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Psychological Therapy in a Pharmacological World
By James E. Campbell
AuthorHouseCopyright © 2011 James E. Campbell, M.D.
All right reserved.
Chapter OneIn the physical world when we are hurt, it is good judgment to get away from the source of our pain: hot stove, sharp knife, loud sound, huge pressure, rancid smell. These and many more stimuli trigger in us the desire to get away from the stimuli. In the physical world, this is an appropriate response.
In the psychological realm, all therapists know dealing with pain means we must embrace it; we must confront it; we need to experience it emotionally. Through opening ourselves up to the uncomfortable event, or experience, we begin the process of assimilating and healing. The language expressions we use in discussing these therapies are "working through, getting in touch, uncovering, experiencing the feeling, etc."
Perhaps my instructors told me this, and I did not listen, or the lecture was given on a day I did not make it to class, which is doubtful, as I think I had a near perfect attendance record, but I do not recall anyone ever telling me there are a lot of problems caused by people taking what they have learned in the physical world and attempting to apply it to the psychological world. It would have been useful if this had been said over and over.
Some of the psychiatric disorders I see as being created by people's attempt to get away from, or to avoid events in the psychological world:
PRIMARY PROBLEMS LIKE Anxiety Obsessive Compulsive DO Phobias Social Phobia Hallucination Nightmares SECONDARY PROBLEMS LIKE Childhood oppositional behaviors
When patients present with primary problems like anxiety or phobias, which I associate with avoidant behavior, I share the following simile: [I recognize the hypocrisy of using a physical simile to explain what is happening at a psychological level. I do it for two reasons: one, we do not have stand-alone words to explain the events, and secondly, as I said before, people are primed from birth to learn from their physical world experiences.]
It is as if there is a part of the brain which has been set aside to look out for our safety and for much of its life this part of the brain observes our behaviors. Going into avoidance awakens this part of the brain. So, whenever avoidant behaviors occur this part of the brain puts one on notice that a problem exists, by energizing the emotional experience. If I avoid driving, this part of the brain will embellish activities related to driving with fear, or if I avoid places with a lot of people, it embellishes these places, where there are a lot of people, with fear. This ever vigilant part of the brain does not seem to be able to discern whether an avoidant behavior is reasonable, justifiable or frivolous. I think this part of the brain was operational long before speech, and it has never made a direct connection to the reasoning part of the brain. So, this brain function puts energy on whatever has been avoided, and it will only respond to our actions or our behaviors.
Avoided experiences are tagged dangerous until proven not to be by our actions, leaving us with a negative feeling, or sense of fear, or anxiety; the feeling emerges again and again in the person's mind, whenever there is a trigger for it to do so. In psychoanalytic terminology, it is suppressed and then reemerges, whenever the defenses are let down. It is as if an alert switch has been thrown, and the effects of this appear to be somewhat accumulative over time; the more times we throw the switch the greater is the associated fear attached to the event being avoided.
If we understand this rather simple defensive operation of the mind, we can better understand why certain approaches are likely to work, while others do not work. We can also understand what is going to make the condition worse. Examples of problems I see in the office:
A woman discovers her two-year-old grandchild playing with scissors found while rummaging around in papers left on the coffee table. Since then the grandmother has been totally fearful of all sharp items, and she has had to remove all of them from the house.
A man comes home and is playing with his infant daughter when she makes a sudden backwards surge and nearly falls out of his arms. Since then he breaks into a sweat when he thinks about being left alone with her, and he is avoiding holding her or changing her diapers.
A ten year old hears the news about a house being broken into, and, now, he must check all the doors and windows 3-5 times each night before going to bed. If someone opens a door to the house before he goes to sleep, he starts the process all over again.
An executive driving to work has a thought about pulling under the semi-truck which is next to him. He breaks into a sweat, has a panic attack, and will no longer drive to work using the expressway, adding thirty-five minutes to each leg of his trip.
Psycho-dynamically we could have a ball with all of these cases. It might take years to see an improvement. Medication might speed up the improvement for these events, but studies show a higher relapse rate when medications are used alone.
Before I tell you the simple technique I use with this type of patient, I want you to know I use the same approach on my patients with nightmares, and hallucinations.
