The Decline of Big Pharma and the Rediscovering of Psychotherapy


An article in the December Archives of General Psychiatry just reported that only 43 percent of people who sought treatment for depression went to a psychotherapist. This is part of a larger trend over the past couple of decades that has seen the number of people referred for therapy by physicians drop nearly 50 percent. 

Today, physicians dispensing meds are the main source of treatment for most depressed people. At the same time, there’s increasing evidence that Cognitive-Behavioral approaches--along with other forms of psychotherapy--work at least as effectively as meds for many clients, and have no side effects.


Curious about the latest therapeutic advances in working with depression? Here are a few useful resources you might want to check out.

In “Deconstructing Depression,” featured in the November/December 2010 issue, Peg Wehrenberg distinguishes between four very different varieties of depression--neurobiological, traumatic, situational, and attachment-related--that are currently lumped together by DSM-IV.

This coming March at the 2011 Networker Symposium, she’ll also offer a workshop called “The Ten Best-Ever Depression Management Techniques,” demonstrating how to best match treatment with a client’s specific form of depression.

Starting January 7, Michael Yapko will be giving a webinar, “Beyond Pills: Effective Therapy with Depressed Clients,” which not only surveys the empirically-supported treatments for depression, but also explores how hypnosis and mindfulness practice can enhance accepted psychotherapeutic methods. As part of the webinar, he’ll be presenting a clinical video demonstration.

Please let us know your questions--as well as what you’ve seen from your own experiences--about what works and what doesn’t when treating depression.

Rich Simon
Editor, Psychotherapy Networker

12.14.2010   Posted In: NETWORKER EXCHANGE   By Rich Simon
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    • Not available avatar 12.21.2010 13:03
      I am not a big fan of meds, it seems like psychotherapy gets to the root of the issue and sometimes medication masks the symptoms and they are never addressed.
      • Not available avatar 12.21.2010 13:31
        I think CBT is so important while working with a client who is dx with depression. It gives them tools to work with and empowers them. However,often times, the depression is physiological and needs med. mgmt. I have seen positive results with both. Ideal situation is using both simultaneously.
        • Not available avatar 12.21.2010 14:18
          I ageee meds are necessary for depression with the goal to wean off the meds over time CBT is one approach however I believe there are multiple psychotherapy approaches whic can be utilized in a perscriptive manner depending on how the client responds. some of the approaches include Mindfulness, Narrative, psychoeducational, and motivational interviewing just to name a few. and at times it is effective to integrate some of the approaches, again depending on the clients responses to treatment approaches.
        • 0 avatar Colleen M. Crary, M.A. 12.21.2010 15:09
          As a person with C-PTSD (which was undiagnosed properly for over 2 decades)and an M.A. in Forensic Psychology (perhaps one day I will be a therapist, not sure atm) I believe that meds can be helpful *FOR THE SHORT TERM*. For example, in getting a patient settled and focused enough so that "talk therapy" (not a total fan of CBT) can be effective. But meds should be used _sparingly_ and _for short lengths of time_.

          The withdrawal from Cymbalta and Xanax and some of the others after long-term use can be extremely daunting. And I am quite dismayed at the heavy-handed use of meds by the military and some psychiatrists, particularly in the treatment of anxiety disorders. Some of the people in my organization are on chemical cocktails so heavy (5+ medications) that they have trouble functioning--and I cannot see how CBT or any type of therapy is helping them when they are doped up, overweight, and overmedicated.

          So, short term, in order to enhance and expedite talk therapy is great. Long term and heavy doses--no.

