The Elephant on the Couch: Side-Effects of Psychotherapy (Berk & Parker, 2009)

[ScottTriGuy]

I have a friend who was seeing a psychotherapist for many months and when my friend's depression did not lift, the psychotherapist admitted that she was not helping. I was surprised by that admission, not something I've heard of frequently from that profession.

But I was to be even more surprised.

Wanting to help my friend find other potential support for his depression, the psychotherapist referred him to her psychic.

I'm disappointed to say that my friend (a super smart sciencey-type guy) went to the psychic. I guess that speaks to how desperate he was.

Not surprisingly, the psychic offered nothing useful.

My friend still battles (at times disabling, with suicidal ideations) depression.

On a similar note:
I have another friend, a Social Worker, who works in a hospital's cancer unit as a counsellor with terminal patients. The counsellors are instructed not to bring up death with the dying patient, and not to encourage discussion of the patient's feelings / thoughts / meaning about their imminent death.

So its not just the elephant in the room that's not being talked about at this cancer unit. Its also the Grim Reaper. Waiting impatiently.

 

[Arnie Pye]

My friend still battles (at times disabling, with suicidal ideations) depression.

I had depression and thoughts of suicide for many years. I have been treating myself for the last 5 or 6 years with 5-HTP which works wonders for me. It doesn't eliminate the depression completely but reduces it a lot.

Disadvantages of 5-HTP :

1) It doesn't work for everyone - but then neither do the pills peddled by doctors.

2) The most frequently manufactured products are in doses of 100mg. 200mg doses are also easily available. In my opinion these are both too high a dose to start with, and 50mg is the best starting dose.

3) 5-HTP raises cortisol. (I realise some people might consider this an advantage, but I don't.) I've never seen any research which looks into how much it actually does this. I suspect the effect is slight, but can't prove this.

Advantages of 5-HTP :

1) In many countries, including the UK, 5-HTP is available over the counter and online without a prescription. Reading reviews on Amazon is well worth doing.

2) If it is going to work you'll probably know within a week, unlike prescribed SSRIs which people are told won't show an effect for at least 6 weeks. If 5-HTP doesn't work for you then you won't have any problems getting off it if you've only been on it a week. If you've been taking an SSRI for 6 weeks and it doesn't work your doctor is likely to raise your dose and persuade you to continue taking it for another 6 weeks (at least). By the time you decide that it really isn't helping you could have been on it for a few months and you may suffer withdrawal symptoms. For some people these withdrawal symptoms can be severe.

3) If you take 5-HTP and find it helps but then want to come off it for a some reason I haven't heard of anyone having any difficulties attached to withdrawal, although personally I would always reduce dose slowly. I have stopped taking 5-HTP in summer a couple of times and had no problems doing that.

Other info

1) I've only ever tolerated or needed 50mg 5-HTP per day, and I currently take it 5 days a week. Bear in mind that some people need far higher doses than I take - my dose is low. It is not unusual for people to end up taking, say 50mg or 100mg two or three times a day. If it is only taken once a day then evening is best because it increases levels of melatonin.

2) If someone is already taking drugs that affect serotonin then taking 5-HTP is NOT a good idea. There is a possibility, when mixing anti-depressants of any kind (and some pain relievers too) of a condition called serotonin syndrome, which can be fatal.

https://en.wikipedia.org/wiki/Serotonin_syndrome

Anyone reading this should always do their own research. There may be reasons why 5-HTP isn't suitable for you that don't apply to me.

 

[Tom Kindlon]

Why is the adverse side of the ledger neglected?

If these exemplars of omission and commission are accepted as potential cost risks to psychotherapy, why do we neglect this side of the ledger? First, it may be that we assume that the caveat emptor principle holds – that if a patient is referred to a psychotherapist who is clearly ineffective, exploitative or insensitive, they would choose not to return, thus preventing exposure to any distinct adverse event. For those who chose to stay, however, two processes may occur that, because they are neither overt nor clearly causal, may not be appreciated as generating adverse events. First, the ‘boiling frog’ principle, in which we adjust to stressors if they occur incrementally or slowly, and become accepting. Thus, when omission and commission concerns are less evident, blatant or immediate, a patient may continue with the psychotherapy despite a progressive smouldering enmeshment process that, because it unfolds slowly or subtly, builds to the boiling frog analogy. Examples include an unstructured meandering psychotherapy that fails to address the patient's problems, or the therapist subtly prioritizing their own needs. Worse, the patient may be unaware of the exploitation and, as one consequence of the confused agendas, even enjoy it. As Beddoe observed: ‘Within days Max's visits became the most anticipated event in my day’ [4].

