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PaperclipPerfector  5mo ago (text post)   2320 thread views

Wellness Wednesday for November 22, 2023

The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:

  • Requests for advice and / or encouragement. On basically any topic and for any scale of problem.

  • Updates to let us know how you are doing. This provides valuable feedback on past advice / encouragement and will hopefully make people feel a little more motivated to follow through. If you want to be reminded to post your update, see the post titled 'update reminders', below.

  • Advice. This can be in response to a request for advice or just something that you think could be generally useful for many people here.

  • Encouragement. Probably best directed at specific users, but if you feel like just encouraging people in general I don't think anyone is going to object. I don't think I really need to say this, but just to be clear; encouragement should have a generally positive tone and not shame people (if people feel that shame might be an effective tool for motivating people, please discuss this so we can form a group consensus on how to use it rather than just trying it).

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Hello all, how are you? I hope you all have been doing well.

I haven't been doing so great. I have personal contacts and a support system, but I think this community is one of the few places where my actual feelings will be understood, and my thoughts appreciated.

I'm struggling with finding psychotherapy that's effective for my combination of depression and anxiety, which I've dealt with since I was a child. I had my first recognizable depressive episode in the first grade, not kidding, so this is something that's obviously deep-rooted and temperamental in nature. In that sense, I'm not looking for "insight therapy" where I'm supposed to suddenly figure out what's causing my problems, but for skills-based therapy that can provide discrete and specific interventions I can rely on when my distress or my anhedonia get the better of me. Even solutions-focused brief therapy sounds better than insight therapy at this point.

I actually have a pretty good handle on my emotions and their causes -- counselors in the past have said I have a lot of insight into my problems. The issue isn't that I don't understand them, or are alienated from the true causes, but that I don't know what to do about the negative behaviors I have already identified I have. I'm not really coming into psychotherapy looking for a diagnosis, but a treatment.

I'd like to illustrate my problems with psychotherapy by talking about my most recent, and current, attempt at seeing a shrink.

The most concerning sign of my worsening depression is my attitude towards other people has gotten pretty harsh -- I'm quick to get angry, make snap judgments, even be tempted to be rude -- which is outside of the norm for me. I see this problem as more of a symptom than an underlying issue; I feel more pessimistic and irritable, so I'm eager to lash out. My real problem, I think, is that I don't have as much patience for others as I used to, because I feel on edge all the time.

Unfortunately, I think my new therapist saw this as a bigger part of my problems than it is, and we ended up going down a rabbit hole of "let's explore your feelings of annoyance to see what they tell you about your hidden emotions," and "your negative judgments of other people must be reflective of too much self-criticism." I didn't get any value out of this.

Another issue for me is that psychotherapists are all-in on "unconditional positive regard." This often feels to me like therapists pledging never to actually criticize the problems of the clients who are coming in for a critical eye on their problems.

My current therapist likes to bill himself on being "shame-free," but I'm coming to believe that the optimal amount of shame for personal growth, even in a therapeutic relationship, is not zero. While I don't think a therapist should be mean to their clients, I do think some level of fatherly Jordan-Peterson-style, "get yourself together, man, make something of yourself, you're better than this!" would be incredibly helpful and motivating.

One particular incident stands out -- I was talking about how I got in a social media rabbit hole of drama-reading that made me angry (a common thing for me, as themotte knows), and how I knew I shouldn't do it but did it anyway. He was quick to jump in and suggest "taking the shouldn't out of it," which instantly rubbed me the wrong way and made me feel like my convictions weren't being respected. He seemed surprised when I expressed a strong resolve to just... not use social media, because I see it as harmful to me. Has he never had a client who resolved to avoid things that are bad for them?

It's not that I feel my "shouldn'ts" in this area are imposed on me, or act as a source of guilt... I just recognize that this thing isn't something I like, it's not compatible with my value system, and I don't want to do it any more. I worry this particular therapist has made "avoiding negative judgments" so integral to his therapeutic approach that even when a client comes with an earnest sense that a particular behavior is wrong for them, he still feels the need to taboo their sense of resolution as maladaptive.

I do wonder if this is just a personality difference between men and women, where the average man is motivated more by rising to the challenge of fulfilling expectations and the average woman is motivated more by knowing people care about her and will support her regardless. This is one of the strong reasons why I wonder if the severe over-representation of women in psychology is really distorting the practice, so much so that even men are tailoring their treatment of male clients to the average woman's preferences and needs. When someone a while ago talked on here about "lefty mental health," think that was part of what they were talking about.

So, I feel like my current bout of therapy isn't working. We're not clicking. I've never actually had this happen before, despite trying therapy several times in my life -- I've always just kind of gone along with things, not thinking too much about what I'm looking to get out of therapy other than someone to listen. Now that I've thought critically about what I want to gain from treatment, I'm more judicious about what I need in a therapist. So I don't think this particular guy has the expertise or the right frame of mind to offer skills-based therapy, and is just generally a bad fit for me.

But I'm kind of stuck. As I've said, I've tried psychotherapy several times in my life, and it's made little difference in the overall trend of my mental health. In an earlier attempt at therapy, the only actual unit of value was the advice to use deep, slow breathing as a quick antidote to anxiety (something something parasympathetic nervous system), which to this day can legitimately feel like taking some sort of dissociative drug in terms of how chilled out it can make me.

