Psychotherapy

It is generally recognized that the combination of psychotherapy with drug therapy is more effective than the use of each of these methods separately. They are not alternatives to solving the problem, but, on the contrary, complement each other perfectly. When conducting psychotherapy is of great importance the activity of the patient, his involvement in the process. Active participation of the patient allows him to develop certain behavioral skills and mechanisms of self-regulation, which teach to cope effectively with difficult life situations and increase the chances of a person not to fall into repeated depression in the future.

The most common currently and effective in the treatment of depressive disorders are three types of psychotherapy: psychodynamic, based on the work of Freud and his followers and the methods of psychoanalysis developed by them, behavioral therapy and cognitive psychotherapy.

According to the psychoanalytic concept, the cause of depression is unresolved and suppressed unconscious conflicts. This approach was most detailed in Freud’s book “Sadness and melancholy”. According to his ideas, the basis of depression is laid in infancy, when the child is taken from the mother’s breast. The resulting mental trauma and lack of adequate compensation cause a state of dissatisfaction and the development of self-esteem disorders, leading ultimately to the development of depression in adulthood. The views of Freud on depression was developed in the works of Melanie Klein and Donald Winnicott.

The merit of the psychoanalytic school is a detailed study of the core of depression and a correct indication of the role of unconscious factors in its development. The task of the therapist in the conduct of psychoanalysis is the discovery of repressed traumatic situation, the awareness of her patient, re-experiencing and healing. At the same time, the psychodynamic school pays insufficient attention to other sources of unconscious conflicts that are not directly related to the traumatic removal from the mother’s breast. Its big drawback is also the neglect of social factors and traumatic situations from the present, which can lead to the development of a depressive episode. Psychoanalysis is a long process, sometimes treatment can be delayed for many years, which limits the widespread use of this method in successful therapy of depression.

Behavioral psychotherapy appeared in the Arsenal of psychotherapists relatively recently, finally formed into a whole doctrine, it was only in the 50s of the last century, after which it quickly gained popularity and developed in several directions. Common to all types of behavioral therapy is the idea of human behavior as a result of training, which radically distinguishes it from psychodynamic concepts. Behavioral therapy is aimed at solving the current problems of the patient by changing behavioral patterns, passivity, rejection of pleasure, isolation from the environment.

The Creator of cognitive therapy is Aaron Beck, who has tried to combine the best of both approaches. Cognitive psychotherapy combines the work with the actual problems of the patient, and with his deep beliefs and perceptions. Beck believes that the cause of the depressive disorder is inherent in the patient’s worldview and interpretation of the events happening to him. The aim of cognitive therapy is to change the patient’s negative thinking to positive by careful individual work and detection of cognitive, mental errors in the patient’s reasoning.

Currently, the last two methods are often combined into one called “cognitive-behavioral therapy”. From the name it is clear that in this way an attempt is made to combine both approaches, correction and behavioral and mental errors. Perhaps it is no exaggeration to say that cognitive-behavioral therapy is the most common type of psychotherapy now. Its popularity is explained by the relative brevity, especially in comparison with psychodynamic therapy, in which treatment can last for years, and the resulting relative cheapness, a large number of empirical (experimental) data confirming its effectiveness.

On average, ten to twenty psychotherapeutic sessions are required to achieve some result. In my case, it took more than fifty. I visited a therapist for a year and a half, once a week, each session lasted about an hour. During the sessions, we discussed the situations that concern me from today’s life, possible options for their development and what effect they can have on my life.

In favor of cognitive-behavioral therapy, I can say that first of all, some effect is achieved due to the fact of communication with the therapist. If the latter manages to establish reliable contact with the patient, to create a trusting relationship, the very expression of accumulated fears, the opportunity to share them with someone in a safe environment, “pour out the soul” already leads to some subjective changes in the emotional status of the patient. In my case, it happened that way, after a short period of rubbing, I quickly opened up to the therapist and immediately felt some relief. Passing sessions after that was no longer a burden, on the contrary, I was looking forward to them. Also, therapy really helped me to deal with some hypertrophied fears, to realize that their consequences may not be as severe as I initially thought.

