Technology is worshipped in U.S. culture, but when it comes to transforming depression and emotional suffering, is this predilection for technology justified?
Technology worship means a reverence for machines, manipulations, and manuals designed to control. It also means valuing the objective and the quantifiable over the subjective and the non-quantifiable, and prizing the synthetic versus the natural.
An American penchant for mental health technology, techniques, and technician practitioners is evidenced in several ways. Synthetic antidepressants are now taken by 11% of Americans. Electroconvulsive/shock treatment continues to utilized despite its severe adverse effects. And psychotherapies that can be reduced to standardized manuals of techniques (such as cognitive-behavioral therapy) are taken more seriously than other approaches that are equally effective and often more interesting and fun.
What is problematic about technology worship? What does science tell us about the effectiveness of technological mental health treatments compared with other approaches? And what non-technological variables are crucial for transforming immobilizing depression and emotional suffering?
Respect versus Worship of Technology
A rejection of technology worship does not mean the rejection of technology. Instead, it means a recognition that machines, manipulations, and manuals can be—depending on the arena—helpful, useless, or dangerous.
Perhaps the twentieth century’s most well-respected critic of technology worship was Lewis Mumford (1895-1990). As a young man, Mumford was fascinated by electrical engineering, and his first published articles were in Modern Electrics in 1911. Later, he came to be well-known as a critic and historian of architecture, urban planning, literature—and technology. Mumford’s two-volumed The Myth of the Machine (Technics and Human Development and The Pentagon of Power) has compelled many of us to rethink Western civilization.
Mumford was not anti-technology, only opposed to the irrational, dehumanizing use of such. He understood that technology worship results in the reduction of all of life to objects of manipulation, and such a reductionism results in eliminating a great deal of what makes life worth living.
With respect to depression, the worship of technology creates a cultural edge for synthetic drugs such as antidepressants, for electroconvulsive/shock machines, and for technique-type psychotherapies that can be reduced to training manuals. In this arena of emotional suffering, does the preference for techniques, machines, and the synthetic make sense?
Synthetic Drugs versus Natural Substances
St John’s Wort is used as a natural herbal treatment for depression, and in April 2002, the Journal of the American Medical Association (JAMA) published “Effect of Hypericum perforatum (St John’s Wort) in Major Depressive Disorder,” a study funded by the National Institute of Mental Health (NIMH). Of note, JAMA’s accompanying financial disclosure about the lead author of the study stated that “Dr. Davidson holds stock in Pfizer [manufacturer of Zoloft].”
Omitted from the article title, the antidepressant Zoloft was also examined in this study. And Zoloft’s performance also went unmentioned in the study press release, which reported only that St John’s Wort was ineffective compared with the placebo. The study result that the general public never heard about was that Zoloft did almost as poorly as St John’s Wort, and both were less effective than the placebo. Specifically, on the study’s primary depression measure, 32% of placebo-treated patients experienced remission, better than the 24% remission for the St John’s Wort-treated patients or the 25% remission for the Zoloft-treated patients. The corporate media, which routinely relies on press releases rather than actually reading scientific articles, reported only on St John’s Wort’s ineffectiveness but did not mention that Zoloft did almost as poorly as did St John’s Wort.
Thanks to a lazy media, Zoloft manufacturer Pfizer avoided a publicity hit when this study was published in 2002. However, GlaxoSmithKline, the manufacturer of the antidepressant Paxil, wasn’t so lucky in 2004.
Glaxo thought itself brilliant when, in a campaign to sell Paxil for both depression and social anxiety, the drug company recruited celebrity spokesmen athletes, former Pittsburg Steeler quarterback Terry Bradshaw and running back Ricky Williams, then playing with the Miami Dolphins. Bradshaw worked out great for Glaxo, but Williams was another matter. In July 2004, Williams announced that he found marijuana to be “ten times more helpful than Paxil.” That made sports pages headlines.
The geniuses at Glaxo apparently missed the fact that the free-spirited Williams, who had dreadlocks before they were fashionable, had Bob Marley tattoos all over his body, named his first child Marley, was friends with Marley’s children, and had stated he didn’t see anything wrong with marijuana because it is “just a plant.” After Williams’s announcement that he found marijuana to be ten times more helpful for his anxiety than Paxil, Glaxo purged him from the Paxil website.
