Sunday Dialogue: Treating Mental Illness — Letters that should have been in the new york times

MAY 25, 2013

Readers discuss the benefits of talk therapy versus medication.

To the Editor:

We tend to divide treatments for mental illness into “psychological” approaches and “biological” ones; the former typically involve “talk therapy” and the latter medication. But this either-or way of thinking obscures the fact that talk therapy affects the brain and is no less biological than pills.

Numerous findings over the last two decades demonstrate how talk therapy alters the brain. Disabling conditions like clinical depression and anxiety can be treated effectively by understanding distorted patterns of thought, becoming aware of emotional conflicts that have not been conscious, or practicing new behaviors. Talk therapy is a potent treatment for serious mental disorders and not simply for the “worried well,” as it is sometimes characterized.

These conditions can also be treated with medication, either alone or in combination with talk therapy. Whereas the effects of medication tend to go away once the medication is stopped, the benefits of talk therapy can be enduring because of the significant changes that take place not only in the “mind” but in the “brain,” too. This is a real-life example of what the Nobel laureate Eric Kandel has discovered: learning affects the ways in which the brain forms new connections.

Why does this matter? It is important that the public know that talk therapy is an important tool in the healing process precisely because of its powerful effects on the brain. Medication, which is lifesaving for many, tends to be overprescribed. Rather than being introduced as part of a comprehensive treatment that includes psychotherapy, it is often used in its place. We should be aware of the cultural trends that devalue psychotherapy and the listening healer and the unintended consequences that may ensue.

LARRY S. SANDBERG
New York, May 20, 2013

The writer is a psychoanalyst, a clinical associate professor of psychiatry at Weill Cornell Medical College and the co-author of “Psychotherapy and Medication: The Challenge of Integration.”

Editors’ Note: We invite readers to respond by Thursday for the Sunday Dialogue. We plan to publish responses and Dr. Sandberg’s rejoinder in the Sunday Review. E-mail: letters@nytimes.com

Readers React

It is good to see talk therapy get a fair hearing in the lay press as a “biological treatment.” Those of us who have used both talk therapy and medication in practice have known about the evidence, both clinical and experimental, and have been informing our patients accordingly for a long time. That it has not gotten enough traction in our society, and that there has not been more confirming research, bear witness to the enormous power of the insurance industry (which does not pay psychiatrists enough to do psychotherapy or conjoined treatment) and the pharmaceutical industry (which has a vested interest accentuating the benefits of medication).

While psychoanalytic psychotherapy is more useful to patients in the long run, it is harder to get the most out of this treatment in the beginning because of the physical symptoms of their depression/anxiety, which are more rapidly addressed with medication. I usually put it bluntly — that it is hard to get much from talking when you are not sleeping and feel physically as if you have been run over by a steamroller.

Most patients cannot afford true conjoined treatment. And I refuse to see patients for only the 8 to 15 minutes allotted by their insurance for a “medication visit.” So we do the best we can with longer visits with less frequency, even though the reimbursement for this is quite poor.

The brain is a wonderful organ. It heals. And it can be helped to heal.

DAVID GORENBERG
West Tisbury, Mass., May 23, 2013

The writer is a psychiatrist in private practice and a former clinical associate professor of psychiatry at the University of Pennsylvania.

Dr. Sandberg makes an excellent case for multi-modality therapy of mental illness — chemical and interpersonal. But until we determine that this approach is part of the right of all Americans to quality health care, most people will not have the financial wherewithal to acquire the benefits of talk therapy, nor will most insurers cover what can be a protracted and expensive alternative to a pill.

To be brief, who is going to pay for this?

LEONARD A. ZWELLING
Bellaire, Tex., May 22, 2013

The writer is an oncologist.

Perhaps one of the most pernicious of the “cultural trends that devalue psychotherapy” is our national penchant for the quick fix. While talk therapy may be equally, and, as Dr. Sandberg points out, more lastingly effective, it can take months or years to achieve the kinds of results that pills seem to deliver in hours or days. This may be the allure that medicine has in our culture. Until we learn, collectively and individually, that there are no shortcuts to what we value in life, least of all to our mental wellness, we will likely continue to feel the effects of our hurried, half-baked efforts.

RACHEL WYNER
New York, May 22, 2013

The writer is a doctoral student in clinical psychology at the New School.

As a social worker and psychotherapist, I could not agree more with Dr. Sandberg regarding the effectiveness of talk therapy and the degree to which it is marginalized in practice. The reasons for this are well known.

Most individuals seeking help for mental health problems are treated by primary care providers, who are far more likely to suggest or prescribe medication than recommend therapy. Psychiatrists behave similarly. Health insurance companies frequently provide better coverage for pharmaceutical treatment than psychotherapy.

Meanwhile, pharmaceutical companies advertise across the media, creating the illusion that psychotropic medications cure anxiety and depression. Ask yourself: When’s the last time you saw a commercial for talk therapy? The average American’s view of therapy is most likely shaped by “The Sopranos” or Woody Allen movies.

The publication this month of the D.S.M.-5, the long-awaited and deservedly maligned new edition of the psychiatric diagnostic manual, is unlikely to improve matters. The D.S.M.-5 was created in a vacuum by psychiatrists, with little input from the psychologists, social workers, counselors and nurses who compose the majority of the mental health work force. This is hardly a recipe for a balanced approach that leverages the benefits of therapy and medication.

With psychiatry always at the head of the table, is it any wonder that medication usually ends up being the main course?

ALEX CAREY
Nashville, May 22, 2013

I had psychotherapy for five years and learned what probably caused my lifelong depression. I understood but felt no better. Only medication changed the way my life felt.