If therapy has anything to offer me, I don't think it consists of therapeutic theories or piercing insight, but would offer more practical steps to counter negative self-talk and reduce bad thought/behavior spirals. The problem I have is not that I don't understand my problem and don't understand when my thoughts and behaviors are unhelpful, it's that, in the moment, I either feel egosyntonically aligned with the unhelpful things, or I feel situationally powerless to counter it. What I need is a therapist who recognizes that, and can provide direct and practical advice.

But increasingly I just feel like psychotherapy is a dead-end, and what I actually need is to finally get my GP to refer me to a psychiatrist, who might be willing to try one of the fancier anti-depressants that sometimes help people with treatment-resistant anxiety and depression. I've bounced between a few SSRIs and SNRIs in my life, but haven't seen much difference other than the fucked-up sex drive.

Hell, shock my brain at this point, I just don't want to feel on edge any more.

Any thoughts? Please be gentle.

I've bounced between a few SSRIs and SNRIs in my life, but haven't seen much difference other than the fucked-up sex drive.

Are you certain they didn't make things better? I had to go on and off of SSRIs and SNRIs like 4 times before I finally accepted that it wasn't coincidence that better things seem to happen to me when I'm on them, and worse things seem to happen when I'm off them. I really thought it was coincidence at first, but eventually realized that I notice and accept the better things when I'm on these drugs.

Not OP, but I tried 3 SSRIs and 1 SNRI and they didn't help in the least.

I definitely believe both you and OP that there are probably people for which these drugs have no effect. But I also think it's worth doublechecking, since I definitely had my aforementioned experience.

SSRIs have pretty weak effect sizes, but that's not the same as them being entirely useless after all.

Thankfully, Scott has a deep dive on the subject, sparing me the trouble:

https://slatestarcodex.com/2018/11/07/ssris-an-update/

All this leads to the third thing I’ve been thinking about. Given that the effect size really is about 0.3, how do we square the scientific evidence (that SSRIs “work” but do so little that no normal person could possibly detect them) with the clinical evidence (that psychiatrists and patients often find SSRIs sometimes save lives and often make depression substantially better?)

The traditional way to do this is to say that psychiatrists and patients are wrong. Given all the possible biases involved, they misattribute placebo effects to the drugs, or credit some cases that would have remitted anyway to the beneficial effect of SSRIs, or disproportionately remember the times the drugs work over the times they don’t. While “people are biased” is always an option, this doesn’t fit the magnitude of the clinical evidence that I (and most other psychiatrists) observe. There are patients who will regularly get better on an antidepressant, get worse when they stop it, get better when they go back on it, get worse when they stop it again, et cetera. This raises some questions of its own, like why patients keep stopping antidepressants that they clearly need in order to function, but makes bias less likely. Overall the clinical evidence that these drugs work is so strong that I will grasp at pretty much any straw in order to save my sanity and confirm that this is actually a real effect.

Every clinician knows that different people respond to antidepressants differently or not at all. Some patients will have an obvious and dramatic response to the first antidepressant they try. Other patients will have no response to the first antidepressant, but after trying five different things you’ll find one that works really well. Still other patients will apparently never respond to anything.

Overall only about 30% – 50% of the time when I start a patient on a particular antidepressant, do we end up deciding this is definitely the right medication for them and they should definitely stay on it. This fits national and global statistics. According to a Korean study, the median amount of time a patient stays on their antidepressant prescription is three months. A Japanese study finds only 44% of patients continued their antidepressants the recommended six months; an American study finds 31%.

Suppose that one-third of patients have some gene that makes them respond to Prozac with an effect size of 1.0 (very large and impressive), and nobody else responds. In a randomized controlled trial of Prozac, the average effect size will show up as 0.33 (one-third of patients get effect size of 1, two-thirds get effect size of 0). This matches the studies. In the clinic, one-third of patients will be obvious Prozac responders, and their psychiatrist will keep them on Prozac and be very impressed with it as an antidepressant and sing the praises of SSRIs. Two-thirds of patients will get no benefit, and their doctors will write them off as non-responders and try something else. Maybe the something else will work, and then the doctors will sing the praises of that SSRI, or maybe they’ll just say it’s “treatment-resistant depression” and so doesn’t count.

In other words, doctors’ observation “SSRIs work very well” is an existence statement “there are some patients for whom SSRIs work very well” – and not a universal observation “SSRIs will always work well for all patients”. Nobody has ever claimed the latter so it’s not surprising that it doesn’t match the studies.

This is 2018, pretty sure the "SSRIs are a placebo" thing came out after that.

I strongly disagree, I'm quite confident it was a relatively mainstream argument well before 2018, Scott wrote a post in 2014 to which this serves as an update, and that was partially motivated by the claims that SSRIs were useless/placebos.

Edit: The placebo theory is clearly mentioned in the text excerpt I posted as well as in his original blog post.

I mean that there was some big meta-analysis released a lot more recently than Scott wrote his article, which got a lot of press coverage. I think it was this one but I'm not 100% sure.

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