Doing instead of Being
Recently I read a blog on the importance of being instead of
doing. This essay was focused upon
mindfulness and its use in people's daily lives. To learn "to be" instead of "to do", however,
implies that one has learned how to do.
For many of our clients, doing is still a challenge.
For this week's blog, I'm inspired to write about our
clients who don't know how to do. Change
requires action. In order to change, we
have to do something differently. It's
not enough to reflect on change or to think about change.
Medicine and psychiatry have contributed to this
passivity. When we immerse people in the
story that their problems stem from "bad brain chemistry", we take away any
sense of agency they might have. Within
this narrative, our difficulties are not related to our lives or our
relationships or our behaviors. We have
a disease like diabetes that must be treated with the right medications by an
expert. We aren't called to do anything
to help ourselves. In the daily practice
of medicine and psychiatry, this is the attitude that I frequently
encounter. People come to me seeking the
"right" medication that will make them feel "normal", though few can actually
tell me what normal would feel like.
When I inquire more deeply, it's often the absence of emotion. Clients even use the term "clinical
depression" to refer to a depression that is endogenous, driven from within,
outside the range of what they can influence.
"Clinical depression" requires a medication.
I usually try to understand what people mean by
depression. Does it mean excess sadness,
indifference to life, hopelessness, despair, helplessness, or what? These words mean so more to me than
"depression". People often struggle to
define what they mean when they say depression.
The word is often a synonym for unhappy or miserable.
I find Jaak Panksepp's concept of depression helpful. He speaks about a seeking system (which more
conventional psychology calls the dopaminergic reward system). All animals are hardwired to seek, Panksepp
says. What we seek varies by
species. Humans often seek what Marshall
Rosenberg calls "needs", which include safety, love, connectedness, pleasure,
and meaning and purpose. We develop
strategies for seeking, which may work more or less well. When our seeking is frustrated, we feel
angry. When the outcome of our seeking
is uncertain, we feel anxious. When we
come to believe that our seeking will never succeed, we get sad. Stay sad long enough, and someone diagnoses
you as depressed. This fits well with
Aaron Beck and the cognitive therapists' definition of depression as learned
helplessness. We've learned that nothing
we do will get us what we want. Often
this is because our seeking is misguided or the strategies we have developed
are ineffective.
Antidepressant medications are considered the standard of
care currently for depression. This is
despite recent studies, which question their efficacy. The most notable of these studies is that of
Kirsch, et al., from 2008, from the University of Hull in the UK. This team of researchers noted that published
studies of antidepressant medications showed only modest benefits over placebo
treatment and when unpublished trial data are included, the benefits fell below
currently accepted levels for clinical significance, meaning that the benefits
would have been too small to actually be noticed by patients or their doctors
or by family members. A large enough
study can show statistical benefits that are so small as to be clinically
useless. Kirsch and his colleagues obtained data on all the clinical trials submitted
to the US Food and Drug Administration (FDA) for the licensing of four new
antidepressants. They found that drug--placebo
differences increased as a function of initial severity, rising from virtually
no difference at moderate levels of initial depression to a relatively small
difference for patients with very severe depression, reaching conventional
criteria for clinical significance only for patients at the upper end of the very
severely depressed category. They determined that the relationship between
initial severity and antidepressant efficacy was attributable to the decreased
responsiveness to placebo among very severely depressed patients, rather than
to an increased responsiveness to medication.
Curious,
isn't it, that antidepressant medications are considered standard of care for
depression when they don't actually do very much beyond placebo (which can be
quite powerful, however).
