-Caveat Lector- <A HREF="http://www.ctrl.org/"> </A> -Cui Bono?- From http://www.philosophynews.com/whip/pc/ARCHIVED/pc200002.htm Pt 1 {{<Begin>}} Philosophical counseling February 22, 2000 Medicating the mind (part 1) by PETER B. RAABE RELATED LINKS >>>at site<<< * Shadow Syndromes by Ratey & Johnson * The Enigma of Health by Gadamer * More articles by Peter Raabe Many of the feelings that help define us as human beings, and help us cope with human affairs, are now being diagnosed as disorders that need to be "corrected" with psychotropic drugs. In fact, a recent issue of a popular magazine carries advertisements for pharmaceutical products claiming to combat everything from feeling uncomfortable in a crowd ("social-affective disorder") to excessive worry ("adjustment disorder" or "depressive disorder" -- which may mean a man still feeling low even though it has been six months since his spouse left him). The advertising copy literally says swallowing the pills will end your worries. Some professional therapists are insisting that sadness, anger, depression, and even the inability to finish a task have nothing to do with a person's character, self-esteem, or internal belief system, but rather are "hidden psychological disorders" or "shadow syndromes" (e.g., John J. Ratey and Catherine Johnson, Shadow Syndromes (Pantheon, 1997). They believe "shadow syndromes" are simply inherent in the structure and chemistry of the individual brain, and recommend that these syndromes be treated with a regimen of powerful medication. In the six years between 1990 to 1996, prescriptions in the United States for the antidepressant fluoxetine (sold under the brand name "prozac") rose from 136,000 to 2.5 million. The total number of prescriptions for all similar medications written in 1996 alone was 5.4 million. While the use of medicines to correct a mechanical malfunction in cerebral biochemistry seems legitimate and justified, the use of psychopharmaceuticals to control emotional distress, confusion, or depression is a highly contentious issue for many philosophical counselors. This is because the use of drugs to alter feelings or thoughts seems to be based on the faulty assumption that feelings of distress must have originated in a chemical imbalance in the brain because drugs can be used to change the brain's chemistry and thereby alleviate feelings of distress. The question of which came first, the feelings or the chemical imbalance, is a chicken-and-egg problem. Research has shown that while the chemical activity within the brain generates thoughts, thinking causes a change in the chemical activity within the brain. In other words, the relationship between brain chemistry and thinking is clearly reciprocal. This reciprocity is what causes concern among philosophical counselors when medication is used to treat a client in distress. They see the medication of the brain as a simultaneous medication of the mind. By prescribing psychotropic drugs, the assumption that causality rests in brain chemistry has been affirmed. The problem with this assumption is that it relegates external reasons for emotional distress to a place of lesser importance. The resultant predicament this causes can be illustrated with the following case based on a true story. "Stan," an average college student and a player on a winning basketball team, visited a philosophical counselor with the consent of his psychiatrist. He was taking both antidepressant and antipsychotic medication to combat what he described as profound sadness, confused feelings, and anger that could erupt seemingly for no reason. Stan explained how distressed he had been lately at his having become unreasonably angry with his friend Karl. During the course of discussion with the philosophical counselor the story emerged of how Stan considered Karl to be a far better basketball player than himself, how Karl never had any problems getting girls and always had several girlfriends at the same time, and how Karl had recently charmed Stan's girlfriend away from him, supposedly as a harmless joke. Stan said he could understand why his girlfriend had left him and gone with Karl. He wondered if he was even worthy of a girlfriend considering how poorly he played basketball compared to Karl. But through all this he insisted Karl was a good friend, and that "all's fair in love and war," even between friends. When asked to define what a friend is, Stan responded that it is someone you respect but are inferior to. Over the weeks that followed Stan told of how his mother had remarried when he was young, how he had several younger step-siblings, and how his stepfather treated "his own flesh and blood" with more love and respect than he felt Stan deserved. His stepfather was quick to point out his faults, and never offered to help Stan correct his mistakes. His stepfather taught Stan to develop a negative view of the world, the people in it, and himself. Stan remembered asking his stepfather questions that were judged by his stepfather to be bad questions that a good boy would not have asked. Stan said his