Category Archives: Psychiatric Medications

September 5, 2017 · 9:01 pm

New book for those who wonder about the value of diagnoses and medications in biblical counseling


What kind of messages about mental health diagnoses and medications do you receive in your community? What do you hear about these in the church? Silence? Warm embrace? Implicit or explicit rejection?

Mike Emlet, a former family practice physician and now counselor, has written a small book to introduce readers to a nuanced and biblical take on the value of diagnoses and medications. Descriptions and Prescriptions: A Biblical Perspective on Psychiatric Diagnoses & Medications (New Growth Press, 2017) comprises 22 short chapters exploring the pros and cons of both arenas for those who are “too cold” or “too warm” towards the use of mental health diagnoses and medications.

In the first section Mike explores some of the weaknesses of the current DSM (psychiatric diagnostic system). Those who are “too cold” and who think the system is fraught with problems may find themselves saying “yes, exactly.” But rather than just stop there, he begins to articulate implications for ministry responses—how to go deep to understand the person behind the diagnosis. There is much the pastor or counselor can learn.

One key point is made here and in later chapters: we live in bodies and Scripture takes this seriously. So learn about the symptoms a person experiences.

So, you might think this book is negative on the value of diagnoses. It is not. Chapter 9 begins to describe the potential value of diagnoses, especially to those who tend to see mental health problems ONLY as spiritual and ONLY or usually involving just the will. If there is one thing the reader should get from this chapter is that humility is in order. If you don’t put much stock in diagnoses you likely don’t put much stock in published research exploring symptom clusters. As an example, Mike briefly discusses the multivariate experiences of those with obsessions and compulsions. This little window into the problem of OCD should remind us that we must work hard to understand the many subtle forms of obsessional thinking and consider how best to describe and care for the person suffering with them.

On the final page of chapter 9, Mike takes on one crucial criticism—that since you can’t see structural differences in the brain that implicate a particular diagnosis then the diagnosis isn’t real. From his point of view, this is a simplistic understanding of biology and diagnoses.

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The second section explores the challenges and benefits of psychiatric medications. Mike gives a very brief overview of the categories of medications and how they work (what we know and what we don’t know). He summarizes the research as indicating a modest positive effect, though also showing that other means are quite effective (placebo and counseling). Such results show us that there are a range of helpful responses. While it is true that medications for anxiety and depression aren’t cures and aren’t without their side effects, it is important to remember that the individual in front of you may in fact benefit immensely. Thus it is good to remember that we don’t offer advice to others based on population statistics. Rather wisdom is in order for this particular person.

 

 

In probably the best part of the book, Mike walks the reader through a wisdom approach to the use of medications—walking the tightrope as he suggests. Too much suffering and too little suffering can be hazardous to our spiritual health. We can make idols out of medications or out of not taking them. Medications aren’t good or bad on their own. It is how we approach them that matters.

He makes this statement nearing the end of the book,

“I hope you have seen that there is not a clear-cut “right” or “wrong” answer. There is no universal “rule” that we can apply to all people at all times. There is no simple algorithm. Rather, the use of these medications is a wisdom issue, to be addressed individually with those we counsel. There will always be a mix of pros and cons, costs and benefits to carefully consider.”  (p. 87)

This answer may frustrate those who want a clear-cut “this is right/wrong” response. However, counselors are not umpires calling what is “fair” or “foul.” Instead we are walking with and helping others look for relief (what can I do to make the moment better?) and look for acceptance (what is God up to in my life?).  Sometimes relief means medications, other times it means examining thoughts, habits, perceptions, etc. Sometimes acceptance means pursuing other goals beyond symptom relief, other times it means understanding accepting that God has, in his providence, allowed them to have a body that needs external supports.