The thing is that, being in a depressed state, you do not delve into the essence of your problem, it scares and disarms you so much that you continue to engage in its mental chewing on a superficial level, do not take the next step, just feel that it will continue to be bad and scary. The role of the therapist is to take you by the hand and mentally go through this path, critically evaluate it, do what the patient is not able to do on their own. It is important to avoid any pressure on the part of the therapist, it should only help you to understand the hypertrophy of the problem by asking questions, offering to evaluate the possible variants of development of events.

As a result, your problem does not disappear, but its value, significance, if very roughly, decreases.cognitive-behavioral therapy does not eliminate the source of your pain, but teaches you to live with it. Well, that might be justified, too. Such therapy did not cure me, and I did not take less drugs, but in some situations I began to feel more confident, less fixated on certain problems that worried me at that time.

As for psychoanalysis, I have only a brief experience of this procedure, which I interrupted after several sessions, and I still believe that I did the right thing. For all the fidelity of the theoretical basis of the method, to its practical results, I am extremely skeptical. First, it repels the duration and cost of the process. Secondly, the method is extremely subjective, very much depends on the personality of the psychoanalyst, his ability to correctly interpret the signs that your subconscious mind gives.

I also have strong doubts about the treatment of the depressive disorder itself by psychoanalytic methods. It seems to me that psychoanalysis can be effective in cases where the cause of neurotic disorder is reduced to some one suppressed root episode. This occurs in the pathogenesis of various phobias and obsessive-compulsive conditions. If the therapist manages to get to the displaced episode and help the patient to realize and relive it, then there is a recovery or a marked reduction in symptoms. To illustrate, we can consider the example given by Freud in lectures on the introduction to psychoanalysis, I will allow myself to give this passage as a whole:

“Nineteen-year-old blooming gifted girl, the only child of her parents, whom she surpasses in education and intellectual activity, was an unruly and playful child, and in recent years without apparent external causes has turned into a nervous. She is very irritable, especially against her mother, always unhappy, depressed, prone to indecision and doubt, and finally admits that she is not able to walk alone in the squares and large streets. We will not deal with her difficult painful condition, requiring at least two diagnoses, agoraphobia and neurosis of obsessive-compulsive conditions, but will focus only on the fact that this girl has also developed a ceremonial bedtime, from which she makes her parents suffer. We can say that in a sense, any normal person has his own ceremonial laying down to sleep or requires compliance with certain conditions, the failure of which prevents him from falling asleep; he clothed the transition from a state of wakefulness to sleep in certain forms, which he repeats in the same way every evening. But anything that requires a healthy sleep environment can be rationally understood, and if external circumstances cause the necessary changes, then it is easily obeyed. But the pathological ceremonial is uncompromising, it is able to achieve the price of the biggest victims, and it is in the same way covered by the rational justification and at superficial consideration it seems different from normal only by some exaggerated carefulness. But if you look closer, you can see that the veil of rationality is too short, that the ceremonial includes requirements that go far beyond rational justification, and others that directly contradict it. Our patient as a motive for their night precautions leads to the fact that she needs to sleep and it should eliminate all sources of noise. To this end, she acts in two ways: she stops the big clock in her room, all the other clocks are removed from the room, she does not tolerate even the presence of her tiny clock on the bracelet in the nightstand. Flower pots and vases are made on the Desk so that they could not fall at night, break and disturb her in her sleep. She knows that all these measures can only have a seeming justification for demanding peace, the ticking of a small clock can not be heard, even if they remained on the bedside table, and we all know from experience that the uniform ticking of a clock with a pendulum never interferes with sleep, but rather acts sleepy. She also recognizes that the fear that flower pots and vases left in their place at night can fall and break themselves is unlikely. For other requirements of the ceremony she no longer refers to the need of rest. Indeed, the requirement that the door between her room and her parents ‘ bedroom remain half-open, the fulfillment of which she achieves by inserting various objects into the half-open door, it seems, on the contrary, can become a source of disturbing noise. But the most important requirements apply to the bed itself. The pillow at the head of the bed should not touch the wooden headboard. A small pillow for the head can lie on a large pillow only as forming a rhombus; head then she puts exactly along the long diagonal of the rhombus. The feather bed (”Duchent”, as we say in Austria), before it can be covered, must be whipped so that its edge at the feet became quite thick, but then it will not miss the opportunity to smooth this accumulation of feathers again.

