All posts by johnsommersflanagan

Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

Paradoxical Intention, Part II: Transformative Epiphanies

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Often, I have the honor of getting a personal preview of Rita S-F’s Godblogs. I sit in a cushy chair, shut my eyes, and let her words create images in my brain. It’s not unusual for her readings to stimulate unusual thoughts. But, last week, while listening, I was taken with a particular epiphany.

She was reading about how easy (and destructive) it is to be judgmental; I can’t recall the details. In response, a voice in my head spoke gently,

“I wonder if it might help if you could try, just a little, to be even more judgmental. . .” followed by an additional internal commentary “. . . said no one ever.”

The thought—of trying to be even more judgmental—made my lips curl upward into a smile. I felt an urge to laugh. Then, naturally, I thought of Viktor Frankl.

As I wrote in my last blog (https://johnsommersflanagan.com/2021/12/06/paradoxical-intention-dont-try-this-at-home-or-maybe-dont-try-it-anywhere/), Frankl was the first person I know of who explicitly discussed paradoxical intention as working like a joke to the psyche. I’ve written about that, but I’d never felt it in my gut. This time I did actually feel it. Then, and in response to the thought of intending to be “even more judgmental,” along with the urge to laugh, I also felt a small internal push back toward acceptance.  

Paradoxical intention has two parts. First, there’s the intention. I’ve tried the intention part of paradoxical intention with myself (and used it with clients) in specific situations when physical behaviors or responses feel outside of voluntary control. One example is the twitching eye syndrome. If you have an eye that’s prone to twitching, you can try to make it twitch more or try to make it twitch when it hasn’t been twitching. That’s the intention part. The other part is for the intention to be aimed toward the opposite of your goal. In the case of listening to Rita’s blog, the thought of intending to be more judgmental was received and then produced psychological push-back. What was different than any other response I’ve ever felt about paradoxical intention was my urge to smile and laugh. I’d never felt like laughing when I tried to make a bothersome eye twitch . . . twitch more.

Later—while driving I-90 west—a place where I’m prone to feeling intermittent anger toward drivers I label in my mind as “stupid,” I did another experiment.

“I wonder,” I thought to myself, “if maybe I could try to start feeling just a little angrier toward those other drivers. Being alone in the car, I tried it out with a brief litany of profanity. In response, I felt increased anger. That wasn’t good. But within seconds, my brain started the natural push-back. I took note of my greater anger and quickly judged it as unpleasant. Then, I noticed an internal psychological push-back toward the center. I suddenly wanted the anger—which usually feels so justified in the moment—to go away. And so, I let it go.

Paradoxical intention isn’t a magic trick. Nothing in the world of human psychology is magical. Paradoxical intention operates on natural psychological dynamics. Laura and Fritz Perls would have called it an internal polarity. Behaviorists like to call it a form of overcorrection. The popular press tends to reduce it to a term I can’t help but find offensive: reverse psychology.

Although you might try paradoxical intention on your children or your friends, because of one central underlying principle, that’s not a great idea. The underlying principle is best expressed by an old (and bad) joke.

“How many mental health professionals does it take to change a light bulb?”

“Only one. But the light bulb has to want to change.”

You could try a little paradoxical intention . . . on yourself . . . but only if you want to experience a new transformative epiphany.

Clinical Interviewing, Cool Counseling, Counseling and Psychotherapy Theory and Practice, Writing

Paradoxical Intention: Don’t Try This at Home (or maybe don’t try it anywhere)

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People want change.

People don’t want change.

As W. R. Miller noted in his treatise on motivational interviewing (MI), ambivalence is nearly always the order of the day. Most people, most of the time, would like to be better and healthier versions of themselves. And, most people, most of the time, resist becoming better and healthier versions of themselves.  Who knew?

Alfred Adler may have been the first modern psychotherapist to write from a non-psychoanalytic perspective about how to work with individuals not interested in changing. What follows is a complex quote from Adler. He’s writing about how to work with a patient who is depressed, but not motivated or willing to change. You may need to read this excerpt several times to track it and appreciate Adler’s method. You may see all those words below and not want to put in the effort. That’s okay. You can stop reading now if you don’t want to gather in the nuance sprinkled into Adler’s indirect suggestion.

