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Healing The Soul in the Age of the Brain
Becoming Conscious in an Unconscious World
by Elio Frattaroli, M.D.
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Question of the Week
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Q:
I have been in twice-a-week psychotherapy for five years, since I was about 30. I have been on Zoloft (and sometimes Klonopin) for five years as well. I started the therapy/medication after a period of intense depression and anxiety during graduate school. Recently, I reduced the therapy to once a week (although the session is a bit longer than standard), and I also reduced the medication from 150mg/day to 100md/day, because I have been doing well. For the last five days, I've been feeling much more depressed and anxious, and I don't think it's simply withdrawal because I stepped down the dose a couple of months ago.
First, do you think the reduction in dosage could be causing the change? Second, one of my main concerns is drug "poop out," because I might be one of those people who need medication indefinitely. So I guess my question is, can psychotherapy help protect against poop out?
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A:
I'm sure you understand that without knowing you or meeting you personally I can only make general comments in response to your questions.
I believe that symptoms are caused by inner conflict between an unconscious emotion trying to become conscious (which is disruptive but offers the possibility of change and growth) and the everyday personality that is geared to keeping the emotion unconscious (which maintains stability and comfort but at the cost of limiting the possibility of change). What medication does, when it works, is change the balance of forces in this inner conflict, either by diminishing the pressure of the unconscious emotion or increasing the effectiveness of the personality's defense/coping mechanisms. (If there is a genetic disposition or "chemical imbalance" it doesn't cause symptoms by itself; it simply aggravates the inner conflict so that it takes less stress to produce symptoms.)
According to this model, a fairly sudden increase in anxiety level (sudden enough that you can specify that it began five days ago) COULD be due to the Zoloft suddenly losing its effectiveness five days ago, but it's much more likely to be due to an emotionally stressful situation that happened or started five days ago that stirred up (increased the pressure from) a disturbing unconscious emotion. Of course there could be a combination of some stress and some decreased effect of Zoloft (whether from poop-out or simply from the decreased dosage that you wouldn't necessarily notice unless there WAS some stress) That's something you can sort out with your therapist.
On the question of psychotherapy protecting against poop-out. Psychotherapy helps us become more conscious and more accepting of our disturbing emotions and develop new and better ways of coping with them when they do get stirred up. In other words, it decreases inner conflict. That doesn't guarantee that you will never develop symptoms again. It means it will take more stress to provoke an inner conflict strong enough to produce symptoms and it will be easier to cope with the stress so that the conflict never gets to the point that symptoms become necessary. In that sense psychotherapy should protect against poop out because the medication will be necessary less often and won't need to be as effective when it is necessary.
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Previous Questions:
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Q:
What recommendations would you make for a couple one who is
involved in therapy and is "quest minded" and the other "swimming pool"
minded.
[for those who don't know about the swimming pool and the quest, they are
philosophies of life — and of psychiatric treatment — that Dr. Frattaroli
discusses in Chapter 5].
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A:
I'm sure there's a lot behind your question but, on the surface,
I would have to say that this isn't necessarily a problem. Both the swimming
pool and the quest are important needs in life and there is a
complementarity between them, perhaps not unlike the complementarity between
husband and wife.
It is fairly typical for people to choose partners who have different
personalities, different strengths, and different weaknesses from
themselves. Usually this follows a particular pattern: My partner has and
openly shows emotional attitudes that are repressed and disowned by myself.
In effect my partner becomes not only another person I care about but also a
projected image of my own dark side about which/whom I feel very ambivalent.
On the one hand, I need to reconnect with my dark side/partner to become a
whole person. On the other hand I am very intolerant of my dark side/partner
and so need to be at war with it/him/her. (There's lots more about this,
both as it applies to couples and to psychotherapy, in Chapter 11)
Having said all that, I do think the quest is a richer philosophy of
life than the swimming pool, and in fact it actually contains the swimming
pool within it. Growth is more interesting than stability, but you can't
have growth without stability. So if one partner has a richer, more complete
vision of life than the other then that entails a certain responsibility: to
respect the needs and fears of the other and to recognize that you have
something to teach. If you can't achieve this kind of respectful, empathic
attitude and get out of the vicious cycle of couple-conflict (which is
pretty difficult to do when you're embroiled in such a conflict) then it
means that your vision is, in some respects at least, just as restricted as
your partner's and you both have work to do. Sometimes that work requires
couples therapy. But often if the quest-minded person is able to become more
conscious — more accepting of his/her own dark side — in individual
therapy, the relationship naturally improves as a result. Often the partner
gets better too, because they do end up learning and expanding their
horizons, now that you've become a better teacher!
