention. Entitled,Why guys won’t get off the couch – to get on the couch, the piece is well written and comprehensively researched. The writer highlights the fact that men are far less likely to seek out therapeutic support when they experience distress. She also points out that symptoms often manifest in a very different manner in men. For example, men tend to report feeling “stressed” rather than “sad” or depressed. Men are also more likely to be aggressive or irritable, turning to alcohol, drugs or over-working as a means of managing their problems.

Most importantly, the article notes that misconceptions about therapy often deter men from calling a therapist. Indeed, a man I recently spoke to inquiring about therapy expressed concern about whether therapy would in some way “change” him.

I try to work with the underlying belief that what people (men and women) really want is to become more and more faithful to who they truly are! For men, in particular, I have found that once they begin to incorporate this sense within themselves, it is easier to accept the evolution that is inherent in their personality as it develops. I think that once men begin to get more genuinely in touch with their own personal values, they become better able to acknowledge their own resources.

While men are more likely at first to keep their distress to themselves, I find that pretty soon they are able to convey these feelings to me and in this way they acquire a greater capacity to be more genuine and true to themselves.

Of course there are different approaches to therapy and the choice depends on a series of factors. Also, it is not easy for men to form a true picture of what therapy is like (…how can it not be caricatured?).

While I work in a psychoanalytically-oriented manner with my patients, it remains difficult if not impossible to summarize succinctly the sheer quality of the actual process. If I could briefly highlight one aspect that I facilitate in my own personal work with men, it is that I try and help them ‘unlock a door’ to their internal world. It is this unsuspecting world and in discovering it’s presence within them that they can find a level of comforting coherence in their lives.

Considering Canada’s Mental Health Strategy…

September 2nd, 2011

Globe and Mail, August 31, 2011

Globe and Mail, August 31, 2011

The Globe and Mail recently published (August 31, 2011) an article by Andre Picard (their Public Health reporter), entitled, Mental Health Strategy Doesn’t Go Far Enough. In this article, Picard discusses Canada’s confidential and long-anticipated draft for its mental health strategy. The article explains the need for a strategy and its purpose, and  notes that Canada is the only G8 country without such a strategy. To this end, I think the article is useful.  However, while Picard is very well intentioned, one can’t help but notice that his major criticism of what is in the draft is directed at what he describes as the lack of funding devoted to brain research and traditional psychiatric ways of treating the more serious mental health conditions. He doesn’t like the strategy’s focus on a ‘recovery model’ (the notion that people will get better with support) in mental health…he would prefer one that focuses more on brain science.

In respect to funding for mental health, the reality is (and this is not noted in the article) that inordinate amounts of money have been and are currently being directed towards brain research (remember the 90′s…the decade of the brain). Indeed the search for the “cause’” of schizophrenia has been going on for more years than we care to remember, and at one time or another pretty much every organ system in the human body has been cited as it’s cause.  It is conceivable that we are not even classifying this illness (or other psychotic illnesses for that matter) correctly.

The long and short of my argument is that we need to view all mental illness holistically, that the mental illnesses psychologists and psychiatrists are seeking to alleviate in people invariably incorporate a complex interaction of psychological, genetic-developmental, biological and social factors. Making arguments for discrete ’causes’, or indeed ‘leading causes’ for that matter, is reductionistic and misleading. Of course it is important to allocate funding to further our understanding of brain function, but don’t let us tow a particularly popular current line of thinking and make exaggerated claims or inferences either about what we can achieve in allaying people’s suffering from an understanding of brain function alone. Indeed, if the brain is the primary focus of our understanding of mental health,  people are likely to be disappointed.

Psychiatric Medications: Looking at “Anatomy Of An Epidemic”

August 23rd, 2010

Anatomy of An Epidemic

Over the past year, the debate over psychiatric drug use has become increasingly heated.The Journal of the American Medical Association (January 6, 2010) printed a review of a study that demonstrated that for all but the severest cases of depression, there was a negligible difference between antidepressant drugs and placebos. Newsweek (January 29, 2010) picked up the story and did a cover on the study and the value of psychiatric drugs. Concern about the efficacy of psychiatric drugs was also discussed in the New Yorker (August 23, 2010).

Indeed, the percentage of people incapacitated by mental disorders has been increasing dramatically over the last thirty years. This is not an increase in the number of people diagnosed with disorders but due to the medications introduced to treat the illnesses!

Robert Whitaker, an award winning scientific journalist (not a psychiatrist or psychologist) has amassed data and put the numbers and implications together clearly in his book, “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America”.This book has been both timely and relevant. Whitaker covers the history of psychiatry in America in a comprehensive manner, drawing on 50 years of literature and patient interviews. He asks a most important question … if psychiatric wonder drugs are so effective, why have the numbers of people on disability using these drugs increased dramatically?

His critics have horribly attacked him saying that he has been unethical for his reporting, which makes psychiatric medications look bad. After all, say his critics, some patients may hesitate to take the drugs if they know it might have serious negative effects. But the overall statistics are overwhelmingly bad in the long run, and his reporting revealed that despite evidence that medications are helpful in the short run (sometimes dramatically so), the long term story is radically different. In the long run, patients simply become more ‘tolerable’, chronically disabled individuals. Moreover, there seems to be evidence of a dramatic shortening of life, primarily from physical side effects.

When psychoanalysts and psychoanalytic therapists make recommendations that sensible psychoanalytic therapy by trained practitioners can help patients with a wide variety of disorders, it is useful to have books like “Anatomy of an Epidemic” as a reading available for a source of accurate information.