negative effects of therapy

More people are in therapy now than a generation ago. Some benefit from it, some don’t. Not everybody is comfortable opening up to a stranger, something I totally understand, because I would find it hard to bare my soul to someone in the transactional way in which therapy occurs in practice. That is why I empathize readily and try to put patients at their ease. It is also why I feel for those who are mortified at the thought of opening up, and weep hot tears of shame after they do.

It was in 2009 or so that I began to notice that therapy had limitations. Sometimes therapy didn’t help a patient at all. Sometimes it created a new set of problems for the patient, usually interpersonal, which made me question what I was doing wrong.

At that time I could not find much useful research on why therapy might be ineffective or harmful. I went over the notes of my sessions and summarized their outcomes as honestly and objectively as I could, trying to figure out how therapy worked, or didn’t work, for different patients.

A combination of psychiatric medicines and psychotherapy using an eclectic approach benefitted at least 80% of patients. Some patients said their medicines were very effective and they didn’t need to know what was wrong with them, and that it was enough that I knew what was wrong with them!

But when patients did benefit from therapy, I was never convinced that it wasn’t only because I had seen many more summers than a lot of my patients had, plus I had looked closely at the inner lives of hundreds of people over the years. Then, was it more of experience and less of method that mattered? It’s hard to tell, because for a professional in any field, domain knowledge becomes second nature, something taken for granted.

Many types of therapy exist, with rigorous rules laid down for their practice. But I still see therapy as quite subjective because, no matter what a method is in theory, it finally passes through the medium of the therapist’s psyche and is influenced/modified by the person she is and the antecedents that made her who she is. It is not as simple as cooking from a recipe, though, in that too, the nature of ingredients can differ due to local factors and the final product can turn out different than what is expected.

***

As a psychiatrist I am expected to be neutral when a patient tells his story. But I have to separate the chaff from the grain in his jumbled outpourings, for which I have to judge what is chaff and what is grain. A certain amount of subjectivity creeps in right away. And every prompt and um-hum might seem a micro-judgment to him, regardless of my neutral tone and expression.

The deepest currents of meaning and knowledge take place within the individual through one’s senses, perceptions, beliefs and judgments . . .

This requires a disciplined commitment to remain with a question intensely and continuously until it is illuminated or answered . . .

– Clark Moustakas

Psychotherapy as a treatment modality is necessarily, inherently, a heuristic process for a psychiatrist attempting to tune into a patient’s frequency. She first has to put herself in his shoes to see where he is coming from.

I am well aware that I can fall prey to cognitive biases in this heuristic process: availability bias, confirmation bias, egocentric bias, framing, representativeness – and all sorts of unconscious ones besides. And, sometimes, I do. Just as judges do, despite having strict laws to base their judgments on, because judges are also human, and deal with the unpredictable doings of other humans. An investigative interview conducted by police to gather information can also falter if a suspect is hard to read, or ready to confess to anything he’s accused of, out of sheer anxiety.

There are  hundreds of variables in the complex therapeutic relationship between psychiatrist and patient that influence what is said and what meaning is taken. The patient is not a passive recipient of psychotherapy; he is a thinking person who is weighing what and how much he can tell his doctor.

Intuition, thin-slicing, tacit knowing and non-verbal communication are as important as what is being said. Sometimes I pick up on a tell and pursue it with surprising results, but cannot explain how that happened, not even to myself. If I were contributing data to an evidence-based study I would feel restricted because staying with a script would mean not following up important leads that I catch in the spaces between utterances, the non-verbal parts.

I have often been guilty of positivity bias and shown more optimism than a patient’s situation merited. I have had to check my inner Pollyanna several times when empathy and wishful thinking briefly eclipsed facts.

So, basically, I have to watch out for my own biases all the time.

***

I recently revisited the problem of negative effects of therapy after a 20-year-old girl told me that she had confronted the adults in her joint family about the sexual abuse she had been subjected to by a family member as a little girl. She had not wanted to, but an older cousin who had been similarly abused by the same person had convinced her she should. She felt exposed, angry and confused, because the adults ‘trivialized’ it – played it down – exactly the way she knew they would.

In the earliest years of my clinical practice I might have naïvely suggested exactly what the cousin had, with the expectation that her mother at least would support her. And I might have counted the unhappiness and anger she felt when that didn’t happen as some sort of ‘negative effects of therapy’.

