December 18, 2009

Intentionality In Treatment

abilify augment.JPG
the Abilify was supposed to improve your symptoms but you got better anyway

As a follow up to advice in psychiatry.

Intentionality in treatment matters, and it is conveyed in subtle ways. 

In an experiment, a subject could be put through a electric shock experiment, or a auditory tone experiment, as chosen by a second subject.  However, sometimes this choice was reversed by a computer, and the resultant switch was revealed to the subject.  In other words, he would see on the computer "Subject B chose to give you tones; however, you will receive shocks."

In this way, Subject A would think Subject B intentionally gave him shocks, or unintentionally.



intentionality of pain.JPG
You can see that the subjects experienced the pain as more severe when they thought it was on purpose.  However, look carefully, you see something else: when it's by accident, they got used to the pain.  When it was on purpose, they didn't get used to it.


II.

Cognitive reframing can be used everywhere.

There are plenty of examples related to pain, but it's better if this can be applied more generally.  When things are bad, is there a way to experience them as less bad?  Instead of studying something as vague as "sadness" or "anxiety" let's look at something concrete:  losing money.

When subjects were given $30 to gamble (max win $572, max loss $30) subjects were measured on how loss averse they were:


loss aversion.JPGThen these same subjects were given a cognitive reframing: "pretend you are a trader" "think like a pro" etc.

This technique reduced loss aversion:

loss aversion reduction.JPGnot just subjectively, but even as measured by skin conductance, which measures arousal and sympathetic nervous system activity (similar to lie detector):


scr loss aversion.JPG

Graph A shows that while people were more aroused (by skin conductance) to losses than to gains ("Attend" is simply gambling without using the reframing trick)--  when given the cognitive reframing (the "Regulate") this arousal disappeared.  "Thinking like a trader" neutralized a physical response.

When you tease out the people who are good at reframing (Graph B, the "Regulators") the difference between using the reframing and not using it is even bigger.

Clearly some people are naturally good at this, and others are not; but the technique can be universally tried.  The more you practice, the better you'll be.

III.

But the important part of this message is that a person's experience of anything is very much influenced by context, presentation.

Psychiatry has adopted a policy of pulling aside the curtain: letting the patient in on the language usually reserved for practitioners, which is fine, except that it is almost always misunderstood.  "Dirty drug," "bipolar", "flip him into mania"-- "augment with Abilify"-- these terms convey information to the patient that is usually not intended-- not to mention being factually empty.  They are never corrected, because the psychiatrist has forgotten how to speak in ordinary but still  descriptive language.

Every university hospital has a "Treatment Resistant Depression" clinic.  However, they are by referral only; a patient can't just call and make an appointment.  So why name it that?  It's a signal to doctors, "send them here."  But it's not a secret signal-- the patient knows what it's called.  What message does that send to the patient?


---

http://twitter.com/thelastpsych






Comments

The problem with psychiatri... (Below threshold)

December 19, 2009 12:28 PM | Posted by Anonymous: | Reply

The problem with psychiatric wards as I think thats where your going there. (Not that you belong in a psychiatric ward) After the first experience patients become used to it. I personally even liked it after a time, hey free meals, a cot and if I'm doing well a psychotic woman to fuck when I'm not doing A or B.

Problem with that is like I said you start to like it. I think instead of making you feel stigmatized there should be an institution for higher learning. Evaluate patients academically and determine if they would do well in an education program FREE OF COST. Determine their weaknesses, their strengths and offer them a get out of jail free card should they do well on the exam.

This way we have more to look forward to then an empty house and a disability check.

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Really cool post. This remi... (Below threshold)

December 19, 2009 4:25 PM | Posted by Robert Gordon: | Reply

Really cool post. This reminds me of a situation I had with a friend a couple months ago. He was having difficulty meeting women, and would not know what to say or how to act when he approached them. Instead of telling him what to say, or giving him tips: I simply told him, pretend as if you are (name of guy that he reveres as a pimp daddy), and it worked. By taking on the new frame, he was able to somehow "know" exactly what to do and what to say. There is some real gold in the science of reframing and what I believe you are saying in this post is that medicine is not always necessary to curing depression, sometimes all that's necessary is a new frame. I think something like NLP might be more effective than CBT in a clinical setting, but I don't know how this would be able to come into fruition.

