The Mystery Known as Depression, Part 11/12

11. TREATING DEPRESSION: MEDICATION VS. PSYCHOTHERAPY

The biggest argument about depression nowadays is how to subdue it and bring it under control. The opposing camps are the medication supporters versus conventional psychotherapy. The latter includes old-fashioned "talk therapies" like psychoanalysis, in which the patient "free associates," seeking to understand what in his past has caused the depression. But dominating the field are the cognitive-behavioral therapies, which focus on the present by attempting to help the patient change his thought and behavior patterns. It seems for the moment, however, that the group in favor of medication has won. Today, psychiatry has become an unwitting arm of the drug companies. Millions of Americans are on selective serotonin reuptake inhibitors (SSRI’s), like Prozac, Zoloft, and Paxil, the current gold standard in depression treatment, or a tricyclic antidepressant such as imipramine.

A psychologist investigating depression and its treatment, Ellen Frank, of the Pittsburgh School of Medicine, concludes that antidepressants are most effective when the dosage is sustained over time. "The dose of antidepressant that gets you well, keeps you well,” she told Science News in an article about the clash between proponents of psychotherapy versus drugs in the treatment of depression. (Bower, 1991) In the study, first published in the Archives of General Psychiatry, Frank and her colleagues tracked the treatment of 230 people who had experienced recurring periods of major depression for an average of 12.5 years. (Frank, et al., 1990) Of the 53 subjects who received and stayed on a full daily dose of imipramine, 41 remained free of depression for the entire three years. This study also found that psychotherapy plus drugs had no real advantage over the drugs alone -– not particularly convincing testimony to the efficacy of psychotherapy.

Similar results have been found with use of the SSRIs, drugs that are often prescribed indefinitely. Paradoxically, when one is given antidepressants, one may become suicidal; not because of the drugs but because the medication allows for more access to unconscious pain. The drugs, which are supposed to help in repression, actually lift the burden of total repression from the system, which has had to do it all on its own, so that feelings are now coming up. Tranquilizers, on the other hand, may dampen the imprint enough so that the pain does not intrude. The more pain, the greater the dose required. I have seen patients who attempted suicide by ingesting doses that would have been lethal for almost any human being, but who were only put to sleep for 12 hours. They had such massive amounts of pain activating the brain that the medication could not induce death. And deep depressives who had such high underlying activation that ordinary sleeping pills were ineffective.
Since the symptoms of anxiety and depression seem so different, one is tempted to label them as two different diseases. But the fact that repressive drugs can help with both depression and anxiety shows that they are simply different ways the body has of handling the same kind of pain. Drugs may help with both but for different reasons. In anxiety, they serve to plug the holes in the repressive system since the pain is leaking into conscious- awareness. In the depressive, as I noted, they function it is to take over some of the job of repression, so that the body is not so burdened. The body feels better because it doesn't have to do everything by itself.

Depression and anxiety are not necessarily separate "diseases"; they are reactions at different stages of neurologic evolution, both involving pain and fear and a stressed nervous system. Anxiety comes first where there is pure unadulterated terror with no possibility of defense; and depression second when repression is possible. If we examine animals it seems that they are anxious until placed into a situation with no behavioral opportunities, then they show symptoms of depression. Rats were kept on a slippery slope over a moat of water. When they were exhausted they would fall into the water. After a short time they could not move, were not curious or adventurous—they gave up and seemed depressed.

A depressed person who is not in therapy needs tranquilizers for the same reason that our patients might need them as they approach strong feelings: Repression is weak, so chemical help is needed to bolster it. The drugs help normalize our inner pain-killing pharmacy. We don’t want patients with weak defenses to have a free-fall down into remote and high- valence, first-line pain. Medication allows for a slow, methodical descent; it keeps the patient in the primal zone. When patients relive enough of their painful history, they no longer need alcohol, drugs, cigarettes, or painkillers. Less pain, less pain-killers. The difference is that in conventional therapy medication becomes the end-game, the sole ploy. In our therapy, medication is used to achieve our goal, not instead of it.

When it comes to exploring the subconscious roots of depression in most modalities today, the mantra seems to be: Don’t go there. There is still the idea that dealing with the deep unconscious is dangerous; and it certainly is, when done without proper knowledge. Within the cognitive school of psychotherapy it is believed that the depressive is locked into "self-defeating" thoughts. Thus, the patient must identify which of these thought patterns are "distorted" and, after that, by way of reason and logic, come up with another way of thinking, one which is "rational" and self-affirming rather than self-defeating. This kind of solution, or attempt at solution, is next to antidepressants on the front line of treatment today. It usually comes from those who assert that we can think our way out of problems; that is, we can literally think our way to health. This is part of the new “reframing” school where we turn something bad into something neutral and inoffensive. We reframe the situation so it won’t hurt; there is no notion of deep brain processes, nor of historical imprinted events. Another name for it is pure solipsism. To such therapists, pain is simply all in your mind.