          Thank you for this forum,
          Colleen M. Crary, M.A.
          Fearless Nation PTSD Support
        • Not available avatar 12.23.2010 08:40
          I totally agree with you.
      • Not available avatar 12.22.2010 03:12
        I totally agree. I struggle with the derth of therapists who are fearful instead of courageous in working with depressed patients. Fear leads to managing the symptoms and shutting down the life energy instead of looking at the full potential of the person and how they can retrieve those shut down parts. IFS (Internal Family Systems Therapy) is powerful for treating depressed patients. Donna Roe Daniell, LCSW www.findbalanceinyourlife.com
      • Not available avatar 12.22.2010 03:19
        I have been a psychotherapist for over 35 years and have treated numerous people successfully for depression without drugs ... part of my frustration over the last few decades is that most people who walked into my office had already been put on anti-depressants by their physicians and so I was not only working with their emotional issues, but also helping them get off pharmaceuticals. I strongly believe in the link between learning to identify, express and release old anger in a newly empowered way and overcoming depression... combined with helping people get in touch with their authenticity, their soul and validating this experience for them. The only time I've seen necessary for pharmaceuticals is in cases of extreme PTSD from childhood trauma...
        • Not available avatar 12.22.2010 11:25
          A recent article address the fact that medication use was up but therapy treatment was down which leads one to wonder how this could be. Who is doing the prescribing? The obvious answer is physicians. Why are they not providing referrals is my next question?
        • Not available avatar 01.06.2011 05:43
          Please read my comment above, posted Jan. 6, 2011.
      • Not available avatar 12.22.2010 03:46
        One aspect of therapy is the clinician assisting the patient to dissociate their mental state with the physical state. Pharmacological solutions are limited in their capacity to manage psychosis and the mind/body connection/disconnection should be at the forefront of any ongoing treatment. Experiences and learned response to inside forces should always be explored and discussed, and then medication being the adjunctive to the psychotherapeutic focus. Patients need to understand the root of their affliction and therapy should discover this, then work to mend it. Pharmacological treatment alone is similar to applying a bandage on an open fracture.
      • Not available avatar 12.23.2010 03:50
        An article appears today in Medpage, once again showing the strong effects of placebo. http://www.medpagetoday.com/PainManagement/PainManagement/24056?utm_content=GroupCL&utm_medium=email&impressionId=1293093041681&utm_campaign=DailyHeadlines&utm_source=mSpoke&userid=270111 It is not surprising, albeit disappointing, that so many patients, and their doctors, turn to something that has a good chance of working easily. It is also important to realize that some depressions are biochemically related to other physical disorders such as pituitary tumors. Unless the underlying tumor, in such cases, are treated the many psychological symptoms will not remit no matter how much therapy one has.
      • Not available avatar 01.06.2011 05:41
        Speaking from the other side of the couch, I have noticed that there is a bit of a'fad' band wagon in the therapy world that seems to go in cycles. Several years ago the trend was to think that everyone needed meds, today the trend is often to decide that no one does. As someone who has personally suffered from a depression/anxiety disorder since I was a kid (of course, one could also just say that I was just moody, tempermental, an insomniac and generally bitchy) and who has many family members with mental/emotional disorders, I can tell you first-hand that some people benefit from long-term meds, and some don't. My grandmother was over medicated and didn't get out of the psych ward until they finally took her off medication. Personally, since I started taking 10mg of paxil a day, I have gone from being disfunctionally sleepless, disproportionately nervous, and generally a neurotic mess, to being completely functional and generally happy. I am from a secure family, my parents are happily married after 50 years, my sister is happily married, as am I, life is good, I have no financial worries and I love my job. How is it logical then, that I should I be as miserable as I was before I went on paxil - more miserable than the friends I have whose fathers deserted them, whose marriages are a shambles and who hate their jobs? How does that make sense? I have tried therapy (with a fabulous, top-notch therapist), meditation, exercise, diet, self-help books, etc, etc, etc,... While all of these things are terrific and helpful, they didn't do a single thing for my anxiety and depression. Today, all my problems and hang-ups are exactly the same as they have always been, but they have shrunk from mountain-size to mole-hill size, they are manageable and they don't run or ruin my life. I believe that I have a chemical imbalance in my brain and I intend to take paxil for the rest of my life. For those whose comments below indicate a pre-conceived carry-all opinion, please consider approaching your patients as unique individuals with unique disorders, some of whom may be like me.
        • Not available avatar 01.12.2011 04:40
          I too believe I have a chemical imbalance. I have been on prozac for 20 years, and it "pooped out" Now Im trying different combinations and it is very difficult. It has been 6 months of trial and error, and very stressful and lonely. Thanks for your insights.
    • Not available avatar 12.21.2010 13:39
      I agree that at times med mgmt is effective however in too many cases clients are placed on meds and left to believe that the medication is a necessity for a period extended over a number of years. If med mgmt and CBT are used together the reach should be to eventually remove the need for medication
      • Not available avatar 12.22.2010 04:28
        I honestly thought the numbers were already in. It's the combination of both meds, judiciously prescribed and talk therapy (concurrently, not consecutively)that the studies have shown to be most effective.
    • Not available avatar 12.21.2010 13:46
      I have been both a client/patient and a therapist. In my experience, while medication is often helpful at the start, as time goes on it becomes much less helpful, and by the time several years have gone by, is an outright drag on recovery. However, by then, the medications are very difficult to wean off of. Add to this the fact that doctors are very reluctant to help clients wean off (for fear of potential lawsuits), and you have a lot of people on meds that aren't helping them, and are in fact, for many, sapping motivation, adding weight (my guess is by modifying metabolism in some susceptible individuals) and damping down positive as well as negative emotions.
      • Not available avatar 12.21.2010 14:08
        I agree that medication can play an important role in assisting a client to manage depression especially at the beginning phases of therapuetic intervention but I am beginning to see clients who depend heavily on medication and who don't appear invested in finding a more psychodynamic approach to address the issues in their lives that are at the root of the depression.
    • Not available avatar 12.21.2010 14:11
      While medication is not the first thing I go for, as a client, I went through years of therapy, made loads of changes and was perplexed by the depression that persisted. I was prescribed Lexapro years after therapy and it changed my life as much as therapy did. No more crazy anxiety popping out of nowhere, no more sleep paralysis and no more depression. I've been taking it for 10 years without having to increase the dosage and have no side effects. So, I can safely say.....both have their time and place. Depends on the person. I would, however, never recommend medication without therapy.
      • Not available avatar 12.21.2010 15:23
        I am an LMFT, in therapy, and on both and Lexapro and Welbutrin. Maj. Dep. Dis is a family disease and a shitty childhood left me with PTSD and a Gen. Anxiety Dis. Therapy has helped a great deal with the attachment issues and the situational stuff while the meds help with the neurobiological and traumatic stuff. I don't know why we need to have this either/or conversation. I refer when there does't seem to be a situational pre-cursor to the depression or when the depression is worsening despite therapy. And I don't use CBT; I match technique to client need--that's why we have so many theories; because psychotherapy is not a one size fits all.
      • Not available avatar 12.31.2010 06:25
        Just read your comment...can you tell me more about lexapro as i have never heard of it. I am taking paxil and am experiencing depression at the moment which is difficult as you likely know.

