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I find that the idea of “Locus of Control” often comes up in treatment. (1)
A person with an Internal locus of control is said to believe that they have control over their own decisions and things that happen in their lives. A person with an external locus of control, believes that their personal decisions and things that happens in life, are determined by external factors (the situation that they find themselves in).
So, very often, in treatment, it is important to establish what things a person has control over, and what things a person does not have control over. I’d say in probably 70 to 80% of the people I see, there are distortions in their notions of control. Sometimes, they feel like they should be able to control everything. Even those situations which we have no control over. Other times, they don’t feel like they have control over anything, including any aspect of themselves.
An exaggerated notion of external locus of control is often associated with depression. An exaggerated notion of internal locus of control is often associated with anxiety and anger. The point is, that there are some things you can control in your life and within yourself, and there are other things that you cannot. As with many things in life, the point is finding the most realistic balance between the two. This is not something that is easily done, and will be a continual balancing act for almost everyone.
Everyone doubts themselves from time to time. And at major life transitions, doubt is an extremely common thing. When a child goes from junior high to high school, they doubt themselves. When a high school student transitions to college, they doubt themselves. When a child attends a new school, they doubt themselves. When you get a new job, you doubt yourself.
But for some people, they have deeply rooted feelings of defectiveness. And it’s not technically correct that they “feel” defective, but rather that they think they are defective and that results in a number of different emotions (sadness, shame, anxiety, anger). For some people, their whole way of seeing what happens in the world is organized around their beliefs that they are defective. Jung developed the notion of a ‘complex’ that was later also used by Freud. More recently, the notion of a ‘schema’ has arisen from cognitive therapy (or Schema Focused Cognitive Therapy), which has many similar characteristics to a complex.
A complex is described as “In Jung’s use of the term, a complex is literally a grouping of parts around some central emotional theme. For example, if you had a leg amputated as a child, you might develop a complex about it. Your complex might involve all the thoughts and emotions built up over a lifetime about the absent leg and the impact it might have had on people’s reactions to you, your opportunities in life, or anything else relating to the amputated leg. Unlike Freud, Jung did not assume most of these complexes were sexual in nature. A complex was due to some twist or turn in life that had a big emotional impact on a person.” (1)
A schema is described as “a mental structure that represents some aspect of the world. This learning theory views organized knowledge as an elaborate network of abstract mental structures which represent one’s understanding of the world. Schema theory was developed by R. C. Anderson, a respected educational psychologist.” (2)
In the Bible, it explains that,
“9(H) That which has been is that which will be, And that which has been done is that which will be done. So there is nothing new under the sun. 10 Is there anything of which one might say, “See this, it is new”? Already it has existed for ages Which were before us.” (3)
Psychologists often lose this perspective on things. But the fact of the matter is, most often, they are just using different words to describe things that have been observed by others. They feel important for their ‘ground breaking’ discoveries, but all they have really done is re-label concepts that have been explored and understood by others. The Last Psychiatrist would call this narcissism.
There are a number of ways that a person may develop a defectiveness complex. Problems with motor skills, problems learning how to walk, problems with a sensory system (such as vision or hearing), learning disabilities, and other problems that may occur during childhood. Sometimes there is an early severe fever that results in motor or learning problems. Sometimes there is an acute physical problem. Regardless, it is something that must occur early in life. What tends to happen is that all subsequent things that happen are filtered through this ‘complex’ or ‘schema’ and are seen by the person as supporting the fact that they are defective.
I remember one woman who developed Rocky Mountain Spotted Fever as a child. As a result, she was uncoordinated and clumsy. So, she was constantly reminded of the fact of her ‘defectiveness’ by bumbling clumsiness. Subsequently, all things that happened in her life were filtered through this belief and frame of reference. She never had the confidence to ask for a raise, or seek a job that was consisent with her true abilities. She never had any luck in relationships because she expected others to discover that she was defective, and drove men away because of this. All of these things were seen as just more evidence for her defectiveness. Now, the person doesn’t usually have a conscious awareness of how this developed. But unconsciously, it influences how they interpret things in their lives, what they remember from the past (their personal failures), and their expectations for the future (continued failure, rejection, etc…).
These difficulties often take several years of treatment in order to resolve. The ‘complex’ or the ‘schema’ is well defended within the individual and extremely difficult to challenge. The individual often develops information supporting their notion that they are defective despite any evidence to the contrary. The explanation that this is a ‘complex’ or ‘schema’ often helps the indvidual come to the realization that their view is distorted based on beliefs that were developed through early life experiences. Once they develop this insight, they can begin to understand and change the ‘complex’ or ‘schema’ that has been so self-limiting in their lives.