Book Recommendation: Great first text for those who either over-estimate the value of mental health diagnoses or medications or those who minimize their value. Author leans to a conservative approach and probably spends more time speaking to those who might over-value medications. Yet, he also repeatedly affirms that biblical counseling must take seriously the fact that humans are embodied souls and that diagnoses and medications have value, albeit limited value. Great text to start the conversation and lead to deeper study about our responses to suffering, especially for beginning pastoral counselors and lay helpers.

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May 2, 2016 · 3:18 pm

Alternative to talk or pharmacological therapies for depression?


For many of my clients, medications are necessary for their moderate to severe depression. With SSRIs or mood stabilizers, they are able to function at home and at work and can better benefit from talk therapy. But in every case my clients report side effects from their meds. It is always a bit of art-form to balance benefits and side effects. That is the world we live in and the best we can do now. One of the key problems with all psychopharmacological interventions is that drugs provide a systemic solution when often we may need a targeted approach. Consider a person with ADHD who takes a stimulant that will help them focus in class yet must deal with increased blood pressure, heart rate and potential for insomnia. The stimulant does not just target the frontal lobe but impacts the whole body.

Wouldn’t it be great if we could target an intervention to a particular part of the brain?

“The brain is not a bowl of soup and you add the chemical and you stir,” she says. “Chemicals work within networks, within systems, within pathways. And where in the brain a chemical may be working is as important as knowing what chemical you should use.”

I read the above quote in this news item about the problem of rumination in treatment resistant depression. Helen Mayberg, author of the above quote, is researching Broadman Area 25 and its connection to the problem of rumination–where a person struggles to turn off negative thoughts about self and the world. She and other researchers are wondering why some people do well with talk therapy while others seem not to benefit. Instead of looking at the possibility of a less helpful form of talk therapy, they wondered whether the problem is that the person cannot get away from their negative thoughts enough to engage in the work of counseling.

One of the interventions being tried is to practice disconnecting from ruminations by paying attention to what is going on in the present. To help with the learning of this skill one researcher is testing whether 5 sessions of having an electrode on your wrist create an itching sensation while the patient practices paying attention to a decreasing amount of electrical stimulation.

Sound crazy? It just might be. I am always wary of any “5 sessions or less” advertisement. But before we toss out the idea, if a targeted treatment could help turn down the volume on a rumination, wouldn’t that be a help to many?

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June 20, 2015 · 3:23 pm

Do Psychotropic Drugs Cause Violence and Aggression?


There are no adequate words to describe the recent racially-motivated mass murder of nine church members by a 21 year old, yes disturbed, male. Grievous…insane…terroristic…nothing truly captures the gravity of the situation.

As the details of the shooter’s life begin to surface, there have been several reports that the young man was taking Suboxone, a prescribed medication in the opiate family to help avoid the massive withdrawal symptoms from things like heroin or abused narcotic painkillers. As a result, there are a number of articles touting a connection between Suboxone use and aggression.

But do psychotropic drugs cause violence?

At best, we only have correlations between aggression and drug use. Thus, we need to be very careful when we blame violence on the ingestion of substance, whether prescription or otherwise. Correlations do not tell us causation. Even when we have a direct positive relationship (e.g., increased use of substance A followed by increased behavior B), we still do not have enough to say that there is a direct cause.

Correlations between prescriptions usage and violence do exist

There are a few studies that indicate a correlation between prescription drug use and violence. However, the relationship is connected mostly by those who stop taking their medication. It may be that the cause of violence is the noxious side-effects leading to a dis-use of the med resulting in an increase in psychiatric symptoms. So, do psychiatric symptoms correlate with increased violence? One study completed on a large psychiatric inpatient population determined that the rate of violent behavior one year post psychiatric hospitalization stood at about 27%. The numbers go higher if the person also has a co-morbid substance abuse problem (interestingly, men and women have about the same rate of violence but male violence tends to have more victims).

Certain medications seem to encourage more anger, aggression, and violence. Opiates tend to have a mollifying effect. People who use them may feel euphoria or calmness at first. As the narcotic wears off, there may be in increase in anxiety, pain, or agitation. There are, however, some who report increase angry and violent thoughts. One particular study suggests that prior personality factors may influence aggressive responses in an individual.