After establishing a sympathetic relation, I give suggestions for a change of conduct in two stages. In the first stage my suggestion is “Only do what is agreeable to you.” The patient usually answers, “Nothing is agreeable.” “Then at least,” I respond, “do not exert yourself to do what is disagreeable.” The patient, who has usually been exhorted to do various uncongenial things to remedy this condition, finds a rather flattering novelty in my advice, and may improve in behavior. Later I insinuate the second rule of conduct, saying that “It is much more difficult and I do not know if you can follow it.” After saying this I am silent, and look doubtfully at the patient. In this way I excite his [her/their] curiosity and ensure his attention, and then proceed, “If you could follow this second rule you would be cured in fourteen days. It is—to consider from time to time how you can give another person pleasure. It would very soon enable you to sleep and would chase away all your sad thoughts. You would feel yourself to be useful and worthwhile.”

I receive various replies to my suggestion, but every patient thinks it is too difficult to act upon. If the answer is, “How can I give pleasure to others when I have none myself?” I relieve the prospect by saying, “Then you will need four weeks.” The more transparent response, “Who gives me pleasure?” I counter with what is probably the strongest move in the game, by saying, “Perhaps you had better train yourself a little thus: do not actually do anything to please anyone else, but just think about how you could do it!” (Adler, 1964a, pp. 25–26)

Similar to Adler, Viktor Frankl also wrote about using “anti-suggestion” or paradox. Frankl was keen on this method as a means for treating anxiety, compulsions, and physical symptoms. An excerpt from our theories textbook describing Frankl’s paradoxical intention follows.

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Paradoxical Intention

. . . In a case example, Frankl discussed using paradox with a bookkeeper who was suffering from chronic writer’s cramp. The man had seen many physicians without improvement; he was in danger of losing his job. Frankl’s approach was to instruct the man to:

Do just the opposite from what he usually had done; namely, instead of trying to write as neatly and legibly as possible, to write with the worst possible scrawl. He was advised to say to himself, “now I will show people what a good scribbler I am!” And at that moment in which he deliberately tried to scribble, he was unable to do so. “I tried to scrawl but simply could not do it,” he said the next day. Within forty-eight hours the patient was in this way freed from his writer’s cramp, and remained free for the observation period after he had been treated. He is a happy man again and fully able to work. (Frankl, 1967, p. 4)

Frankl attributed the success of paradox, in part, to humor. He claimed that paradox allows individuals to place distance between themselves and their situation. New (humorous) perspectives allow clients to let go of symptoms. Frankl considered paradoxically facilitated attitude changes to represent deep and not superficial change.

Given that Frankl emphasized humor as the therapeutic mechanism underlying paradoxical intention, it fits that he would use a joke to explain how paradoxical intention works,

The basic mechanism underlying the technique…perhaps can best be illustrated by a joke which was told to me some years ago: A boy who came to school late excused himself to the teacher on the grounds that the icy streets were so slippery that whenever he moved one step forward he slipped two steps back again. Thereupon the teacher retorted, “Now I have caught you in a lie—if this were true, how did you ever get to school?” Whereupon the boy calmly replied, “I finally turned around and went home!” (Frankl, 1967, pp. 4–5)

Frankl believed paradoxical intention was especially effective for anxiety, compulsions, and physical symptoms. He reported on numerous cases, similar to the man with writer’s cramp, in which a nearly instantaneous cure resulted from the intervention. In addition to ascribing the cure to humor and distancing from the symptom, Frankl emphasized that paradox teaches clients to intentionally exaggerate, rather than avoid, their existential realities.

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I’m writing about paradoxical intention today because of an inspiration from Rita’s blog yesterday. There’s so much ostensible hate, judgment, and certainty in contemporary discourse. That got me thinking about whether a paradoxical approach might be timely and effective. Yesterday, I tried it on myself. Stay tuned, in my next post, I’ll write about how a little paradox worked out for me, and how it might help shift some of the lamentable, polarized arguments happening all around us.  

Happiness, Personal Reflections, Suicide Assessment and Intervention, Uncategorized

For a Win-Win-Win on Giving Tuesday – Support College Student Mental Health

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After facing an overwhelming number of choices on Black Friday and Cyber Monday, now we’re faced with another litany of excellent choices for Giving Tuesday. There are so many wonderful charities to support. You can’t go wrong with supporting food banks, shelters, and other organizations that push back against poverty. You also can’t go wrong supporting children, minorities, education, and the environment . . . these are all huge needs.