Now, this young girl wanted to transcend that experience, build a successful career, so that the memory – and the perpetrator – became insignificant in her life. She didn’t want to talk about it. In fact, she said, “I will not be a victim and give him so much importance”. To deal with it in her own way was her prerogative; sometimes therapy means leaving well alone. True, time might never heal a wound completely, but neither might therapy.

***

There’s more literature published on the negative effects of psychotherapy now than what was available to me in 2009.

These are some of the negative effects of therapy listed by various researchers. Most psychiatrists encounter them and find ways to reduce their impact.

  • Worsening of symptoms: Symptoms can worsen temporarily in the first 2-3 sessions because old scabs may be peeled off, leaving old wounds exposed.
  • Treatment failure: The worst cases I have seen are those where someone unfamiliar with mental illness has failed to diagnose a psychotic break and has tried to reduce the patient’s agitation with ‘counselling’.
  • Emergence of new symptoms: Patients who present early in the course of a mental illness can develop new symptoms unrelated to therapy, e.g. obsessions being addressed in therapy could turn out to be prodromal symptoms of schizophrenia. Acting out, common during therapy, might be reported as an alarming new symptom, or worsening caused by therapy.
  • Heightened concern regarding existing symptoms: The line of questioning leading to a diagnosis can be unsettling for a patient. Explaining the biological or psychological basis of symptoms helps, also outlining what can be done, treatment-wise.
  • Suicidality: a patient treated for depression sometimes snaps out of inertia and finds the energy to plan and execute a suicide. So all involved – doctor, patient and the people the patient lives with – must be alert to signs. In some cases, depression might be the only visible part of a deeper disturbance, and the provisional diagnosis might not point to the possibility of self-harm.
  • Occupational problems: People sometimes function best on high alert, juggling multiple balls and deftly keeping them all up in the air, albeit at a steep cost to their mental health. If a patient is distracted from this hyperfocused state too fast with the intention of reducing anxiety, he might lose focus and drop all the balls, and this can cause serious problems at work. Therapy takes time.
  • Stigmatization: This can happen when a patient shares the fact of his treatment with people he believes are his wellwishers, but they use it to control him instead. He might be disillusioned  and need support to hold on to the gains he has made.
  • Changes in the social network: Self-awareness and insight are products of therapy. A patient might distance himself from toxic people and develop healthier social ties. This could have negative effects on his support system, yet be positive for his growth.
  • Strains in relationships: If a patient gains new perspectives and seeks a more equitable relationship, a close family member whose self esteem is tied up with his sick role might react angrily and put a strain on the relationship.
  • Therapy dependence: A clarification at the beginning that therapy will only be for a short time – the way a plaster cast is retained only until broken bones are healed – can pre-empt dependence.
  • Undermining of self‐efficacy: Some people fall in their own estimation if they see themselves as needing to be propped up by another person. A psychiatrist must watch for this and prevent damage to a patient’s self-image.

Recent studies have concluded that adverse effects occur in 5-20% of patients, and 50% of patients show no clinically significant change with therapy. Most of the published research is based on patients being treated by therapy alone. Since psychiatric treatment is a combination of phamaco- and psychotherapy, our patients ought to be doing better than what these numbers show . . .

***

Psychotherapy is not like fundamental Physics. It’s a human interaction, with all its imperfections. If anything, mental illness is closer to String Theory in its simplest form! Most psychiatric symptoms are an exaggeration of normal thoughts and feelings, like the vibrations of strings that make them look like particles. They can be toned down with medicines and psychotherapy.

Calling therapy an art would make the treated patient a product. Calling it a science would mean that a patient’s recovery is backed by strong measurable evidence and the results can be replicated in another patient by repeating the process. How is that possible, when each patient, his circumstances, as well as a therapist’s own inner life are all in flux all the time? The approach has to fit the need of the moment and a lot depends on the rapport between doctor and patient.

It is difficult to observe the effects of psychotherapy on patients – the way one might study the effect of heat on copper sulphate crystals – because the therapist factor greatly affects the process, as does the patient’s capacity for introspection and abstraction. For that matter, even pharmaceuticals do not have the same effect on every patient and, therefore, a list of  possible idiosyncratic side effects comes with every medicine.

Therapy is only possible because the experience of being human is common to all of us. We have all been there, or been somewhere like it.