    • Not available avatar 12.21.2010 14:11
      It has long been detrimental for physicians to prescribe antidepressants and anti anxiety meds without strongly recommending psychotherapy at the same time. In my practice I have found that the combination is the most effective.
    • Not available avatar 12.21.2010 14:23

      I've used neurofeedback in conjunction with therapy very successfully to treat depression in both adults and teens. Certain patterns of electrical activity are associated with depression, and neurofeedback can often be used to alter that pattern, dramatically reducing the time needed to successfully treat depression. Typically in depression we see left frontal slowing. I've been using neurofeedback in my little corner of a large public agency for over 5 years, and it has become a permanent part of my therapeutic toolbox.
      • Not available avatar 12.22.2010 01:26
        I have also used neurofeedback in a private group practice to successfully treat depression in some clients who wanted an alternative to med management. When I previously worked in a large community health center I was told to keep alternative methods away. I'm curious how you got support for neurofeedback at your agency?
      • Not available avatar 12.28.2010 06:06
        Could you share what equipment you use for neurofeedback and perhaps what to avoid using? Thanks for your input to the discussion.
    • Not available avatar 12.21.2010 14:57
      Although medication may often kickstart a process of healing, pills don’t teach skills. And medication don’t change the situation! There will always be a place for approaches that work on the cerebral cortex rather than the brain stem.
    • Not available avatar 12.21.2010 15:08
      I believe that there are cases which require meds and cases which require both meds and therapy. My experience has been that very frequently individuals who have experienced significant improvement in mood, thoughts and behavior along with insight and skills and thus, have discontinued meds under supervision have elected to restart meds since they experience a negative shift that only the discontinuation of meds seemed to account for.
      • Not available avatar 12.22.2010 08:57
        I think part of the negative shift you may be observing is the reaction to the discontinuation of medications/the withdrawal effect - which frequently causes worse symptoms than the original ones, and is hard to tolerate. I think the key is early intervention with psychotherapy before trying medication in the first place - which means creating opportunities for individuals to seek help earlier on, and to educate primary care physicians to make more therapy referrals before prescribing.
    • Not available avatar 12.21.2010 15:24
      One of the strongest reasons for my emphasis on psychotherapy as the mainstay of treatment for depression, and also many forms of anxiety, is that only psychotherapy, through narrative reconstruction, combined with cognitive behavioral processing out of destructive thoughts and beliefs, brings about a transformative change in a client that medications does not even address. I have found that this protocol brings out a client's strengths and native abilities, allowing a client to gain the tools and confidence to respond to challenges in her or his life that are at the root of most emotional difficulties. The assumption that brain function is the primary concern in treating depression (neurotransmission problems) leads many to believe that medication is primary and psychotherapy a possible secondary treatment mode. They overlook the effects that situational depression has on changing brain chemistry, as is recovery from depression effective in restoring normal limbic activity in the brain. In conclusion, we must guage the severity and duration of a depressive episode, when determing the psychiatric consultation and resulting prescription of antidepressants are useful to allow the client to regain a level of emotional energy and stabilization, to respond to psychotherapy.
      • Not available avatar 12.22.2010 03:19
        one of the biggest challenges facing vets is feeling like they are "damaged goods" after so much extreme trauma of war. They are missing "joy" and often feeling like they cannot fit back into a fast moving and very demanding society. Yes the drugs may help, and psychotherapy..but love is the key. Understanding that they have many wonderful qualities and that they are worthy of love and abundance is necessary.
    • Not available avatar 12.21.2010 15:28
      In area of country where I practise, agencies covered by state health care will cover med appts & psychotropic meds, but not counseling. Some of the people use some of their small amt of money to pay for psychotherapy w me as even they sense the need for both treatments.
    • Not available avatar 12.21.2010 15:41
      Being a masters level clinician in a community mental health setting I have seen the persistent pendulum swing towards psychotropics as the treatment of choice for the majority of folks seeking behavioral health treatment.It does appear that psychotherapy is still in favor with more middle class clients while indigent or lower class clients favor medication.
    • Not available avatar 12.21.2010 16:22
      The OP writes: "At the same time, there’s increasing evidence that Cognitive-Behavioral approaches--along with other forms of psychotherapy--work at least as effectively as meds for many clients, and have no side effects."

