Psychotherapy case: drugs

[_Martin_Taylor]

[Martin Taylor 950825 11:00]

Bill Powers (950825.0100 MDT)

There seems to be
little point in my repeating what I've said so many times before about
drug treatments. I have stubbornly clung to the hope that you, as one of
the tiny handful of psychotherapists I know who understand PCT would
become a pioneer in learning how to develop PCT as the basis for a new
approach. Is it time for me to give up on that hope?

Not having been privy to those conversations, I am unclear as to why you
think the use of drugs is inconsistent with PCT. I would have thought there
was a good case for presuming that some kinds of drug would be useful
for helping to correct pathologies that can afflict a hierarchic control
system.

Within HPCT there seem to be many possible root causes of what outsiders
see as problems requiring psychotherapy, but they all boil down to a
reorganization that has got stuck in an unfortunate state of the hierarchy.
Perhaps there are positive feedback loops that lead to saturation in
some part of the hierarchy, rendering external data ineffective and
fixing some reference levels in "unfortunate" states. Perhaps there are
conflicting control systems whose nonlinearities make matters worse rather
than better when the gain of either changes. Perhaps some chemical intrinsic
variable is in a state that causes some reference to drive some perceptual
control systems to saturation. Perhaps ...

But no matter what, if we are to believe HPCT and the principle of
reorganization, then something is stuck that normal reorganization is not
apparently correcting.

What might the effects of drugs be? I can think of three potentially useful
effects, and there are probably more: changing the overall gain of control
systems (making the controller "care less"--not careless), changing the
values of some intrinsic variables, and changing the rate and likelihood
of reorganization.

If there are hung-up feedback loops, changing the gain is likely to unhang
them, allowing external data to affect perceptions and thereby change lower
reference levels. If some metabolic feedback loops are keeping intrinsic
variables in "bad" states (as seems to be the case in at least some
schizophrenia), then changing those loops might allow the perceptual
hierarchy to change its behaviour without changing its structure. If the
rates of reorganization change, perhaps those changes might "unstick"
whatever is stuck. To use a metaphor, one can get a postage stamp off
a letter by peeling it, using strong force, or by steaming it to loosen
the glue. The first way (not using drugs) may work, but may tear the
stamp; the second (using drugs) may allow the skilled peeler to remove the
stamp with no sign of the small force involved.

I grant the case that the need for psychotherapy is often in the perception
of a third party, not that of the patient. But I think that's a different
issue. And I grant that, from a PCT viewpoint, the effects of no drugs
is yet known. But given that therapy is being attempted, and that
straightforward PCT approaches through the patient's perceptual system have
not had any effect, what is wrong in principle with approaches through
other effects on the (presumed) intrinisic variables or on the global
parameters of the hierarchy?

Martin

[Bruce_Abbott]

[From Bruce Abbott (950827.1345 EST)]

Bill Powers (950825.0945 MDT) --

    Martin Taylor (950825.11:00)

    Not having been privy to those conversations, I am unclear as to
    why you think the use of drugs is inconsistent with PCT. I would
    have thought there was a good case for presuming that some kinds of
    drug would be useful for helping to correct pathologies that can
    afflict a hierarchic control system.

My reason is quite simple; you mention it yourself at the end of your
post:

    And I grant that, from a PCT viewpoint, the effects of no drug is
    yet known.

The human system is a _system_, not a bag full of fragmentary cause-
effect relationships. There are and can be no simple direct connections
between putting a highly active biochemical into the bloodstream and a
change in the way the control systems of the nervous system, or those of
the biochemical system, are working. The medical approach, particularly
in the hands of practitioners rather than basic researchers, has always
been and is still oriented around a superficial treatment of superficial
symptoms, with essentially no grasp of why any given drug treatment has,
or fails to have, a given effect.

From a researcher's perspective, this is right on the mark. But for the

practioner, who is facing a difficult problem requiring an immediate
solution, the primary focus must be on discovering a solution that appears
to work. A lot of "what-to-dos" have been found long before anyone had any
idea how they work; asperin, for example, was known to the ancient Greeks,
and it has only been in the last few years that anyone had any notion of
what asperin does in the body to reduce pain and inflamation.

If would be far better, of course, to develop the cure based on a thorough
understanding of the mechanisms involved and their modes of failure. The
problem is that we currently lack the required understanding. And as Bill
notes, the practitioner's immediate need to discover an effective treatment
often produces solutions which may work, some of the time, in some of the
cases, for reasons which are poorly understood if at all. There is a
certain irony in the fact that success at discovering sometimes effective
treatments (including drugs) via a process essentially of trial and error
has tended to promote this approach at the expense of fundamental research
aimed at elucidating the mechanisms whose malfunctions we seek to correct.
However, I do not fault practitioners for trying whatever treatments which,
in their experience, have appeared to be effective in similar cases in the
past. The fault lies with us, the researchers and theorists, who have not
yet caught up with the needs of the practitioner. We should be able to tell
the practitioner, here is how the system works; given the symptoms you
describe, here are the failure-modes that can produce them, and here is what
can be done (if anything can be done) to correct the problem. In most cases
we are simply unable to do that given the current state of our understanding.

What PCT currently has to offer the practitioner, even in its present
limited state of development, is a general mechanism (the control system),
whose properties are well-understood (at least in the simplest examples).
This mechanism, when operating properly, attempts to keep its perceptual
inputs aligned with its references, variously referred to as its wants,
desires, goals, and so on. But its ability to do so can be compromised by a
variety of circumstances, including conflict with other control systems,
excessive gain, insufficient damping, excessive transport lag, and many
others. Analysis of these problems will undoubtedly illuminate many
difficulties which come to the attention of psychotherapists.

Bill Powers (950827.0100 MDT) --

My objection to the use of drugs is very simple. If the drugs remove the
symptom, then it will not be necessary to reorganize at the higher
levels that were responsible for the symptom. The roots of the problem
will remain unchanged; if the drug is removed, they will again produce
problems, either the same one or a different one. And all the while that
the drug is in the system, it will be having many other effects of which
we know nothing and which we may fail to recognize as being created by
the drug -- in which case, of course, we will have to look for another
drug to counteract those effects, and so on without end. This is
probably the origin of the gross overmedication that goes on nowadays,
particularly with old people eating enough pills before breakfast to
spoil their appetites.

I agree that drugs are over-prescribed. However, there are no doubt many
cases in which a drug is doing something beneficial even though we do not
yet understand how it accomplishes its effect. Bill's suggestion that drugs
may work by masking the symptom and thus preventing needed reorganization is
a cogent one, but drugs may work in other ways as well, which may prove
consistent with a PCT-based therapeutic approach.

As an example, consider bipolar affective disorder (manic-depressive
psychosis). People who suffer from this disorder experience slow, periodic
changes in their emotional state ranging from mania to severe depression,
with accompanying irrational thinking at each of these extremes. A simple
salt, lithium chloride, often proves able to stabilize this emotional system
although there is currently little understanding as to the means by which it
accomplishes this effect. From the control system point of view, however,
one can see the problem as involving an insufficiently damped control system
whose actions are driving its controlled variable past its reference level
in both directions. In this analysis lithium could have one of several
effects. For example, it might act by slowing the system's rate of change,
or by effectively increasing the system's damping factor. These changes
would reduce or eliminate overshoot and restore the system's stability.

Such an effect might not be possible through ordinary reorganization; a
PCT-based therapy aimed toward resolving conflict between competing control
systems or toward teaching the client more effective means of control over
emotions would fail, since the problem is inherently a structural failure in
the biochemical control system involved.

Anyway, that's my two cents.

Regards,

Bruce