‘It came upon her now, as it always had done: a happy flood of feeling, a wild unrest. This moment counts. This moment, and no other. That old man with a crutch, that woman crying, the boy with a spinning top, those lovers smiling: they were part of something known and shared and remembered, an oft-recurring richly coloured pattern. The child who fell in the gutter was herself and so was the the girl who waved from an upper window, “This was what I was once, I’ve been them all” – that aching heart, that burst of sudden laughter, those angry tears, that bubble of desire.’

– From Mary Anne, by Daphne du Maurier

So, the ability to synthesise the disparate facts of an anxious or depressed patient’s life into a cogent whole that he confidently recognises as a better and manageable version of himself is perhaps neither an art nor science. It is a perspective, or a skill, like the ability to do mental math like a whizz, or the ability to visualise a prospective movie frame by frame while reading a novel.

A psychiatrist ultimately uses her personhood as an instrument to empathise with the patient; she syncs her mind with the patient’s, then disengages herself to analyse the information objectively. It takes time, effort and a lot of introspection to get closer to the unachievable target, perfection, on the lines of ‘aim at a star and you’ll shoot high’. Even so, some unexpected developments – side effects – can occur in the process of therapy and must be dealt with as par for the course, the way we do with medications.

A little about taking medicines for depression and anxiety

‘Depression’ and ‘anxiety’ are two problems for which people often seek help. Help from family physicians, counsellors, psychologists, therapists, psychiatrists, reiki experts, yoga teachers, NLP practitioners, astrologers and a host of other possibly helpful people.

Very depressed people don’t much care what happens to their lives, and very anxious people can barely listen to anyone, even if they try. It’s difficult to reach them. Medicines can bring down depression or anxiety enough to help the patient think a little more clearly, and listen to what people concerned about his wellbeing are telling him.

Many antidepressants reduce both anxiety and depression. Extremely anxious people may need an additional dose of an anti-anxiety medicine for a week or two.

  • Antidepressants are not addictive and are usually given as a course for a few months.
  • Side effects usually appear at the beginning of treatment, last just a couple of weeks or so, and get lesser day by day. In case they don’t go away, there are other options.
  • Side effects cause some discomfort, but don’t affect work – and life in general – enough to discontinue their use. You don’t have to throw the baby out with the bathwater.
  • Therapeutic effects are seen in less than a fortnight with some antidepressants, although some can take up to 1½ months to make a difference.
  • The choice of medicine depends on what side effects you are trying to avoid.

These medicines are like an umbrella. Under their calming influence a patient can sort out his life. He can do this either on his own – by coming up with better ways of coping, or by talking things over with his psychiatrist, a psychologist or a therapist. And really, if the depressive episode or anxiety attack was brought on by a situation, talking things through with a friend may be enough!

He can explore meditation, yoga or any other lifestyle changes that he finds useful, and make them a part of his life from then on. If he can figure out what triggers anxiety or depression in him, that’s useful too.

More medicines to combat side effects of psychiatric medicines – isn’t that unfair?

This seems like the ultimate injustice, if I go by people’s blogposts.

Actually, there are very few situations where this needs to be done. It usually happens with antipsychotics, the strong medicines used to treat severe conditions like schizophrenia.

We can’t inject medicines directly into thousands of those tiny synapses (the little spaces where two nerve cells in the brain meet and communicate through chemicals) that are defective in schizophrenia. Orally administered medicines go all over the body and affect other systems.

Even then, it is possible to switch to a medicine that does not cause the particular side effect that the patient finds distressing. For example, one antipsychotic causes restlessness and a need to keep moving. Changing to another equally effective antipsychotic gets rid of this side effect. Since every patient does not get every side effect listed in the books, we can be optimistic about finding a fit, a medicine to match the patient’s needs.

Agreed, we are sometimes in a situation where we have to prescribe more medicines to control side effects of medicines used for treatment. Research is underway to find better molecules that will be as free of side effects as possible. Until then we have to titrate doses of medicines to minimize side effects, without compromising on effectiveness.

I can say with certainty that the medicines being prescribed today are far superior to those that were available 25 years ago, mainly in terms of side effects. And a preview of those in the pipeline tells me better medicines are on their way.

Side effects of psychiatric medicines

I am often surprised by blogposts where someone declares that he will never see a psychiatrist. I wonder what else can be done for illnesses that are a result of neural circuits that don’t work, because connections between some nerve cells are lost and need to be reestablished. This is how medicines work. And they DO work.