stepfather was never a friend to him and that he had convinced Stan he could never do anything right. When the counselor asked if he could perhaps think of one thing he had gotten right since then, Stan could not answer. When she asked him about the fact that he was a player on a winning basketball team, Stan said his ability to concentrate and focus on the game had deteriorated dramatically over the past month and he was considering quitting the team. The sessions continued in this vein. Stan revealed that he expected only perfection from himself. When he failed to reach this goal on the basketball court, Stan saw it as a confirmation of his own and his stepfather's low opinion of him. He recalled all his failures -- every missed basket -- in vivid detail but could not think of a single success. He was even worried that he was failing to do what the counselor expected of him in the counseling sessions. But by the end of the fourth session the counselor was already beginning to see some improvement in Stan's self-confidence. Stan was clearly enjoying the opportunity to speak freely and to ask questions without the fear that his questions would be judged good or bad. The counselor and Stan agreed that Stan had a serious case of low self-esteem and that he would probably benefit from an exploration of a number of issues such as what he believed about himself and why, what friendship is all about, and what success means when you are part of a team. When Stan arrived for his fifth session he was smiling broadly. He began by announcing to the counselor that he had discovered the meaning of life. His conclusion was that "the purpose of life is movement." This puzzled the counselor who asked Stan to explain. Stan said when he looked around him it was as if he could see movement in everything. This explained where his problems had come from. He said that when he now comes up against a problem with a girl he simply tells himself "everything is movement" and the problem goes away. In this way, he assured her, he could now solve any problem he might encounter. "In fact," he told her, "I feel invincible." The philosophical counselor sensed that something was not right. She asked Stan if he had been drinking. Stan said he had not. She then asked if his medication had been changed. Stan replied that he had gone to see his medical doctor and the doctor had doubled the dosage of his antidepressants. The counselor cautioned him that his euphoric state may just be the result of the increased medication, and not because all of his problems had been resolved. Stan agreed this might be the case but said it simply did not matter as long as all his problems were gone. She explained that the antidepressants were like taking a painkiller for a broken leg: they alleviate the pain but do not fix the leg. But Stan was confident that the counselor's services were no longer required. Finally the counselor warned him that just like his medication had been increased as his body had adapted to the original dosage, it would probably adapt to this higher dosage as well. "When that happens," she told him, "you're likely to be faced with the reasons for your depression and anger again. Are you simply going to have your doctor increase the dosage again?" But Stan was adamant. He did not return after the fifth session. What the philosophical counselor had seen in Stan as axiological issues -- that is, issues of negative self-evaluation and low self-esteem -- had instead been perceived by Stan's medical doctor as a malfunction in brain chemistry and diagnosed as requiring psychotropic drug intervention. Psychiatrists Jerome and Julia Frank point out in their book Persuasion and Healing (Johns Hopkins, 1991) that it is possible that a drug's physical effects on the brain can undermine therapy by relieving the symptoms that motivate a patient to "work." It is this "work" that eventually resolves the problems which created the need for medication in the first place. But drugs work faster; they can help a client feel good overnight. How can the long hours of hard work and painful emotions encountered in counseling compete with that! Philosopher Hans-Georg Gadamer argues that modern psychiatric drugs seem to have "instrumentalized" the human body. In his book The Enigma of Health (Stanford, 1996), he finds it worrisome that through psychiatric drugs "doctors are now able not only to eliminate and deaden various organic disturbances, but also to take away from a person their own deepest distress and confusion." His point is that using drugs in psychotherapy is often simply the act of "taking away" rather than helping the person to resolve, readapt, and reintegrate into society. What Gadamer's argument suggests is that just like physical pain indicates a cause of that pain, so mental or psychological pain denotes the presence of a reason for that pain. If it is clearly a mistake to believe that in using a medication to take way the physical indicator (the pain) we have eliminated the cause of the pain, then it is likewise clearly a mistake to believe that in using a