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).