Psychiatry is about biology.

Psychiatry is mainly about behaviour disturbances caused by biology. Psychological factors are relevant only where, for example, too many stressful experiences can impact ‘risk genes’ and cause mental illness. Or being stressed for a long time can prevent brain cells from growing. Things like that.

IMG_1445

The brain is an organ. The ‘mind’ is a process. This process happens because cells in the brain connect environmental cues, thoughts and feelings, and generate actions. Mental illnesses are a result of this process being interrupted at different points.

Going by what I’ve come across on the net, most people seem upset by side effects of psychiatric medicines. If the rule ‘start low and go slow’ is followed there should be practically no side effects. At least, no more than what you get when you take an antihistaminic for a cold.

Medicines are not magic potions. They are not going to make your longstanding problems disappear overnight. They need to reach a certain level in the body before they show the effects you want to see. This can take a few days. If you start with a high dose, or raise the dose too fast, there will certainly be side effects.

Starting low introduces the medicine to your body and lets you know what sort of side effects you can expect. For example, if you are likely to react with stomach acidity, you’ll get a mild attack with a small dose, and something can be done about it.

Signs of mental illness

This series of articles on how to recognize common psychiatric problems was published in the newspaper DNA between January and April 2012.

Anxiety / Tension: why it needs treatment

http://www.dnaindia.com/health/comment_anxious-all-the-time-seek-help-to-relax_1676607

Severe mental illness, or Psychosis

http://www.dnaindia.com/health/comment_psychosis-between-15-and-25-be-a-little-more-careful_1676639

What are the symptoms of ‘mental illness’?

http://www.dnaindia.com/health/comment_are-they-mood-swings-or-mental-illness_1676648

OCD, or Obsessive Compulsive Disorder

http://www.dnaindia.com/health/comment_ocd-when-theres-too-much-of-one-thing_1676610

Schizophrenia

http://www.dnaindia.com/health/comment_relatives-of-schizophrenics-face-10-times-more-risk_1676630

Mood Swings: when ‘moodiness’ needs treatment

http://www.dnaindia.com/health/comment_bipolar-disorder-when-the-mood-swings-just-like-a-see-saw_1676617

Depression

http://www.dnaindia.com/health/comment_depression-when-everything-seems-boring-theres-a-problem_1676620

ADHD, or Attention Deficit Hyperactivity Disorder

http://www.dnaindia.com/analysis/column_adhd-some-children-just-cant-stay-still_1693165

‘Difficult’ children

http://www.dnaindia.com/analysis/column_criminal-behaviour-nip-it-in-the-bud_1693163

About this blog

About children and parents

I believe that being a parent is a privilege and a responsibility.

I have a certain amount of experience dealing with children: babysitting siblings and cousins through the teens,  a stint as a resident doctor in the Pediatrics Department at St. Martha’s Hospital, Bangalore, before qualifying as a psychiatrist; training in the Child Guidance Clinic at NIMHANS as part of the post-graduation course; seeing children with psychological problems in clinical practice for more than 15 years; finally, raising my own children.

The last has been the most instructive. Being together, watching, listening, guiding, trying to stay tuned without intruding into their space, and of course, the arguments and deals. Like most parents I know, I have learnt a lot from the little ones.

About the role of religion/spirituality in raising children

Religion can be a robust positive force in shaping children’s values. I believe we can use it to teach children to respect other people’s beliefs, even when they are different from their own. Religion can help children develop a conscience, a moral compass, from which should flow empathy, integrity, courage – qualities we want in our kids. It can be a scaffold for a child to stand on while he builds his value system brick by brick; he can discard it when the stronger structure of his adult personality is firmly in place, if  he wants to.

About mental health

I have been talking and writing about mental health now and then.  I might put up some of what I’ve been saying on this blog and add to it as I go along.

About whatever appeals to me in nature

Life is short. I remember when I used to think there was lots of time – when I was eighteen, and had just entered medical college. I appreciate the beauty of the earth in a different way now; I look at things and places as something I have had the good fortune – or privilege – to see. That’s what the photos on this blog are, an acknowledgement of that privilege.

About human history, especially ancient times and how we came to be 

I don’t think I’ll ever stop being fascinated by how we evolved to be who we are today. I know so little about it that everything I read is new information. I write down the things that help me piece together the history of ordinary people.