Suboxone is one of those drugs used to combat opiate abuse. Itself an opiate, if taken for a long period of time it becomes the addiction without the euphoria. The goal of the medication is to get off the opiate onto Suboxone and then slowly taper on Suboxone to the point that opiates are not longer needed.

There is little evidence that SSRIs and other psychotropics cause or even encourage violence. What is true is that violence, like everything else, is a multifactored event. Those prone to addiction, isolation, delusion, paranoia, impulse control problems may have increased risk to resort to violence. Those with particular personality features may be prone to violent responses. Certainly, environmental factors are also in play: culture, education, economic resources, history of victimhood all have potential impact on the choice to use violence to solve problems. And finally, faith and character (which itself is developed due to nature/nurture) plays a significant role in how we see others and whether we afford them with kindness and compassion.

If nothing is to blame, is there anything we can do?

It is good to resist the impulse to blame any one thing for the cause of violence. However, it is legitimate to take each of the factors commonly present in violence and to examine them one-by-one to see how we may intervene. Talk about gun availability and gun cultures. Talk about mental illness. Talk about medication (mis-use, over-use, adherence). Talk about racism and prejudices? Talk about poverty. Talk about substance abuse. Look for small ways that we can intervene and begin to change the way we talk about violence in our society. Look for the micro-aggressions and decide to stand against them early and often.

Will we always have individuals bent on destroying others? Yes. But, let us be known for being peace-makers.

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January 30, 2015 · 4:05 pm

PTSD “A Disease of Time”


David Davies, part of the staff of “Fresh Air” on NPR, has conducted an 35 minute interview with David Morris, a journalist who was embedded in a unit in Iraq and who suffers from PTSD resulting from an explosion he survived. David has written a book, The Evil Hours: A Biography Of Post-Traumatic Stress Disorder. If you want to better understand the experience of PTSD and its impact on a person, you should listen to this show (or read the transcript). For therapists, Morris discusses his experiences with Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). He also describes the use of propranolol when repeating trauma stories.

Here’s a couple of my take-aways:

  • PTSD is a disease of time.

“…in some ways, PTSD is a disease of time. And a lot of people – PTSD is many things, but one of the things it is a failure to live fully in the present. And I think what happens a lot of times with traumatic – survivors of trauma is they have these compulsive returns to awful events, and they are unable to live in the now.”

  • The best treatment never removes all symptoms of PTSD

“The best we can do is work to contain the pain. Draw a line around it. Name it. Domesticate it, and try to transform what lays on the other side of that line into a kind of knowledge, a knowledge of the mechanics of loss that might be put to use for future generations.”

  • Honest reflections of the impact of PE and CPT (and why so many dropout from PE treatment)
  • Honest admission about the most common “treatment” of PTSD–alcohol (and evidence why so many end up abusing it!)
  • War traumatizes far too many but rape is 5x more traumatizing

[in discussing how helplessness/lack of control is a significant factor in the development of PTSD] “Yeah, the helplessness is one of the main predictors of who’s going to end up with PTSD and who doesn’t. And the idea that you have absolutely no control over your environment is very hard for people to deal with because, you know, you are basically completely helpless and unable to control your destiny and your survival….and that’s one thing I discovered in the book is I thought – you know, we sort of assume that PTSD is sort of the realm of soldiers and veterans, when in fact, the most common and most toxic form of trauma is rape.

…a soldier may have some control over his or her environment. They have a weapon with them; they can move; they can take cover. But oftentimes in the cases of rape, the victim is completely overwhelmed and trapped and cornered. And from the moment the attack begins, they are rendered almost completely helpless, which is interesting. And you see that in the diagnosable rates of who gets PTSD and who doesn’t. Rape survivors tend to have it almost 50 percent of the time, whereas your average war veteran – particularly for Iraq and Afghanistan veterans – the rate of PTSD diagnosis is more around 10 to 12 percent. So a rape victim – rape is, in a manner of speaking, five times more traumatic than combat.”

