Depression, demoralisation and CBT for everyone

ResearchBlogging.orgI was roving through my Twitter feed this morning,when I got word (via Gail Eva) of a paper debating the introduction of an enormous amount of money to provide CBT to people in England with anxiety and depression. The paper is in the British Journal of Psychiatry here and it’s available in its entirety.

While there is no doubt that in New Zealand there are plenty of people with mental health problems who simply do not get seen within the mental health system, it’s difficult to know whether an initiative like this one in the UK will ‘fix’ the problem. We’ve seen similar increases in the number of especially men start to openly acknowledge depression which has made the job of getting help to them much easier (especially in the chronic pain population), but I do have a quiet unease at the psychologification of our health system, and the potential for medicalising what is normal sadness, fear, grief, frustration and even demoralisation.

How does this fit with chronic pain, you ask?  Well, over the 20 or so years I’ve worked in the field, I’ve watched the waxing and waning of the use of diagnoses of depression, with similar waxing and waning of ways of treating the low mood and sleep problems that so many of our patients have.  It’s unsurprising to me that many people with chronic pain feel lousy – you try having an aching body all day every day, not knowing when or if it’s ever going to lessen.  And try that on top of losing a job, relationship strain, losing all the fun things in life like sports and going out, and rotten sleep, and I doubt whether anyone would feel exactly chipper.  BUT giving someone a label and managing their problem is not the same thing.

Using medication was one of the mainstays for managing low mood in people with chronic pain, especially in the earlier years – in fact, there are some people today who still believe in a ‘multimodal’ approach of polypharmacology, and this inevitably includes antidepressant medication of either a tricyclic or SSRI variant.  This can mean some of my patients are on eight or nine drugs, and they still feel lousy!

Now we’re more likely to give a label of ‘demoralisation’ to someone who is simply fed up with having chronic pain and can’t see a way forward.  To me that fits quite nicely – if nothing is working to take their pain away, and they don’t know what their next best step forward is, it makes sense that they start to feel demoralised.  Medication doesn’t seem to help demoralisation very much though.  So it’s more about learning to live differently, thinking differently about self, world, future, and starting to take those steps towards living the life that holds the values that are important.

So, what’s my beef with the extra funding for psychologically-based therapy?  Well, it’s a couple of things really.  Firstly, if we can’t get people with acute or sub-acute low back pain to be seen for programmes that directly address their need to start taking steps towards normality – and these programmes are lead by occupational therapists and physiotherapists – then I don’t see that many people will actually be referred for this type of input.

You see, there is still a big gap in communication between what a doctor sees and hears and what the patient says and believes.  Referrals to PGAP (a sub-acute reactivation programme for people with pain) have been scarce in New Zealand because, in part, GP’s don’t really identify this approach as appropriate for their patients.  Many GP’s still want to find a ‘cure’, and these psychosocial things that I’ve been banging on about for years now don’t seem to directly address what these GP’s think is important – finding the ’cause’ and ‘fixing it’.  More to the point, patients don’t want to think about psychosocial aspects of their problem six weeks or so after it starts – they’re mainly interested in getting rid of it too!  What many fail to see is that their pain is getting the blame for what could be called ‘situational distress’ – a crap situation in work, family and the world.

Some of the points made by Summerfield in this paper are so similar to this, and yet he’s talking about mental health.  Here are a couple:

‘But a technical fix cannot solve problems whose locus is not in the body but in a particular situation in life. Moreover, once a psychiatric formulation is deployed as the explanation for a person’s problems, the moral economy of the situation alters. Attention shifts to a diagnosed condition for which the patient is not responsible, and from which they are not expected to recover without professional help. Agency passes from patient to therapist in expectation of an expert cure.’

What is the cultural background to this debate? To coin an aphorism, citizens are on average as tough as the culture they are living in expects them to be. Yet over the past 40 years in particular, the concept of a person in Western culture has come to emphasise not resilience but vulnerability, and with ‘emotion’ as its currency. This momentous shift has its roots in the way that medico-therapeutic ways of seeing have come to dominate everyday explanations for the vicissitudes of life, and the vocabulary of distress. What has been described as a culture of therapeutics invites citizens to see a widening range of experiences in life as inherently risky and liable to make them ill.

Does this sound familiar? Our workplaces which are so much less dangerous, physically demanding and risky than those 100 years ago, are still seen as the source of ill health and injury. Our bodies are still pretty much the same as they were 100 years ago (except perhaps a little more well-padded) but seemingly need more treatment, more time off work, more babying. Is this reality, or is it simply the way we view ourselves now?

Read the rebuttal of this proposal in the UK written by David Veale. He suggests that CBT is less effective unless therapists are specifically trained in it at postgraduate level, he makes the points that CBT is designed to help people help themselves, and that it is a cost-effective way to help people get back to their valued directions in life.

I’m sure that CBT is as good as the therapist. But would people in NZ get to access this kind of therapy, and if they did, would they get the kind of therapy that enhances independence and helps people reconceptualise themselves as people first, not a diagnosis?And if they got to see psychologists, would they be able to translate their learning to the ‘real world’?  or would they continue to see themselves as ‘suffering’ from something that they need help with?  What kind of labels would people get and how long would they wear them?  Maybe, just maybe, CBT and ACT need to be delivered not just by clinical psychologists, but adopted by every treatment provider – or even more radical, taught in schools so it’s seen as a normal way to question one’s own thinking… Perhaps ‘demoralisation’ can be simply a step towards living a life that has value instead of a step towards ‘depression’ and mental illness?

Summerfield, D., & Veale, D. (2008). Proposals for massive expansion of psychological therapies would be counterproductive across society The British Journal of Psychiatry, 192 (5), 326-330 DOI: 10.1192/bjp.bp.107.046961


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