A second contribution is that, while there is usually a clear-cut causal process in establishing a drug side-effect, it is less easy to argue any temporal causal link associated with psychotherapy. For example, if a depressed patient is commenced on an antidepressant drug, and they report immediate sedation and weight gain, the drug is the a priori causal agent. For a depressed patient receiving ineffective or inappropriate psychotherapy, negative consequences lack the immediacy of a distinctive drug side-effect. Even if the patient feels some discomfort about the psychotherapeutic approach and/or the psychotherapist themselves, there is a risk that such concerns will be rationalized (e.g. ‘I'm aware that therapy will take a long time’; ‘I'm not so sure about my therapist, but maybe that's my fault’) rather than being linked to something lacking or inappropriate in therapy.

If patients were given information about possible adverse effects or simply that it may not work, they might stop earlier when less harm had been done (or in some cases never start).

However, unlike with drug therapies, information on possible adverse effects is generally not given with psychotherapies or indeed many other non-pharmacological interventions.

 

[Cheshire]

I just came across blogposts and articles linked to this topic:

A Synopsis of the Side Effects of Psychotherapy – What Should Clinicians Know?
by Dr James Graham

It overlaps with the elephant on the couch paper and adds a few interesting things. One interesting remark is that, contrary to a pharmaceutical treatment, psychotherapy's side effects question the therapists' skills:

A therapist has a legal responsibility and may face malpractice if the reported side effects were caused by incorrect therapist behavior rather than perhaps just aberrant patient behaviour.

http://psychscenehub.com/psychinsights/the-side-effects-of-psychotherapy/

A Disorder for Everyone?
by Keir Harding

This article is focused on the way people are labelled as having a personality disorder and how this can lead to harsh treatment and be stigmatising:

The event comes at a poignant time. Earlier in the week I’d lost someone I was relatively close to (as close as you can be to someone you have never met) on twitter to suicide and I was at an event where her passing was to be acknowledged. She was almost described as someone who ‘had’ personality disorder and I was glad to be able to point out how much she (and eminent psychiatrists) rejected that label for her presentation, how she felt that it had led to a ‘care’ plan she felt to be brutal and dehumanising and how she saw the label as something that had led to the staff around her acting in a way that was toxic to her. So in a week where the damage labels can do is on my mind more than usual I was off to find out more.

Those are the problems within the system, let alone the insult inherent in labelling someone as having a disordered personality. I can intellectually accept that we all have personality traits, that some of those can cause us difficulties (mine do!) and that if they cause us serious difficulties that could be described as a disorder. The difficulty in this field is that the majority of the people getting this label are those who have lived through experiences of neglect, abandonment and outright abuse. To then label them as disordered rather than seeing them as having an understandable response to their experiences then seems to be somewhat callous.

Jacqui Dillion (Dr Jacqui Dillion no less) finished the day off with a description of her journey through life, services and activism. It was a captivating talk with far too many people who you might expect to be helpful being outright abusive. We heard experiences being discounted as illness, emotions being discounted as illness, anger about not being believed discounted as illness and a host of people who should have helped replicating the abuse of the past. It was this part of the day I found most affecting and it was heartening to hear Jacqui talking of what made life liveable for her again. Not some magic therapy but someone who would listen, someone who would validate and someone who empathise.

https://thediagnosisofexclusion.wordpress.com/2017/12/11/a-disorder-for-everyone/

Some mental health services are telling patients: ‘If you really wanted to kill yourself, you would have done it’
(HT @JohnTheJack )

This heartbreaking article talks about the way understaffed wards try to get rid of suicidal patients sometimes with a few badly used behavioural tools:

The approach to suicide prevention Laura is receiving is based on a behavioural “carrot and stick” approach to mental health. The idea is to shape behaviours into ones which are healthier in the medium term by positively reinforcing only “healthy” boundaried behaviours, though distress can increase in the short term. This kind of approach is very dangerous if it is transmitted in a judgmental, blaming way; it should only ever be attempted slowly in collaboration with patients with the explicit recognition that change is incredibly hard, and that patterns of behaviour in the face of overwhelming distress have developed for an understandable reason.