The depressive often tells the conventional therapist, “I just can’t make it. I’m stuck.” And the therapist is warm and encouraging and insists, “Yes you can.” The therapist is unwittingly putting a gloss on the patient’s real feeling, which is the imprint. The imprint, which expresses itself as a feeling of “I’m stuck, I can’t make it,” is primary because the person is unable to change that imprint. Certainly not by talking to a therapist. It is not something thought-out. It is implicit in the birth experience. Optimism or Positive Behavior therapy ignores real feelings which must be dealt with. There is simply no recognition of imprinted memory, even though the process of methylation should inform us otherwise.
There are no such things as self-defeating thoughts, only self-defeating feelings: "I'm no good. I can't do anything." These are not just thoughts suspended in air that one must take back and exchange for new thoughts. They are anchored to physiochemical realities inside that must be addressed. They are evolved not just concocted. Do we actually think that the person makes up these thoughts out of whole cloth? Or do they reflect his life? Further, what and where is this "self" that one is defeating? And what self is doing the defeating? Are there, therefore, two selves?

The real self is the one who has undergone the terrible traumas and is suffering and feeling hopeless and unloved because of real-life early experience. It sends messages up to the thinking centers, which come up with the idea that one is unloved, even while there is a wife and children who are totally devoted to the victim. And a cognitive therapist is quick to point out all this: “After all, you are loved so why do you feel so unloved? You have to change your negative thoughts.”

If we ignore the exigencies of critical periods in the brain’s development during which its key systems require that certain needs – such as the need for touch – must be met, then we’ll never understand why present-day encouragement doesn’t work, even if it comes from a kindly and well-meaning psychotherapist. The depressive's "negative" and "self-defeating" thought patterns emanate directly from deep lying imprints and are in accord with the body’s internal, physiochemical reality. It is the deep-lying imprint wending its way to the top level that results in those defeatist ideas. Thus, the neo-cortex translates the feeling into the specialty of the cortical level – ideas. That cortex does not know that it is responding to something that lies in the depths of the mind. It thinks it is reacting independently. But its free-will has been robbed for a time by exigencies of the imprint. The problem is that the ideas are not in accord with current outside reality. The internal reality always takes precedence over the external one, and the so-called "distorted" thoughts – the ones that cognitive therapists say you have to struggle against – are only symbols for the underlying pain. The evolutionary extensions of the imprint have priority in the psychic economy. We do react to reality but which reality? If we have no notion of an internal one that takes precedence because it has to do with survival, then we must go astray.

That internal reality can represent decades of experience, reinforcing the same few prototypical feelings: "No one wants me. I'm in the way. They hate me." It is true that one can activate and motivate the depressive, encourage him and point to alternatives, and that strategy may help. But all of that is still just fighting against the prototype, which is much stronger and more powerful than words. Ultimately, the prototype will prevail. By and by, the person will fall back into depression. Trying to conquer the prototype means, in effect, conquering your own physiology – a vain task. So long as the imprint is left intact there can be no long-lasting therapy of depression. Without a theory of brain levels we are forced to remain on the last evolutionary level, talking the disease to death.

The notion of depression when unhinged from neurobiology becomes ephemeral and vague and lends itself solely to behavioral explanations. Once we understand that there are generating causes, deep imprints, in producing depression, we understand that cognitive procedures cannot be effective. Deep depression is by definition immune to talk therapy because the “disease” is non-verbal, involves deep-in-the-brain repression, which can’t be reached by new ways of thinking. Ideas and insight work on the upper front, left side of the brain – the cognitive part of the brain – while many of the actual feelings are registered and coded deep on the right side of the brain, leaving the traumatic imprint untouched below the repressive barriers. And that is why insight and talk therapy never reaches the basis of one’s depression. Medication, on the other hand, calms the pain bio-chemically. Both approaches disconnect thought from feeling. It also suppresses the one thing that can make us well -– our history.

Whether they are in favor of treating depression with medication or psychotherapy or a combination of both, most psychotherapists in the field adhere to the notion that suppressing depression is the same as curing it. It is certainly possible to suppress symptoms, to give the patient relief, and help him function better and enjoy life more. But the underlying problem remains, as reflected by the fact that the symptoms usually return when treatment ceases, and many chronic depressives elect to stay on the medication permanently in order to suppress their symptoms indefinitely. So long as we leave the imprint intact in dealing with the depressive there will be no cure and a vulnerability to more disease.