 

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September 8, 2014 · 9:15 am

Criticism of Biblical Counseling: Are Joyce’s Concerns Valid?


Katheryn Joyce has recently published a long post about the rise of Biblical counseling and the concerns some have about the movement [read it here].

Most people who have thoughts about counseling and Christianity tend to fall into one of to categories: Those who oppose biblical counseling as dangerous and those who oppose the various versions of Christian psychology as shallow and full of humanistic ideology. Very few people try to maintain identity in both worlds. If you have read my “about me” you will find I’m one of those who does accept the label of biblical counseling and Christian psychology (more on this below)

I encourage both proponents and opponents of Biblical Counseling to read her essay. Let me even take the liberty to suggest some starting questions to keep in mind as you read. While the essay may not answer the questions, having them in mind will keep you from solidifying stereotypes of either sides.§ If you are inclined to reject biblical counseling, consider these questions:

  1. Where might I find a more thorough history of biblical counseling and its various permutations?
  2. What main biblical counseling author voices are missing in this piece? [Note that the mentioned ACBC was, until recently, known as NANC (National Association of Nouthetic Counselors)]
  3. What failures in Christian psychology movement(s) led to the need for a biblical counseling movement?

If you are inclined to defend biblical counseling, consider these questions

  1. Even if some of the bad examples of biblical counseling do not represent you or the heart of the movement, what aspects of the movement may support or encourage some of these distortions?
  2. How might you better communicate “sufficiency of Scripture” to outsiders?
  3. Does biblical counseling seek to eliminate symptoms or improve spiritual responses to symptoms? How might it better acknowledge the body when talking about the causes of mental health problems?
  4. Where does fear of “integration” hinder the maturation of biblical counseling as a movement?

Indeed, these questions have already been asked and answers given in a variety of locations. Readers unfamiliar with biblical counseling should start with websites such as this one, CCEF, ACBC, BCC, and the Society of Christian Psychology to find further and deeper readings on related topics.

Where the Concerns are Valid

Not acknowledging benefits from psychological research. Joyce notes that a good biblical counseling session looks a lot like a good professional counseling session. Why? Well, it is obvious that change happens best in the context of kind, compassionate relationships. Why the similarity? While it is true that psychotherapists didn’t discover empathy, it is true that psychotherapy research has expanded our understanding of the best way to encourage trust relationships in therapy. In addition, some of the cognitive, affective, and dynamic interventions developed from these models are used within biblical counseling. I have absolutely no problem from biblical counseling deriving benefit from interventions developed in other models of therapy. I only desire biblical counselors or acknowledge that benefit. It is clear Jay Adams benefited from Mowrer (and said so to boot). We can do the same. We can admit that Marsha Linehan has revolutionized our understanding of how we work with people exhibiting symptoms of borderline personality disorder.

Emphasizing false dichotomies. Joyce quotes Heath Lambert in this piece (near the end),

“I’m concerned [that] if we say, ‘Oh my goodness, people with hard problems need physicians and need a drug,’ we’re going to lose much of what the Bible has to say about hard problems.”

The quote above is in the context of dealing with difficult or serious mental illness. He worries that if the church creates two categories of problems (normal and special), those with serious problems will no believe that the bible has things to say about those suffering with suicidal ideation or schizophrenia. It seems that some biblical counselors take a negative stance on psychiatry and medical intervention because they fear doing so will hinder the work of the Spirit through the bible. I would argue that this dichotomy does not need to exist. I agree that the bible speaks to everyone, whether they are having difficulty or easy problems. I don’t think that use of medications or medical practitioners has to hinder pastoral care. The message that others get when we suggest that medical intervention need to be avoided is that somehow it is less spiritual to seek a medical intervention. This is patently false. Now, not every medicine is worth taking. Some may create more problems then they solve. But that fact should not cause us to lump all professional/medical care into the same category.