      In other words, therapy works no better than a placebo? Because that's what's been repeatedly demonstrated in recent studies about medications (except in cases at the outset of severe clinical depression). Actually, it's what Big Pharma knew all along and, with the cooperation of the American Psychiatric Association, kept hidden.

      It's almost shocking to see this come up for discussion without mention of Robert Whitaker's recent book, "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America." It's not an alarmist screed by a conspiracy theorist. It's based on empirical evidence: In cultures that don't resort to long-term use of psychotropic drugs, recovery rates are much higher.

      Every therapist should read it.

      I say this as both a therapist and a person who has been on antidepressants for 20 years. During my initial use, they made a remarkable change for me -- saved my life, in fact. But they have done nothing for me in years. But trying to get off them is a nightmare. Whitaker produces evidence that this is so because the drugs permanently alter the brain's structure.

      • Not available avatar 12.22.2010 05:43
        What do you mean nightmare. I also have been on meds for 20 years, increased dosage, added addiitional meds, and nothing seems to help at this time. Im considering weaning off meds, but it feels so daunting.
    • Not available avatar 12.21.2010 16:52
      Why do we continue to read that medication is no more effective than placebo?
    • Not available avatar 12.21.2010 17:11
      Drugging clients. Interesting to say.
      There is a talk by Ken Robinson on the website RSA.com, "Changing the Paradigm of Education". In it he says that we are drugging our children, and he shows a map of where ADD is prevalent. Children live in the most stimulating times ever and we ask them to sit in schools for far too many hours and pay attention to boring work. When they can't sit still we deem their behavior a problem and medicate them. Is the same thing happening with depression?
      I will suggest that the field of psychology needs to change it paradigm as well. The advent of Neuroscience will at some point incorporate psychology. Far too many mental illness may not be illnesses at all. As Howard Gardner suggested 20 or more years ago, we are all differently oriented, we are not the same. We must begin to understand others as we now understand people with different sexual orientations, which was also once a diagnosed "illness." The is not psychology which needs treatment, but social psychology which needs educating.
      One thing seems certain, if we react to someone as if they're behavior is the problem it will be.
      T A Hoppe dustproduction@gmail.com
    • Not available avatar 12.21.2010 18:05
      Acupuncture (specifically NADA 5-needle protocol) can help tremendously in detoxing off of prescription meds. Of course acupuncture can be of great use to regulate sleep and anxiety. Amino acids are an alternative to pharmaceuticals as well. Acupuncture can also can decrease side effects of medications.
      • Not available avatar 12.27.2010 02:59
        Acupuncutre is very helpful for many things, along with yoga and more holistic approaches. We need to move beyond duality/either or thinking and see the complexity, and the whole of ourselves and our clients.Different approaches and options need to be available for everyone. Clients need the freedom to choose options that meet their needs. We as a profession need to advocate and educate, not be run over by big pharma and big insurance. However, neuroscience and other advances may be our saving grace.
    • Not available avatar 12.21.2010 18:28
      I have the kind of depression where if I go off Wellbutrin and Lamictal, within a short period of time I am thinking of running the car in the enclosed garage, thinking of whether to bring my cats with me, planning to take valium first, etc.... should I run it late at night when neighbors wouldn't notice, I'll need a full tank of gas, etc. I know that the suicidal ideation is my major sign the depression is back and in full swing. I go back on the medication and in short order no more suicidal ideation. Also I get very hopeless and teary.... it's really bad. I would NEVER want to try to treat it with exercise, mindfulness, acupuncture, CBT etc. It feels very physical, like a fever when you're sick but worse because it's your mind that is kaflooey. For me it was a question of finding the right medication combination which took some doing. I've been on the meds for over 10 years now and will never go off. I'm 'me' with the meds, I'm stable. I'm sure there is depression than can be treated with other things than meds but not mine. That's my 2 cents, my experience. I feel worst because my son, when he was in high school, had to live with me with the depression untreated. By the way, I've been a psychologist since the late 80's and have seen many varieties of depression. I think it's really easy to talk opinions about this when you've never had serious depression. Let's hear from more of us who have. K in New Jersey
      • Not available avatar 12.22.2010 05:57
        Ive been on meds for 20 years. Had to increase dosage recently, due to "poop out" and combine new drugs. Nothing seems to be working now. Up to recently I felt "me with the meds" also, but am beginning to think they have just been a bandaid. Anyone else that feels these meds may have very bad long term effects?
      • Not available avatar 12.22.2010 09:08