And more often, patients are thrown out with no help at all:

Tom is 22 and has made a couple of serious attempts on his life following prolonged periods of depression. “When I regained consciousness after the last attempt”, he said, “I was told ‘If you really want to kill yourself, you would have done it’.” Tom, like many other people, feels like when he now contacts the crisis team, they treat him brusquely. “It is like they will only take me seriously if I actually die”, he continued. “I am told again and again ‘well if you really want to kill yourself, that’s your choice’.”

Laura, 60, has also made multiple attempts on her life. She has been told that she should “take responsibility” when she is feeling suicidal, an idea fuelled by the neoliberal discourse of rights and responsibilities which has taken hold of mental health services. “There is a strict management plan and boundaries in place”, she said. “I am allowed to call the crisis team three times a week, and the calls are time-limited. When I do call, I am only allowed to talk about the present not the past”, she says. “If I try to talk about anything else, or call at another time, I am told I am ‘threatening suicide’.”

http://www.independent.co.uk/voices...ed-staff-high-risk-underfunding-a8110186.html

 

[Woolie]

I have another friend, a Social Worker, who works in a hospital's cancer unit as a counsellor with terminal patients. The counsellors are instructed not to bring up death with the dying patient, and not to encourage discussion of the patient's feelings / thoughts / meaning about their imminent death.

!! What do they talk about then? What a nice day it is?

 

[ScottTriGuy]

!! What do they talk about then? What a nice day it is?

Canadians always default to talking about the weather, so probably.

 

[Invisible Woman]

I have another friend, a Social Worker, who works in a hospital's cancer unit as a counsellor with terminal patients. The counsellors are instructed not to bring up death with the dying patient, and not to encourage discussion of the patient's feelings / thoughts / meaning about their imminent death.

How unbelievably cruel!

If it were me I would rather no counsellor at all than a counsellor taking up my resources deliberately not giving me the help I need.

If they're not going to help folk come to terms with death and dying, why are they there at all? Sounds to me like they should be fired.

 

[Daisy]

Both my brother and the husband of a friend's appear to have experienced a similar sort of psychotherapy whereby traumatic events were " put in a box". The memory of those events can no longer be accessed consciously at least. Both use the same terminology so it sounds like they had the same sort of therapy.

Although this may be a short term solution to coping with the events long term it has caused problems for both families. Sadly as sometimes happens in families history repeats itself and both my brother and my friends husband are ill equipped to deal with this because the memories of the previous experience are in the box.

Although the conscious memory maybe in the box, I'm not convinced that the emotions relating to those memories have been so well contained.

I say to my brother you must remember so and so which happened in our childhood and he genuinely doesn't. He has very few memories of childhood at all.

Having seen the impact of this kind of therapy on both families I'd advise anybody who comes across it to be very cautious indeed.

 

[Woolie]

A Disorder for Everyone?

I'm a bit conflicted about the personality disorder question. Mental health professionals treat ppl with this diagnosis with utter contempt. So I agree the diagnosis should be banned, it does more harm than good. Also, I'm not convinced it's a disorder as such. Just a problematic way of thinking, feeling and interacting.

But the way that some troubled people attribute their problems to "past trauma" can be hugely damaging to those around them, and I don't like the way therapists encourage this. If you've ever talked with decent parents whose PD offspring have blamed them for everything that went wrong in their life, you'll know what I mean. This sort of other-blaming has been going on too long in mental health settings, and needs to stop.

Whether we agree with the label or not, we've probably all known a person with a BPD-like temperament - someone who's funny and entertaining, who seems to want to get close to us fast (perhaps a little too fast), and they're quick to share their harrowing stories of multiple past wrongs that have been done to them. But then as soon as this person feels let down by us in some way, everything switches. We get added to that list of terrible people. We hear our past actions being recounted in ways that are unrecognisable. Its not necessarily lying. Its the powerful biasing effect of their strong emotions.

Anyway, if you've ever had that experience you'll realise that accounts of past "traumas" in highly emotive people should be taken with a pinch of salt. They can be very hurtful - to the person being accused.