psychotropic drug to eliminate a mental or psychological pain we have eliminated the reason for that pain. But despite cases like Stan's, and Gadamer's persuasive argument, philosophical counselors have not utterly condemned the use of psychotropic drug therapy. Some argue that if one of the most important goals in philosophical counseling is helping to make the client feel better, then why not allow this goal to be reached by means of drugs? And if swallowing a pill can end your worries, why bother with counseling at all? Others point out that making a person feel better is not all a drug does. There are many other effects which are often accepted as a reasonable price to pay for the relief of metal anguish. But what price is too high when peace of mind is involved? These issues and more will be discussed by a number of philosophical counselors in my next column. ____________________ Dr. Raabe welcomes inquiries by email >>>See end of Pt 2<<< , telephone at (604) 986-9446, or regular postal mail at Dr. Peter B. Raabe, 46-2560 Whiteley Court, North Vancouver, B.C., Canada, V7J 2R5. Copyright (c) 2000 by the Philosophy News Service. All rights reserved. {{<End>}} Pt 2 http://www.philosophynews.com/whip/pc/ARCHIVED/pc200003.htm {{<Begin>}} Philosophical counseling March 22, 2000 Medicating the mind (part 2) by PETER B. RAABE RELATED LINKS >>At site<< * Medicating the Mind (Part 1) * Blaming the Brain: The Truth About Drugs and Mental Health * American Philosophical Practitioners Association (APPA) * WHiP Archive: Philosophical Counseling An information leaflet from the National Parkinson's Foundation in Gainesville, Florida, explains that more than 40% of people with Parkinson's disease (a degenerative neurological disorder) develop depression. It says that this depression "should be evaluated, treated and monitored on an ongoing basis by a physician." By implying that the depression can be treated by a physician, the leaflet leaves the reader with the impression that it is caused by a neurobiological malfunction. The reader is thereby led to the conclusion that medication is called for. What is wrong with this picture? Most psychotherapists agree that depression is a symptom of something. What they do not agree on is whether depression, and other so-called mental disorders, are symptomatic of a chemical imbalance in the brain or of an irrational thought process in the mind. Some philosophical counselors are now even proposing the hypothesis that depression, rather than being caused by a chemical imbalance or irrational thoughts, is a perfectly reasonable reaction to certain seemingly hopeless situations in life. But if depression is sometimes reasonable, why use drugs to get rid of it? In the 1980s seratonin-based drugs flooded the marketplace and became the cure- all of choice for treating depression. When risks of their use started to be made public in the early '90s, there was a brief but widespread rejection of the practice of taking a pill to reduce depression. The view that depression was the result of social rather than chemical factors was once again dominant within the helping profession. In 1995 only 20 percent of psychiatrists felt that depressed individuals should be treated with drugs. But since then the next generation of "more reliable" and "safe" drugs have been developed and aggressively promoted by pharmaceutical corporations, and drug use has increased correspondingly. Discursive therapy is once again being perceived as an adjunctive treatment to maximally implemented drug therapy. Canadian psychiatrist Heinz Lehman was one of the early pioneers of what is sometimes called "biologic psychiatry" or drug therapy for mental illness. In an interview broadcast in February 2000 on CBC television, Lehman said he and his colleagues at a Montreal psychiatric hospital had discovered that empathetic discussions were very effective therapy for the majority of their patients. But they were forced to abandon such discussions, and compelled to give their patients psychoactive drugs, when hospital administrators deemed therapy sessions too expensive in comparison to the cost of newly developed medications. In other words, their treatment of choice was discussion but this was almost entirely abandoned due to financial considerations. Research has shown that the type of improvement following antidepressant medication is indistinguishable from the improvement following cognitive therapy (Imber, et al, in the Journal of Consulting Clinical Psychologists [1990]). Research has also shown that two-thirds of all psychotherapy patients put on drug treatments for depression do as well as or better with a placebo than those treated with an active medication (Greenberg and Fisher The Limits of Biological Treatments for Psychological Distress [Lawrence Erlbaum Associates, 1989]). Researchers have theorized from this that the positive "chemistry" between the patient and the doctor may be more important to the well-being of most patients than the chemistry in the medication. Not only is the necessity of psychopharmaceutical treatment