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Alone's response: Along ... (Below threshold)

December 19, 2009 5:03 PM | Posted by Alone: | Reply

Alone's response: Along these lines, in Current Psychiatry released today, an article about a patient with severe depression (and bulimia and etoh and PTSD) who was tried on multiple meds and ECT-- and leuprolide and removal of her ovaries!-- varying/poor success. Finally, he treats her with sleep deprivation, and it helps.

article here: The bedtime solution

I'm not suggesting that had they done this 5 years ago it would have worked as well-- or that it will/won't ever work again-- or that she could even go medication free with proper control of sleep. The real message is that there can't be an artificial hierarchy of treatments in the absence of such evidence. You can't place sleep manipulation "below" Abilify as a strategy, unless it is less safe (!?) or less efficacious (?).

The authors don't write, but it would be great to know (if anyone knows them) how they presented this option to the patient: as a hail mary, as an obvious strategy, as a "different way to manipulate serotonin" etc.

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This is a really interestin... (Below threshold)

December 19, 2009 5:39 PM | Posted by Anonymous: | Reply

This is a really interesting subject and I hope you discuss it more as time goes on.

Re: Robert Gordon: do you think there would be a "type" of person taking your advice who would feel MORE pressure having to "live up to" the stereotype? Or, maybe from a slightly different viewpoint ... how do you "reframe" an approach to avoid client resistance and take into account situational "failure"?

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RE: AnonymousThe act... (Below threshold)

December 19, 2009 6:52 PM | Posted, in reply to Anonymous's comment, by Robert Gordon: | Reply

RE: Anonymous
The act of reframing should not create resistance at all. In order to properly execute a reframe it should be completely covert. I did not tell my friend that he is projecting his own abilities onto this man and that it's really all inside of him and he should just go and do it. I told him that he should try pretending to be this man, "do the things he would do."

In the case of situational failure, his mind is still working within the frame of a "successful person," he will likewise do what is necessary to overcome the failure. Much like in Alone's article above-- when given the frame of a "trader" or a "pro" the subjects did the things that they knew were necessary, without the imaginary road blocks.

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You do make a compelling ar... (Below threshold)

December 20, 2009 12:57 PM | Posted by niroz: | Reply

You do make a compelling argument, however, it puzzles me as to then why have two meta analysis's found no effect for a therapy which try's exactly what your advocating (convince the patient to get better), that is, neuro-linguistic programming?

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It seems that most of the r... (Below threshold)

December 20, 2009 1:36 PM | Posted by Robert Gordon: | Reply

It seems that most of the research done on NLP has focused only on certain aspects of NLP that have nothing to do with reframing. Such as "eye-accessing cues," not sure exactly what these do, and "predicate matching," which refers to matching the style of a client's speech. I would examine the meta-analysis's you speak of to see if they discuss reframing at all. Understandably, it would be difficult to generalize a method of reframing in a way that one could do an actual scientific study on it, at least I haven't thought of a way, and neither has anyone else apparently.

If you look at the book Mind Lines by Michael Hall, you will get a sense of the multitude of various reframing techniques that have the potential to create this kind of instant psychological magic to occur. Like I said earlier, I don't know quite how these techniques would be able to be used in therapy, but it is my opinion that it should definitely be researched more in depth (NLP - reframing only). And studies such as the one that Alone examined above, are only scratching the surface of what could be a huge discovery in Psychology/Psychiatry.

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I think all you have to do ... (Below threshold)

December 20, 2009 2:29 PM | Posted by Anonymous: | Reply

I think all you have to do is get on mental health websites to see what diagnoses like "treatment resistant depression" and "recurrent major depression" mean to patients. I've seen patients use it to decribe just how bad things are for them. I've got this diagnosis, see how bad it is? I don't just have small d depression I have the BIG D depression. I don't just have depression, I have Major depression. I don't just have major depression, I have SEVERE major depression and it's recurrent. That's why I was saying in the previous comment section that I wish mental health professionals wouldn't reinforce depression. I know it's unintended, but I don't really see how it's helpful for patients to hear they've got a chronic illness. Those diagnoses are very powerful to someone who is despondent. The last thing I needed was to be reinforced in my belief that this was how it would always be. And isn't that what "recurrent" means? It means chronic. It means it's coming back again. It means it sucked to be me.