Along with the preceding charity types, this year Rita and I are wholeheartedly supporting college student mental health. We’ve seen the struggles firsthand and we believe college students can benefit from greater access to mental health services. Specifically, we’re supporting a University of Montana Foundation project called “The University of Montana Mental Health and Happiness Fund.” We see the University of Montana Mental Health and Happiness Fund as a win-win-win. Here’s why.

The first win is that the funds will go to provide more hours of mental health counseling for college students. Unfortunately, more than ever before, college students are stressed and experiencing mental health struggles. These struggles can include suicidal thoughts and behaviors. As far as age groups vulnerable to death by suicide, the college student age group is among the highest (along with older males). Supporting college student mental health can literally save lives and help college students graduate and become significant contributors to their communities. Currently, Counseling Services at the University of Montana needs more counselors to meet increased needs.

The second win is about “workforce development.” In Montana, and around the nation, we need a continuous flow of competent and capable mental health professionals. That’s why the first priority of the University of Montana Mental Health and Happiness Fund is to support a ½ time Counseling Intern for UM’s Counseling Services department. Funding an intern means that the intern gains valuable experience and supervision and can then go out and contribute to mental health in the community. If we receive more funds than expected, we will either fund a second ½ time counseling intern or we will fund happiness promotion projects at UM and within the Western Montana area.

The third win is basic economics. College students contribute to local economies. When they graduate, college students also create capital. College students become entrepreneurs, scientists, grant writers, community leaders, parents, and grandparents. In all these roles, college graduates will do better and be better if they have better mental health.  

Our 2021 fundraising goal is $45,000. We’ve already raised over $22,000. Please help us reach our goal so we can contribute to positive mental health and happiness at the University of Montana.

If you’re interested in joining Rita and me in supporting the University of Montana Mental Health and Happiness fund here are the instructions.

  1. Click on this Link for Support
  2. As you complete the donation form, about halfway down the page, you will see “Designation Choice.” Choose “Other.”
  3. In the Additional Comments/Info Section – type/write University of Montana Mental Health and Happiness Fund

Thanks for considering college student mental health for this Giving Tuesday!

Cool Counseling

Have You Heard about the Therapist Throw-Down?

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A friend recently alerted me to the “Therapist Throw Down.” I haven’t watched the whole competition, but I did view the promo video, and I love it, not only because there’s a brief image of me doing counseling at the beginning (which is cool), but because the deep voice and introduction to the competition is completely hilarious.

I’m very jealous of the Therapist Throw Down because I wish I’d thought of it, or somehow been a part of it. Maybe next year. Here’s the link to the promo video:  https://www.youtube.com/watch?v=6Gm9vTr1sTk

And of course, for lots of excellent educational psychotherapy videos, check out the sponsor of the Throw Down, Psychotherapy.net: https://www.psychotherapy.net/

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Writing

The Feminist Lab in Counseling and Psychotherapy Theories

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Sometimes when I’m talking about feminism in my theories class, I refer to it as the F-word. I feel like I have to do more “selling” of feminist therapy than any other approach. Maybe I’m just imagining it, but I hear rumors like, “I hope we get to skip feminist therapy in the lab” and “How do you practice feminist therapy?”

The answers are: “No, you don’t get to skip feminist therapy” and “Because feminist therapy is technically eclectic, you can practice it nearly any which way you like.” Freedom is another F-word, and there’s plenty of that when you’re being afeminist.

Yesterday, while facilitating a grad lab where the practicing happens, it was fascinating to observe feminist therapy in 10 minute snippets. I heard a beautiful self-disclosure. I heard talk of clothes and bodies and of the wish to be taken seriously. No one mentioned the patriarchy . . . but everyone . . . hopefully . . . got to taste and talk about oppression and hierarchy and the wish to be a free and expansive self.

Someone even talked about farting. Someone else about dancing. Others about uninhibited delight.

Should you be interested in what prompted these interactions, I’m attaching my feminist lab instructions here:

ch-10-lab-exploring-and-practicing-feminist-therapyDownload

Love, Personal Reflections, Politics

Let’s Go Rita!

