Blind Spots, Elephants and Fairies

We all have blind spots but we do not know what or where they are, or anything about them. If we are fortunate we may have a suspicion but it is easily dismissed, and if we are unfortunate we are acting with complete certainty that nothing gets past us.

Blind spots are areas of considerable discomfort and we probably wish they would go away so we are inclined to ignore them. We may take advantage of courses and conferences but we are likely to select topics and events that we are already interested in and not to notice or see as relevant those papers and presentations which mean nothing to us and arouse no interest. In that way, we keep our blind spots intact.

One subject that has the potential to be a blind spot is psychopharmacology and I can talk about it because it is not mine. I came across it by accident by joining a clinical research team exploring dependence on benzodiazepines known as the Withdraw Project in Birmingham, UK, in the 1980s (Hammersley 1995). These drugs were prescribed from the 1960s for symptoms of anxiety or insomnia without anyone being aware that people quickly became dependent on them and had problems withdrawing. It was a costly mistake and because the underlying problem of blind spots was not addressed, it has been repeated since with SSRI antidepressants.

Symptoms v underlying cause

An important blind spot is the fact that drugs treat symptoms and not the underlying cause. The assumption that is made is that getting rid of symptoms is in some way helpful. It may be a result that many people seek and it certainly fits with superficial research protocols that only measure reported symptoms. But drugs cannot treat or be helpful in relationship difficulties, historical trauma or abuse. over-working, inadequate parenting and other problems. They are not a treatment for anything psychological, such as an emotional reaction to what has happened to us.

Medication circumvents the important assessment and formulation process which psychotherapy involves to determine the causation and process of symptom development. It is for this reason that pharmaceutical companies developed the myth of serotonin deficiency as a so-called cause of depression, which still appears to be swallowed by large numbers of people and the medical profession (Lacasse & Leo 2005). This is a profound blind spot and although many medical practitioners are aware of drug's limitations, they are constrained by "accepted practice", which is code for "we don't want to spend any more money than we need to". Drugs are thought to be quick and cheap.

Elephants in the room

We are familiar with the metaphor of "the elephant in the room" which describes a blind spot that neither the therapist or client can see, although it is clearly huge and taking up a lot of room. When people are taking psychotropic drugs and enter therapy, there is already another person in the dynamic relationship. In other words, the client has previously consulted a medical practitioner whose intervention is affecting therapy and usually continues unchallenged and ignored. We would not normally accept into therapy a client who is being treated elsewhere, but we could accept a client receiving treatment elsewhere from an untrained practitioner if that person is a medical practitioner. Even worse, accepting clients who are also being treated by psychiatrists with no psychological or therapeutic training is a blind spot which is widespread.

Well, these elephants are heavyweights and have the ability to crush anything they stand upon, the client, their symptoms, their trust in therapy and even the therapist themselves. People entering therapy often describe being "given" a prescription for which they should feel grateful, or, "told" what drugs they are to take from an expert to whom they should defer. Here in the UK, most prescribers of psychotropic medication have no psychological or therapeutic training and are offered inducements to prescribe by pharmaceutical companies to accompany the propaganda of suggestions of chemical deficiency (Goldacre 2012).

Yet symptoms are important and necessary because they are often the means of access to what is troubling a person. It is important to see symptoms as expressions of emotion which have not been acknowledged because society is largely ignorant of emotions and their purpose or regards them as a weakness. So a person may not recognise fear, anger, shame or sadness and expect that they should only feel continual joy. Clients, therefore, rely on us as therapists to rename symptoms, interpret them as the means by which people interpret their experiences, and validate the person.

If we ignore prescribed drugs, we may not recognise what they may be doing. They are usually either sedatives or stimulants and if they are having any effect, the person is not really experiencing their feelings or cannot access them, put words to them, or express them. The drugs have cognitive effects too and interfere with memory processing and recall. The more sedative drugs such as antipsychotics may make it difficult for people to recall the conversation after a therapy session and therefore develop their thinking and reflection between sessions. Benzodiazepines are sedatives too and interfere with cognitive and emotional processing as well as being likely to induce dependence (Hammersley 2016)

Omnipotent fairies

The most overused prescription drugs in the UK are SSRI antidepressants which are stimulants but there is little evidence that they have any beneficial effects and may make people feel suicidal. Evidence of ineffectiveness,(Kirsch 2005) dependence and increases in suicidal ideation (Bielefeldt, Danborg & Gotzsche 2016) has been largely ignored and many people have been told that they will have to take them for years or the rest of their lives. We frequently talk about the placebo effect in research but it is the expectation that some omnipotent fairy will arrive with the drug and take all our problems away. And what matters most is that we believe in fairies. It removes the responsibility we have for our own decisions and lives and the need to recognise mistakes or our own frailty and humanity, regardless of whether we are the client or therapist.

An analytic understanding of the role of the drug (Kohut 1971) regards the drug as a replacement for the object who failed the client. Weegmann (2002) comments that "Artificial self-objects like drugs may be sought in lieu of proper self-structures... there is no actual building of, or nutrients to, the self. The drug is seen as omnipotent... making it much more difficult to be able to learn from reality". The role of the therapist is to replace both the failed object and the drug in order for healing to take place, But this is hard work, time-consuming and costly so a fairy who arrives with a magic wand to miraculously remove the symptoms is too often welcomed, rather than challenged. Failure on the part of therapists to challenge prescribing is still a blind spot we should avoid and open our eyes to what is all around us.

Diane Hammersley
B.Sc., M.Ed., Ph.D., C.Psychol.,C.Sci.,AFBPsP., EuroPsy.
Chartered Counselling Psychologist

References

Bielefeldt, A.O., Danborg, P.B. and Gotzsche, P.C., (2016) "Precursors to suicidality and violence on antidepressants: systematic review of trials in adult healthy volunteers", Journal of the Royal Society of Medicine, Vol. 109(10) 381-392.

Goldacre, B. (2012) Bad Pharma: How drug companies mislead doctors and harm patients, London, 4th Estate.

Hammersley, D.E. (1995) Counselling People on Prescribed Drugs, London, Sage.

Hammersley, D. E. (2016) "The interface between psychopharmacological and psychotherapeutic approaches", in B. Douglas, R. Woolfe, S, Strawbridge,E. Kasket and V. Galbraith (Eds) The Handbook of Counselling Psychology, 4th Ed. London, Sage.

Kirsch, I. (2005) "Medication and suggestion in the treatment of depression", Contemporary Hypnosis, 22(2): 59-66.

Kohut, H. (1971) The Analysis of the Self, New York, International University Press.

Lacasse, J.R. and leo, J. (2205) "Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature" PLoS Med 2(12): e392 DOI: 10.1371/journal.pmed.0020392.

Weegmann, M. (2002) "The vulnerable self: Heinz Kohut and the addictions", in M. Weegmann and R. Cohen, The Psychodynamics of Addiction, London, Whurr Publishers Ltd.