I needed some hope that I could be free from mental illness, and as long as I was encouraged to believe my condition was chronic, well then it was.

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This is a tricky slope: Ra... (Below threshold)

December 20, 2009 4:20 PM | Posted by xon: | Reply

This is a tricky slope: Rather than "cognitive reframing", this is properly called lying. To your self. While this has certain utilities employed in certain contexts, Robert Gordon's story made me think of another story -- "When you have to sign that note for a new luxury car or mortgage for your third 'investment property' condo, and you work in a nail salon, or are a vitamin supplements 'executive', or have a business originating mortgages just imagine you're [insert name of rich, irresponsible asshole here].

We need to re-frame, but it's not so simple as "Just be someone else." Which suggests that the re-framing isn't the most important part.

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Oh, great, Last. You have a... (Below threshold)

December 21, 2009 11:52 AM | Posted by medsvstherapy: | Reply

Oh, great, Last. You have attracted a bunch of NLP advocates. Sigh. An entire psychological architecture rivaling L. Ron Hubbard's, based upon some sketchy evidence that when we tell lies we may be a bit more inclined to look to the left rather than right. (A fun party trick: train yourself to look to the right when lying; it will totally bug your NLP friends).

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Is it bad that I was readin... (Below threshold)

December 21, 2009 12:18 PM | Posted by Roger: | Reply

Is it bad that I was reading TLP's analysis of those studies and the whole time I was thinking, "Ok, now exactly what does the author want to be true?". I need to get out more.

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anonymous wrote - "I think ... (Below threshold)

December 21, 2009 1:49 PM | Posted by Anonymous: | Reply

anonymous wrote - "I think all you have to do is get on mental health websites to see what diagnoses like "treatment resistant depression" and "recurrent major depression" mean to patients. I've seen patients use it to decribe just how bad things are for them. I've got this diagnosis, see how bad it is? I don't just have small d depression I have the BIG D depression. I don't just have depression, I have Major depression. I don't just have major depression, I have SEVERE major depression and it's recurrent. That's why I was saying in the previous comment section that I wish mental health professionals wouldn't reinforce depression."

Like with chronic pain, some people who haven't had the experience of depression tend to dismiss the suffering of people with depression. And, yes, some people cling to their diagnosis as proof that they're suffering.

I'm all for empowering people but I don't see how hiding a diagnosis does that - in fact it's pretty much treating the patient as a child and not an adult. After all, if you're an adult and you haven't shown yourself to be a danger to yourself or others, you can always choose not to accept the diagnosis if you don't think it's accurate and seek another doctor, therapist or treatment.

I'd suggest that you're much more likely to find people who want to talk about how bad their depression is (or compete to win the dubious title of most depressed person evar!) on the kinds of websites you're visiting. People who minimalize their depression, or who deny they're depressed when they are, aren't likely to be hanging around on websites discussing depression.

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There is more to NLP than j... (Below threshold)

December 21, 2009 2:35 PM | Posted, in reply to medsvstherapy's comment, by Anonymous: | Reply

There is more to NLP than just eye-accessing cues. You should read a book on it before you criticize it (as should anyone claiming to do research on "NLP").

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I don't see reframing as ly... (Below threshold)

December 21, 2009 10:10 PM | Posted by Anonymous: | Reply

I don't see reframing as lying. Patients know when they're depressed, so why not just call it depression. That's not lying. Why all the drama? I don't see how omitting the words "treatment resistant" would be lying to patients.

The words "treatment resistant," "severe," and "recurrent," speak volumes, and I can't see how it's particularly helpful.

I don't advocate MHP's hiding a diagnosis like bipolar disorder, personality disorders, etc. As long as the adult is legally competent to make treatment decisions, then they should be treated as such. But, I think it's a stretch to call it a lie when a MHP doesn't tell the patient they're treatment resistant.

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Cognitive reframing : what ... (Below threshold)

December 22, 2009 2:12 AM | Posted by deen: | Reply

Cognitive reframing : what a beautiful phrase to describe what happens in the mind of a victim. They didn't mean to, so it's not that bad.

