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Saturday, March 29, 2014

Holistic Therapy--Yes But I Won't Be Using That Word

Well, I feel as if I have been drug kicking and screaming into the holistic revolution.

After years of resisting it, I just have to give in.

But outside of the title of this article, I still won't be using the word.  Why?  Because it is a buzzword.  It means so many different things that it means nothing.  It is a way of saying, "I'm with you; I'm with the modern IN crowd."  But the word means so many things it starts to mean nothing.

But what I do want to do is be comprehensive in the way I approach depression.  Cognitive therapy is not the only way.  Behavior therapy is not the only way.  Medication is not the only way.  Even electroconvulsive therapy may have its place.  Exercise is definitely a factor in recovery, and I believe that for some people nutrition may be important.

I did not reach this conclusion because of a desire to be part of a feel good movement.  I reached it out of pure practicality and what works.  Or what doesn't work would be a better description.  What doesn't work as well as we wished it worked.  And that would include pretty much every treatment that we know of now.

When I started learning cognitive therapy, in 1980, it was relatively new.  It was not inconceivable that cognitive therapy, or cognitive therapy combined with behavioral therapy, or cognitive therapy combined with medication, etc. just might cure most people.  Sadly, that has not been the case.  The ultimate solution to the riddle of depression lies a ways off--perhaps fifty years, perhaps a century.  Talking therapy has proved to be just as limited as medication.  Cognitive therapy has more research evidence behind it than psychoanalytic therapy.  But that doesn't mean it is much more effective.

However, there are a variety of interventions and coping techniques which can help depression:
spiritual techniques
mindfulness techniques, e.g. meditation
positive psychology techniques (such as altruism and volunteering)

These are just a few.

Why did I resist the idea of a comprehensive "holistic" approach?  It seemed just too much of a catchphrase, better at making authors money and being part of a feel good movement than really helping people.  The research for holistic approaches was often flimsy when one actually looked into it.  That is beginning to change.  Research into alternative techniques (alternative to medication and talking therapy) is growing in amount and in quality.

Also, I was simply overly focused on pure psychotherapy research and too much of a true believer.  Perhaps I can be forgiven for being a "true believer" in a technique which had really quality research showing that it worked.  What the research also showed, however, was that it worked only up to a point.  It worked for certain people and not others.  Or it worked partially for some people.  For awhile it seemed that there must be a moderator variable in there somewhere.  If we gave it for 40 sessions instead of 20, maybe that would make it much better  If we combined it with other treatments, or if we used it only for certain patients, or if patients would only do their homework, etc. then maybe it would work for almost everyone.  And each of these was a legitimate issue, but it never solved the whole puzzle. 

It's not that I have quit believing in cognitive psychotherapy.  It is still the main treatment I would recommend for someone who has mild to moderate depression.  If I had a family member with depression, I would want them to have cognitive behavioral therapy, and maybe medication.

It's just that it is now clear that no matter how you slice and dice psychotherapy, it will have limited results.  The same is true of antidepressants.

I have been reacquainting myself with the new biological research into the underlying brain issues associated with depression.  It is clear that for some types of depression, and maybe all severe depressions, there is a biological substratum.  We now believe that chronic stress releases so much cortisol over such a long period of time that it damages certain parts of the brain.  There is evidence for this as a possible cause of depression.

The brain can regenerate cells in some areas.  One of those areas is the critical hippocampus.  It is involved in memory and also in controlling our anxiety/fight or flight mechanism (HPA axis).  Regeneration of hippocampal cells is stimulated by brain derived neurotrophic hormone (BDNH), which in turn is released after exercise.  Outcome studies are pointing to excellent treatment effects for depression with exercise.

Thus, theoretical and basic science findings such as this are encouraging me to think more broadly.

Secondly, outcome studies of exercise and other techniques such as medication are showing good effects.  Cognitive therapy has a lot of good research behind it, but now we are starting to see some really good research outcomes for exercise and positive psychotherapy.

Thirdly, as I have improved my own healthy behaviors, I feel less hypocritical asking my patients to work on theirs.  I am more comfortable now advocating that other people do things which I used to avoid working on for myself.

