Tuesday, 2 December 2014

Out of the slough of despond

TA CBT MBSR are all tied up in my mind and are all tied up in The Mind, but are probably completely different entities to people who actually work with the mind.  I've never really engaged with any of them but sort of have a belief that they are a) born in the Arts Block and hence b) rather unscientific but c) seem credible to me as a way of making sense of the world.

TA - transactional analysis is a set of beliefs and ground-rules that was invented by a Canadian psychologist called Eric Berne.  I read his book Sex in Human Loving when I was a student and it helped make sense of women in general and one woman in particular.  Berne recognised the importance of intuition in daily life and also wrote a best seller called The Games People Play which suggested that other people have agendas of which they may not themselves be aware.

CBT - cognitive behavioral therapy is (correct me if I'm completely off-beam) about mobilising the rational part of our brain to damp down, re-direct and control the flood of emotional responses that also originate ["lower down"] in the head. It has elements of think-yourself-well and therapists who use the technique try to find strategies and procedures for coping and taming those elements of our emotional thinking that are bad, or which the client believes to be harmful.

MBSR - mindfulness-based stress relief has been championed by a PhD-level molecular biologist Jon Kabat-Zinn who practiced Zen Buddhist meditation techniques in the tradition of Thích Nhất Hạnh and brought these two strands in his life into a method for dealing with pain, anxiety, stress and depression.

I've always wanted these practices to be true, especially the latter two CBT and MBSR.  But at the same time with another part of my mind I've been cranking my skeptical radar to max power and also recognised that wanting something to be true is the first step towards deluding yourself that it is true. The 13th November 2014 issue of Nature has an issue with a cover dulled by The Great Depression and asking "how science can lift the fog from the leading mental disorder".  One of the key things for people who don't suffer from clinical depression is to appreciate it is nothing like "feeling a little down today" - Winston Churchill famously called it "the black dog", to acknowledge its quite frightening and potentially aggressive power. The metaphor won't work for most British readers who will immediately think of their grandfather's tubby, waddly and supremely unthreatening black labrador.  You can hear depression articulated by the quintessentially articulate but periodically depressed and suicidal Stephen Fry.

Well, part of The Great Depression feature is an interesting article A Change of Mind by Emily Anthes.  The bottom line is that there are two classes of treatment for depression a) anti-depressant drugs and b) psychotherapy especially CBT. Nobody wants a 'cure' that will alleviate the symptoms while requiring continued administration of the therapy, so the criterion of record is whether after the cure you can throw away the cane and walk tall again. If that is what we want to acheive, then CBT is, after many properly controlled clinical trials, the clear winner: curing 42-66% of patients compared to 22-40% of patients on the drugs. It's not a level playing field because CBT is much more expensive to administer: those therapists need their house in Hampstead and the villa on the Côte d'Azur and the fast car to move comfortably between the two. The problem for science is that we really have no clue as to how or why it works, despite the evidence that work it does.  I think it's also fair to add that CBT doesn't work for everyone, and nor does amitriptyline, one of the drugs that has proven efficacy according to the definitive epidemiologists at the Cochrane Collaboration. You should read Emily Anthes article for yourself, but one factor that has the ring of truth is a small study that connected brain activity in the right anterior insula with response to the two forms of therapy in a horses-for-courses way.  The insula connects the emotional brain in the amygdala and the thinking brain in the prefrontal cortex, underactive insula was more responsive to CBT and overactive took well to some classes of drug.  This is a bit like diabetes: type I diabetes occurs when the pancreas fails to produce enough insulin; type II diabetes is a failure in the insulin receptors to react to the insulin that is available - both have the effect of unregulated glucose metabolism.

Worldwide 350 million people suffer from depression: that's about 1:20.  Another useful catch-all statistic is YLD - years lost to disability. This is a measure of the walking woundedness. As a killer depression is well behind stroke and heart attack and HIV, but for YLDs it is highest on the list with 75 million YLDs annually, way ahead of 50 million for back pain (dang! but we should never have come down from the trees to walk upright); 40 million from chronic anaemia; 30 million chronic lung complaints and 20 million from diabetes.  That sort of makes sense, as it means that the 350 million spend about one day in five unable to get out of bed in the morning.  I think it's probably true that some people can CBT themselves in that same way that amputees can cudgel their brain into believing their arm is back under conscious control. For some people in the slough of despond it is possible to believe that these things will pass. I feel better already.

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