        I am a social work student, but I have also experienced serious depression in the past. I was over-medicated (effexor, wellbutrin, risperdal)-- my reaction to the withdrawal from effexor caused a depression that I had never experienced before and lead to the prescribing of the additional medications. I was also taking Lyrica for pain. I think these medications can have a detrimental impact on the brain - at least that was my experience. With a lot of therapy, group therapy, meditation, and mindfulness practice, I was able to wean off the multiple prescriptions slowly, and I have continued to be healthy, prescription-free.
    • Not available avatar 12.21.2010 18:32
      I am a person that has benefited from both medication and therapy. At first I just had therapy. It was helpful, but I continued to have mood swings. When I went on medication, therapy was even more helpful because I was stable enough to apply what I was learning, instead of always being in a crisis. In my earlier years, my doctor tried to get me off the medication a number of times, and the results were not good. I would much rather be on medication and sane, than drug free and "crazy". I am now a therapist, and believe both are important.
    • Not available avatar 12.22.2010 00:11
      Medication to give a quick boost of encouragement so that they can become engaged and do the work needed for the CBT. In order to change the thinking there has to be at least a modicum of belief that change can happen and the meds offer that. If the patient is able to use the tools provided, then the meds can be short term.
    • 0 avatar judith gibson 12.22.2010 00:36
      As person who deals with long-term disability and pain, I am so thankful that many years ago my family practice physician said that pain and depression exacerbate one another. I'm an LIMHP and with several meds have been able to have a stable, good life with friends, family, and amazingly satisfying work. Help from professionals like he, who work with the whole individual without preconceived ideas of what helps EVERYBODY, has saved my life many times over. I'm a fan of psychotherapy for lots of folks, too; but for me, as well as for some of my clients, "fixing" our situations with counseling alone isn't an option. I hope we can all continue to listen carefully to folks, let them know about the options available, and assume that almost everybody should decide what's best for him/her at the time.
    • Not available avatar 12.22.2010 02:35
      It TOTALLY depends on the client, the client's experience, and the nature of the depression. As therapists, we should not limit ourselves with specific predjudices against any particular therapies. It is our job to know and understand as many therapies as possible (chemical and not), use them appropriately, or refer to those better skilled in a particular therapy.
    • Not available avatar 12.22.2010 04:39
      I am enjoying this conversation. Thanks, Rich. My pet peeve about this topic is that it is so often offered in the language of drugs “vs” psychotherapy. It’s not a contest. Our job is to become knowledgeable enough and creative enough to discover and implement the best course of treatment for each individual client. In my experience, the way to do that is to think expansively, not in the constrictive terms of “either/or’s.”
    • Not available avatar 12.22.2010 04:41
      I work in an impoverished area of Appalachia doing family intervention with “seriously disturbed” minors. Very often it is easy to see why a child is depressed and to help their parents to help them with that …. IF…. the parent’s have not yet been indoctrinated into the cult of the “chemically imbalanced thinking.” If they have, generally, by the time we see the child, they are often on an unthinkable array of high powered medications that are creating their own chemical imbalance – and the presenting problem is worse. When there is any bad report, dosage tends to be increased. When a parent asks that the medication be decreased there is sometimes, perversely, a tendency to increase or add a med.

      We need to educate the parents that these doctors have no actual knowledge of their child’s brain chemistry nor do they generally observe the behaviors they are treating - the parent’s reports are the only measuring instrument. They should be very assertive – but these are often poorly educated people dealing with a “medical expert”. Often times, of course, the parent’s own issues (as is true with all us parents) create distortions about a child and these are treated as literal facts by the psychiatrists. The rash diagnostic conclusions drawn from such parental reports by physicians would sometimes make for good humor, were it not impacting real kids.

      One child about to turn 18, issued a chilling statement. Approximately: “I can’t wait until my 18th birthday, so for the first time that I can remember; I can experience the world un- medicated.”
    • Not available avatar 12.22.2010 07:23
      I just read an article from the New York Times regarding a study that stated 31% of college students are so depressed it is difficult to function. What are the implications here? Are most going to start a lifetime of medication beginning at the student health center, or find other ways? The article alluded as well to hopelessness among almost half of the students questioned. On another note, I have never forgotten the depression management group I ran as an intern using basic CB techniques and the vast improvement of most of the clients.
    • Not available avatar 12.22.2010 09:00
      Could you post that NYT link?