questionable, but the consumer who takes a drug for depression has to pay a price. For example, common side-effects of antidepressant medications are nervousness, restlessness, sleep disturbances, nausea, tremors, constipation, bladder problems, blurred vision, dizziness, and drowsiness. Taking a drug to relieve depression may also result in a chemical dependency, not only because of the intrinsic addictive nature of some drugs, but because of the body's natural adaptation to a prescribed dosage which must be increased in order to maintain the drug's perceived level of effect. If taking a drug is often no more effective than a therapeutic discussion, if it leaves the client vulnerable to a variety of side effects, and if it requires increased dosages to maintain perceived effects, why would anyone want to take a drug in the first place? There are a number of possible answers. It may be because taking medication is more private. That is, it does not require an individual to divulge and argue about sensitive personal material with an often judgmental authority figure. Furthermore, pills are often cheaper than therapy. It may also be because our fast-food society has conditioned people to expect a quick fix for whatever ails them, forcing doctors to prescribe pills rather than counseling in an attempt to give their patients what they want. Unfortunately, many physicians and psychotherapists see emotional distress as having a biological or chemical origin. The problem with this is that prescribing medication can convince a patient that his problem is beyond voluntary control, even when the origin of his problem lies within his familial or societal environment. By adopting a reductionist scientific model and defining the range of subjective human experiences and emotions largely in terms of degrees of pathology, psychotherapy has, until very recently, championed a mechanistic conception of human thinking and conduct linked more closely with objective chemical reactions than with subjective reasons, intentions, and desires. Philosophical counseling on the other hand sees the importance of dealing directly with those very human concerns. Jon Mills, philosophical counselor and professor of psychology and philosophy in Toronto, points out that "there is a presumptive bias in the medical, psychiatric, and behavioral sciences that views the mind from a reductive ontology. The standard mentality is to give a pill for any psychological ailment and wait for the results." From his own experience Mills has found that medication may ameliorate the severity of symptoms, but it has little effect on eliminating the source of a client's malaise. Even when medication works, he says, there are often many needs and conflicts that a pill could never address. Philosophical practitioner and professor, Wanda Dawe, agrees: "If the client originally presented with some one or more philosophically interesting problems with which he was struggling, no medication can possibly provide the solution." Michael Russell says that he is not at all opposed to medication because he does not see an inherent conflict or incompatibility between human affect seen as choice, and seen as a physiological matter subject to helpful chemical intervention. Russell, who is professor of philosophy and human services at California State University, research psychoanalyst and philosophical counselor, says, "There are plenty of people who are extremely miserable, dangerous, etc., without medication, and in a reasonable position to make good use of one form of counseling or another with it. " He asks rhetorically why it should be considered "an inauthentic path" to take when a person uses a drug to treat a distressing mood which could not be alleviated by means of philosophical counseling. Paul Sharkey, vice president of the American Philosophical Practitioners Association (APPA), says that he has had clients "who, after beginning a course of medication, were much more, rather than less, inclined to engage in philosophical reflection. Most of them recognized that even when their biological conditions were stabilized (and sometimes even because of it) they still had a lot to do to resolve the various kinds of issues confronting them (issues of ethical responsibility, meaning, purpose, etc.) which they were simply incapable of addressing while not taking medication." Eite Veening, one of the pioneers of philosophical counseling in the Netherlands, says the practice of prescribing antidepressants is not as frequent in the Netherlands as it is in the US. Veening suggests that the issue of whether medication should or should not be prescribed is a question of who is in charge; it concerns the issue of what the client wants from the philosophical counselor. Veening sees the client as being allowed to make his own decisions regarding what kind of treatment he wants. While the counselor may explain and discuss the impact of medication on thinking with a client who is perhaps taking an antidepressant, his primary role, according to Veening, is to deal with the client's philosophical beliefs