Just how helpful are some of these alternative therapies?  Exercise has been shown to be quite helpful, perhaps yielding as large an antidepressant effect as current medications on the market.  Nutrition has not been as well studied as exercise.  However, one Australian study published in the prestigious journal Lancet, found that there was a correlation between fish consumption and a lowered risk of depression.  (Correlation studies such as this have to be followed by experimental studies to be fully interpretable, however).  Omega 3 fatty acids are thought to be very important in proper brain function.  Other foods, such as protein, are important because they provide a good supply of all the necessary amino acids.

Well, that's enough for now.  I hope to write more about this later.

Monday, March 10, 2014

Deilberate Mind

This state of mind is about living life in a consciously deliberate fashion. It may seem strange that this would have anything to do with mindfulness, since mindfulness generally incorporates a form of meditation which involves no thinking at all.  However, to meditate in this way is actually very deliberate and focused.

In a sense, deliberate mind takes away blame.  We oftentimes blame others because we see our lives as stimulus and response.  You do something, and I react.  Therefore, my reactions are your fault.  To live life with full consciousness on the other hand, or at least as full consciousness as possible, would involve living life so that less blame shunted onto other people for our negative feelings.

To live deliberately is to take responsibility for my actions and feelings.  And if, as sometimes happens, someone has harmed me and made life difficult for me, then deliberate mind is more focused on finding a solution than on my anger or blame at the other person.

To live life deliberately is also to live life consciously--conscious of what I am doing and why I am doing it.  To live unconsciously is to live without a knowledge of what is truly driving me.  We may never understand all of our feelings, but at least we can live in such a way that we can take considerable responsibility for what we think, do, and feel.

Thursday, February 06, 2014

Games, Belonging, and Avoiding Depression in Retirement

I am no expert in game theory, but there is something which is now so clear to me that I just need to write something about it on this blog.

Many people, when they retire, become depressed because they no longer play a role in society.  They are no longer part of the "big game."  (This is a phrase I picked up from a Harrison Ford movie.  I'll figure out which one later.)

For each of us, the "game" involves reaching a goal.  It often involves gaining something, which gives us some satisfaction.  What we gain could be a game of checkers, a smile from someone we like, or status within a group.  The kind of game I am talking about generally does not involve "winning" in any all or nothing fashion.  To win is simply to participate and to achieve some kind of goal.

In this kind of participation, we are "known" by others. They see us as part of their circle.  They expect something from us.  They may expect us to do our part and pull our weight.  We may be seen as doing something particularly well, such as playing checkers, scrapbooking, or giving political opinions.  If we are "in the game" others may seek to have us as an ally when there is conflict.  Or they may expect us to be an enemy, but either way we are known to them.  If we do not show up, our absence is noted.

In this way, we have "self objects" (see Heinz Kohut on self objects).  And we are a self object to them.

People retiring may look forward to having nothing that they have to do.  But they are no longer part of the "big game."  In a worst case scenario, they go into a state of deprivation for face to face contact, which can lead to depression.  Many persons who retire do not quickly go on to develop dementia.  Their minds are still capable of analysis and decision making, but they no longer have a role to play.  They are no longer a part of the "game."

In a best case scenario, people still have a role to play at church, at the VFW, or at the country club.  They can still run for an office.  It may not be earth shaking in importance, but it's just as good.  They are not irrelevant to the people around them.  There is a reason to make an effort, to strive, to think, and to progress.

Unfortunately, for some people no such "game" is available.  They are shut ins, or there are no available groups in which they can participate in any meaningful way.  If elderly people are not seen as desirable participants, then they are shut out of the "game."  One cannot easily barge into a system.

I believe that to some degree elderly participants can form their own groups.  But I also believe that it is even better when younger groups (people younger than retirement age) can find value and purpose in including older persons.

This issue is not limited only to retired persons, however.  It can also apply to disabled persons.  It can also apply to newly divorced persons.  It can apply to people who have been dislocated and/or have moved to a new geographic area.

Well, I've said my peace for now.  More on this later.