      If so, thanks.
    • Not available avatar 12.22.2010 09:02
      As a person recovering from depression and anxiety, I found that a combined approach worked best. Today I am able to stay in a positive frame of mind by watching what I eat - sugar and wheat lead to definite down feelings, taking nutritional supplements - theanine by Thorne is really helpful right now, continuing in "talk therapy" for support, Using ESM (Emotional Self Management - an energy psychology) and working with an Applied Knesiologist. My primary care doctor has been helpful by signing for blood tests that track improving health. I tried drugs for a couple of years for anxiety and depression and felt they were only mildly effective. Fortunately, my AK doctor muscle tested a bunch of samples and we found the one that was helpful to my body. This saved a lot of time and frustration with experimentation.
    • Not available avatar 12.22.2010 15:32
      I am a psychoanalyst, and am very successful helping people with depression. I think if the depression is severe it is useful for medication to be part of the treatment, until they have come out of the depression enough to be weaned off the medication. The problem with medication is that it encourages a view and belief in the patient that privileges the chemical imbalance aspect of the problem and dismisses the life experiences and life situations that are causing the depression.
    • Not available avatar 12.22.2010 21:38
      Fascinating as this discussion is, it fails to consider the reality that the kind of depressed clients who walk upright into our private practices seeking help are a very tiny fraction of the much larger population of depressed and otherwise mentally ill individuals, most of whom are chronic, dysfunctional and incapable of asking for much of anything, let alone help to get well. The idea that these individuals can assist in their own recovery may be true for the limited few of these who understand that the concept of recovery actually applies to them and who have the resources (cash, insurance, a support system) to access therapy and who also recognize that there is a normal (beyond their current state) that is attainable by them. However, by definition, these are the highest functioning souls.
      Having worked with these populations in a variety of settings, I could rail with the best of them at the failure of the systems that are designed to care for these individuals and, instead, suck them dry and further deprive them of hope for anything better. And I could declare with absolute certainty that most meds are over prescribed and create dependency and often further disable clients because of their side effects.
      Or, I can tell you that these individuals are my heroes. They get up every day and come together in programs where they form, on however limited a basis, community. I laughed with them, I cried with them and I hope I supported their process. I gave them my presence and shared theirs, to the extent that it was possible to do so. We shared human contact. Anything else was mere happenstance and, possibly, ego (mine!).
      I can also tell you that, no matter my skills and good intentions, none of them would ever attain what we might describe as "wellness." And few if any could have even begun to consider such concepts as "cause" and "effect" as it might have related to their current condition.
      So, when we speak of helping our depressed and otherwise mentally ill clients, we must first be prepared to be present with them and hope that they will come to trust us enough to let us in. Their world is not like ours and, when invited in, we must be gracious guests. When someone is 7'5" tall, my telling him/her to think short thoughts is meaningless, to say nothing of useless, especially if the only entrance into my purportedly normal (and thereby desireable) world is designed for people no larger than 3'2" in height. In my experience, depressed patients do better in group therapy than in individual therapy. They don't need to feel sick so much as they need to find/form community.
      When clients show up, that tells me they are motivated. It is possible that meds will be helpful, or not. Unless they want meds, I am willing to work with them as is. Is this always successful? No. But it's a place of beginning and that is crucial. Once the client engages, then it may be possible to consider other potential treatment options.
      Unless my client represents harm to self or others, I am not the decider about my client's decisions. At best, my input may be sought and considered. My task is to create and maintain an airspace, a cushion of relative comfort, a sacred space where the client can think, reflect, consider and make decisions for him/herself.
      On a good day (and I've had some), this approach works well for me.

      Caryn, Oxnard, CA
    • Not available avatar 12.23.2010 03:14
      With the recent research on the effectivess of treating depression with medication, it's good to see the timeliness of what you have planned. I've been a follower of Michael Yapko for number of years and have used his techniques to treat depression with hypnosis. I look forward to what he has to offer in this upcoming series.

      Jennifer Sneeden, LMFT
      Boca Raton Therapist
    • Not available avatar 12.23.2010 10:35
      It is also important to assess for potential medical causality regarding depression. For example, some pituitary tumors and other neuroendocrine disorders often present with depression, anxiety, and even look bipolar (often misdiagnosed as such). Neither therapy nor psychotropics will fix such cases. Few of the psychiatrists I know assess for such things and even fewer therapists are aware of the prevalence and impact of these disorders.
    • 0 avatar Sara L. 12.24.2010 18:18
      Back in the day when practices actually had an integrative approach (with psychiatrists, clinical social workers, psychologists, family therapists, etc. all in the same practice)---things were far different than today. I see the mental health system today as fragmented and often doing a disservice to clients and to practitioners.