Interestingly, the notion of a ‘complex’ was developed by Carl Jung (a psychoanalyst), and the notion of schema-focused cogntive therapy has been expounded by Jeffrey Young 
Although I’m not keen on some of Jung’s notions (such as the collective unconscious and archetypes), I’m not one to ‘throw the baby out with the bath water.’ I have to largely agree with the following statement from Jung, “The patient who comes to us has a story that is not told, and which as a rule no one knows of. To my mind, therapy only really begins after the investigation of that wholly personal story. It is the patient’s secret, the rock against which he is shattered. If I know his secret story, I have a key to treatment.” (4) I find this to be exactly the case in treatment with my patients. My mentor likes to quote the old proverb:
“For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.”
In treatment, I try to find the nail. Once the nail is found, the battle is won. It’s not necessarily won right at the point that the nail is found, because we have riding, battle, and defense of the kingdom left, but it is the pivotal point around which the treatment revolves. There are many reason’s which people come to feel defective, and the discovery of this reason is the nail which leads to the ultimate success of treatment. And, I think the notion of war is appropriate to psychotherapy. It’s a war against the emotional difficulties of the patient, and often entails numerous battles. Sometimes, the enemy is more easily vanquished, and other times, the battles are ongoing and intense. So, God be with you, in your own battles.
Remember the verse from the Bible, “I can do all things through Christ who strengthens me.” (5) You may well need this strength to win your battle. But, I believe in you and the power of God, as I believe in my patients. Fight the good fight, and keep working hard to get to a better place in your life.
(1). http://www.psywww.com/intropsych/ch13_therapies/jungian_therapy.html
(2). http://en.wikipedia.org/wiki/Schema_%28psychology%29
(3). Ecclesiates 1:9-10.
(4). Jaffe and Jung
(5). Philippians 4:13
John Grohol, PsyD, has a new post on psychcentral.com about “Another Brain Fad for Depression?“ He notes, 
and this is my phrasing, that the serotonin theory of depression has finally gone the way of the dodo bird. I felt pretty certain this would happen sooner or later. But, it’s only to be replaced with a new theory for the meager effects of antidepressants….”they heal brain cells.” It’s a cute new theory that I expect to be presented as fact in the new bouncing smiley comercials for Zoloft.
And the studies just keep coming. This time with Paxil showing that it was no better than placebo in adolescents, plus a relative increase in adverse events compared to placebo.
John Grohol, PsyD has a writeup on PsychCentral.
After I ended my last post, I got to thinking that maybe Irving Kirsch already had something to say on the matter of the effectiveness of antidepressants for children. Turns out, he did.
Basically, on the very limited number of studies that were available, he found the same thing for SSRIs that he found with adults–75% of the effects of SSRIs was duplicated by placebo. For tricyclic antidepressants, it was 98%. He concluded that SSRIs did not offer a clinically significant difference over placebo, and TCAs were completely ineffective.
So, my advice would be to first consider psychotherapy, unless the depression is very severe to the extent that the child or adolescent has a great deal of difficulty in functioning. Certainly, you want to have a thorough physical examination with a physician as the first step to rule out any physical causes.
Now, there are many (probably most) psychotherapists will recommend antidepressants anyway, because that is the way they’ve been trained. But there are those out there who will support your efforts to overcome your mild to moderate depression without medication. I would want to try that first with children for two reasons. The first is that we do not know what the long-term effects of these medications are on the brain. The second is a philosophical communication (or unconscious communication) that occurs when you take medication versus participate in psychotherapy. I think the communication with medication can often be that there’s something wrong with your brain. You needn’t bother changing anything in your life, just take this pill. At least with psychotherapy there can be the communication that something is wrong in your life, in your relationships, in the way you think, in internal conflicts that need to be resolved, or in your activity level that needs to change. It’s a matter of teaching people to be in control of their lives versus teaching them they are controlled by their biology.
That’s what the latest study published in the American Journal of Psychiatry says. In a nutshell, they initially selected their subjects based on whether they were depressed and were excluded based on a number of factors (one of which was previous failure to respond to prozac or adverse reactions to prozac). All of the participants were initially tried on prozac, with dosage increases in waranted. Those who didn’t respond to prozac were excluded from the continuation phase. Then they were randomly assigned to continue on prozac or placebo. So, the placebo group is abruptly taken off of prozac and put on sugar pill while prozac group experiences no such disruption. The authors thought this was okay because of prozac’s “long half-life.”
The study found that 42% of the prozac group relapsed within 6 months, whereas 69% of the placebo group relapsed. With an even stricter measure of relapse, only 22% of prozac group relapsed, whereas 48% of the placebo group relapsed.