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This morning, being behind not only on my grading, course planning, writing, and housecleaning, I also found myself behind on current events. As a consequence, I was forced (not literally, of course) to do an internet search to understand the meaning of the “Let’s go Brandon” catchphrase or meme or whatever we’re calling such things in our contemporary and ever-changing vernacular.

What I found was—on its face—disturbing. After having won his first NASCAR event, a man named Brandon is being interviewed by an NBC reporter. He looks so young, so happy, and so excited to talk about his first victory. In the background, there is chanting. Although not PERFECTLY clear, if you listen closely and look at the video clip, some in the crowd are shouting, “Fuck Joe Biden.” The reporter, in an effort to weave the chanting into her interview, explicitly interprets the chanting as “Let’s go Brandon!”

At a deeper level, the chants, their interpretation, their re-interpretation, and their current use as a method for mocking and insulting President Biden, represent a deep, sad, and pathetic powerlessness. We all feel it. We all want to shout out our own beliefs, because, of course, we think our own beliefs are the best beliefs and the right beliefs and the beliefs that should be heard above the roar of the crowd.

What saddens me the most is that it also represents not only the deep divisions in our country (and the world), but that it has become viral fodder for confirmation bias and spinning. People see whatever they’re inclined to see in the chant. Is it evidence of fake news or disrespect for the presidency? Have we caught the press intentionally remaking reality or have we caught Trump supporters in their anti-patriotic hypocrisy? The facts don’t matter much anymore. Polarizing is the thing. Sloganizing is the thing. It’s not so much about what unites us; it’s about what divides us.

Like many, I feel a paradox. I care about the deep divisions. I wish I could bridge them. At the same time, I don’t care for people stoking deep divisions. I wish to ignore them.

All this brings me to something that I unequivocally and unapologetically wish would go viral . . . instead of the popular outrage and mockery.

After discovering and lamenting the Let’s Go Brandon mockery, I read Rita Sommers-Flanagan’s Sunday morning blog post. Hers are the messages I wish would catch fire on the internet.

She wrote:

“God,” I whisper, awake and facing morning, “You know I’d like to extend my reach; do things that make me feel important and complete. I’d like to turn the tide of hate into an ocean of love. I’d like to make the fear go away.”

This is the call for unity, love, and peace that SHOULD be in my newsfeed.

Here’s another line: “I am of your doing, and you of mine.” Just spectacular.

Rita’s blog is titled, “Short visits with an honest God.” Should you be interested in deeper unity, here’s the link to her blog: https://godcomesby.com/ . . .

And here’s the link to this morning’s post: https://godcomesby.com/2021/11/14/the-long-gray-bird/?fbclid=IwAR1kYlUDhLOUdj0lV-9001MnEIeK3XCsCd-FjkAmlZinBTMp7z1lq0NkEyw

Happiness, Research, Writing

Research is Hard: Procrastination is Easy

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Before and after a quick trip to NYC (see the photo), I’m teaching the research class in our Department of Counseling this year. This leads me to re-affirm a conclusion I reached long ago: Research is hard.

Research is hard for many reasons, not the least of which is that scientific language can look and feel opaque. If you don’t know the terminology, it’s easy to miss the point. Even worse, it’s easy to dismiss the point, just because the language feels different. I do that all the time. When I come upon terminology that I don’t recognize, one of my common responses is to be annoyed at the jargon and consequently dismiss the content. As my sister Peggy might have said, that’s like “throwing the baby out with the bathtub.”  

Teaching research to Master’s students who want to practice counseling and see research as a bothersome requirement is especially hard. It doesn’t help that my mastery of research design and statistics and qualitative methods is limited. Nevertheless, I’ve thrown myself into the teaching of research this semester; that’s a good thing, because it means I’m learning.

This week I shared a series of audio recordings of a woman bereaved by the suicide of her former husband. The content and affect in the recordings are incredible. Together, we all listened to the woman’s voice, intermittently cracking with pain and grief. We listened to each excerpt twice, pulling out meaning units and then building a theory around our observations and the content. More on the results from that in another blog.

During the class before, I got several volunteers, hypnotized them, and then used a single-case design to evaluate whether my hypnotic interventions improved or adversely affected their physical performance on a coin-tossing task. The results? Sort of and maybe. Before that, I gave them fake math quizzes (to evaluate math anxiety). I also used graphology and palmistry to conduct personality assessments and make behavioral and life predictions. I had written the names of four (out of 24 students) who would volunteer for the graphology and palmistry activities, placed them in an envelope, and got ¾ correct. Am I psychic? Nope. But I do know the basic rule of behavioral prediction: The best predictor of future behavior is past behavior.