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With regard to what xon bri... (Below threshold)

December 22, 2009 6:17 AM | Posted by fraise: | Reply

With regard to what xon brings up about a "tricky slope", I see a difference between "think like a trader" and "pretend to be X" - namely, one is general and another is a specific individual. Giving someone a general context of thought (not pretense, but thought) for reframing is an implicit nod towards the fact that it is the person themself who is responsible for producing what that general context means, and choosing their own behavior accordingly. Whereas giving someone the name of a specific individual X and, additionally, saying "pretend", well, that removes a great deal of autonomy from the person supposed to be reframing. Certainly, an enlightened outside observer could recognize that the person has projected their own inner abilities/qualities onto X, but with an admonition like "pretend to be X", will the person themself be likely to recognize it? Or does it instead postpone their eventual realization? Wouldn't something more empowering be healthier, instead of implying that the person is so deficient, they have to pretend to be someone else entirely? (For instance, "think like a pimp daddy"... though good lord, the last thing we women need are more players and pimp daddies. If that's what that guy wanted to be, OK, but ugh, this here woman loves it when she's engaged as an individual, not a hen. Humans versus peacocks. That's another discussion, though.)

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Anon - "I don't see reframi... (Below threshold)

December 22, 2009 9:11 AM | Posted, in reply to Anonymous's comment, by Anonymous: | Reply

Anon - "I don't see reframing as lying. Patients know when they're depressed, so why not just call it depression. That's not lying. Why all the drama? I don't see how omitting the words "treatment resistant" would be lying to patients."

This is, again, about the individual. Not all depression is the same. It's not very useful for someone with severe depression to approach it like it's not severe. If a patient is "treatment resistant" they'll know that already since they would have already tried a variety of treatments that don't work. Creating false hope or unrealistic expectations is just setting up an already depressed person for failure. The world is full of people selling empty hope to desperate people (fake cures for cancer, depression, schizophrenia, AIDS, autism, etc). We call these people con artists and quacks.

I'm all for offering people hope but realistic hope (and a proper diagnosis in the first place). I also realize that mental healthcare in the US is a particular nightmare due to the profit-driven nature of medicine in America. (Which is not to say it's not crappy elsewhere too, just that between the Scientologists, Big Pharma and the insurance companies, mental health in the US is a minefield of epic proportions.)

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Anon - "This is, again, abo... (Below threshold)

December 22, 2009 8:59 PM | Posted by Anonymous: | Reply

Anon - "This is, again, about the individual. Not all depression is the same. It's not very useful for someone with severe depression to approach it like it's not severe."

So, you say it's about the individual but then proceed to describe what's not useful for people with severe depression as if we're all the same. We're not all the same. I didn't find it the least bit helpful to be told I had treatment resistant, recurrent major depression level severe. What that said to me was that they agreed it was all pretty hopeless.

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Anonymous said: "There is m... (Below threshold)

December 23, 2009 10:53 AM | Posted by medsvstherapy: | Reply

Anonymous said: "There is more to NLP than just eye-accessing cues. You should read a book on it before you criticize it (as should anyone claiming to do research on "NLP")."

--Exactly. I heard a lecture years ago on "NLP," and was interested. So, I read a bunch. I kept looking for some 'meat' in all of the verbosity. Bottom line: like I said above. If you have specific studies supporting all the espoused glories of NLP, it won't take up too much room to post a few articles here. Thanks.

BTW: it helps to be familiar with the fundamental, basic, well-recognized lit on cognitive psychology (either beck is good as a starting place), social persuasion (cialdini is a good starting place), and assertiveness training (too numerous to shake a stick at) in order to tell what is new and unique, compared to what is rehashed basic, well-known, psychological/interpersonal knowledge. So, read up before you criticize it.

