Medication within therapy

• Recovery from Shame by Ike, 12/25/97
  • SSRI medications by Steve Colameco, 12/29/97
    
    

One of the reasons the SSRIs are overprescribed is that they work so well in so many people, leading busy medical practitioners to reach first for what worked in the other cases of similar illness. My own way of assessing a new patient requires that I identify the one or many affects that seem to be involved in both the chief complaint and the presentation of self, after which I check to see whether that pattern of affects is a matter of hardware, firmware, or software. When chronic shame (for example) has been triggered and maintained by troubled relationships, I advise a form of therapy that addresses those relationships.

Yet it is important to recognize that shame and relational pathology are reciprocally related. Just as empathic failure can trigger shame affect, interference with the biological mechanisms that subserve this (or any) affect can produce a clinical situation in which that affect remains present as the climate of one's life rather than a momentary bit of weather. So chronic shame produced by a biological glitch can act as a terrible impediment to intimacy. I tend to use the SSRIs when careful history (and, often, failure of verbal or interpersonal therapy) suggest to me that an individual remains stuck in shame. Competent psychotherapy must recognize that we are both biological and social animals.

I believe with Tomkins that we humans have evolved with a set of nine innate affects from which we develop a highly personal library of emotions and scripts. Of these nine affects, two feel wonderful, one is so brief that it has no flavor, and six feel just awful. The clinician who uses the affect pattern chart to assess a new patient will rarely use the cumbersome term "depression." Rather, s/he will note which one or many affects have become more or less stable phenomena of someone's life rather than brief, momentary reactions to stimuli. Steady-state distress-anguish, fear-terror, anger-rage, dissmell, disgust, or shame-humiliation are equally likely to be described as "depression." Strategies for the reduction of "anxiety" rarely help people with chronic dissmell or disgust or shame. All therapy should be strategic, all therapy should be capable of alteration when it doesn't work.

So Steve and I agree that the SSRIs are prescribed too much, even if we may differ in our understanding of the biology and biography of shame affect. Yesterday seems to have been the 10th anniversary of the day Prozac was okayed by the Food and Drug Administration. I'd sure hate to have to go back to the world of psychiatry as it was before we owned that powerful weapon against the disorders it treats. And I'm proud of a medical profession that has learned so much about this new approach to affective illness in so short a period of time.

• Thanks, Don! by Steve , 12/30/97