and opinions. Veening holds that a client's emotional issues are psychological and therefore "his feelings will be his concern, not mine." Mills says in his own practice he has seen drugs work in a number of ways: They can relieve his patient's symptoms without removing the desire to talk; they can help his patient cope and manage therapy better; they can aid his patients to distance themselves from examining other problems; they can mask the original issue or underlying problem. Dawe cautions that when medication screens a problem, "the client moves from a position of restricted or unrealized liberty to a position of still greater unfreedom." This leads her to think that "in any discussion of patient/client substance dependency, the issue of the individual's liberty and capacity for self-governance would be raised." For Dawe the question is, "If one is to be held up/together by some strings, however gossamer, who will be the puppeteer?" Along a similar line of argument, Maria Colavito, president of the Biocultural Research Institute in Florida, psychologist, and philosophical counselor takes a different stance on the issue. She maintains that, according to the scientific model, the environment selects for appropriate mental and emotional development in each individual's ecosystem. In that case, she asks, "who are we to alter it pharmacologically?" She argues that if emotions outside the accepted curve of so-called normalcy are in fact the way some individuals adapt to their environment then medicating them to force their emotions back into that acceptable range of normalcy is nothing less than new millennial eugenics. However, Lou Marinoff, president of the APPA cautions philosophical counselors to remember that their clients are autonomous beings, and as such have the right to request, accept, and reject any of the variety of treatments offered. "If the client terminates the counseling process because his problem is under symptomatic control [through medication] that is his business. As long as he poses no threat of harm to others, the counselor is bound to let him go." Philosophical counselors respect the autonomy of their clients, and part of the meaning of autonomy, according to Marinoff, is "the liberty to choose freely, and perforce to make unwise choices at times. Making mistakes presents [the client with] opportunities for learning." Marinoff believes that while the philosophical counselor can and should voice her professional opinion, she should not interfere "in the client's autonomous choice to take medication or terminate counseling. The same would be true of clients who self-medicate with alcohol or non-prescription drugs, saying they feel better and therefore require no further counseling." According to Marinoff, "a philosophical counselor is not the best judge, nor any judge, of his client's better interest." While philosophical counselors are divided as to the advisability of altering a client's thoughts and emotions with medication, consumers of psychotropic medication can similarly have mixed feelings about taking them. The following message was received by email and is reprinted with permission: "I have received psychological counseling on and off for many years, and having taken many 'rounds' of different psychotropic drugs to relieve depression. The drugs are not all they are cracked up to be ... For me, the drugs can alleviate the worst, blackest end of the depression, allowing me to at least care enough to make the effort to get counseling. Without the drugs, I wouldn't have been able to believe that psychological counseling could help me, and would probably not be here today. I agree that the relationship between mind and brain is a highly reciprocal one. I think [drugs] work best for people to whom depression is a real disability, but I do believe that they are over-prescribed." ____________________ Dr. Raabe http://www.interchange.ubc.ca/raabe/ welcomes inquiries by email [EMAIL PROTECTED],[EMAIL PROTECTED] telephone at 604-986-9446, or regular postal mail at Dr. Peter B. Raabe, 46- 2560 Whiteley Court, North Vancouver, B.C., Canada, V7J 2R5. Copyright (c) 2000 by the Philosophy News Service. All rights reserved. {{<End>}} A<>E<>R ~~~~~~~~~~~~~~~ Integrity has no need of rules. -Albert Camus (1913-1960) + + + + + + + + + + + + + + + + + + + + + + + + + + + + The only real voyage of discovery consists not in seeking new landscapes but in having new eyes. -Marcel Proust + + + + + + + + + + + + + + + + + + + + + + + + + + + + "Believe nothing, no matter where you read it, or who said it, no matter if I have said it, unless it agrees with your own reason and your common sense." --Buddha + + + + + + + + + + + + + + + + + + + + + + + + + + + + It is preoccupation with possessions, more than anything else, that prevents us from living freely and nobly. -Bertrand Russell + + + + + + + + + + + + + + + + + + + + + + + + + + + + "Everyone has the right...to seek, receive and impart information and ideas through any media and regardless of frontiers." 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