      Re: depression---if it is clinical (chemical) then medication can be extremely helpful (or if it is major depression with psychotic features then why would meds be withheld?) And why would meds be withheld except in the worst case scenarios? Sometimes meds are pretty much all that's needed (after education about these meds and the clinical depression is discussed--short term supportive therapy), sometimes meds and a lot of psychotherapy are both needed, sometimes meds and CBT are the ticket, or psychotherapy alone, etc.

      If the diagnostics are off, then the treatment will be also. What bothers me today is that with the fragmentation of care, I think the diagnostics are quite often off. Then it doesn't matter what is done, it won't be of help in the way it can be.
      Just tossing scripts at patients can be a problem, doing only psychotherapy (and being married to that position) or only CBT can all be problematic, I think.
      I've seen unipolar and bipolar depression be misdiagnosed as schizophrenia or borderline, I've seen meds given when they weren't needed and another type treatment was, I've seen CBT used only when the practitioner is versed just in that treatment or mainly in that treatment, I've seen patients in psychotherapy who were classic ADHD who did need meds go without them for far too long, spending too much time and money in psychotherapy.
      The bottom line to me is being a top-rate diagnostician first and foremost. If that not gotten right, then forget the whole thing. If the diagnostics are right (or close as they can be at this time) and an integrative approach is taken, then we all do better.
    • Not available avatar 12.27.2010 20:04
      How can you say that therapy has no side effects? Where is the conclusive research that shows that? Certainly, therapy that is less than fully effective has a lot of side effects, including disinclining people to turn to therapy again and, perhaps, increasing the length of suffering when medications may have been helpful for that particular individual. Neither medications nor psychotherapy are anywhere near as effective, today, as we would like (or as we pretend). The unexplained variance is generally at least as great as the explained variance, if not greater. With regards to depression, evidence suggests a similar outcome, given enough time, of therapy, meds, or neither. As research moves (hopefully) from linear to complex and dynamical analyses we may understand more, including the meaning of initial conditions, but for now our methods are much to crude and ineffective. Choosing between psychotherapy and psychopharmacology, today, is like choosing between a rock or a stick.
    • Not available avatar 12.28.2010 05:01
      My experience with clients who are receiving meds for depression and anxiety is that it is just putting a bandaid on an open wound. Without the tools to know how to cope with life's difficulties, clients are just walking around "numbed up" to the causes of the depression and anxiety which more often than not is a lack of coping skills. Giving these skills they can learn how to live again. No medication can provide that.
      • 0 avatar Sara L. 12.28.2010 14:05
        Then perhaps those clients were not diagnosed properly. For if one is truly clinically depressed, medication will not "numb you up", in fact, if you don't need it, it won't do much of anything at all---even if anxiety-disordered, if the right medication and dose is prescribed, it will not "numb you up"---and for those who have ADHD (and here I will speak about adults with ADHD), it can severely impact their professional lives and also personal lives. Why would medication be withheld? Why would it not be tried first thing unless the patient doesn't want it? When a person with adult ADHD is given meds for ADHD (if they will take medication) they will NOT respond as if on speed. IF they do, they've been incorrectly diagnosed. An adult with ADHD will find the right med (and dose) to be soothing (NOT stimulating) and will be able to focus in a consistent way, even if the task is something they do not like (ie, a task at work that must be done that they would have much difficulty with otherwise.)

        To say that "no medication can provide that" and (re: skills so "they can learn to live again" seems to miss the point I made earlier---the brain is just as "medical" as the knee, as the heart, as the kidney, liver, etc.--it's the executive center!

        Who would tell a person who has a severed ACL in their knee to cope with it by walking more slowly, by avoiding sports, never skiing again, etc? For that's what it would take and this could be done. If someone is adamantly opposed to surgery they can limit themselves and NOT have an ACL reconstruction. If an ACL replacement IS done (which involves surgery which we all know is high risk--surgery always is) then all of the activities that were done previously can be done again---there need not be coping skills "taught" where a person has to learn how to live again with a ruptured ACL in their knee. I watched my husband at age 40 try to do just this as his doctor said...that he was too "old" to require an ACL reconstruction (ie, he was not a professional athlete, etc.) This was all bunk. My husband had an ACL reconstruction with PT after and within a year could do anything he could do before, to include running, skiing, tennis, etc. without his knee going out on him.