The treatment technique for unwanted thoughts is simply trying to convince the brain the person is no longer in avoidance of the thoughts, or the actions. What do I do? I have the person set aside five minutes three times a day, and during this time I have them flood their mind with as many related issues, or thoughts, as possible; the more horrific the thoughts the better. In fact, I encourage patients to push their thoughts to the point of ridiculousness. I know in my office when they have succeeded; it is when they have taken their fears and blown them up to such a catastrophic level they begin to smile or laugh at themselves. I tell them, "Perfect, you have accomplished exactly what I wanted you do."
A young male patient of mine had been working on going out on a date, and finally the day came. He was extremely anxious, but as he approached the door separating him from his date, his thoughts went to the school and the dance he was headed for. He visualized himself dancing with his date; he was spinning her so quickly she tripped and fell to the floor, starting a chain reaction; other people were falling all over the floor, someone shorted out the lights, and as the band played The Walls of Jericho the crowd caused the building to fall by hysterically running into the walls. When he rang the doorbell he was nearly laughing at his image of the disaster which might lie ahead, and the anxious state was averted. It turned out to be a good dating experience for him.
If unwanted, or anxious, thoughts occur between the scheduled sessions, they are to be remembered, and they are to be added to the five-minute exercise. If it is a hallucination the patient is trying to get rid of, I will have them try to have the hallucination three times a day for five minutes. If hallucinations occur it is fine; if they do not occur that is ok, but if they appear any time in-between, they are told to go away and come back at the scheduled time. If, after a couple days of this exercise, the thoughts have not vanished, the frequency can be increased to four times daily, a very unusual experience in my practice. More likely, the person will not have the thoughts after twenty-four to forty-eight hours of doing the exercise. I then have patients reduce the time to 2.5 minutes for a couple more days and if there is no recurrence, they can stop the exercise. The same pattern is used for any obsessive-compulsive focus (i.e. sharp objects).
I warn all my patients this function of their brain is astute; a week or two after the initial improvement, perhaps even a month after the thoughts are gone, they should expect the brain to bring the old thoughts back, or a new challenge may come into their mind to see how they deal with it. If they say, "Oh yes, I remember you, and you are not going to push me into avoidance," the thought, and the feeling it previously created, will generally be gone for good. If the thought jerks one back into an avoidant behavior, the symptoms will start all over. At this juncture, I might also add 5-10 mg of Fluoxetine.
Why does this work for hallucinations? I do not have a tested explanation. My initial experience was during a period when I was doing about 60% in-patient work. I had three pregnant schizophrenic ladies admitted within 2-3 weeks of each other; all were in a major psychotic state. They were hallucinating severely, and I struggled with what options I had. I did not want to put them on anti-psychotics if I could help it. With some trepidation, I told the first lady I would like her to try and have the hallucinations for five minutes three times a day, and if the voices or visions come at any other time, she was to tell them she wanted them to come back at a time she chose. Within forty-eight hours the hallucinations were at nearly zero. She was discharged off all medications, and she sustained off medicine throughout her pregnancy.
The next two patients followed basically the same recommendation, and they both had a nearly identical result. One reported 85-90% reduction in her hallucinations, but reported this as a walk in the park for her. To my recollection, all went home off of any anti-psychotic medication, and they maintained the improvement.
Since then I routinely tell all my hallucinating patients about the exercise. Many of them use it with a very good outcome. Some, on occasion, do not. My success with the procedure has encouraged me to keep it as a treatment intervention. I am not certain why it works, but I believe it relates to interrupting the avoidant mechanisms. The positive results may, according to a recent theory, be related to the part of the brain that discerns between internal and external speech. By asking the patient to create the hallucination, perhaps the brain learns to recognize the pathway, and it may become clearer to the brain that the experience is coming from within. I definitely use this with kids that are reported to be hallucinating, because it stops the experience most of the time.
How do I use this with nightmares? I suggest the patient try and have the nightmare. Rarely has anyone ever actually had the nightmare again. When it has happened, I encourage them to try it a few more nights. For those where it continues, I train them to alter their dream while it is occurring.
For all of my anxious, Obsessive Compulsive, social phobic, etc., patients, I tell them there is a treatment (non-medical) which can be helpful to them. The treatment is a cognitive behavioral approach; I know it as stimulus/block response I give a brief summary of the approach. Then I tell them they can do this treatment, to a large extent on their own, without paying the one to three hundred dollars an hour for the therapy. In lay terms, it simply means do not do the OCD behavior. Do not do the avoidant behaviors in anxiety or social phobias. I make it clear the outcome has a lot to do with their effort in this area. I frequently add 5-10 MG of Fluoxetine to the therapy mix. In my practice, I have been very pleased with the outcome. More importantly, my patients have been happy with the outcome.