NIMH and drug companies are not exactly in the practice of funding studies to check out Ricky Williams’s claim that marijuana is superior to antidepressants, but there are a boatload of studies comparing antidepressants with another natural substance, a sugar pill. Just as there are millions of people around the world who swear by marijuana, there are millions of Americans who swear by their antidepressant drugs. For depressed people as a group, do antidepressants work any better than a placebo sugar pill?
Author of The Emperor’s New Drugs, Irving Kirsch (professor emeritus at the University of Connecticut and professor of psychology at the University of Hull in the United Kingdom and Harvard) in 2002 examined 47 depression treatment studies that had been sponsored by drug companies on the antidepressants Prozac, Paxil, Zoloft, Effexor, Celexa, and Serzone. Many of these studies had not been published, but all had been submitted to the Food and Drug Administration (FDA), so Kirsch used the Freedom of Information Act to gain access to all the data. Kirsch discovered that in the majority of the trials, antidepressants failed to outperform sugar pill placebos.
“All antidepressants,” Kirsch reported, “including the well-known SSRIs (selective serotonin reuptake inhibitors), had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and other researchers describe it as “clinically negligible.”
Some Americans believe that electroconvulsive therapy (ECT), commonly known as electroshock, has gone the way of bloodletting, but it is still utilized by U.S. psychiatry, and in 2006 received a celebrity boost from Kitty Dukakis’s book about her ECT. ECT has a high potential for serious adverse affects, but is it still worth the risk?
In 2004, Joan Prudic, professor of psychiatry at Columbia University, and her team at New York State Psychiatric Institute conducted a major study of ECT involving 347 patients at seven hospitals. Reported in the journal Biological Psychiatry were both the immediate outcomes and the outcomes over a 24-week follow up period. With respect to immediate outcomes, Prudic reported: “In contrast to the 70 to 90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3 to 46.7%.” Even worse for ECT advocates, Prudic noted that, “10 days after ECT, patients had lost 40% of the improvement.”
There are also studies comparing ECT with a placebo (called “sham ECT”). In sham ECT, patients receive muscle-relaxing and anesthetizing drugs that routinely accompany ECT, and they are hooked up to the ECT apparatus, but they receive no electric voltage. Psychiatrist Colin Ross reports, “No study has demonstrated a significant difference between real and placebo (sham) ECT at one month post-treatment.” (Ross, C. A. (2006). “The Sham ECT Literature: Implications For Consent to ECT,” Ethical Human Psychology and Psychiatry, 8(1):17-28).
Psychiatry is well aware of the bad press of ECT, including Sylvia Plath’s ordeal, so today ECT is more pleasant to observe, but the adverse effects have not changed. While anesthetic and muscle relaxant drugs keep patients from writhing in agony as seizures are induced, brain damage still occurs. In January 2007, the journal Neuropsychopharmacology published an article about a large-scale study on the cognitive effects (immediately and six months later) of currently used ECT techniques. The researchers found that modern ECT techniques produce “pronounced slowing of reaction time” and “persisting retrograde amnesia” (the inability to recall events before the onset of amnesia) that continue six months after treatment.
Does Psychotherapy Technique Matter?
While psychotherapy, like any treatment, often has a positive outcome, scientific effectiveness requires that a treatment be superior to a placebo. However, creating a “psychotherapy placebo”—an event that appears to the patient, therapist, and researcher to be psychotherapy but is not psychotherapy—is scientifically problematic. More easily accomplished, psychotherapy can be compared with other treatments, and different psychotherapies can be compared with one another.
Of all psychotherapies, the one most researched, well known, and highly touted by the mental health establishment is called cognitive-behavioral therapy (CBT). CBT is integration of cognitive and behavioral therapy and consists of an array of techniques for transforming self-defeating thoughts, beliefs, and behaviors. For example, patients learn to identify their “dysfunctional thoughts” (e.g., exaggerations and black-and-white thinking). CBT is commonsense stuff, and many psychotherapists utilize it along with several other approaches. CBT prides itself on techniques that can be defined in manuals such as the Beck manual, and there are CBT workbooks that are assigned to patients for homework.