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Q:
I've been an anxious child all of my life. In my early teens I developed
depression even though it wasn't diagnosed until I was in my late teens. To
me, my depression feels "chemical"...When I'm not on antidepressant
medication I am lethargic and incapable of doing anything productive. So my
question is: Was I just born depressed?...It just seems to me that I was
born melancholic with no hope except medication. Is this an accurate
account?
A:
I can't answer questions about a particular person without actually
meeting that person for a face-to-face evaluation, but I can make a few
general comments that are related to this question.
It is certainly possible that there are genetic and other biological
factors that can predispose a person to be anxious or depressive, but even
in these cases I don't believe that either anxiety or depression are ever
entirely chemical. I believe they are always a response to emotional stress
and an inner emotional conflict. In fact, anxiety or depression can be a
good thing in that they often point to emotional stresses — in
relationships or in work situations — that we need to pay attention to.
A person may be more reactive to emotional stress if he has a biological
predisposition to anxiety or depression, but I believe there is always an
emotional reason for the anxiety or depression. In the last chapter of my
book I give an example from my own life: I describe a panic attack I
experienced myself which, at the time, felt chemical to me but which
eventually I was able to feel the emotional basis for.
Medication is definitely not the only hope for people with anxiety and
depression. It is true that some people do need to be on medication for many
years but dynamic psychotherapy can be immensely helpful for these people as
well. Resolving an inner emotional conflict through psychotherapy can make a
person less reactive — in fact research suggests
that it actually changes a person's brain chemistry — and able to live
normally either without medication or with less medication than would have
been necessary otherwise. In addition, using psychotherapy to identify
emotional stresses in relationships or at work can help a person think more
clearly about how to change destructive patterns.
I personally have never met a teenager who suffered from anxiety or
depression who did not also have problems in his or her family. Of course,
there is always a chicken-and-egg question about how much the family
problems caused the anxiety/depression and how much the anxiety/depression
caused the family problems, but, either way, I believe that psychotherapy
aimed at helping the teenager deal with the family problems always helps the
anxiety/depression. Family therapy is often helpful as well. Medication may
be necessary, but I would never recommend it as the only treatment.
In chapter 5 and chapter 17 of the book, I give several examples of patients I
treated for depression whose stories illustrate these ideas.
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Q: Are the ideas in your book relevant to helping people deal with the current world crisis?
A: Yes, I believe they are. The book is about a crisis in modern
psychiatry that reflects a larger crisis in modern culture. This larger
crisis has been brought clearly into focus, and also brought to a head, by
the attacks of September 11.
Over the last twenty years or so there's been a dehumanizing trend in
psychiatry: an overemphasis on the physical and on externals—on brain and
behavior—and an underemphasis on the emotional and spiritual, the inner life
of the soul. If you look at society generally, you see the same
dehumanizing trend: an overemphasis on the physical and on externals—the
pursuit of material possessions, creature comforts, physical appearances—and
an underemphasis on the inner life. Our society is big on doing but short
on feeling, and this creates a serious imbalance in our lives.
Since September 11, we've been much more aware of the tension and the
choice between doing and feeling. Despite the encouragement of government
officials we've had less interest in doing “business as usual” and have
become more attuned to inner values and to the needs and concerns of our
fellow human beings. But there's still a big part of us that agrees with the
government and would rather be shopping.
“Healing the Soul in the Age of the Brain” is about finding the balance
between doing and feeling, integrating the materialistic part of ourselves
that would rather be shopping with the spiritual and humanistic awareness
that was heightened by the attacks of September 11.
For more on this question, see my commentary, Healing in a Time of Terror.
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Q: How can I get a referral for psychotherapy or psychoanalysis?