This makes prozac sound pretty good for kids, does it not?? It does….
But there’s a catch. I’ll just focus on the “stricter” measure of relapse for now. This was based on scores on a scale that measures sympoms of depression the CDRS-R. Scores >= 40 over two sessions with a psychiatrist (separated by 2 weeks) were considered to be relapses, whereas scores under 40 were not considered to be relapses. How do we know whether 69% of the prozac group didn’t have scores of 39 (not relapsed), whereas 69% of the placebo group had scores of 41 (relapsed)?? We don’t know, because we don’t know any scores. We don’t know if the differences are truly clinically significant, because we don’t know what the differences in the actual scores were.
Also, the fact that the study was set up to only include people who respond to prozac, we know nothing about how this would work if applied to the general population of children who are depressed. In other words, the deck was stacked in prozac’s favor. The authors, in my opinion, just seemed to gloss over the possibility that the increased “relapse” in the placebo group could have been caused by the abrupt discontinuation of prozac.
I suppose we’ll have to wait another 10 years for Irving Kirsch to publish an analysis on whether antidepressants provide any clinically significant benefit over placebo. I, for one, am not convinced by this poorly designed and written study.
Well not actually duds. Just good placebos. I’ve posted on this before and the data keeps coming in (See this article). The previous studies were extended to include the newer generation of antidepressant medication (fluoxetine, venlafaxine, nefazodone, and paroxetine).
All studies are biased and have an agenda. The Last Psychiatrist thinks that reporting on this story in the press is a move to promote antipsychotics for depression. I’d say that’ll probably happen.
The fact is, there is a large proportion of people who are depressed, and don’t want to think about psychotherapy or go through the process. They would prefer to take a pill. So, don’t worry, the pills will still be there. Only now, they’ve got worse side effects….
I’m a psychologist, and so my bias is towards psychotherapy. Very few of my patients, want, or take, medications. That said, I believe a signfiicant portion of people who take antidepressant medication would prefer psychotherapy if they were given the option. The majority of antidepressants that are prescribed in the nation are prescribed by the family doctor. Even though I work in “the sticks,” I am not hurting for business. However, there are a lot of psychologists in the field who struggle to build a practice. This is good news if it leads to more people recieving psychotherapy instead of medication; however, I don’t think this is very likely to occur. What’s more likely is a new set of biased data promoting the next wonder drug…. And again, this is OLD news. Studies like this have been around for 10 years, and now with the antidepressant patents running out… Suddenly, everybody takes notice….
Back in graduate school, I began to speculate about the nature of the placebo effect and psychotropic medication. I did many literature searches and read as many articles as I could find on the subject. What I discovered was the placebo effect is a powerful demonstration of the interaction between mind and body, and that the effects of many medications can be largely explained by this effect despite attempts at experimental rigor with double-blind experiments.
The review article by Kirsch and Sapirstein (1998) comparing the efficacy of antidepressant medication to placebo. One of their findings was that 75% of the effects of antidepressant medications could be explained by the placebo effect. Indeed, it was further suggested that the remaining 25% of the effect could be due to an active placebo effect. Meaning that because of side effects, the participants figured out they were in the active drug group, which enhanced their beliefs that they would benefit. Because of my research on cognitive dissonance, I speculated an additional possibility for why side effects enhance the placebo effect. When people suffer as a result of something that they believe will be helpful, this sets up an inconsistency of beliefs that must be resolved (“I’m taking this antidepressant medication, but I have trouble with sexual functioning now….But you know it’s worth it, because this is really helping me!”) So, the medication comes to be more valued because of the side effects, not in spite of them.
My dissertation was on cognitive dissonance (how people react and change their beliefs unconsciously when they are inconsistent). Cognitive dissonance theory might predict that people might believe that they are being helped more by a medication that actually has a slightly negative effect as opposed to a true placebo (such as a sugar pill). Additionally, dissonance would be increased by paying for the medication. Therefore, I would expect that people who pay for medication out of their pockets might have a somewhat better effect with medication. Generally, enhanced placebo effects from medications would need to a nuisance and not extremely negative. In other words, it’s difficult to develop a positive attitude about a medication with a serious negative effect. However, the more serious the condition, the greater the negative side effects could be, and the person could still come to the conclusion “I have these horrible side effects, but you know, it’s worth it because I feel better.”
Beliefs are powerful in all emotional disorders. If you truly believe something is beneficial, it usually will be. This also applies to some extent to a lot of physical disorders. Kirsh and others recommend that experimental procedures for medication be revised to include an active placebo group (a group that takes medication that causes some similar side effects), so that the true effectiveness of medication can be determined. I support this idea wholeheartedly.
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