Let me go around the other, often very small details of this ceremony; they would not teach us anything new and would take us too far from our goals. Do not lose sight, however, that all this is not so smooth. At the same time, it does not leave the fear that not everything is done properly; everything must be checked, repeated, the doubt arises about one or the other precaution, and as a result, it takes about two hours, during which the girl herself can not sleep and does not allow frightened parents to sleep.

The analysis of these torments was not as simple as in the case of the obsessive action of our first patient. I had a girl to do suggestive hints and propose interpretations, which every time she was rejected with a resounding “no” or accepted with contemptuous doubt. But this first negative reaction was followed by a period when she herself was engaged in the possible interpretations proposed to her, selected the appropriate thoughts, reproduced memories, established connections, until, on the basis of her own work, she accepted all these interpretations. As it happened, it is also more inferior in the performance of the obsessive precautions and before the end of treatment declined from just ceremonial. You should also know that the analytical work, as we now do, directly excludes the sequential processing of a single symptom until its final clarification. Moreover, sometimes you have to constantly leave one topic in full confidence that you will return to it again in another connection. The interpretation of the symptom that I am about to tell you is thus a synthesis of results that, interrupted by other work, take weeks and months to produce.

Our patient is beginning to gradually realize that during her sleep preparations, she removed the clock as a symbol of the female genitals. Watches, which can be symbolically interpreted in a different way, acquire this genital role due to the periodicity of processes and the correct intervals. A woman can boast that her menstruation occurs with the correct clockwork. But especially our patient was afraid that the ticking of the clock would interfere with sleep. The ticking of the clock can be compared to the pulsation of the clitoris during sexual arousal. Because of this unpleasant feeling she really woke up repeatedly, and now this fear of erection was expressed in the requirement to remove from herself at night running hours. Flower pots and vases, like all vessels, are also female symbols. The precaution that they do not fall and not break, therefore, not devoid of meaning. We know a common custom to break a vessel or plate during the engagement. Each one present takes a shard that we should understand how the waiver of claims for the bride from the point of view of the marriage custom to monogamy. Regarding this part of the ceremony the girls got a memory and some thoughts. Once as a child, she fell with a glass or clay vessel, cut her fingers, and was bleeding heavily. When she grew up and learned the facts of sex life, she had a frightening thought that on the wedding night she would not bleed and she would not be a virgin. Her precaution against the fact that the vase did not break, means, thus, the denial of the entire complex, associated with virginity and bleeding at the first intercourse, as well as the denial of the fear of bleeding and opposite to him the fear of] not to have bleeding. To prevent the noise for which it took these measures, they had only a remote relationship.

The main meaning of her ceremony, she guessed one day, when she suddenly realized the order that the pillow did not touch the headboard. Pillow for her has always been a woman, she said, and the vertical wooden backrest – man. Thus she wanted – by magic, I might add – to share a man and a woman, i.e. to separate the parents to prevent them before the marital act. This same goal she tried to achieve before, until the introduction of ceremonial, more direct way. She feigned fear, or used existing tendency to fear in order not to give close the door between the bedroom and the nursery. This requirement still remains in her present ceremonial. Thus she created itself opportunity eavesdrop on for parents, but, using this opportunity, she once acquired insomnia, which lasted months. Not quite pleased with the opportunity to interfere with her parents in this way, she sometimes made sure that she slept in the marital bed between her father and mother. Then the “pillow” and”headboard” really couldn’t connect.”

From this example, it becomes clear that the success of the interpretation of painful symptoms in psychoanalysis is very dependent on the professionalism of the therapist, requires patient work and really helps in a number of disorders lead to recovery. The problem is that in the case of depression, it is rarely possible to identify any one episode from the patient’s past, which served as the direct cause of the disease. There are many such episodes, they are superimposed on each other, increase internal tension, until it finds a way out in the symptoms of the disease. Obviously, a lot of work needs to be done to identify and work out, one after another, each such traumatic event. And of course, psychodynamic therapy does not help the patient to solve his problems with real events occurring in the present.

Data on the effectiveness of psychoanalysis in depression are contradictory and, at least for me, unconvincing. Effective and reliable tools for detecting suppressed unconscious material in the Arsenal of psychoanalysts today I do not see. But they existed and were actively used in the 60s of the last century. Such tools were psychedelic drugs.