A: I cannot answer personal questions or give advice about individual
situations. However, I can give some general advice. For people who are
not currently in treatment but are considering psychotherapy or
psychoanalysis, my first recommendation would be to ask for a referral from
someone you trust who is knowledgeable about psychotherapy and
psychoanalysis. If you don't know anyone like this, you can find names and
phone numbers of qualified psychoanalysts in your area through the American
Psychoanalytic Association's web site at
apsa.org/members/olroster.htm. (By the way, psychoanalysts come in
different sexes and personality styles so it is perfectly acceptable to
schedule consultations with two or more analysts in order to get a sense of
who you are most comfortable with).
An alternative route would be to contact one of the accredited training
institutes of the American Psychoanalytic Association. They all offer some
form of consultation/referral service and, in some cases, may be able to
offer psychoanalysis at reduced fees. Contact information can be found at
apsa.org/organiz/institut.htm.
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Q: I've already begun seeing a psychotherapist but I'm not sure whether the
treatment is helping. How do I decide whether this is the right therapist
and the right treatment for me?
A: Once again, I cannot answer personal questions or give advice about
individual situations, but I do have some general advice that I typically
give in this kind of situation.
If you've read my book, you know that I consider the most important
qualification for psychotherapists is that they be engaged in their own
psychotherapeutic process and have had or are currently having their own
treatment in dynamic psychotherapy or psychoanalysis. It is perfectly
legitimate to ask your therapist whether he or she has ever been in therapy,
and what kind of therapy it was. You might also ask what kind of training
program the therapist graduated from and whether the training involved
learning how to work with transference and countertransference.
For people already in psychotherapy and having doubts about whether it
is helping, my standard advice is to be completely open and direct with your
therapist or psychiatrist about your questions, concerns, complaints and
criticisms, and express them as forcefully (and as negatively) as you really
feel them. It could be that something important in the psychotherapeutic
process is coming to a head that can only be dealt with if you bring your
negative feelings about the therapist or the therapy into the open.
A good therapist should be able to respond to criticism in a relatively
non-defensive manner and should be able to listen to your negative feelings
and use them to understand you better and help you understand yourself
better. If you feel good about the way your therapist responds to your
concerns and criticisms, and especially if you learn something useful about
your own negative feelings in the process, that is generally a good sign.
If, on the other hand, weeks go by and you feel the therapist hasn't heard
your criticism or hasn't been able to respond to it usefully, even though
you've brought it up repeatedly, you might then consider seeking a second
opinion. But it's a good idea to tell your therapist you are planning to do
that. Once again, you can learn a lot about the therapist from his or her
reaction to your decision to seek a second opinion.
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Q: In your editorial, The Price of Prozac, you state that mental
illness is never only physical. Does this mean you don't believe that
depression is caused by a chemical imbalance? And are you completely against
using anti-depressant drugs?
A: Yes to the first question; No to the second.
I do not believe that depression is caused by a chemical imbalance. I
believe it may be influenced or aggravated by a chemical imbalance but I
think of depression as primarily emotional — caused by an inner emotional
conflict. Even when there is a chemical or hormonal imbalance, that
imbalance doesn't directly cause the depression but rather contributes to
the emotional imbalance that causes it.
I'm not at all against anti-depressant drugs. I am against the way
antidepressants are generally used today, which is to get rid of painful
feelings as if they were merely chemical glitches, without any concern for
the emotional meaning of the pain — what a person might be feeling depressed
about. When I prescribe antidepressants my goal is not to eliminate a
person's pain, but to relieve the pain enough that the person can feel it
without being overwhelmed by it. If, as I believe, the pain of depression
is a signal that something is out of balance in our emotional life, then
that pain is something we should be paying attention to, not something we
should be in a rush to get rid of.
See Chapter 5 of the book for the stories of two depressed patients I
treated, one with the help of medication, the other without. See Chapter 17
for stories of two other patients who definitely needed antidepressants but
for whom it was vitally important to understand that they also needed to be
depressed. In fact it was only through becoming depressed — overriding the
effect of their medication — that they ultimately became able to heal and
grow.
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Each week, one question will be selected and answered in this section. Previous week's questions will appear as well, in order of most recent to least recent.
If you'd like to submit a question to Dr. Frattaroli about his book or his ideas, use the link provided.
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