Does CBT work? Are CBT’s specific techniques the reasons why it works? And do CBT techniques work better than other non-technique psychotherapies?
A form of CBT was the only non-drug treatment studied in the $35 million NIMH funded “Sequential Treatment Alternatives to Relieve Depression” (STAR*D) . STAR*D is the largest study ever done of sequential depression treatments in which nine different psychiatric drugs were also examined. In Step One of STAR*D, all depressed patients were given the antidepressant Celexa, and in Step Two, those patients who failed to respond to Celexa received other treatments, and if their second treatment failed, there was a third and, if necessary, a fourth treatment step.
First, the good news about CBT. In STAR*D, among those patients who initially failed Celexa, three groups in Step Two switched from Celexa to one of three other antidepressants, and their remission rates ranged from 25% to 26.6%. But one group in Step Two switched from Celexa to a form of CBT, and its remission rate was better at 41.9%—this unmentioned in the study press release. STAR*D researchers did not assess whether differences in treatment effectiveness were statistically significant (STAR*D researchers had several financial relationships with drug companies).
While CBT works as well or better than antidepressants, does it work any better than non-technique psychotherapies? In 2008, psychologists Pim Cuijpers and Annemicke van Straten at the University of Amsterdam reported on a meta-analysis of 53 studies, each of which compared two or more different types of psychotherapy for depression. Included were varieties of CBT, psychodynamic therapy, behavioral activation therapy, social skills training, problem-solving therapy, interpersonal therapy, and nondirective supportive therapy. Study results were reported in the Journal of Consulting and Clinical Psychology.
The major findings? The authors concluded, “We found no indication that cognitive-behavioral therapy is indeed more efficacious than other psychological treatments.” Actually, interpersonal therapy was slightly more effective, however, the authors make clear, there were “No large differences in efficacy between major psychotherapies.” The equivalent effectiveness of all psychotherapeutic approaches has long been called by psychologists “the Dodo Bird Effect,” the term coming from the Dodo bird in Alice in Wonderland who famously said, “Everybody has won, and all must have prizes.”
If Not Technology and Technique, What is Most Important?
For his book The Great Psychotherapy Debate, psychologist Bruce Wampold at the University of Wisconsin reviewed the psychotherapy outcome literature, examining hundreds of studies and meta-analyses. Wampold found that outcome effectiveness does not depend on the specific techniques of psychotherapy, but instead depends on so-called “non-specific” factors such as the nature of the alliance between therapist and their client as well as the client’s confidence in the therapy and in their therapist.
Psychologist Michael Lambert at Brigham Young University, like Wampold, has spent a good part of his career studying psychotherapy outcome. Lambert, in the Handbook of Psychotherapy Integration, estimates that the “factors responsible for client improvement in psychotherapy” can be broken down in this manner: (1) 40% of client improvement can be explained by “events external to therapy”; for example, changes in social support or fortunate events that have nothing to do with treatments; (2) 30% can be explained by “therapist characteristics” such as empathy, acceptance, warmth, encouragement; (3) 15% can be explained by “expectancy” or the placebo effect, which can be enhanced with greater therapist credibility; (4) 15% can be explained by “techniques” which can increase expectancy, and so therapist and client belief in a technique may be more important than the technique itself.
The reality is that what gets most of us out of our immobilizing depression and other unpleasant emotional places is decidedly non-technological. What helps most is support and love, faith and confidence, exercise and humor, courage and determination, and serendipity and luck—all very subjective, non-quantifiable, and ill-suited for a manual of techniques.
In a society in which many of their patients worship technology, psychiatrists and psychologists have gained prestige by embracing technology, techniques, the objective, and the quantifiable. However, there has been a price for ignoring subjective and non-quantifiable dimensions. The price paid by mental health professionals is that many of them have become, by their own definition, “psychotic”—losing contact with reality, at least those human realities that are non-technical and highly subjective but are of vital importance in transforming our emotional difficulties. And their patients pay the price of losing out on potential antidotes for their suffering.
Bruce E. Levine, a practicing clinical psychologist, writes and speaks about how society, culture, politics and psychology intersect. His latest book is Get Up, Stand Up: Uniting Populists, Energizing the Defeated, and Battling the Corporate Elite. His Web site is www.brucelevine.net
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.