Today is Friday, which means I don’t have many appointments, which means I’m working on some long overdue research reports. Two different happiness projects are burning a hole in my metaphorical research pocket. The first is a write-up of a short 2.5-hour happiness workshop on counseling students’ health and wellness. As it turns out, compared with the control group, students who completed the happiness workshop immediately and significantly had lower scores on the Center for Epidemiologic Studies Depression scale (p = .006). Even better, after 6-months, up to 81% of the participants believed they were still experiencing benefits from the workshop on at least one outcome variable (i.e., mindfulness). The point of writing this up is to emphasize that even brief workshops on evidence-based happiness interventions can have lasting positive effects on graduate students in counseling.

Given that I’m on the cusp of writing up these workshop results, along with a second study of the outcomes of a semester-long happiness course, I’m stopping here so I can get back to work. Not surprisingly, as I mentioned in the beginning of this blog, research is hard; that means it’s much easier for me to write this blog than it is to force myself to do the work I need to do to get these studies published.

As my sister Peggy used to say, I need to stop procrastinating and “put my shoulder to the grindstone.”

Clinical Interviewing, Happiness, Suicide Assessment and Intervention

Who Wants a Two-Day Professional Workshop on Strengths-Based Suicide Assessment and Treatment?

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I’ve got a friend who writes to me in acronyms. TBH is “To be honest.” LMK is “Let me know.” IMHO is “In my humble opinion.” FYI is “For your information.” YSKAT is “You should know about this.”

When I read my friend’s emails, there are always more letters than words, if YKWIM (you know what I mean).

This leads me to my PP (promotional point).

TBH signing up for a two-day SBSASTW (strengths-based suicide assessment and treatment workshop) isn’t everyone’s COT (cup of tea). TAI (think about it). That’s like 13 hours of suicide-related content. If you TAI, it CBYD (could bring you down).

That’s why, we will weave some PDC (pretty damn cool) EBHIs (evidence-based happiness interventions) into our 13 hours. This will be the MFE (most fun ever) two days of suicide training on November 19 and 20. YCBOI (you can bet on it).

But IMHO, woohoo. Really YSKAT. IMHO signing up for a two-day strengths-based suicide assessment and treatment workshop is TRTTD (the right thing to do).

YAMBWing (You also may be wondering), when John writes “we” is he going with the singular “we” or is he indicating there will be other presenters. TBH, John doesn’t know, but he’s hoping to recruit some of the amazing participants from this summer MHP (Montana Happiness Project) retreat to join in on the FUN (fricken unbelievably nice).

OK. I’ve had it with all these letters. And so, if you want to sign up, check out “Session three” on this link: https://www.familiesfirstmt.org/umworkshops.html

If that doesn’t help, send me an email (john.sf@mso.umt.edu) and I’ll see if I can help you figure out how to sign up. Just LMK. The session is also Zoomable.

Personal Reflections

Flying (Literally) with Privilege

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This view: The larches and Missions as we descend into Missoula

Flying is more or less privilege. Think about it; we’re looking down on everyone. Maybe that’s why I still feel a charge of excitement when I get to fly somewhere. . . especially on my favorite airline . . . which will remain unnamed in this story.

Flying privilege moves past the abstract as soon as we begin forming lines, because there’s not just one line. I’m a TSA pre-check person, a recent holiday gift I value. Earlier today I strolled past lined-up throngs in Portland, shrugging off minor traces of guilt. All those long faces staring into their cell phones or glaring at me. I don’t have a solution to the security checkpoint lines; I just don’t care to populate them.

Other than my holier than thou security line experience, on this particular trip my favorite airline treated me like a bottom-feeder. I would have gladly eaten the cake left by the anonymous French princess or flight attendant or whomever it was who said the poor could just eat cake, but then I recalled my recently discovered gluten sensitivity and demurred, “Um, no thanks, I think I’ll pass.”

Hours earlier, while checking in, my computer informed me I had no seat on my outgoing Seattle flight. No seat = bad omen. The airline also wouldn’t print me a boarding pass for my second flight. No boarding pass = Not good. I found an email offering me $250 to take a “later” flight. Briefly, I weighed my options. Let’s see, will I give up or shorten my planned trip to see my 95-year-old father who’s on hospice? The question was about cash vs. connection. You know the answer. We all know the answer.