Where the Concerns are Overplayed

Heath Lambert gets it right when he claims that all counseling models will fail, due primarily to the quality of the practitioner. Biblical Counselors do much work that is commendable and successful. Joyce’s piece may suggest that most biblical counselors are ineffective and incompetent. This is not true. Matthew Stanford suggest he has never seen a biblical counselor do well with difficult cases. That may be the experience of my friend, but I can attest to seeing biblical counselors working well with people with serious personality disorders, delusions and other difficult mental illnesses. Now, the truth is, these counselors have succeeded because they did not follow the stereotype and reject learning from professional psychology. Further, these same counselors did not take “sufficiency” to mean that they could only use the bible in considering how to respond to their clients.

Take a moment and read her piece. Review the questions above and keep an open mind to both sides of this story.

[§ I have written on the relationship between Christian psychology and biblical counseling in the Journal of Psychology and Theology, volume 25, 1997. You can buy that essay here.]

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April 3, 2013 · 9:13 am

Psychopharmacology for counselors? Take a class at Biblical!


This summer, Jim Owens, PsyD will be offering a one weekend class (Aug 23-24) entitled, Essential Psychopharmacology for Counselors. Jim is a board member here at Biblical and has extensive training in psychopharmacology. In fact, he is board certified by the Prescribing Psychologist Registry. He will review traditional and alternative medicines commonly used today as well as best practices for engaging prescribers. In his course description he says,

The ever-growing use of medications, both traditional and complementary, to treat mental health problems, has both helped and harmed many people. Approximately 80% of all psychoactive medicines are prescribed or recommended by non-specialists, who frequently have little time, training or experience to accurately diagnose the person’s condition. Therefore, trained counselors and psychotherapists are in a crucial position to aid their clients in getting appropriate treatment. This involves knowing some basics regarding which available talk therapies as well as medications are most likely to be helpful for those struggling with certain problems. It is also important to know how to interact with your clients’ physician(s) and other health care providers.

Get CEs!

The course is 1 graduate credit (includes some pre and post course work) OR, 9 CE hours for counselors. Biblical is an approved provider of CES for counselors by NBCC. To read more on costs and other CE approved courses this summer, click here.

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November 7, 2012 · 5:28 am

Do you see or hear things that do not exist?


English: Neurologist and writer Oliver Sacks a...

English: Neurologist and writer Oliver Sacks at the 2009 Brooklyn Book Festival. (Photo credit: Wikipedia)

What does it mean if you hear things that no one else hears? Sees things that no one else sees? Does it mean you are having a spiritual experience? Or, do you have some form of psychotic disorder?Thanks to a student (HT Heather), I submit for your reading pleasure a NY Times essay by Oliver Sacks. Dr. Sacks suggests there may be some other possible reasons why you might hear or see or feel something that isn’t heard, seen, or felt by others. In fact, he points to research that a large portion of those who do have these experiences never tell others or doctors about them for fear of being labeled falsely with schizophrenia.

Ever had either hypnogogic or hypnopompic hallucinations (ones that happen just as you fall asleep or awaken)? Did is scare you? Can you imagine telling others about it? If you find these kinds of unusual experiences interesting, I encourage you to read any of Dr. Sacks’ books.

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October 17, 2012 · 7:03 pm

The biological roots of PTSD…and resilience


Brain structures involved in dealing with fear...

Brain structures involved in dealing with fear and stress. (Photo credit: Wikipedia)

A good friend of mine pointed me to a recent Nature essay that describes the biological markers for PTSD and resilience–and provides some of the answer of why some seem to recover fairly quickly while others continue to struggle. Here’s a couple key quotes:

“Functional magnetic resonance imaging (fMRI), which tracks blood flow in the brain, has revealed that when people who have PTSD are reminded of the trauma, they tend to have an underactive prefrontal cortex and an overactive amygdala, another limbic brain region, which processes fear and emotion…”

“People who experience trauma but do not develop PTSD, on the other hand, show more activity in the prefrontal cortex.”