        I think we sell our patients short (or border on malpractice) when we don't give them the option of medication when the medication will treat a medical mental illness. This said, I think there are many therapies and a reason for that. But we do best to be wise and not married to any one pet theory or treatment---or we might treat our patients poorly and short-change them.
        Again, I fear that diagnostics are not being taught in an integrative way anymore. Clinical major depression, unipolar and bipolar depression are NOT "sadness"or coping problems, and are not due to a "lack of coping skills"---clinical depression is a medical illness and deserves the right to be recognized as such! If you get pneumonia you don't want to be instructed in "how to breathe."
    • Not available avatar 12.28.2010 14:45
      I think anyone who can categorically dismiss antidepressants has never experienced serious depression. Yes, they are inadequate, full of side effects, of limited usefulness long-term for some people, and horrible to come off of -- speaking from personal experience. At the same time, also speaking from personal experience, hours of yoga and meditation daily, extensive lifestyle changes, and years of talk therapy don't always do it either. Chemotherapy sucks for cancer but depression kills a lot of people too, so it seems for the moment we are stuck with our inadequate collection of treatments.

      The thing I've found as shocking as the willingness of GP docs to prescribe meds without referring to therapists (which IS shocking) and the lack of adequate support from MDs in helping to get people OFF the meds, is the lack of awareness by both MDs and licensed therapists to the many physiological dimensions that underlie depression. How many docs or therapists take adequate histories -- including family history (not just of mood disorders), diet, exercise, supplement regimes, general knowledge about preventative self-care? How many are aware of the potential for a wide range of medical conditions to produce mood disorders well beyond hypothyroidism and pituitary tumors? Adrenal fatigue, CFS/fibro, a range of post-viral symptoms, chronic inflammation, hypertension, leaky gut, perimenopause, etc etc are chronic multi-system conditions that are still often misdiagnosed and then treated as primarily mood disorders. The mitochondrial dysfunction that is increasingly understood as underlying many of these conditions simultaneously messes with neurotransmitters, most of which are produced in the gut (how many therapists inquire as to gut health of their clients?). How many psychs or therapists are prepared to refer to a good nutritionist, for example? Or to recommend cortisol/hormone/neurotransmitter level testing? Or to refer to a good functional medicine doc who is prepared to take some time to look at the whole person?

      Even as therapists we are often still not looking at the whole person when we talk about depression; much of our language still engages in this mind/body separation that doesn't make much sense anymore. I really don't believe that depression and anxiety are primarily a "lack of coping skills" unless coping skills are understood also in terms of what biological resources the person has had to bring and can bring to ongoing stress. Coping in the face of stress, in other words, is not primarily or just a cognitive process. The body/mind's life-long stress load and its current capacity to "cope" with stress has to be looked at in a systemic way, well beyond I believe what current models of CBT (or many other modes of talk therapy) provide.

      I think our whole health care delivery system is so ill equipped to deal with the multi-system stress-mediated disorders of which depression and anxiety are a part. So it's left to exhausted, unhappy and stressed out individuals to piece together systems of care where the care-delivery clinicians don't speak to each other or even speak the same language or have the same conception of diagnosis, treatment, or recovery. Let's hope this is all changing for the better.
      • Not available avatar 12.29.2010 03:26
        12.29.10 Dec 45:30 and you other respondents: I too have seen the pxs of inadequate diagnostic work-up and it is getting worse as the disciplines go their separate ways. Therapists unaware of medical illnesses which have psychiatric sxs: MDs considering and treating Adjustment D/Os as more severe mood disorders. And the systems constraints on front-end time leading to a variety of malicious outcomes. I.e., need the fullest possible work-up to begin with and keep open mind until reasonably sure. I regularly have to 're-do' assessments in one agency I work at b/c the inquiries into a variety of domains are truncated (or non-existent) by a slavish adherence to a politically correct theory of treatment and recovery (North Carolina public system). So wish all of you who have given this your thoughts and hearts a Good New Year!
    • Not available avatar 12.29.2010 15:46
      Dear colleagues, all of you have so many thoughtful and helpful things to say. I think we also need to allow for our clients' participation in the decision-making, no? We may well have advanced training and specialized knowledge, but afterall, they have the right to make informed decisions about how they choose to proceed. Look, lets be honest; no one enjoys talk therapy as much as a therapist. Its not for everyone. We live in a society where everyone has come to expect to be satisfied instantly. If they don't choose to participate in therapy, we can't force them, whether we have earned MSWs, PhDs, or MDs.
      (ps - I am a clinical social worker, with 25+ years experience as a therapist, and a lifetime struggle with depression; all modes of treatment welcome.)
    • 0 avatar Hellmut Noelle 01.04.2011 13:28
      I've found that clients find their concerns about side effects are often minimized or ignored by their doctor. To assist my client's in their journey I've reframed the medication as an emotional pain medication to allow the real problem to be addressed more easily. Another thought, when was the last we heard of a client going through 1 years or more of withdrawal from therapy? Anti-drepressants, well, it happens all too often.
    • Not available avatar 01.12.2011 13:53
      So, how do you get your clients off the antidepressants after they have made healthy changes and are symptom free? Some people are very sensitive to these meds and even the smallest change can put them into withdrawal. Any help?
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