Regarding the medical side of the treatment of OCD, about 70% of my patients (adult or children) are on 10mg-20mg of Fluoxetine. I have a number of OCD patients doing very well on 5-10 mg. I will increase the dosage every 10-12 weeks, if I see only a small response. I know some doctors suggest a more rapid titration, but given the lasting results, a low incidence of complicating side effects, and a generally satisfied patient, I use the slower approach.
I have occasionally increased the Fluoxetine to 40 mg for some OCD patients. If I have not seen the results I want at that level I will generally add small increments of Anafranil. You can follow with blood levels if concerned about the P450 enzyme issues. Typically, I do not go over 50 mg of Anafranil when combining it. I have found the combination is very effective, and I get few side effects from the Anafranil when used in this combination. Remember, I am generally using very low doses of Fluoxetine, and I am frequently reducing the dose from the 80-100 mg patients are on when they come to see me, down to 10-20 mg to re-capture the positive effect of the medication.
In children, I use a similar approach with one difference; if Fluoxetine alone does not work, I will try the FDA approved Fluvoxamine next.
About sixty percent of my anxious or depressed adults are on 10 mg Fluoxetine. I have never seen poop-out on this medicine; patients have very few reported side effects; I have had less than three patients switch to mania while on it during the entire time it has been on the market. I have had three adults and one child report, what appeared to have been, suicidal ideation while on the medicine; the generic seems to work fine, and it costs my patients $9.50 for three-months of treatment if they do not use their insurance. What others describe as Fluoxetine poop-out I see as over saturating the system. I have seen very few issues with this medication not resolved by decreasing the dose.
Depression is often related to the avoidant disorders in several ways. One, people hate depression and want it to go away. Nothing is abnormal there. What is problematic is when people do not acknowledge they are depressed; this sets up a process for failure much like when an alcoholic does not admit to a drinking problem.
Some depressions may be biological, and I am not saying we should not consider medicine. I personally believe a high percentage of depressions are not, and I will soon share with you how I identify them. In my practice, I find many so-called treatment refractory patients are non-responsive because they are on the wrong type of medication, or even worse, many should not be on medicine at all. I recall this attitude by a lot of psychoanalysts in my training years, and want to assure you this is not my mind set. I am not interested in the issue of psychotherapy vs. pharmacotherapy. I encourage accurate assessment and treatment. I am not advocating years of psychotherapy. I am generally suggesting a couple of sessions to guide the person's thinking in a better direction, and some education about the problems, so they have a conceptual framework to use in working out the problems they are having. Sometimes a shift in the type of medication being used can also help.
When patients are depressed there are a couple of considerations, we, as doctors, should attempt to separate out:
Is this a biological depression?: or is it faulty genes? Is this a depression resulting from faulty thinking?
I know we have all heard this. The faulty genes' issue seems to me to be getting more and more difficult to quickly identify. When I came into practice thirty-five years ago, if someone told me their grandmother was depressed, their mother was depressed and their daughter is depressed, I would feel pretty comfortable the depression was genetic. Back then, patients were not usually put on medicine at the first appointment. One tried to understand their issues, or lack of issues, first.
Today the experience is more complex and more distorted. My average patient tells me their mother, brother, two children and three aunts have all been diagnosed bipolar. When I explore the symptoms of each family member, I find mother and her three sisters have all been treated for alcoholism, and their diagnosis was made while they were in rehab programs. The children and one aunt have attention deficit disorder, and the brother is in jail because of dealing drugs and beating up on his wife.
Perhaps you can make some sense out of this type of original history, but my inclination is to go back into their histories and gather information about what their problems might really be.
When I am finished with my assessment, I sometimes tell patients I believe they are depressed, because they are doing all the correct behaviors to be depressed. Some patients are relieved when I tell them this, because it opens up the door for them to see improvement, if they can break their negative cycle. Others will be furious at me.
How dare I make a suggestion they might have some responsibility* for their illness? After all, the last five psychiatrists they had seen all said their problem was biological, and they would need to be on medicine forever. As you might suspect I do get a few walkouts. [*Responsibility written in this manner means the word as it is currently defined and generally used.]
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