Of course, we need to understand that we are complex beings with complex histories and current social connections. We don’t only look at neural activity but with increasing understanding, we learn how experiences such as childhood trauma, poor social support influence brain activity.

Some worry that the discussion of biological features of PTSD will lead only to increasing chemical interventions (meds, surgeries, etc.). I do not believe this to be the case given that we are also learning about the ways that current relationships and psychotherapies are altering brain activity.

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September 14, 2012 · 3:46 pm

Thomas Szasz, critic of psychiatry, dies


Did you see the obituary notice for Thomas Szasz, a 92-year-old psychiatrist who made it his life’s work to attack his own profession? If not, read the NYT’s article here. Szasz’ beef with psychiatry centered on two complaints: the diagnostic system treated individuals as having “things” rather than describing what they do (thus making it seem like people have diseases AND the coercive nature of treatments (forced treatment and meds for psychotic individuals.

What makes Szasz important to Christian counseling is that many biblical counselors and nouthetic counselors touted Szasz in their criticism of secular psychology and psychiatry. The Bobgans and Jay Adams used Szasz quotes to bolster their own criticisms.

How he was right AND wrong about diagnoses

Szasz was right in that DSM diagnoses tend to treat problems as discrete disease states when in fact they are descriptions of clusters of symptoms. More Venn diagram than discrete thing. Yet, Szasz and his ilk often used examples of diagnoses that he thought were not disease states. Well, some of these diagnoses have turned out more disease than not disease. Take ADHD for example. Many critics complained that there wasn’t anything that could be seen under a telescope…thus ADHD isn’t a real disease. Well, we can see significant differences in brain activity in the frontal lobes of those carrying the diagnosis. While we can’t yet point to a specific cellular structure or gene (and we likely never will since it is more complex than just biology), we are understanding the biological aspects of a number of mental health diagnoses.

Szasz was right that some portions of psychiatry treated those diagnosed as victims and ignored responsibility. Interestingly, as our understanding of genes and brain functioning have improved, the victim mentality has decreased. We are doing better in identifying responsibility even as we are more articulate about the effects of the Fall on the body.

We should thank critics like Szasz for pointing out serious flaws in the foundation of mental health philosophy and practice. And yet we should avoid the all/nothing approach that Szasz and his opponents took in criticizing or defending psychiatry. One common human reaction is to either (a) always look to be the critic, or (b) always look to explain away criticism. Both responses are normal but disastrous to helping others.

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January 31, 2012 · 10:48 am

New drugs for depression?


This morning, NPR’s Morning edition ran a news report on some medicines that may help in the fight against depression. What makes this an interesting story is that the drugs are not typical (a street drug and a motion sickness drug) and that they work quite quickly–some even in one day! In addition, these drugs do not appear to work on the neurotransmitters serotonin or norepinephrine–the focus of most of our current antidepressants–but on glutamate, another neurotransmitter.

Listen to or read the story here.

Ketamine (known on the street at Special K) may have some capacity to form new connections between neurons. The assumption is that those who suffer with depression have had significant loss of neural connections.

Like with every drug, there may be some serious side effects with Ketamine: experiencing light trails (hence why clubbers use it) and foggy memories.

Findings, however initial, should (a) encourage us that better relief may be possible for millions of people, (b) remind us how little we really know about the brain, and (c) remember that those who suffer from serious depression and who seek medical treatment also must suffer with the experience of being a guinea pig of practitioners. This last point cannot be underscored enough. Medicines are never a panacea. And, we rarely can tell why one drug seems to work with some and doesn’t with others. In fact, much of what we know about drugs is shrouded in theory. Give a serotonin boosting compound to depressed people and they seem to get better suggests that the problem is that depressed people have too little serotonin in their synaptic clefts. Of course, this is mostly theory since some data may suggest that some have lower levels of serotonin and are not depressed at all.

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