29 May 2015

Cognitive Reapprasial, Behavior Therapy, and Women

That I should be concerned with matters of mental health treatment should come as no surprise to you, Dear Reader. Recently, two different articles have come to my attention. I'd like to share and discuss them here. (Spoiler alert: Since this is my blog, that's what's about to happen.)

The first article is An Experimental Study on the Effectiveness of Disclosing Stressful Life Events and Support Messages: When Cognitive Reappraisal Support Decreases Emotional Distress, and Emotional Support Is Like Saying Nothing at All, written by Anika Batenburg and Enny Das, edited by Daniel Houser. This piece was published online 22 December last year on PLoS One, which bills itself as "a peer-reviewed, open-access journal".

What Batenburg and Das explored is whether there is the answer to the $64,000 question, "How can we best support others in difficult times?" They identified three support messages (i.e., what you say to be helpful): cognitive reappraisal (dissecting things), socio-affective (emotional support and comfort), and "no response"; matched with two kinds of disclosure conditions: cognitive reappraisal and emotional disclosure (sharing emotions).

For their study, they had half of their participants write "about their deepest emotions about a current most stressful event that affected them and their lives"; the other half, "about positive and negative consequences of a current most stressful event, their perceptions of the stressful event, challenges and opportunity arising from the event, cognitive reappraisal of their coping strategies and their positive thoughts about the stressor". All participants were given fifteen minutes in which to write. (I hope the latter group had more than fifteen minutes just to read their instructions!)

The thinking was that the emotional disclosure group (the one sharing their deepest emotions) would benefit more from socio-affirmitive support messages, and that the cognitive reappraisal group would benefit more from cognitive reappraisal support messages. Seems a bit obvious, right? If you're sharing emotions, you want someone to offer comfort; if you're trying to work things out, you'd rather have someone offer some perspective to help you do that.

Except, it didn't go that way.

It turned out that both groups benefited more from cognitive reappraisal support messages. In fact, socio-affirmitive support messages weren't all that noticeably more helpful than no response at all. To be honest, I'm not surprised by this. I don't find "there, there, it'll be okay" helpful in the slightest. If anything, socio-affirmitive support messages often convey to me that the other person is at best naive about what I'm facing. They don't understand what I'm going through, and the best they can offer is to try to mollify me. I don't have any higher threshold for being patronized than the next person, so I find this kind of support fairly useless.

I take it for granted that anyone I feel close enough to that I would come to them during a crisis wants me to feel better. That is, after all, why I go to them. This isn't to say that I'm dispassionate, or that I'm somehow above being comforted on an emotional level. Just last week, for instance, I sought out one of my friends and just asked her for a hug. I outright sobbed for several minutes. I needed that. It's rare for me to seek that kind of support; so rare that I think even members of my inner circle will be surprised to read about that.

The participants in the Batenburg and Das study engaged in "expressive writing", explained here:
"Lepore, Greenberg, Bruno, and Smyth suggested that expressive writing enables three important underlying mechanisms to cope with trauma; directing attention to the stressor and related emotions, habituation to the emotions, and cognitive restructuration."
I've worked diligently over the years to align my speaking voice with my writing voice, and I think those with whom I converse regularly will attest that having a verbal conversation with me is a lot like what it's like to read something I've written. (It's just more interactive and I'm funnier in person.) If expressive writing leads to those three coping mechanisms, then it stands to reason that expressive talking (if such a thing is recognized) would also lead to them. That's precisely why I share what I share, whether privately or publicly in this blog. I'm an expressive dude.

That brings me to the second article that caught my attention last night, How bias in mental health care hurts women, from the lab to the medicine cabinet, written by Erin Anderssen and published Tuesday on the Canadian website, The Globe and Mail. Anderssen makes a compelling argument that mental health care has done very little to recognize the sex-specific impact and needs of women with mental health concerns. She covers everything from the higher incidence of heart problems related to depression in younger women down to the fact that even most of the lab rats used in research are male.

The key specific matter addressed by Anderssen is that in Canada, mental health is treated primarily through pharmaceuticals rather than therapy. That's certainly true here in the United States as well, and I imagine that's true of most countries. Just taking the pills isn't enough, she argues, and my own anecdotal experience can attest to that.
The disorders most commonly diagnosed in women – depression, anxiety and insomnia – are also the ones most likely to respond to therapy, an approach that women are significantly more likely than men to prefer over drugs.
Drawing on commentary from doctors and researchers, Anderssen makes clear that therapy is the most prudent form of treatment for women with mental health issues. At present, though, the attitude toward therapy continues to regard it as some kind of luxury indulgence rather than a necessary form of treatment. For instance, she cites a pilot program in New Brunswick that offered twelve weeks of peer support to women with postpartum depression. Only 12% of the women treated by the program were still depressed when it concluded. Despite the success, the city rejected funding a full version of it at $142,000 a year.

I find discussing most anything in monetary terms disgusting, and particularly something like mental health, but even if we're to reduce the matter to dollar signs, "the cost of providing peer support would be roughly half the amount of the average hospital stay for a woman with postpartum depression," says the doctor discussing that program. Maybe the problem is that the New Brunswick city council didn't include enough women. I don't know, and Anderssen doesn't say, but we know that most legislators are male, and most of them consistently display detachment from issues that are women-centric. The most obvious proactive solution there is to elect more women to office.

Or there's the example Anderssen gives of insomnia, which "is diagnosed twice as often in women as men. It has a circular relationship to mental illness: People with it are five times more likely to have anxiety and depression, and having it makes you more likely to be depressed and anxious." Research shows that cognitive behavior therapy is even more effective in treating insomnia than are sleeping aids, but it isn't nearly as readily available. Women over 65 years of age are twice as likely to be prescribed sleep aids than are their male counterparts. These sleep aids are understood to cause quite a few falls and fractures among the seniors taking them, which costs Canada something like $2 billion a year. Anderssen notes that a forthcoming study projects that if even 20% of the seniors who fall can be kept from doing it - which cognitive behavioral therapy is shown to accomplish - that alone could save Canada "hundreds of millions".

So if the argument is that therapy is expensive, my response is, "Duh. You know what else is expensive? Treating all the things that arise because a patient didn't receive therapy."

Now, back to Batenburg and Das, who reported that two-thirds of their participants were women. In the section on Limitations and Future Research, they recognize this as a limitation. However, the 2:1 ratio of engagement is consistent with the figures cited by Anderssen about incidence of mental health in women as well as response to therapy treatment. They note that
"...It could be that gender has an effect on moderators of the psychological process, such as personality traits or coping strategies. For example, a meta-analysis focused on gender differences in coping showed that females cope by engaging in social relationships and they try to create change (in cognitive and actual terms) more frequently than men do. On the other hand, males rely more often on stress reduction activities or they tend to distract themselves (i.e., diversions)."
If cognitive reappraisal is the more effective means of support messaging, and if women respond more favorably to therapy, then it seems to me a no-brainer that mental health systems need to get past the obsolete idea of therapy being some kind of self-indulgence for those who can afford it. (On an entirely selfish note, my hope is that as we expand access to therapy, that I can get in on it myself.)