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Thanks for pointing this ou... (Below threshold)

December 24, 2009 4:25 PM | Posted, in reply to fraise's comment, by Robert Gordon: | Reply

Thanks for pointing this out to me. It makes a lot of sense to suggest a pretense of thought and not a specific individual when it comes to reframing. I really appreciate your post, and would love to get into the humans vs. peacocks discussion :)

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You really really really sh... (Below threshold)

December 27, 2009 11:13 AM | Posted by Ramon Leon: | Reply

You really really really should turn on full news feeds rather than forcing feed readers to visit your blog. Despite what you may think, it will only increase your readership as people like me don't click on ads anyway but may recommend your feed to others who might. You're losing a lot of feed traffic by not having real news feeds, trust me, I'm a fellow blogger, and this is a fact.

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Did you know you are advert... (Below threshold)

January 12, 2010 11:59 AM | Posted by rachael202: | Reply

Did you know you are advertising for the scientology (dianetics) cult on your blog?

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Case it wasn't obvious, thi... (Below threshold)

January 12, 2010 12:01 PM | Posted, in reply to rachael202's comment, by Anonymous: | Reply

Case it wasn't obvious, this is probably the google optimizer detecting terms about skin conductance / lie detector (which are cognate to the scientological emeter.)

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Rachael: Is it possible th... (Below threshold)

January 25, 2010 11:07 PM | Posted by Anonymous: | Reply

Rachael: Is it possible that the more commenters mention a certain cult by name (as well as its founder, etc.), the greater the odds become that the optimizer will produce ads that refer to said comments, which then refer to the ads, etc., etc.?

No point in blaming Alone for a situation that developed because a few selfish people decided to use his thoughtful post as an excuse to anoint themselves. It all started because the first comment took a discussion that ought to have included and encouraged those who actually suffer from depression and turned it into a tool-measuring contest between people who fancy themselves amateur therapists.

======================================

If a psychiatrist makes an intelligible argument that it is perhaps irresponsible of other psychiatrists to use terminology indiscriminately, and to ignore the effects of their words on patients, that is an argument that needs to be considered in context. You can have another selfish discussion about rebranded positive thinking, creative visualization and the rest of it anywhere else on the web. Anywhere at all.

Be sensitive to the fact that Alone is addressing a situation that can make life less tolerable for a specific group of people who are sometimes in danger of checking out (see David Foster Wallace), and that perhaps a discussion about depressed people's welfare should defer to the actual topic. You are also condescending to talk about people who often feel that others are condescending. They really don't need more of that -- especially from amateur therapists.

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"But it's not a secret sign... (Below threshold)

February 20, 2010 1:41 PM | Posted by JayEnn: | Reply

"But it's not a secret signal-- the patient knows what it's called. What message does that send to the patient?"

I think this is one of the major reasons doctors resist the Borderline Personality Disorder diagnosis, and sometimes opt for the more palatable Bipolar diagnosis (since in many cases, the symptoms are hard enough to tell apart)...

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Isn't it incredibly patroni... (Below threshold)

September 1, 2010 4:42 PM | Posted by bobsy: | Reply

Isn't it incredibly patronizing and condescending to call someone who doesn't agree with the meds "treatment resistant", as if it's their fault that the drug isn't working. It is the meds that are the problem in this case, not the service user's "non-compliance". God, isn't some of the language of psychiatry chillingly similar to the kind of language used by the Nazis-Aldous Huxley once said that in the "Brave New World" that many people in future societies would be dosed up on meds as a form of social control. I believe that many anti-depressants work no better than placebo, but I won't mention the names of them due to potential legalities. However, I can tell you that fish oils, exercise and stress management techniques have something going for them, but they won't make Big Pharma richer-and by the way, I used to have severe depression-could barely get out of bed in the morning and was sedated up to the eyeballs on 2 other psychiatric drugs. And I'm NOT a Scientologist. Anti-Depressants may work like a band aid for some people, but being highly sedated will not allow one to do the deeper work on oneself that is required whilst having a fuller range of emotions and feelings-even CBT has been found to be as effective as drugs when it comes to many psychiatric problems, because it works with what's going on inside the head, no conventional drug can give me clarity in thinking, it's just bad science to assume so. But stuff like CBT and breathing and relaxation are much cheaper than lifelong anti-depressants, because they're shorter-term therapy-but one can use their benefits long-term for free after the initial treatment period. There also needs to be far more research into the role of nutrition, lifestyle and trauma related factors in mental illness, instead of peddling the old lie that it's all caused by a chemical imbalance that you're born with.

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