Without a seat, and missing a boarding pass, I approached the gate. I found a very pleasant woman. She explained. “You’re on the bottom of the list. I think we’ll get you on, but I can’t give you a seat and I can’t print your second boarding pass until we get people to be bumped and agree to take a later flight.”

“Bumped.” What a fun word. I think what she really meant was “left behind.”

After three straight 12-hour University of Montana work days, I was too tired to be expressive), and so I blandly asked, “How did I end up on the bottom?” She started to say it was my “Saver” seat status, but looked at her computer screen, hesitated, and then said “maybe you were the last person to check in,” before completely clarifying her response with a weak smile and the words, “I don’t know.”

Feeling the “bump” closing in on me, I asked, “What’s the later flight?” Turns out, there was no later flight. The very pleasant woman mumbled something about “tomorrow,” then detoured to “the closest alternative airport is Spokane,” and then stopped talking midsentence.

Half livid and half hopeless, I thanked her for the information and ambled off to a part of the airport where I could send whining texts to family and friends in relative peace. Three years ago, my favorite airline had twice upgraded me to first class. Oh, how the mighty had fallen.

I also purchased some consolation treats, which is another tool in the toolbox of being an unhappy, but still relatively privileged person.

At the penultimate moment, I escaped the bump, and was assigned a back-row seat. Oddly, the flight attendant, looking distressed, noted that my assigned seat was taken. Apologizing profusely, she took me up to a palpably better seat, and then came by and whispered, “I’ll get you compensation.” I ended up with a $25 credit in my airline account . . . for no good reason. I’ll let you guess why I got the compensation.

The worst (maybe) was yet to come. Rather than having a seat I originally selected, the airline did what airlines sometimes do: They put me in a middle seat, way in the back of the next flight (row 36). You would have thought I bought a cheap ticket. I didn’t. The whole idea that airlines can take away your personally selected assigned seat and give it to someone else just seems wrong.  

As I end this melancholy reflection, I’m aware this sounds like a pathetic, long, drawn-out whine. Do I feel sorry for myself? Sure. But that’s not the point. I feel sorry for everyone. Even though I enjoy being in the short, privileged line (and having an assigned seat on the plane, or at the metaphorical table), there’s still a panoply of things for which to feel EVEN MORE sorry. Airlines have continually faced financial conundrums, and global pandemics don’t make that easier. All the flight personnel were unyieldingly nice and kind. I could bitch and moan and throw money around to get me mega-privilege (first class, anyone?), but someone will always be on “the bottom of the list,” and, no doubt, they have just as good a good reason as I do for wanting a good seat and for hoping to get to their destination on time.

Now I’m just back from visiting Max, my father, an immense and positive influence in my life and on the world . . . which is just one more reason why, even when threatened with a bump and stuck in a middle seat with two big people on each side, not only am I one of the lucky ones . . . I’m also FLYING. 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections, Research, Therapy with Adolescents, Writing

The Efficacy of Antidepressant Medications with Youth: Part II

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After posting (last Thursday) our 1996 article on the efficacy of antidepressant medications for treating depression in youth, several people have asked if I have updated information. Well, yes, but because I’m old, even my updated research review is old. However, IMHO, it’s still VERY informative.

In 2008, the editor of the Journal of Contemporary Psychotherapy, invited Rita and I to publish an updated review on medication efficacy. Rita opted out, and so I recruited Duncan Campbell, a professor of psychology at the University of Montana, to join me.

Duncan and I discovered some parallels and some differences from our 1996 article. The parallels included the tendency for researchers to do whatever they could to demonstrate medication efficacy. That’s not surprising, because much of the antidepressant medication research is funded by pharmaceutical companies. Another parallel was the tendency for researchers to overstate or misstate or twist some of their conclusions in favor of antidepressants. Here’s the abstract:

Abstract

This article reviews existing research pertaining to antidepressant medications, psychotherapy, and their combined efficacy in the treatment of clinical depression in youth. Based on this review, we recommend that youth depression and its treatment can be readily understood from a social-psycho-bio model. We maintain that this model presents an alternative conceptualization to the dominant biopsychosocial model, which implies the primacy of biological contributors. Further, our review indicates that psychotherapy should be the frontline treatment for youth with depression and that little scientific evidence suggests that combined psychotherapy and medication treatment is more effective than psychotherapy alone. Due primarily to safety issues, selective serotonin reuptake inhibitors should be initiated only in conjunction with psychotherapy and/or supportive monitoring.