WILLIAM STOTT
Santiago, Chile, May 22, 2013

Dr. Sandberg’s invoking of the wondrous potential of learning in arguing for the value of talk therapy is a powerful construct for me. As an adult education specialist and recent wayfarer through the mental health system, I attribute my hard-won health to the hybrid approach that Dr. Sandberg advocates.

I could not have been cured with lithium alone. In fact, I know I am not “cured”; I am relieved and assisted. It has been the awakening process of psychotherapy that has allowed my at-first grudging, then fuller, acceptance of medication to clear my mind.

My brain was soothed and cleared so my mind could accept the talk therapy that has become transformative. This helped me immeasurably in self-acceptance, in proving to me my brain is not only healable, but also capable of quite amazing evolution even in the grips of mental illness.

LAURA JO SWARTLEY
Seattle, May 22, 2013

Like Dr. Sandberg, I too believe that mental distress cannot always be reduced to a chemical imbalance treated solely with the perfect drug cocktail.

Cross-cultural studies of depression and anxiety demonstrate how different peoples around the world address mental illness, with and without the aid of psychiatric drugs: through family relations, religious traditions, rituals or local forms of “talk” therapies. Together, they show how healing is multidimensional and irreducible to chemicals in the brain. Healing is as much about social relationships, empathy, compassion, dialogue, vindication, and examinations and recommendations from experts as it is about finding the right drug.

With that said, psychotherapy cannot be applied in a one-size-fits-all manner in such a culturally diverse country as the United States, in which 13 percent of the population is foreign-born. Western psychotherapies are grounded in certain intellectual and professional traditions that privilege concepts like the importance of “insight” or self-understanding. Different cultural orientations understand the self and mind differently, and insight may not always be the right goal. We thus need to examine carefully our psychotherapeutic techniques and their benefits (or lack thereof) for our heterogeneous population.

IAN HSU
Cambridge, England, May 22, 2013

The writer is a graduate student in medical anthropology at the University of Cambridge.

There’s talk therapy and then there’s talk therapy. There is a great deal of evidence that structured talk therapies such as cognitive behavioral therapy and dialectical behavioral therapy can transform minds and brains in highly positive ways. Used in conjunction with careful medication regimens, these therapies can have dramatic and lasting impacts even for seriously mentally ill individuals. However, these therapies require intensive training and rigorous application.

Sadly, what mostly passes for therapy in the United States is an unstructured farrago of psychodynamic chitchat that provides little more than a placebo effect. It is a tragedy and an ethical outrage that help-seeking individuals receive mostly ineffective treatment when effective treatment should be readily available.

BOB BENNETT
Chief Executive, Family Service
Agency of San Francisco
San Francisco, May 22, 2013

To the Editor:

As a culture we must embrace talk therapy the same way we embrace primary care providers. Therapy has real emotional and biological benefits for those faced with serious mental illness and individuals inappropriately labeled as “the worried well.”

I strongly believe that it can also be beneficial, at times, for everyone else. I do not suggest that everyone has a disability or a mental illness or should be on psychotropic medication. I argue, rather, that mental wellness is part of physical wellness. Life is hard, and there should be no shame if an individual chooses to ask for support and help from a professional.

The raging debate around the newly published D.S.M.-5 unfortunately fuels stigmatizing of mental illness. Yes, medication is overprescribed. Yes, diagnoses can be inappropriate and negative labels. But the bigger problem is the disparaging, isolation and stigmatizing of people who are going through a tough time and/or are faced with real, diagnosable illnesses. If we can all recognize the benefits of therapy, perhaps we can increase our societal empathy and our individual well-being.

J. CURT GLEESON
Charlottesville, Va., May 22, 2013

The writer is a mental health counselor.

The Writer Responds

Ms. Swartley and Mr. Stott present contrasting pictures of their treatment experiences. Ms. Swartley received combined treatment — medication and talk therapy — that worked well together, while Mr. Stott spent years in talk therapy, only belatedly finding relief through medication. Mr. Stott’s unfortunate experience is not an argument for or against talk therapy. Rather it highlights the importance of open-mindedness on the part of clinicians to all treatment options and the need to re-evaluate the effectiveness of any treatment at reasonable intervals. Five years is not a reasonable interval.

Mr. Carey and Ms. Wyner note cultural trends that contribute to the devaluation of talk therapy. A consequence of these trends is that patients are more likely to pursue talk therapy after many medication trials that are either ineffective or insufficient to bring about relief — the opposite experience of Mr. Stott. Media attention that highlights the problematic use of stimulants in young people and antipsychotic drugs in the elderly may herald a period of increased caution with regard to medication prescribing and a more balanced perspective about the different kinds of treatment that are available.

Mr. Bennett rightly points out that there are different kinds of psychotherapy and that the evidence base for their effectiveness varies. However, he denigrates and misrepresents a psychodynamic approach as “chitchat” and dismisses it as “ineffective,” suggesting such practitioners are less rigorously trained than those practicing other forms of therapy. There are good and bad psychotherapists of all persuasions. Research findings support the potential value of psychodynamic treatment for panic disorder, depression and borderline personality disorder among other more complex conditions. Individuals seeking treatment should ask not only what kind of therapy is being offered, but what alternatives exist and why a particular kind of therapy is being suggested.

Finally, Dr. Zwelling asks about money and access to care. This is, no doubt, a major impediment. Maybe if we keep in mind the Centers for Disease Control and Prevention’s estimates that depression alone leads to a loss of productivity from $17 billion to $44 billion per year, the cost of treatment will seem like a small price to pay.

LARRY S. SANDBERG
New York, May 23, 2013