The dilemma in psychiatry and psychotherapy today is the focus on the level of presenting symptoms. This makes drugs necessary and makes treatment palliative and non- curative. The idea of repressing symptoms with drugs may work, but it ultimately goes astray because the symptoms are just that: symptoms of an underlying, unconscious pain. Without probing into history, all one can do is treat appearances (phenotypes) instead of causes (genotypes).
There are many new drugs on the market that are heralded as a “breakthrough.” I will discuss one recent one that makes that claim, and that is Ketamine. It is something that was used as a light anesthetic fifty years ago, and was called “twilight sleep.” But it is claimed to be effective in the treatment of depression. The question is why?

Ketamine was originally aimed at horses in veterinary medicine, then transferred to humans. It is not yet legal as a treatment for depression. In experimental studies it is reported as quite effective. It was first tried by scientists at the National Institute of Mental Health.
Thoughts of suicide diminished and depression eased for a time, though not over a long time period. So what happens once this drug is infused into the patient’s system? There is a feeling of dissociation and feeling drugged. Thoughts of suicide diminished and depression eased for a time, though not over the long term. So what happens once this drug is infused into the patient’s system? There is a feeling of dissociation and feeling drugged. What Ketamine does is fill up the space between neurons with the neurotransmitter glutamate, producing a flood of the drug in the prefrontal cortex. And that helps activate mental activity, making the person better able to handle feelings. Their conclusion was that depression is caused by an imbalance in the regulating action of glutamate. Ketamine does activate parts of the limbic system, including the anterior cingulate cortex. In this sense it is an “upper,” gathering up energy and activating the system against its basic repression/deadness, thus lifting depression. Remember, that anything that eases repression will help depression. Generally, then, any medication to combat depression must energize against repression. In short we need to soften the massive repression involved in depression if we are to help patients. Thus the biochemical GABA – gamma amino butyric acid, which works to inhibit the transmission of nerve impulses – is partially undone with ketamine, thus lessening some of the repressive work accomplished with GABA (Diazgranados et al., 2010; Vutskits et al., 2007).

The researchers believe that it is that imbalance that is responsible for depression. I believe we need to ask, what caused that imbalance in the first place? Since its effects are ephemeral I believe we need to first discover how to right the balance that endures. It seems to me that it might well be the early traumas that disrupt so much neurochemical balance in the brain. Depressives may be low on glutamate because excessive activity became dangerous; that is, during the trauma at birth shutting down was survival.

Every breakthrough has one key effect: easing repression and lifting its gates. Since I posit that depression is repression elevated to a higher level, it would make sense that easing repression would make a permanent difference. Otherwise we are obliged to work around the edges, tweaking symptoms and never reaching causes.

Symptoms are signs of something wrong; we don’t want to drive the warning signal away. We want to heed its message. In conventional therapy we have extracted the symptom out of the person for treatment, instead of seeing how the symptom emanates out of a biologic history. We make the symptom well, not the person.

There is an interview in the British scientific journal, New Scientist with psychologist Joe Griffin, the co-creator of the therapeutic approach known as Human Givens, which has gained some acceptance in Great Britain. (Kiser, 2003) He states: “Research shows that any therapy or counseling that encourages people to introspect about their past will inevitably deepen depression.” With this advice, all one can do is focus on the here-and-now and never get better. It is the essence of historical solipsism. There is no past, nothing affecting us in our history. It is a turn on the Freudian notion of the dangers lurking when we meddle with the unconscious. When we ignore or don’t understand history we are confined to an ahistorical therapy. This can lead to a futility on the part of the doctor and patient; sitting by helplessly, infusing drug after drug into the patient to control her symptoms, or discussing them endlessly, in vain.

In order for psychotherapy to be effective, we need to take the heart of the feeling—“I can’t make it”—and trace it back to its origins in the brainstem, which is what Primal Therapy does. If we simply try and convince the patient through a talk-therapy session that yes, he/she can make it, we are widening the gap between his/her waking, thinking mind and his/her feelings. The feelings are real and are part of neurophysiology. In our therapy we take the phrase, “can’t make it,” and use it to allow the patient to feel it further; once locked into the feeling it will take him/her down the chain of pain in ordered fashion. In psychotherapy we have to be careful not to be a cheerleader for the patient and simply try and make her feel better through verbal comfort and consolation. He/She appreciates our encouragement, thrives on it, comes back for more, and each day therefore becomes more distant from herself. It will not make his/her better. And what is “better?” Being him/herself, being in alignment with feelings, there is nothing better than that. Our verbal encouragement makes him/her not herself, however, and if we rely on kinds words only, he/she will not be in accord with how he/she really feels. If the reality of inner feelings is, “I feel unloved,” then encouragement by a kindly therapist defies reality.

As psychotherapists, we want to be a good parent for the patient as much as he/she wants us to be. We know that parents should encourage and support their children. But feelings are engraved in the patient’s system, after that it is too late to make any easy changes through the use of kind words and verbal encouragement. The window of opportunity has passed. We cannot love neurosis away.