The main difference from our 1996 review was that in the late 1990s and early 2000s, there were several SSRI studies where SSRIs were reported as more efficacious than placebo. Overall, we found 6 of 10 reporting efficacy. An excerpt follows:

Our PsychInfo and PubMed database searches and cross- referencing strategies identified 10 published RCTs of SSRI efficacy. In total, these studies compared 1,223 SSRI treated patients to a similar number of placebo controls. Using the researchers’ own efficacy criteria, six studies returned significant results favoring SSRIs over placebo. These included 3 of 4 fluoxetine studies (Emslie et al. 1997, 2002; Simeon et al. 1990; The TADS Team 2004), 1 of 3 paroxetine studies (Berard et al. 2006; Emslie et al. 2006; Keller 2001), 1 of 1 sertraline study (Wagner et al. 2003), and 1 of 1 citalopram study (Wagner et al. 2004).

Despite these pharmaceutical-funded positive outcomes, medication-related side-effects were startling, and the methodological chicanery discouraging. Here’s an excerpt where we take a deep dive into the medication-related side effects and adverse events (N.B., the researchers should be lauded for their honest reporting of these numbers, but not for their “safe and effective” conclusions).

SSRI-related medication safety issues for young patients, in particular, deserve special scrutiny and articulation. For example, Emslie et al. (1997) published the first RCT to claim that fluoxetine is safe and efficacious for treating youth depression. Further inspection, however, uncovers not only methodological problems (such as the fact that psychiatrist ratings provided the sole outcome variable and the possibility that intent-to-treat analyses conferred an advantage for fluoxetine due to a 46% discontinuation rate in the placebo condition), but also, three (6.25%) fluoxetine patients developed manic symptoms, a finding that, when extrapolated, suggests the possibility of 6,250 mania conversions for every 100,000 treated youth.

Similarly, in the much-heralded Treatment of Adolescents with Depression Study (TADS), self-harming and suicidal adverse events occurred among 12% of fluoxetine treated youth and only 5% of Cognitive Behavioral Therapy (CBT) patients. Additionally, psychiatric adverse events were reported for 21% of fluoxetine patients and 1% of CBT patients (March et al. 2006; The TADS Team 2004, 2007). Keller et al. (2001), authors of the only positive paroxetine study, reported similar data regarding SSRI safety. In Keller et al.’s sample, 12% of paroxetine-treated adolescents experienced at least one adverse event, and 6% manifested increased suicidal ideation or behavior. Interestingly, in the TCA and placebo comparison groups, no participants evinced increased suicidality. Nonetheless, Keller et al. claimed paroxetine was safe and effective.

When it came to combination treatment, we found only two studies, one of which made a final recommendation that was nearly the opposite of their findings:

Other than TADS, only one other RCT has evaluated combination SSRI and psychotherapy treatment for youth with depression. Specifically, Melvin et al. (2006) directly compared sertraline, CBT, and their combination. They observed partial remission among 71% of CBT patients, 33% of sertraline patients, and 47% of patients receiving combined treatment. Consistent with previously reviewed research, Sertraline patients evidenced significantly more adverse events and side effects. Surprisingly and in contradiction with their own data, Melvin et al. recommended CBT and sertraline with equal strength.

As I summarize the content from our article, I’m aware that you might conclude that I’m completely against antidepressant medication use. That’s not the case. For me, the take-home points include, (a) SSRI antidepressants appear to be effective for some young people with depression, and (b) at the same time, as a general treatment, the risk of side effects, adverse effects, and minimal treatment effects make SSRIs a bad bet for uniformly positive outcomes, but that doesn’t mean there won’t be any positive outcomes. In the end, for my money—and for the safety of children and adolescents—I’d go with counseling/psychotherapy or exercise as primary treatments for depressive symptoms in youth, both of which have comparable outcomes to SSRIs, with much less risk.

And here’s a link to the whole article:

psychotherapy-or-meds-for-youthDownload